Mitral valve insufficiency

Introduction to mitral insufficiency Due to anatomical and/or functional abnormalities of the mitral valve, the left ventricle partially returns to the left atrium when the left ventricle contracts, which is called mitral regurgitation. The most common cause of rheumatism is more common in northern China, mostly occurring in the 20-40 years old, more common in women. Rheumatic heart disease mitral insufficiency is caused by mitral valve damage left after repeated rheumatic inflammation, causing stiffness, deformation, and curling of the valve. Fusion and shortening of the valve junction, accompanied by chordae The shortening, fusion or rupture of the papillary muscle causes the mitral valve to be incompletely closed, causing a series of changes in hemodynamics. Other common causes include mitral valve prolapse, mitral valve degeneration, myocardial ischemia, infective endocardium, and congenital malformations. Most of the clinical manifestations are chronic. The prognosis depends mainly on the degree of valve insufficiency, atrial ventricular enlargement, cardiac function, basic etiology, recurrence of rheumatic activity, and whether complications occur. Early diagnosis and early treatment are the key. There is no specific cure for this disease, and surgical treatment can cure it. basic knowledge The proportion of the disease: the probability of the population is 0.006% Susceptible people: no special people Mode of infection: non-infectious Complications: heart failure, atrial fibrillation, respiratory infection

Mitral insufficiency etiology

(1) Causes of the disease

Mitral regurgitation is caused by recurrent episodes of rheumatic fever, thickening of the valve, scar formation and valve leaf contracture, as well as chordae tendine adhesion, rupture and papillary muscle scar formation and shortening, which limits valve movement and affects its closure, usually without valve calcification Deposition or only mild calcareous deposition.

(two) pathogenesis

Pathogenesis

The mitral valve structure includes the leaflets, annulus, chordae and papillary muscles. The function of the mitral valve, especially the closing function, depends on the structural integrity and functional coordination of the above parts, when any part of the above is damaged or functional. Disorders can cause insufficiency, leading to reflux of the left ventricular systolic blood, forming mitral regurgitation, or mitral regurgitation.

Before the normal soft mitral valve, about 1/3 of the leaflets in the posterior lobe fit in the systolic phase, and the papillary muscle contraction and the chordae tendine are tightened to maintain a good closed state. The rheumatic mitral regurgitation has the following pathology. change:

1 leaflet, papillary muscle and chordae shortening;

2 leaflets and papillary muscles, chordae adhesion;

3 valve leaf adhesions, the above changes caused the valve can not be properly closed, the disease is often longer in the lesions often have calcium deposition.

2. Pathophysiology

According to the corresponding hemodynamic changes in the degree of mitral regurgitation, it can be divided into three phases.

(1) Left ventricular compensation period: simple mitral regurgitation is incomplete in the left ventricular systolic phase. Except for most of the blood entering the aorta, some blood is refluxed to the left atrium, so that the left atrium receives the pulmonary vein from the diastolic phase. Return blood and left ventricle counter-bleed, so the left atrial filling volume and pressure can be increased, if the mitral regurgitation is simple, without mitral stenosis, in the left ventricular diastolic, although the left atrial flow into the left ventricle is normal Increased, but increased blood can still quickly fill the left ventricle, so the left atrial pressure can be quickly reduced to normal level, so that the left atrium and pulmonary vein pressure has a buffer gap, plus the left ventricle has a better compensation mechanism and a longer generation In the interim period, the simple mitral regurgitation is different from the simple mitral stenosis, and there is no obvious clinical manifestation of left atrial enlargement and pulmonary congestion in a long period of time. In the case of long-term diastolic volume overload, the left ventricle Gradual eccentric hypertrophy and enlargement, in the compensatory period, echocardiography found that the left ventricular end-systolic volume index increased and the left ventricular peripheral diameter shortened rate decreased, reflecting the left ventricle Decreased function, in patients with rheumatic mitral regurgitation, the pathological progress depends on the degree of rheumatic activity and the presence or absence of concomitant endocarditis caused by valve leaf rupture, chordae rupture and other causes of the severity of dysfunction If the above situation is combined, the left ventricle and the mitral annulus are further affected and enlarged, causing an increase in the reverse flow, thereby forming a vicious circle, which causes the disease to progress and deteriorate rapidly.

