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M. Dalao, MD - Cardiology
The amount of MR in this patient is likely to be:
C) 3+ or D) 4+
Correct: (C) or (D). 3+ or 4+. Explanation: This patient has a lateral wall-hugging jet reaching all the way to the roof of the left atrium. A wall-hugging jet area tends to be 40-50% smaller than a free jet area for a given regurgitant volume. In such patients examining the size of vena contracta, proximal isovelocity surface area (PISA) and calculating the effective regurgitant orifice area would be helpful for volumetric quantitation. Though the PISA is not well visualized in this patient, the diameter of the vena contracta is about 5 mm, which is consistent with at least 3+ mitral regurgitation. The mechanism of the lateral wall hugging jet in this patient was a tethered posterior leaflflet secondary to a rheumatic process. The other mechanism to cause a laterally directed jet would be a severely prolapsing anterior mitral leaflet.
2012 Wiley Publisher
A 27 year old man presents to the emergency department after being found unconscious
on a park bench. BP is 102/44, HR 124 BPM, Temp 39.0 C. Physical exam is notable
for an early decrescendo diastolic murmur best heard over the RUSB, cold and mottled
extremities, and lesions on the forearm as seen below. Which of the following is the
most appropriate first step in initial management strategy:
A) Intraaortic balloon pump IV antibiotics nitroprusside
B) IV antibiotics
E) Coronary angiography and possible PCI
Correct: (C) Nitroprusside. Explanation: This patient patient presents comatose with track marks on the skin, likely secondary to IV drug use. The physical exam suggests acute aortic insufficiency associated infectious endocarditis. Physical exam findings consistent with this diagnosis include a widened pulse pressure, water hammer pulse, early decrescendo diastolic murmur, Janeway lesions, Roth spots, splinter hemorrhages, and Osler nodes. Acute aortic insufficiency from any cause is a surgical emergency, and the most important aspect of treatment is prompt surgical intervention. Until surgery can be provided, however, the patient may be temporized. IABP is relatively contraindicated in moderate to severe AR, as the balloon inflflates during diastole and would drive flflow upstream, worsening AR. While IV antibiotics are indicated, they are unlikely to change the acute course and are not the most pressing intervention. Phenylephrine is a pure vasoconstrictor, which may increase blood pressure, but would worsen aortic insufficiency. While blood pressure is low, the primary deficiency in this patient is poor forward flow leading to low cardiac output. Nitroprusside is a vasodilator which will decrease afterload and decrease aortic insufficiency. While blood pressure may fall slightly, the benefifit will likely outweigh the cost. Dopamine or doputamine should be added since the medical management for acute AI is inotropes plus vasodilators for stabilization. Aortic valve repair should be performed as soon as possible. Coronary artery disease is inconsistent with this patient's presentation and physical exam findings. While CAD is commonly associated with calcific aortic stenosis and regurgitation in the elderly, it is uncommon in young patients
2012 Wiley Publisher
Questions taken from the BoardVitals Cardiology CME Question Bank.