• goals = FULL + FAST + FORWARD

Carpentier's pathophysiological triad

• Aetiology = cause of disease
• Lesions = results from disease
• Dysfunctions = results from lesions

Carpentier's functional classification

• Type I = normal leaflet motion

• Type II = excessive leaflet motion + prolapse/flail segments

• Type III = restricted leaflet motion

  • IIIa = ⬇opening = restriction in diastole
  • IIIb = ⬇closure = restriction in systole

• Severity

  • Grade I
  • Grade II
  • Grade II
  • Grade IV
    • EROA > 0.4 cm2
    • RF > 50%
    • RVol > 60 mL

• Overview
  • 1.7% general population
  • most frequent L-sided VHD in community
  • 2nd commonest L-sided VHD in hospital
• Incidence
• Prevalence
• Gender

• Primary = diseased valve = leaflet abnormality
  • degenerative
  • infectious = IE
• Secondary = normal valve = functional = ventricular remodelling
  • LV failure
  • annular dilatation ⮕ supraventricular arrhythmias + LA dilatation

• VOLUME OVERLOAD

• blood flows back into LA during LV systole

  • LA volume overload
  • LA dilatation, APO, ⬆PAP
  • arrhythmias due to LA dilatation

• ⬆risk PHTN = RVF

• acute MR

• ⬆volume in LA = ⬆pulmonary pressures

• chronic MR

• LV dilatation to maintain CO

• ⬆risk MACE
• AF (esp if LA dilatation)

• Heart failure
  • forward = fatigue
  • backward = SOB, orthopnoea

• murmur
  • pansystolic murmur at apex
  • may radiate to left axilla (AS doesn't)
  • Gallavardin phenomenon = AS radiates to apex
• S3

• ECG

  • RAH
  • p mitrale

• CXR

  • cardiomegaly

• echo

• TOE is gold standard

• large / eccentric MR jets

• primary MR

  • valve repair
    • repair better than replacement
    • benefits clearly established

• secondary MR

  • potential impact of surgery unclear

• transcatheter mitral valve intervention

  • less advanced than TAVI (mitral valve more complex)
  • MitraClip = edge-to-edge technique = double-orifice mitral valve
  • coronary sinus annuloplasty

• acute MR

  • surgical emergency
  • diuretics + vasoD
  • temporisation = IABP

• chronic MR

  • treat HF = ACEi, BB, digoxin, CCB

• Pre-op
  • severe + asymptomatic
    • proceed with appropriate intraop and postop monitoring
• Intra-op
  • better tolerated than stenotic lesion
  • same as AR = maintain forward flow, ⬇regurgitant volume = "full fast forward"
  • 1:PL = "full"
    • adequate PL volume
    • avoid overload = ⬆stretch = ⬆MR / LVF
  • 2:rate = "fast"
    • HR 80-100 = high-normal
    • avoid bradycardia = ⬆LVEDV = ⬆regurgitant fraction ⮕ ⬇CO
  • 3:rhythm
    • Sinus
    • treat AF aggressively
  • 4:INO
    • very important
    • avoid -ve INO, eg BB
    • consider +ve INO, eg dobutamine
  • 5:AL = "forward"
    • avoid ⬆SVR = ⬆afterload = ⬆regurgitant fraction = ⬇CO
      • avoid excessive AL ***
    • consider vasoD = nitroprusside
  • prevent ⬆PVR = ⬆risk RVF
• Post-op

• pregnancy
  • RHY = defend SR
    • acute AF + HDI = cardioversion
  • PL = caution aortocaval compression = ⬇PL
  • AL = prevent ⬆AL
  • EDB preferred

Final FRCA In A Box

http://www.themitralvalve.org/mitralvalve/functional-classification

https://www.anesthesiaconsiderations.com/mitral-regurgitation

Risk Factors for Mitral Valve Surgery: Atrial Fibrillation and Pulmonary Hypertension, 2019

https://asecho.org/wp-content/uploads/2018/02/Zoghbi-Case-Studies-Quantification-of-Severity-of-Mitral-Regurgitation-with-New-ASE-Guidelines.pdf