Case Discussion <病史>      This 69-year-old gentleman was a businessman. He could walk up-stair to 4-floor without exercise intolerance before. Two months ago, he suffered from rhinorhea, sorethroat, and productive cough with whitish sputum initially. He visited a local medical doctor where upper respiratory tract infection was informed. His symptoms improved a little after some medicine was taken. However, sudden onset of dyspnea attacked while working one week later. He denied either chest tightness, cough, palpitation or leg edema at that time. Rest or postural change did not relieve the dyspnea. Nocturnal dyspnea and orthopnea progressed in one month. Therefore, he was sent to our emergency room for help.       According to his statement, he denied hypertension, DM or hyperlipidemia. He denied any cardiac or pulmonary disease. No smoking or drinking was complained of. He also denied any traumatic history.       On arrival of the emergency room, the body temperature was 35.3℃, pulse rate was 100 per minute, and blood pressure 163/100 mmHg. Throat was not injected. Jugular vein engorgement was noted. Bilateral basal crackles were heard and the accessory muscle respiration was disclosed. PMI was located at 5th intercostal space. There was no RV heave. Heartbeats were regular but a grade IV/VI pansystolic murmur with thrill was noticed at the cardiac apex radiating to the neck, spine and top of the head. Abdomen was flat and soft, and liver and spleen were not palpable. He was admitted for further evaluation and treatment. <Course and Treatment >       Chest X-ray revealed normal cardiac size and bilateral pleural effusion. The pleurocentesis was performed and the biochemistry results of pleural effusion were listed as below. The cytology was negative of malignant cells. He was referred to undertake the echocardiography, which disclosed normal chamber size, severe eccentric mitral regurgitation, and chordae tendinae rupture of anterior leaflet. The left ventricular ejection fraction was 68%, and no regional wall motion abnormality was noticed. There was also no evidence of infective endocarditis and degenerative valvular disease was impressed. His dyspnea subsided gradually after pleurocentesis and diuretics given. The diagnostic cardiac catheterization was done after his condition stabilized. The coronary artery was patent. Cardiovascular surgeon was consulted for surgical intervention. <Lab> CBC + Differential count WBC Seg Lym RBC Hb MCV Hct Plt  9310 63.8% 25.1% 4.46 13.3 89.7 40.6 192000 BCS Na K Cl Ca Glucose GOT BUN Cre 141 mM/l 4.0 mM/l 110 mM/l 2.17 mM/l 94 mg/dl 49 mg/dl 20 mg/dl 1.2 mg/dl Total Protein Albumin Globulin LDH Sugar 6.9 g/l 3.9 g/l 3.0 g/l 371 U/l 94 mg/dl Pleural effusion Total Protein Albumin Globulin LDH Sugar 2.5 g/l 1.5 g/l 1.0 g/l 156U/l 126mg/dl <病案討論>  1. Pathophysiology of acute MR: (1) Acute MR→ LV volume overloading→ increased LV preload→ increased LV total stroke volume. (2) The unprepared left atrium and left ventricle cannot accommodate the regurgitant volume→ pulmonary congestion. 2. Pathophysiology of chronic MR: (1) Chronic MR→ development of eccentric cardiac hypertrophy→ increase in LV end-diastolic volume (2) The increase in LV and LA size allows accommodation of the regurgitant volume at a lower filling pressure 3. Etiology of acute MR: (1) Disorders of the mitral valve leaflets (2) Disorders of the chordae tendinae: such as infective endocarditis, rheumatic valvular heart diseases, trauma, acute rheumatic fever, spontaneous rupture (ex. degeneration). (3) Disorders of the papillary muscles (including myocardial ischemia) 4. Medical treatment: in order to diminish the amount of MR, increasing forward output, reducing pulmonary congestion; medication including after-loading reducing agents, diuretics, nitrates, ventricular rate-controlling agents and antiarrhythmics. 5. The indications of surgical intervention: severe MR and symptoms limiting lifestyle; evidence of increasing myocardial dysfunction; atrial fibrillation (chronic MR); ischemic MR (should be managed aggressive). The goal of surgical treatment is to improve symptoms and preserve LV function. 