Mitral Incompetence

Question 1

Mitral incompetence presentation

Answer 1

This patient has been short of breath and tired. Please examine his cardiovascular system.

Question 2

Clinical signs of Mitral incompetence

Answer 2

1. Scars: lateral thoracotomy (valvotomy)
2. Pulse: AF, small volume
3. Apex: displaced and volume loaded
4. Palpation: thrill at apex
5. Auscultation:
   - Pan-systolic murmur (PSM) loudest at the apex radiating to the axilla. Loudest in expiration.
   - Wide splitting of A2 P2 due to the earlier closure of A2 because the LV empties sooner.
   - S3 indicates rapid ventricular filling from LA, and excludes significant mitral stenosis.
6. Pulmonary oedema
7. Evidence of the Cause: signs of endocarditis
8. Severity: left ventricular failure and atrial fibrillation (late). Not murmur intensity
9. Other murmurs, e.g. ASD

Question 3

Congenital Causes of Mitral incompetence

Answer 3

There is an association between cleft mitral valve and primum ASD

Question 4

Acquired Causes of Mitral incompetence

Answer 4

i. Valve leaflets
a. Acute: Bacterial endocarditis
b. Chronic
1- Myomatous degeneration (prolapse)
2- Rheumatic
3- Connective tissue diseases
4- Fibrosis (fenfluramine/pergolide)
ii. Valve annulus
a. Chronic
1- Dilated left ventricle (functional MR)
2- Calcification
iii. Chordae/papillae
a. Acute: Rupture
b. Chronic:
1- Infiltration, e.g. amyloid
2- Fibrosis (post‐MI/trauma)

Question 5

Investigation of Mitral incompetence

Answer 5

1. ECG: p‐mitrale, atrial fibrillation and previous infarction (Q waves)
2. CXR: cardiomegaly, enlargement of the left atrium and pulmonary oedema
3. TTE/TOE:
   - Severity: size/density of MR jet, LV dilatation and reduced EF
   - Cause: prolapse, vegetations, ruptured papillae, fibrotic restriction and infarction

Question 6

Management of Mitral incompetence

Answer 6

1- Medical
⚬⚬ Anticoagulation for atrial fibrillation or embolic complications
⚬⚬ Diuretic, β‐blocker and ACE inhibitors
2- Percutaneous: mitral clip device for palliation in inoperative cases of mitral valve prolapse
3- Surgical
⚬⚬ Valve repair (preferable) with annuloplasty ring or replacement
⚬⚬ Aim to operate when symptomatic, prior to severe LV dilatation and dysfunction

Question 7

Prognosis of Mitral incompetence

Answer 7

• Often asymptomatic for >10 years
• Symptomatic – 25% mortality at 5 years

Question 8

Auscultation in Mitral Incompetence

Answer 8

1- Pan-systolic murmur (PSM) loudest at the apex radiating to the axilla. Loudest in expiration.
2- Wide splitting of A2 P2 due to the earlier closure of A2 because the LV empties sooner.
3- S3 indicates rapid ventricular filling from LA, and excludes significant mitral stenosis.

Question 9

Mitral valve prolapse

Answer 9

1. Common (5%), especially young tall women
2. Associated with connective tissue disease, e.g. Marfan’s syndrome and HOCM
3. Often asymptomatic, but may present with chest pain, syncope and palpitations
4. Small risk of emboli and endocarditis
5. Auscultation
   - Mid-systolic ejection click (EC).
   - Pan-systolic murmur that gets louder up to A2.
   - Murmur is accentuated by standing from a squatting position or during the straining phase of the Valsalva manoeuvre, which reduces the flow of blood through the heart.

Question 10

Auscultation in Mitral Valve Prolapse

Answer 10

• Mid-systolic ejection click (EC).
• Pan-systolic murmur that gets louder up to A2.
• Murmur is accentuated by standing from a squatting position or during the straining phase of the Valsalva manoeuvre, which reduces the flow of blood through the heart.