In mitral regurgitation the mitral valve does not close fully, so blood leaks back into the left atrium with each beat. Chronic leaks come from valve prolapse or a stretched ventricle, while a sudden leak from a ruptured chord or papillary muscle after a heart attack is an emergency.
Key symptoms
- Shortness of breath on exertion or lying flat
- Fatigue and less exercise tolerance
- Palpitations from atrial fibrillation
- Sudden severe breathlessness in acute cases
What you find on exam
- Holosystolic murmur at the apex that radiates to the axilla
- Displaced apical impulse in chronic cases
- Mid-systolic click in mitral valve prolapse
- Crackles, leg edema or an S3 in heart failure
Tests
- Transthoracic echocardiogram: cause, severity, ventricle size and function
- ECG: atrial fibrillation, left atrial enlargement
- Chest X-ray and BNP if heart failure is suspected
- Transesophageal echo to plan repair
Treatment basics
- Guideline heart failure therapy when the ventricle is weak
- Anticoagulation if atrial fibrillation is present
- Surgical repair for a severe leak with symptoms or a failing ventricle
- Transcatheter edge-to-edge repair for patients at high surgical risk
- Acute leak: nitroprusside to reduce afterload, balloon pump and urgent surgery
Red flags
- Sudden pulmonary edema, especially days after a heart attack
- Low blood pressure with a new murmur
- New atrial fibrillation or a falling ejection fraction
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.