Mitral Regurgitation (Viva questions for medicine practical exam)

Mitral Regurgitation occurs due to mitral valve prolapse it is also known as mitral valve insufficiency , the most common cause of which is Rheumatic Heart disease! following are the questions commonly asked in vivas about mitral regurgitation.

· Mitral valve prolapse. · Infective endocarditis.
· Rheumatic heart disease. · Papillary muscle dysfunction.
· Left ventricular dilatation. · Cardiomyopathy.
· Coronary artery disease. · Connective tissue disorders.
· Annular calcification.

Acute myocardial infarction (rupture of the papillary muscle).
· Endocarditis (due to perforation of the mitral valve leaflet or the chordae).
· Trauma.
· Myxomatous degeneration of the valve

Electrocardiography (ECG), looking for broad bifid P waves (P mitrale), left ventricular hypertrophy,
atrial fibrillation. When coronary artery disease is the cause, there is often evidence of inferior or
posterior wall myocardial infarction.
· Chest radiograph, looking for pulmonary congestion, large heart, left atrial en-largement and
pulmonary artery enlargement (if severe and longstanding).
· Echocardiogram to determine the anatomy of the mitral valve apparatus, left atrial and left ventricular
size and function (typical features include large left atrium, large left ventricle, increased fractional
shortening, regurgitant jet on colour Doppler, leaflet prolapse, floppy valve or flail leaflet). The
echocardiogram provides baseline estimation of left ventricle and left atrial volume, an estimation of
left ventricular ejection fraction, and an approximation of the severity of regurgitation. It can be helpful
to determine the anatomic cause of MR. In the presence of even mild TR, an estimate of pulmonary
artery pressure can be obtained.
· Trans-oesophageal echocardiography is useful in those in whom transthoracic echocardiography
provides non-diagnostic images. It may give better visual-ization of mitral valve prolapse. It is useful
intraoperatively to establish the anatomic basis for MR and to guide repair.
· Cardiac catheterization is useful to determine coexistent coronary artery or aortic valve disease.
Large ‘v’ waves are seen in the wedge tracing. Left ventriculogram and haemodynamic
measurements are indicated when non-invasive tests are inconclusive regarding the severity of MR,
LV function, or the need for surgery

Because of reduced systolic ejection time, secondary to a large volume of blood regurgitating into the left

· Grade 1: Murmur is so faint that it is heard only with special effort.
· Grade 2: Murmur is faint but readily detected.
· Grade 3: Murmur is prominent but not loud.
· Grade 4: Murmur is loud.
· Grade 5: Murmur is very loud.
· Grade 6: Murmur is loud enough to be heard with the stethoscope just removed from contact with
the chest wall.

· Mitral regurgitation.
· Tricuspid regurgitation.
· Ventricular septal defect (this generally radiates to the right of the sternum).

· Asymptomatic patients: antibiotic prophylaxis for endocarditis.
· When atrial fibrillation develops: digitalis to slow ventricular response.
· Heart failure: diuretics and inotropes, but major consideration should be given to surgery

Moderate to severe symptoms despite medical therapy (NYHA functional class III or IV), provided
that left ventricular function is adequate.
· Patients with minimal or no symptoms should be followed up every 6 months by echocardiographic
or radionuclide assessment of left ventricular size and systolic function. When the ejection fraction
falls to 60% (Circulation 1994; 90: 830-7), or when left ventricular end-systolic dimension is greater
than 45 mm (JAm Coil Cardiol 1984; 3: 23542), mitral valve repair or replacement should be
con-sidered even in the absence of symptoms.

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