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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