mitral valve prolapse
DESCRIPTION
Workshop 12 Group 3 Section D. Mitral Valve Prolapse. MM 23 y/o . Chief complaint : Palpitations History of Present Illness:. Review of Systems. No dizziness, nor loss of consciousness No cough or colds No PND or orthopnea. Physical Examination. Conscious, coherent, ambulatory - PowerPoint PPT PresentationTRANSCRIPT
Mitral Valve Prolapse
Workshop 12Group 3Section D
MM 23 y/o Chief complaint : PalpitationsHistory of Present Illness:
4 years PTA
•Palpitations ( irregular), heartbeats associated with increased sweating and shortness of breath.
•Medication: verapamil for 3 days, taken intermittently for palpitation
Few hours PTA •Palpitation accompanied by shortness of
breath
Review of Systems
No dizziness, nor loss of consciousness
No cough or colds No PND or orthopnea
Physical Examination
Conscious, coherent, ambulatory BP 110/70 CR 80/min regular RR
16/min BMI 19 Symmetrical chest expansion, narrow AP
diameter of the chest, no retractions, clear breath sounds
Adynamic precordium, AB at 5th LICS MCL no murmurs, (+) midsystolic click follwed by 2/6 mid-systolic crescendo murmur noted at the apex
Laboratory and Ancillary Tests 2D Echo-doppler:
Mitral Valve Prolapse, Anterior Mitral Valve Leaflet with moderate MR
Slightly dilated left atrium woth no evidence of thrombus
12 Lead ECG Sinus rhythm Occasional premature atrial complexes
1. What are the common physical examination findings of MVP?
Common PE findings of MVP
Auscultation Mid – late (non- ejection)
systolic click (0.14s) after S1 Systolic clicks: multiple and
may be follwed by a high-pitched, late systolic crescendo-decrescendo murmur, “ whooping” or “honking”- heard best at apex
Early click-murmur▪ Standing, during valsalva
maneuver, and with ant intervention that decreases LV volume
Delayed and complex click-murmur▪ Squatting, isometric exercises
which increase LV volume
Laboratory Examination
ECG- normal but may show biphasic or
inverted T waves in leads II, III and aVF,
and occasionally supraventricular or
ventricular premature beats
2DEcho – systolic dysplacement (in the parasternal long axis
view) of the mitral valve leaflets by at
least 2mm into the LA superior to the plane of the mitral annulus
Color flow – helpful in revealing associated
MR
2. What are the common and uncommon symptoms of MVP?
Population group
14 - 30 years old Women Increased familial incidence
Reference: Fauci et al. Harrison’s Principles of Internal Medicine, 17th ed.
Common Symptoms * Patients are mostly asymptomatic Others may manifest with: Easy fatigability Shortness of breath Palpitation Non-anginal chest pain Light-headedness Syncope
Reference: Fauci et al. Harrison’s Principles of Internal Medicine, 17th ed.
Uncommon Symptoms Transient ischemic attacks Congestive cardiac failure Endocarditis
in MR associated with MVP Sudden death
Reference: Fauci et al. Harrison’s Principles of Internal Medicine, 17th ed.
Symptoms related to autonomic dysfunction are usually associated with genetic inheritance:
Anxiety Panic attacks Arrhythmias Exercise intolerance Palpitations Atypical chest pain Fatigue Orthostasis Syncope or presyncope Neuropsychiatric symptoms
Thakkar, B. (2008) Mitral Valve Prolapse < http://emedicine.medscape.com/article>
Symptoms related to progression of mitral regurgitation :
Fatigue Dyspnea Exercise intolerance Orthopnea Paroxysmal nocturnal dyspnea (PND) Progressive signs of congestive heart
failure (CHF)
Thakkar, B. (2008) Mitral Valve Prolapse < http://emedicine.medscape.com/article>
3. What are the long-term complications of MVP?
In most studies, MVP has a complication rate of less than 2 percent per year2,15 .
The age-adjusted survival rate in men and women with MVP is similar to that in patients without this common clinical disorder
Complications of Mitral Valve Prolapse
Atrial fibrillation and other arrhythmiasCongestive heart failurePulmonary hypertensionRuptured mitral valve chordaeInfective endocarditisCentral nervous system embolic
events
O'Rourke RA. The mitral valve prolapse syndrome. In: Chizner MA, ed. Classic teachings in clinical cardiology. Cedar Grove, N.J.: Laennec, 1996:1049-70.
Congestive Heart FailureGradual progression of mitral
regurgitation
progressive dilation of the left atrium and left ventricle
atrial fibrillation, moderate to severe mitral regurgitation
LV dysfunction
congestive heart failure
Infective Endocarditis A serious complication of
MVP MVP is the leading
predisposing cardiovascular disorder in patients with endocarditis.
Because the absolute incidence of endocarditis is extremely low in the entire MVP population, the risk of its developing in these patients has been a subject of considerable debate.
Thromboembolic Events Rarely, fibrin emboli may cause visual problems
related to occlusion of the ophthalmic or posterior cerebral circulation.
