A 65-year-old woman presents to your office for follow-up of a murmur she was told about several years prior. She denies any symptoms, but is not very active. Her past medical history is significant for hypertension and diabetes, both of which have been well controlled. On examination, she is in no acute distress. BP is 125/75 mmHg, with a resting heart rate of 70 bpm. Lungs are clear. Cardiac examination reveals a displaced PMI. S1 is soft. S2 reveals an increased P2 component. There is a right ventricular (RV) lift. An S3 is present. There is a grade III/VI holosystolic murmur heard at the apex radiating to the base. She has no peripheral edema. Chest X-ray demonstrated cardiomegaly with prominence of the central pulmonary vasculature.
An echocardiogram is performed on this patient (Fig. below).
Left ventricular (LV) systolic dimension is 4.7 cm. Ejection fraction is 45%. There is posterior leaflet prolapse. There is a very eccentric jet of MR, which is read out as 2+.
What do you recommend next?
Mitral valve surgery. The presence of mild LV dysfunction with LV dilation is a class I indication for surgery. TEE would be the next test of choice prior to surgery to confirm the severity and mechanism of MR and assess suitability for surgical repair. While exercise echo is reasonable in asymptomatic patients with severe MR to assess functional capacity the patient already has indications for surgery.
A 40-year-old woman is referred to your office for evaluation of a murmur heard during a routine physical examination. She is asymptomatic. She used to jog 2 to 3 miles a day without problems but over the past few years has stopped exercising. She had frequent febrile illnesses as a child, but her past medical history is otherwise unremarkable.
Physical Examination:
An echocardiogram is performed (Fig. below);
Proximal flow convergence radius (PFCR) using color 3D across the mitral valve indicates an orifice area of 1.2 cm2 . Resting PA pressures are 35 mmHg. Splittability score is 5. LV size and function are normal.
Which of the following would be the most reasonable next step in management?
Stress echocardiogram, to assess for mitral pressures post stress. She has moderate mitral stenosis. The fact that she has stopped exercising may be a clue to the onset of symptoms. An assessment of functional capacity and post-stress mitral pressures would be useful in management There are insufficient data for immediate referral for intervention. Follow-up in a short period of time may not be unreasonable; however, 2 years is too long a period.
A stress echocardiogram is performed. Patient exercises for 6 metabolic equivalents (METs). Right ventricular systolic pressure post stress is estimated at 70 mmHg.
Which of the following would be an appropriate next step?
Consideration for percutaneous valvuloplasty. Her functional capacity is below average for her age. Her valve is favorable for percutaneous valvuloplasty (splittability score of 6) and she had a significant rise in PA pressures post stress. Ideally, the splittability index should be 8 or less for optimal results post balloon valvuloplasty. A increase in mean valve gradient of 15 mmHg with exercise is a class I indication by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. A βblocker would not be an unreasonable addition, but she should be followed more frequently than every 2 years. In addition, she does have class I indication for intervention. She has normal LV function and is in sinus rhythm—there is no role for digoxin in this setting. Valve replacement is considered only if the valve is deemed unsuitable for percutaneous valvuloplasty or surgical repair.
A 50-year-old woman presents to you for evaluation. She complains of easy fatigability, as well as abdominal fullness and right upper quadrant pain. She also notes marked swelling in her legs. She has recently been diagnosed with asthma and is also undergoing evaluation for recurrent diarrhea. On examination, she has a BP of 100/60 mmHg. Heart rate is 96 bpm. There is elevation in jugular venous pressure, with a large a wave and a prominent v wave. Lungs are clear. Cardiac examination reveals a nondisplaced PMI. Rhythm is regular. S1 and S2 (including P2 ) are normal. A diastolic murmur is heard along the sternal border, which increases with inspiration. A pansystolic murmur is also heard in this area. Hepatomegaly is present, along with ascites and peripheral edema.
What is the most likely cause of this patient’s signs and symptoms?
Carcinoid. The history and examination are consistent with tricuspid stenosis and regurgitation. (She has symptoms of fatigability from decreased cardiac output, signs, and symptoms of systemic venous congestion— hepatic distension and right upper quadrant pain, peripheral edema, and ascites. There is a diastolic murmur along the sternal border, which increases with inspiration, along with a prominent a wave in the JVP. In addition, she has a pansystolic murmur and a prominent v wave.) However, no evidence for mitral stenosis is noted on examination. Isolated rheumatic tricuspid stenosis is very rare. Thus, other causes for tricuspid stenosis should be considered. The second most common cause of tricuspid stenosis is the carcinoid syndrome. She also has bronchospasm and diarrhea, which go along with this diagnosis. She has a normal P2 , making primary pulmonary hypertension unlikely. Liver disease in and of itself would not produce elevation in the JVP.
A 28-year-old man is referred to your office for a second opinion regarding his hypertension. On physical examination, he is in no acute distress. BP is 160/90 mmHg, symmetric in both arms. Pulse rate is 75 bpm. Cardiac examination reveals a nondisplaced PMI. S1 is normal. It is followed by a highpitched sound widely transmitted throughout the precordium. A short II/VI systolic ejection murmur is heard. S2 is normal.
What is the most important diagnostic test to perform next?
Check lower extremity BP. He has a bicuspid aortic valve (an ejection sound is heard, along with a short systolic ejection murmur). There is an association between bicuspid aortic valves and coarctation of the aorta. Therefore, looking for discrepancy between the upper and lower extremity BP would be paramount.
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