(2) left ventricular failure period: left ventricular decompensation period, on the one hand due to decreased cardiac output, causing increased left ventricular end-diastolic pressure (LVEDP), on the other hand increased mitral regurgitation, further left atrial pressure Increased, leading to pulmonary congestion and acute pulmonary edema, long-term pulmonary congestion can cause pulmonary arteriolar spasm, contraction, and gradually increase pulmonary artery pressure; long-term pulmonary hypertension can cause pulmonary intima and medial hyperplasia, resulting in right ventricular systolic load Excessive weight leads to right ventricular hypertrophy and expansion.

(3) right ventricular failure: right ventricular dysfunction symptoms in the late stage of mitral regurgitation, clinical manifestations of systemic venous congestion.

Mitral insufficiency prevention

Prevention of rheumatic heart disease, if you can effectively control the infection of a chain pharyngitis, you will not get rheumatic fever, rheumatic heart disease will not occur, the main preventive measures are:

Primary prevention

Refers to the prevention of the first episode of rheumatic fever, the key is early diagnosis and treatment of methyl chain tonsillitis, where fever, sore throat or discomfort, headache, abdominal pain, pharyngeal congestion and sputum tonsils have secretions should be swallowed swab culture before treatment To determine the presence or absence of a chain growth, if positive, should start antibiotic treatment immediately.

In addition to penicillin allergy, penicillin should be the drug of choice for all patients, for the following reasons:

1 All strains of Streptococcus hemolyticus are equally sensitive to penicillin;

2 After applying for more than 40 years, the average bacteriostatic and bactericidal concentration of penicillin against this bacteria did not change, still around 0.005g/ml;

3 There is no sign of resistance to penicillin;

4 so far no other antibiotics against streptococcal infection activity and clinical effect than penicillin G;

5 penicillin is relatively inexpensive, the antibacterial spectrum is narrow, so it will not inhibit the normal flora, can avoid double infection, and has fewer side effects than other effective antibiotics. Beta-penicillin is suitable for patients who can not complete oral penicillin treatment for 10 days; Personal history or family history; or geographical, socio-economic environment in patients with high RF area, intramuscular injection of benzathine alone is more painful, injection with benzathine penicillin plus procaine penicillin injection is not painful, mixed injection The dose of benzathine penicillin should be: 600,000 U for patients <27 kg and 1.2 million U for patients with >27 kg. For most small patients, a mixture of benzathine penicillin 900,000 U and procaine penicillin 300,000 U Good results can be obtained, but this preparation is not suitable for adolescent or adult patients. For areas with low RF incidence, penicillin V can be treated orally. Penicillin V has acid stability and absorption, and the concentration of penicillin produced is higher. High, for children and adults, the dose is 250mg, 3 times / d, a total of 10 days, must emphasize the importance of continuous medication for 10 days, even if the symptoms disappear after a few days of medication, should be served for 10 days, less than 10 Day effect Significantly reduced, but more than 10 days can not increase the efficacy, its treatment of streptococcal pharyngitis is the same or almost the same as oral penicillin, for adults, 2 times / d drug efficacy is not reliable, 3 to 4 times / d is better , but the maximum dose does not exceed 1g / d, followed by cephalosporin IV, VI0.25g, 4 times / d, a total of 10 days, but can not be used for patients with penicillin anaphylactic shock, tetracycline has not been produced domestically, sulfadiazine can not eliminate the chain Cocci, therefore not used to treat streptococcal angina, but continuous use of sulfadiazine is effective in preventing RF recurrence.

2. Secondary prevention

(Prevention of recurrence of rheumatic fever) Continuous antibiotic treatment is needed for patients with a clear history of rheumatic fever or existing rheumatic diseases to prevent recurrence of rheumatic fever.

(1) Precautionary period: Depending on the risk of recurrence, in general, people with upper respiratory tract infections, crowded living, poor medical conditions, and multiple episodes of history have a high risk of recurrence and a long time to prevent medication. On the contrary, it can be shortened appropriately. Patients with rheumatoid carditis have a relatively high risk of recurrence of carditis. They should receive long-term antibiotic prophylaxis until adult or lifelong prevention. On the contrary, patients who have not had rheumatic carditis have recurrence. The risk of involvement is low and antibiotic prophylaxis can be stopped in a few years. In general, prevention should last until at least 5 years after the patient reaches the twenties or the last rheumatic fever.