Patients younger than 45 years who have MVP are at greater risk for cerebrovascular accidents than would be expected in similar patients without MVP.
Therefore, it has been recommended that antiplatelet drugs such as aspirin or anticoagulants be administered to patients with MVP who have a history of suspected cerebral emboli
4. What population group is associated with an increased predilection for MVP?
Idiopathic MVP
Cause of MVP may be a genetically determined collagen disorder
Electron microscopy: fragmentation of collagen fibrils
Reduction in the production of type III
collagen
Fauci, et al. 2008. Harrison’s Principles of Internal Medicine, 17th ed.Venugopalan. 2008. Mitral Valve Prolapse.
<http://emedicine.medscape.com/article/890425-overview>
Hereditary Connective Tissue Disorders
Mitral valve prolapse is a frequent finding in patients of this population
Ehler-Danlos
syndrome
Marfan syndrome
Osteogenesis
imperfecta• Others: Fragile X syndrome, Martin-Bell syndrome, Polycystic kidney disease (adult type), Periarteritis nodosa
Fauci, et al. 2008. Harrison’s Principles of Internal Medicine, 17th ed.Venugopalan. 2008. Mitral Valve Prolapse.
<http://emedicine.medscape.com/article/890425-overview>
5. When do you give prophylactic treatment in MVP?
Clinical approach to determination of the need for prophylaxis in patients with
suspected MVP
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
A reasonable approach for endocarditis prophylaxis should consider the following: the degree to which the patient’s underlying
condition creates a risk of endocarditis the apparent risk of bacteremia with the procedure the potential adverse reactions of the prophylactic
antimicrobial agent to be used; and the cost-benefit aspects of the recommended prophylactic regimen
Failure to consider all of these factors may lead to overuse of antimicrobial agents, excessive cost, and risk of adverse drug reactions
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
Prophylaxis is recommended in individuals who have a higher risk for developing endocarditis than the general population and is particularly important for individuals in whom endocardial infection is associated with high morbidity and mortality
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
Endocarditis prophylaxis recommendedHigh-risk category Prosthetic cardiac valves Previous bacterial endocarditis Complex cyanotic congenital heart
diseaseEg. Single ventricle states,
Transposition of the great arteries, Tetralogy of Fallot
Surgically constructed systemic pulmonary shunts or conduits
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
Moderate-risk category Acquired valvular dysfunction (eg,
rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvular
regurgitation and/or thickened leaflets
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
Endocarditis prophylaxis NOT recommendedNegligible-risk category Isolated secundum atrial septal defect Surgical repair of ASD, VSD or PDA Previous coronary artery bypass graft
surgery Mitral valve prolapse without valvular
regurgitation Physiologic, functional, or innocent heart
murmurs Previous Kawasaki disease without valvular
dysfunction Previous rheumatic fever without valvular
dysfunction Cardiac pacemakers and implanted
defibrillatorsPrevention of Bacterial Endocarditis: Recommendations by the
American Heart Association
Prophylaxis Prophylaxis at the time of cardiac surgery
should be directed primarily against staphylococci and should be of short duration
First-generation cephalosporins are most often used
Prophylaxis is most effective when given perioperatively in doses that are sufficient to assure adequate antibiotic concentrations during and after the procedure
Antibiotics should be used only during the perioperative period - initiated shortly before a procedure and should not be continued no more than 6 to 8 hours
In the case of delayed healing, or of a procedure that involves infected tissue, it may be necessary to provide additional doses of antibiotics
Prophylaxis
Antimicrobial prophylaxis administered within 2 hours following the procedure will provide effective prophylaxis
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
Streptococcus viridans is the most common cause of endocarditis following: dental or oral procedures certain upper respiratory tract
procedures bronchoscopy with a rigid bronchoscope surgical procedures that involve the
respiratory mucosa esophageal procedures
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
The recommended standard prophylactic regimen for all these procedures is a single dose of oral amoxicillin to be administered 1 hour before the anticipated procedure Adult dose is 2.0 g Pediatric dose is 50 mg/kg (not to exceed adult
dose) For individuals who are unable to take or
unable to absorb oral medications, parenteral Ampicillin sodium is recommended
Durack DT. Prevention of infective endocarditis. N Engl J Med. 1995
Individuals who are allergic to penicillin Clindamycin hydrochloride Azithromycin or clarithromycin
When parenteral administration is needed in an individual who is allergic to penicillin, clindamycin phosphate is recommended
Durack DT. Prevention of infective endocarditis. N Engl J Med. 1995
Prophylaxis Enterococcus faecalis is the most
common cause of bacterial endocarditis that occurs following genitourinary and gastrointestinal tract surgery or instrumentation
Antibiotic prophylaxis should be directed primarily against Enterococci
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
High-risk patients Ampicillin plus gentamicin
High-risk patients allergic to ampicillin/amoxicillin Vancomycin plus gentamicin
Moderate-risk patients Amoxicillin or ampicillin
Moderate-risk patients allergic to ampicillin/amoxicillin Vancomycin
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association