Mitral regurgitation clinical presentation

What are the clinical signs in mitral regurgitation?
Auscultatory findings in Mitral regurgitation
Heartsounds in mitral regurgitation
Murmur of mitral regurgitation
What are the important cause of mitral regurgitation ?
Clinical features of papillary muscle dysfunction
Causes and clinical features of Acute Mitral regurgitation
Medical and surgical management of mitral regurgitation

Medical and surgical management of mitral regurgitation

Management include medical and surgical modalities

Medical management include

• Prophylaxis of IEC and RF.
• Afterload reduction is achieved with ACE inhibitors or nifedipin

Symptomatic patient are given

• Diurectics and digoxin in heart failure
• In patients with atrial fibrillation
• Drugs to reduce the heart rate is given.
• Anti coagulation and cardioversion is given if required
• Anticoagulants are given in patients with atrial fibrillation and embolic episodes.

Surgical options include 

Mitral valvuloplasty 

MitralValve replacement

Indications for MV repair (Valvuloplasty or annuloplasty) are the following

1.Mitral valve prolapse
2.Mitral valve annular calcification
3.Chordal rupture
4.Papillary muscle rupture

MV repair helps to maintain the annulo cardo papillary muscle continuity.

What are the indication for mitral valve replacement

Class III, IV symptoms

Severe  MR with following

1.Left ventricular ejection fraction <60

2.LV and systolic diameter >50mm by echo.

Clinical features of papillary muscle dysfunction

Conditions where you get murmur of Papillary muscle dysfunction 

• Ischemia
• Dilatation of left ventricle
• Rupture of papillary muscle
• Fibrosis of papillary muscle

What are the signs of papillary muscle dysfunction ?

• Left ventricular S4
• Late systolic or pansystolic murmur with late systolic accentuation
• What are the murmurs in papillary muscle dysfunction ?
• Late systolic murmur
• Holosystolic with late systolic accentuation (severe LV dusfunction)
• Holosystolic murmur
• Decrescendo murmur

What are the characteristic of murmur in papillay muscle dysfunction ?

It is a late systolic murmur, or PSM with late systolic accentuation

Soft murmur of 2/6 intensity

There is poor correlation between intensity and severity of murmur.

Variabilities are present in intensity, configuration of frequency.

What is the basis of murmur in papillary muscle dysfunction ? 

Papillary muscle function is especially needed in the later part of systolic. So the murmur is PSM  with late systolic accentuation.

What is the basis of decrescendo murmur in papillary muscle dysfunction ?

Decrescendo nature of murmur is due to decreased size of left ventricular toward the end of systolic which help in better co-aptation and less reflux. 

What is the significance of S4 in MR due to papillary muscle dysfunction?

Absence of S4 with a late systolic murmur rules out the papillary muscle dysfunction.

Causes and clinical features of Acute Mitral regurgitation

What are the causes of acute mitral regurgitation

• Infective endocarditis
• Acute rheumatic fever
• Mitral valve prolapse
• Marfan syndrome
• Myocardial ischemia
• Trauma
• Idiopathic
• Prosthetic valve dysfunction

What is the clinical presentation of acute MR ?

Acute pulmonary oedema

Hypotension

What are the clinical signs of acute MR ?

Acute mitral regurgitation produces a set of clinical sign different from chronic mitral regurgitation

• Tachycardia 
• Hypotension
• A wave / v wave in JVP
• Absence of cardiomegaly
• Forcible apex
• Palpable P2
• Thrill present
• Left parasternal heave present
• Loud P2
• LV S3, S4
• Loud descrendo murmur at the apex

So the striking differences are in blood pressure, absence of cardiomegaly, pulmonary artery, hypertension(PAH), left ventricular S4 (LVS4) and decrescendo murmur 

Murmur of mitral regurgitation

Type of systolic murmur in MR is determined by the chronicity of murmur and its etiology

• Holosystolic murmur – Mitral regurgitation begins during isovolumetric contraction phase and continue till isovolumetric relaxation phase. Heard in rheumatic mitral regurgitation
• Tapering holosystolic murmur occur due to severe mitral regurgitation with a small left atrium occur in acute MR.
• Holosystolic murmur with mid systolic accentuation is heard in severe mitral regurgitation
• Holosystolic murmur with late systolic accentuation occur in MVP and papillary muscle dysfunction
• Late systolic murmur heard in mitral valve prolapse and papillary muscle dysfunction.

