Mitral regurgitation

104 topics across 6 chapters

Chapter 1

Mitral valve & cardiac physiology fundamentals

Mitral valve anatomy: leaflets, annulus, chordae, papillary muscles

2 subtopics

Identify scallops/segments (A1-A3, P1-P3) and commissures

Understand annular dynamics and the role of the saddle shape

Cardiac cycle & pressure-volume relationships relevant to MR

2 subtopics

Trace the normal sequence of valve opening/closure across systole/diastole

Explain why MR can reduce effective forward cardiac output despite preserved EF

Hemodynamics of regurgitation: preload/afterload, forward vs regurgitant stroke volume

2 subtopics

Differentiate regurgitant volume, regurgitant fraction, and effective regurgitant orifice area (EROA)

Predict how afterload reduction changes MR severity (acute vs chronic contexts)

Left atrial and left ventricular remodeling in chronic MR

2 subtopics

Describe LA dilation consequences: AF risk and thromboembolism implications

Recognize LV dilation patterns and thresholds used in surgical timing discussions

Chapter 2

Etiology & mechanisms of mitral regurgitation

Primary (degenerative) MR: myxomatous disease, MVP, flail leaflet

2 subtopics

Mechanism of MVP: leaflet prolapse vs flail; chordal elongation vs rupture

Recognize degenerative MR phenotypes: Barlow disease vs fibroelastic deficiency

Secondary (functional) MR: ischemic and non-ischemic LV remodeling

2 subtopics

Tethering and annular dilation: concept of leaflet coaptation depth and tenting area

Ischemic MR: papillary muscle displacement patterns after MI

Acute MR mechanisms: papillary muscle rupture, chordal rupture, endocarditis

3 subtopics

Post-MI papillary muscle rupture: presentation, exam, and emergency pathway

Chordae tendineae rupture: triggers (trauma, degenerative) and echo clues

Endocarditis-related MR: perforation, vegetation, abscess, and embolic risk

Carpentier classification & valve dysfunction language (Type I/II/III)

2 subtopics

Map Carpentier types to typical causes (e.g., Type II → prolapse/flail)

Use mechanism language to communicate with surgeons/interventionalists (repair planning)

Chapter 3

Clinical presentation & bedside assessment

Symptoms & natural history: asymptomatic phase to heart failure

2 subtopics

Differentiate acute vs chronic MR symptom patterns and compensation

Recognize progression triggers: AF onset, LV dysfunction, pulmonary hypertension

Cardiac auscultation: MR murmurs and key maneuver effects

3 subtopics

Identify holosystolic murmur at apex with axillary radiation and correlate to MR

Explain how handgrip/squatting typically increases MR murmur intensity

Distinguish MR murmur features from MVP (mid-systolic click ± late systolic murmur)

Physical exam & complications: pulmonary edema, AF, pulmonary hypertension

3 subtopics

Recognize signs of left-sided congestion: orthopnea, rales, pleural effusions

Atrial fibrillation in MR: rate vs rhythm strategy basics and anticoagulation triggers

Pulmonary hypertension and RV dysfunction: why it matters for prognosis and surgery

Differential diagnosis of a systolic murmur (MR vs TR vs AS vs VSD)

2 subtopics

Differentiate MR vs TR using location, radiation, and respiration effects

Differentiate MR from AS and VSD using timing, quality, and associated findings

Chapter 4

Diagnostics: echo-first workflow & severity assessment

Transthoracic echocardiography (TTE): core views & MR screening

2 subtopics

Perform a structured TTE MR read: mechanism, jet direction, chamber sizes, LV function

Recognize common pitfalls: eccentric jets, Coanda effect, loading conditions

MR severity quantification on echo: qualitative, semiquantitative, quantitative

4 subtopics

Qualitative signs: color jet characteristics, pulmonary vein flow, CW Doppler density

Semiquantitative metrics: vena contracta width and its limitations

Quantitative methods: PISA/EROA calculation steps and common error sources

Integrate parameters into a final severity grade (avoid single-metric diagnosis)

Transesophageal echo (TEE) & 3D echo for mechanism and repair planning

2 subtopics

TEE indications: nondiagnostic TTE, endocarditis suspicion, pre-procedural planning

