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Mitral Regurgitation Home / A Guide to the MRCP PACES Examination / Station 3 (Cardiovascular) / Mitral Regurgitation

Relevant physical signs

Inspection
Scars, especially mitral valvotomy scar in left axilla
Implantable cardiac device (e.g. PPM for high-grade block with atrial fibrillation, implantable cardiac defibrillator for cardiomyopathy with EF < 30%
causing functional MR)
Visible apex beat
Hands
Stigmata of infective endocarditis (clubbing, Osler’s nodes – painful, Janeway lesions – painless)
Pulse
Rhythm: typically MR is associated with atrial fibrillation
Character: in severe MR, pulse may be jerky (rapid upstroke with short duration)
Volume: often variable if the patient is in AF
Conjunctival pallor (rare cases of valve haemolysis associated with infective endocarditis)
Jugular venous pulsation
Elevated in right heart failure
Giant v waves (functional tricuspid regurgitation secondary to severe MR)
Precordium
Inspect: implantable cardiac devices, valvotomy scars
Palpate
Apex beat
Thrusting – volume overloaded left ventricle
Double apex beat – palpable S3
In severe MR, may be displaced infero-laterally
Thrill over the mitral area (correlates to MR severity)
Right ventricular heave (pulmonary hypertension)
Thrill of tricuspid regurgitation (pulmonary hypertension with functional TR)
Auscultate
S1 – soft in severe MR
S2 – loud if MR is complicated by pulmonary hypertension
Widely-split in severe MR (large proportion of systolic volume flows into left atrium rather than aorta, resulting in aortic valve closing
earlier)
S3 – this signifies rapid ventricular filling from increased pre-load. It is a marker of severe regurgitation, but only in the context of other
clinical signs of severe MR
S4 – only if in sinus rhythm! Represents forceful atrial contraction against a non-compliant ventricle, and is a marker of severity of MR
Pan-systolic murmur loudest at the apex and radiating to the axilla, loudest in expiration
In functional MR, the murmur may be mid, late or pan-systolic
In severe MR, there may be a mid-diastolic murmur, which is a flow murmur signifying increased flow across the mitral valve
Tricuspid area for a pan-systolic murmur of functional tricuspid regurgitation – to differentiate from MR murmur, will usually be associated
with giant v waves
Pulmonary area for Graham-Steell murmur of pulmonary regurgitation (pulmonary hypertension secondary to mitral regurgitation)
Lung bases: crepitations of pulmonary oedema (may not be present if the patient is on diuretics)
Pedal / sacral oedema for signs of right heart overload
Complete examination by:
Looking at vitals chart, particularly temperature and blood pressure
Urine dipstick for evidence of microscopic haematuria (rheumatic heart disease)
Obtain an electrocardiogram (AF, left atrial hypertrophy / dilation)
Examine the abdomen for pulsatile hepatomegaly

Differential diagnosis of a pan-systolic murmur

Mitral regurgitation (loudest at the apex in expiration, radiates to axilla)

Tricuspid regurgitation (best heard at lower left sternal edge in inspiration, usually associated with v waves)
Ventricular septal defect (usually very loud and harsh, heard all over the precordium but loudest at LLSE)
Mitral valve prolapse (causes a late systolic murmur associated with an opening snap – may radiate up the left sternal edge as opposed to the axilla)

Causes of mitral regurgitation

 Rheumatic fever
Previous mitral valvotomy
Mitral valve prolapse
Infective endocarditis
Ischaemic heart disease
Left ventricular dilation (functional MR due to displacement of the mitral valve annulus and chordae tendinae, causing mitral regurgitation)
Mitral annular calcification
Connective tissue disease
Systemic lupus erythematosus (Libman-Sachs endocarditis)
Rheumatoid arthritis
Congenital disorders
Marfan’s syndrome
Ehlers-Danlos syndrome
Pseudoxanthoma elasticum
Osteogenesis imperfect

Causes of acute mitral regurgitation

Acute rupture of chordae tendinae (post-myocardial infarction)

Infective endocarditis
Trauma

Clinical signs of severe mitral regurgitation

Soft S1
Widely-split S2
S3
S4, if in sinus rhythm
Displaced apex beat
Palpable thrill over mitral area
Presence of a mid-diastolic murmur
Pulmonary oedema
Pulmonary hypertension (loud S2, right ventricular heave)
Signs of right ventricular failure (raised JVP, dependent oedema)

Investigations

Electrocardiogram
Rhythm: atrial fibrillation
Left atrial hypertrophy (bifid p waves in lead II if in sinus rhythm)
Left ventricular hypertrophy
Evidence of ischaemic heart disease (can cause MR)
Chest radiograph
Double right heart border (left atrial enlargement)
Cardiomegaly
Pulmonary oedema
Prominent pulmonary arteries (pulmonary hypertension)
Transthoracic echocardiogram
Confirm diagnosis of MR
Assess severity
Establish underlying mechanism (infective endocarditis, ischaemic MR, functional MR, rupture of papillary muscle, prolapse of one or two leaflets of
the mitral valve)
Assessment of left ventricular function
Assessment of right ventricular function
Assessment of estimated pulmonary artery systolic pressure
Coronary angiography
To exclude ischaemic heart disease as a cause for MR
To evaluate if CABG will be required at the time of potential mitral valve replacement

Management

There is no indication for prophylaxis against infective endocarditis in native valve disease. The indications for prophylaxis against infective endocarditis
are:
Previous episode of infective endocarditis
Prosthetic valves
Prosthetic material used for valve repair
Cyanotic congenital heart disease, not corrected
 Corrected congenital heart disease within the last six months
Repaired congenital heart disease with residual defects near the prosthesis
Atrial fibrillation
Requires rate control (choice between beta blocker, calcium channel antagonist, digoxin)
Anticoagulation to prevent thromboembolic disease
Cardiac failure
Diuresis for congestive symptoms (spironolactone if class IV)
Angiotensin converting enzyme inhibitor for cardiac remodeling
Beta blockade to reduce myocardial oxygen demand
Follow-up: six-monthly transthoracic echocardiogram

Indications for mitral valve replacement

Symptomatic MR (NYHA class III or IV)

Class I: no limitation of physical activity
Class II: slight limitation of physical activity (dyspnoea, palpitations, fatigue with ordinary activity)
Class III: no symptoms at rest, but marked restriction in physical activity
Class IV: symptoms at rest
EF < 60%
LV end-systolic diameter > 45mm

Presentation

Sir, this patient has a grade 4/6 pan-systolic murmur heard loudest over the apex in expiration and which radiates to the axilla. This is most in keeping with
mitral regurgitation. Clinically, it is at least moderate in severity: the apex beat is displaced, the first heart sound is soft, and the second heart sound is loud. This
is associated with a right ventricular heave and the jugular venous pulse is elevated, signifying pulmonary hypertension with right heart overload. The pulse is
irregular, which is in keeping with atrial fibrillation complicating the disease. I would expect the patient to be anti-coagulated, but I do not detect any overt
signs of bleeding clinically. There are scattered crepitations at the lung bases, which signify pulmonary congestion secondary to mitral regurgitation. There is no
scar to suggest previous mitral valvotomy. In summary, this patient has moderately-severe mitral regurgitation.

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