Mitral regurgitation

1. Mitral regurgitation Dr Husain Tayib M.R.C.P {UK} F.R.C.P {London}

2. Mitral regurgitation Normal heart

4. Mitral regurgitation LA AO PA RA LV RV

5. Mitral regugitation Aetiology * MVP { Myxomatous mv } ,commonest in developed world *Damage to the cusps : _RVD _ IE _ Congenital Cleft MV *Damage to chordae : _RVD _ IE _ Trauma _ Degenerative * Damage to papillary muscles : _Ischaemia _ Infarction _ Infiltrative _ HCM * Damage of MV annulus : _ Calcification _ IE { abscess } * Dilatation of MV ring : _ IHD _ CMP _ acute RV

7. Mitral regurgitation pathophysiology Lv volume OL…. LV dilatation maintain normal COP later….. LV decompensate LVEDP rise LV wall tension increase…… LV fail ….. pulmonary congestion….PH ……CHF LV dilatation ….dilated MV ring…. > MR Back pressure ….dilated LA …..AF … La thrombus ….. PHP .. ….. CHF …… thrombo-embolic phenomenon

8. Mitral regurgitation Clinical features : Symptoms : _Dyspnoea { pulmonary congestion } _Fatigue { low COP } _ Palpitation { AF , increased stroke volume } _Oedema , Ascites { RVF } _ Systemic embolization { stroke , ischaemic limb etc.. } Signs : _ Pulse… Jerky .. AF .. _Apex … Displaced hyperdynamic _ Apical Pansystolic murmer +/_ Thrill …. 3rd HS _Signs of pulmonary congestion …{ crepitations , Pul. Oed. } _Signs of PH and RVF .. Loud P2 .. Lt.PS heave … Oedema …

9. Mitral regurgitation Investigations : * ECG … LAH , LVH ….AF * Chest X-ray… LA enlargement … Pulmonary congestion .. … LV enlargement …Pulmonary oedema … * ECHO …. Dilated LA and LV ….Dynamic LV … ….Structural abnormalities of MV { e.g. MVP } * Doppler … { CW … PW … color dopler .. } _ Detects and quantifies MR _ * Cardiac catheterization…. Dilated LA and LV …. MR … …..Assess PH … ….. Detect coexisting CAD …

10. Mitral regurgitation ECG LVH"DOL" LVH AF

11. Mitral regurgitation Chest X-ray PA view

12. Mitral regurgitation 9 CFM CF-M-mode 2-d Echo CFM

13. Mitral regurgitation CW dopler MR Normal

14. Mitral regurgitation Cardio-angiography

15. Mitral regurgitation Management Medical : _ For mild and moderate cases * Diuretic *Vasodilators , e.g. ACEI * Digoxin For AF *Anticoagulant if AF *Antibiotic Prophylaxis against IE Surgical : * MV valvoplasty {Repair } *MV replacement Indications: _ Worsening symptoms _Progressive cardiomegaly _ Deterioration of LV F EF <60% , LVEDD > 55

16. Artificial valves Carpentier-Edwards Carpentier-Edwards porcine Pericardial St.jude Medotroic Starr-Edwards

17. Complications of artificial valves 1-Infective Endocarditis 2-Thrombosis and thrombo embolism 3-Haemolysis 4-Valve dysfunction

18. Mitral regurgitation

19. Mitral regurgitation Indications for Surgery in Isolated ,Severe Chronic MR *Emerging (minor criteria): _Any symptoms of heart failure _Or sub optimal exercise tolerance test _Flail mitral leaflet _Left atrial diameter >45mm _Paroxysmal atrial fibrillation _Abnormal exercise end-systolic volume index or ejection fraction

20. Mitral valve prolapse Normal MVP

21. Mitral valve prolapse General information _Most common cause of isolated MR _Occurs in 5% of adults _Most discovered at ages 20- 40 _Affects women > men _MV “floppy” or incompetent _Caused by myxomatous changes _ May occurs with marfan syndrome _Cordae may rupture

22. Mitral valve prolapse Clinical features _May be asymptomatic _ Mid systolic click +/_ late systolic murmer or PSM _ MR -- chronic , or acute {rupture CT} _ CHF _ Increased risk for : * IE *Arrythmias *Increased risk of embolic stroke and TIA { small } * Sudden death { rare }

26. Mitral valve prolapse CXR ECG

27. Mitral valve prolapse M-mode ECHO Late systolic MVP Holosystolic MVP

28. Mitral valve prolapse 2-d ECHO CFM

29. Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1

30. Thank you