3D echo: commissural view orientation and segment localization for repair/TEER

Stress testing & exercise echo for asymptomatic MR and symptoms mismatch

2 subtopics

Exercise testing endpoints: symptoms, BP response, arrhythmias, functional capacity

Exercise echo: uncovering dynamic MR and pulmonary pressure rise

Adjunct testing: ECG, CXR, biomarkers, CMR, and cardiac cath when indicated

5 subtopics

ECG patterns: AF, LVH, prior MI clues; when ambulatory monitoring helps

Chest X-ray: LA enlargement, pulmonary venous congestion, edema

Biomarkers: BNP/NT-proBNP for prognosis and symptom interpretation (limitations)

Cardiac MRI (CMR) in MR: LV volumes, regurgitant fraction, fibrosis assessment

Cardiac cath: coronary evaluation pre-op and hemodynamics when echo is discordant

Chapter 5

Management: medical therapy, follow-up, and timing of intervention

Risk stratification & surveillance: stages, echo follow-up intervals, red flags

3 subtopics

Stage MR (A-D) and relate stage to management decisions

Plan surveillance echo frequency based on severity and LV size/function

Red flags requiring urgent referral: acute symptoms, new AF, LV EF drop, PH

Medical management for chronic MR: HF therapy, BP control, AF management principles

3 subtopics

Use diuretics and BP control to manage congestion and reduce symptoms (when appropriate)

Guideline-directed medical therapy (GDMT) principles in secondary MR with HFrEF

↗ Atrial fibrillation in MR: rate vs rhythm strategy basics and anticoagulation triggers (see Chapter 3)

Acute severe MR stabilization: oxygenation, afterload reduction, MCS, urgent consults

3 subtopics

Immediate stabilization priorities: airway/oxygenation and pulmonary edema treatment

Afterload reduction and inotropes: when to consider (conceptual, not dosing)

Mechanical circulatory support concepts (IABP/Impella/ECMO) and escalation triggers

Indications for mitral valve repair vs replacement (primary MR focus)

3 subtopics

Repair vs replace: advantages, contraindications, and expected outcomes

Timing in asymptomatic severe primary MR: LV EF/LV size, AF, pulmonary pressures

Role of high-volume valve centers and repair probability in decision-making

Functional (secondary) MR treatment pathway: GDMT, CRT, revascularization, TEER selection

4 subtopics

Optimize HF medications and volume status before considering interventions

Cardiac resynchronization therapy (CRT): which patients may improve MR

Revascularization in ischemic MR: CABG/PCI concepts and patient selection

TEER candidacy basics: anatomy, symptom status, optimized GDMT requirement

Chapter 6

Procedural options & special populations

Surgical mitral valve repair: common techniques & durability considerations

3 subtopics

Annuloplasty ring/band: purpose, sizing concepts, and impact on MR recurrence

Leaflet repair options: triangular/quadrangular resection, neochords

Post-repair assessment: residual MR, transmitral gradient, SAM risk

Surgical mitral valve replacement: prosthesis choices & anticoagulation basics

3 subtopics

Mechanical vs bioprosthetic valves: durability vs anticoagulation trade-offs

Anticoagulation basics after MVR: INR monitoring concepts and drug interactions

Valve complications: thrombosis, pannus, structural valve degeneration, endocarditis

Transcatheter edge-to-edge repair (TEER) and other transcatheter options

3 subtopics

↗ TEER candidacy basics: anatomy, symptom status, optimized GDMT requirement (see Chapter 5)

TEER procedure overview: transseptal access, clip positioning, residual gradient concerns

Post-TEER follow-up: echo parameters, antithrombotic strategy concepts, complications

MR in pregnancy, perioperative non-cardiac surgery, and athletics

3 subtopics

Pregnancy and MR: hemodynamic changes, risk assessment, delivery planning concepts

Non-cardiac surgery with MR: pre-op evaluation and intra-op hemodynamic goals

Sports participation: when MR is compatible with competitive athletics (conceptual)

Endocarditis, rheumatic disease, and valve-related complications

3 subtopics

↗ Endocarditis-related MR: perforation, vegetation, abscess, and embolic risk (see Chapter 2)

Rheumatic mitral disease: mixed MS/MR patterns and long-term considerations

Infective endocarditis prophylaxis: who qualifies and dental procedure basics