| At a glance | Backflow of blood from LV to LA in systole; acute presents catastrophically, chronic insidiously. | Obstruction to LV inflow at the mitral valve — almost always rheumatic; opening snap with diastolic rumble. |
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| Classic presentation | Acute MR (papillary muscle rupture, endocarditis with cordal rupture):; • Sudden severe dyspnea, flash pulmonary edema, cardiogenic shock; • Hypotension, tachycardia; Chronic MR (insidious onset):; • Dyspnea on exertion, fatigue, decreased exercise tolerance; • Palpitations (often from new AFib as LA dilates); • Late: signs of LV… | Progressive exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea; Fatigue from low cardiac output; Hemoptysis (pulmonary venous hypertension, ruptured bronchial veins); Palpitations (atrial fibrillation), embolic stroke; Hoarseness (Ortner syndrome — recurrent laryngeal nerve compression by enlarged LA); Loud S1, opening snap… |
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| Workup / key labs | BNP, BMP, troponin (if acute presentation), blood cultures (if endocarditis suspected) | Severe MS: mitral valve area ≤1.5 cm² (very severe ≤1.0), mean transmitral gradient >5-10 mmHg at heart rate 60-80, resting pulmonary artery systolic pressure >50 mmHg.; CBC, BMP, TSH (Afib workup); BNP, troponin if dyspnea acute; Anti-streptolysin O if history unclear |
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| Imaging | ECG: LA enlargement (broad notched P in lead II — 'P mitrale'), LVH, AFib in chronic MR; CXR: cardiomegaly (LA enlargement causes elevation of left main bronchus and 'double density' at right heart border), pulmonary edema in acute or decompensated; TTE — first-line: identifies mechanism, measures severity (regurgitant volume,… | Transthoracic echo — diagnostic; planimetry of mitral valve area, mean gradient, pulmonary artery pressure, Wilkins score for valvuloplasty candidacy; Transesophageal echo to exclude LA appendage thrombus before percutaneous mitral balloon valvuloplasty (PMBV) or cardioversion; ECG: P mitrale (broad notched P in lead II), atrial… |
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| First-line treatment | Acute severe MR — surgical emergency:; • Stabilize: afterload reduction with IV nitroprusside or nitroglycerin, intra-aortic balloon pump if shock; • Diuresis for pulmonary edema; • Emergent surgical repair or replacement; Chronic primary MR — surgery indicated when:; • Symptomatic severe MR, regardless of LVEF; • Asymptomatic severe MR… | Diuretics (furosemide, torsemide) for pulmonary and systemic congestion; Rate control for Afib: beta-blocker (metoprolol, bisoprolol) or non-dihydropyridine CCB (diltiazem, verapamil) to lengthen diastolic filling time; Anticoagulation with WARFARIN (target INR 2-3) for Afib, prior embolism, or LA thrombus — DOACs are CONTRAINDICATED in… |
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