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Cardiac Case: 46-year-old Woman with Shortness of Breath when Walking

by Joseph Alpert, MD

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    00:01 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.

    00:08 She said this has started some months ago and has been gradually getting worse.

    00:16 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.

    00:34 On physical exam, she has a systolic and diastolic murmur over the mitral area.

    00:40 Let's talk about that for a moment.

    00:42 So, you roll her a little on the left side, you listen over the apex, and let's first do her systolic murmur.

    00:50 You hear -- first let's do normal, lub-dub, lub-dub, and here's what she has, lub-whoo-dub, lub-whoo-dub, lub-whoo-dub.

    01:00 This is consistent with mitral regurgitation.

    01:03 When you listen carefully in diastole, here's what you here.

    01:07 Let's do normal again, lub-dub, lub-dub, now the murmur of mitral stenosis, lub-duduuuu, lub-duduuuu, lub-duduuuu.

    01:17 So, this lady has both mitral stenosis and some mitral regurgitation.

    01:21 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.

    01:29 She had a history of what sounded like acute rheumatic fever when she was 10 years old and somebody thought so cuz 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.

    01:46 So, the critical elements here is first of all, in the history, there's unusual exercise-induced fatigue and shortness of breath.

    01:55 That shouldn't be occurring in a 46-year-old.

    01:58 The second point is she has a history that's very suggestive of she had acute rheumatic fever when she was 10 years old.

    02:05 In fact, somebody thought so because she was treated for many years with oral penicillin.

    02:10 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.

    02:25 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.

    02:39 We would also have an electrocardiogram done as a baseline.

    02:43 And here we see one section of the Echo.

    02:47 The Echo is an amovie 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.

    03:03 And this is the reason she's short of breath.

    03:06 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.

    03:20 So, this is a lady with mitral stenosis. It's pretty severe.

    03:26 She has a little bit of mitral regurgitation but that's not the most important part.

    03:30 We can see that also on the Echo and this is quite severe mitral stenosis secondary to rheumatic fever as a child.

    03:37 If the valve is not fibrotic or heavily calcified, it can be dilated with the balloon catheter in the catheterization laboratory and the patients are put on anticoagulants either one of the older one’s warfarin or one of the new ones, for example, rivaroxaban or apixaban and why are we putting them on anticoagulation? Cuz 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.

    04:08 And that occurs in a 46-year-old would be some terrible event.

    04:12 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.

    04:27 Many of these patients also had 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.

    04:38 So, either way we have an excellent chance of making this lady much better by improving the flow of blood across her mitral valve.

    04:47 And here we see actually an operative picture of a stenotic mitral valve that was removed.

    04:53 You can see how narrow the little black space in the middle is the only opening.

    04:58 All the rest is scar tissue and calcification.

    05:01 That's cut out at cardiac surgery and a prosthetic valve is sewn in, markedly improving this patient's symptoms.


    About the Lecture

    The lecture Cardiac Case: 46-year-old Woman with Shortness of Breath when Walking by Joseph Alpert, MD is from the course Cardiovascular Cases.


    Included Quiz Questions

    1. Valvular heart disease
    2. Penicillin allergy
    3. Hypertrophic cardiomyopathy
    4. Hypertension
    5. Aneurysm
    1. Dilatation with a balloon catheter and anticoagulation treatment
    2. Dilatation with balloon catheter alone
    3. Anticoagulation treatment alone
    4. Surgical mitral valve replacement
    5. Course of penicillin
    1. Surgical mitral valve replacement and anticoagulation treatment
    2. Balloon catheter alone
    3. Anticoagulation treatment alone
    4. Balloon catheter with anticoagulation treatment
    5. Surgical mitral valve replacement without anticoagulation treatment

    Author of lecture Cardiac Case: 46-year-old Woman with Shortness of Breath when Walking

     Joseph Alpert, MD

    Joseph Alpert, MD


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