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

MITRAL
REGURGITATION
Present by
Dionisius Giri S
(C111 09 309)
Supervisor :

dr. Muzakkir Amir, Sp.JP.FIHA,FICA

Department of Cardiology and Vascular Medicine

Medical Faculty of Hasanuddin University
Makassar 2014

PATIENT IDENTITY

Name
: Mrs. DS
Age
: 25 years old
Gender
: Female
MR
: 646185
Day of Admission : January 11th
2014

HISTORY TAKING
Chief Complaint : Shortness of breath
History of illness:
Suffered since 1years ago and got worsen 5
days before admitted to the hospital. It was
experienced while doing minimal activity
walking to the bathroom and relieved with
resting. Sometimes awaked during at night time
that caused by sudden shortness of breath,
patient sleep with sit potition. Chest pain (+), on
the left chest, since 1 month ago before

spread until to the left arm,penetrate

to the back, feels like kneaded. Cough
(+) since 6 days ago with sputum of
white coloured, Fever (-), history of
fever 3 day before admitted to the
hospital. Nausea (-), Vomite (-),
palpitation (-), Cold sweats (+).
Defecation and urination: as ussual his
habituation

Past Medical History

History

of DM (-)
History of hypertension (-) since
History of smoking (-)
History of medicine (+) treated in RSWS on
February 2013, with VHD, and got
Spironolakton
Family History

History of cardiovascular disease in

family (-)

RISK FACTORS

Modified

Non- Modified

Hipertension

Gender : Female

Diabetes

Age

Mellitus

General Status

Moderate illness/ Well nourished/ Conscious

Nutritional Status: Normal

Weight : 50 kg
Height : 155 cm
BMI
: 20.8 kg/m2

Vital Sign

Blood Pressure : 100/70 mmHg

Pulse Rate

Respiratory Rate

: 32 tpm

Temperature

: 36.8 0C (axilla)

: 114 bpm

PHYSICAL EXAMINATION
Head and Neck Examinations
Eye
: Conjunctiva anemic (-/-), Sclera icteric
(-/-)
Lip
: Cyanosis (-)
Neck

: JVP R +2 cmHO potition 30

Chest 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 /-

 Pretibial edema +/+

Dorsal pedis edema +/+

Inspection
Auscultation
Palpation
Percussion

: Flat, follows breathing movement

: Peristaltic sound (+), normal
: No mass, no tenderness, liver and
spleen unpalpable
: Tympani (+)

Inspection
: Heart apex was not visible
Palpation
: Heart apex was not palpable
Percussion
: Right heart border in right
parasternal line,
Left heart border in left
midclavicular line
ICS V.
Auscultation
: Heart Sounds : S I/II regular, murmur
(+)
sistolik grade 3/6 apex

s
Extremitie
Abdomen
Heart

Electrocardiogram (ECG)

14/1/201
4

ECG interpretation
Rhythm: Sinus rhythm
Heart rate : 117 bpm
Regularity : reguler
Axis
: RAD
P wave
: P mitral 0,12 s on II,avL lead
PR interval : 0,20 s
Q pathologies
:QRS complex : duration 0,12 s, configuration RS, QS on I,avL, v2 leads

ST Segment
: 0,08 s isoelectric
T wave
: 0,12 s
Conclution :
Sinus tachycardi rhythm, HR 117 bpm, LAE, RAD

Radiology findings

THORAX FOTO INTERPRETATION

Cardiomegaly with lung

edeme
Efusion pleura dextra
Proper with Mitral Heart
Disease description

LABORATORIUM
HEMATOL

RESULT

OGY

6/1/2014
NORMAL

UNIT

VALUE

WBC

7,6

4,00-10,0

(10/UI)

RBC

4,42

4,00-6,00

(106/UI)

HGB

12,4

12,0-16,0

(gr/dL)

HCT

38,0

37,0-48,0

(%)

PLT

237

150-400

(103/uL)

GDS

117

140

Mg/dL

Ureum

81

10-50

Mg/Dl

Creatinin

1,1

<1,3

Mg/dL

Na

138

136-145

mmol/L

SGOT

92

<41

mmol/L

SGPT

55

<38

Mg/dL

PT

11.1

10-14

detik

APTT

28,5

22-30

detik

CK

748

L<190,P<18

u/L

CKMB

24

7
<25

u/L

TROPONIN T

<0,02

<0.05

ECHOCARDIOGRAPHY

INTERPRETATION
Conclusion
sistolic LV function is good, EF 63,33%
(on tachicardi)
Dimensional chambers of heart:
LA,RA,RV dilatation
Decrease RV function
MR severe
TR moderate-severe
PR Trivial
PH moderate-severe (mPAP 59 mmHg)

Working DIAGNOSIS
Severe MITRAL
REGURGITATION
CHF NYHA III

MANAGEMENT
Bed rest
Oxygen 3-4 lpm via nasal canule
Cardiac diet
IVFD NaCl 0.9% 500 cc/24 hr
Dobutamin 5 g/kgBB/jam
Lasix 40 mg/8 jam/ SP if BP 90
Spironolakton 25 mg x 1
Simarc 2 mg 1 x 1

DISCUSSION
MITRAL REGURGITATION

Normal mitral valve function

depends on perfect function
of the complex interaction
between the mitral leaflets,
the
subvulvar
apparatus
(chordae
tendinae
and
papillary
muscles),
the
mitral annulus, and the left
An imperfection in any one
ventricle.

of these
components can cause the valve to leak.

