Figure. Echocardiogram.
Online Clinical Case Study (April 2009)
The
content of the Office Cardiology Series is provided by:
Dr. LAW Kwan Kin MBChB (CUHK), MRCP (UK), FRCP (Glasg), FHKAM (Medicine), Specialist
in Cardiology
Dr. LI Siu Lung, Steven FHKAM (Med), FRCP (Glasg), FRCP (Edin), FRCP (Lond),
Specialist in Cardiology
Dr. WONG Shou Pang, Alexander FRCP, FHKAM (Med.), FHKCP, Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙羅君健醫生、李少隆醫生及王壽鵬醫生提供。
A 66-year-old lady was incidentally found to have a grade 3/6 pan-systolic murmur over the apex and radiating to the left axilla. She had no palpitation or heart failure symptoms. Her exercise tolerance was satisfactory and she could manage her daily housework without any difficulties. Resting ECG showed sinus rhythm and left ventricular hypertrophy. Chest radiograph showed mild cardiomegaly. An echocardiogram was performed (Figure).
Figure. Echocardiogram.
Answers
| 1. |
What was the diagnosis? |
| This patient had a marked prolapse of the posterior mitral valve leaflet with severe anterior-directed mitral regurgitation (Figure 1). The left atrium and left ventricle were mildly dilated but the left ventricular end-systolic dimension was 3.6 cm only. The left ventricular systolic function was still preserved with an ejection fraction of 63%. | |
| 2. |
How would you manage this patient? |
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Management of patients with severe chronic mitral regurgitation due to mitral valve prolapse depends on the symptoms, left ventricular function, degree of left ventricular dilatation, onset of atrial fibrillation, and presence of pulmonary hypertension (Figure 2). Asymptomatic patients with normal LV function (>60%) and end-systolic dimension less than 4 cm, no atrial fibrillation or pulmonary hypertension can be observed and re-evaluated with an echocardiogram every 6 months. No specific medication has been proven to be beneficial in these patients. Dental assessment and antibiotic prophylaxis for infective endocarditis is important. Mitral valve surgery should be performed when there is LV dysfunction (EF <60%) or the end-systolic dimension is greater than 4 cm in asymptomatic patients. Onset of atrial fibrillation and the presence of pulmonary hypertension are also considered by most cardiologists as appropriate indicators for surgical intervention. Mitral valve repair is the procedure of choice if the valve is amenable for repair and a skillful operator of this technique is available. This procedure preserves the native mitral valve without implantation of a prosthesis, and therefore avoids the risks for chronic anticoagulation (except in patients with atrial fibrillation) and the potential complications of a valve prosthesis. It is now reasonable to consider mitral valve repair in patients with asymptomatic chronic severe mitral regurgitation with normal LV dimension and function in whom the likelihood of successful repair without residual regurgitation is greater than 90%. However, this procedure is highly technically demanding and success depends predominantly on the availability of an experienced operator. For those patients who are symptomatic, surgical intervention is indicated if there is no advance in LV dysfunction (EF <30%) or enlargement (LV end-systolic dimension greater than 5.5 cm). Even if the LV function is severely impaired or the LV is grossly dilated, surgical intervention can still be considered if there is high chance of preserving the chordal apparatus. Otherwise, medical therapy is all that can be offered. Therefore, according to this guideline, this patient is being observed clinically and an echocardiogram will be performed every 6 months to monitor the LV size, and function as well as the pulmonary artery pressure. She will be referred for surgery if she becomes symptomatic, develops atrial fibrillation, or echocardiographic criteria for surgery are met.
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A young adult with multiple "boils" on face
A 20-year-old gentleman had acne for a few years and was being treated with herbal medicine. In the past month he has complained that his acne was gradually getting worse, with the formation of “boils”. He was prescribed oral doxycycline and topical clindamycin but no improvement was seen after 3 weeks. There were no systemic symptoms, such as fever or arthralgia. Aside from the acne, he enjoyed good health. On examination, there were multiple papules, pustules, inflammatory nodules and abscesses on his face. There were necrotic and scabbed lesions over his mandible. Comedones were also seen in focal areas.
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