[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]”This patient attended A&E on account of breathlessness. Please examine their cardiovascular system and discuss your findings with the examiners.”[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191738″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][/vc_column][/vc_row]
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- Cardiovascular 0%
This patient has mitral regurgitation.
The definition of this most common of murmurs is systolic retrograde flow to the left atrium from the left ventricle.Chronic mitral valve incompetence typically progresses slowly over many years. Once entrenched, severe mitral valve incompetence has a significantly poor prognosis.Mitral valve incompetence generally evolves slowly because the heart effectively compensates for the incompetent volume by:
- left atrial enlargement
- left ventricular (LV) volume overload
- progressive LV dilatation
Patients over the age of 50 with severe organic mitral valve incompetence, have an annual morality of 6% versus 3% for moderate mitral valve incompetence.
Mitral regurgitation is the most common cause of heart failure, along with aortic stenosis. When looking for evidence of left sided heart disease from mitral valve abnormalities, Mitral regurgitation is primarily associated with the arrhythmia of atrial fibrillation, although features of left atrial hypertrophy may be present, if the patient is in sinus rhythm.When classifying mitral valve incompetence, the main categories are functional (as in from dilated cardiomyopathy or coronary artery disease for example) and degenerative, which are due to underlying valvular abnormalities, such as structural valve leaflets damage.
Causes of mitral valve incompetence
- Coronary artery disease
- Infective endocarditis
- Rheumatic heart disease (most common in the developing world)
- Left ventricular hypertrophy
- Mitral valve prolapse (MVP)
- Myxomatous disease
- Annular calcification
- Untreated tertiary syphilis
- Marfan syndrome
- 12-lead electrocardiogram
- atrial fibrillation or sinus rhythm (with left atrial hypertrophy)
- evidence of left ventricular hypertrophy
- Plain chest radiograph (for evidence of cardiomegaly and decompensated left sided cardiac failure)
- Baseline bloods:
- Complete/full blood count and differential (anaemia, infection)
- Renal function (secondary renal dysfunction from heart failure)
- Liver function tests (for secondary liver dysfunction from congestive cardiac failure)
- B-type Natriuretic Peptide (BNP)
- < 100 pg/mL = no heart failure
- 100-300 pg/mL suggest heart failure
- > 300 pg/mL = mild heart failure
- > 600 pg/mL = moderate heart failure
- > 900 pg/mL = severe heart failure
- C-reactive protein (for infection)
- Urinalysis (for proteinuria and haematuria for infective endocarditis)
- Gold standard for assessing mitral valve incompetence, with trans-oesophageal superior to trans-thoracic.
- Reduction of the pre-load with diuretics such as bendoflumethiazide
- LV remodelling with ACE-I (such as ramipril)
- Arrhythmic control with beta-blockers (such as bisoprolol and/or digoxin – latter has no prognostic benefit but does improve symptoms in moderate to severe heart failure)
- Stroke prevention in atrial fibrillation with either warfarin or a NOAC
- Reduction in risk factors for coronary artery disease (statin)
The most manageable form of surgical mitral valve disease is degenerative mitral valve disease (primary mitral valve disease). The advantages of mitral valve repair comprise of a lower operative mortality; better left ventricular function preservation, and reduced prosthetic valve-related complications such as thromboembolism, anticoagulant-related haemorrhage and endocarditis. There are unfortunately no randomized trials comparing outcomes after mitral valve repair and replacement with respect to degenerative disease.
In non-rheumatic valves, mitral valve repair is universally preferred to replacement. This is because any preservation of the mitral valve apparatus, such as even just the posterior chordae is preferable to complete ablation.
Surgical intervention indications in patients with active/acute infective endocarditis include
- decompensated congestive heart failure
- intra-cardiac abscess
- antibiotic-resistant sepsis
- systemic septic embolism
- rarely the presence of large vegetations
Currently surgery is not indicated in mild to moderate disease, and watchful waiting with medical management is the preferred choice.
In functional mitral valve incompetence, commonly associated with heart failure, surgery has less of a role. While coronary artery bypass grafting is the norm, it is by no means clear from the research that it has significant long term benefit.
In secondary heart failure, i.e. functional, resynchronization therapy (CRT – cardiac resynchronization therapy) has a therapeutic role due to the presence of wall motion abnormalities. It has been found that CRT improves the cardiac output and the patient’s symptoms.
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