Mitral regurgitation: Difference between revisions
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==Background== | ==Background== | ||
*Annual incidence of degenerative Mitral Valve (MV) disease ~3% in industrialized countries | [[File:Blausen 0645 MitralValve Regurgitation.png|thumb]] | ||
[[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.]] | |||
*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> | |||
*Other etiologies of MR: | *Other etiologies of MR: | ||
**Cardiac ischemia | **Cardiac ischemia | ||
**[[Endocarditis]] | **[[Endocarditis]] | ||
**[[Rheumatic disease]] | **[[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>: | *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 | **Development of NYHA class II symptoms | ||
| Line 12: | Line 20: | ||
==Clinical Features== | ==Clinical Features== | ||
*Heart failure symptoms | [[File:Phonocardiograms from normal and abnormal heart sounds.svg|thumb|Phonocardiograms of common cardiac murmurs.]] | ||
*[[Heart failure]] symptoms | |||
*Atrial dilatation and [[atrial fibrillation]] | *Atrial dilatation and [[atrial fibrillation]] | ||
*[[Pulmonary hypertension]] | *[[Pulmonary hypertension]] | ||
*Ischemic mitral incompetency, following [[myocardial infarction]] or [[LV aneurysm]] | *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 | **Most common mechanism of MR in developed countries | ||
**Dysfunction of ventricular wall leads to papillary muscle dysfunction | **Dysfunction of ventricular wall leads to papillary muscle dysfunction or chordae rupture | ||
**Posterior papillary muscle and supporting ventricular wall most commonly affected | **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== | ==Differential Diagnosis== | ||
| Line 24: | Line 36: | ||
==Evaluation== | ==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 | *Clinical history and exam | ||
**[[Myocardial infarction]], [[endocarditis]], trauma | **[[Myocardial infarction]], [[endocarditis]], trauma | ||
**Dyspnea, tachycardia, pulmonary edema | **Dyspnea, tachycardia, pulmonary edema | ||
| Line 32: | Line 46: | ||
**S4, apical systolic murmur | **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> | **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<ref>DiSandro D et al. Acute Mitral Regurgitation Treatment & Management. eMedicine. Dec 28, 2015. http://emedicine.medscape.com/article/758816-treatment.</ref> | ==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]] | *Appropriate treatment if [[myocardial infarction]] must include catheterization or [[thrombolysis]] | ||
*Pulmonary edema | *[[Pulmonary edema]] | ||
**Oxygen | **[[Oxygen]] | ||
**Nitrates and diuresis may improve filling pressures and treat edema | **[[nitroglycerin|Nitrates]] and [[diuretics|diuresis]] may improve filling pressures and treat edema | ||
**Early intubation for impending respiratory failure | **Early intubation for impending respiratory failure | ||
*Decrease afterload | *Decrease afterload | ||
**Nitroprusside can be considered in normotensive patients to increase cardiac output and decrease MR | **[[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 | **Intra aortic balloon pump may decrease afterload, increase forward cardiac output and reduce regurgitation | ||
*Inotropes | *[[Inotropes]] | ||
**Dobutamine pressor of choice as | **[[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]] | *[[Heart Murmurs]] | ||
==External Links== | |||
*[http://www.emdocs.net/acute-valvular-emergencies-pearls-pitfalls/ emDocs - Acute Valvular Emergencies: Pearls and Pitfalls] | |||
==References== | ==References== | ||
Latest revision as of 17:17, 13 November 2024
Background
- Annual incidence of degenerative Mitral Valve (MV) disease causing MR ~3% in industrialized countries[1]
- Other etiologies of MR:
- Cardiac ischemia
- Endocarditis
- Rheumatic disease
- SLE, scleroderma, amyloidosis, sarcoidosis
- Connective tissue disease (myxomatous degeneration, Marfan, Ehlers-Danlos)
- HOCM
- Dilated cardiomyopathy
- Mitral valve prolapse
- Congenital disorders
- Criteria for MV repair[2]:
- Development of NYHA class II symptoms
- Deterioration in LV function
- LV end systolic diameter < 4.5 cm with EF > 60% to protect LV function[3]
- However, recent evidence suggests best outcomes of MV repair are in asymptomatic or minimally symptomatic patients selected for surgery soon after echo dx[4]
Clinical Features
- Heart failure symptoms
- Atrial dilatation and atrial fibrillation
- Pulmonary hypertension
- Ischemic mitral incompetency, following myocardial infarction or LV aneurysm[5]
- 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
Evaluation
- 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[6]
- 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
- Traditional grading is different from ischemic MR grading
- 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[7]
- Appropriate treatment if myocardial infarction must include catheterization or thrombolysis
- Pulmonary edema
- 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
- ↑ Kouchoukos NT. Problems in mitral valve replacement. In: Kirklin TW. eds. Advances in Cardiovascular Surgery. Grune & Stratton, New York,1973:205-16.
- ↑ Adams DH, Anyanwu AC. Seeking a higher standard for degenerative mitral valve repair: begin with etiology. J Thorac Cardiovasc Surg 2008;136:551-6.
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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
- ↑ DiSandro D et al. Acute Mitral Regurgitation Treatment & Management. eMedicine. Dec 28, 2015. http://emedicine.medscape.com/article/758816-treatment.
- ↑ Sonoda M et al. Effects of Dobutamine Infusion on Mitral Regurgitation. Echocardiography. 1998 Jan;15(1):13-20.