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Case 250

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A 45-year-old male patient from Brumadinho attends the cardiology clinic to investigate prior valvulopathy. Six months ago he began presenting a constant and migratory arthralgia, asthenia, dyspnea (NYHA III), palpitations, fatigue and, for the past 37 days, he has had evening fever. On examination: holosystolic murmur IV / VI in cardiac tip, mesosystolic click radiating to sternal border and negative Rivero Carvalho maneuver. He was admitted to the hospital and underwent immediate imaging investigation, which revealed the attached findings. Hemoculture was performed, which was positive for Streptococcus gordonnii, leading to the diagnosis, at the end, of endocarditis.

Considering the clinical history and the presented images, what is the diagnosed valvulopathy?

a) Tricuspid insufficiency

25%

b) Tricuspid prolapse

25%

c) Aortic stenosis

25%

d) Mitral prolapse

25%
   

Image analysis

Video 1:  Transthoracic echocardiogram short axis parasternal view, cross-section showing preserved valve opening movement, at the cost of thickened and redundant leaflets, with evidence of opening and closing of commissures.

 

Video 2: Transthoracic echocardiogram with color Doppler in the sagittal plane, apical four-chamber view. The source displayed in red corresponds to the flow from AE to VE, while the one in blue indicates the flow from VE to AE. Evidence of a lighter-looking blue flow, corresponding to moderate to major central regurgitation.

 

Image 1: Transthoracic echocardiogram short axis parasternal view, cross-section at the level between the 2nd and 4th left intercostal spaces, near the sternal border. Mitral valve in opening, thickened, presenting a redundant anterior (FA) and posterior (FP) leaflet, with a completely loose tissue aspect due to important myxomatous degeneration (yellow outline).

(CAL: anterolateral commissure; CPM: posteromedial commissure).

 

Image 2: Transthoracic echocardiogram in the sagittal plane, apical four-chamber view, showing thickened, redundant (yellow outline) leaflets which prolapse to the left atrium, beyond the line that delimits the plane of the mitral annulus (red arrow).

(AE: left atrium, MV: mitral valve, LV, left ventricle, AD: right atrium, VT: tricuspid valve, RV: right ventricle)

Highlights

- Mitral valve prolapse is the most common cardiac valve abnormality and the most frequent cause of surgical mitral regurgitation. However most patients have a good prognosis.

- Prolapse is suspected on cardiac auscultation, in which a holosystolic murmur in the mitral focus is observed, in a context where a mesositolic click is the most characteristic sound of this valvulopathy.

- Diagnostic confirmation is done exclusively on the echocardiogram showing the thickened and redundant leaflets towards the LA, beyond to the mitral annulus.

- PVM is associated with a variety of nonspecific clinical manifestations, with potential risks of cardiac insufficiency, arrhythmic complications (AF), infective endocarditis and sudden death.

- There is no proven therapy, in which the definitive treatment of a hemodynamically important mitral regurgitation is surgical correction. However, most cases do not require interventions.

References

- Elyse Foster, M.D. Mitral Regurgitation Due to Degenerative Mitral-Valve Disease. In N Engl J Med.2010;363:156-65.

- P. Lancellotti et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). In: European Journal of Echocardiography (2010) 11, 307–332.

- Matthew J Sorrentino, Catherine M Otto, Susan B Yeon. Mitral valve syndrome. UpToDate [internet] 2016 [acesso em Set2016]. Disponível em: http://www.uptodate.com

- Sorrir Pislaru, Maurice Enriquez-Sarano, Catherine M Otto, Susan B Yeon. Definition and diagnosis of mitral valve prolapse. UpToDate [internet] 2016 [acesso em Set2016]. Disponível em http://www.uptodate.com

- Infective endocarditis - Overview and Recommendations. DynaMed Plus [internet] 2016 [acesso em Set2016]. Disponível em: http://www.uptodate.com

- Diretriz para Normatização dos Equipamentos e Técnicas de Exame para Realização de Exames Ecocardiográficos. Arq Bras Cardiol, volume 82, (suplemento II), 2004

Author

Giovanna Vieira Moreira, 5th year medical student at UFMG

E-mail: giovieiramoreira[at]gmail.com

Supervisors

Maria do Carmo Pereira Nunes, Cardiologist at the HC-UFMG, leader of the research groups in tropical diseases echocardiography and percutaneous mitral valvuloplasty, coordinator of the echocardiography service of the HC-UFMG and Professor of the Internal Medicine Department at UFMG

Email: mcarmo[arroba]waymail.com.br

Reviewers

Luísa Bernardino, Laio Bastos, Raíra César, Ivan Debeus, Juliana Albano e Profª Viviane Parisotto.

Translated by

Lucas Augusto Carvalho Raso, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: lucasraso[at]hotmail.com

Test question

a)

25%

b)

25%

c)

25%

d)

25%

e)

25%
   

Commentics

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