Mitral regurgitation: Difference between revisions

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===Diagnosis===
==Background==
*Most common cause is papillary / chordae rupture after MI<ref>Kosowsky JM: Infective Endocarditis and Valvular Heart Disease, in Marx JA, Hockberger RS, Walls RM, et al (eds): Emergency Medicine: Concepts and Clinical Practice, ed. 7. St. Louis, Mosby, Inc., 2010, (Ch) 81: p.1072-1074.</ref>
[[File:Blausen 0645 MitralValve Regurgitation.png|thumb]]
**Day 2-7
[[File:Mitral Regurgitation scheme1.png|thumb|Schematic drawing of mitral regurgitation. During systole, contraction of the left ventricle causes abnormal backflow (arrow) into the left atrium. 1) Mitral valve; 2) Left ventricle; 3) Left atrium; 4) Aorta.]]
*MI, Endocarditis, Trauma
*Annual incidence of degenerative Mitral Valve (MV) disease causing MR ~3% in industrialized countries<ref>Kouchoukos NT. Problems in mitral valve replacement. In: Kirklin TW. eds. Advances in Cardiovascular Surgery. Grune & Stratton, New York,1973:205-16.</ref>
*Severe dyspnea, tachycardia, pulmonary edema
*Other etiologies of MR:
*Suspect if new-onset pulm edema + normal heart size
**Cardiac ischemia
*Cardiogenic shock may develop
**[[Endocarditis]]
*S4, apical systolic murmur
**[[Rheumatic disease]]
**[[SLE]], [[scleroderma]], [[amyloidosis]], [[sarcoidosis]]
**[[Connective tissue disease]] (myxomatous degeneration, [[Marfan syndrome|Marfan]], [[Ehlers-Danlos syndrome|Ehlers-Danlos]])
**[[HOCM]]
**[[Dilated cardiomyopathy]]
**[[Mitral valve prolapse]]
**Congenital disorders
*Criteria for MV repair<ref>Adams DH, Anyanwu AC. Seeking a higher standard for degenerative mitral valve repair: begin with etiology. J Thorac Cardiovasc Surg 2008;136:551-6.</ref>:
**Development of NYHA class II symptoms
**Deterioration in LV function
**LV end systolic diameter < 4.5 cm with EF > 60% to protect LV function<ref>Mohan JC and Mohan V. Subclinical left ventricular systolic dysfunction in chronic mitral regurgitation and its potential impact on management: quo vadis? Indian Heart J. 2012 May; 64(3): 249–253.</ref>
*However, recent evidence suggests best outcomes of MV repair are in asymptomatic or minimally symptomatic patients selected for surgery soon after echo dx<ref>Anders S, Said S, Schulz F, et al. Mitral valve prolapse syndrome as cause of sudden death in young adults. Forensic Sci Int 2007;171:127-30</ref>


Important to note;
==Clinical Features==
Clinical evaluation may be misleading leading to underestimation of mitral regurgitation severity. The classic holosystolic murmur can be much reduced in intensity. The tachycardia may make the murmur difficult to even appreciate. Even transthoracic echocardiography with color Doppler may be inadequate and underestimate the degree of regurgitation. <ref>Mitral Regurgitation, Ahmed MI, McGiffin DC, O'Rourke RA, Dell Italia LJ. Current Problems in Cardiology Volume 34, Issue 3, March 2009, Pages 93–136</ref>
[[File:Phonocardiograms from normal and abnormal heart sounds.svg|thumb|Phonocardiograms of common cardiac murmurs.]]
*[[Heart failure]] symptoms
*Atrial dilatation and [[atrial fibrillation]]
*[[Pulmonary hypertension]]
*Ischemic mitral incompetency, following [[myocardial infarction]] or [[LV aneurysm]]<ref>Kosowsky JM: Infective Endocarditis and Valvular Heart Disease, in Marx JA, Hockberger RS, Walls RM, et al (eds): Emergency Medicine: Concepts and Clinical Practice, ed. 7. St. Louis, Mosby, Inc., 2010, (Ch) 81: p.1072-1074.</ref>
**Most common mechanism of MR in developed countries
**Dysfunction of ventricular wall leads to papillary muscle dysfunction or chordae rupture
**Posterior papillary muscle and supporting ventricular wall most commonly affected
***[[Dyspnea]], [[tachycardia]], [[pulmonary edema]] (especially if new, and no cardiomegaly)
***S4 heart sound
***Apical systolic [[murmur]]


