Mitral Incompetence (Mitral Regurge) PDF

Mitral incompetence (Mitral Regurge) ertga3  mitral stenosis : narrowing in orifice in diastole. Or ventricular relaxation mitral incompetence : widening in orifice in ventricular contraction or systole Mitral regurgitation (MR), or mitral incompetence, is a form of valvular hea...

Mitral incompetence (Mitral Regurge) ertga3  mitral stenosis : narrowing in orifice in diastole. Or ventricular relaxation mitral incompetence : widening in orifice in ventricular contraction or systole Mitral regurgitation (MR), or mitral incompetence, is a form of valvular heart disease in which the mitral valve does not close properly when the heart pumps out blood. It is the abnormal leaking of blood backwards from the left ventricle, through the mitral valve, into the left atrium, when the left ventricle contracts, i.e. there is regurgitation of blood back into the left atrium. MR is the most common form of valvular heart disease. Causes (Aetiology) of mitral incompetence Rheumatic heart disease due to: Fibrosis & retraction of cusps in chronic form of the disease. Congenital. Functional : due to left ventricular dilatation. 7sl dilatation in lt ventricle so mitral valve is dilated too Surgical: following mitral commissurotomy or prosthetic valve dysfunction. over diltation bec of the surgery Mitral valve prolapse. Papillary muscle dysfunction e.g. ischemic heart disease & cardiomyopathy.  el dm byegy mn lung oxygnated lazem b3d keda el orifice y2fl 34n el ventricle tdo5 eldm ll aorta f bsbb el widening hyb2a fyi gap m3n el casp mt2srt4 f bsbb keda goz2 mn eldm hyro7 llaorta w goz2 hyrg3 ll left atrium Hemodynamic of mitral incompetence (1) Left atrial dilatation: casp mt2srt4 In chronic mitral incompetence, the left atrium dilates to accommodate increased volume of blood it receives. The left atrium receives the normal pulmonary venous return plus the regurgitant stream from the left ventricle during systole. This dilatation may reach aneurysmal dimensions and prevent early increase of the left atrial pressure and pulmonary venous pressure. so no pulmonary congestion during artrial diltation lesa mzhrt4 Pulmonary congestion , therefore, does not occur in compensated mitral incompetence and occurs only with the onset of left ventricular failure. The regurgitant stream of blood stirs the contents of the left atrium with every systole, cause systolic pulsations of the left atrium and prevents stasis and thrombosis. Thrombo-embolism therefore, is much less in mitral incompetance than in mitral stenosis. mitral in competence left atrial dialate bec of the accumlation of blood but no thrombus formation bec blood is stiring or moving mitral stenosis bec of accumlation of blood causing thrombus bec the blood is stagnant  (2) Left vent dilatation: In chronic mitral incompetence, the left ventricle dilates in order to accommodates the increased volume of blood it receives from the left atrium during diastole. It receives the normal A-V flow plus the regurgitant blood from the previous beat. Concomitant with this dilatation, wall hypertrophy occurs to maintain the contractility of the ventricular wall in the face of this volume load and to maintain the cardiac output (eccentric hypertrophy). However, in old-standing cases, the compensating hypertrophy is exhausted and the left ventricle progressively dilates and ends with failure. Left ventricular dilatation itself is a cause of mitral regurgitation due to dilatation of A-V ring and thus a vicious circle occurs. faliure : means the not all the blood go to the aorta so there is pulmonary congesion The onset of heart failure is marked by rise of the end-diastolic pressure , left atrial pressure and pulmonary venous pressure. In long-standing heart failure, pulmonary arterial hypertension eventually develops and constitutes a pressure load on the right ventricle. mitral stenosis pulmonary congesion appear early no lt ventricular faliure was atrophy but there is right heart faliure mitral incompetence pulmonary congesion appear at the stage of left ventricular faliure then lead to rt heart faliure by pulmonary hypertension What is the difference between eccentric and concentric hypertrophy? hypertrophy or thickness only Concentric hypertrophy is associated with increased left ventricular wall thickness whereas eccentric hypertrophy is characterized by dilatation of the left ventricular chamber; however, there occurs a general increase in the overall size of cardiomyocytes under both conditions = abnormal hypertrophy hypertrophy or thickness+ diltation  During systole a part of blood regurgitates from left ventricle to left atrium leading to: - Low cardiac output - Increased blood volume in left atrium causing its dilatation. During diastole a large volume of blood reaches left ventricle causing left ventricular enlargement which may end in left ventricular failure.  read only Compensated mitral incompetence: If the MR develops slowly over months to years, the individual will enter the chronic compensated phase of the disease. In this phase, the left ventricle develops eccentric hypertrophy in order to better manage the larger than normal stroke volume. The eccentric hypertrophy and the increased diastolic volume combine to increase the stroke volume (to levels well above normal) so that the forward stroke volume (forward cardiac output) approaches the normal levels. In the left atrium, the volume overload causes enlargement of the left atrium, allowing the filling pressure in the left atrium to decrease. This improves the drainage from the pulmonary veins, and signs and symptoms of pulmonary congestion will decrease. These changes in the left ventricle and left atrium improve the low forward cardiac output state and the pulmonary congestion that occur in the acute phase of the disease. Individuals in the chronic compensated phase may be asymptomatic and have normal exercise tolerances.  