darkhorse
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A 63-year-old man is evaluated for a rash. During evaluation, you note a grade 3/6 holosystolic murmur at the apex that radiates throughout the precordium and is loudest along the left sternal border. The left ventricular point of maximum impulse is diffuse and displaced laterally. The heart rate is 94/min and blood pressure is 136/80 mm Hg. Jugular venous pressure is increased. The rest of the findings on physical examination are unremarkable, except for an area of contact dermatitis under the patient’s wristwatch band. The patient works full-time as a dairy farmer and has not seen a physician for 10 years. He denies shortness of breath, orthopnea, or paroxysmal nocturnal dyspnea. Electrocardiogram shows sinus rhythm with left atrial enlargement. Echocardiography shows myxomatous degeneration of the mitral valve, with partial flail of the posterior leaflet and severe mitral regurgitation. The left atrium is enlarged. The left ventricle is also enlarged, measuring 71 mm in diastole (normal range, 37 to 57 mm) and 51 mm in systole (normal range for fractional shortening, 28 mm to 44 mm). The left ventricular ejection fraction is estimated at 52% (normal ≥55%).
Which of the following statements about surgical intervention for this patient is true?
A. Surgery is indicated if the left ventricle remains dilated after 8 weeks of afterload-reducing therapy with an ACE inhibitor.
B. Surgery is indicated if the findings on myocardial perfusion imaging with sestamibi are normal.
C. Surgery is indicated if transesophageal echocardiographic imaging shows that the mitral valve is amenable to repair.
D. Surgery is indicated despite the absence of symptoms.
E. Surgery is contraindicated based on the presence of left ventricular systolic dysfunction.
Edited by darkhorse on 11/18/07 - 07:03 AM
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| cool doctor
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A
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| darkhorse
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The correct answer is D
Educational Objectives
Understand the indications for surgical intervention in patients who have chronic severe mitral regurgitation.
Critique
Surgery is indicated in patients who have chronic severe mitral regurgitation and symptoms of heart failure, evidence of left ventricular systolic dysfunction (left ventricular ejection fraction <60% or left ventricular internal diameter in systole >45 mm), atrial fibrillation, or pulmonary hypertension. Surgery should be considered earlier if the mitral valve is amenable to repair.
Although this patient has no symptoms of heart failure, he has evidence of left ventricular systolic dysfunction. Surgery is indicated, regardless of the valve anatomy. ACE inhibitor therapy does not play a role in the treatment of severe mitral regurgitation other than its use in primary cardiomyopathy with secondary (functional) mitral regurgitation. Because of the high operative risk, surgical intervention is contraindicated in patients who have severe left ventricular systolic dysfunction (ejection fraction <30%), unless mitral repair is likely. Myocardial perfusion imaging plays no role in the assessment of the appropriateness or timing of intervention in patients who have chronic severe mitral regurgitation. Because of his age, this patient should undergo preoperative heart catheterization with coronary angiography to identify coronary artery disease. Surgical revascularization should be performed at the time of valve surgery.
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