1. Workshop 12 Group 3 Section D

2. Chief complaint : Palpitations History of Present Illness: 4 years PTA Palpitations ( irregular), heartbeats associated with increased sweating and shortness of breath. Medication: verapamil for 3 days, taken intermittently for palpitation Few hours PTA Palpitation accompanied by shortness of breath

3.  No dizziness, nor loss of consciousness  No cough or colds  No PND or orthopnea

4.  Conscious, coherent, ambulatory  BP 110/70CR 80/min regularRR 16/minBMI 19  Symmetrical chest expansion, narrow AP diameter of the chest, no retractions, clear breath sounds  Adynamic precordium, AB at 5 th LICS MCL no murmurs, (+) midsystolic click follwed by 2/6 mid-systolic crescendo murmur noted at the apex

5.  2D Echo-doppler:  Mitral Valve Prolapse, Anterior Mitral Valve Leaflet with moderate MR  Slightly dilated left atrium woth no evidence of thrombus  12 Lead ECG  Sinus rhythm  Occasional premature atrial complexes

7.  Auscultation  Mid – late (non- ejection) systolic click (0.14s) after S1  Systolic clicks: multiple and may be follwed by a high- pitched, late systolic crescendo-decrescendo murmur, “ whooping” or “honking”- heard best at apex  Early click-murmur ▪ Standing, during valsalva maneuver, and with ant intervention that decreases LV volume  Delayed and complex click- murmur ▪ Squatting, isometric exercises which increase LV volume

8. ECG- normal but may show biphasic or inverted T waves in leads II, III and aVF, and occasionally supraventricular or ventricular premature beats 2DEcho – systolic dysplacement (in the parasternal long axis view) of the mitral valve leaflets by at least 2mm into the LA superior to the plane of the mitral annulus Color flow – helpful in revealing associated MR

10.  14 - 30 years old  Women  Increased familial incidence Reference: Fauci et al. Harrison’s Principles of Internal Medicine, 17 th ed.

11. * Patients are mostly asymptomatic Others may manifest with:  Easy fatigability  Shortness of breath  Palpitation  Non-anginal chest pain  Light-headedness  Syncope Reference: Fauci et al. Harrison’s Principles of Internal Medicine, 17 th ed.

12.  Transient ischemic attacks  Congestive cardiac failure  Endocarditis  in MR associated with MVP  Sudden death Reference: Fauci et al. Harrison’s Principles of Internal Medicine, 17 th ed.

13.  Anxiety  Panic attacks  Arrhythmias  Exercise intolerance  Palpitations  Atypical chest pain  Fatigue  Orthostasis  Syncope or presyncope  Neuropsychiatric symptoms Thakkar, B. (2008) Mitral Valve Prolapse

14.  Fatigue  Dyspnea  Exercise intolerance  Orthopnea  Paroxysmal nocturnal dyspnea (PND)  Progressive signs of congestive heart failure (CHF) Thakkar, B. (2008) Mitral Valve Prolapse

16.  In most studies, MVP has a complication rate of less than 2 percent per year 2,15.  The age-adjusted survival rate in men and women with MVP is similar to that in patients without this common clinical disorder

17. Atrial fibrillation and other arrhythmias Congestive heart failure Pulmonary hypertension Ruptured mitral valve chordae Infective endocarditis Central nervous system embolic events O'Rourke RA. The mitral valve prolapse syndrome. In: Chizner MA, ed. Classic teachings in clinical cardiology. Cedar Grove, N.J.: Laennec, 1996:1049-70.

18. Gradual progression of mitral regurgitation progressive dilation of the left atrium and left ventricle atrial fibrillation, moderate to severe mitral regurgitation LV dysfunction congestive heart failure

19.  A serious complication of MVP  MVP is the leading predisposing cardiovascular disorder in patients with endocarditis.  Because the absolute incidence of endocarditis is extremely low in the entire MVP population, the risk of its developing in these patients has been a subject of considerable debate.

20.  Rarely, fibrin emboli may cause visual problems related to occlusion of the ophthalmic or posterior cerebral circulation.  Patients younger than 45 years who have MVP are at greater risk for cerebrovascular accidents than would be expected in similar patients without MVP.  Therefore, it has been recommended that antiplatelet drugs such as aspirin or anticoagulants be administered to patients with MVP who have a history of suspected cerebral emboli

22. Cause of MVP may be a genetically determined collagen disorder Electron microscopy: fragmentation of collagen fibrils Reduction in the production of type III collagen Fauci, et al. 2008. Harrison’s Principles of Internal Medicine, 17 th ed. Venugopalan. 2008. Mitral Valve Prolapse.

