6. Aetiology * MVP { Myxomatous mv },commonest in developed world *Damage to the cusps : _RVD _ IE _ Congenital Cleft MV *Damage to chordae : _RVD _ IE _ Trauma _ Degenerative * Damage to papillary muscles : _Ischaemia _ Infarction _ Infiltrative _ HCM * Damage of MV annulus : _ Calcification _ IE { abscess } * Dilatation of MV ring : _ IHD _ CMP _ acute RV

8. Lv volume OL…. LV dilatation maintain normal COP later….. LV decompensate LVEDP rise LV wall tension increase…… LV fail ….. pulmonary congestion….PH ……CHF LV dilatation ….dilated MV ring…. > MR Back pressure ….dilated LA …..AF … La thrombus ….. PHP.. ….. CHF …… thrombo-embolic phenomenon

9. Clinical features : Symptoms : _ Dyspnoea { pulmonary congestion } _Fatigue { low COP } _ Palpitation { AF, increased stroke volume } _Oedema, Ascites { RVF } _ Systemic embolization { stroke, ischaemic limb etc.. } Signs : _ Pulse … Jerky.. AF.. _Apex … Displaced hyperdynamic _ Apical Pansystolic murmer +/_ Thrill …. 3 rd HS _Signs of pulmonary congestion … { crepitations, Pul. Oed. } _Signs of PH and RVF.. Loud P2.. Lt.PS heave … Oedema …

10. Investigations : * ECG … LAH, LVH ….AF * Chest X-ray … LA enlargement … Pulmonary congestion.. … LV enlargement … Pulmonary oedema … * ECHO …. Dilated LA and LV ….Dynamic LV … ….Structural abnormalities of MV { e.g. MVP } * Doppler … { CW … PW … color dopler.. } _ Detects and quantifies MR _ * Cardiac catheterization …. Dilated LA and LV …. MR … …..Assess PH … ….. Detect coexisting CAD …

12. Chest X-ray PA view

16. Management Medical : _ For mild and moderate cases * Diuretic * Vasodilators, e.g. ACEI * Digoxin For AF * Anticoagulant if AF * Antibiotic Prophylaxis against IE Surgical : * MV valvoplasty {Repair } * MV replacement Indications: _ Worsening symptoms _Progressive cardiomegaly _ Deterioration of LV F EF 55

20. Indications for Surgery in Isolated,Severe Chronic MR *Emerging (minor criteria): *Emerging (minor criteria): _Any symptoms of heart failure _Or sub optimal exercise tolerance test _Any symptoms of heart failure _Or sub optimal exercise tolerance test _Flail mitral leaflet _Flail mitral leaflet _Left atrial diameter >45mm _Left atrial diameter >45mm _Paroxysmal atrial fibrillation _Paroxysmal atrial fibrillation _Abnormal exercise end-systolic volume index _Abnormal exercise end-systolic volume index or ejection fraction or ejection fraction

22. General information _ Most common cause of isolated MR _ Occurs in 5% of adults _Most discovered at ages 20- 40 _Affects women > men _MV “ floppy ” or incompetent _Caused by myxomatous changes _ May occurs with marfan syndrome _Cordae may rupture

23. Clinical features _May be asymptomatic _ Mid systolic click +/_ late systolic murmer or PSM _ MR -- chronic, or acute {rupture CT} _ CHF _ Increased risk for : * IE *Arrythmias *Increased risk of embolic stroke and TIA { small } * Sudden death { rare }

30. Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1