(2) Prevention program:

1 intramuscular injection of benzathine penicillin G: a common solution is long-acting penicillin preparation benzathine penicillin G 1.2 million U, intramuscular injection, once every 4 weeks, in acute RF high-risk countries and regions, and high-risk patients, preferably every 3 weeks Intramuscular injection 1 time.

2 oral antibiotics: patients with low risk of RF recurrence, such as those who have reached the end of puberty or adolescence or at least 5 years without recurrent rheumatic fever, can be changed to oral antibiotic prophylaxis, according to the recommended doses:

A. Sulfadiazine: body weight > 27kg, dose 1.0g, 1 time / d, weight 27kg, 0.5g per day, side effects are light and rare, occasionally can cause leukopenia, should check blood cell count every 2 weeks, pregnancy Advanced patients are banned because sulfadiazine can cross the placental barrier and compete with the bilirubin in the fetus for albumin binding sites.

B. Penicillin V: The dose is 250mg, 2 times / d, the allergic reaction is the same as the intramuscular injection of penicillin, and the penicillin skin test should be used before use.

C. Erythromycin: 250mg, 2 times / d, suitable for allergic to penicillin and sulfa drugs.

D. Chinese medicine such as honeysuckle, berberine, astragalus, cork, dandelion, radix isatidis, and andrographis paniculata; Chinese patent medicines such as silver yellow tablets, Yinqiao tablets, anti-inflammatory tablets, silver yellow needles, etc. have good effects on hemolytic streptococcal infection, choose application.

According to a recent WH0 report, 33,651 patients with RF or RHD were enrolled in secondary prevention for treatment in 1986-1990, but only about 63.2% of patients completed secondary prevention, 95.7% of whom used long-acting penicillin. Intramuscular injection once, 2.1% oral penicillin, 0.1% sulfadiazine, 2.1% erythromycin, 0.3% of patients had adverse reactions to penicillin, 53 cases of RF recurrence, accounting for 0.4% of patients/year, if not prevented The recurrence rate of rheumatic fever is as high as 60% of patients per year.

3. Prevention of complications

Patients with mitral regurgitation or replacement of prosthetic valves should pay special attention to the prevention of infective endocarditis.

1 regular oral examination, if there is oral infection, it should be treated early;

2 Antibiotics should be used even before a small operation.

Mitral insufficiency complications Complications, heart failure, atrial fibrillation, respiratory infection

1. Infective endocarditis: The most dangerous complication of mild to moderate mitral regurgitation is infective endocarditis, which can cause a sharp deterioration of cardiac function, which is more common than simple mitral stenosis.

2, atrial fibrillation and arterial embolism: mainly seen in advanced mitral regurgitation, often combined with mitral stenosis.

3, respiratory tract infection: long-term pulmonary congestion is likely to lead to pulmonary infection, can further aggravate or induce heart failure.

4, heart failure: is a common cause of complications and death.

5, embolism: due to the attachment of the wall thrombus, cerebral embolism is the most common.

Mitral insufficiency symptoms Common symptoms Heart valve disease Pulmonary congestion Jugular vein squeaky voice Fatigue palpitations systolic murmur Dizziness Difficulty

Symptom

The natural course and symptoms of mitral regurgitation depends on the severity of reflux, the compliance of the left atrium and the pulmonary hypertension, and whether there is a combination of cardiac and coronary disease, combined with its pathophysiological changes, may have the following corresponding Symptoms:

(1) Left ventricular compensation period: the asymptomatic period of compensation period is longer, before the occurrence of left ventricular failure (left heart failure), there may be several years or even more than 10 years of asymptomatic period, occasionally due to heart discharge Increased volume and increased apex beats cause mild palpitations.

(2) Left ventricular failure period: Once left heart failure occurs, the condition often develops rapidly. The main symptoms of chronic mitral regurgitation include:

1 Heart discharge decreased: visceral and limb blood supply caused by low cardiac output caused by left heart failure, manifested as fatigue, fatigue, dizziness and so on after activity.

2 pulmonary congestion symptoms: manifested as labor dyspnea, mild pulmonary congestion often in heavy physical labor, strenuous exercise; moderate, severe pulmonary congestion may occur paroxysmal nocturnal dyspnea, sitting breathing, but chronic mitral valve The incidence of acute pulmonary edema and hemoptysis is less common than mitral stenosis.

