B. Mitral regurgitation – Explanation
mitral regurgitation: primary (degenerative) MR and secondary (functional) MR.
From the patient’s past medical history we can see that she has had a relatively recent
myocardial infarction. The most important complications of a myocardial infarction that
we need to recognise in this stem is mitral valve dysfunction and an atrial arrhythmia.
VALVULAR HEART DISEASE
We have listed the common heart valve disorders here. There are certain keywords
that if you see in the exam, would help point you towards a specific heart valve disorder.
We have written them in red for you on this page.
Aortic stenosis
Aortic valve stenosis is the most common valvular heart disease in the UK hence the
most commonly asked heart valve question. The two most common pathogenesis are
age-related degenerative sclerocalcific changes to valves (most common cause, usually
an elderly patient) and congenital bicuspid aortic valve (seen in a younger person with
aortic stenosis).
Signs
Ejection systolic murmur best heard at the 2
nd intercostal space, at the right sternal
border which radiates to carotid arteries.
Mitral regurgitation
Mitral regurgitation (MR), which is also known as mitral insufficiency, is the second most
common heart valve disorder.
Signs
Soft S1 and S2, pansystolic murmur at the 5
th intercostal space in the left midclavicular
line which radiates to the axilla.
A useful method to remember is to remember this phrase “when cooking, you really do
not want to regurgitate onto the cooking pan”. This is a good way to remember
pansystolic murmurs are found in mitral and tricuspid regurgitation (and also in
ventricular septal defects).
Mitral valve prolapse
Mitral valve prolapse is common inheritable connective tissue disorders like Marfan’s
syndrome, Ehlers Danlos syndrome and osteogenesis imperfecta. Most patients are
asymptomatic. The classical case would be a slim young female with low blood
pressure. Mitral valve prolapse is a risk factor for mitral regurgitation.
Signs
Mid-systolic click, best heard at 5
th intercostal space in the left midclavicular line,
followed by a mid or late-systolic murmur with findings accentuated in the standing
position.
Ever watch basketball? The MVP (Most Valuable Player which has the same acronyms
as mitral valve prolapse) is the best performing player of the basketball season. He is
tall, thin, with long arms (like in Marfan syndrome) and has loose joints (like in Ehlers
Danlos syndrome). He shoots from the middle of the court with great “syspense” and
finishes with the ball entering the net with a click (mid-systolic click).
Mitral stenosis
Rheumatic heart disease is the commonest cause of mitral stenosis worldwide.
Signs
Mid-diastolic murmur with an opening click (the click represents the mitral valve
opening) best heard at the 5
th intercostal space in the left midclavicular line.
Michael Schumacher who is one of the greatest Formula One drivers ever has the same
initials as mitral stenosis. He had a terrible accident in the middle of his ski trip which
he almost diad”
Aortic regurgitation
Aortic regurgitation causes include rheumatic heart disease, infective endocarditis,
Marfan syndrome amongst others.
Signs
Early diastolic murmur, best heard at left sternal edge
Pulmonary stenosis
Signs
Ejection systolic murmur best heard over pulmonary area, radiates to the left shoulder
or infraclavicular region.
Tricuspid regurgitation
Signs
Pansystolic murmur best heard over tricuspid region.
Other common mnemonics that can help you remember heart murmurs are:
Left sided murmurslouder with Expiration
Right sided murmurs louder with inspiration
