MITRAL REGURGITATION

AETIOLOGY
Acute MR 1) Infective endocarditis 2) Chest Trauma 3) Acute rheumatic fever with carditis

CHRONIC MR
RHD Infective endocarditis Congenital MR Marfans Syndrome SLE Degenerative MV disease ( MV prolapse)

RHEUMATIC MR

Commonest cause of chronic MR

Rheumatic involvement of mitral valve causes Fibrosis ,thickening, calcification, & shortening Of Mitral leaflets & chordae tendinae. This results in improper closure of valve cusps during systole

PATHOPHYSIOLOGY OF ACUTE MR

with sudden onset of acute MR, the regurgitant blood flows back into left atrium, causing acute increase in left atrial pressure & pulmonary arterial pressure. Left ventricle is unable to maintain cardiac output Both these factors lead to acute pulmonary oedema & features of left ventricular failure There is also decrease in sytemic vascular resistance to help increase forward flow This results in diastolic pressure Sytolic pressure , this leads to increase in pulse pressure leading to water hammer pulse

PATHOPHYSIOLOGY OF CHRONIC MR

CLINICAL FEATURES

Symptoms chronic MR may be asymptomatic for many years palpitation Left ventricular failure: exertional breathing, orthopnea Right heart failure: raised JVP,pedal edema,hepatomegaly In acute MR: due to pulm oedema dyspnoea,orthopnea,cough , tachycardia,tachypnea Due to reduced CO: exhaustion,weakness, fatigueibility

SIGNS

Pulse: high volume initially,which may become collapsing. JVP: may be normal or raised in RVF BP : wide pulse pressure in severe MR Pumonary edema: tachypnea, rhonchi , crepitations. Cold extremeties Inspection & Palpation: Apex shifted outward & downward with hyperkinetic precordium

Auscultation S1 soft S2 split due to early closure of aortic valve severe MR P2 loud- pulm HTN

MURMUR
High pitched & usually pansytolic murmur best heard at apex radiating to axilla & left interscapular area. Pulmonary area : ejection sytolic murmur due to pumonary artery hypertension

PAN SYSTOLIC MURMUR

SIGNS INDICATING SEVERE MR

High volume pulse Left ventricular third heart sound Wide split s2 Pansytolic murmur Mid diastloic flow murmur at apex

COMPLICATIONS
Atrial fibrillation Infective endocarditis Left ventricular failure Pulmonary hypertension Right ventricular failure Embolism

MANAGEMENT
INVESTIGATIONS ECG: sinus tachycardia normal axis echocardiography : enlarged left atrium & ventricle and also shows valve pathology Thoracic Roentgenogram: cardiac enlargement sec to left ventricular enlagement. Chest X-ray: show left ventricular enlargement, pulmonary HTN.

COLOUR DOPPLER

TREATMENT
A)

B)

Medical surgical

MEDICAL

Infective endocarditis prophylaxis Rheumatic fever prophylaxis Digoxin ,diuretics,vasodilators,-to reduce afterload Diuretics:furosemide 2-3mg/kg/d orally i.v 1mg/kg/d Check serum electrolytes periodically K+ supplements required when patient is on furosemide KCl 1mg/kg/d

SURGICAL

Pumonary artery HTN Asymptomatic child : evidence of ventricular dyfunction

Prosthetic valve repair Mitral valvuloplasty

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