A 43-year-old woman is being evaluated for a heart murmur. She is physically active and takes a yoga class three times a week without difficulty. She exercises on a treadmill twice per week. She denies any chest pain or pressure, palpitations, and shortness of breath.
She had arthroscopic knee surgery two years ago after sustaining a knee injury while running. Otherwise, her past medical history is unremarkable.
Her blood pressure is 122/78 mm Hg and pulse is 67 /min. Her BMI is 25 kg/m². There is a blowing 3/6 holosystolic murmur heard best at the apex. Lungs are clear on auscultation. Her physical examination is otherwise unremarkable.
EKG shows normal sinus rhythm with non-specific ST segment and T wave changes. Echocardiogram shows normal left ventricular size and function, an ejection fraction of 65%, and posterior mitral leaflet prolapse with severe eccentric mitral regurgitation. Left atrial size is moderately increased. Pulmonary artery systolic pressure is estimated at 25 mm Hg.
Which of the following is the best recommendation for this patient?

Question

Quizplus · Accepted Answer

This patient has mitral valve prolapse with significant mitral regurgitation (MR), as evidenced by the echocardiogram (ECHO). Patients with chronic severe mitral regurgitation require intervention (mitral valve repair preferred over replacement) if they develop symptoms (i.e., shortness of breath), echocardiographic evidence of cardiac dysfunction (e.g., an ejection fraction < 60% or an end systolic dimension > 40 mm), pulmonary hypertension (i.e., PAP > 50 mm Hg), or new onset atrial fibrillation (Choice D). 11ec193a_9733_1eb5_853d_dbe3e228eb98_MD0002_00 Asymptomatic patients require serial monitoring, with the frequency depending on the severity of MR as seen on ECHO (summarized in above flow chart). This patient with severe mitral regurgitation and no cardiac dysfunction should be evaluated with serial clinical and echocardiographic follow-up every 6-12 months. (Choice A) Current guidelines recommend antibiotic prophylaxis in patients with valvular heart disease repaired with prosthetic valve or prosthetic material (i.e., a mitral or tricuspid ring), history of prior endocarditis, congenital heart disease (e.g., unrepaired cyanotic, within 6 months of repaired congenital heart disease, or repaired congenital heart disease with residual defects), or cardiac transplant with an abnormal valve and regurgitation. (Choice B) Anticoagulation is not indicated in the absence of documented atrial fibrillation (common in mitral valve disease). (Choice C) This patient is very physically active without any cardiovascular symptoms, and therefore has no indication for coronary angiography. Educational objective: Patients with chronic mitral regurgitation (MR) require mitral valve repair if they become symptomatic, show echocardiographic (ECHO) evidence of cardiac dysfunction, develop pulmonary hypertension, or new-onset atrial fibrillation. Asymptomatic patients need serial monitoring with clinical exam and ECHO depending on the severity of the MR. __________ References: Mitral regurgitation: current trends in diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/21441774) Management of less-than-severe mitral regurgitation: should guidelines recommend earlier surgical intervention? (http://www.ncbi.nlm.nih.gov/pubmed/21257316)

A 43-Year-Old Woman Is Being Evaluated for a Heart Murmur