MITRAL VAVLE PROLAPSE

WORKSHOP 12III-C6

Matematico Matias Maulion Medenilla Medina, K. Medina, S.

Mejino Melgarejo Mendoza, A

CC: PALPITATION

• MM•23 years old•Female

4 Years PTA •Irregular palpitations• heart beats associated with increased sweating and SOB•Patient consulted and given Verapamil for which she took for only three days and would take it intermittently for palpitation

Few Hours PTA •Palpitation accompanied by SOB

•CONSULT AND ADMISSION

PHYSICAL EXAMINATION

• Conscious, coherent, ambulatory• BP: 110/70 CR 80/min regular RR 16/min• BMI 19• Symmetrical chest expansion, narrow A-P

diameter of the chest, no retractions, clear breath sounds

• Adynamic precordium, AB at 5th LICS MCL, no murmurs, (+) midsystolic click followed by 2/6 midsystolic cresecendo murmur noted at the apex

REVIEW OF SYSTEMS

(-) dizziness (-) loss of consciousness (-) cough or colds (-) PND or Orthopnea

LABORATORY AND ANCILLARY TEST 2D Echo-Doppler: MVP, anterior

mitral valve leaflet with moderate MR, slightly dilated LA with no evidence of thrombus

123L ECG: sinus rhythm, occasional premature atrial complexes

CXR: Normal

1. WHAT ARE COMMON PHYSICAL EXAMINATOIN FINDINGS OF MVP?

Physical examination Body weight is often low ; asthenic Blood pressure is usually normal or

low Orthostatic hypotension Resting bradycardia

Thoracic skeletal abnormalities suggesting MVP: Scoliosis, pectus excavatum, straightened

thoracic spine, and narrowed AP dm of the chestZippes, D., et al. (2005) Braunwald’s Heart Disease: A textbook of Cardiovascular Medicine, 7th ed. USA:

Elsevier Saunders

Auscultation:▪ Nonejection systolic click at least 0.14 sec after

S1▪ Multiple mid and late systolic clicks along the L

lower sternal border▪ Mid to late crescendo systolic murmur that

continues to A2

Zippes, D., et al. (2005) Braunwald’s Heart Disease: A textbook of Cardiovascular Medicine, 7th ed. USA: Elsevier Saunders

Dynamic Auscultation:End-diastolic LV volume

Critical LV volume is achieved earlier in systole

Click-murmur moves closer to S1

LV systolic volume/ afterload

Lengthens the time from onset of the systole to MVP

Click-murmur moves closer to S2

Zippes, D., et al. (2005) Braunwald’s Heart Disease: A textbook of Cardiovascular Medicine, 7th ed. USA: Elsevier Saunders

Dynamic Auscultation:Response of the Murmur of MVP to Interventions

Intervention Timing Intensity Standing uprightRecumbent or 0Squatting or 0Hand grip +Valsalva +Amyl nitrite +

Fuster, V.,et al. (2008) . Hurst’s The Heart, 12the ed. China: McGrawHill Co.

2. WHAT ARE THE COMMON AND UNCOMMON SYMPTOMS OF MVP?

Symptoms

COMMON Easy fatigability Shortness of

breath Palpitation Chest pain Light-

headedness Syncope

UNCOMMON TIA Congestive

Heart Failure Endocarditis

in MR associated with MVP

Sudden death

Symptoms associated with AUTONOMIC DYSFUNCTION are associated with GENETICALLY INHERITED

MVP: Anxiety Panic attacks Exercise

intolerance Palpitations (may

be a symptom of benign arrythmias)

Atypical chest pain

FatigueOrthostasisSyncope or

presyncopeNeuropsychiat

ric symptoms

Symptoms

FatigueDyspneaExercise intoleranceOrthopneaParoxysmal nocturnal dyspnea

Related to progression of Mitral Regurgitation:

3. WHAT ARE THE LONG TERM COMPLICATIONS OF MVP?

Long term complications:Severe Mitral Regurgitation

over years or decades, due to chordal rupture and massive prolapse of both leaflets

rapidly, due to chordal or endocarditisArrythmias

most commonly ventricular premature contractions and paroxysmal supraventricular and ventricular tachycardia

Long term complications:Transient cerebral ischemic

attacks secondary to emboli from the mitral

valve due to endothelial disruption have been reported,

Infective endocarditis may occur in patients with MR and/or

leaflet thickening

4. WHAT POPULATION GROUP IS ASSOCIATED WITH AN INCREASED PREDILECTION FOR MVP?

Greater frequency among those with Collagen (type 3) Disorders: Marfan’s Syndrome Osteogenesis Imperfecta Ehlers-Danlos Syndrome

5. WHEN DO YOU GIVE PROPHYLACTIC TREATMENT IN MVP?

THANK YOU!