MITRAL REGURGITATION Present by Raissa Safitry (C111 09 346) Supervisor : dr. Pendrik Tandean, Sp.PD-KKV.FINASIM CASE PRESENTATION Department of Cardiology and V ascular Medicine Medical Faculty of Hasanuddin University Makassar 2014
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 1/42
MITRAL REGURGITATIONPresent by
Raissa Safitry
(C111 09 346)
Supervisor :
dr. Pendrik Tandean, Sp.PD-KKV.FINASIM
CAS E P RE S E NTATI O N
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar 2014
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 2/42
PATIENT IDENTITY
• Name : Mr. E
• Age : 21 years old
• Gender : Male
• MR : 660467
• Address : Mamuju
• Date of Admission : April 23th 2014
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 3/42
HISTORY TAKING
A 21 years old man was admitted to Emergency Room Chief complaint : Dyspneu
It was felt since a week ago, worsen in 1 days before
hospital admission, DOE (+) PND (-) Orthopneu (-).
Fever (+) since a week ago, intermitten. Cough (-)
Chest pain (-), history of chest pain (-)
Nausea (-), vomiting (-), epigastric pain (-).
Palpitation (+), Cold sweats (+).
General weakness (+)
Micturition and defecation remains normal as usually.
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 4/42
History of DM (-)
History of hypertension (-)
History of smoking (+) 1 pack/day, stopped in
2009
Past Medical History
Family History
History of cardiovascular disease in family (-)
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 5/42
General Status
Moderate illness/ Well nourished/ Conscious
Nutritional Status: Normal◦ Weight : 50 kg
◦ Height : 155 cm
◦ BMI : 20.8 kg/m2
Vital Sign
Blood Pressure : 120/80 mmHg
Pulse Rate : 120 bpm Respiratory Rate : 30 tpm
Temperature : 38 0C (axilla)
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 6/42
PHYSICAL EXAMINATION
Head and Neck Examinations Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-)Lip : Cyanosis (-)
Neck : JVP R +3 cmH O position 30º
Chest Examination Inspection : Symmetric between left and right chest.
Palpation : No mass, no tenderness.Percussion : Sonor between left and right chest,lung-liver border in ICS IV right anterior. Auscultation: Respiratory sound: Vesicular Additional sound :Ronchi -/- Wheezing /-
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 7/42
• Inspection : Heart apex was not visible
• Palpation : Heart apex was not palpable
•
Percussion : Right heart border in right parasternalline, Left heart border in left midclavicular lineICS V.
• Auscultation : Heart Sounds : S I/II regular, murmur (+)sistolic grade 3/6 in apexHeart
•
Inspection : Flat, follows breathing movement • Auscultation : Peristaltic sound (+), normal
• Palpation : No mass, no tenderness, liver andspleen unpalpable
• Percussion : Tympani (+)Abdomen
• Pretibial edema -/-
• Dorsal pedis edema -/-
Extremities
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 8/42
Electrocardiogram (ECG) 23/04/2014
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 9/42
ECG interpretation
Rhythm : Sinus rhythm
Heart rate : 115 bpmRegularity : regular Axis : +115P wave : P mitral 0,12 s on II,avL leadPR interval : 0,16 sQ pathologies : -
QRS complex : duration 0,08 s, ICRBBBST Segment : 0,08 s isoelectricT wave : 0,12 sConclusion :Sinus tachycardi rhythm, Normoaxis, ICRBBB
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 10/42
Chest X Ray
• Increased bronchovascular
marking,
• Suprahilar vascular dilatation,• No specific process in both of
lung
• CTI: 0,8, double contour
(LAE), cardiac waist
disappear, apex upward(RVE), small aorta knob.
• Normal sinus and
diaphragma.
• Intact bone
Conclusion:
• Cardiomegaly with sign of
pulmonary oedema (MHD)
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 11/42
LABORATORIUM
HEMATOL
OGY
RESULT NORMAL
VALUE
UNIT
WBC 6,1 4,00-10,0 (10³/UI)
RBC 4,94 4,00-6,00 (106
/UI)
HGB 13,0 12,0-16,0 (gr/dL)
HCT 52,1 37,0-48,0 (%)
PLT 235 150-400 (103/uL)
GDS 117 140 Mg/dL
Ureum 18 10-50 Mg/Dl
Creatinin 0,7 <1,3 Mg/dL
6/1/2014
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 12/42
Na 138 136-145 mmol/L
SGOT 42 <41 mmol/L
SGPT 16 <38 Mg/dL
PT 11.1
10-14 detik
APTT 25,0 22-30 detik
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 13/42
ECHOCARDIOGRAPHY
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 14/42
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 15/42
Working DIAGNOSIS
CHF NYHA IIMITRAL REGURGITATION
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 16/42
MANAGEMENT
Bed rest
Oxygen 3-4 lpm via nasal canula
IVFD NaCl 0.9% 500 cc/24 hr
Furosemide 20 mg/24 hours/IV
Digoxin 0,25 mg 1x1
Captopril 12,5 3x1 2 mg 1x1
PCT 500 3x1
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 17/42
DISCUSSION
MITRAL REGURGITATION
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 18/42
Normal mitral valve function depends
on perfect function of the complex
interaction between the mitral
leaflets, the subvulvar apparatus(chordae tendinae and papillary
muscles), the mitral annulus, and the
left ventricle.
