Presentasi kasus

MITRAL REGURGITASI &

MITRAL STENOSIS
Disusun oleh :
Sylvia Resna Sari 1102012291

Pembimbing :
dr. Sidhi Laksono, SpJP
 STATUS PASIEN

Nama : Ny. S
Umur : 28 tahun
Pekerjaan : Ibu Rumah Tangga
Agama : Islam
Alamat : Cibubur
No. RM : 2013-461832
Tanggal masuk RS : 06 Maret 2017
Tanggal pemeriksaan : 10 Maret 2017
 ANAMNESA

Anamnesis dilakukan secara: AutoAnamnesa di

bangsal Flamboyan
Tanggal: 10 Maret 2017 Pukul :23.53

Keluhan Utama : Sesak nafas memberat sejak 2

hari SMRS
Keluhan Tambahan : Batuk berdahak & berdarah
2 hari SMRS
 RIWAYAT PENYAKIT SEKARANG

Sejak 2 hari sebelum pasien datang ke IGD RSUD

Pasar Rebo pasien mengeluhkan sesak napas, sesak dirasakan
pasien hilang timbul. Sesak dirasakan pasien datang tiba-tiba
dan tidak dipengaruhi oleh aktifitas, biasanya sesak yang
dirasakan pasien membaik jika tidur dengan keadaan
setengah duduk . Pasien pun mengeluh batuk berdahak sejak
2 hari yg lalu, dahak berwarna kuning dan disertai darah.
Sebelumnya pasien sering merasakan badannya ngilu-ngilu,
dan hilang dengan sendirinya.
 RIWAYAT PENYAKIT SEKARANG

Pagi hari sebelum pasien datang ke IGD RSUD Pasar

Rebo, tiba-tiba pasien mengeluhkan sesak yang semakin
memberat sehingga pasien benar-benar sulit untuk bernafas
dan tidak membaik setelah pasien beristirahat, batuk
berdarah (+), dada terasa berdebar-debar (+), mual muntah
(+), nyeri ulu hati (+), pusing (-), demam (-) dan nyeri dada (-).
Pasien mengatakan nafsu makan baik dan BAB BAK dalam
batas normal. Riwayat kaki bengkak disangkal.
 RIWAYAT PENYAKIT DAHULU

Riwayat dengan keluhan seperti ini (+)

Riwayat asma (-).
Riwayat alergi obat (-)
Riwayat diabetes mellitus (-)
Riwayat hipertensi (-)
Riwayat TB paru (-)
Riwayat penyakit jantung (+) 2013 di rawat di
ICU dengan Kelainan katup
RIWAYAT PENYAKIT KELUARGA

Riwayat asma (-)

Riwayat TB paru (+) pada ayah pasien
Riwayat diabetes melitus (-)
Riwayat hipertensi (+) pada ayah
pasien
RIWAYAT PENGOBATAN

Simax
OBH
Racikan
 RIWAYAT KEBIASAAN

Merokok (-)
Minum alkohol (-)
Obat-obatan terlarang(-)
Herbal/Jamu ( + )
Obat NSAID ( - )
Lingkungan Berdebu ( + )
STATUS GENERALIS

Keadaan Umum : Tampak sakit sedang

Kesadaran : Kompomentis
Tekanan Darah : 100/80 mmHg
Nadi : 74 x/menit
Suhu : 36,5 oC
Pernapasan : 24 x/menit
Gizi
BB : 34 kg
TB : 155 cm
IMT : 14,15 Kg/m
ASPEK KEJIWAAN

Tingkah laku Baik

Proses Pikir Baik

Kecerdasan Baik
STATUS GENERALIS

Kepala Bentuk
Posisi
: normochepal
: simetris
Warna : Sawo Matang

Kulit Pucat : (-)

Jaringan parut : (-)
Turgor : Baik

Palpebra : Normal

Mata Konjungtiva : Anemis

Sklera : Tidak ikterik
STATUS GENERALIS
Pendengaran : Baik
Telinga Darah & secret : Tidak ditemukan

