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Rapid Review·Cardiovascular

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Valvular Heart Disease

T1Must know

Mitral Regurgitation

Focus on

A blowing holosystolic apical murmur to the axilla, louder with handgrip and leg raise. Primary MR (prolapse, endocarditis, rheumatic, ruptured chordae) gets valve repair when symptomatic or when the EF slips to 60%; secondary MR gets heart-failure therapy first. Acute MR after an MI or endocarditis is pulmonary edema with a soft murmur and an emergency operation.

Key takeaways

Causes

Primary (the valve itself)

mitral valve prolapse (the most common cause in developed countries), infective endocarditis, rheumatic disease.

Secondary

two types.
  • Functional regurgitation from a dilated failing ventricle.
  • Ischemic regurgitation from papillary muscle or chordal rupture after a myocardial infarction.

Clinical features

Acute regurgitation

an abrupt rise in left atrial and ventricular filling pressures causes acute heart failure and pulmonary edema, sometimes cardiogenic shock.

Chronic regurgitation

from asymptomatic to left heart failure (dyspnea, fatigue, an S3 gallop).

Palpitations

atrial fibrillation is common once the left atrium enlarges.
Mitral regurgitation on a phonocardiogram: a holosystolic murmur of even intensity that runs all the way from S1 to S2, heard best at the apex and radiating to the axilla.
What this shows
Mitral regurgitation on a phonocardiogram: a holosystolic murmur of even intensity that runs all the way from S1 to S2, heard best at the apex and radiating to the axilla.

The murmur

a holosystolic blowing murmur at the apex radiating to the axilla.
Mitral regurgitation: pressure-volume loop and pressure tracing. There is no true isovolumetric phase because the mitral valve never fully closes; end-systolic volume falls as blood escapes backward into the left atrium during systole, the returning volume raises end-diastolic volume, and a tall v wave appears on the atrial tracing.
What this shows
Mitral regurgitation: pressure-volume loop and pressure tracing. There is no true isovolumetric phase because the mitral valve never fully closes; end-systolic volume falls as blood escapes backward into the left atrium during systole, the returning volume raises end-diastolic volume, and a tall v wave appears on the atrial tracing.

Louder with more preload (leg raise) or more afterload (handgrip)

because more blood regurgitates.

Diagnosis

Transthoracic echocardiography in chronic disease

left atrial and ventricular dilation, with a falling ejection fraction once decompensated.

In acute regurgitation

the chambers are still normal in size and the ejection fraction is normal or high.

Management

Acute regurgitation

emergency valve repair or replacement.

Chronic primary regurgitation

surgery when symptomatic, or asymptomatic with an ejection fraction under 60 percent.

Secondary regurgitation

medical therapy for the heart failure (Heart Failure).
Acute vs chronic mitral regurgitation
AcuteChronic
PresentationAcute heart failure, pulmonary edema, sometimes shockAsymptomatic to left heart failure, atrial fibrillation
Chambers on echoNormal sizeLeft atrium and ventricle dilated
Ejection fractionNormal or highFalls once decompensated
TreatmentEmergency repair or replacementSurgery if symptomatic or ejection fraction under 60 percent (primary); heart failure therapy (secondary)
Four days after an inferior myocardial infarction, a patient suddenly develops pulmonary edema and hypotension with a new apical systolic murmur; echo shows normal-sized chambers and a high ejection fraction. What is the likely cause and the treatment?

Acute ischemic mitral regurgitation from papillary muscle rupture: the chambers have not had time to dilate, and the ejection fraction is normal or high. It needs emergency valve repair or replacement.

How it's tested

Asymptomatic woman with MVP, a holosystolic apical murmur to the axilla, severe MR on echo and an EF of 58%: mitral valve repair — an EF of 60% is already dysfunction in MR.

Day 4 after an inferior MI: sudden pulmonary edema, hypotension and a soft apical murmur: posteromedial papillary muscle rupture — echo, balloon pump, emergency surgery.

HFrEF with a dilated LV, tethered leaflets and moderate MR: secondary MR — optimize GDMT and CRT before any valve intervention.

Which maneuver makes the MR murmur louder: handgrip (more afterload) and leg raise (more preload); Valsalva softens it.

Severe primary MR in a patient at prohibitive surgical risk: transcatheter edge-to-edge repair.

Go deeper

Guidelines: 2020 ACC/AHA Valvular Heart Disease Guideline

Related Step 2 pages: Mitral Valve Prolapse, Mitral Stenosis, Post MI Complications, Infective Endocarditis, Heart Failure, Heart Sounds & Murmurs

High-yield images2
Mitral regurgitation on a phonocardiogram: a holosystolic murmur of even intensity that runs all the way from S1 to S2, heard best at the apex and radiating to the axilla.
Mitral regurgitation: pressure-volume loop and pressure tracing. There is no true isovolumetric phase because the mitral valve never fully closes; end-systolic volume falls as blood escapes backward into the left atrium during systole, the returning volume raises end-diastolic volume, and a tall v wave appears on the atrial tracing.

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# What is the most common cause of mitral regurgitation in developed countries?

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