Page 115 - Clinical Pearls in Cardiology

Valvular Heart Diseases 103

The clinical course and physical signs of a patient with
either predominant stenosis or regurgitation do not differ
strikingly from that of a patient with one or the other
lesion in isolation.
The clinical clue towards the presence of co-existing
stenosis in a patient with dominant mitral regurgitation is
the presence of a prolonged apical mid-to-late diastolic
rumbling murmur. An apical diastolic murmur may be
heard in isolated severe mitral regurgitation also, but this
murmur is usually short and is confined to early- and
mid-diastole, and it usually follows the low pitched S3.
7. What are parameters taken into account when
considering surgical intervention in patients with
mitral regurgitation?
Mitral regurgitation of moderate severity can be treated
medically with diuretics and vasodilators like ACE
inhibitors. The patients should be referred for surgical
interventions (mitral valve replacement or repair), if they
have any one of the following criteria:
• Worsening of symptoms
• Left ventricular ejection fraction below 60%
• End-systolic dimension of the left ventricle
approaches 45 mm or more.
In patients with ventricular dilatation and mitral
regurgitation, it is very important to determine which
of the two abnormalities is the predominant problem.
This is because if ventricular dilatation is the underlying
cause of mitral regurgitation (referred to as functional
MR), then mitral valve replacement may actually worsen
the ventricular function, as the dilated ventricle can no
longer empty into the low pressure left atrium. So surgical
interventions like valve replacement are not advocated
for those with functional mitral regurgitation. ESC