Mitral Regurgitation Overview

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Questions and Answers

What is a primary advantage of mitral valve repair over valve replacement?

It eliminates the need for anticoagulant therapy.

It has higher long-term success rates than replacement.

It preserves the integrity of the heart's subvalvular structures, better maintaining LV function. (correct)

It is a less complex and faster surgical procedure.

Which of the following is NOT a recommended criterion for considering mitral valve surgery in asymptomatic patients?

A progressive decrease in left ventricular ejection fraction (LVEF).

A left ventricular end-systolic dimension (LV ESD) greater than or equal to 40 mm.

Mitral valve anatomy that predicts a high probability of successful and durable repair.

A markedly enlarged left atrium. (correct)

Why are more aggressive interventions recommended for mitral valve repair, especially in cases of myxomatous mitral regurgitation?

Because the patient is likely to experience a faster recovery than after valve replacement.

Because waiting can lead to adverse long-term consequences. (correct)

Because it's the only option for myxomatous mitral regurgitation.

Because it is a less invasive procedure compared to replacement.

What is a potential long-term complication of using a mechanical valve prosthesis for mitral valve replacement?

Thromboembolic and hemorrhagic complications Signup and view all the answers

Which of the following is a typical component of mitral valve repair during valvuloplasty?

Insertion of an annuloplasty ring. Signup and view all the answers

Which of the following is NOT considered one of the five functional components of the mitral valve apparatus?

Aortic valve Signup and view all the answers

In the context of acute myocardial infarction (MI), which papillary muscle is more prone to rupture leading to acute mitral regurgitation (MR)?

Posteromedial papillary muscle Signup and view all the answers

What is a key distinction between primary and secondary mitral regurgitation (MR)?

In primary MR, the leaflets/chordae are primarily responsible, whereas in secondary MR, the regurgitation is due to the remodeling of the ventricle or related structures. Signup and view all the answers

Which process is LEAST likely to result in acute mitral regurgitation (MR)?

Mitral valve prolapse due to myxomatous degeneration. Signup and view all the answers

What is a common consequence of the rheumatic process on the mitral valve?

Rigidity, deformity, and retraction of the valve cusps Signup and view all the answers

Mitral regurgitation can occur as a congenital anomaly, most commonly from:

A defect of the endocardial cushions. Signup and view all the answers

In addition to the functional components of the mitral valve, what else can cause secondary (functional) mitral regurgitation?

Left ventricular (LV) remodeling and annular dilation. Signup and view all the answers

What can lead to 'acute-on-chronic' mitral regurgitation in patients with myxomatous degeneration of the valve?

Rupture of chordae tendineae. Signup and view all the answers

What structural abnormality is commonly associated with an ostium primum atrial septal defect?

Cleft anterior mitral valve leaflet Signup and view all the answers

Which of the following is NOT a typical consequence of radiation exposure to the mitral valve?

Leaflet thinning Signup and view all the answers

What is a primary mechanism contributing to mitral regurgitation (MR) in patients with dilated cardiomyopathy and an LV end-diastolic dimension reaching 6 cm?

Annular dilation and ventricular remodeling Signup and view all the answers

The mitral regurgitation (MR) associated with hypertrophic obstructive cardiomyopathy (HOCM) is typically characterized by which of the following?

Dynamic nature dependent on systolic anterior motion Signup and view all the answers

Atrial functional mitral regurgitation (MR) in patients with chronic persistent atrial fibrillation (AF) is primarily caused by:

Atrial remodeling and annular dilation Signup and view all the answers

Which of the following conditions is most likely to result in mitral regurgitation due to annular calcification?

Advanced renal disease Signup and view all the answers

What is the primary mechanism through which chronic severe mitral regurgitation (MR) tends to progress over time?

Tension on the posterior mitral leaflet due to LA enlargement Signup and view all the answers

In patients with mitral regurgitation (MR), what happens to the left ventricular (LV) afterload?

Reduced afterload Signup and view all the answers

What is the initial compensatory mechanism for mitral regurgitation (MR) in the left ventricle (LV)?

More complete LV emptying Signup and view all the answers

What influence does the size of the regurgitant orifice have on the regurgitant volume in mitral regurgitation (MR)?

Directly proportional relationship Signup and view all the answers

According to the content, when is transcatheter edge-to-edge repair (TEER) considered reasonable for mitral regurgitation?

In selected patients after GDMT has been optimized Signup and view all the answers

When should direct oral anticoagulants not be used in patients with mitral regurgitation (MR)?

In patients with moderate or severe rheumatic mitral stenosis Signup and view all the answers

In the absence of systemic hypertension, what is the current status regarding the use of vasodilators for treating chronic severe MR with preserved left ventricular (LV) function?

