Case No 1

History:65 year old lady, not diabetic or hypertensive, presents with one month history of gradual and progressive shortness of breath with PND and orthopnea. She also reports having had an upper respiratory tract illness and cough six weeks ago.

Past medical history : Non.

Social History: Non-smoker.

Physical examination: Positive for 10 cm JVP. PR 105 BPM. BP 110/65 mmhg. Halfway up bilateral chest rales. Diffuse point of maximal apical impulse, regular soft S1 , S3 and grade 3/6 holosystolic murmur over the apex. 2+ LLE.
 
Question 2

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What is the etiology of this patient’s mitral regurgitation ?

Mitral valve endocarditis
 Ischemic papillary muscle dysfunction
 Rheumatic heart disease
 Cardiomyopathy with functional MR
 Mitral valve prolapse
The echocardiogram shows a normal leaflet morphology beside mild degenerative changes. The LV is dilated and dysfunctional , resulting in tethering of the mitral leaflets . this results in leaflet closure occurring toward the apex rather than at the annular plane. This leads in restricted mitral leaflet closure and MR.
There is no MVP , which is defined on 2-D echo by systolic displacement of one or both leaflets > 2 mm past the annular plane into the LA in the PLAX view, the color jet is often eccentric .
Mitral valve endocarditis and vegetations typically appear on 2D as echo-producing, irregular masses attached to the atrial surface of the valve leaflet and exhibiting independent motion.
The existence of isolated ischemic papillary muscle dysfunction is disputed as a cause of severe MR. A segmental wall motion abnormality is nearly always present and is not present on this echocardiogram.
In rheumatic mitral disease, the leaflets are thickened and tethered in diastole. Significant MR is usually associated with at least moderate mitral stenosis with severe subvalvular disease.
 
 
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