GROUP 7 - DHB

MITRAL VALVE INSUFFICIENCY

Polo - Case Report: Pathophysiology and treatment (powerpoint)

Raga - Diagnostic tests and Diagnosis of Mitral Valve Insufficiency
Roguel - Overview and Clinical exam
Rone - Medical and Dental management

REVIEW OF LITERATURE

A. Overview of Cardiovascular System

Heart
● The heart is a hollow muscular organ that is somewhat pyramid shaped and lies within
the pericardium in the mediastinum. It is connected at its base to the great blood vessels
but otherwise lies free within the pericardium.

Surfaces of the Heart

● The heart has three surfaces: sternocostal (anterior), diaphragmatic (inferior), and a
base (posterior). It also has an apex, which is directed downward, forward, and to the
left.
 ● Note that the base of the heart is called the base because the heart is pyramid shaped;
the base lies opposite the apex. The heart does not rest on its base; it rests on its
diaphragmatic (inferior) surface.

Borders of the Heart

● The right border is formed by the right atrium; the left border, by the left auricle; and
below, by the left ventricle. The lower border is formed mainly by the right ventricle but
also by the right atrium; the apex is formed by the left ventricle. These borders are
important to recognize when examining a radiograph of the heart.
Chambers of the Heart
● The heart is divided by vertical septa into four chambers: the right and left atria and the
right and left ventricles. The walls of the heart are composed of cardiac muscle, the
myocardium; covered externally with serous pericardium, the epicardium; and lined
internally with a layer of endothelium, the endocardium.
○ The right atrium lies anterior to the left atrium and consists of a main cavity and a
small outpouching, the auricle.
○ The right ventricle lies anterior to the left ventricle and communicates with the
right atrium through the atrioventricular orifice and with the pulmonary trunk
through the pulmonary orifice.
○ The walls of the right ventricle are much thicker than those of the right atrium.
○ The left atrium is posterior to the right atrium and forms the greater part of the
base or the posterior surface of the heart.
○ The left atrium is posterior to the right atrium and forms the greater part of the
base or the posterior surface of the heart.

● The tricuspid valve guards the atrioventricular orifice and consists of three cusps
formed by a fold of endocardium with some connective tissue enclosed: anterior, septal,
and inferior (posterior) cusps. The anterior cusp lies anteriorly, the septal cusp lies
against the ventricular septum, and the inferior or posterior cusp lies inferiorly. The bases
of the cusps are attached to the fibrous ring of the skeleton of the heart (see below),
whereas their free edges and ventricular surfaces are attached to the chordae
tendineae.
● The pulmonary valve guards the pulmonary orifice and consists of three semilunar
cusps formed by folds of endocardium with some connective tissue enclosed.
● The mitral valve guards the atrioventricular orifice. It consists of two cusps, one anterior
and one posterior, which have a structure similar to that of the cusps of the tricuspid
valve. The anterior cusp is larger and intervenes between the atrioventricular and aortic
orifices.

A. Position of the tricuspid and pulmonary valves.

B. Mitral cusps with valve open.
C. Mitral cusps with valve closed.
B. Clinical Examination

Inspection (general)
● Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from
abnormal perfusion by either an increased amount of reduced hemoglobin or abnormal
hemoglobin. Peripheral cyanosis is commonly due to cutaneous vasoconstriction
secondary to exposure to cold air or water, or from hyperadrenergic states including
severe heart failure; the later leads to pallor and coldness of the extremities, and
cyanosis of the digits when severe.

Inspection (focused)
● Clubbing refers to the swelling of the soft tissue of the terminal phalanx of a digit with
subsequent loss of the normal angle between the nail and the nail bed.

Palpation (extremities)
● Inspiration causes the intrathoracic pressure to become more negative, facilitating
venous return to the right heart, transiently increasing right ventricular volume; this
causes a leftward bulging of the interventricular septum, which slightly limits left
ventricular filling, resulting in a small decline in left ventricular output and systolic blood
pressure.

Jugular venous pulse

● The right internal jugular vein is best for examining the jugular venous pulse (JVP)
waveform and estimating central venous pressure. A JVP >8cm is elevated; however,
many physicians cannot diagnose heart failure by examining the JVP

Palpation (chest and abdomen)

● The most inferolaterally palpable beat with the patient supine and in the left lateral
position is the apex beat or impulse. It’s usually at or medial to the left midclavicular line
in the fourth or fifth intercostal space and is a tapping, early systolic outward thrust
localized to a point about 2 finger tips in size. Thrills are palpable, low-frequency
vibrations felt when your hand touches the chest wall, usually associated with heart
murmurs.

