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. Understanding Venous Insufficiency and Leg Ulcers

The shifting paradigm in mitral regurgitation

Mitral regurgitation (MR) also known as Mitral insufficiency is a valvular heart disease. Abnormal leaking of the blood into the left atrium of the heart from the left ventricle through the mitral valve leads to Mitral regurgitation. The mitral valve (MV) is a highly complex organ. Anatomically speaking, it is composed of two valve leaflets, the anterior and the posterior, attached through the mitral valve annulus and the two major papillary muscles to the left ventricular wall. It is closely related to the aortic valve and the left atrium and is supported by the connecting tissue. Any disturbance in the functioning of the portions of the mitral valve system or the Mitral valve failing to close in its anatomical plane leads to valvular insufficiency or Mitral Regurgitation.

The common cause of Mitral regurgitation is myxomatous degeneration of the valve. It is more in males and that too in late ages. It is a defect in the collagen which stretches out of the leaflets of the valve and the chordae tendineae. When the valve is closed, due to stretching, the leaflets prolapse into the left atrium leading to Mitral Regurgitation. Dilatation of the left ventricle causes secondary Mitral Regurgitation. Symptoms of acute MR include signs of congestive heart failure, low cardiac output, pulmonary edema and some others. Chronic MR is symbolized by exercise tolerance, without any evidence of heart failure and is generally asymptotic.

Mitral regurgitation when severe may lead to left ventricular failure, then to congestive heart failure and then to death. Physicians now see MR in a different way, thanks to the recent insights into this field. Patients who are slightly asymptotic have a better chance of survival than with symptotic ones. Generally seen, Surgery is considered risky and even the result is unfavorable to the patient. The stage or degree of the MR depends on the ERO (effective regurgitant orifice) which is the degree of left atrium compliance (gradient for MR) and the closing force imposed on the leaflets. Simply eradicating the MR may not improve the situation. Other factors like improving hemodynamics, reversing the ventricular remodeling need to be done. MV repair along with advanced operative techniques makes surgery a choice of therapy for patients with significant MR. MR Repair presently performed posterior leaflets or prolapse of the anterior with durable results and low risk.

The severity of the MR is usually dependant on physical examination and the history of the patient, but not always. Echocardiography is performed to quantify MR. It is identified as mild, moderate or severe by approximating the area of regurgitation into the left atrium as seen by the color flow mapping. It was later found to be quite unreliable. Color Doppler is now used for quantification of the severity of MR. It is not only the severity that needs to be focused on, but also the complex decision making process that goes on which determines the outcome of the therapy. Some of the factors that need to be taken into account are the age-factor of the patient (special attention on 80 or more), genetic diseases like diabetes, chronic kidney disease, chronic obstructive pulmonary disease, physical health and endurance, level of physical activity, sternness of the LV dysfunction. The experience and the qualification of the surgical team along with the mechanism of the MR also matters. MR due to mitral annular calcification (MAC) needs MV replacement for infectious endocarditis, but only after clean debridement.

A new technique is the use of biventricular pacing in the setting of ventricular dysynchrony (left bundle branch clock). The results are satisfactory with decreased MR, reverse remodeling, visible change in the symptoms and decreased rate of mortality. It can be clearly said that MR is a complex issue in the medical history. A perfect combination of a team of experienced doctors with accurate and advanced tests like transesophageal echocardiography required to determine the severity of MR is mandatory for success.

By: Judah98 Friedman98

Judah Friedman is the author of this article on Cardiovascular Consultants. Find more information about Cardiovascular Consultants here.

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