Aetiology * MVP { Myxomatous mv },commonest in developed world *Damage to the cusps : _RVD _ IE _ Congenital Cleft MV *Damage to chordae : _RVD _ IE _ Trauma _ Degenerative * Damage to papillary muscles : _Ischaemia _ Infarction _ Infiltrative _ HCM * Damage of MV annulus : _ Calcification _ IE { abscess } * Dilatation of MV ring : _ IHD _ CMP _ acute RV

Lv volume OL…. LV dilatation maintain normal COP later….. LV decompensate LVEDP rise LV wall tension increase…… LV fail ….. pulmonary congestion….PH ……CHF LV dilatation ….dilated MV ring…. > MR Back pressure ….dilated LA …..AF … La thrombus ….. PHP.. ….. CHF …… thrombo-embolic phenomenon

Clinical features : Symptoms : _ Dyspnoea { pulmonary congestion } _Fatigue { low COP } _ Palpitation { AF, increased stroke volume } _Oedema, Ascites { RVF } _ Systemic embolization { stroke, ischaemic limb etc.. } Signs : _ Pulse … Jerky.. AF.. _Apex … Displaced hyperdynamic _ Apical Pansystolic murmer +/_ Thrill …. 3 rd HS _Signs of pulmonary congestion … { crepitations, Pul. Oed. } _Signs of PH and RVF.. Loud P2.. Lt.PS heave … Oedema …

Investigations : * ECG … LAH, LVH ….AF * Chest X-ray … LA enlargement … Pulmonary congestion.. … LV enlargement … Pulmonary oedema … * ECHO …. Dilated LA and LV ….Dynamic LV … ….Structural abnormalities of MV { e.g. MVP } * Doppler … { CW … PW … color dopler.. } _ Detects and quantifies MR _ * Cardiac catheterization …. Dilated LA and LV …. MR … …..Assess PH … ….. Detect coexisting CAD …

Chest X-ray PA view

Management Medical : _ For mild and moderate cases * Diuretic * Vasodilators, e.g. ACEI * Digoxin For AF * Anticoagulant if AF * Antibiotic Prophylaxis against IE Surgical : * MV valvoplasty {Repair } * MV replacement Indications: _ Worsening symptoms _Progressive cardiomegaly _ Deterioration of LV F EF 55

Indications for Surgery in Isolated,Severe Chronic MR *Emerging (minor criteria): *Emerging (minor criteria): _Any symptoms of heart failure _Or sub optimal exercise tolerance test _Any symptoms of heart failure _Or sub optimal exercise tolerance test _Flail mitral leaflet _Flail mitral leaflet _Left atrial diameter >45mm _Left atrial diameter >45mm _Paroxysmal atrial fibrillation _Paroxysmal atrial fibrillation _Abnormal exercise end-systolic volume index _Abnormal exercise end-systolic volume index or ejection fraction or ejection fraction

General information _ Most common cause of isolated MR _ Occurs in 5% of adults _Most discovered at ages _Affects women > men _MV “ floppy ” or incompetent _Caused by myxomatous changes _ May occurs with marfan syndrome _Cordae may rupture

Clinical features _May be asymptomatic _ Mid systolic click +/_ late systolic murmer or PSM _ MR -- chronic, or acute {rupture CT} _ CHF _ Increased risk for : * IE *Arrythmias *Increased risk of embolic stroke and TIA { small } * Sudden death { rare }

Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1