Mitral regurgitation is
retrograde flow of blood from
LV to LA through incompetent
mitral valve during systolic
phase.
Causes by Primary (intrinsic
valvular disease) and
Functional (regional or global
LV remodelling )

Primary (intrinsic
valvular
disease)
MR is almost always
(90%) associated with
MS in RHD
Degenerative
processes of leaflets
and chordal
structures
Infective endocarditis
Mitral annular
calcification

Structurally normal
leaflets and chordae
tendineae
Ischemic heart disease
(Ischemic MR)
Idiopathic dilated
cardiomyopathy
Mitral annular
dilatation

Etiology

Pathophysiology of MR
Mitral regurgitation
Systolic (Retrograde)
Acute
Volume overload in LA & LV
ed LA, LV Pressure

ejection into LA

Chronic
ed LV afterload (into LA)
ed LA/LV size/ compliance

Pulmonary edema ed Cardiac output

LA dilatation ed contractility
AF
CO
Pulmonary congestion

Pathophysiology

Symptoms of MR

Dyspnea
Fatigue
Orthopnea
Palpitation
Pulmonary edema (often the
initial manifestation)

Physical Exam

Palpation may reveal the following:

Brisk carotid upstroke and hyperdynamic cardiac
impulse
Prominent LV filling wave
Auscultation may reveal the following:

Diminished S1 in acute MR and chronic severe MR

with defective valve leaflets
Wide splitting of S2 as a result of early closure of
the aortic valve
S3 as a result of LV dysfunction or increased blood
flow across the MV
Accentuated P2 if pulmonary hypertension is
present
Characteristic murmur

Auscultation

Clinical Features
Acute
Present with sudden
onset of pulmonary
edema, hypotensio,
cardiogenic shock
Murmur early
systolic, soft
inaudible
Normal LA size and
compliance

Chronic
Usually
asymptomatic, if
there is present with
low CO symptom
Over time CHF
features
Increased LA size
Lower CO

Diagnostic Tests

CXR: LA and LV enlargement

ECG: LV hypertrophy,
sometimes AF

Echo:
LAE
LV enlargement

Medical Therapy
ACE-Inhibitor
Diuretic
Nitrat
Digoxin
Antibiotic

Surgical intervention
Symptomatic with severe MR
Asymptomatic with severe MR and
preserved LV function
Asymptomatic with severe MR and
LVESD > 45 mm and EF < 55%

DISCUSSION
HEART FAILURE

DEFINITION
rt
a
e
H
ure
l
i
a
F
Heart is no longer able to pump an
adequate supply of blood in relation
to the venous return and in relation
to the metabolic needs of the body
tissues at the particular moment
iv e
t
s
ge
n
o
rt
C
Hea re
u
Fail

The state in which

abnormal circulatory
congestion occurs as the
result of heart failure.

ETIOLOGY OF HEARTFAILURE
Miocard
Disease
CAD
Cardiomyopathy
Iatrogenic

Miocarditis

Miocard Mechanical
Dysfunction
Pressure overloaded
(Stenosis Aortae,
Hypertension, Coartatio
Aortae)
Volume Overloaded
(Mitral/Aortae Regurgitation,
Congenital Heart Disease,
Hipertransfusion)
Miocard Filling Inhibitating
(Cardiac Tamponade,
Pericarditis)

The Framingham criteria for CHF

CHF considered present if 2 major or 1 major & 2 minor

Major Criteria

Minor Criteria

Paroxysmal Nocturnal

Extremity edema

Dyspnea

Nocturnal cough

Cardiomegaly

Decreased vital

Gallop S3

pulmonary capacity

Hepatojugular reflux

(1/3 of maximal)

Increased of JVP

Hepatomegaly

Rales or ronchi

Pleural effusion

Acute pulmonary edema

Tachycardia (

Prolonged circulation

time(> 25 sec)

Weigh loss 4,5 kg in 5

days in

120bpm)

Dyspnea deffort

clASSIFICATION OF CHF

PATHOPHYSIOLOGY OF CHF
Plaque in
coronary
artery

Symptomatic
Congestive
Heart Failure

Blood flow to
heart muscle
is reduced.
Heart muscle
lacking of
oxygen

Ischemia of
heart muscle
can lead to
myocardial
infarction

Pulmonary
edema
Abnormal
Heart rhythm

The heart
muscle cant
pump
adequately

Sign & symptomp of chf

CHF MANAGEMENT
Optimalized
Oxigenation

NonFarmakolog
i

Reduce Physical
Activity
Low salt, enough
calories and
proteins detary

CHF MANAGEMENT
Farmakologi

Managing
preload

Managing
afterload

Managing
contractility

Neurohormonal
modulation
Diuretics

Venodilator

Inotropic agents :
Cardiac glycosides
B- adrenergic

ACE
inhibitors
ARB
blockers
CCB

blockers
ACE
inhibitors
ARB

Thank You