Imaging Studies
Chest radiography
The cardiac silhouette often is normal in patients with mitral valve prolapse (MVP).
Acute mitral regurgitation presents with acute pulmonary edema and, often, a normal cardiac silhouette if it is secondary to a rupture of a valve apparatus.
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.
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.
Other Tests
Electrocardiography (ECG)
Chronic mitral regurgitation
Atrial fibrillation is often present secondary to a dilated left atrium. The ECG shows evidence of left ventricular hypertrophy and left atrial enlargement.
Coronary artery disease
Evidence of inferior and posterior Q waves may be present, indicating prior infarction.
Mitral valve prolapse
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
The ECG may reveal evidence of an acute myocardial infarction, more commonly inferior or posterior.
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 coronary artery disease.
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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.
