Mitral regurgitation: Difference between revisions

(Created page with "===Diagnosis=== *Most common cause is papillary / chordae rupture after MI *Suspect if new-onset pulm edema + normal heart size *Severe dyspnea, tachycardia, pulmonary edema *Car...")
 
 
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===Diagnosis===
==Background==
*Most common cause is papillary / chordae rupture after MI
[[File:Blausen 0645 MitralValve Regurgitation.png|thumb]]
*Suspect if new-onset pulm edema + normal heart size
[[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.]]
*Severe dyspnea, tachycardia, pulmonary edema
*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>
*Cardiogenic shock may develop
*Other etiologies of MR:
*S4, apical systolic murmur
**Cardiac ischemia
**[[Endocarditis]]
**[[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>


===Treatment===
==Clinical Features==
*Decrease pulmonary edema
[[File:Phonocardiograms from normal and abnormal heart sounds.svg|thumb|Phonocardiograms of common cardiac murmurs.]]
**O2, nitrates, diuretics
*[[Heart failure]] symptoms
*Increase forward flow
*Atrial dilatation and [[atrial fibrillation]]
**Decrease afterload
*[[Pulmonary hypertension]]
**Consider nitroprusside in normotensive pts
*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]]
 
==Differential Diagnosis==
{{Valvular emergencies DDX}}
 
==Evaluation==
[[File:MV anatomy.jpg|thumbnail|MV Anatomy in PSS]]
[[File:MV anatomy PSL.jpg|thumbnail|MV Anatomy in PSL]]
[[File:MV anatomy Apical.jpg|thumbnail|MV Anatomy in Apical]]
*Clinical history and exam
**[[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==
[[Valvular Emergencies]]
*[[Valvular Emergencies]]
*[[Heart Murmurs]]
 
==External Links==
*[http://www.emdocs.net/acute-valvular-emergencies-pearls-pitfalls/ emDocs - Acute Valvular Emergencies: Pearls and Pitfalls]
 
==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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