Auscultation (heart sounds)

● Regarding timing, at a resting heart rate of 75beats/minute, ventricular systole lasts 0.30
seconds and diastole 0.50 seconds. Depending on the frequency and amplitude of the
sound, the human ear may not distinguish separate sounds that are 0.01-0.02 seconds
or less apart.
● First heart sound “the lub”: The first heart sound (S1) consists of a first component of
mitral valve closure a second component from tricuspid valve closure, and is heard the
loudest between the left lower sternal border and apex with the stethoscope diaphragm
firmly pressed. Wide audible splitting of S1 (up to 0.06 seconds) is usually abnormal, and
may occur due to delay in the onset of the right ventricular pressure pulse and thus delay
in closure of the tricuspid valve, which may occur in in patients with right bundle branch
block, Ebstein’s anomaly, or right atrial myxoma.
 ● Second heart sound “the dup”: The second heart sound (S2) is split into audibly distinct
aortic (A2) and pulmonic (P2) components. Normal physiologic splitting widens with
inspiration because the increased right heart volume takes longer to empty, the maximal
split being 0.03 seconds. Splitting is heard best at the base of the heart (left/ right upper
sternal border) with the stethoscope diaphragm firmly pressed. Splitting that persists with
expiration is usually abnormal when the patient is in the upright position.
● Third heart sound: The third heart sound (S3) or ventricular gallop arises from the
sudden termination of excessive early rapid diastolic filling & stretching of the left
ventricle at the time of the atrioventricular valve opening, with timing like the “-ky” in
“Kentuc-ky”. An S3 is a dull thud lower in pitch than S1 or S2, and is best heard in the
left lateral position with the bell at the apex during expiration (left-sided S3) or at the left
sternal border/subxiphoid during inspiration (right-sided S3).
● Fourth heart sound: The fourth heart sound (S4) or atrial gallop is a low-pitched short
thud (but higher pitched than S3), presystolic sound produced in sinus rhythm during
atrial systole with ejection of a jet of blood against a stiff or non-compliant ventricle,
usually having elevated ventricular end-diastolic pressure.

Auscultation (other sounds)

● Ejection sounds are sharp, high-pitched click(s) occurring in early systole and closely
following S1. They may be aortic or pulmonic in origin, require a mobile valve for their
generation, and begin at the time of maximal valve opening.

Auscultation (murmurs)
● Murmurs are caused by rapid, turbulent blood flow, usually through damaged valves,
which causes vibrations which are then acoustically transmitted as sound. During
regurgitation, the valve is prevented from closing fully, which allows blood to spurt
backward, and a blowing or hissing sound is heard.

C. Diagnostic Tests

Electrocardiography
● It is a vital test for determining the presence and severity of acute
myocardial ischemia, localizing sites of origin and pathways of
tachyarrhythmias, assessing therapeutic options for patients with
heart failure, and identifying and evaluating patients with genetic
diseases who are prone to arrhythmias. ECG remains the basic
method to assess the heart’s electrical activity.

Exercise Testing
● most fundamental and widely used tests for the evaluation of
patients with cardiovascular disease. It is easy to administer, inexpensive, and readily
available in hospital or practice settings. Exercising muscles require energy to contract
and relax thus this test determines if the heart muscles receive adequate oxygen and
blood flow during physical activity.
Echocardiography
● most commonly used and comprehensive cardiac imaging modality and is generally
considered the first test of choice for assessing cardiac structure, including the size and
shape of the cardiac chambers as well as the morphology and function of cardiac valves.
It can be performed quickly, with minimal patient inconvenience and discomfort, and
provides immediate clinically relevant information at relatively low cost.
Chest x-ray (CXR)
● most common radiographic examination and one of the most difficult to interpret.It uses
certain electromagnetic waves to create pictures of the structures in and around your
chest. This test can help diagnose and monitor conditions such as pneumonia, heart
failure, lung cancer, tuberculosis, sarcoidosis, and lung tissue scarring, called fibrosis.
Nuclear Cardiology test
● measure the amount of blood flow to the heart muscle. Doctors use these tests to
diagnose and assess coronary artery disease and cardiac ischemia. These tests are
also called heart perfusion imaging tests or cardiac nuclear stress scans.
● There are two types of Nuclear Cardiology tests:
1. Cardiac SPECT (Single Photon Emission/ Computed Tomography)
2. Cardiac PET-CT (Positron Emission Tomography/ Computed Axial Tomography)

● Both tests begin with an injection of radioactive chemicals (radionuclides) into your
bloodstream through an IV. The radionuclides give off gamma rays, which are detected
by imaging equipment that includes a gamma camera plus an attached CT scanner. The
resulting picture, called a nuclear or PET scan, helps your doctor assess blood flow to
your heart muscle and assess heart function.
● During cardiac PET-CT, additional images and measurements are taken, including the
following:
1. Structural (or anatomical) images of your coronary arteries
2. A calcium score, or a measurement of the calcium deposits in your coronary
arteries
3. A measurement of blood flow to your heart muscle tissue. This helps your doctor
determine if you have disease in more than one of your coronary arteries (called
multi-vessel disease)

