Internal Medicine

0521779407-14 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:16

Mitral Insufficiency (MR) 991

Signs & Symptoms

■Holosytolic or crescendo systolic murmur, which radiates to axilla

or back

■PMI – hyperdynamic and displaced to left and downward

■Soft S1

■S3 present

■Increased P2 and parasternal lift (pulmonary artery hypertension

present)

■Elevated JVP and ascites (pulmonary artery hypertension and right

heart failure present)

tests

■ECG

➣Left atrial abnormality

➣Atrial fibrillation

➣Left ventricular hypertrophy

➣ST and T wave changes, Q waves (papillary muscle dysfunction)

■Chest X-Ray

➣Cardiomegaly (chronic MR)

➣Enlarged and giant left atrium (chronic MR)

➣Normal heart and left atrial size (acute MR)

➣Pulmonary venous congestion may be present

■Echo/Doppler (very important)

➣Detect and quantitate MR

➣LV systolic function

➣LV diastolic and systolic dimensions

➣Enlarged left atrium with moderate/severe MR

■Cardiac Catheterization

➣Pulmonary capillary wedge elevated

Elevated and prominent V wave in acute MR

V wave may be normal in chronic MR

➣Pulmonary artery hypertension

➣Cardiac output and index low and not increase with exercise

➣Assess severity of MR, LV systolic function, and LV diastolic and

systolic volumes

➣Coronary angiography required prior to valve repair/replace-

ment in older patients

differential diagnosis

■Idiopathic hypertrophic subaortic stenosis

■Ventricular septal defect