Term
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Definition
This patient has evidence of MR on examination.
He has a PSM in the mitral area which radiates to the apex and axilla
The apex is laterally displaced relative to 5th ICS mid clavicular line.
Whether or not it was thrusting: I did notice it was not thrusting in nature.
Regular pulse, no evidence of pul HTN
No elevated JVP
No loud P2
No RV heave
Clinically euvolaemic
In terms of differentials, my top differentials would be mitral regurgitation but it could also be
mitral valve prolapse
tricuspid regurgitation or
ventricular septal defect |
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Term
what clinical features on examination would lead you to suspect that this patient has significant or severe MR?
What symptoms would you be specifically asking about? |
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Definition
A raised JVP
RV Heave
Loud P2 or S3 gallop
Displaced apex beat which may be thrusting in nature
Specific symptoms
Dyspnoea
Reduction in ET
Symptoms of fluid overload |
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Term
| Are there any other tests you would like to perform in this patient (with MR)? |
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Definition
Check temperature, if elevated may point towards infection
ECG looking for AF and P-mitrale
Urine dipstick looking for heamaturia and proteinuria which may be observed with IE
FBC - anaemia could exacerbate breathlessness
WCC, CRP and ESR in addition to renal profile
CXR looking for cardiomegaly
ECHO to look at mitral valve, extent of severity of any regurgitation and whether there are any concomitant vegetations or prolapse.
Also to assess LVEF and look for evidence of pul HTN. Both may suggest more immediate referral for surgery
IE specific
Fundoscopy looking for Roth's spots of IE |
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Term
| What is the relevance of the JVP |
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Definition
It is a visible reflection of RA pressures
various abnormalities in right heart pressures may be seen in the JVP
For example elevated JVP may be seen in pulmonary HTN |
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Term
| Suppose this patient with MR had an elevated JVP and RV heave what would you want to do? |
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Definition
This would suggest this patient has severe MR with evidence of pulmonary HTN
I would expedite a referral to a Cardiologist as they may want to assess and expedite surgery for this patient.
This is because it is better perform mitral valve surgery earlier and before the patient develops significant HTN |
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Term
| Can you tell me the indications for MV replacement? |
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Definition
If the patient is symptomatic and there are features of
Pulmonary HTN or fluid overload
In an asymptomatic patient with declining EF, pulmonary HTN and LV dilatation.
Acute MR following an MI |
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Term
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Definition
Degenerative causes: age related MR
Regurgitation secondary to underlying MVProlapse (look out for concomitant CTD such as Ehlers-Danlos a/w MVP.
Acquired cause include papillary muscle rupture in setting of MI
Infective: in the setting of rheumatic fever or IE. |
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Term
| Advise the patient when discussing between options of a metallic and tissue valve |
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Definition
Decision is made between patient, surgeon and cardiologist
Mechanical valves may last longer but require anticoagulation. Prosthetic valves do not require anticoagulation but have shorter life span of approx 10 years
ESC recommends bio-prosthetic valves to be considered for patients >65 for mitral valves and >70 years for aortic valve, those who are at risk of haemorrhage, poorly compliant with medication, and young women of child bearing age.
Metallic valves may be considered in other patients and in the elderly, who are already on anticoagulation. |
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