History
Note the following:
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The initial symptoms of dyspnea and fatigue can rapidly progress to orthopnea and paroxysmal nocturnal dyspnea.
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Patients with anginal-type pain may have underlying ischemia.
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Atypical chest pain can be associated with mitral valve prolapse (MVP) syndrome.
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In patients with MVP, palpitations and atypical chest pain are the most frequent complaints.
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Coronary artery disease (CAD) is often accompanied by dyspnea, fatigue, orthopnea, and fluid retention. Chest pain is usually minimal in these patients.
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With underlying CAD, regurgitation usually is associated with symptoms of angina pectoris.
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Regurgitation also can develop acutely with myocardial infarction, secondary to papillary muscle rupture.
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In acute mitral regurgitation from sudden disruption of the mitral valve, the symptoms are due to acute pulmonary edema.
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When mitral regurgitation is due to left ventricular dilatation and altered valve function, patients often have chronic left-sided heart failure.
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Chronic mitral regurgitation can be tolerated for many years.
Physical Examination
The classic murmur of mitral regurgitation is a high-pitched holosystolic murmur beginning with the first heart sound and extending to the second heart sound. The intensity usually is constant throughout systolic ejection, often radiating to the axilla. The harshness of the murmur does not correlate with the magnitude of the valvular defect. Patients with severe disease often have a third heart sound, a consequence of the increased ventricular filling volume that is ejected into the left ventricle under higher than normal pressure. Patients with mitral valve prolapse often have a mid-to-late systolic click and a late systolic murmur. These patients are usually female and often have orthostatic hypotension.
Patients with coronary artery disease can have the above mentioned murmur any time during systole, accompanied by an atrial gallop.
In acute mitral regurgitation, the examination usually is consistent with acute pulmonary edema and left ventricular failure. The heart size usually is normal, but an audible systolic thrill is often present. The murmur often is harsh. It may be heard over the back of the neck, vertebra, and/or sacrum and may radiate to the axilla, back, and left sternal border.
Importantly, nearly one third of patients with acute severe mitral regurgitation following myocardial infarction may present without a clinically appreciable murmur. [3]
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Acute mitral regurgitation. Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
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Acute mitral regurgitation. Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.
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Acute mitral regurgitation. Severe mitral regurgitation as depicted with color Doppler echocardiography.
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Acute mitral regurgitation. Four-chamber apical view of a two-dimensional transthoracic echocardiogram demonstrates mitral valve prolapse (MVP), a common cause of mitral regurgitation.