3 palpitations: often due to decreased cardiac output caused by compensatory heart rate, or due to concomitant arrhythmia, such as atrial fibrillation or premature contraction.

4 other:

A. Mild, moderate mitral regurgitation is complicated by infective endocarditis: there may be corresponding clinical symptoms.

B. Severe left ventricle, left atrial enlargement may have left chest pain and swallow discomfort.

(3) right ventricular failure period: involving the right ventricle and right heart dysfunction, may have upper abdominal fullness, liver pain, loss of appetite, oliguria, lower extremity edema.

2. Signs

(1) Left ventricular compensation period:

1 The apex beats to the left and down.

2 apical area can reach a limited and powerful lifting impulse: suggesting left ventricular hypertrophy.

3 The heart of the voiced voice expands to the lower left.

4 characteristics of auscultation noise:

A. systolic murmur in the apical region: a louder (3/VI level) is heard in the apical region, which is rougher, has a higher pitch, and has a longer time limit. The full systolic murmur is often concealed by the first heart sound; Or the sound of the papillary muscle may occur, according to the direction of the reflux beam, the noise can be left to the left, the left shoulder and the left sternal border, the noise is often weakened during inhalation, slightly enhanced during exhalation; left heart Reduced in depletion, enhanced after heart failure correction.

B. The apical area has a third heart sound (S3): pathological S3, which is a characteristic feature of moderate to severe mitral regurgitation. The left ventricular filling is excessive during the early filling of the diastole, causing enlarged left ventricular wall vibration. Caused.

C. apical mid-diastolic murmur: patients with severe mitral regurgitation, due to increased blood flow rate and increased blood flow through the mitral valve during diastole, can be followed by a short, low-profile diastolic middle murmur after S3. The murmur does not extend to the late diastole.

D. Pulmonary valve area second heart sound (P2) division: the left ventricular contraction time interval is shortened, the aortic valve closure is advanced, and P2 division occurs; P2 hyperthyroidism can be hyperthyroidism.

(2) Left ventricular failure period:

1 diffuse beats can be seen in the anterior region.

2 apical area full systolic miscellaneous sound can be reduced; and P2 can be further advanced.

3 The inner part of the apical area can be heard in the early (early) period.

4 The base of the lungs is fine and wet.

(3) Right heart failure period:

1 Tricuspid valve area can smell 3 ~ 4 / VI systolic hairy murmur.

2 body circulation venous congestion signs:

A. Jugular vein engorgement, pulsation.

B. Liver is large.

C. Positive for jugular venous return.

D. Ascites sign.

E. Lower extremity edema.

Examination of mitral insufficiency

X-ray inspection

Under fluoroscopy, left ventricular pulsation enhancement and left atrial dilatation pulsation can be seen in systole, such as X-ray film: posterior anterior position sees left atrium, left ventricular shadow increases; right atrium can show double atrial shadow, visible pulmonary congestion; right anterior oblique position Shows that the left atrium expands and the esophagus moves backwards, shifts to the right, and the right ventricle increases in the late stage. When the acute mitral regurgitation is incomplete, the left atrium and left ventricle may be small or only slightly enlarged, mainly manifested as pulmonary edema. Signs.

2. ECG

Mild mitral regurgitation ECG can be normal; moderate to severe left atrial hypertrophy and left ventricular hypertrophy, strain.

3. Echocardiography (UCG)

(1) M-type and two-dimensional UCG: patients with rheumatic valvular disease can be seen with thickening of the valve, chordae, papillary muscle thickening, shortening or prolongation, and the chordae rupture can be seen as "continuous swaying", visible when the leaflet is prolapsed "Hammock-like" changes; systolic mitral valve anterior and posterior dysplasia, and visible gaps, spacing > 2mm, two-dimensional UCG can show the specific location of the closure of the fracture or the leaflet hole, sputum, etc.; indirect signs have left ventricular enlargement The left ventricular outflow tract is widened, the left atrium is enlarged and the atrioventricular ring is expanded.

(2) Doppler UCG: Pulse Doppler detected high-speed, wide-frequency turbulent spectrum in the left atrial side, and color Doppler showed a multicolored mosaic counterflow in the left atrium of the systolic period. The origin and direction of the backflow beam can be displayed.

(3) Quantitative diagnosis: UCG is a semi-quantitative diagnosis of mitral regurgitation. There are many methods, and should be comprehensively analyzed in clinical application.