Napas cuping hidung : Tidak ditemukan

Hidung dan Sinus Nyeri tekan : Tidak ditemukan
Paranasal Sekret : Tidak ditemukan

Trismus : Tidak ada

Faring : faring hiperemis (-)
Mulut Lidah : tidak kotor, tidak deviasi.
Uvul : Tidak deviasi

Trakea : Tidak deviasi

Kelenjar tiroid : Tidak ada pembesaran
Leher Kelenjar limfe : Tidak ada pembesaran
JVP : 5 +3 cmH2O
Tonsil : T1-T1 tenang, hiperemis (-)
STATUS GENERALIS

Inspeksi :
Saat statis, hemitorak asimetris dengan
dada kiri terlihat lebih cembung
sedangkan saat dinamis, hemitorak
asimetris dengan dada kiri tertinggal
Palpasi :
Fremitus suara melemah pada dada
kiri. Tidak teraba adanya massa.

Paru
Auskultasi :
Perkusi :
Suara dasar napas vesicular +/+, suara
Hipersonor pada paru kiri dan sonor napas
pada paru kanan.
tambahan rhonki +/+, wheezing -/-
STATUS GENERALIS

PALPASI
INSPEKSI
ictus cordis teraba di ICS 5 linea
ictus cordis terlihat
midclavicularis sinistra

Jantung
Perkusi
AUSKULTASI
batas jantung kiri di ICS 6 linea axillaris
Bunyi jantung I-II normal irregular,
anterior kiri, batas
gallop (+/+) pan sistolik
jantung kanan di ICS 5 linea para
murmur (+)
sternalis kanan..
STATUS GENERALIS

PALPASI
INSPEKSI Raba supel, nyeri tekan epigastrium
Perut cembung, scar (-), pelebaran (+), hepar dan lien tidak teraba
vena (-) membesar, nyeri lepas (-).

Abdomen

PERKUSI
Timpani pada seluruh kuadran AUSKULTASI
abdomen , shifting dullness (-), Bising usus (+) normal
undulasi (-), liver span 16 cm.
STATUS GENERALIS
Ekstremitas
Atas Bawah

Motorik 5555/5555 5555/5555

Sensorik Raba,nyeri,panas,dingin (+) Raba,nyeri,panas,dingin (+)
Refleks Fisiologis
Bicep (+/+) Bicep (+/+)
Tricep (+/+) Tricep (+/+)
Patella (+/+) Patella (+/+)
Achilles (+/+) Achilles (+/+)

Refleks Patologis
Hoffman-trommner (-/-) Hoffman-trommner (-/-)
Babinski (-/-) Babinski (-/-)
Chaddock (-/-) Chaddock (-/-)
Oppenheim (-/-) Oppenheim (-/-)
Schaeffer (-/-) Schaeffer (-/-)
Gordon (-/-) Gordon (-/-)
Gorda (-/-) Gorda (-/-)

Pulsasi Teraba/teraba Teraba/teraba

Udem +/+ +/+
 PEMERIKSAAN PENUNJANG
Jenis
(06 Maret 2017 ) Hasil Satuan Nilai rujukan
pemeriksaan
Hematologi
Hemoglobin 14.9 g/dL 11.7-15.5
Hematokrit 42 % 32-47
Eritrosit 4.9 Juta/L 3.8-5.2
Leukosit H 18.90 10/L 3.60-11.00
Trombosit 193 Ribu/L 150-440
Hitung jenis
Basofil 0 % 0-1
Eosinofil 0 % 1-3
Netrofil
0 % 3-5
batang
Neutrofil
86 % 50-70
segmen
Limfosit 8 % 25-40
 PEMERIKSAAN PENUNJANG
Jenis pemeriksaan Hasil satuan Nilai rujukan

