Mitral Regurgitation is pretty common. when you hear this murmur and are trying to determine the underlying cause, think about the individual components of the mitral valve and particular disease states which might affect them. Let's start at the annulus and work our way down....- Annulus: This may be dilated from cardiomyopathies, or calcified in diseases like rheumatic fever or chronic renal insufficiency.
- Leaflets: The mitral leaflets can fail in a number of disease states including infectious endocarditis (acute or chronic), rheumatic fever, autoimmune diseases (SLE, scleroderma), myxomatous degeneration (MVP), Connective Tissue Diseases like Marfan's syndrome, or with congenital anomalies.
- Chordae: These can be damaged or rupture under ischemic, infected, or traumatic conditions, and in rheumatic heart disease.
- Papillary Muscles: These muscles can rupture after trauma or infarct. They become 'dysfunctional' in ischemic conditions or when the LV becomes dilated (myopathy or aneurysm). Papillary muscles can also become infected, and rarely can be infiltrated with amyloid deposits or granuloma (eg. sarcoid).
- Inspection/Palpation: Apical impulse may be displaced to the left and is brisk and hyperdynamic.
- Heart Sounds: S1 may be soft, S2 may be widely split from early A2 closure. You may hear a loud P2 if pulmonary hypertension is present. S3 can be heard in volume overloaded states.
- Murmur: This is a holosystolic murmur that starts right after S2 (and may even obscure it). It is high-pitched, loudest at the apex, and radiates to the axilla. There is minimal respiratory variation - this may help you distinguish it from Tricuspid Regurgitation.
- Special Tests: The murmur is accentuated with maneuvers that increase afterload (eg. bilateral isometric hand grip or by transient arterial occlusion with a blood pressure cuff). The murmur will be diminished by decreasing preload - like going from a crouching position to standing, or with valsalva.
Good Links:
- Here is a good review on the Evaluation and Management of Mitral Regurgitation.
- This is the JAMA article for systolic murmurs.
I am a medical resident on cardiology and I also wrote a few words about mitral regurgitation.
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