1 using pulse Doppler sampling in the left atrium, according to the length of the reflux beam in the left atrium,

2 Using the ratio of the color Doppler flow beam area to the left atrial area to estimate the backflow, the following formula can be used: MR = maximum reflux area / left atrial area, <20% is mild, 20% to 40 % is moderate, 40% to 60% is moderate to severe, and >60% is severe.

3 The blood flow convergence method quantifies the mitral regurgitation, which has been reported at home and abroad, and its clinical value needs further study.

(4) Transesophageal UCG: In addition to the more detailed and accurate observation of the two-dimensional structure of the mitral valve and its attachments (chord, papillary muscle, annulus), the detection rate of atrial thrombus is higher, on the second tip The detection of regurgitation is more sensitive than conventional transthoracic UCG, and it is often possible to detect extremely mild reflux that is not easily found by transthoracic UCG.

(5) Three-dimensional, four-dimensional UCG: can observe the structure and movement of the leaflets in three-dimensional direction, more intuitively observe the starting position, direction and shape of the reflux beam, which is of great help to the diagnosis, and can give the surgical plan Provide more valuable information.

4. Left ventricular angiography

Right anterior oblique position and left lateral position. According to the situation of contrast agent appearing in the left atrium during left ventricular angiography, the reflux is divided into 4 levels:

(1) 1/4 degree: The contrast agent reflux beam is not behind the left atrium and is removed when the next ventricle is dilated.

(2) 2/4 degrees: refluxing contrast agent reaches the posterior wall of the left atrium, but does not reach the same gray as the left ventricle

(3) 3/4 degrees: The left atrial contrast agent is incremented to the same gray level as the left ventricle.

(4) 4/4 degrees: The contrast agent of the first systolic reflux has reached the entire left atrium, and a contrast agent is visible in the pulmonary vein.

Diagnosis and diagnosis of mitral insufficiency

According to its clinical manifestations, all the characteristic signs of mitral regurgitation, that is, the apical region has a loud (3/VI), rougher, higher pitch, longer time, full systolic murmur-like murmur with S3; Combined with laboratory tests, especially echocardiography, not only qualitative diagnosis of mitral regurgitation, but also semi-quantitative diagnosis of reflux.

Mitral regurgitation must pay attention to the following differential diagnosis, first of all should be identified as functional or organic mitral regurgitation.

1. Functional mitral regurgitation:

Hypertension, coronary heart disease (papillary muscle dysfunction), primary cardiomyopathy, aortic regurgitation or massive left to right shunt (> pulmonary circulation 50%) congenital heart disease (ventricular septal defect, arterial catheterization Closed) and other diseases, causing the left ventricle or mitral annulus to expand and produce relative mitral regurgitation, can hear more loud (> 2 / VI) and rough systolic murmur in the apical region, its noise In the case of cardiac insufficiency, the murmur is reduced after the improvement of cardiac function and the reduction of left ventricle. On the contrary, the systolic murmur of patients with organic mitral regurgitation is relieved in the case of cardiac insufficiency, and is obviously enhanced after the improvement of cardiac function. Patients with functional mitral regurgitation each have their corresponding clinical features and can be identified.

2. Organic mitral regurgitation:

When clinically diagnosed rheumatic mitral regurgitation, the first non-rheumatic mitral regurgitation should be identified:

(1) mitral valve prolapse: regardless of primary or secondary (cardiomyopathy, coronary heart disease, etc.), due to mucinous degeneration of the mitral or chordae, the valve is hypertrophied, the chordae tendon is prolonged, In the middle of the contraction, due to the excessive chordae, when the mitral valve prolapses to the extreme point, it suddenly tightens, causing the valve to suddenly stop, resulting in a click sound. When the two leaflets are obviously displaced beyond the plane of the annulus, they cannot be normally closed. , can lead to contraction, late reflux murmur, it is also known as "systolic mid-kappy-systolic late murmur syndrome", clinically mild mitral valve prolapse when the apical region only systolic mid-term click When the prolapse is heavier, there is a mid-systolic click sound and a late systolic murmur; when the prolapse is severe, a full systolic murmur occurs, and there is often no click sound, and the M-mode echocardiogram is in the middle or middle systolic anterior flap. The leaf and/or posterior leaflet closure line (CD segment) showed a "hammock-like change". Two-dimensional ultrasound images showed that one or two leaves of the mitral valve were detached to the left atrium, and color Doppler was visible along the prolapse. The mitral valve has a regurgitation beam, while there is no reflux during mild prolapse, where the left ventricle is dilated The factors of end-stage capacity reduction (such as deep inhalation, three-dimensional, forced period of Valsalva action, inhalation of isoamyl nitrite, etc.) can increase the prolapse of the leaflets, the click sound is advanced, and the systolic murmur becomes longer and louder; The factors of increased left ventricular end-diastolic volume (such as deep exhalation, squatting, relaxation of Valsalva movement or oral propranolol) can reduce the prolapse of the valve leaflets, delaying the click sound, shortening the systolic murmur and Reduced.