Kimia klinik
(06 Maret 2017 ) 20
SGOT U/L 0-35

SGPT 16 U/L 0-35

Tropinin I kuantitatif <0.01 Ng/mL 0.00 0.02

Ureum darah 21 mg/dL 20-40

Kreatinin darah 0.62 mg/dL 0.35-0.93

eGFR 121.8 mL/min/1.73 m

GDS 117 mg/dL <200

Gas Darah +
Elektrolit
pH 7.437 7.370 7.400

p CO2 18.7 mmHg 33.0 44.0

p O2 115.0 mmHg 71.0 104.0

HCO3- 12.4 Mmol/L 22.0 29.0

HCO3 standard 16.6 Mmol/L

TCO2 13 Mmol/L 19 - 24

BE ecf -11.1

BE (B) -9.90 Mmol/L -2 - +3

Saturasi O2 98.30 % 94.00 98.00

Natrium (Na) 138 Mmol/L 135-147

Kalium (K) 3.7 Mmol/L 3.5-5.0

Klorida (Cl) 103 Mmol/L 98-108

PEMERIKSAAN PENUNJANG
Interpretasi:

Cor >50%. Trakea tidak deviasi. Tampak

corakan kasar bronkhovasikuler pada kedua

lapang paru dan tampak perselubungan

bagian tengah sampai bawah pada lapang

paru kanan. Sinus costofrenicus dan

diagfragma baik. Tulang-tulang dinding

dada dan jaringan lunak baik.

Kesan: kardiomegali
Bronkhopneumonia
 PEMERIKSAAN PENUNJANG
(06 Maret 2017 )
Interpretasi : (06 Maret 2017 )

Kecepatan dan kalibrasi : 25 mm/s dan 10 mm/mV

Irama : asinus
Heart rate : 166 x/menit
Axis` : Normoaxis
Gelombang P : fibrilasi
Interval P-R : irreguler
Gelombang QRS : sempit, durasi normal
Segmen ST : depresi lead II, III, aVF
Gelombang T : inversi pada lead 2

Kesimpulan : asinus rhythm, atrial fibrilasi

 PEMERIKSAAN PENUNJANG
(08 Maret 2017 )
 PEMERIKSAAN PENUNJANG
(08 Maret 2017 ) Interpretasi ECHO :
Dimensi ruang jantung : giant LV, smallish RV (RV tertekan LV) LVH (-)
Kontraktilitas global LV : normo dengan EF : 57%
Analisa segmental : global normokinetik
Kontraktilitas global RV dengan TAPSE : 19 mm
Katup mitral : MR severe ec RHD; MS moderate-severe ec RHD, MVA planimetri 0.9
Katup tricuspid : Tidak tervisualisasi dengan jelas, kesan terdapat TR dgn jet eksentrik, PH
Katup Aorta : AR moderate severe ec RHD
Katup Pulmonal : morphologi dan fungsi normal
Thrombus (-), Spontaneus Echo Contrast (+)

Conclusions :
Fungsi sistolik LV & RV normal
MR severe ec RHD
MS moderate-severe ec RHD
AR moderate-severe ec RHD
TR mild-moderate ec fungsional
PH
RESUME
ANAMNESA:
Dua hari yang lalu sebelum pasien dating ke IGD
RSUD Pasar Rebo pasien mengeluh sesak nafas dan
keesokan harinya pada pagi hari sebelum pasien datang ke
IGD RSUD Pasar Rebo, tiba-tiba pasien mengeluhkan sesak
yang semakin memberat sehingga pasien benar-benar sulit
untuk bernafas dan tidak membaik setelah pasien istirahat
dalam posisi setengah duduk, batuk berdarah (+), dada
terasa berdebar-debar (+), mual muntah (+), nyeri ulu hati
(+).Riwayat kaki bengkak disangkal.
RESUME
Pada pemeriksaan fisik ditemukan JVP meningkat (5+3
cmH2O), pada Inspeksi iktus cordis terlihat, Palpasi ictus cordis teraba
di ICS 5 linea midclavicularis hingga axillaris anterior sinistra, Perkusi
batas jantung kiri di ICS 6 linea axillaris anterior kiri, batas jantung
kanan di ICS 5 linea para sternalis kanan. Auskultasi Bunyi jantung I-II
normal irregular, gallop (+/+) pan sistolik murmur (+).