Cardiovascular Magnetic Resonance Imaging

● used to detect or monitor cardiac disease and to evaluate the heart's anatomy and
function in patients with both heart disease present at birth and heart diseases that
develop after birth. Cardiac MRI does not use ionizing radiation to produce images, and
it may provide the best images of the heart for certain conditions.
Cardiac Computed Tomography
● Cardiac CT is a heart-imaging test that uses CT technology with or without intravenous
(IV) contrast (dye) to visualize the heart anatomy, coronary circulation, and great vessels
(which includes the aorta, pulmonary veins, and arteries).It passes through sections of
the heart from different angles.
 Different types of CT:

1. Calcium-Score Screening Heart Scan - test used to detect calcium deposits

found in atherosclerotic plaque in the coronary arteries.
2. Coronary CT angiography (CTA) - noninvasive heart imaging test currently
undergoing rapid development and advancement. High-resolution, 3-dimensional
pictures of the moving heart and great vessels are produced during a coronary
CTA to determine if either fatty or calcium deposits (plaques) have built up in the
coronary arteries.
3. Total Body CT Scan - diagnostic technique that uses computed tomography to
help identify potential problems or diseases before symptoms even appear.

Cardiac Catheterization
● test during which flexible tubes called catheters are inserted into the heart via an artery
or vein under x-ray guidance to diagnose and sometimes treat certain heart conditions.
During right heart catheterization, a vein from the neck, arm, or leg is used to enter the
right side of the heart to measure pressures and oxygen content. During left heart
catheterization, an artery from the wrist, arm, or leg is used to enter the left side of the
heart, usually to perform coronary angiography, which refers to the injection of contrast
dye into the coronary arteries to determine the amount of blockage from atherosclerotic
plaque.

CASE REPORT
Satomi, H., Hirose, N., Oka, S., Oi, Y., (2020), General Anesthesia for an Oral Surgical
Procedure in a Patient with Severe Heart Valve Disease Scheduled for Cardiac Surgery:
A case report. J Anesth Clin Care 7: 55.

A. Diagnosis of Mitral Valve Insufficiency

There are two types of Mitral Valve Insufficiency, the primary, or degenerative mitral
regurgitation is most commonly caused by mitral valve prolapse. And the secondary mitral
regurgitation, also known as functional mitral regurgitation, is caused by ischemic heart disease
or heart failure. Whether mitral disease is primary or secondary, all of these underlying
conditions can lead to increased intracardiac pressure, left ventricular (LV) dysfunction, and the
inability for the mitral valve leaflets to coapt.

Most patients with chronic mitral regurgitation are asymptomatic but may exhibit fatigue,
exercise intolerance, and dyspnea upon exertion as the disease progresses. Dyspnea and
fatigue are early signs; pulmonary hypertension indicates disease progression and leads to LV
failure, orthopnea, and peripheral edema.

Diagnosing Mitral Valve Insufficiency starts from thorough medical history and family
history of heart disease, followed by physical and clinical examination. Mitral regurgitation is
initially diagnosed based on careful auscultation. Often, the regurgitation is detected as a
murmur, most typically heard at the apex as systolic, blowing, high pitched, and radiating toward
the axilla; however, the intensity of this murmur does not indicate the severity of the disorder.
In patients with severe mitral regurgitation, regurgitant blood flowing back into the left ventricle
produces an S3, indicative of LV failure, with a brisk dropoff of arterial pulse palpation, lateral
placement of the apical pulse, and a palpable thrill.

Once the clinical presentation and examination findings lead to a suspicion of mitral
regurgitation, other diagnostic tools are used to confirm the diagnosis such as follows
1. Echocardiogram:
● Transesophageal echocardiography (TEE) - is a test that produces pictures of
your heart. TEE uses high-frequency sound waves (ultrasound) to make detailed
pictures of your heart and the arteries that lead to and from it. Unlike a standard
echocardiogram, the echo transducer that produces the sound waves for TEE is
attached to a thin tube that passes through your mouth, down your throat and
into your esophagus. Because the esophagus is so close to the upper chambers
of the heart, very clear images of those heart structures and valves can be
obtained.
● Transthoracic Echocardiogram (TTE) - a technician obtains views of the heart by
moving a small instrument called a transducer to different locations on the chest
or abdominal wall. A transducer, which resembles a microphone, sends sound
waves into the chest and picks up echoes that reflect off different parts of the
heart.
2. Electrocardiography
3. Exercise Test
4. Cardiac Catheterization

B. Medical Management

A 56-year-old male patient was diagnosed with hypertension and a coexisting chronic
renal failure on dialysis at 40 years of age and was receiving hemodialysis (3 times a week).
Subsequently, at 55 years of age, he was diagnosed with Aortic Stenosis and Mitral
Regurgitation and scheduled for aortic and mitral valve replacement. He was prescribed with
omeprazole, rebamipide, precipitated calcium carbonate, etizolam, triazolam, and mianserin
hydrochloride and olmesartan medoxomil.

