Present by

FARINA DWINANDA F

(C111 09 887)

Supervisor :

dr. Khalid Saleh, Sp.PD-KKV, FINASIM

Chf nyha iII ec. MITRAL REGURGITATION

CASE PRESENTATION

Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University

Makassar 2014

PATIENT IDENTITY

• Name : TN.M• Age : 50 years old• Gender : male• MR : 669126• Day of Admission : 25 Juni 2014

Chief Complaint : Shortness of breath

It was felt since ± 2 month ago and got worsen 3 days before

admitted to the hospital. It was experienced while doing physical

activity. There is no complaint while doing the same activity. Since 2

days ago, patients do nothing but still feel the SOB during rest.

Patient can not sleep since the Sob getting worse with lying flat.

Sometimes awaked during at night time that caused by sudden

shortness of breath. History of chest pain (-). Cough(-), Wheezing (-)

Fever (-), history of fever 1 day before admitted to the hospital.

Nausea (-), Vomite (-), palpitation (-), Cold sweats (-). Oedema

extremities (+) in pretibial. Defecation and urination: Normal.

HISTORY TAKING

Family History

Past Medical History

• History of DM (-)• History of

hypertension (+)• History of smoking

(+)

Family History

• History of cardiovascular disease in family (-)

RISK FACTORS

ModifiedNon- Modified

• Gender : Male

• Age 50 years old

• Hypertension

• Smoking

General Status

*Moderate illness/ Well nourished/ Conscious

*Nutritional Status: Normal

*Weight : 60 kg

*Height :165 cm

*BMI : 22,0 kg/m2

Vital Sign

*Blood Pressure : 160/100 mmHg

*Pulse Rate : 76 bpm

*Respiratory Rate : 28 bpm

*Temperature : 36.5 0C (axilla)

PHYSICAL EXAMINATION

Head and Neck ExaminationsEye : Conjunctiva anemic (-/-), Sclera icteric (-/-) Lip : Cyanosis (-)

Neck : JVP R+3 cmH₂O potition 30º

Chest ExaminationInspection : Symmetric between left and right chest.Palpation : No mass, no tenderness.Percussion : Sonor between left and right chest, Auscultation: Respiratory sound: Vesicular Additional sound : Ronchi +/+ (mediobasal) ,Wheezing -/-

• Inspection : Heart apex was not visible

• Palpation : Heart apex was not palpable • Percussion : Right heart border in ICS

II right parasternal. Left heart border in ICS 7 midclavicular.

• Auscultation : Heart Sounds : S I/II regular, murmur (+) sistolik at apex

Heart• Inspection : Flat, follows breathing

movement• Auscultation : Peristaltic sound (+),

normal• Palpation : No mass, no tenderness,

liver and spleen unpalpable

• Percussion : Tympani (+)Abdomen

• Pretibial edema +/+• Dorsal pedis edema +/+Extremitie

s

Electrocardiogram (ECG)

ECG interpretation

Rhythm: Sinus rhythmHeart rate : 70 bpmRegularity : regulerAxis : Right Axis DeviationP wave : 0,08 sPR interval : 0,16 sQRS complex : duration 0,12 s, configuration QS in II,III, aVFST Segment : 0,08 sT wave : 0,12 sConclution : Sinus rhythm, HR70 bpm, RAD, LVH , configuration QS in II,III,aVF

Radiology findings

THORAX FOTO INTERPRETATION

• Cardiomegaly with lung oedeme

• Bilateral efusion pleura

LABORATORIUM

HEMATOL

OGY

RESULT NORMAL

VALUE

UNIT

WBC 13,9 4,00-10,0 (10³/UI)

RBC 5,46 3 4,00-6,00 (106/UI)

HGB 18,5 12,0-16,0 (gr/dL)

HCT 54 37,0-48,0 (%)

PLT 237 150-400 (103/uL)

