Term
| Presenting a patient with breathlessness and mechanical mitral valve replacement |
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Definition
The physical signs are
A central sternotomy scar (this patient had 2 scars)
Sinus rhythm with normal pulse pressure
Metallic first heart sound (if metallic s2 it would be aortic)
Normal JVP and apex beat
No RVHeave
In view of his breathlessness i would ix further with
inflammatory markers, FBC, biochemistry
CXR, ECG and ECHO
If these do not find a cause for his breathlessness I would continue to assess his respiratory system. |
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Term
| what is the longterm management for patients with metallic MV replacements? |
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Definition
I would want to perform serial echocardiograms to check functioning of the valve
Patients will require anticoagulation and monitoring of INR to ensure it is in the range that is appropriate for the type of valve in place.
AV INR 2-3 Target 2.5
MV INR 2.5-3.5 Traget 3 |
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Term
| Tell me the possible reasons for MV replacement |
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Definition
MS - but no evidence of AF (patient is in SR), and no evidence of pulmonary HTN (which occurs due to increased LA pressures)
MR
IE |
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Term
| What advice might you give this patient for antibiotic prophylaxis (AP) against IE |
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Definition
I would refer to the latest guidelines for this as historically there has been a change in guidance for which procedure require AP
ESC 2018 recommends AP for high risk dental procedures that involve manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa
Other procedures, such as respiratory or urological procedures, for which AP was recommended in earlier versions of the guidelines, are no longer regarded as high-risk, and AP is no longer advised. |
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Term
| fast forward 5 years, you see this patient in clinic and detect a new systolic murmur. What would be the significance of this? |
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Definition
I would want to investigate if this patient has developed valvular incompetence with his replaced mitral valve.
I would assess this with an echocardiogram which could tell me if there are new valvular lesions that might be causing the systolic murmur (new AS or TR)
How would you differentiate between AS and TR?
Murmurs heard at different sites on the chest
TR: obvious sign is CV waves in JVP which can be seen from the end of the bed
Different characters. AS: ESM TR: PSM |
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Term
| Other than mechanical MV what other clinical signs did you identify? |
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Definition
Patient was in SR
Two central sternotomy scars with no evidence of vein harvesting which suggests it is unlikely he has had CABG, perhaps a re-do of his valve
He has multiple campbell de morgan spots (cherry angiomas)
He had a mark on his posterior thorax which I thought was bruising but, on closer inspection, i think it was a telangiectatic nevus. |
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Term
| Considering his two central sternotomy scars, what do you think is the possible significance of this? |
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Definition
He may have had re-do surgery
There are no scars on his legs so it is unlikely that he has had coronary artery bypass grafting. |
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Term
| timing of the mechanical heart sound is important. Why? |
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Definition
metallic first HS is typical for MV replacement
Metallic second HS may indicate an AV replacement |
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Term
| In a patient with metallic MV replacement in sinus rhythm, which cause of valve dysfunction does this point away from? |
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Definition
| SR suggests mitral stenosis is an unlikely cause for his initial valve dysfunction. |
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Term
| In a young patient with isolated mitral valve prolapse what treatment would you offer? |
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Definition
| I would offer mitral valve repair in the place of replacement in the first instance as one of my surgical options. |
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