A 50-year-old man presents for his first physical examination in several years. He notes that a murmur had been documented a number of years ago. He is entirely asymptomatic. On examination, he has a BP of 120/70 mmHg with a pulse rate of 58 bpm. Neck veins are not distended. Carotid upstrokes are brisk. Lungs are clear. Cardiac examination reveals a nondisplaced PMI. S1 is soft; S2 is normal (with a preserved A2 ). An S3 is heard. A III/VI holosystolic murmur is heard at the apex radiating to the base and carotids, which increases with handgrip.
Echocardiogram reveals myxomatous mitral valve disease with posterior leaflet prolapse and severe MR. The prolapse involves the P2 (middle) segment and is severe. There is no calcification of the valve. End-systolic dimension is 3.0 cm; end-diastolic dimension is 5.6 cm. Ejection fraction is 65%. TR velocity is 2.9 m/s.
Which of the following would be most appropriate at this time?
Consider elective mitral valve repair at a hospital where repair is performed with a high degree of success or if he wishes to defer surgery, follow up at 6 monthly intervals with echo. Referral for surgery is reasonable (class IIa indication) if chance of repair is >95%. There are no data to suggest a beneficial role for the addition of afterload-reducing agents in the absence of systemic hypertension (again by ACC/AHA guidelines). There is absolutely no role for the prophylactic use of amiodarone. Close clinical follow-up is reasonable, but repeat evaluation should not be deferred for 2 years. Guidelines use LV dimensions and ejection fraction to guide surgical intervention, even in the absence of symptoms. As such, these patients should have clinical reevaluation and echo every 6 months.
The patient agrees to close medical follow-up. However, he does not present back to your office until 2 years later, now with complaints of dyspnea. A repeat echocardiogram reveals an ejection fraction of 45% with an end-systolic dimension of 4.7 cm.
What do you recommend?
Referral for mitral valve repair. He is now symptomatic with depressed ejection fraction and a dilated LV. This is a class I indication for surgery. Valve repair as opposed to replacement is the preferred surgical treatment. Medical therapy may be needed as an adjunct, but is insufficient as the sole treatment.
An 80-year-old man with severe AS is turned down for surgical AVR due to significant comorbidities. He is referred to you for consideration for transcatheter AVR.
Which of the following findings is considered a contraindication for this procedure?
Life expectancy <1 year. Life expectancy of <1 year, despite treatment of AS, is an absolute contraindication for TAVR. Severe peripheral artery disease precludes a transfemoral approach; however, the procedure may be done via a transapical approach, a transsubclavian approach, and even a transaortic approach. Severe pulmonary disease and an inaccessible apex preclude a transapical approach but the other approaches remain available. Active endocarditis is a contraindication to the procedure. The available valves are suitable for annular sizes between 19 and 29 mm.
A 35-year-old man presents to your office for evaluation of valvular heart disease. He complains of shortness of breath with only modest amounts of exertion, as well as two-pillow orthopnea. He also complains of easy fatigability, as well as lower extremity edema and abdominal fullness. On examination, he is in no acute distress. He is normotensive. Jugular venous pressure is elevated, with a prominent a wave. The v wave is not easily discerned. S1 is loud. S2 is normal. A sound is heard in diastole, 0.07 milliseconds after S2 . A diastolic rumble is heard at the apex. A diastolic murmur is also heard along the left sternal border, which increases with inspiration. Mild hepatomegaly is present. There is 2+ peripheral edema.
What is your diagnosis?
Mitral and tricuspid stenoses. The loud S1 , opening snap, and apical diastolic rumble are features of mitral stenosis. The presence of the diastolic rumble along the sternal border, which increases with inspiration, along with the prominent a wave in the JVP and evidence of systemic venous congestion (hepatomegaly and peripheral edema) suggests that concomitant tricuspid stenosis is present as well.
An 80-year-old man presents to your office with complaints of chest tightness when climbing up a flight of stairs. His past medical history is unremarkable. On physical examination, he is in no acute distress. BP is 140/80 mmHg; pulse is 78 bpm and regular. Chest is clear. Carotid upstrokes are diminished. The PMI is sustained, but not displaced. A fourth heart sound is present. The second heart sound is diminished and single. A loud late-peaking systolic murmur is heard, loudest at the second intercostal space, radiating to the neck.
Which of the following would be a reasonable next step in this patient’s management?
Cardiac catheterization. By physical examination, the patient has severe AS (no A2 of second heart sound, late-peaking murmur, and diminished carotid upstrokes). A stress test would not be appropriate in a patient with symptomatic AS. An echocardiogram would usually be the first step, but proceeding directly to catheterization to measure transvalvular gradients and assess coronary anatomy would be reasonable. SL NTG could have disastrous consequences in this setting. By reducing preload, it may precipitate syncope.
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