Pada pemeriksaan penunjang laboratorium ditemukan

leukositosis , pada rontgen thorax ditemukan kesan
bronchopneumonia dan kardiomegali, pada EKG ditemukan Atrial
Fibrilasi dan pada ECHO di temukan MR berate c RHD, MS sedang-
berat ec RHD, AR sedang-berat ec RHD, TR ringan-sedang ec
fungsional PH.
 Pengkajian masalah
MR & MS ASMA BRONKIAL
Atas dasar : sesak yang semakin Atas dasar : sesak nafas ,
memberat, batuk berdarah (+), dada terasa frekuensi nafas 40x/menit.
berdebar-debar (+), mual muntah (+). Auskultasi terdengar suara
Riwayat kaki bengkak disangkal.
tambahan rhonki +/+, wheezing -
Pada pemeriksaan fisik ditemukan JVP /-. Leukositosis, pada
meningkat (5+3 cmH2O), pada Inspeksi
pemeriksaan rontgen thorax
iktus cordis terlihat, Palpasi ictus cordis
teraba di ICS 5 linea midclavicularis hingga
Tampak corakan kasar
axillaris anterior sinistra, Perkusi batas bronkhovasikuler pada kedua
jantung kiri di ICS 6 linea axillaris anterior lapang paru dan tampak
kiri, batas jantung kanan di ICS 5 linea para perselubungan bagian tengah
sternalis kanan. Auskultasi Bunyi jantung I- sampai bawah pada lapang paru
II normal irregular, gallop (+/+) pan sistolik kanan.
murmur (+). Pada pemeriksaan ECHO di
temukan MR berat ec RHD, MS sedang-
berat ec RHD, AR sedang-berat ec RHD, TR
ringan-sedang ec fungsional PH.
Diagnosis kerja

Mitral Regurgitasi dan Mitral

Stenosis

Bronkhopneumonia
Diagnosa banding

Insufisiensi mitral

Regurgitasi aorta
PEMERIKSAAN ANJURAN

Kateterisasi
CT scan
jantung
TATALAKSANA
IGD Ruangan
Ceftriaxone 1x 2mg
O2 nasal cannule 4 L Lasix 2x1 amp
IUFD RA /8jam Atorvastatin 1x20mg
Lanoxin Simarc 1x2mg
Lasix 1 amp iv Digoxin 1x0.125 mg
Spironolakton 1x25mg
Alprazolam 1x0,5 mg
OBH 3x1 cth
Valsartan 1x40mg
PROGNOSIS

Ad vitam : ad malam

Ad functionam : ad malam

Ad sanationam : ad malam
 MITRAL REGURGITASI &
MITRAL STENOSIS

TINJAUAN PUSTAKA
 Stages of Progression of VHD
( Valvular Heart Disease)
Stage Definition Description
A At risk Patients with risk factors for the development of
VHD
B Progressive Patients with progressive VHD (mild-to-moderate
severity and asymptomatic)
C Asymptomatic Asymptomatic patients who have reached the
severe criteria for severe VHD
C1: Asymptomatic patients with severe VHDin
whom the left or right ventricle remains
compensated
C2: Asymptomatic patients who have severe
VHD, with decompensation of the left or right
ventricle
D Symptomatic Patients who have developed symptoms as a result
severe of VHD
 Diagnostic Testing Diagnosis and Follow-Up
Recommendations COR LOE
TTE is recommended in the initial evaluation of
patients with known or suspected VHD to confirm
the diagnosis, establish etiology, determine severity,
assess hemodynamic consequences, determine I B
prognosis, and evaluate for timing of intervention

