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Mitral Regurgitation (Incompetence)

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When the left ventricle contracts in systole there is retrograde systolic flow of blood from the left ventricle to the left atrium

Aetiology

Reflux of blood back into the LA leads to Left atrial volume overload and symptoms depend on part on the ability of LA to handle reflux volume with increased LVEDP.
Rapid acute MR such as seen in myocardial infarction results in acute pulmonary oedema.
Chronic onset MR allows the LA to increase in size without the same increase in left atrial pressure and pulmonary oedema

Causes

Cause	Details
Mitral Valve Prolapse (MVP)	Mitral Valve Prolapse is the most common cause of MR in developed countries. It occurs when the mitral valve leaflets abnormally bulge (prolapse) back into the LA during systole, leading to incomplete closure of the valve and regurgitation of blood.
Rheumatic Heart Disease	Rheumatic heart disease, post streptococcal throat infections, scarring and deformation of the mitral valve leaflets and chordae tendineae, leading to mitral regurgitation. Seen in developing countries.
Ischaemic Heart Disease	IHD can lead to MR due to damage to the papillary muscles or left ventricular remodeling after a myocardial infarction. The papillary muscles, which anchor the mitral valve, may become dysfunctional or ruptured, leading to valve leakage.
Endocarditis	Infective endocarditis damages the mitral valve leaflets or chordae tendineae, leading to acute or chronic MR. Can cause valve perforation, rupture of chordae, or the formation of vegetations that prevent proper valve closure.
Degenerative Valve Disease	Degenerative changes in the mitral valve, such as annular dilation or calcification, can result in mitral regurgitation. These changes are often age-related and can lead to a weakened valve structure, causing incomplete closure during systole.
Cardiomyopathy	Dilated or hypertrophic cardiomyopathy can cause mitral regurgitation due to the distortion of the mitral valve apparatus. In dilated cardiomyopathy, the enlargement of the left ventricle can lead to annular dilation, while in hypertrophic cardiomyopathy, abnormal septal motion can impair valve function.
Congenital Mitral Valve Abnormalities	Some individuals are born with congenital defects that affect the mitral valve, such as cleft mitral valve or parachute mitral valve, leading to regurgitation. These abnormalities can cause improper valve closure from birth.
Connective tissue disease	Marfan's disease, Osteogenesis imperfecta, Myxomatous degeneration.
Trauma	Blunt chest trauma can cause acute mitral regurgitation by rupturing the chordae tendineae or papillary muscles, leading to a sudden onset of valve dysfunction.

Clinical* = signs suggesting severity

Palpitations - AF, emboli ? stroke
Dyspnoea, Fatigue, Cardiac failure, Small pulse volume*
Displaced diffuse apex beat + S3 + PSM [S3 represents rapid filling of ventricle due to the large volume atrium]
Enlarged LV*, S3 and early diastolic rumble*
Soft S1 and early A2*, Pulmonary hypertension*

Investigations

FBC, U&E, Raised CRP - Endocarditis
ECG: may show AF, p mitrale with large left atrial mass
CXR: LA enlarged, cardiomegaly, pulmonary oedema, mitral valve calcification
Echocardiography: dilated LA and LV. Assess LV function, regurgitant jet visible on colour flow mapping and doppler. May show pulmonary hypertension. TOE better defines the anatomy and cause.
Cardiac catheter: evidence of MR jet on LV contrast injection. Large V wave on PA wedge trace.

Management

Management Strategy	Details
Medical Management	Diuretics: ABC, Oxygen, IV Frusemide to treat LVF. Vasodilators: ACEi/ARBs reduce afterload and the regurgitant volume and improving cardiac output. Beta-blockers/Digoxin: Manages AF heart rate and reduce myocardial oxygen demand. Anticoagulation: Warfarin or DOAC or Heparin for Atrial fibrillation to prevent thromboembolism.
Surgical Management	Mitral Valve Repair: Preferred over replacement especially for degenerative mitral regurgitation. Annuloplasty, leaflet resection, or chordal replacement. Mitral Valve Replacement: when repair is not feasible. Replace with mechanical (metal) or bioprosthetic (tissue) valve.
Percutaneous Mitral Valve Interventions	MitraClip: A transcatheter procedure used in high-risk surgical candidates. The device clips the mitral valve leaflets together to reduce regurgitation. Transcatheter Mitral Valve Replacement (TMVR): An emerging option for patients who are not suitable candidates for surgery.
Management of Atrial Fibrillation	Rate Control: Beta-blockers, calcium channel blockers, or digoxin to control heart rate. Rhythm Control: Antiarrhythmic drugs or cardioversion to maintain sinus rhythm in selected patients. Anticoagulation: Essential to prevent thromboembolic events.
Monitoring and Follow-up	Echocardiography: Regular echocardiograms assess valve, left ventricular function, and pulmonary pressures. Clinical Assessment: Regular follow-ups, assess functional status, manage meds as needed.
Lifestyle Modifications	Exercise: Moderate exercise but avoid strenuous activities if symptomatic. Dietary Management: Sodium restriction reduce fluid retention and alleviate symptoms. Smoking Cessation: Smoking cessation is crucial for overall cardiovascular health.

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