A 42-year-old woman, who underwent mitral valve replacement with a bileaflet tilting disk valve for rheumatic disease, presents to the emergency room with complaints of severe dyspnea. On examination, she has a BP of 120/60 mmHg. Heart rate is 83 bpm. Chest reveals bilateral crackles, one-third up. Cardiac examination reveals a nondisplaced PMI. Prosthetic clicks are muffled. A long diastolic rumble is heard at the apex. Her past medical history is otherwise unremarkable.
An echocardiogram is ordered on the above patient.
Which of the following would you expect to see?
Mean gradient across the mitral prosthesis of 17 mmHg. The clinical presentation and examination are suggestive of prosthetic mitral stenosis (long diastolic rumble, muffled closing click, and clinical heart failure). The PMI is not displaced, so it is unlikely that she has significant LV dysfunction. There are no clinical signs of severe MR. Given the acute onset of symptoms, acute valvular thrombosis leading to valvular obstruction is high on the differential. If this were the case by ACC/AHA guidelines, reoperation would be the preferred treatment approach. If other comorbidities were prohibitive, thrombolytic therapy could be considered.
A 26-year-old woman presents to your office for evaluation. She was told she had a murmur many years ago. She has a history of palpitations, but is otherwise asymptomatic. On examination, she is in no acute distress. Prominent v waves are noted in the JVP. Carotid upstrokes are normal. Chest is clear to auscultation. Cardiac examination reveals a nondisplaced PMI. Auscultation reveals a widely split first heart sound, with a loud second component that sounds like a click. A holosystolic murmur is heard at the right sternal border, which increases with inspiration. Hepatomegaly is present. An echocardiogram is performed (Fig. below).
What is the most likely cause for her palpitations?
Arrhythmias secondary to an accessory pathway. The examination is highly suggestive of Ebstein anomaly (presence of TR, widely split first heart sound). The echocardiogram confirms this. Accessory pathways are frequently associated with this condition.
No intervention is performed for the patient. She returns to your clinic 3 months later. She describes an episode of transient word-finding difficulty, which lasted for a number of seconds. This occurred while she was recovering from a fractured tibia. A CT scan was performed, which was negative. She is concerned that she may have a recurrence.
What is the most appropriate next test for her?
Echocardiography with saline contrast study. Ebstein anomaly is frequently associated with cardiac shunts (either patent foramen ovale, or atrial or ventricular septal defect). The setting of a TIA in someone who has been immobilized (such as with a fracture) raises the concern of paradoxical embolism of a venous thrombus to the systemic circulation.
A 21-year-old man presents to your office for evaluation. He tells you that a murmur was noted a few days after birth. He is presently asymptomatic. On examination, he is normotensive. Pulse is 65 bpm and regular. Carotid upstrokes are normal. Chest is clear. Cardiac examination reveals a nondisplaced PMI. An RV lift is present. A systolic thrill is present in the suprasternal notch. A highpitched sound is heard after S1 . A crescendo–decrescendo systolic murmur is heard at the left second intercostal space. A2 is normal.
Which of the following would you expect to find on echocardiography?
Vmax across the pulmonic valve of 4 m/s. The physical examination is consistent with pulmonic stenosis (presence of thrill, RV heave, ejection click, and crescendo-decrescendo murmur loudest over the pulmonic area). Normal carotid upstrokes and preserved A2 make significant AS unlikely. The murmur is not consistent with a regurgitant murmur.
The patient returns 1 year later for follow-up.
Which of the following is a definite indication for intervention?
He tells you of an episode of syncope. The presence of exertional dyspnea, angina, syncope, or near-syncope are class I indications for intervention. For gradients between 30 and 39 mmHg, there is some divergence of opinion about the role of intervention (class IIb for gradients 30 to 39). There is no role for intervention in those with gradients <30 mmHg who have no symptoms. A peak-to-peak gradient >40 mmHg by catheterization is a class I indication for intervention, even in an asymptomatic patient.