A 33-year-old woman who recently immigrated to the United States is brought to the emergency department with severe shortness of breath and hemoptysis. Physical examination reveals a diastolic murmur. Chest x-ray shows severe pulmonary vascular congestion and edema. She is admitted to the hospital, treated with diuretics, and begins to feel better. However, during her hospitalization, she develops right-sided hemiparesis. Which of the following additional findings in this patient would be most suggestive of combined disease involving the mitral and aortic valves rather than exclusive mitral involvement?

Question

A 33-year-old woman who recently immigrated to the United States is brought to the emergency department with severe shortness of breath and hemoptysis.  Physical examination reveals a diastolic murmur.  Chest x-ray shows severe pulmonary vascular congestion and edema.  She is admitted to the hospital, treated with diuretics, and begins to feel better.  However, during her hospitalization, she develops right-sided hemiparesis.  Which of the following additional findings in this patient would be most suggestive of combined disease involving the mitral and aortic valves rather than exclusive mitral involvement?

Quizplus · Accepted Answer

11ec160b_3a94_2013_9249_b76581888d20_MD0001_00 This patient's physical examination findings are suggestive of mitral stenosis (MS). In isolated MS, cardiac and pulmonary pressures proximal to the stenotic mitral valve are markedly elevated. However, diastolic pressure in the left ventricle (LV) is usually near normal or even decreased with severe stenosis. Increased LV diastolic pressure in a patient with MS suggests concomitant aortic valve dysfunction. Rheumatic heart disease almost always affects the mitral valve, but both the mitral and aortic valves are affected in about 25% of cases. Aortic valve involvement typically involves combined aortic stenosis and regurgitation, both of which can increase LV diastolic pressure. Rheumatic deformation of the aortic valve can also predispose to infective endocarditis even when the valve is functionally normal. This patient's right-sided hemiparesis is most likely due to embolism, which could have originated from an atrial mural thrombus secondary to atrial dilation from MS or an endocarditis-related valvular vegetation (less likely). (Choices B and D) Severe, isolated MS can cause increased pulmonary artery pressure (pulmonary hypertension) via backward transmission of elevated pulmonary capillary wedge pressure. Longstanding pulmonary hypertension can result in reduced pulmonary vascular compliance due to endothelial remodelling and capillary obliteration. (Choice C) Pulmonary capillary wedge pressure (an estimate of left atrial pressure) will increase with any significant left-sided valvular pathology (ie, both isolated MS and combined aortic and mitral valve disease). (Choices E and F) Right ventricular dilatation can occur in MS when the resulting pulmonary hypertension is severe enough to cause right heart failure. Tricuspid regurgitation can occur as a complication of right ventricular dilatation. Educational objective: Isolated mitral stenosis causes elevated upstream pressures in the left atrium and pulmonary veins and arteries. Left ventricular end diastolic pressure (LVEDP) is normal or decreased due to obstruction of blood flow through the stenotic valve. An elevated LVEDP suggests additional downstream pathology (eg, aortic valve disease, left ventricular failure).

A 33-Year-Old Woman Who Recently Immigrated to the United States