Mitral regurgitation

 

Disease:

Cause

·     Dilated left ventricle

·     Degeneration

·     Infective endocarditis

·     Connective tissue disease

Complications

·     Left heart failure

·     Atrial enlargement

·     Atrial tachyarrhythmias

·     Pulmonary hypertension

·     Right heart failure

Diagnosis

·     History

·     Examination: displaced apex, pansystolic murmur -> axilla

·     ECG: P waves wide/bifid/inverted, ↑QRS amplitude

·     TTE: regurgitation, complications

 

Echo diagnosis:

Regurgitation

·     Direction of jet (concentric, eccentric)

·     Size of jet

·     Size of orifice

·     Size of vena contracta

·     Size of convergence zone (PISA shell radius)

·     Regurgitant volume

·     Regurgitant fraction

Complications

·     LV function (beware LVEF overestimated!)

·     LV eccentric hypertrophy

·     LA enlargement

·     PA pressure

·     RV function

 

Echo severity:

 

Mild “at risk”

Mod “progressive”

Sev “severe”

PISA radius

<0.4

0.4-1

>1

Vena contracta

<3mm

3-7mm

>7mm

Valve orifice

<0.2

0.2-0.4

>0.4

Jet area

<20%

20-40%

>40%

Regurgitant volume

<30mL

30-60mL

>60mL

Regurgitant fraction

<30%

30-50%

>50%

MV diastolic flow

A dominant

Variable

E dominant

PV systolic flow

Fast

Slow

Reversed

 

Anaesthesia

Goals

·     “Full, fast, forward”

·     Euvolaemia

·     High/normal heart rate

·     Low/normal afterload

Management

·     General good (↓SVR)

·     Regional good (↓SVR)

·     Opioids good (↓SVR) and bad (↓HR)

·     Vasopressors bad in excess (↑SVR)

 

 

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