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C A S E P R E S E N TAT I O N

CHF fc III ec Mitral Stenosis


Nur Ikhwaini binti Ismail (C111 09 851) Supervisor :
Prof. Dr. dr. Ali Aspar Mappahya, SpPD, Sp.JP(K), FIHA, FAsCC, FINASIM, FICA

Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2014

Patient Identity
Name Age old Gender Address MR Day of Admission 2014 : Mrs. S : 30 years : Female : Dusun Lamaeto : 658915 : April 13rd

HISTORY TAKING
Chief Complaint : shortness of breath (SOB) It was felt since 5 years ago and worsen in 1 month before admitted to the hospital, accompanied by heart palpitation and worsen while doing some activities. Patient claimed that she slept better by using more than a pillow, and easily woke up in the middle of sleep due to SOB. No chest pain nor faint occured. Cough (+) with transparent, non blood-mixed mucus (+), common cold (+) in which often relapse since childhood Fever (-), Nausea (-), vomitting (-), epigastric pain (+), defecation normal, urinary normal. History of having rheumatic fever at the age of 15 which was poorly treated

Past Medical History History of rheumatic fever which was poorly treated at the age of 15 History of heart disease (-) History of DM (-) History of smoking (-) History of hypertension (-)

Family History History of heart disease in family (-)

General Status Compos mentis/Moderate illness/ Well nourished Nutritional Status: Normal Weight : 47 kg Height : 159 cm BMI : 18.5 kg/m2

Vital Sign Blood Pressure Heart Rate Respiratory Rate Temperature

: : : :

90/50mmHg 110 bpm 24 bpm 36.6 0C (axilla)

PHYSICAL EXAMINATION
Head and Neck Examination
Eye : Conjunctiva anemic (-/-),Sclera icteric (-/-) Lip : Cyanosis (-) Neck : JVP R+1 cmH20

Thorax Examination

Inspection : Symmetric between left and right chest. Palpation : No mass, no tenderness. Percussion : Sonor between left and right chest, lung-liver border in ICS IV right anterior. Auscultation: Respiratory sound: Vesicular Additional sound : Ronchi -/-, Wheezing -/-

Heart examination :
Inspection : Palpation : Percussion : visible ictus cordis (+) palpable ictus cordis (+) Upper heart : ICS II parasternalis linea sinistra Bottom heart : ICS IV parasternalis linea dextra left Heart : ICS IV midclavicularis linea sinistra Right heart : ICS IV parasternalis linea dextra Auscultation : heart sound I/II regular, diastolic murmur (+) heard at the apex ICS 3/4

Abdomen examination

Inspection : flat, according to breath movement Auscultation : peristaltic (+) normal Palpation : mass tumor (-), pain (-), liver and spleen are impalpable Percussion : thympany (+), ascites (-)

Extremities examination

Pretibial oedema -/-

Electrocardiogram (ECG)

14/4/2014

ECG interpretation
Rhythm Heart rate Regularity Axis P wave PR interval Q pathologist QRS complex ST Segment T inverted Conclusion : Sinus pause : 110 bpm : irreguler- AFRVR ( atrial fibrillation with rapid ventricular response of 110 bpm) : Right Axis Deviation (RAD) : 0,08 s : difficult to be evaluated : : Duration 0,08 s : ST depression on leads II, III, aVF : : HR 110 x/minute, AFRVR, RAD

Radiologic findings
Increased bronchovascularisation No specific processes on both lung areas Enlargement of Cor with CTI 0.67, raise of pulmonalis cone, raise of left auricle, lifted apex and diminished aorta Both sinus and diaphragm are in good condition All bones in intact Conclusion : Cardiomegaly with mitral heart disease appearance.

