The dynamic mitral valve is prone to three diseases, which are known as mitral stenosis (MS), mitral regurgitation (MR), and mitral valve prolapse (MVP). As a key anatomic and functional structure, advanced disease of this valve may lead to complications such as heart failure and death [1].

MS is commonly caused by rheumatic fever, which is rare in industrialized countries but still prevalent in developing regions. The disease presents in young adults usually in the third or fourth decade with symptoms such as fatigue, palpitations, chest pain, hemoptysis [2]. When MS progresses, the patient may experience dyspnea on exertion, orthopnea, as well as paroxysmal nocturnal dyspnea [3]. Among the clinical features are jugular vein distension and a displaced apical impulse. On auscultation, there is a loud S1 (first heart sound), split S2 (second heart sound), an opening snap, and a diastolic rumble.

MR typically develops as a consequence of aging mechanisms, ischemic disease, rheumatic fever, or prolapse [2] [4]. There are two forms of MR, which are acute (rare) and chronic. Often the result of valvular infection, the presentation of acute MR mimics that of acute heart failure. However, chronic MR evolves gradually and may be asymptomatic in the early stages. Features include fatigue, dyspnea, palpitations, and so forth. Auscultation findings include an apical holosystolic murmur with a soft S1, split S2, and possibly a third heart sound (S3).

MVP is found in up to 3% of the population [5] and is more predominant in young women [2]. While many individuals with prolapse do not exhibit symptoms, some will have fatigue, dizziness, dyspnea, palpitations, chest pain, anxiety, and presyncope. The palpitations may be triggered by emotional stress. The hallmark murmur is a mid-to-late systolic click.

• Heart Disease

  KEYWORDS: IL-10; IL-4; Rheumatic heart disease; mitral valve disease; polymerase chain reaction [ncbi.nlm.nih.gov]

  Top Rated Valvular Heart Disease Program The Nancy & Bill Thompson Heart Valve Center is one of a handful of clinics nationwide dedicated to state-of-the-art screening, diagnosis and treatment of valvular heart disease. [hoag.org]

• Mitral Valve Prolapse

  What is mitral valve prolapse (MVP)? Mitral valve prolapse is a condition in which the two valve flaps of the mitral valve do not close smoothly or evenly, but instead bulge (prolapse) upward into the left atrium. [heart.org]

  Mitral Valve Prolapse Mitral valve prolapse (Figure 2B) is a common condition, occurring most frequently in women; some types are hereditary. [ahajournals.org]

• Heart Murmur

  If you have a heart murmur, your doctor may recommend that you visit a cardiologist. [mayoclinic.org]

  Mitral valve regurgitation also produces a distinct sound (heart murmur) that a doctor may hear through a stethoscope. To continue reading this article, you must login. [health.harvard.edu]

  Your doctor may listen to your heart with a stethoscope to determine if you have a heart murmur that may indicate a mitral valve condition. [rwjbh.org]

• Late Systolic Murmur

  Physical examination most often reveals the presence of a mid-systolic click and a mid to late systolic murmur, which reflects the timing of prolapse in the setting of excess tissue and chordal elongation without chordal rupture (i.e. flail leaflet) 2 [mitralvalverepair.org]

  In the 1960s, Reid7 and Barlow and colleagues1 proposed that mid to late systolic clicks and apical late systolic murmurs were of mitral valvar origin. [heart.bmj.com]

  Typically, MVP is a diagnosis commonly detected by cardiac auscultation with one or more systolic clicks and/or a mid-to-late systolic murmur detected on a careful auscultation. [ncbi.nlm.nih.gov]

• Diastolic Murmur

  A mid-late diastolic murmur, best heard, with the patient in the left lateral position, with the bell of the stethoscope (see separate Heart Auscultation article). Atrial fibrillation. [patient.info]

  The indicative low rumbling diastolic murmur is best heard in expiration at the apex, with the bell of the stethoscope. Ongoing elevated pulmonary artery (PA) pressures put strain on the right ventricle, and will eventually cause this to fail. [academic.oup.com]

  PHYSICAL EXAMINATION An apical rumbling, diastolic murmur is characteristic and will immediately follow an opening snap, if present. [aafp.org]

• Amenorrhea

  A 31-year-old female patient at 30 weeks of amenorrhea was admitted to the obstetrics department with 40 degrees C hyperthermia and New York Heart Association (NYHA) class 4 dyspnea. [ncbi.nlm.nih.gov]

• Anuria

  Critical preoperative state is defined as ventricular tachycardia or fibrillation, aborted sudden death or cardiac massage, ventilation prior to surgery, inotropic support, ventricular assist device/balloon pump preoperatively or acute renal failure (anuria [escardio.org]

• Radiculopathy

  Decreased thoracic kyphosis (straight back) is a known cause of hastening back or neck problems, radiculopathy, or even myelopathy. The study aim was to examine the relationship between MMVD, straight back, and the need for cervical fusion. [ncbi.nlm.nih.gov]

Individuals with a clinical presentation suggestive of mitral valve disease warrant a thorough workup consisting of the patient and family history, physical exam including auscultation [2], and the appropriate studies.