● Patient’s New York Heart Association functional classification was class II and American
Society of Anesthesiologists physical status was class III, respectively. In this case,
because his cardiac function was kept, we decided to prioritize the oral surgery to
prevent postoperative endocarditis of aortic and mitral valve replacement
● In principle, preoperative dialysis is performed on the day before the surgery. However,
in this case, because the scheduled surgery time was short and the possibility of both
intraoperative fluid overload and blood transfusion were low, the priority was given to the
prevention of intraoperative circulatory failure due to excessive circulating blood volume
insufficiency. Thus, preoperative dialysis was performed 2 days before the operation.
● In this case, the blood pressure decreased during the operation. Usually, when dealing
with hypotension in the cases of combined AS and MR, AS is prioritized, which tends to
be more fatal, and the first intervention is to administer α-stimulants, such as
phenylephrine, to maintain SVR.
 ● Furthermore, to prepare for unexpected situations, request for an emergency dialysis
and a cardiologist to be on standby.

C. Dental Management

The patient’s present dental condition included severe periodontitis and radicular cysts
associated with both maxillary canines, right maxillary first premolar, first molar as well as right
mandibular second molar. Thus, he was scheduled for multiple tooth extraction and radicular
cystectomy. In cases of oral lesions in patients with valvular heart disease scheduled for a
cardiac surgery, the oral treatment may be prioritized to prevent odontogenic infections.

The occurrence rate of Infective Endocarditis has been reported to be 3-10 per 100,000
people, among which 10%–20% are related to oral bacteria . Therefore, dental treatment before
cardiac surgery is important for the infective endocarditis prevention.
● The procedure was performed under general anesthesia with local anesthesia to
correspond with the strict intraoperative circulation management and resuscitation in
such complications. To prevent endocarditis, cefazolin 1g was used in intravenous
administration preoperatively.
● When entering the operation room, the patient’s BP and HR were 160/85 mmHg and 93
beats/min, respectively. Before anesthesia induction, an arterial-line was inserted into
the right radial artery under local anesthesia following the circulation evaluation with
APCO was initiated.
● Anesthesia was induced with 0.3mg fentanyl in divided administration and 3mg
midazolam.
● After anesthesia induction, a central venous catheter was inserted into the right internal
jugular vein, and the CVP was measured. Anesthesia was maintained with 2 L/min of
oxygen, 3 L/min of air, 1.5%-3.0% sevoflurane, and 0.1-0.3 µg/kg/min of remifentanil,
and the partial pressure of end-tidal carbon dioxide was maintained at 40 mmHg by
controlled respiration. In addition, a total of 5.6 mL of local anesthetics (1% lidocaine with
1:400000 adrenalines) was implemented to the upper and lower jaws and the procedure
began.
● The intraoperative BP and HP were constantly stable at about 110/70 mmHg and 60
beats/min, respectively. However, during maxillary teeth extraction, these reduced to
70/38 mmHg and 52 beats/min, respectively. The decrease in the CO was determined as
the main factor of hypotension, so a total of 4mg of ephedrine was given with 2 mg per
administration.
● Hemodynamics was stable until the end of the procedure, anesthesia awakening was
good, and the patient was sent to the intensive care unit after extubation. The surgery
and anesthesia durations were 130 min and 225 min, respectively. The total infusion and
bleeding volumes were 450 mL and 127 g, respectively.
● The postoperative course was good, and the patient was temporarily discharged 4 days
later, with a heart valve replacement scheduled in 2 months.
 REFERENCES

● Braunwald's Heart Disease E-Book: A Textbook of Cardiovascular Medicine by Mann,

Zipes, Libby and Bonow
● Computed Tomography of the Cardiovascular System by Gerber, Kantor and Williamson
● What to Expect During Cardiac Catheterization by Michelle G. Glowny and Frederic S.
Resnic Originally published 21 Feb 2012
● American Heart Association
● Diagnosing and managing mitral regurgitation by Coleman, Wesley MPAS, PA-C;
Weidman-Evans, Emily PharmD, BC-ADM; Clawson, Rebecca PA-C, MAT
● How to manage mitral valve regurgitation. An article from the e-journal of the ESC
Council for Cardiology Practice by Dr. Raphael Rosenhek , FESC
● Physical Examination of the Cardiovascular System by John P. Higgins published 2015.
● Clinical Anatomy by Regions 9th edition by Richard S. Snell, MD, PhD.