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Acute Mitral Regurgitation Workup

  • Author: Daniel DiSandro, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Dec 28, 2015
 

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.

See the videos below.

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 College of Medicine

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

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

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

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

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

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

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

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

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

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

  10. Zito C, Manganaro R, Khandheria B, et al. Usefulness of left atrial reservoir size and left ventricular untwisting rate for predicting outcome in primary mitral regurgitation. Am J Cardiol. 2015 Oct 15. 116(8):1237-44. [Medline].

  11. Arsalan M, Squiers JJ, DiMaio JM, Mack MJ. Catheter-based or surgical repair of the highest risk secondary mitral regurgitation patients. Ann Cardiothorac Surg. 2015 May. 4(3):278-83. [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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