A 46-year-old woman who comes to the
doctor complaining that she gets short of breath
whenever she goes out to walk her dog.
She said this has started some months
ago and has been gradually getting worse.
When you take a history with her, she
tells you that the only serious illness she had
was when she was 10 years old,
she had a long-lasting sore throat
that was associated with some joint
pains that lasted for a number of weeks
and she was treated for
many years with oral penicillin.
On physical exam, she has a systolic
and diastolic murmur over the mitral area.
Let's talk about that for a moment.
So, you roll her a little on the
left side, you listen over the apex,
and let's first do her systolic murmur.
You hear -- first let's do
normal, lub-dub, lub-dub,
and here's what she has, lub-whoo-dub,
This is consistent with mitral regurgitation.
When you listen carefully in
diastole, here's what you hear.
Let's do normal again, lub-dub, lub-dub.
Now the murmur of mitral stenosis,
lub-duduuuu, lub-duduuuu, lub-duduuuu.
So, this lady has both mitral
stenosis and some mitral regurgitation.
Now, she's pretty young so we
don't think this was due to heart attack
with damage to the papillary
muscle or anything else.
She had a history of what sounded like acute
rheumatic fever when she was 10 years old
and somebody thought so cause they
treated her for many years with oral penicillin,
and of course, that can lead
to damage to the mitral valve
then eventually leads to mitral stenosis
and sometimes with some mitral regurgitation.
So, the critical elements
here is first of all, in the history,
there's unusual exercise-induced
fatigue and shortness of breath.
That shouldn't be occurring in a 46-year-old.
The second point is she has a history that's
very suggestive of she had acute rheumatic fever
when she was 10 years old.
In fact, somebody thought so because she
was treated for many years with oral penicillin.
She had a long-lasting sore throat and
often associated with acute rheumatic fever
is severe joint pains and there
can be a number of other findings
but this suggest that she
definitely had acute rheumatic fever
and that can lead to damage to the mitral valve.
And so, when we listen, we hear
this systolic murmur of mitral regurge
and we hear the diastolic
murmur of mitral stenosis.
What are the diagnostic options?
Well, of course we would
first do an echocardiogram.
We would also have an
electrocardiogram done as a baseline.
And here we see one section of the Echo.
The Echo is a movie so it's
moving but you can see here
there's the left atrium, there's
the left ventricle, and what you see
is a very thickened abnormal stenotic
mitral valve where the arrow is pointing to.
And this is the reason she's short of breath.
The stenotic mitral valve results in
elevated pressure in the left atrium
which is transmitted back to the lung so she
has elevated capillary pressures in the lung
that leads to some edema in the
lung and some shortness of breath.
So, this is a lady with mitral stenosis.
It's pretty severe.
She has a little bit of mitral regurgitation
but that's not the most important part.
We can see that also on the Echo
and this is quite severe mitral stenosis
secondary to rheumatic fever as a child.
If the valve is not fibrotic or heavily calcified,
it can be dilated with a balloon catheter
in the catheterization laboratory and
the patients are put on anticoagulants
for example warfarin, and why are
we putting them on anticoagulation?
Cause there's high risk for a
blood clot forming in the left atrium
which could break off and go
to the brain and cause a stroke.
And that of course in a 46-year-old
would be some terrible event.
So, if there's advanced fibrosis and calcification,
she will need surgical mitral valve replacement
and of course, continued anticoagulation
treatment because she's still going to have a large
left atrium where a clot could form.
Many of these patients also have atrial
fibrillation which also puts them in increased risk
for developing a clot in the left atrial
appendage which can break off and cause a stroke.
So, either way we have an excellent
chance of making this lady much better
by improving the flow of
blood across her mitral valve.
And here we see actually an operative picture
of a stenotic mitral valve that was removed.
You can see how narrow the little black
space in the middle is the only opening.
All the rest is scar tissue and calcification.
That's cut out at cardiac surgery
and a prosthetic valve is sewn in,
markedly improving this patient's symptoms.