===Treatment===
==Differential Diagnosis==
*Decrease pulmonary edema
{{Valvular emergencies DDX}}
**O2, nitrates, diuretics
 
*Increase forward flow
==Evaluation==
**Decrease afterload
[[File:MV anatomy.jpg|thumbnail|MV Anatomy in PSS]]
**Consider nitroprusside in normotensive pts
[[File:MV anatomy PSL.jpg|thumbnail|MV Anatomy in PSL]]
**Dobutamine
[[File:MV anatomy Apical.jpg|thumbnail|MV Anatomy in Apical]]
*Consult Cards/CT Surg
*Clinical history and exam
*Intra-aortic balloon pump, emergency surgery
**[[Myocardial infarction]], [[endocarditis]], trauma
**Dyspnea, tachycardia, pulmonary edema
**Suspect if new-onset pulmonary edema, alongside normal heart size
**[[Cardiogenic shock]]
**S4, apical systolic murmur
**Clinical evaluation with auscultation may underestimate MR severity<ref>Mitral Regurgitation, Ahmed MI, McGiffin DC, O'Rourke RA, Dell Italia LJ. Current Problems in Cardiology Volume 34, Issue 3, March 2009, Pages 93–136</ref>
*[[Echocardiography]] grading
**Traditional grading is different from ischemic MR grading
***Eyeball grading of color jet from 1+ to 4+, set to color gain that minimizes background noise
***Color jet area in atrium during maximal MR jet, obtain both PSL and apial 4 chamber, at Nyquist limit scale set of 60 cm/s
[[File:MR Grading Eyeball.png|thumbnail|MR Grading by Eyeball of Color Jet]]
[[File:MR LA area.png|thumbnail|MR Grading by LA Maximal Jet Area]]
**Ischemic MR grading based on lesion severity of papillary muscle
**Factors that increase MR grading severity
***[[Hypertension]]
***Concomitant [[aortic stenosis]]
**Mitral valve anatomy and scalloping much better appreciated in TEE over TTE
 
==Management==
*Supportive measures until definitive surgery<ref>DiSandro D et al. Acute Mitral Regurgitation Treatment & Management. eMedicine. Dec 28, 2015. http://emedicine.medscape.com/article/758816-treatment.</ref>
*Appropriate treatment if [[myocardial infarction]] must include catheterization or [[thrombolysis]]
*[[Pulmonary edema]]
**[[Oxygen]]
**[[nitroglycerin|Nitrates]] and [[diuretics|diuresis]] may improve filling pressures and treat edema
**Early intubation for impending respiratory failure
*Decrease afterload
**[[Nitroprusside]] can be considered in normotensive patients to increase cardiac output and decrease MR
**Intra aortic balloon pump may decrease afterload, increase forward cardiac output and reduce regurgitation
*[[Inotropes]]
**[[Dobutamine]] pressor of choice as α agonism and increased afterload minimal compared to beta agonism<ref>Sonoda M et al. Effects of Dobutamine Infusion on Mitral Regurgitation. Echocardiography. 1998 Jan;15(1):13-20.</ref>
**Avoid [[beta-blockers]] as mild to moderate tachycardia allows less time for LV to backfill
*'''Consult Cardiology or Cardiothoracic Surgery for definitive management'''
 
==Disposition==
*Admit for severe presentations


==See Also==
==See Also==
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*[[Heart Murmurs]]
*[[Heart Murmurs]]


==Source==
==External Links==
*Tintinalli
*[http://www.emdocs.net/acute-valvular-emergencies-pearls-pitfalls/ emDocs - Acute Valvular Emergencies: Pearls and Pitfalls]
*Kosowsky JM: Infective Endocarditis and Valvular Heart Disease, in Marx JA, Hockberger RS, Walls RM, et al (eds): Emergency Medicine: Concepts and Clinical Practice, ed. 7. St. Louis, Mosby, Inc., 2010, (Ch) 81: p.1072-1074.
 