TTE is recommended in patients with known VHD

with any change in symptoms or physical I C
examination findings
Periodic monitoring with TTE is recommended in
asymptomatic patients with known VHD at intervals
I C
depending on valve lesion, severity, ventricular size,
and ventricular function
TTE : Transthoracic Echocardiography
 Diagnostic Testing Diagnosis and Follow-Up
Recommendations COR LOE
Cardiac catheterization for hemodynamic
assessment is recommended in symptomatic patients
when noninvasive tests are inconclusive or when
there is a discrepancy between the findings on I C
noninvasive testing and physical examination
regarding severity of the valve lesion
Exercise testing is reasonable in selected
patients with asymptomatic severe VHD to 1)
confirm the absence of symptoms, or 2) assess the IIa B
hemodynamic response to exercise, or 3)
determine prognosis
 Frequency of Echocardiograms in Asymptomatic
Patients With VHD and Normal Left Ventricular Function
Stage Valve Lesion
Stage Aortic Stenosis Aortic Mitral Stenosis Mitral
Regurgitation Regurgitation
Progressive Every 35 y Every 3-5 y Every 35 y Every 35 y
(stage B) (mild severity (mild severity) (MVA >1.5 cm2) (mild severity)
Vmax 2.02.9 m/s) Every 1-2 y Every 12 y
Every 12 y (moderate (moderate
(moderate severity) severity)
severity
Vmax 3.03.9 m/s)
Severe Every 1 y Every 1 y Every 12 y Every 6 months
(stage C) (Vmax 4 m/s) Dilating LV (MVA 1.01.5 cm2) to 1 y
more frequent Every 1 y Dilating LV
(MVA <1 cm2) more frequent
MR & MS
MITRAL STENOSIS
 Stages of Mitral Stenosis
Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic Consequences Symptoms
A At risk of MS Mild valve doming during diastole Normal transmitral flow velocity None None
B Progressive MS Rheumatic valve changes with Increased transmitral flow Mild-to-moderate LANone
commissural fusion and diastolic velocities enlargement
doming of the mitral valve leaflets
MVA >1.5 cm2 Normal pulmonary
Planimetered MVA >1.5 cm2 pressure at rest
Diastolic pressure half-time

<150 ms
C Asymptomatic Rheumatic valve changes with MVA 1.5 cm2 Severe LA enlargement None
severe MS commissural fusion and diastolic
(MVA 1.0 cm2 with very severe Elevated PASP >30 mm
doming of the mitral valve leaflets
MS) Hg
Planimetered MVA 1.5 cm2
Diastolic pressure half-time
(MVA 1.0 cm2 with very severe
150 ms
MS)
(Diastolic pressure half-time

220 ms with very severe MS)

D Symptomatic Rheumatic valve changes with MVA 1.5 cm2 Severe LA enlargement Decreased
severe MS commissural fusion and diastolic exercise
(MVA 1.0 cm2 with very severe Elevated PASP >30 mm
doming of the mitral valve leaflets tolerance
MS) Hg
Planimetered MVA 1.5 cm2 Exertional
Diastolic pressure half-time
dyspnea
150 ms

(Diastolic pressure half-time

220 ms with very severe MS)

 Mitral Stenosis: Diagnosis and Follow-Up
Recommendations COR LOE
TTE is indicated in patients with signs or
symptoms of MS to establish the diagnosis, quantify
hemodynamic severity (mean pressure gradient,
mitral valve area, and pulmonary artery pressure), I B
assess concomitant valvular lesions, and
demonstrate valve morphology (to determine
suitability for mitral commissurotomy)
TEE should be performed in patients considered
for percutaneous mitral balloon commissurotomy to
assess the presence or absence of left atrial I B
thrombus and to further evaluate the severity of
mitral regurgitation
 Mitral Stenosis: Diagnosis and
Follow-Up
Recommendations COR LOE
Exercise testing with Doppler or invasive
hemodynamic assessment is recommended to
evaluate the response of the mean mitral gradient
and pulmonary artery pressure in patients with I C
MS when there is a discrepancy between resting
Doppler echocardiographic findings and clinical
symptoms or signs
 Mitral Stenosis: Medical Therapy

