Mitral Regurgitation in Emergency Medicine Workup

  • Author: Daniel DiSandro, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: Nov 1, 2010
 

Imaging Studies

  • Chest radiography
    • The cardiac silhouette often is normal in patients with mitral valve prolapse (MVP).
    • With chronic mitral regurgitation, left ventricular and left atrial enlargement are present.
    • The left atrium can be large enough that it produces elevation of the left mainstem bronchus.
    • Occasionally, the double density sign can be seen along the right heart border, which is produced by the shadow of the wall of the dilated left atrium.
    • The heart size of patients with coronary artery disease (CAD) can range from normal to significant dilatation of the left ventricle and left atrium.
    • Mitral regurgitation presents with acute pulmonary edema and a normal cardiac silhouette with acute mitral regurgitation that is secondary to a rupture of a valve apparatus.
  • Two-dimensional echocardiography
    • Evidence of posterior motion of valve leaflets during mid-systole is present in patients with mitral valve prolapse.
    • Annular calcifications may be seen in patients with coronary artery disease. In addition, evidence of posterior or inferior wall motion abnormalities may be observed.
    • With acute mitral regurgitation, the ruptured chordae tendineae or papillary muscle, as well as perforated interventricular septum, can be visualized. The left atrium and ventricle are generally of normal size.
    • Transesophageal echocardiography provides a better estimate of the severity of damage.
      Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
      Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.
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Other Tests

  • Electrocardiography
    • Chronic mitral regurgitation
      • Atrial fibrillation often is present secondary to a dilated left atrium.
      • The ECG shows evidence of left ventricular hypertrophy and left atrial enlargement.
    • CAD: Evidence of inferior and posterior Q waves may be present, indicating prior infarction.
    • MVP
      • Patients most commonly have ST- and T-wave changes, with T-wave inversions in the inferior leads.
      • ECG may reveal an underlying arrhythmia (eg, sinus arrhythmia, sinus arrest, atrial fibrillation, premature ventricular contractions [PVCs]).
    • Acute mitral regurgitation: ECG may reveal evidence of an acute myocardial infarction, more commonly inferior or posterior.
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Procedures

  • Cardiac catheterization
    • Angiography is considered to be the criterion standard in the assessment of the severity of the disease.
    • Mitral regurgitation is graded on a scale from 0 (none), 1 (mild), 2 (moderate), 3 (moderately severe), to 4 (severe).
    • The severity is based on the opacity of the left atrium.
    • The regurgitant volume can be calculated based on information from the catheterization.
    • In addition, this test will identify those with underlying CAD.
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Contributor Information and Disclosures
Author

Daniel DiSandro, MD  Clinical Assistant Professor, Department of Emergency Medicine, Drexel University

Daniel DiSandro, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert M McNamara, MD, FAAEM  Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Paul Blackburn, DO, FACOEP, FACEP  Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. [Guideline] Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. Sep 23 2008;52(13):e1-142. [Medline]. [Full Text].

  2. Borer JS, Bonow RO. Contemporary approach to aortic and mitral regurgitation. Circulation. Nov 18 2003;108(20):2432-8. [Medline].

  3. Carabello BA. Management of valvular regurgitation. Curr Opin Cardiol. Mar 1995;10(2):124-7. [Medline].

  4. Carabello BA. Mitral valve disease. Curr Probl Cardiol. Jul 1993;18(7):423-78. [Medline].

  5. Fenster MS, Feldman MD. Mitral regurgitation: an overview. Curr Probl Cardiol. Apr 1995;20(4):193-280. [Medline].

  6. Filsoufi F, Salzberg SP, Adams DH. Current management of ischemic mitral regurgitation. Mt Sinai J Med. Mar 2005;72(2):105-15. [Medline].

  7. Gaasch WH, Eisenhauer AC. The management of mitral valve disease. Curr Opin Cardiol. Mar 1996;11(2):114-9. [Medline].

  8. Schon HR. Medical treatment of chronic valvular regurgitation. J Heart Valve Dis. Oct 1995;4 Suppl 2:S170-4. [Medline].

  9. Wisenbaugh T. Mitral valve disease. Curr Opin Cardiol. Mar 1994;9(2):146-51. [Medline].

 
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Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.
Severe mitral regurgitation as depicted with color Doppler echocardiography.
Four-chamber apical view of a 2-dimensional transthoracic echocardiogram demonstrates mitral valve prolapse (MVP), a common cause of mitral regurgitation.
 
 
 
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