Cases of mitral valve causing mitral regurgitation: the MV ...
[Pages:15]2/19/2018
Cases of mitral valve causing mitral regurgitation: the MV prolapse spectrum
Judy Hung, MD Cardiology Division Massachusetts General Hospital
Boston, MA
Harvard Medical School
CASE
? Mr. M; 50 Year male presents to internist for annual physical. He feels well, no complaints ? Hyperlipdemia ? No tobacco; rare ETOH ? Well childhood ? Works as insurance broker
? Medications: Simvistatin 20 mg
? FH: Stroke in Elderly Grandmother ? Exam: 120/78; 70 bpm; CV-normal; no
murmur
Harvard Medical School
1
10 years later:
Feels well, recently retired but maintains active lifestyle-golf, part
time work at former company
Annual Exam: A new systolic murmur heard
2/19/2018
Harvard Medical School
AN ECHOCARDIOGRAM IS ORDERED Normal MV
Harvard Medical School
2
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Summary of Echo Findings:
Mitral valve prolapse; predominantly of the posterior leaflet; Moderate MR LVID 52 mm; 30 mm; LVEF 77% LA 45 mm RVSP= 25 mmHg (assuming RAP of 10 mmHg)
Harvard Medical School
What to do?
1. Refer for mitral valve replacement 2. Refer for mitral valve repair 3. Treat with afterload reducing agents 4. Watchful waiting
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3
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5 months later.......
He develops URI symptoms: cough, SOB, rhinitis; initial improvement with antibiotics; Then dyspnea with exertion and decreased exercise tolerance returns and worsens: stairs are now a problem; can't do yard work
Harvard Medical School
IMPRESSION: 1. No evidence of pulmonary edema. 2. Mild bilateral hilar prominence with suggestion of cranial redistribution of pulmonary vasculature suggesting pulmonary venous hypertension. However these findings canHaalsrvoarredsMulet dfriocaml School overcirculation caused by an ASD.
4
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AN ECHOCARDIOGRAM IS ORDERED
August, 2010
March, 2011
Harvard Medical School
March, 2011 ECHOCARDIOGRAM
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Summary of Echo #2
Mitral valve prolapse; posterior leaflet prolapse with flail and ruptured chord Severe MR LVID 54 mm; 34 mm; LVEF 73% RVSP= 47 mmHg (assuming RAP of 10 mmHg)
Harvard Medical School
Posterior Leaflet Flail (Transesophageal Echo)
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What happened to patient?
Harvard Medical School
Mitral Valve Prolapse
? Systolic displacement of one or both mitral leaflet into the left atrium of greater than 2 mm beyond annular plane. ?Occurs with or without mitral regurgitation ?Occurs with or without leaflet thickening ?In patients with leaflet thickening, myxomatous changes present on pathoanatomy Harvard Medical School
7
2/19/2018
Flail Leaflet = significant MR
Tip of the leaflet is in left atrium due to loss of convex shape of the
mitral leaflets; there is "eversion" of the normal convex shape of the
leaflet scallop
Harvard Medical School
Mitral Valve Chordal Anatomy
aka secondary
chordae
Provides basic structural support
Responsible for coaptation
aka primary chordae
Harvard Medical School
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