Describe the frequency of murmur in MR

Murmur in MR is a high pitched murmur. In severe MR, When the  pressure gradient decreases towards the end of systole low pitched vibrations can occur.

Where will you auscultate for MR murmur?

Classically heard in mitral area

If the anterior leaflet is affected murmur conduct towards axilla

If the posterior mitral leaflet is affected it will be conducted to base of heart.

Murmur may be heard over entire vertebral column if there is large left atrium.

Which is the ideal position, for auscultation  for MR and Why?

Left lateral position is the most suitable position because there is accentuation of halosystolic nature of murmur

Intensity of murmur is increases in this position

What is effect of VPC (Ventricular premature contraction)

Following ventricular premature beat there won’t be any beat to beat variation of murmur.

Following VPV beat to beat variation of murmur occur in aortic stenosis.

What are the causes of decreased intensity of murmur in MR

Murmur may be of decreased intensity in low flow states and associated valve lesion.

Low flow states are Left ventricular dysfunction and Pulmonary artery hypertension

Associated valve lesions that reduce the murmur intensity is Mitral stenosis

Etiology of MR – MR due to following reasons are associated with low intensity of murmur

• MR due to acute myocardial infarction
• MR due to left ventricular dilation 
• MR due to papillary muscle dysfunction

Other causes are 

Obesity

COPD (Chronic obstructive pulmonary disease)

What is Seagull’s murmur

When patient develop infective endocarditis over mitral regurgitation it will alter the character of murmur resulting in musical quality to the murmur. Ruptured chordac act as the string of musical instrument also called as Cooing Dove murmur. Can also occur in acute myocardial infarction and acute rheumatic fever.
Murmur of mitral regurgitation

Typical murmur of mitral regurgitation

• High pitched
• Soft blowing
• Pansystolic murmur
• Best heard with diaphragm of stethoscope
• Patient in left lateral position
• At the height of expectation
• The murmur radiate towards the left axilla and inferior angle of scapula

Heartsounds in mitral regurgitation

What are the causes of soft S1 in mitral regurgitation

• It is due to the incomplete opposition of valve cusps
• There is partial closure of mitral valve orifice at the onset of ventricular systoli

Causes of loud S1 in MR

• Co-existing mitral stenosis
• MVP – MR
• MR due to papillary muscle dysfunction

What are the causes of left ventricular S3 in MR

• It is due to elevated left ventricular end diastolic volume (LVEDV)
• Due to left ventricular dysfunction – LV dysfunction 

What are the important cause of mitral regurgitation ?

Mitral regurgitation can occur secondary to lesion of mitral annulus, chordac, papillary muscle, left ventricular lesions. 

Caspal lesions

• Rheumatoid heart disease
• Mild valve pro-lapse
• Infective endocarditis
• Trauma

Annular lesions 

• Dilatation of annulus – Dilated cardiomyopathy ,Ischemic heart disease
• Annular calcification

Chordal lesions

• Mitral valve prolapse
• Infective endocarditis
• Trauma

Papillary muscle dysfunction

• Myocardial infarction
• Angina

Left ventricular lesions

• Aneurysm
• Hypertrophic cardiomyopathy

Connective tissue diseases associated with mitral regurgitations are 

• Marfan syndrome
• Ehler Danlos syndrome
• Rheumatoid arthritis

Related topics

What are the clinical signs in mitral regurgitation?

Mitral regurgitation is associated with following clinical findings

Pulse : Normal or hyperkinetic pulse, Atrial fibrillation may be present, normal pulse pressure

JVP : Normal or raised

Apex beat : Forceful

Apical systolic thrill is felt

Late left parasternal heave

Soft S-1

Loud P2 (if PAH+)

Left ventricular S3

Flow murmur (MDM) at mitral area

High pitched blowing pansystolic murmur is heard in mitral area that is conducted to axilla / base of heart

Describe  the pulse in mitral regurgitation

In mild MR – Normal

Moderate to severe MR -  Hyperkinetic

Irregulary irregular in atrial fibrillation

Peripheral pulse may be absent in embolism due to atrial fibrillation.

