Valvular

Mitral Regurgitation

PATHO

  • Incompetent valve ➔ blood shot back up into left atria during systole ➔ left atria volume overload ➔ left HF sx

  • Chronic ➔ ↑ LV EDV ➔ dilation of LV ➔ eccentric remodeling ➔ L HF ➔ R HF overtime

  • Causes:

    • Mitral valve prolapse (MCC)

    • Ischemia (acute MI) can ➔ ruptured tendineae ➔ acute MR

    • Dilated cardiomyopathy & left HF

    • Endocarditis, Rheumatic fever ➔ pancarditis (mostly endocardium ➔ valvulitis)

SSX

  • Left HF sx (dyspnea, pulmonary edema, shocky)

  • Palpitations (LAE ➔ a-fib)

  • Holo/pan-systolic blowing murmur that radiates to axilla

    • ↑ intensity with ↑ preload (squatting/supine), ↑ afterload (handgrip), LLR

    • ↓ intensity with ↓ preload (valsalva/standing/vasodilators), inspiration (↑ R preload & ↓ L preload)

    • Wide split S2 (A2 then P2) with inspiration

      • Normally less blood ejected with inspiration

      • Even less when blood shot back up into atria ➔ shortened LV systole ➔ early aortic valve closure (A2 way before P2)

  • Quiet S1 & S3 (more severe) or S4 (less severe)

  • Laterally displaced PMI

DX

  • ECHO (Transthoracic) shows regurgitant jet with abnormal valve movement

  • EKG/CXR shows LAE (p-mitrale), LVH

TX

  • Acute MR needs surgery! (and chronic that doesn't respond to tx)

    • Control SX til surgery: ACEi/ARB, vasodilators (you want meds to ↓ afterload in MR... unlike MS)

  • Try to repair valve instead of replacing (valve replacement has ↑ mortality and needs to be replaced in 10yrs)

  • Mild MR should get serial ECHO

Mitral Valve Prolapse

PATHO

  • Idiopathic (MC), Marfan, rheumatic heart disease, endocarditis ➔ valve abnormality ➔ leaflets move into L atrium during systole

  • Severe ischemia of papillary muscles ➔ chordae tendineae rupture ➔ severe MR

  • Connective tissue disorders ➔ glycosaminoglycan deposits that land on mitral valve

  • Rheumatic fever ➔ valve damage

    • Affected valves: Mitral > Aortic > Tricuspid > Pulmonary

SSX

  • Mid/late-systolic click ± mid/late systolic murmur of MR

    • Less blood on left (from inspiration or valsalva) ➔ ↑ severity of MVP ➔ earlier click and longer murmur

    • More blood on left (squatting/supine) ➔ ↓ severity of MVP ➔ later click and longer murmur (but ↑ afterload may ↑)

DX

    • ECHO (Transthoracic) shows leaflets of mitral valve not where they are supposed to be

TX

    • Observation unless there is MR - TX the MR...

    • MVP with mild MR should be followed

      • Can develop a-fib or worsening of MR ➔ irreversible LV remodeling