MITRAL

REGURGITATION
(MR)
 MITRAL VALVE APPARATUS

Anterior & posterior leaflets

Mitral annulus or ring

Chordae tendinae

Pappillary muscles

Problem in any one or more can

lead to MR
 Etiology of chronic MR
RHD
Congenital MR (MVP/cushion defects)
IE
IHD
CMP
Injury / surgery
CT disorders RA/ SLE/ AS/ Marfans
Amyloidosis/ sarcoidosis
 Etiology of acute MR

IE
AMI (rupture of pappillary muscle)
Trauma
Surgery
Acute RF
 Pathology of MR

33% of MR by chronic RHD

More frequently in males
Rheumatic process produces rigidity, deformity,
retraction of valve cusps,commisural fusion, chordae
tendinae shortening, contraction & fusion
Massive calcification of mitral annulus
Degeneration of mitral valve/ annulus
 Pathology of MR

Congenital MR
-defect in endocardial cushion
-corrected transposition
In AMI / LV aneurysm
-fibrosis of pappilary muscle
-ischaemia to pappillary muscle
-rupture or dilation
 Pathophysiology of MR
Leaking of blood volume & pressure from LV to the LA during systole

2 outlets from LV ( Aortic forward flow & mitral backward leak )

Increase LA pressure gradient & volume

Rapid decrease in LV tension / function

Increase LV end diastolic volume ( extra from LA )

Decrease Aortic flow from LV ( CO )

 Pathophysiology of MR contd..
Regardless of etiology , MR is progressive

LA enlargement increases tension on posterior leaflet, pulls it

away from mitral orifice - MR

LV enlargement increases regurgitation which in turn enlarges

LA & LV
Mitral regurgitation begets Mitral regugitation

Later giant LA,LVH,PH follow

 Symptoms of MR

Progressive fatigue ( CO)

Exertional dyspnea ( CO)
Orthopnea
PND ( rare)
Hemoptysis
Systemic embolism
Exhaustion, weight loss, cachexia ( CO)
 Physical signs

Pulse high volume / collapsing ( severe MR)

JVP prominent a wave PH
prominent v wave TR
Apex beat diffuse , hyperdynamic, down & out
Left parasternal lift
Systolic thrill at apex
 Auscultatory signs in MR

S 1 soft , muffled
PSM- at apex ,radiates to axilla if anterior
leaflet is involved and
to back if posterior leaflet is involved,
increases with expiration
- cooing / seagull quality ( chordae
tendinae rupture), musical quality( filal leaflet)
P2 loud, wide split S2 (PH)
 Severity of MR

Presence of systolic thrill at apex

Large LV

Presence of S3

Flow MDM without MS

 ECG in MR

P mitrale ( LA enlargement)

LVH / LV enlargement

+- AF
 Chest X ray

Cardiomegaly LA, LV & then RV enlargement

Calcification of mitral leaflets / annulus

Signs of pulmonary venous HTN / PH

Pulmonary edema ( later stages )

 ECHO in MR
Useful in diagnosis & to asses complications
LA & LV enlargement

Ruptured chordae tendinae / erratic motion of the involved leaflets

Doppler ECHO imaging detects MR & asses the severity of MR

LA clots & vegetations, etc

 Complications of MR

IE
CCF
PH
Atrial fibrillatiion
 Medical management of MR

Treatment of CCF
Treatment of AF
Prophylaxis of RF
Prophylaxis of IE

IV nitropruside / nitroglycerine reduce the afterload

& MR
 Surgical management of MR

Mitral valvuloplasty / annuplasty

-preferred in young
-mitral valve repair work
Indications Annular dilation
Flial leaflets
MVP
ruptured chordae tendinae
 Surgical management of MR

Mitral valve replacement ( MVR)

By mechanical / biological prosthesis

Indications MS with MR
-severe MR
-markedly deformed, shruken
valves & calcified leaflets
 Mechanical prosthetic valves

Larged ball valve ( star Edwards)

Tilting disc valve ( St. Jude)

Advantage longevity
Disadvantage lifelong anticoagulations

Tilting disc preferred for its less size / lesser

complications
 Bioprosthesis

Porcine bio prosthesis

Pericardial xeno graft prosthesis

Advantage low incidence of thrombo-embolism

Disadvantage short lived (require replacement)

Preferred in very young/ very old/ pregnancy

THANK YOU