An imperfection in any one of these components can
cause the valve to leak.
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 19/42
Mitral regurgitation is retrograde
flow of blood from LV to LA throughincompetent mitral valve during
systolic phase.
Causes by Primary (intrinsicvalvular disease) and
Functional (regional or global LVremodelling )
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 20/42
Primary
(intrinsic valvulardisease)
◦ MR is almost always
(90%) associated withMS in RHD
◦ Degenerative processesof leaflets and chordalstructures
◦
Infective endocarditis◦ Mitral annular
calcification
Functional
(regional or global LV
remodelling)
Structurally normal leaflets
and chordae tendinae
◦ Ischemic heart disease(Ischemic MR)
◦ Idiopathic dilated
cardiomyopathy
◦
Mitral annular dilatation
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 21/42
Etiology
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 22/42
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 23/42
Pathophysiology
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 24/42
Symptoms of MR
• Dyspnea
• Fatigue
• Orthopnea
• Palpitation
• Pulmonary edema (often the initial
manifestation)
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 25/42
Physical Exam Palpation may reveal the following:
Brisk carotid upstroke and hyperdynamic cardiacimpulse
Prominent LV filling wave
Auscultation may reveal the following: Diminished S1 in acute MR and chronic severe MR with
defective valve leaflets
Wide splitting of S2 as a result of early closure of the
aortic valve
S3 as a result of LV dysfunction or increased blood flowacross the MV
Accentuated P2 if pulmonary hypertension is present
Characteristic murmur
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 26/42
Auscultation
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 27/42
Clinical Features
Acute
Present withsudden onset ofpulmonary edema,
hypotensio,cardiogenic shock
Murmur earlysystolic, softinaudible
Normal LA sizeand compliance
Chronic
Usuallyasymptomatic, ifthere is present
with low COsymptom
Over time CHFfeatures
Increased LA size
Lower CO
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 28/42
Diagnostic Tests • CXR: LA and LV enlargement
• ECG: LV hypertrophy,sometimes AF
• Echo:
– LAE – LV enlargement
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 29/42
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 30/42
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 31/42
Surgical intervention
• Symptomatic with severe MR
• Asymptomatic with severe MR and
preserved LV function
• Asymptomatic with severe MR and LVESD >45 mm and EF < 55%
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 32/42
DISCUSSION
HEART FAILURE
DEFINITION
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 33/42
The state in which abnormal
circulatory congestion occurs as
the result of heart failure.
DEFINITION
Heart is no longer able to pump anadequate supply of blood in relation to the
venous return and in relation to the
metabolic needs of the body tissues at the
particular moment
ETIOLOGY OF HEARTFAILURE
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 34/42
ETIOLOGY OF HEARTFAILURE
MiocardDisease
CAD
Cardiomyopathy
Iatrogenic
Miocarditis
Miocard MechanicalDysfunction
Pressure overloaded
(Stenosis Aortae, Hypertension,Coartatio Aortae)
Volume Overloaded
(Mitral/Aortae Regurgitation,Congenital Heart Disease,
Hipertransfusion)
Miocard Filling Inhibitating
(Cardiac Tamponade, Pericarditis)
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 35/42
Major Criteria Minor Criteria
• Paroxysmal Nocturnal Dyspnea
• Cardiomegaly
• Gallop S3
• Hepatojugular reflux
• Increased of JVP
• Rales or ronchi
• Acute pulmonary edema• Prolonged circulation time(> 25
sec)
• Weigh loss ≥ 4,5 kg in 5 days in
response to treatment of CHF
• Extremity edema
• Nocturnal cough
• Decreased vital
pulmonary capacity (1/3
of maximal)
• Hepatomegaly
• Pleural effusion• Tachycardia (≥ 120bpm)
• Dyspnea d’effort
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 36/42
clASSIFICATION OF CHF
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 37/42
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 38/42
PATHOPHYSIOLOGY OF CHF
Plaque incoronary artery
Blood flow toheart muscle isreduced. Heartmuscle lacking
of oxygen
Ischemia ofheart musclecan lead tomyocardial
infarction
Symptomatic
CongestiveHeart Failure
Pulmonaryedema
Abnormal Heartrhythm
The heartmuscle cant
pumpadequately
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 39/42
Sign & symptom of chf
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 40/42
CHF MANAGEMENT
Non-Farmakologi
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 41/42
Farmakologi
8/10/2019 Case Presentation Kardio Raissa
http://slidepdf.com/reader/full/case-presentation-kardio-raissa 42/42
Thank You