6. Prognosis: (1) Acute vs. chronic; symptom severity; etiology. (2) Ejection fraction (3) Chronic MR: end-systolic diameter (ESD) < 2.6 cm/m2, end-systolic volume (ESV) < 50ml/m2, exercise with peak oxygen consumption <= 18 ml/kg/min (4) Early mortality: Degenerative MR: 0-2% Ischemic MR: 7-26% Valve repair is better than valve replacement due to preservation of subvalvular apparatus (5) Late mortality:      (A) 95% NYHA Fc I-II in earlier surgical intervention: Survival rate 5y 10y 15y Degenerative 85-90% 80% 70% Rheumatic 90-96% 84-93% 78% (partly due to younger age)      (B) Ischemic MR: poorer prognosis than non-ischemic MR, better survival in aggressive management.        繼續教育考題 1. (A) Which of the following echocardiographic appearances would be seen in a patient with mitral regurgitation (MR) with rheumatic etiology? A  thickened chordae/leaflets B  reduced motion of leaflets C  prolapsing/flail leaflet D  normal leaflets E  ruptured chordae 2. (D) Which of the following statements regarding the treatment of mitral regurgitation is true? A  α-blockers area the drugs of choice for patients with mitral valve prolapse and palpitation B  vasodilator therapy is recommended for chronic treatment of MR C  valve repair is more feasible in patients with rheumatic valvulitis than in those with degenerative valve disease D  even in patients with lower left ventricular ejection fraction (LVEF) < 50%, surgical treatment is better than medical treatment E  the risk of surgery is much greater than patients in their sixth decade and above as compared to younger patients 3. (B) The most common valvular lesion resulting from external blunt chest trauma (as in an automobile accident) is which of the following? A  tricuspid stenosis B  tricuspid regurgitation C  aortic stenosis D  aortic regurgitation E  mitral regurgitation 4. (B) Each of the following statements regarding the acute evaluation of a patient with a blunt cardiac trauma is true EXCEPT: A  CXR should be obtained urgently B  serum cardiac-specific troponin measurements correlate with the  presence and prognosis of blunt myocardial injury C  echocardiography provides useful information in this setting D  arrhythmias and conduction block are common 5. (C) Normal (innocent) murmurs are usually which type of murmur? A  early systolic B  presystolic C  midsystolic D  holosystolic E  early diastolic 6. (A) All of the following are true regarding the echocardiographic assessment of MR except: A  color flow doppler echocardiography provides an accurate quantitative assessment of MR B  pulse Doppler can provide an indirect assessment of MR C  regurgitant color flow Doppler jets directed toward the atrial wall underestimate the severity of MR D  echocardiography may be used to assess the hemodynamic consequences of MR E  determining the etiology of MR is one of the most important applications of echocardiography 7. (E) All of the following features suggest acute as opposed to chronic MR except: A  no cardiomegaly on chest X ray B  a normal ECG C  a systolic murmur that radiates to the neck D  a systolic murmur that clearly ends before S2 E  normal jugular venous pressure 8. (B) Each of the following is considered a high-risk lesion that predisposes to infective endocarditis, EXCEPT: A  aortic stenosis B  mitral valve prolapse with systolic click (no murmur) C  patent ductus arteriosus D  ventricular septal defect E  chronic aortic regurgitation 9. (C) Each of the following statements regarding cardiovascular disease in patients with Marfan syndrome is true EXCEPT: A  approximately 60-80% of patients with Marfan syndrome have mitral valve prolapse on echocardiography B  the development of aortic regurgitation correlates with the aortic root diameter C  patients with Marfan syndrome do not need to be considered for elective aortic root replacement until the aortic root diameter exceeds 6 cm D  β-blockers should be administered to all patients with Marfan syndrome unless a contraindication exists. 10. (E) Which of the following conditions is likely to precipitate symptomatic heart failure in patients with previously compensated left ventricular dysfunction? A  atrial fibrillation B  marked sinus bradycardia C  infection D  marked anemia E  all of the above