CHF NYHA IV ec SEVERE

MITRAL REGURGITATION
By : Susianty Kosa
Supervisor : dr. Pendrik Tandean, Sp.PD

Name
: Tn.A
Age
: 71 years
Gender
: Male
MR.Num
: 39.21.86
Date Admitted: 7th July 2009

Chief complaint: Shortness of breath

History taking:
Experienced 2 week before admitted. Precipitated by
exertion & lying position, not by cold weather. Frequently
waking up in the night gasping for breath. If he walked
about 6 meters far, he would get breathless
Chest pain (-)
Cough (+) with white sputum
Fever (-), history of fever (-), headache (-)
Nausea (-), vomitting(-), epigastric pain (-), appetite was
decresed
Defecation and urination is normal

History

of hospitalized in Sinjai
hospital about 5 days with the same
complain and then referred to WS
hospital
Hypertension was denied
Diabetes Mellitus (-)

Present status:
Severe illness/ Under nutrition/Conscious
Vital signs:
BP : 90/60 mmHg
HR : 88 bpm irregular
RR : 36x/minute
T
: 36,5C

Head : Anemia (-) Icterus (-) Cyanosis ( - )

Neck :
No mass, no pain
JVP R+3 cmH2O
Chest :

Inspection
: Symmetric sinistra et dextra
Palpation
: No mass, no tenderness
Percussion : Sonor sinistra et dextra
Auscultation : breath sound was
bronchovesicular,
additional sound : Rhonchi +/+
Wheezing -/-

Heart:
Inspection : ictus cordis was not visible
Palpation : ictus cordia was not palpable
Percussion : Upper border : ICS II sinistra
Lower border : ICS V sinistra
Right border :2 cm to the right of right
parasternal line
Left border
: 4 cm of the Left
Medioclavicular Line to the lateral
Auscultation : S1/S2 regular, pansystolic murmur

 Abdominal :
Inspection : Convex, moving with respiration
Palpation : palpable liver 3 cm below the right
costal margin on deep inspiration, regular surface,
hard consistency, soft edge.
Percussion : shiffting dullness (+)
Auscultation : Peristaltic sound (+), normal
Peripheral Edema( -/-)

LABORATORY FINDINGS
Complete blood
count
WBC: 6.8x103/l
RBC: 4,65x106/l
HGB: 13,3gr/dl
HCT: 133x103
PLT: 191x103/l
Electrolyte
Sodium: 132
Potassium: 2,9
Chloride: 99

Blood chemistry:
Total Bilirubin : 5.21 mg/dl
Direct Bilirubin: 3.25mg/dl
Total protein:
7.0 mg/dl
Albumin : 3.6 mg/dl
Globulin : 3.4 mg/dl
Cholesterol Total: 96
Cholesterol HDL :20
Cholesterol LDL: 69

 Anti HCV rapid test : -ve

HbsAg: -ve

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY
(CONT)

Interpretation:
Sinus arrhythmia
HR 120 bpm
RAD
LVH
Atrial Fibrilation Rapid respone

Conclusion:

Cardiomegaly with sign of lung

congestive

ECHOCARDIOGRAPHY

ECHOCARDIOGRAPHY

Description:

MVA : 1,8-2,2 cm3

EF 66%, LA :6,1
Mitral valve excursion :1,5
RV : 3,2 , LVEDS: 3,1
Severe Mitral Insufisiensi
Severe Tricuspidal Insufisiensi
Mild moderate mitral stenosis
PH (+)

Conclusion:

Severe MI , severe TR.

Mild moderate MS
Secondary pulmonal hypertension

Conclusion:

Hepatomegaly with congestive liver

CHF

NYHA IV ec SEVERE
MITRAL REGURGITATION

Heart Diet 1
restriction of dietary sodium
O2 2 4 liter/minute
IVFD RL 16 dpm
Lasix 20mg /12hr/iv
Captopril 12,5mg twice daily
Aspilet 80mg 1 x 1
Digoxin 0.25mg 1x1
Spironolactone 100mg 1x1
Alprazolam
1x1
Laxadyn syr 3 x 1 t.s

Ranitidin

150mg twice daily

Curcuma 3x1

DISCUSSIONS

Congestive heart failure

(CHF) is an imbalance
in pump function in
which the heart fails
to maintain
the circulation of blood
adequately.

