cardiovascular disorders
Mitral Regurgitation
Symptoms and Signs of Mitral Regurgitation
 causes the same symptoms and signs as acute Symptoms and Signs (dyspnea, fatigue, weakness, edema) and is initially asymptomatic. Symptoms develop insidiously as the LA enlarges, pulmonary artery pressure and venous pressure increase, and LV compensation fails. Symptoms include dyspnea, fatigue (due to heart failure), orthopnea, and palpitations (often due to Atrial Fibrillation ). Rarely, patients present with ). Inspection and palpation may detect a brisk apical impulse and sustained left parasternal movement due to systolic expansion of an enlarged LA. An LV impulse that is sustained, enlarged, and displaced downward and to the left suggests LV hypertrophy and dilation. A diffuse precordial lift occurs with severe MR because the LA enlarges, causing anterior cardiac displacement, and Pulmonary Hypertension causes right ventricular hypertrophy. A regurgitant murmur (or thrill) may also be palpable in severe cases. Onauscultation,the first heart sound (S1) may be soft (or occasionally loud). A third heart sound (S3) at the apex reflects a dilated LV and severe MR. The cardinal sign of mitral regurgitation is a holosystolic (pansystolic) murmur, heard best at the apex with the diaphragm of the stethoscope when the patient is in the left lateral decubitus position. In mild MR, the systolic murmur may be abbreviated or occur late in systole. The murmur begins with S1 in conditions causing leaflet incompetency throughout systole, but it often begins after S1 (eg, when chamber dilation during systole distorts the valve apparatus or when myocardial ischemia or fibrosis alters dynamics). When the murmur begins after S1, it always continues to the second heart sound (S2). The murmur radiates toward the left axilla; intensity may remain the same or vary. If intensity varies, the murmur tends to crescendo in volume up to S2. MR murmurs increase in intensity with handgrip or squatting because peripheral vascular resistance to ventricular ejection increases, augmenting regurgitation into the LA; murmurs decrease in intensity with standing or the Valsalva maneuver. A short rumbling mid-diastolic inflow murmur due to torrential mitral diastolic flow may be heard following an S3. In patients with posterior leaflet prolapse, the murmur may be coarse and radiate to the upper sternum, mimicking Aortic Stenosis . MR murmurs may be confused with those of Tricuspid Regurgitation , which can be distinguished because tricuspid regurgitation murmur is augmented during inspiration. 