Recommendations COR LOE

Anticoagulation (vitamin K antagonist [VKA] or
heparin) is indicated in patients with 1) MS and AF
(paroxysmal, persistent, or permanent), or 2) MS and a I B
prior embolic event, or 3) MS and a left atrial
thrombus
Heart rate control can be beneficial in patients IIa C
with MS and AF and fast ventricular response
Heart rate control may be considered for patients
with MS in normal sinus rhythm and symptoms IIb B
associated with exercise
 Mitral Stenosis: Intervention
Recommendations COR LOE
PMBC is recommended for symptomatic patients
with severe MS (MVA <1.5 cm2, stage D) and
I A
favorable valve morphology in the absence of
contraindications
Mitral valve surgery is indicated in severely
symptomatic patients (NYHA class III/IV) with severe MS
(MVA <1.5 cm2, stage D) who are not high risk for surgery I B
and who are not candidates for or failed previous PMBC

Concomitant mitral valve surgery is indicated for

patients with severe MS (MVA 1.5 cm2, stages C or I C
D) undergoing other cardiac surgery
 Mitral Stenosis: Intervention (cont.)

Recommendations COR LOE

PMBC is reasonable for asymptomatic patients
with very severe MS (MVA 1 cm2, stage C) and
IIa C
favorable valve morphology in the absence of
contraindications
Mitral valve surgery is reasonable for severely
symptomatic patients (NYHA class III/IV) with severe
IIa C
MS (MVA 1.5 cm2, stage D) provided there are other
operative indications
 Mitral Stenosis: Intervention (cont.)
Recommendations COR LOE
PMBC may be considered for asymptomatic
patients with severe MS (MVA 1.5 cm2, stage C) and
IIb C
favorable valve morphology who have new onset of
AF in the absence of contraindications
PMBC may be considered for symptomatic patients
with MVA >1.5 cm2 if there is evidence of IIb C
hemodynamically significant MS during exercise
PMBC may be considered for severely
symptomatic patients (NYHA class III-IV) with severe
MS (MVA 1.5 cm2, stage D) who have suboptimal IIb C
valve anatomy and are not candidates for surgery or
at high risk for surgery
 Mitral Stenosis: Intervention (cont.)
Recommendations COR LOE
Concomitant mitral valve surgery might be
considered for patients with moderate MS (MVA IIb C
1.62.0 cm2) undergoing other cardiac surgery
Mitral valve surgery and excision of the left atrial
appendage may be considered for patients with
severe MS (MVA 1.5 cm2, stages C and D) who have IIb C
had recurrent embolic events while receiving
adequate anticoagulation
 Indications for Intervention for Rheumatic Mitral Stenosis

AF indicates atrial fibrillation; LA, left atrial; MR, mitral regurgitation; MS, mitral stenosis; MVA, mitral valve area; MVR,
mitral valve surgery (repair or replacement); NYHA, New York Heart Association; PCWP, pulmonary capillary wedge
pressure; PMBC, percutaneous mitral balloon commissurotomy; and T , pressure half-time.
MITRAL REGURGITASI
 Stages of Primary Mitral Regurgitation
Grade Definition Valve Anatomy Valve Hemodynamics* Hemodynami Symptoms
Consequences
A At risk of MR Mild mitral valve prolapse with No MR jet or small central jet area None None
normal coaptation <20% LA on Doppler
Mild valve thickening and Small vena contracta <0.3 cm
leaflet restriction
B Progressive MR Severe mitral valve prolapse Central jet MR 20%40% LA or Mild LA enlargement None
with normal coaptation late systolic eccentric jet MR No LV enlargement
Rheumatic valve changes with Vena contracta <0.7 cm Normal pulmonary
leaflet restriction and loss of Regurgitant volume <60 mL pressure
central coaptation Regurgitant fraction <50%
Prior IE ERO <0.40 cm2
Angiographic grade 12+