==References==
<references/>


[[Category:Cards]]
[[Category:Cardiology]]

Latest revision as of 17:17, 13 November 2024

Background

Blausen 0645 MitralValve Regurgitation.png
Schematic drawing of mitral regurgitation. During systole, contraction of the left ventricle causes abnormal backflow (arrow) into the left atrium. 1) Mitral valve; 2) Left ventricle; 3) Left atrium; 4) Aorta.

Clinical Features

Phonocardiograms of common cardiac murmurs.

Differential Diagnosis

Valvular Emergencies

Evaluation

MV Anatomy in PSS
MV Anatomy in PSL
MV Anatomy in Apical
  • Clinical history and exam
  • Echocardiography grading
    • Traditional grading is different from ischemic MR grading
      • Eyeball grading of color jet from 1+ to 4+, set to color gain that minimizes background noise
      • Color jet area in atrium during maximal MR jet, obtain both PSL and apial 4 chamber, at Nyquist limit scale set of 60 cm/s
MR Grading by Eyeball of Color Jet
MR Grading by LA Maximal Jet Area
    • Ischemic MR grading based on lesion severity of papillary muscle
    • Factors that increase MR grading severity
    • Mitral valve anatomy and scalloping much better appreciated in TEE over TTE

Management

  • Supportive measures until definitive surgery[7]
  • Appropriate treatment if myocardial infarction must include catheterization or thrombolysis
  • Pulmonary edema
    • Oxygen
    • Nitrates and diuresis may improve filling pressures and treat edema
    • Early intubation for impending respiratory failure
  • Decrease afterload
    • Nitroprusside can be considered in normotensive patients to increase cardiac output and decrease MR
    • Intra aortic balloon pump may decrease afterload, increase forward cardiac output and reduce regurgitation
  • Inotropes
    • Dobutamine pressor of choice as α agonism and increased afterload minimal compared to beta agonism[8]
    • Avoid beta-blockers as mild to moderate tachycardia allows less time for LV to backfill
  • Consult Cardiology or Cardiothoracic Surgery for definitive management

Disposition

  • Admit for severe presentations

See Also

External Links

References

  1. ↑ Kouchoukos NT. Problems in mitral valve replacement. In: Kirklin TW. eds. Advances in Cardiovascular Surgery. Grune & Stratton, New York,1973:205-16.
  2. ↑ Adams DH, Anyanwu AC. Seeking a higher standard for degenerative mitral valve repair: begin with etiology. J Thorac Cardiovasc Surg 2008;136:551-6.
  3. ↑ Mohan JC and Mohan V. Subclinical left ventricular systolic dysfunction in chronic mitral regurgitation and its potential impact on management: quo vadis? Indian Heart J. 2012 May; 64(3): 249–253.
  4. ↑ Anders S, Said S, Schulz F, et al. Mitral valve prolapse syndrome as cause of sudden death in young adults. Forensic Sci Int 2007;171:127-30
  5. ↑ Kosowsky JM: Infective Endocarditis and Valvular Heart Disease, in Marx JA, Hockberger RS, Walls RM, et al (eds): Emergency Medicine: Concepts and Clinical Practice, ed. 7. St. Louis, Mosby, Inc., 2010, (Ch) 81: p.1072-1074.
  6. ↑ Mitral Regurgitation, Ahmed MI, McGiffin DC, O'Rourke RA, Dell Italia LJ. Current Problems in Cardiology Volume 34, Issue 3, March 2009, Pages 93–136
  7. ↑ DiSandro D et al. Acute Mitral Regurgitation Treatment & Management. eMedicine. Dec 28, 2015. http://emedicine.medscape.com/article/758816-treatment.
  8. ↑ Sonoda M et al. Effects of Dobutamine Infusion on Mitral Regurgitation. Echocardiography. 1998 Jan;15(1):13-20.
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