Mitral regurgitation 

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Thank you for asking me to perform a cardiovascular of examine Mr. X, who presented with SOB.

 

The salient finding on examination were a pan-systolic murmur loudest in the mitral region, which increased on expiration and radiated to the axilla, which I believe is consistent with mitral regurgitation.

 

I will now present my findings in full before commenting on differentials, aetiology, severity and complications.

 

The patient was comfortable at rest with normal/increased WOB.

 

On examination of the hands, there was/was no stigmata of IE, clubbing, peripheral cyanosis, or xanthomata.

 

The pulse was ____ and regular/irregular (if irregular, consistent with atrial fibrillation).

 

The blood pressure was ____.

 

On examination of the face, there was no scleral icterus, or conjunctival pallor. There was no central cyanosis. Dentition was adequate/inadequate.

 

The JVP was/was not elevated at ___ cm above the sternal notch with normal waveforms/prominent A-wave/prominent V-wave.

 

The carotid pulse was normal character/small volume (severe) in character.

 

On inspection of the praecordium, there were/were not scars and nil obvious deformity.

 

On palpation, the apex beat in the was / was not displaced (suggestive a large left ventricle) and was / was not volume loaded (forceful but unsustained). There were/were not any palpable thrills. There was/was not a left parasternal heave or palpable P2, which would suggest pulmonary hypertension.

 

On auscultation, as aforementioned, there was a systolic murmur loudest in the mitral region, which increased on expiration, and radiated to the axilla. This was soft with dynamic Valsalva and louder with isometric maneuvers.

 

There was a normal/soft/absent first heart sound with physiological/fixed/reversed splitting of the second heart sound, with/without an additional third heart sound (severe if present).

 

On further examination, there was/was not evidence of left and right heart decompensation with sacral oedema or peripheral oedema, and vesicular breath sounds/bibasal inspiratory crackles. There was/was not a pulsatile liver, and nil gross ascites.

 

In summary, my findings are consistent with mitral regurgitation.

 

Other differentials include:

• MVP - longer on Valsalva

• Aortic stenosis with Gallavardin’s phenomenon

• VSD - The holosystolic murmur of a VSD may resemble MR but the former is usually loudest at the left sternal border and can be accompanied by parasternal thrill

• HOCM - increase on Valsalva

• Tricuspid regurgitation

 

In terms of severity:

• In terms of signs of severity, there was/was not a small volume pulse (very severe), a displaced enlarged left ventricle, a soft first head sound, a third heart sounds, aortic component of A2 heard earlier, an early diastolic rumble, or findings of pulmonary hypertension or left ventricular failure.

 

In terms of the aetiology:

• There was / was not findings of associated connective tissue disease (RA, AS)

• Rheumatic heart disease is less likely as it is rarely isolated

• I could not ascertain the exact aetiology, however differentials include degenerative disease of the valve, functional MR secondary to cardiomyopathy, or papillary muscle dysfunction from left ventricular failure or ischaemia.

 

I would proceed from here by:

• Confirming my diagnosis with an echocardiogram and assess severity

• I would screen for AF with an ECG, and a CXR for any signs of pulmonary congestion

 

What are the aetiologies?

• Chronic:

  • Functional MR secondary to dilated ventricle (ischaemic, dilated CM)

  • Degenerative myxomatous change

  • MV prolapse

  • Papillary muscular dysfunction secondary to ischaemia

  • Rheumatic

  • Connective tissue disease - RA, AS

  • Congenital

• Acute

  • IE

  • AMI with chordae rupture or papillary muscle dysfunction

  • Surgery

  • Trauma

 

Indication for surgery in primary MR

• Class 1 = symptoms + severe (regurgitant volume >60ml or regurgitant fraction > 50%, vena contracta > 0.7cm, effective regurgitant orifice > 0.4cm)

• Vena contracta width (VCW) was defined as the narrowest width of the proximal jet

• Or asymptomatic but LV systolic dysfunction (LVEF < 60%, and end systolic dimension > 40mm).