MITRAL REGURGITATION
Present by
Raissa Safitry
(C111 09 346)
Supervisor :
dr. Pendrik Tandean, Sp.PD-KKV.FINASIM
CASE PRESENTATI ON
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar 2014
PATIENT IDENTITY
Name : Mr. E
Age : 21 years old
Gender : Male
MR : 660467
Address : Mamuju
Date of Admission : April 23th
2014
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.
Chest pain (-), history of chest pain (-)
Cough (-)
General weakness (+)
(Nausea (-), vomiting (-), epigastric pain (-).
Palpitation (+), Cold sweats (+).
Micturition and defecation remains normal as usually.
History of DM (-)
History of hypertension (-) since
History of smoking (+) 1 pack/day, stopped in
2009.
History of medicine (-)
Past Medical History
Family History
History of cardiovascular disease in family (-)
RISK FACTORS
Non- Modified
Modified
Gender : Male
Age
Smoke
General Status
Moderate illness/ Well nourished/ Conscious
Nutritional Status: Normal
Weight : 50 kg
Height : 155 cm
BMI : 20.8 kg/m
2
Vital Sign
Blood Pressure : 120/80 mmHg
Pulse Rate : 120 bpm
Respiratory Rate : 30 tpm
Temperature : 38
0
C (axilla)
PHYSICAL EXAMINATION
Head and Neck Examinations
Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-)
Lip : Cyanosis (-)
Neck : JVP R +3 cmHO potition 30
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 /-
Inspection : Heart apex was not visible
Palpation : Heart apex was not palpable
Percussion : Right heart border in right parasternal
line, Left heart border in left midclavicular line
ICS V.
Auscultation : Heart Sounds : S I/II regular, murmur (+)
sistolik grade 3/6 in apex
Heart
Inspection : Flat, follows breathing movement
Auscultation : Peristaltic sound (+), normal
Palpation : No mass, no tenderness, liver and
spleen unpalpable
Percussion : Tympani (+)
Abdomen
Pretibial edema -/-
Dorsal pedis edema -/-
Extremities
Electrocardiogram (ECG)
23/04/2014
ECG interpretation
Rhythm : Sinus rhythm
Heart rate : 115 bpm
Regularity : reguler
Axis : +115
P wave : P mitral 0,12 s on II,avL lead
PR interval : 0,16 s
Q pathologies : -
QRS complex : duration 0,08 s, ICRBBB
ST Segment : 0,08 s isoelectric
T wave : 0,12 s
Conclution :
Sinus tachycardi rhythm, Normoaxis, ICRBBB
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)
LABORATORIUM
HEMATOL
OGY
RESULT NORMAL
VALUE
UNIT
WBC 6,1 4,00-10,0 (10/UI)
RBC 4,94 4,00-6,00 (10
6
/UI)
HGB 13,0 12,0-16,0 (gr/dL)
HCT 52,1 37,0-48,0 (%)
PLT 235 150-400 (10
3
/uL)
GDS
117
140 Mg/dL
Ureum
18
10-50 Mg/Dl
Creatinin 0,7 <1,3 Mg/dL
6/1/2014
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
CK L<190,P<187 u/L
CKMB <25 u/L
TROPONIN T <0.05
ECHOCARDIOGRAPHY
INTERPRETATION
Conclusion
sistolic LV function is good, EF 63,33% (on
tachicardi)
Dimensional chambers of heart: LA,RA,RV
dilatation
Decrease RV function
MR severe
TR moderate-severe
PR Trivial
PH moderate-severe (mPAP 59 mmHg)
Working DIAGNOSIS
CHF NYHA II
MITRAL REGURGITATION
MANAGEMENT
Bed rest
Oxygen 3-4 lpm via nasal canula
IVFD NaCl 0.9% 500 cc/24 hr
Furosemide 20 mg/24 hours/IV
Captopril 12,5 3x1 2 mg 1x1
PCT 500 3x1
DISCUSSION
MITRAL REGURGITATION
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.
Mitral regurgitation is retrograde
flow of blood from LV to LA through
incompetent mitral valve during
systolic phase.
Causes by Primary (intrinsic
valvular disease) and
Functional (regional or global LV
remodelling )
Primary (intrinsic
valvular
disease)
MR is almost always
(90%) associated with
MS in RHD
Degenerative processes
of leaflets and chordal
structures
Infective endocarditis
Mitral annular
calcification
Functional (regional or
global LV remodelling
)
Structurally normal leaflets
and chordae tendineae
Ischemic heart disease
(Ischemic MR)
Idiopathic dilated
cardiomyopathy
Mitral annular dilatation
Etiology
Pathophysiology of MR
Mitral regurgitation
Systolic (Retrograde) ejection into LA
Acute Chronic
Volume overload in LA & LV ed LV afterload (into LA)
ed LA, LV Pressure ed LA/LV size/ compliance
Pulmonary edema ed Cardiac output LA dilatation ed contractility
AF CO
Pulmonary congestion
Pathophysiology
Symptoms of MR
Dyspnea
Fatigue
Orthopnea
Palpitation
Pulmonary edema (often the initial
manifestation)
Physical Exam
Palpation may reveal the following:
Brisk carotid upstroke and hyperdynamic cardiac
impulse
Prominent LV filling wave
Auscultation may reveal the following:
Diminished S
1
in acute MR and chronic severe MR with
defective valve leaflets
Wide splitting of S
2
as a result of early closure of the
aortic valve
S
3
as a result of LV dysfunction or increased blood flow
across the MV
Accentuated P
2
if pulmonary hypertension is present
Characteristic murmur
Auscultation
Clinical Features
Acute
Present with
sudden onset of
pulmonary edema,
hypotensio,
cardiogenic shock
Murmur early
systolic, soft
inaudible
Normal LA size
and compliance
Chronic
Usually
asymptomatic, if
there is present
with low CO
symptom
Over time CHF
features
Increased LA size
Lower CO
Diagnostic Tests
CXR: LA and LV enlargement
ECG: LV hypertrophy,
sometimes AF
Echo:
LAE
LV enlargement
Medical Therapy
ACE-Inhibitor
Diuretic
Nitrat
Digoxin
Antibiotic
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%
DISCUSSION
HEART FAILURE
The state in which abnormal
circulatory congestion occurs as
the result of heart failure.
DEFINITION
Heart is no longer able to pump an
adequate 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
Miocard
Disease
CAD
Cardiomyopathy
Iatrogenic
Miocarditis
Miocard Mechanical
Dysfunction
Pressure overloaded
(Stenosis Aortae, Hypertension,
Coartatio Aortae)
Volume Overloaded
(Mitral/Aortae Regurgitation,
Congenital Heart Disease,
Hipertransfusion)
Miocard Filling Inhibitating
(Cardiac Tamponade, Pericarditis)
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 deffort
clASSIFICATION OF CHF
PATHOPHYSIOLOGY OF CHF
Plaque in
coronary artery
Blood flow to
heart muscle is
reduced. Heart
muscle lacking
of oxygen
Ischemia of
heart muscle
can lead to
myocardial
infarction
Symptomatic
Congestive
Heart Failure
Pulmonary
edema
Abnormal Heart
rhythm
The heart
muscle cant
pump
adequately
Sign & symptomp of chf
CHF MANAGEMENT
Non-
Farmakologi
Farmakologi
Thank You