C Asymptomatic severe Severe mitral valve prolapse Central jet MR >40% LA Moderate or severe LA None
MR with loss of coaptation or flail or holosystolic eccentric enlargement
leaflet jet MR LV enlargement
Rheumatic valve changes with Vena contracta 0.7 cm Pulmonary hypertension
leaflet restriction and loss of Regurgitant volume 60 mL may be present at rest or
central coaptation Regurgitant fraction 50% with exercise
Prior IE ERO 0.40 cm2 C1: LVEF >60% and
Thickening of leaflets with Angiographic grade 34+ LVESD <40 mm
radiation heart disease C2: LVEF 60% and
LVESD 40 mm
D Symptomatic severe Severe mitral valve prolapse Central jet MR >40% LA or Moderate or severe LA Decreased
MR with loss of coaptation or flail holosystolic eccentric jet enlargement exercise
leaflet MR LV enlargement tolerance
Rheumatic valve changes with Vena contracta 0.7 cm Pulmonary hypertension Exertional
leaflet restriction and loss of Regurgitant volume 60 mL present dyspnea
central coaptation Regurgitant fraction 50%
Prior IE ERO 0.40 cm2
Thickening of leaflets with Angiographic grade 34+
 Stages of Secondary Mitral Regurgitation
Gradee Definition Valve Anatomy
A At risk of MR Normal valve leaflets, chords,
and annulus in a patient with
coronary disease or
cardiomyopathy
B Progressive MR Regional wall motion
abnormalities with mild
tethering of mitral
leaflet
Annular dilation with mild loss
of central coaptation of the
mitral leaflets
C Asymptomatic Regional wall motion
severe MR abnormalities and/or LV
dilation with severe
tethering of mitral leaflet
Annular dilation with
severe loss of central
coaptation of the mitral
leaflets
D Symptomatic Regional wall motion
severe MR abnormalities and/or LV
dilation with severe
tethering of mitral leaflet
Annular dilation with
severe loss of central
coaptation of the mitral
Valve Hemodynamics*
No MR jet or small central jet area
<20% LA on Doppler
Small vena contracta <0.30 cm
ERO <0.20 cm2
Regurgitant volume <30 mL
Regurgitant fraction <50%
ERO 0.20 cm2
Regurgitant volume 30 mL
Regurgitant fraction 50%
ERO 0.20 cm2
Regurgitant volume 30 mL
Regurgitant fraction 50%
Associated Cardiac Findings
Normal or mildly dilated LV
size with fixed (infarction) or
inducible (ischemia) regional
wall motion abnormalities
Primary myocardial disease
with LV dilation and systolic
dysfunction
Regional wall motion
abnormalities with reduced LV
systolic function
LV dilation and systolic
dysfunction due to primary
myocardial disease
Regional wall motion abnormalities
with reduced LV systolic function
LV dilation and systolic
dysfunction due to primary
myocardial disease
Regional wall motion abnormalities
with reduced LV systolic function
LV dilation and systolic
dysfunction due to primary
myocardial disease
Symptoms
Symptoms due to coronary
ischemia or HF may be present
that respond to
revascularization and
appropriate medical therapy
Symptoms due to coronary
ischemia or HF may be
present that respond to
revascularization and
appropriate medical therapy
Symptoms due to coronary
ischemia or HF may be
present that respond to
revascularization and
appropriate medical therapy
HF symptoms due to MR
persist even after
revascularization and
optimization of medical
therapy
Decreased exercise
tolerance
 Chronic Primary Mitral Regurgitation:
Diagnosis and Follow-Up
Recommendations COR LOE
TTE is indicated for baseline evaluation of LV
size and function, right ventricular (RV) function and
left atrial size, pulmonary artery pressure, and
mechanism and severity of primary MR (stages A to I B
D) in any patient suspected ofhaving chronic primary
MR
CMR is indicated in patients with chronic primary
MR to assess LV and RV volumes, function, or MR
I B
severity and when these issues are not
satisfactorily addressed by TTE
 Chronic Primary Mitral Regurgitation:
Diagnosis and Follow-Up (cont.)
Recommendations COR LOE
Intraoperative TEE is indicated to establish the
anatomic basis for chronic primary MR (stages C and I B
D) and to guide repair
TEE is indicated for evaluation of patients with
chronic primary MR (stages B to D) in whom
noninvasive imaging provides nondiagnostic I C
information about severity of MR, mechanism of
MR, and/or status of LV function
 Chronic Primary Mitral Regurgitation:
Diagnosis and Follow-Up (cont.)
Recommendations COR LOE
Exercise hemodynamics with either Doppler
echocardiography or cardiac catheterization is
reasonable in symptomatic patients with chronic
primary MR where there is a discrepancy between IIa B
symptoms and the severity of MR at rest (stages B
and C)
Exercise treadmill testing can be useful in
patients with chronic primary MR to establish
IIa C
symptom status and exercise tolerance (stages B and
C)
 Chronic Primary Mitral Regurgitation:
Medical Therapy
Recommendations COR LOE

