Mitral Regurgitation Clinical Presentation
- Author: Ivan Hanson, MD; Chief Editor: Richard A Lange, MD more...
History
Acute mitral regurgitation
When associated with coronary artery disease and acute myocardial infarction (typically, inferior myocardial infarction, which may lead to papillary muscle dysfunction), significant acute mitral regurgitation (MR) is accompanied by symptoms of impaired LV function, such as dyspnea, fatigue, and orthopnea. In these cases, pulmonary edema is often the initial manifestation because of rapid volume overload on the left atrium and the pulmonary venous system.
Chronic mitral regurgitation
- Often results from a primary defect of the mitral valve apparatus with subsequent progressive enlargement of the left atrium and ventricle. In this state, patients may remain asymptomatic for years.
- Patients may have normal exercise tolerance until systolic dysfunction of the LV develops, at which point they may experience symptoms of a reduced forward cardiac output (ie, fatigue, dyspnea on exertion, or shortness of breath).
- With time, patients may feel chest palpitations if atrial fibrillation develops as a result of chronic atrial dilatation. For related information, see Medscape's Atrial Fibrillation Resource Center.
- Patients with LV enlargement and more severe disease eventually progress to symptomatic congestive heart failure with pulmonary congestion and edema. At this stage of LV dilatation, the myocardial dysfunction often becomes irreversible. For related information, see Medscape's Heart Failure Resource Center.
Physical
Palpation
- Brisk carotid upstroke and hyperdynamic cardiac impulse
- Prominent LV filling wave may be present
Auscultation
- S1 may be diminished in acute MR and chronic severe MR with defective valve leaflets.
- Wide splitting of S2 may occur due to early closure of the aortic valve.
- S3 may be present due to LV dysfunction or as a result of increased blood flow across the mitral valve.
- P2 may be accentuated if pulmonary hypertension is present.
- Murmur
- Quality
- Usually high-pitched, blowing
- Location
- Usually best heard over the apex
- Usually radiates to the left axilla or subscapular region
- Posterior leaflet dysfunction causes murmur to radiate to the sternum or aortic area
- Anterior leaflet dysfunction causes murmur to radiate to the back or top of the head
- Duration
- Usually holosystolic
- May be confined to early systole in acute MR
- May be confined to late systole in MVP or papillary muscle dysfunction
- S1 will probably be normal in these cases since initial closure of mitral valve cusps is unimpeded.
- A midsystolic click preceding murmur is suggestive of MVP.
- Intensity
- Little correlation exists between intensity of murmur and severity of MR.
- Intensity may be diminished in severe MR caused by LV dysfunction, acute myocardial infarction, or periprosthetic valve regurgitation.
- Quality
Causes
Acute mitral regurgitation
- Coronary artery disease (ischemia or acute myocardial infarction)
- Papillary muscle dysfunction
- The posteromedial papillary muscle is supplied by the terminal branch of the posterior descending artery and is more vulnerable to ischemic insult than the anterolateral papillary muscle, which is usually supplied by both the left anterior descending and circumflex arteries.
- Transient ischemia may result in transient MR associated with angina.
- Myocardial infarction or severe prolonged ischemia produces irreversible papillary muscle dysfunction and scarring.
- Chordae tendineae dysfunction or rupture
- Papillary muscle dysfunction
- Infectious endocarditis
- Abscess formation
- Vegetations
- Rupture of chordae tendineae
- Leaflet perforation
- Status post valvular surgery
- Trauma
- Percutaneous valvuloplasty
- Suture interruption
- Tumors (most commonly atrial myxoma)
- Myxomatous degeneration
- Mitral valve prolapse
- Ehlers-Danlos syndrome
- Marfan syndrome
- Systemic lupus erythematosus (Libman-Sacks lesion)
- Acute rheumatic fever (Carey Coombs murmur)
- Acute global left ventricular dysfunction
- Prosthetic mitral valve dysfunction
Chronic mitral regurgitation
- Rheumatic heart disease
- Systemic lupus erythematosus
- Scleroderma
- Myxomatous degeneration
- Mitral valve prolapse
- Ehlers-Danlos syndrome
- Marfan syndrome
- Calcification of mitral valve annulus
- Infective endocarditis (can affect normal, abnormal, or prosthetic mitral valves)
- Ruptured chordae tendineae
- Trauma
- Mitral valve prolapse
- Endocarditis
- Spontaneous
- Functional MR
- Dilation of mitral valve annulus
- Abnormal tethering of leaflets due to enlargement of LV cavity and stretch of papillary muscles and chordae
- Dilated cardiomyopathies
- Aneurysmal dilation of the left ventricle
- Hypertrophic cardiomyopathy
- Systolic anterior motion of the mitral valve
- Perivalvular prosthetic leak
- Congenital
- Mitral valve clefts
- Mitral valve fenestrations
- Parachute mitral valve abnormality
- Drug-related
- Ergotamine, methysergide, pergolide, anorexiant medications
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