Cardiovascular Patient A


The following is based on a description of a patient that was presented in the New England Journal of Medicine, 2009, volume 361, pages 2261-2269, and 2013 volume 368, pages 1425-1433.

Some of the comments and questions below will make more sense after you have done the "Cardiac Cycle" webpage.

A 55-year-old man with a holosystolic murmur of increasing intensity has been seen regularly by his family physician for the past 3 years. He is referred to a cardiologist. The patient reports no shortness of breath, chest pain, or palpitations. The murmur is heard best in the 5th intercostal space about 5 cm to the left of the sternum. ("Holosystolic" means that the murmur starts at S1 and continues through S2; in other words, the murmur occurs during the isovolumetric contraction and during the ejection phases.)




QUESTION: What is the period of time between S1 and the opening of the aortic valve called?

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QUESTION: Why is it called "isovolumetric"?

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QUESTION: If I tell you the problem is on the left side of the heart, what is the likely possibility?

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QUESTION: Why not aortic stenosis?

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An electrocardiogram shows normal sinus rhythm. A transthoracic echocardiogram reveals severe, anteriorly directed mitral regurgitation (insufficiency) with isolated prolapse of the middle scallop of the posterior leaflet. Flow reversal is detected in the pulmonary veins....(and other) features consistent with severe mitral regurgitation. The transthoracic echocardiogram also shows mildly depressed left ventricular function (ejection fraction, 58%),....and normal right ventricular systolic pressure....




QUESTION: What is meant by "prolapse" and what seems to be the basic problem?

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QUESTION: The "prevalence" of mitral valve prolapse is 2.5%. What does that mean?

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The patient was referred to a cardiac surgeon for repair of his mitral valve. In this patient's case, repair of the valve was felt to be a better option than replacement of the defective valve.


About one year after his operation, he sought care after an episode of transient weakness in his right arm and speech difficulties. He underwent dental scaling 1 month earlier. He notes recent intermittent fevers and weight loss. On cardiac examination, his regurgitation murmur appears to be unchanged. A transthoracic echocardiogram shows a mobile, 12-mm mitral-valve vegetation and grade 2 (mild) regurgitation. Magnetic resonance imaging of the brain reveals recent ischemic lesions.....




QUESTION: What urgently needs to be done here?

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QUESTION: What seems to have happened?

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QUESTION: What patients are particularly at risk?

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