(2) Partial type of atrioventricular tube malformation: a type of atrioventricular tube malformation. Due to the incomplete development of the endocardial pad during the embryonic period, the primary atrial septum stops growing and fails to fuse with the endocardial pad, resulting in atrial septum. Lower defect and mitral anterior and tricuspid valvular fissures, clinical signs: rough systolic murmur in the apical region, second in the left sternal border, systolic murmur in the pulmonary valve between the three intercostals, with pulmonary artery The second heart sound in the valve area is hyperthyroidism and the second heart sound splitting is fixed. The echocardiogram shows the echo loss in the lower part of the atrial septum, the right atrium, the room enlarges, the left atrium and the chamber enlarges; the short axis of the mitral valve shows the anterior valve fissure, color Doppler can see the colorful blood flow across the lower part of the interatrial septum into the lower part of the right atrium, and can show reflux blood flow on the atrial side of the second and tricuspid valve.

(3) papillary muscles, chordae rupture: acute myocardial infarction, infective endocarditis, cardiac trauma, etc. can occur nipple tendon rupture, which causes severe mitral regurgitation, clinically in addition to the original disease manifestations Symptoms and signs of acute mitral regurgitation, such as the sudden appearance of rough systolic murmur in the apical region, conduction to the back, and more systolic fine tremor; rapid pulmonary edema can occur rapidly after the occurrence of murmur, left atrium Without expansion, echocardiography can detect signs of myocardial infarction and infective endocarditis, as well as the "swinging phenomenon" of the free end of the broken chordae.

3. It should be identified as acute or chronic mitral regurgitation.

4. The degree of mitral regurgitation should be further judged (semi-quantitative):

The mitral regurgitation is different, and the effects on left ventricular function and treatment are different. The pulsed Doppler echocardiography is a rough estimate of the mitral regurgitation: the sampling volume is 1/3 of the mitral valve to the left atrium. The inter-exploration and reflux spectrum are mild reflux; the reflux spectrum in the heart chamber of the valve from the valve to the left chamber is moderate reflux; if the left atrium can show turbulence as severe reflux, color Doppler can estimate the degree of return according to the mitral regurgitation range, direction, time and initial width. In recent years, it is recommended to use the reflux score to evaluate the reflux score = mitral regurgitation / Left ventricular cardiac output, when the reflux score <35%, unless the primary disease has progress, generally has no significant effect on left ventricular function, should pay attention to its follow-up observation; when the reflux score >50%, can make Left heart function is obviously impaired, surgical treatment should be considered; 35% to 50% can affect left ventricular function, medication should be used to reduce mitral regurgitation, mitral regurgitation in left ventricular angiography, and color Doppler is generally consistent, such as 1/4 degree of left ventricular angiography, equivalent to a reflux score <20%; 2 / 4 degrees is 20% of the reflux score ~ 40%; 3/4 degrees is 40% to 60% of the reflux score; 4/4 degrees is >60% of the reflux score.

5. The following two points should be noted in the diagnosis of rheumatic mitral regurgitation:

(1) Rheumatic mitral stenosis and mitral regurgitation: how to judge whether it is mainly stenosis or insufficiency.

(2) rheumatic mitral stenosis and mitral regurgitation: systolic murmur heard in the apical region, should be associated with rheumatic mitral stenosis and pulmonary hypertension caused by right ventricular hypertrophy, dilatation, caused by the three tips The regurgitation of the valvular insufficiency and the heart's clockwise transposition, the systolic murmur of the tricuspid valve in the lower sternum is translocated to the mitral valve area.

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