Limited and lacks large, long term prospective studies supporting their use Signup and view all the answers

What type of exercise should be avoided by asymptomatic patients with severe mitral regurgitation, with normal LV size/function, in sinus rhythm?

Isometric exercises Signup and view all the answers

Compared to valve replacement, what is a key difference in surgical risks when considering treatment for chronic severe primary mitral regurgitation?

Repair has lower short-term and long-term risks Signup and view all the answers

Study Notes

Mitral Regurgitation (MR)

Mitral regurgitation (MR) can arise from abnormalities affecting mitral valve components (leaflets, annulus, chordae tendineae, papillary muscles, and myocardium).
Acute MR can result from acute myocardial infarction (MI) with papillary muscle rupture, blunt chest trauma, or infective endocarditis (IE). The posteromedial papillary muscle is more commonly affected in acute MI than the anterolateral one.
Transient acute MR can occur during angina pectoris episodes.
Chronic MR can be primary (degenerative) or secondary (functional). Primary MR involves abnormal leaflet or chordae tendineae function, while secondary MR is caused by LV remodeling, annular dilation, papillary muscle displacement, dyssynchrony, or posterior leaflet tethering.
Rheumatic fever can cause valve rigidity, deformity, retraction, and commissural fusion, along with chordae shortening and fusion.
Congenital MR can occur, often involving endocardial cushion defects; a cleft anterior leaflet can accompany an ostium primum atrial septal defect.
Radiation exposure can lead to leaflet thickening, retraction, and calcification, often with annular and chordal involvement, and sometimes mitral stenosis.
Post-MI MR is common and linked to changes in LV size, shape, and function.
Non-ischemic dilated cardiomyopathy, once LV end-diastolic dimension reaches 6 cm, often leads to MR due to similar annular dilation and ventricular remodeling mechanisms.
Hypertrophic obstructive cardiomyopathy (HOCM) often causes dynamic MR dependent on systolic anterior mitral valve leaflet motion.
Chronic persistent atrial fibrillation (AF) can lead to atrial remodeling, annular dilation and MR due to inadequate leaflet lengthening
Annular calcification, especially prevalent in older women with hypertension and diabetes and advanced renal disease, can cause MR.
Irrespective of cause, severe chronic MR tends to progress because LA enlargement strains the posterior leaflet, exacerbating dysfunction.

Pathophysiology of MR

LV afterload is decreased in MR patients, causing LV decompression into the LA during ejection and a rapid drop in LV tension.
Initial MR compensation involves more complete LV emptying.
LV volume progressively increases with MR severity and declining LV function.
Increased LV volume is often associated with reduced cardiac output (CO).
LV compliance frequently increases.
Regurgitant volume directly correlates with LV systolic pressure and regurgitant orifice size.

Management of MR

Chronic severe MR management depends on the cause.
Anticoagulation (warfarin or direct oral anticoagulants) is necessary with atrial fibrillation, guided by CHA2DS2-VASc risk score.
Direct oral anticoagulants should be avoided with moderate-to-severe rheumatic mitral stenosis or mechanical prosthetic valves.
Cardioversion can be considered.
Vasodilators aren't definitively supported for chronic isolated severe MR with preserved LV function without hypertension.
GDMT (including diuretics, beta-blockers, ACE inhibitors/ARBs, angiotensin-neprilysin inhibitors, mineralocorticoid receptor antagonists, SGLT2 inhibitors, and CRT) may improve secondary MR, especially in ischemic or dilated cardiomyopathy.
Antibiotic prophylaxis for IE is warranted for MR patients with prior IE.
Isometric exercise should be avoided by asymptomatic MR patients with normal LV size and function in sinus rhythm.
Acute severe MR necessitates urgent stabilization and surgical preparation.

Surgical Treatment of MR

For chronic severe primary MR, surgery is indicated when symptoms appear, especially if repair is feasible.
Surgery is also indicated for asymptomatic patients with LV dysfunction (EF ≤60% or LV ESD ≥40 mm).
Progressive LVEF decline or increasing LV ESD on serial imaging also warrants consideration.
Repair, rather than replacement, is preferred, because it avoids thromboembolic/hemorrhagic complications associated with mechanical prostheses, and late valve failure requiring re-replacement in the case of bioprostheses.
Repair preserves LV function better than replacement.

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Description

Explore the various aspects of mitral regurgitation (MR), including its causes, types, and pathological mechanisms. This quiz covers both acute and chronic forms of MR and the underlying abnormalities affecting the mitral valve. Test your knowledge on this important cardiac condition and its implications.