GDS 110 140 Mg/dL

ureum 30 10-50 Mg/Dl

Creatinin 2,3 <1,3 Mg/dL

Na 140 136-145 mmol/L

SGOT 3,6 <41 mmol/L

SGPT 99 <38 Mg/dL

PT 11.9 10-14 detik

APTT 31,6 22-30 detik

CK 97,7 L<190,P<18

7

u/L

CKMB 25,5 <25 u/L

TROPONIN T 0,26 <0.05

ECHOCARDIOGRAPHY

INTERPRETATIONConclusion

* Dysfunction sistolic and diastolic LV,

* EF 50%

* LVH (+)

* Dilation of LA and LV

* MR mild

* Decrease of systolic LV function, EF 50%

* Dimensional chambers of heart : LA and LV dilatation

* LVH (+)

* Global hipokinetic

* Insdequate RV systolic function, TAPSE 1,3 cm

* Heart valves :

- Mitral: MR mild

- Aorta : 3 cuspis, calsification (-)

- Tricuspid : TR trivial

- Pulmonal : normal function and movement

* E/A >2 (pseudonormal)

Working DIAGNOSIS

CHF e.c HHDHT Grade IIMR Mild

MANAGEMENT Bed rest

Oxygen 3-4 lpm via nasal canule

Cardiac diet

IVFD NaCl 0.9% 500 cc/24 hr

Angiotensin receptor Blocker

Valsartan 1x80 mg

Laxative

Laxadyne syr 0-0-II cth

Diuretic

Lasix 2am/8jam/iv

DISCUSSION

HEART FAILURE

The state in which abnormal circulatory congestion occurs as the result of heart failure.

DEFINITION

Heart failure 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

Congestive

Heart

Failure

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

Major Criteria Minor Criteria

• Paroxysmal Nocturnal

Dyspnea

• Cardiomegaly

• Gallop S3

• Hepatojugular reflux

• Increased of JVP

• Rales or ronchi

• Acute pulmonary edema

• Prolonged circulation

time(> 25 sec)

• Weigh loss ≥ 4,5 kg in 5

days in

response to treatment of

CHF

• Extremity edema

• Nocturnal cough

• Decreased vital

pulmonary capacity

(1/3 of maximal)

• Hepatomegaly

• Pleural effusion

• Tachycardia (≥

120bpm)

• Dyspnea d’effort

clASSIFICATION OF CHF

PATHOPHYSIOLOGY OF CHF

Plaque in coronary artery

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

Ischemia of heart muscle can lead to myocardial infarction

Symptomatic Congestive Heart Failure

Pulmonary edema Abnormal Heart rhythm

The heart muscle can’t pump adequately

Sign & symptomp of chf

Managing afterload

Managing preload

Neurohormonal modulation

Managing contractility

Inotropic agents : • Cardiac glycosides• B- adrenergic

• Diuretics• Venodilator

•ACE inhibitors•ARB•β blockers•CCB

•β blockers•ACE inhibitors•ARB

CHF MANAGEMENT

Farmakologi

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 ventricle. An imperfection in any one 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

Functional (regional or global LV

remodelling )

Structurally normal leaflets and chordae tendineae

*Ischemic heart disease (Ischemic MR)

*Idiopathic dilated cardiomyopathy

*Mitral annular dilatation

Etiology

• Dyspnea

• Fatigue

• Orthopnea

• Palpitation

• Pulmonary edema (often the initial manifestation)

Symptoms of MR

Physical ExamPalpation 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

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

• CXR: LA and LV enlargement

• ECG: LV hypertrophy, sometimes AF

• Echocardiografi:

– LAE

– LV enlargement

Diagnostic Tests

Medical Therapy

*ACE-Inhibitor

*Diuretic

*Nitrat

*Digoxin

*Antibiotic

• Symptomatic with severe MR

• Asymptomatic with severe MR and preserved LV function

• Asymptomatic with severe MR and LVESD > 45 mm and EF < 55%

Surgical intervention

Thank You