Laboratory tests

The workup should include a complete blood count (CBC) a complete metabolic panel (CMP).

Imaging

Echocardiography is a critical component of the assessment since it is noninvasive, accessible, and provides information for diagnosis and monitoring of the disease [6]. This modality is sensitive and specific for identifying MS [7] and is the key for diagnosing MR and MVP [8]. This study also allows the clinician to determine the etiology and stage of the valvular abnormality and functionality and size of the atria.

Transthoracic echocardiogram (TTE) reveals mobility, calcification, and thickening of the valve [9]. Moreover, real-time 3-dimensional transesophageal echocardiography (TEE), which is superior to TTE, offers excellent images of the mitral valve [10]. Very importantly, TEE is very beneficial in cases suggestive of endocarditis or presence of thrombi.

Chest radiography is another important investigative study. In patients with MS, a chest X-ray will likely display calcification of the mitral valve, left atrial enlargement, interstitial edema, and prominent pulmonary vasculature. In patients with chronic MR, chest X-ray findings may include left ventricular and left atrial enlargement, and evidence of heart failure such as pulmonary congestion. Similar observations are found in patients with MVP associated with MR.

Other imaging tests such as ventriculography and cardiac magnetic resonance imaging (MRI) may be utilized to measure the regurgitation.

Electrocardiography (EKG)

An EKG is obtained in all patients with cardiac complaints. A typical finding in patients with advanced MS is atrial fibrillation. Other remarkable features include prolonged P wave in lead II, which is indicative of left atrial hypertrophy. Features associated with chronic MR are left ventricular and left atrial hypertrophy, and ST segment changes in lateral leads. Additionally, there are P wave abnormalities in various leads. Occasionally, MVP is associated with benign arrhythmias.

Procedures

Cardiac catheterization is performed selectively prior to surgery. Also, stress EKG is used periodically to monitor MR.

• Hypocapnia

  Blood gases showed severe hypoxemia associated with hypocapnia. The patient needed to be rapidly intubated and was placed on ventilatory support because of acute respiratory failure. [ncbi.nlm.nih.gov]

• Hypercapnia

  Pulmonary vascular pressures should be optimized by avoiding hypoxia, hypercapnia, and acidosis to prevent acute right ventricular decompensation. [academic.oup.com]

• P Mitrale

  Harrison's Internal Medicine 17th edition a b medilexicon.com P mitrale Citing. Stedman's Medical Dictionary. Copyright 2006 Greenberg BH, Massie BM, Brundage BH, Botvinick EH, Parmley WW, Chatterjee K (1978). [en.wikipedia.org]

  In asymptomatic patients, where the systolic PA pressure is 50 mm Hg, non-cardiac surgery is considered safe.7 ECG AF is common, although p-mitrale may be noted if still in sinus rhythm. [academic.oup.com]

• Prominent A-Wave

  He is in chronic atrial fibrillation (AF), his neck veins are distended with prominent V waves, and he has an enlarged pulsating liver and severe peripheral edema. [onlinejacc.org]

• Prominent V-Waves

  He is in chronic atrial fibrillation (AF), his neck veins are distended with prominent V waves, and he has an enlarged pulsating liver and severe peripheral edema. [onlinejacc.org]

• Left Atrial Hypertrophy

  Other remarkable features include prolonged P wave in lead II, which is indicative of left atrial hypertrophy. Features associated with chronic MR are left ventricular and left atrial hypertrophy, and ST segment changes in lateral leads. [symptoma.com]

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3. Carabello BA. Modern Management of Mitral Stenosis. Circulation. 2005;112(3):432-437.
4. Enriquez-Sarano M, Schaff HV, Frye RL. Mitral regurgitation: what causes the leakage is fundamental to the outcome of valve repair. Circulation. 2003;108(3):253-6.
5. Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med. 1999;341(1):1–7.
6. Hung JW, Tan TC. Echocardiography in mitral valve disease. Preface. Cardiol Clin. 2013;31(2):ix-x.
7. Wunderlich NC, Beigel R, Siegel RJ. Management of mitral stenosis using 2D and 3D echo-Doppler imaging. JACC Cardiovasc Imaging. 2013;6(11):1191-205.
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9. Bruce CJ, Nishimura RA. Newer advances in the diagnosis and treatment of mitral stenosis. Curr Probl Cardiol. 1998;23(3):125-92. Review.
10. Schlosshan D, Aggarwal G, Mathur G, Allan R, Cranney G. Real-time 3D transesophageal echocardiography for the evaluation of rheumatic mitral stenosis. JACC Cardiovasc Imaging. 2011;4(6):580-8.