LABORATORIUM
HEMATOLOGY RESULT NORMAL VALUE

14/4/2014
UNIT

WBC RBC HGB HCT PLT GDS Uric acid Creatinine Ureum

6.4 5.12 15.7 47.7 167

4,00-10,0 4,00-6,00 12,0-16,0 37,0-48,0 150-400 140 2,4-5,7 <1,3 10-50

(10/UI) (106/UI) (gr/dL) (%) (103/uL) Mg/dL Mg/Dl Mg/dL Mg/dL

136 6.1
0.6 27

Na K Cl SGOT SGPT PT APTT CK

132 3.0 86 26 30 12.6 ctrl 12.1 24.6 ctrl 26.7 31.00

136-145 3.5-5.1 97-111 <41 <38 10-14 22-30 L<190,P<18 7

mmol/L mmol/L mmol/L mmol/L


mg/dL

second second u/L

CKMB

7.9

<25

u/L

echocardiogram

16/4/2014

Description of wall motion, valves, pericardium Systolic function LV enough, EF 57% Normokinetic global LVH (-) Dimension of heart chambers : LA dilatation, SEC (+) at LA RV systolic function in good, TAPSE 1.8cm Heart valves : Mitral : severe MR ( Wilkins score 6), moderate MR Aorta : 3 cuspis, calcification (-) , mild AR Tricuspid : moderate TR Pulmonal : good function and movement E/A < 1 Minimal pericardial efusion Conclusion: LV systolic function enough, EF 57% Dilatation of LA, SEC (+) at LA Severe MS, moderate MR Mild AR, moderate TR LV dystolic dysfunction

Working DIAGNOSIS

CHF FC III ec Mitral Stenosis

Bed rest O2 3Lpm via nasal cannula Fluid restriction 1200cc / days Anti-coagulant : Simarc 2mg 0-0-1 Diuretic : Furosemide injection 2amp/12hr/iv Digitalis /antiarrythmias: Digoxin 0,25mg 1-0-0 Prophylaxis : Meropenem injection 1 gr/12hour/iv Omeprazole injection 40mg/12hour/iv Ambroxol 30mg 3x1 Ventolin nebuliser /24hour KSR 2x1 Monitor electrolyte level and blood routine ECG/day Education for valve replacement

MANAGEMENT

DISCUSSION

Congestive Heart Failure fc III ec. Mitral stenosis

DEFINITION
Congestive heart failure (CHF) occurs when the heart isn't able to pump blood normally. As a result, there is not enough blood flow to provide the body's organs with oxygen and nutrients

Mitral stenosis (MS) is a narrowing of the inlet valve into the left ventricle that prevents proper filling during diastole. Patients with mitral stenosis typically have mitral valve leaflets that are thickened, commissures that are fused, and/or sub-valvular structures that are thickened and shortened.

Mitral Stenosis
Etiology Symptoms Physical Exam Severity Natural history Timing of Surgery

Mitral Stenosis: Etiology


Primarily a result of rheumatic fever (~ 99% of MVs @ surgery show rheumatic damage ) Scarring & fusion of valve apparatus Rarely congenital Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease Two-thirds of all patients with MS are female.

Mitral Stenosis: Pathophysiology


Normal valve area: 4-6 cm2 Mild mitral stenosis: MVA 1.5-2.5 cm2 Minimal symptoms Moderate mitral stenosis MVA 1.0-1.5 cm2 usually does not produce symptoms at rest Severe mitral stenosis MVA < 1.0 cm2

Mitral Stenosis: Pathophysiology


Right Heart Failure: Hepatic Congestion JVD Tricuspid Regurgitation RA Enlargement Pulmonary HTN Pulmonary Congestion LA Enlargement Atrial Fib LA Thrombi LA Pressure

RV Pressure Overload RVH Continuing Medical Implementation RV Failure

LV Filling
...bridging the care gap

Mitral Stenosis: Symptoms


Fatigue Palpitations Cough SOB Left sided failure Orthopnea PND Palpitation A-fib Systemic embolism Pulmonary infection Hemoptysis Right sided failure Hepatic Congestion Edema Worsened by conditions that cardiac output. Exertion,fever, anemia, tachycardia, Afib, intercourse, pregnancy,

Recognizing Mitral Stenosis


Palpation: Small volume pulse Tapping apexpalpable S1 +/- palpable opening snap (OS) RV lift Palpable S2 ECG: LAE, AFIB, RVH, RAD Auscultation: Loud S1- as loud as S2 in aortic area A2 to OS interval inversely proportional to severity Diastolic rumble: length proportional to severity In severe MS with low flow- S1, OS &