Ischemic heart disease

Valve

disease

Hypertensive

heart disease

Cardiomyopathy
Coronary

artery disease

Major Criteria
Paroxysmal Nocturnal
Dyspnea
Cardiomegaly
Gallop S3
Increased of JVP
Hepatojugular reflux

Minor Criteria
Extremity edema
Cough
Decreased vital
pulmonary
capasity (1/3 of
maximal)

Rales or ronchi

Hepatomegaly

Acute pulmonary edema

Pleural effusion

Prolonged circulation time

Tachycardia

(> 25 sec)

Dyspnea deffort

No symptoms and no limitation in ordinary physical

activity.

II

Mild symptoms and slight limitation during ordinary

activity. Comfortable at rest.

III

Marked limitation in activity due to symptoms, even

during less-than-ordinary activity. Comfortable only at
rest.

IV

Severe limitations. Experiences symptoms even while at

rest.

Managing
preload
Managing
contractility

Managing
afterload
Neurohormonal
modulation

Diuretics
Venodilators

Ca2+

channel blockers
Anti adrenergic
Vasodilators

Cardiac

glycosides
adrenergic
Phosphodiesterase inhibitors

blockers
ACE inhibitors
Angiotensin receptor blockers

condition in
which the mitral
valve does not
seal tightly,
which allows
blood to flow
backward in your
heart

The mitral valve may become

incompetent for four reason:

Abnormal

mitral valve annulus

Abnormal mitral valve leaflets
Abnormal chordae tendinae
Abnormal papillary muscle function

ETIOLOGY of MR
ACUTE
Rupture

CHRONIC
chordae

tendinae
Papillary muscle
rupture
endocarditis

Chronic

rheumatic
heart disease
Severe LV dilatation
Mitral valve prolapse
Marfan syndrome

PATHOPYSIOLOGY of MR
Abnormality of
mitral valve
LVH,
Dilatation an failure

Valve cant close

properly
Left ventricle systole inject
A large high pressure jet into
Left atrium
Left atrium dilates an
Accomodates the increase
Volume an pressure
Backpressure in
the pulmonary vein

RVH and failure

COMPARISON OF ACUTE
MR AND CHRONIC MR
Acute MR

Chronic MR

Normal

P mitral, LVH,
Atrial fibrilation

Heart size
(CXR)

normal

Cardiomegaly, left
atrial enlargement

Systolic murmur

Heard at the base, Heard at the

radiates to the
apex, radiates to
neck, spine, or
the axilla
top of head

Apical thrill

Maybe absent

ECG

present

CHRONIC

MR: History of fatigue an

CLINICAL FEATURES
dyspnea
ACUTE MR: Severe dyspnea due to
pulmonary edema.

 Irregular

pulse indicate for atrial fibrilation

ON PYHSICAL
JVP maybe elevated
EXAMINATION
The apex is displaced downward and laterally

as the left ventricle dilates

Pansystolic murmur and best heard at the apex
Sign of CHF: ascites , peripheral edema

MANAGEMENT
MANAGEMENT

MEDICAL

Afterload-reducing agents (such as nitrates and

antihypertensive drugs) and diuretics are helpful for
maintaining the forward cardiac output in persons with MR
with symptoms and/or LV dysfunction.

Inotropic agents
Because of its antiarrhythmic properties, digoxin is used
if atrial fibrillation is encountered; however, it is not
expected to improve overall cardiac function.

SURGICAL
Mitral

MANAGEMENT

valve repair
Mitral valve replacement
Indications for surgery for chronic mitral
regurgitation include signs of left
ventricular dysfunction. These include an
ejection fraction of less than 0.30 and a
left ventricular end systolic dimension
(LVESD) of greater than 55 mm.

Thank You!