read only Decompensate mitral incompetence In this phase, the ventricular myocardium is no longer able to contract adequately to compensate for the volume overload of mitral regurgitation, and the stroke volume of the left ventricle will decrease. The decreased stroke volume causes a decreased forward cardiac output and an increase in the end-systolic volume. The increased end-systolic volume translates to increased filling pressures of the left ventricle and increased pulmonary venous congestion. The individual may again have symptoms of congestive heart failure. The left ventricle begins to dilate during this phase. This causes a dilatation of the mitral valve annulus, which may worsen the degree of MR. The dilated left ventricle causes an increase in the wall stress of the cardiac chamber as well.  Clinical manifestation of mitral incompetence in valve lesion the patient compensate or decompensate ? if no heart faliure : compensate if there is herat faliure in lt or rt so it is decompansate 1- Compensated mitral incompetence: Before the development of left ventricular failure, mitral incompetence is either an asymptomatic condition or the patient may complain of non-specific symptoms as palpitation or fatigue. palpitation is due to the force of the apex beat or arrhythmia. 2- Decompensated mitral incompetence: With the development of heart failure , the patient complains of congesion congestive symptoms as dyspnea, hemoptysis, and recurrent pulmonary bronchopulmonary infection. Fatigue increases due to reduction of the cardiac output. Complications of mitral incompetence Left ventricular failure. Infective endocarditis. = valve lesion with inflammation which cause vegtation vegetation : lesion then platelet adhere then fibrin adhere which cause small firm clot which is named as vegetation then bacteria invade the vegetation so become fragile and big and go to the rest of the body which cause nonsterile embolism=abcess Clinical manifestations as mitral stenosis No symptoms in mild cases. Symptoms of low cardiac output: Fatigue, confusion, decreased level of consciousness, cool peripheries, hypotension. Symptoms of pulmonary congestion occur later due to left ventricular failure e.g dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, haemoptysis. Palpitation. = tachycardia Symptoms of complication. infective endocarditis and lt heart faiure  ay valve lesion like mitral stenosis and incompetence and aortic stenosis el investigation wa7da : invasive and non invasive ECG not diagnostic Left atrial enlargement (P mitral). Left ventricular enlargement. pattern Chest X-ray not diagnostic Enlargement of left atrium and left ventricle. Pulmonary congestion when left ventricular failure occurs. Echocardiography diagnostic Diagnosis of the mitral incompetence Detection of the severity of the lesion by (Doppler ultrasound). Detection of associated lesions. show the blood flow if it is normal or there is regurge Detection of chamber enlargement. Measurement of ejection fraction. Cardiac catheterization& Angiocardiography invasive same as echo Diagnosis of the mitral incompetence. Detection of the severity of the lesion. Detection of associated lesions. Detection of chamber enlargement. Measurement of ejection fraction Detection of associated coronary artery disease. Treatment of mitral incompetence Medical treatment by3alg el symptoms not the valve lesion Surgical treatment Medical treatment Prophylactic against infective endocarditis before dental or surgical procedure. Therapeutic for: - left sided heart failure - Arrhythmias - Embolism - Infective endocarditis - Rheumatic activity. - pulmonary congesion Surgery repair or replacement Surgery is curative of mitral valve regurgitation. There are two surgical options for the treatment of MR: mitral valve replacement and mitral valve repair. Mitral valve repair is preferred to mitral valve replacement where a repair is feasible as bioprosthetic replacement valves have a limited lifespan of 10 to 15 years, whereas synthetic replacement valves require ongoing use of blood thinners to reduce the risk of stroke. Indications for surgery for chronic MR include signs of left ventricular dysfunction with ejection fraction less than 60%, severe pulmonary hypertension with pulmonary artery systolic pressure greater than 50 mmHg at rest or 60 mmHg during activity, and new onset atrial fibrillation. Surgical indications Marked symptoms not responding to adequate medical treatment. Progressive cardiomegaly. Declining left ventricular function e.g. decreasing ejection fraction. Points of comparison Mitral stenosis Mitral incompetence - Symptoms of lung congestion Early Late - Palpitation Late due to atrial fibrillation Early due to strong apex - Pulmonary hypertension Early Late - Heart failure Right ventricular Left ventricular - Atrial fibrillation (AF) Common Less common - Infective endocarditis Less frequent Commoner -Thrombo embolism Common Infrequent -ECG Right ventricular pattern Left ventricular pattern