23.  Mitral valve prolapse is a frequent finding in patients of this population Ehler-Danlos syndrome Marfan syndrome Osteogenesis imperfecta Others: Fragile X syndrome, Martin-Bell syndrome, Polycystic kidney disease (adult type), Periarteritis nodosa Fauci, et al. 2008. Harrison’s Principles of Internal Medicine, 17 th ed. Venugopalan. 2008. Mitral Valve Prolapse.

25. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

26.  A reasonable approach for endocarditis prophylaxis should consider the following:  the degree to which the patient’s underlying condition creates a risk of endocarditis  the apparent risk of bacteremia with the procedure  the potential adverse reactions of the prophylactic antimicrobial agent to be used; and the cost-benefit aspects of the recommended prophylactic regimen Failure to consider all of these factors may lead to overuse of antimicrobial agents, excessive cost, and risk of adverse drug reactions Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

27.  Prophylaxis is recommended in individuals who have a higher risk for developing endocarditis than the general population and is particularly important for individuals in whom endocardial infection is associated with high morbidity and mortality Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

29. High-risk category  Prosthetic cardiac valves  Previous bacterial endocarditis  Complex cyanotic congenital heart disease Eg. Single ventricle states, Transposition of the great arteries, Tetralogy of Fallot  Surgically constructed systemic pulmonary shunts or conduits Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

30. Moderate-risk category  Acquired valvular dysfunction (eg, rheumatic heart disease)  Hypertrophic cardiomyopathy  Mitral valve prolapse with valvular regurgitation and/or thickened leaflets Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

31. Negligible-risk category  Isolated secundum atrial septal defect  Surgical repair of ASD, VSD or PDA  Previous coronary artery bypass graft surgery  Mitral valve prolapse without valvular regurgitation  Physiologic, functional, or innocent heart murmurs  Previous Kawasaki disease without valvular dysfunction  Previous rheumatic fever without valvular dysfunction  Cardiac pacemakers and implanted defibrillators Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

32.  Prophylaxis at the time of cardiac surgery should be directed primarily against staphylococci and should be of short duration  First-generation cephalosporins are most often used  Prophylaxis is most effective when given perioperatively in doses that are sufficient to assure adequate antibiotic concentrations during and after the procedure  Antibiotics should be used only during the perioperative period - initiated shortly before a procedure and should not be continued no more than 6 to 8 hours  In the case of delayed healing, or of a procedure that involves infected tissue, it may be necessary to provide additional doses of antibiotics

33. Antimicrobial prophylaxis administered within 2 hours following the procedure will provide effective prophylaxis Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

34. Streptococcus viridans is the most common cause of endocarditis following:  dental or oral procedures  certain upper respiratory tract procedures  bronchoscopy with a rigid bronchoscope  surgical procedures that involve the respiratory mucosa  esophageal procedures

35. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

36.  The recommended standard prophylactic regimen for all these procedures is a single dose of oral amoxicillin to be administered 1 hour before the anticipated procedure  Adult dose is 2.0 g  Pediatric dose is 50 mg/kg (not to exceed adult dose)  For individuals who are unable to take or unable to absorb oral medications, parenteral Ampicillin sodium is recommended Durack DT. Prevention of infective endocarditis. N Engl J Med. 1995

37.  Individuals who are allergic to penicillin  Clindamycin hydrochloride  Azithromycin or clarithromycin  When parenteral administration is needed in an individual who is allergic to penicillin, clindamycin phosphate is recommended Durack DT. Prevention of infective endocarditis. N Engl J Med. 1995

38.  Enterococcus faecalis is the most common cause of bacterial endocarditis that occurs following genitourinary and gastrointestinal tract surgery or instrumentation  Antibiotic prophylaxis should be directed primarily against Enterococci

39. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

42.  High-risk patients  Ampicillin plus gentamicin  High-risk patients allergic to ampicillin/amoxicillin  Vancomycin plus gentamicin  Moderate-risk patients  Amoxicillin or ampicillin  Moderate-risk patients allergic to ampicillin/amoxicillin  Vancomycin Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

44.  Endocarditis is a life-threatening disease, although it is relatively uncommon.  Substantial morbidity and mortality result from this infection, despite antimicrobial therapy and enhanced ability to diagnose and treat complications.  Primary prevention of endocarditis whenever possible is therefore very important.  Endocarditis usually develops in individuals with underlying structural cardiac defects who develop bacteremia with organisms likely to cause endocarditis.

45.  Bacteremia commonly occurs during activities of daily living such as routine tooth brushing or chewing.  With respect to endocarditis prophylaxis, significant bacteremia is only those caused by organisms commonly associated with endocarditis and attributable to identifiable procedures.  The procedures for which prophylaxis is recommended are those known to induce bacteremia  Invasive procedures performed through surgically scrubbed skin are NOT likely to produce bacteremia.