Quantitating the Degree of Mitral Regurgitation

1. How can you tell the degree of MR by palpation?

ANS: The MR is greater:

a. The larger the LV by palpation.

b. The greater and later the left parasternal movement. (This may represent the left atrium expanding during systole.)

c. The more palpable an early rapid filling wave and S3 at the apex.

2. How can you tell the degree of MR by auscultation?

ANS: The MR is greater:

a. The louder and longer the apical systolic murmur. However, although ruptured chordae murmurs may be decrescendo, they are almost always at least grade 3/6 in loudness [4].

b. The louder the S3, since this is roughly proportional to the torrential diastolic flow, with the exception of sudden severe MR due to ruptured chordae on a previously normal mitral valve. The S3 here is either soft or absent.

c. The longer and louder the diastolic flow murmur following the S3. (See figure on p. 219.)

d. The wider the split of the S2, unless the development of severe pulmonary hypertension narrows the split.

This phonocardiogram and apical pulse tracing is from a 15-year-old girl with severe rheumatic MR. The pulse tracing was taken over the LV impulse in the supine position and is therefore an apex precordiogram instead of an apex cardiogram, which is taken in the left lateral decubitus position. The phonocardiograms are from the third left parasternal interspace. The upper one is taken at medium frequency; the lower one brings out low and medium frequencies. Note the following signs of severe MR: (1) the widely split S2 of 50 ms; (2) the diastolic flow murmur after the S3; (3) the exaggerated early rapid filling peak of the apical impulse (this would be palpable in the left lateral decubitus position).

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