Mitral valve regurgitation

A.Prof Frank Gaillard et al.

Mitral valve regurgitation is due to functional or anatomical dysfunction of the mitral valve and can lead to striking chest x-ray abnormalities.

The causes of mitral regurgitation are protean and, as such, there is no single group of patients who are affected. Mitral regurgitation can be divided into acute and chronic forms, which have differing aetiologies and imaging features. Causes include: 1

Presentation is dependant on whether the mitral valve disease represents acute or chronic regurgitation. 

Acute mitral regurgitation presents with signs and symptoms of decompensated heart failure (shortness of breath, orthopnoea, PND). Patients may also demonstrate symptoms associated with a low cardiac output, e.g. decreased exercise tolerance. Other signs and symptoms include palpitations and cardiogenic shock.

In chronic mitral regurgitation, there may be relative compensation with limited signs and symptoms. However, these patients tend to be very sensitive to small changes in intravascular volume and prone to cardiac failure.

Typical chest radiographic features of mitral regurgitation include 1-2:

  • frontal projection
    • left atrial enlargement
      • convexity or straightening of the left atrial appendage just below the main pulmonary artery (along left heart border)
      • double density sign: the right side of the enlarged left atrium pushes into the adjacent lung and creates an addition contour superimposed over the right heart
      • elevation of the left main bronchus and splaying of the carina
    • upper zone venous enlargement due to pulmonary venous hypertension
    • left ventricular enlargement is also eventually present due to volume overload

Features of pulmonary oedema may also be present 7.

In acute mitral regurgitation (as seen in acute myocardial infarction or papillary muscle rupture), pulmonary oedema sometimes is localized in right upper lobe even though findings of left atrial enlargement are often absent. 

Treatment depends on the acuteness of presentation.

If mitral regurgitation is acute and secondary to papillary rupture, the treatment of choice is mitral valve replacement. 

If there is concurrent hypotension, an aortic-balloon pump can be used to increase organ perfusion and decrease the degree of mitral regurgitation. In normotensive patients, vasodilators help to decrease afterload.

In chronic MR, vasodilators are used to decrease afterload, e.g. ACE inhibitors. Hypertension is aggressively treated, antiarrhythmics are given where necessary and if there is concomitant mitral valve prolapse or atrial fibrillation, chronic anticoagulation is initiated

The main differential is that of mitral stenosis which also leads to enlargement of the left atrium. Unlike mitral regurgitation, mitral stenosis does not have left ventricular enlargement and usually has less striking enlargement of the left atrium 2

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Article information

rID: 20266
System: Cardiac
Section: Pathology
Synonyms or Alternate Spellings:
  • Mitral regurgitation
  • Regurgitation of the mitral valve
  • Regurgitation of mitral valve

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Cases and figures

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    Case 1
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    Case 1: annotated
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    Case 2 
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    Case 3
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    Case 4: right sided APO due to mitral regurgitation
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