Mitral Valve Regurgitation

Mitral regurgitation involves blood flowing back from the left ventricle into the left atrium during systole.

The Leaflets cannot close completely because the leaflets and chordae tendineae have thickened and fibrosed resulting in their contraction.

Causes
Most

common causes in developed countries: Mitral Valve prolapse Ischemia of the left ventricle Most common cause in developing countries: Rheumatic Heart Disease and its sequelae

Other conditions that lead to mitral regurgitation:

Myxomatous changes enlarge and stretch the left atrium and ventricle. Infective endocarditis may cause perforation of of leaflet, or scarring following the infection. Collagen-Vascular disease Cardiomyopathy Ischemic disease

PATHOPHYSIOLOGY:
Mitral Regurgitation Problems in one or more leaflets

Choradae tendinae

Annulus

Papillary Muscle

Elongate Shorten Tear

Stretched & Deformed by Calcification

Rupture Stretch Pulled out of the position Inability to Contract

Blood regurgitates in the right atrium during diastole Blood force back in Left artium Left atrium stretched, hypertrophy and dilate Blood flowing in R. Atrium Blood going back to lungs

Pulmonary Congestion

Clinical Manifestations
Chronic mitral regurgitation is often asymptomatic but acute mitral regurgitation (ex. That resulting from mycardial infarction) usually manifest as severe congestive heartfailure. Most common Symptoms:

Dyspnea
Fatigue Weakness

Other symptoms:
Palpitation SOB on exertion Cough from pulmunary congestion

Assessment and Diagnostic Findings

Systolic murmur is heard as highpitched, blowing sound at the apex. Pulse maybe irregular due extrasystolic beats or atrial fibrillation.

Doppler echocardiography

used to diagnose and monitor the progression of mitral regurgitation.

This color flow Doppler image was recorded in systole. Flow starts in the left ventricle (LV) beneath the aorta as laminar flow toward the transducer (homogeneous red color). Just before it reaches the upper portion of the interventricular septum, the color turns gold as it nears a velocity of 0.55 meters/second (the Nyquist limit on the color bar to the left) and then aliases to turn blue as the velocity exceeds 0.55 meters/second. As it goes through the defect, it turns a mosaic of colors and projects into the right ventricle (RV). RA, right atrium.

Transesophageal echocardiography

(TEE) provides the best images of mitral valve

Medical Management

Patients with mitral regurgitation benifit from afterload reduction (arterial dilation) by treating with:
ACE inhibitors: Captopril (Capoten) Enalapril (Vasotech) Lisinopril (Prinivil,Zestril) Ramipril (Altace) Hydralazine (Apresoline)

Angiotensin converting enzyme ARBs

Lozartan (Cozar) Valsartan (Diovan)

Beta blockers

Carvedilol (Coreg)
Once symptoms of heart failure develop, the patient needs to restrict his/her activity level to minimize symptoms.

Surgical Management

Mitral Valvuloplasty

Surgical Management

Valve replacement

Mitral Stenosis
An obstruction of blood flowing from the left atrium in to the left ventricle. It is most often cause of rheumatic endocarditis -thickens mitral valve leaflets and chordae tendineae. -leaflets often fuse together. -eventually the mitral valve orifice narrows and progressively obstructs blood flow into the ventricles.

RHEUMATIC ENDOCARDITIS,

PATHOPHYSIOLO GY:
L. Atrium dilate and hypertrophy

Opening narrows to the width of a pencil

resistance to a narrowed orifice in the L. Atrium / pressure Poor ventricular filling

Cardiac Output

Pulmonary circulation becomes congested

Fatigue

Clinical manifestation
Dyspnea Progressive Fatigue Dry cough or wheezing Hemoptysis Palpitation Orthopnea Paroxysmal Nocturnal Dyspnea Repeated Resp. Infections

Assessment and Diagnostic Findings

Pulse weak/irregular Low pitched rumbling diastolic murmur is heard at the apex. Atrial dysrhythmias. Doppler Echocardiography Electrocardiography (ECG) Cardiac Catheterization with angiography.

Medical Management
Anticoagulants to decrease the risk for developing atrial thrombus and may also require treatment for anemia. Avoid strenuous activities and competitive sports

Surgical Mgt.

Valvuloplasty > a procedure in which a narrowed heart valve is stretched open

using a procedure that does not require open heart surgery.

Percutaneous transluminal valvuloplasty

A balloon tipped catheter is passed from the femoral vein into the right atrium. From there, it is threaded to the right ventricle and on to the pulmonic valve, or the atrial septum is punctured for access to the mitral or aortic valves. When the balloon is positioned in the valve, a series of inflation-deflation cycles is required to enlarge the narrowing.

Commissurotomy
Is a surgical incision of a commissure in the body, as one made in the heart at the edges of the commissure formed by cardiac valves,

mitral valve replacement

Mitral valve replacement is a cardiac surgical procedure in which a patient's diseased mitral valve is replaced by a either a mechanical or bioprosthetic valve. MECHANICAL VALVES BIOLOGICAL VALVES

MECHANICAL VALVES The principle advantage of mechanical valves is their excellent durability. The valves available today simply do not wear out! Their main disadvantage is that blood has a tendency to clot on all mechanical valves. If this happens the valve will not function normally. Therefore, patients with these valves must take anticoagulants (blood thinners) for life. There is also a small but definite risk of blood clots causing stroke, even when taking anticoagulants. BIOLOGICAL VALVES There are a variety of biological alternatives for mitral valve replacement. Most are made from pig aortic valves. Their key advantage is that they have a reduced risk of blood clots forming on the valve itself causing valve dysfunction or stroke. The key disadvantage of biological or tissue valves is that they have more limited durability as compared with mechanical valves. They will wear out given enough time. The rate at which they wear out, however, depends on the patient's age. A young boy might wear out such a valve in only a few years, while the same valve might last 10 years in a middle aged person, and even longer in a patient over the age of 70. Of course, as we grow older we expect that we will not need the valve for as many years as our life expectancy is less. The general consensus is that a tissue valve will not need to be replaced if used in a patient over the age of 70 years.