Mitral regurgitation differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Mohammed A. Sbeih, M.D. [3]

Overview

The blowing holosystolic murmur of mitral regurgitation must be distinguished from tricuspid regurgitation and a ventricular septal defect.

Differentiating Mitral Regurgitation from Tricuspid Regurgitation and Ventricular Septal Defects

Physical Examination

All the three cardiac conditions have holosystolic murmur on auscultation. But they can be differentiated by characteristics of the murmur detailed below:

Mitral Regurgitation Tricuspid Regurgitation VSD
  • The murmur in mitral regurgitation is high pitched and best heard at the apex with diaphragm of the stethoscope with patient in the lateral decubitus position.
  • Left ventricular function can be assessed by determining the apical impulse.
  • A normal or hyperdynamic apical impulse suggests good ejection fraction and primary mitral regurgitation.
  • A displaced and sustained apical impulse suggests decreased ejection fraction and chronic and severe mitral regurgitation.
  • The holosystolic murmur can be best heard over the left third and fourth intercostal spaces and along the sternal border.
  • When the shunt becomes reversed ("Eisenmenger's syndrome"), the murmur may be absent and S2 can become markedly accentuated and single.

Echocardiography

The above three cardiac conditions can also be differentiated more definitively using echocardiography where the echogenicity of blood flow across the defective valves or septum can be visualized and the severity can be quantified.

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