Medical therapy for systolic dysfunction is

reasonable in symptomatic patients with chronic
IIa B
primary MR (stage D) and LVEF less than 60% in
whom surgery is not contemplated
Vasodilator therapy is not indicated for
normotensive asymptomatic patients with III: No
B
chronic primary MR (stages B and C1) and Benefit
normal systolic LV function
 Chronic Secondary Mitral Regurgitation:
Diagnosis and Follow-Up
Recommendations COR LOE
TTE is useful to establish the etiology of chronic
secondary MR (stages B to D) and the extent and
location of wall motion abnormalities and to assess I C
global LV function, severity of MR, and magnitude of
pulmonary hypertension
Noninvasive imaging (stress nuclear/positron
emission tomography, CMR, or stress echocardiography),
cardiac CT angiography, or cardiac catheterization,
including coronary arteriography, is useful to establish
etiology of chronic secondary MR (stages B to D) and/or I C
to assess myocardial viability, which in turn may influence
management of functional MR
 Chronic Secondary Mitral Regurgitation:
Medical Therapy
Recommendations COR LOE
Patients with chronic secondary MR (stages B to D)
and HF with reduced LVEF should receive standard
GDMT therapy for HF, including ACE inhibitors, ARBs, I A
beta blockers, and/or aldosterone antagonists as
indicated
Noninvasive imaging (stress nuclear/positron
emission tomography, CMR, or stress echocardiography),
cardiac CT angiography, or cardiac catheterization,
including coronary arteriography, is useful to establish
etiology of chronic secondary MR (stages B to D) and/or I A
to assess myocardial viability, which in turn may influence
management of functional MR
 Indications for Surgery for Mitral Regurgitation

AVR indicates aortic valve replacement; CABG, coronary artery bypass graft; COR, Class of Recommendation; LOE,
Level of Evidence; MR, mitral regurgitation; MV, mitral valve; N/A, not applicable; and NYHA, New York Heart.
AF indicates atrial fibrillation; CAD, coronary artery disease; CRT, cardiac resynchronization therapy; ERO, effective
regurgitant orifice; HF, heart failure; LV, left ventricular; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; MR, mitral
regurgitation, MV, mitral valve; MVR, mitral valve replacement; NYHA, New York Heart Association; PASP, pulmonary artery systolic pressure; RF, regurgitant
fraction; RVol, regurgitant volume; and Rx, therapy.
 DAFTAR PUSTAKA

Nishimura, RA et al. 2014. AHA/ACC Guideline for the Management of Patients

With Valvular
Heart Disease: Executive Summary.
Catherine M. Otto and Robert O. Bonow. 2017.Braunwalds heart disease. Ed.9.
TERIMA KASIH