Describe the JVP in mitral regurgitation

Usually normal

Prominent a wave is seen in PAH (pulmonary artery hypertension); prominent V wave seen in tricuspid regurgitation

Describe the apex beat in mitral regurgitation

Usually apex beat is forceful in MR. In moderate to severe MR due to associated cardiomegaly apex beat is shifted down and out.

Describe the type of LPH (left parasternal heave) in MR

Enlarged left atrium produce late systolic lift and pulmonary artery hypertension produce pansystolic lift.

Related topics

What are the clinical signs in mitral regurgitation

Mitral regurgitation is associated with following findings

Pulse: Normal or hyperkinetic pulse, Atrial fibrillation may be present, normal pulse pressure

JVP  : Normal or raised

Apex beat: Forceful

Apical systolic thrill present

Late left parasternal heave present

Soft S1

Loud P2 (if PAH+)

Left ventricular S3

Flow murmur (MDM) at mitral area

High pitched blowing pansystolic murmur heard in mitral area that is conducted to axilla / base of heart

Describe  the pulse in mitral regurgitation

In mild MR            – Normal

Moderate to severe MR -  Hyperkinetic

Irregulary irregular in atrial fibrillation

Peripheral pulse may be absent in embolism due to atrial fibrillation.

JVP in mitral regurgitation

Usually normal

Prominent a wave in PAH (pulmonary artery hypertension); prominent V wave in tricuspid regurgitation

Describe the apex beat in mitral regurgitation

Usually apex beat is forceful. On moderate to severe MR due to associated cardiomegaly it is shifted down and out.

Describe the type of LPH (left parasternal heave) in MR

Enlarged left atrium produce late systolic left pulmonary artery hypertension produce pansystolic left.

What are the causes of soft S1 in mitral regurgitation

It is due to the incomplete opposition of valve cusps

There is partial closure of mitral valve orifice at the onset of ventricular systoli

Causes of loud S1 in MR

Co-existing mitral stenosis

MVP – MR

MR due to papillary muscle dysfunction

What is the cause of left ventricular S3 in MR

It is due to elevated left ventricular end diastolic volume (LVEDV)

And due to left ventricular dysfunction – LV dysfunction 

Auscultatory findings in Mitral regurgitation

Heart sounds in mitral regurgitation

S1 ( first heart sound) is absent, soft, or it may be buried in the holosystolic murmur of chronic MR.

S2 (second heart sound).In those patients with severe MR, the premature closure of aortic valve may, result in wide but physiologic splitting of S2 .

S3 (third heart sound) in patients with mitral regurgitation after the aortic valve closure sound low pitched S3 may occur.This is heard at the end of rapid filling phase of left ventricle.

S3 in mitral regurgitation is caused by the sudden tensing of the papillary muscles, chordae tendineae, and valve leaflets.

S4 (fourth heart sound) may sometimes audible in acute severe MR if the patient is in sinus rhythm.

Murmur in mitral regurgitation

The most characteristic auscultatory finding in chronic severe MR is a systolic murmur of at least grade III/VI intensity.

In chronic MR it is usually holosystolic.In patients with acute severe MR it is decrescendo and ends in mid to late systole.

In chronic MR the systolic murmur is most prominent at the apex and  it radiates to the axilla. If the MR is due to ruptured chordae tendineae or due to primary involvement of the posterior mitral leaflet with prolapse or flail, then the murmur may radiate anteriorly and is transmitted to the base of the heart and, it may be confused with the AS murmur.

If the MR is due to ruptured chordae tendineae, the resulting  systolic murmur may have a cooing or “sea gull” quality.

MR murmur due to  flail leaflet may produce a murmur that has a musical quality. 

The systolic murmur of chronic MR (not due to MVP) is increased  by isometric exercise (handgrip) but the murmur is reduced during the strain phase of the Valsalva maneuver because it  decrease left ventricular preload.

PSM in MR may sometime be followed by a short, rumbling, mid-diastolic murmur, even if there is no structural MS.