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Transcript
Mitral Valve Vegetation A 44 year-old woman came in for a 2D Echo and M Mode Doppler to rule out a vegetation. She was 165 cm tall and weighed 47.20 kg so her BSA was 1.5 m squared. She had a blood pressure of 119/69 mmHg. 2D RV IVS LV LVPW Normal D 0.7-2.3cm 0.6-1.1cm 3.3-5.5cm 0.6-1.1cm Normal D LA 2.0-3.7cm AOR 3.6cm 2.0-3.7cm LVOT 1.5-2.0cm RVOT 2.2-3.0cm M-mode Diastole RV 2.4cm IVS 1.3cm LV 5.3cm LVPW 1.2cm LA Systole 3.5cm 0.0cm 3.78cm Diastole LAD AOR 3.6cm LV EF 62.0% MV Mn Grad P1/2T MV Area MV DT MV Planim E Vmax A Vmax E/A MV VTI 1.25m/s 0.66m/s 1.88 MR PISA R TV TR Vmax TR Pk Grad RA Pressure RVSP TV VTI 2.72m/s 29.6mmHg 10mmHg 39.6mmHg Left Ventricle: Has an estimated EF of 50 to 55%. Right Ventricle: Is normal. Left Atrium: Is considered to be mildly dilated. Right Atrium: Is mildly dialted. Aortic Valve: Is trileaflet and normal. Mitral Valve: Moderate mitral annular calcification. Mild mitral valve regurgitation. Tricuspid Valve: Is normal in structure. Mild tricuspid regurgitation. The estimated right ventricular systolic pressure is borderline elevated. Summary: 1. The left ventricle has an estimated EF of 50-55%. 2. Moderate concentric left ventricular hypertrophy. 3. Right atrium is mildly dilated. 4. Borderline elevated PA systolic pressure. 5. Mild tricuspid regurgitation. 6. The aortic valve is trileaflet and normal. 7. The left atrium is mildly dilated. 8. Mild mitral valve regurgitation. 9. Mobile vegetation on the mitral valve. 10. Moderate mitral annular calcification. 11. No pericardial effusion. Endocarditis is a cause of vegetations on the heart valves. Endocarditis is exudative and proliferative inflammatory alterations of the endocardium, characterized by the presence of vegetations on the surface of the endocardium or in the endocardium itself, and most commonly involving a heart valve, but also affecting the inner lining of the cardiac chambers or the endocardium elsewhere. Lesions on the valves may interfere with the ejection of blood from the heart by causing insufficiency or stenosis of the valves. Murmurs associated with the heart sounds are the major manifestation and if interference with the blood flow is sufficiently severe congestive heart failure develops. The further hazard with endocarditis, especially if it is bacterial in origin, is that of septic emboli in the lungs or in the other organs. Altered blood flow around the valves is a risk factor in obtaining endocarditis. The valves may be damaged congenitally, from surgery, by auto-immune mechanisms, or simply as a consequence of old age. The damaged part of a heart valve becomes covered with a blood clot, a condition known as non-bacterial thrombotic endocarditis (NBTE). In a healthy individual, a bacteremia (where bacteria get into the blood stream through a minor cut or wound) would normally be cleared quickly with no adverse consequences. If a heart valve is damaged and covered with a piece of a blood clot, the valve provides a place for the bacteria to attach themselves and an infection can be established. The bacteremia is often caused by dental procedures, such as a cleaning or extraction of a tooth. It is important that a dentist or a dental hygienist is told of any heart problems before commencing. Antibiotics are administered to patients with certain heart conditions as a precaution. Another group of causes result from a high number of bacteria getting into the bloodstream. Colorectal cancer, serious urinary tract infections, and IV drug use can all introduce large numbers of bacteria. With a large number of bacteria, even a normal heart valve may be infected. A more virulent organism (such as Staphylococcus aureus is usually responsible for infecting a normal valve. Intravenous drug users tend to get their right heart valves infected because the veins that are injected enter the right side of the heart. The injured valve is most commonly affected when there is a pre-existing disease. (In rheumatic heart disease this is the aortic and the mitral valves, on the left side of the heart.) Clinical and pathological features include: Fever, i.e. fever of unknown origin (often spiking caused by septic emboli) Continuous presence of micro-organisms in the bloodstream determined by serial collection of blood cultures Vegetations on valves on echocardiography, which sometimes can cause a new or changing heart murmur, particularly murmurs suggestive of valvular regurgitation Vascular phenomena: Septic emboli (causing thromboembolic problems such as stroke in the parietal lobe of the brain or gangrene of fingers), Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles), intracranial hemorrhage, conjunctival hemorrhage, splinter haemorrhages Immunologic phenomena: Glomerulonephritis, Osler's nodes (painful subcutaneous lesions in the distal fingers), Roth's spots on the retina, positive serum rheumatoid factor. The transthoracic echocardiogram has a sensitivity and specificity of approximately 65% and 95% if the echocardiographer believes there is 'probabable' or 'almost certain' evidence of endocarditis. Treatment includes high dose antibiotics are administered by the intravenous route to maximize diffusion of antibiotic molecules into vegetation(s) from the blood filling the chambers of the heart. This is necessary because neither the heart valves nor the vegetations adherent to them are supplied by blood vessels. Antibiotics are continued for a long time, typically two to six weeks. Specific drug regimens differ depending on the classification of the endocarditis as acute or subacute (acute necessitating treating for Staphylococcus aureus with oxacillin or vancomycin in addition to gram-negative coverage). Fungal endocarditis requires specific anti-fungal treatment, such as amphotericin B. Surgical removal of the valve is necessary in patients who fail to clear microorganisms from their blood in response to antibiotic therapy, or in patients who develop cardiac failure resulting from destruction of a valve by infection. A removed valve is usually replaced with an artificial valve which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic valves.