Mitral Stenosis: Physical Exam

S1 S1

S2 OS

First heart sound (S1) is accentuated and snapping Opening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apex Pre-systolic accentuation (esp. if in sinus rhythm)

Common Murmurs and Timing

Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis

S1

S2

S1

Auscultation- Timing of A2 to OS Interval

Width of A2-OS inversely correlates with severity The more severe the MS the higher the LAP the earlirthe LV pressure falls below LAP and the MV opens

Say Prrr Pada Pata Papa Tuhuh

Timing Severity Other seconds of MS HSs 0.06 Severe .07-.08 .08-.09 0.10 .12 Modsevere Mod Mild PK
0.1-0.110

A2-S3
0.12-0.18

Mitral Stenosis: Natural History


Progressive, lifelong disease, Usually slow & stable in the early years. Progressive acceleration in the later years 20-40 year latency from rheumatic fever to symptom onset. Additional 10 years before disabling symptoms

Continuing Medical Implementation

Mitral Stenosis: Complications


Atrial dysrrhythmias Systemic embolization (10-25%) Risk of embolization is related to, age, presence of atrial fibrillation, previous embolic events Congestive heart failure Pulmonary infarcts (result of severe CHF) Hemoptysis Massive: 20 to ruptured bronchial veins (pulm HTN) Streaking/pink froth: pulmonary edema, or infection Endocarditis Pulmonary infections

Mitral Stenosis: EKG


LAE RVH Premature contractions Atrial flutter and/or fibrillation freq. in pts with mod-severe MS for several years A fib develops in 30% to 40% of pts w/symptoms

There is atrial fibrillation. No P waves are visible. The rhythm is irregularly irregular (random). There is the suggestion of right ventricular hypertrophy. Right axis deviation and deep S waves in the lateral leads. Another important feature of right ventricular hypertrophy is a dominant R wave in lead V1. The combination of Atrial Fibrillation and Right Axis Deviation on the ECG suggests the possibility of mitral stenosis.

Mitral Stenosis: Role of Echocardiography


Diagnosis of Mitral Stenosis Assessment of hemodynamic severity mean gradient, mitral valve area, pulmonary artery pressure Assessment of right ventricular size and function. Assessment of valve morphology to determine suitability for percutaneous mitral balloon valvuloplasty Diagnosis and assessment of concomitant valvular lesions Reevaluation of patients with known MS with changing symptoms or signs. F/U of asymptomatic patients with mod-severe MS
Continuing Medical Implementation

Mitral Stenosis:Therapy
Medical Diuretics for LHF/RHF Digitalis/Beta blockers/CCB: Rate control in A Fib Anticoagulation: In A Fib Endocarditis prophylaxis Balloon valvuloplasty Effective long term improvement Surgical Mitral commissurotomy Mitral Valve Replacement Mechanical Bioprosthetic

Recommendations for Mitral Valve Repair for Mitral Stenosis


ACC/AHA Class I Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for repair if percutaneous mitral balloon valvotomy is not available Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for repair if a left atrial thrombus is present despite anticoagulation Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),* and a non-pliable or calcified valve with the decision to proceed with either repair or replacement made at the time of the operation.

Recommendations for Mitral Valve Repair for Mitral Stenosis


ACC/AHA Class IIB Patients in NYHA functional Class I, moderate or severe MS (mitral valve area <1.5 cm 2 ),* and valve morphology favorable for repair who have had recurrent episodes of embolic events on adequate anticoagulation. ACC/AHA Class III Patients with NYHA functional Class I-IV symptoms and mild MS.

*The committee recognizes that there may be a variability in the measurement of mitral valve area and that the mean trans-mitral gradient, pulmonary artery wedge pressure, and pulmonary artery pressure at rest or during exercise should also be considered.

THANK YOU

RISK FACTORS
Modified
History of CHD (-) History of hypertension (-)
Non- Modified

Gender : Female Age : 30 years

old
History of rheumatic fever