Congestive Heart Failure

ec Mitral Regurgitation
Farid Ciadinan
C 111 11 260

Supervisor pembimbing:
Dr. Yulius Patimang, Sp.A, Sp.JP, FIHA
Patient’s Identity

 Name : Ny. N
 Sex : Male
 Age : 27 y.o
 Adress : Takalar
 Job :-
 RM no. : 680052
 Date of admission : 13-05-2016
History Taking

 Chief complain: shortness of breath

 Felt since last 2 years. Worsening at last 6 hours ago. Shortness of breath felt
continuously at mild exertion. The shortness of breath become more severe
when patient lying down. Patients could not bear to sleep with one pillow
and had to lie down with a minimum of 2 pillows. Patient often difficult to
sleep and sometimes awaked from sleep at night because of sudden
shortness of breath.
 There are history of repeated tightness since last 1 years especially when
the patient on exertion and reduced when the patient at rest.
 There are not chest pain, palpitation (+)
 Cough (+) without sputum
 Nausea (-), vomiting (-)
 Fever (-)
 There are not history of edema of the inferior extremities
 Past medical history:
o There are history hospitalized in the last one month with shortness of breath
o History have ever suffered from rheumatic fever denied
o There aren’t previous history of hypertension
o There aren’t history of diabetes
o There aren’t history of family have same symptoms
Physical Examination

General Status Vital Sign

 Moderate illness/ Well nourished/  Blood Pressure : 110/70
Conscious mmHg
 Nutritional Status: Normal  Pulse Rate : 1116 bpm
o Weight : 45 kg  Respiratory Rate : 28 bpm
o Height : 155 cm
 Temperature : 36.6 0C
o BMI : 18,7 kg/m2 (axilla)
Head & Neck Examination
 Eyes : anemic -/-, icterus -/-
 Lips : cyanosis (-)
 Neck : tumor mass (-), tenderness (-),
JVP R+2 cmH2O, trachea deviation (-)
Chest Examination
 Inspection : symmetric R=L
 Palpation : mass (-), tenderness (-), VF R=L
 Percussion : sonor R=L
lung-hepar border=right ics iv
right back lung border = right CV TH X
left back lung border = left CV TH X
 Auscultation : breath sound : vesicular
additional sound : ronchi +/+ wheezing -/-
Cardiac Examination
• Inspection : heart apex visible
• Palpation : heart apex palpable
• Percussion : heart border widen
• Auscultation: Irreguler, systolic murmur grade 4/6 LSB ICS
4, S3 gallop
Abdominal Examination
 Inspection : flat and following breath movement
 Auscultation : peristaltic sound (+), normal
 Palpation : mass (-), tenderness (-), liver and
spleen unpalpable
 Percussion : tympani (+), ascites (-)
Extremities
 Oedema : pretibial -/-, dorsum pedis -/-
Electrocardiography
• Supraventrikular ryhtm
• Heart rate 100-150 bpm
• Irreguler
• Normoaxis
• P wave: -
• PR interval -
• QRS complex:
• Duration < 0,12 s
• S V3 + R AVL = 50 smallbox
• Ventrikular extrasystol
• Poor R wave progression
• ST segmen: normal limit
• T interval : Normal limit
• Conclusion: AF RVR, HR 100-150 bpm,
irregular, normoaxis, poor R wave
progression, LVH, ventricular extrasystol
 Laboratory

PEMERIKSAAN NILAI NILAI RUJUKAN UNIT

WBC 8.6 4.00-10.00 10˄3/ul

RBC 4.64 4.00-6.00 10˄6/ul
Hb 13.1 12.0-16.0 gr/dl
PLT 220 150-400 10˄3/ul
PT 90 10-14 Detik
APTT 70.4 22.0-33.0 Detik
GDS 75 140 mg/dl
Ureum 107 10-50 mg/dl
Creatinin 2.02 L(<1.3) P(<1.1) mg/dl
SGOT 314 <38 U/L
SGPT 244 <41 U/L
Natrium 129 136-145 mmol/l
Kalium 5.0 3.5-5.1 mmol/l
Klorida 98 97-111 mmol/l
Chest X-Ray
• Cardiomegaly with signs
of mitral heart disease
along with signs of
pulmonary edema
Echocardiogr
aphy
• Systolic function of left
ventricle is good
• Dilation all of cardiac
chamber
• Hyperthopy eccentric left
ventricular
• MR severe, MS moderate,
TR moderate, PH severe,
PR mild
• Severe pulmonary
hypertension
• Minimal pericardial
effusion
 Working Diagnosis

Congestive Heart Failure e.c Mitral Regurgitation

Treatment

 O23-4lpm
 Fluid restriction
 Digoxin 0,5mg/iv/bolus slowly
 Furosemid loading 40 mg then 40 mg/8hr/IV
 Simarc 2 mg/24hr/oral
Congestive Heart Failure
Introduction

Heart Failure
 Heart is no longer able to pump an adequate supply of
blood in relation to the venous return and in relation to
the metabolic needs of the body tissues at the particular
moment
Congestive Heart Failure
 The state in which abnormal circulatory congestion
occurs as the result of heart failure.
Etiology

Myocard
Myocard Mechanical Dysfunction
Disease
Pressure overloaded
CAD (Stenosis Aortae, Hypertension, Coartatio
Aortae)

Cardiomyopathy Volume Overloaded

(Mitral/Aortae Regurgitation, Congenital
Heart Disease, Hipertransfusion)
Iatrogenic
Miocard Filling Inhibitating
(Cardiac Tamponade, Pericarditis)
Miocarditis
The Framingham criteria for CHF
CHF considered present if 2 major or 1 major & 2 minor
Major Criteria Minor Criteria
• Paroxysmal Nocturnal • Extremity edema
Dyspnea • Nocturnal cough
• Cardiomegaly • Decreased vital pulmonary
• Gallop S3 capacity (1/3 of maximal)
• Hepatojugular reflux • Hepatomegaly
• Increased of JVP • Pleural effusion
• Rales or ronchi • Tachycardia (≥ 120bpm)
• Acute pulmonary edema • Dyspnea d’effort
• Prolonged circulation time(>
25 sec)
• Weigh loss ≥ 4,5 kg in 5 days
in
response to treatment of CHF
Classification of CHF
Pathophysiology of CHF
CHF Management

Non-
Pharmacol
ogy
Pharmacology
Mitral Regurgitation
DEFINITION

 Mitral regurgitation (MR) is retrograde blood flow into the left atrium
resulting from an incompetent mitral valve.
ETIOLOGY
Pathophysiology

 Regurgitant mitral valve function in parallel with systolic flow across the
aortic valve, the impedance to ventricular emptying is reduced.
 Consequently, MR enhance left ventricular emptying
 Almost one half of th regurgitant volume is ejected into the left atrium
before the aortic valve opens
 The volume of MR depends on the impedance to LV emptying and is
increased by hypertension and AS
ACUTE MR

 Sudden early systolic rise of atrial pressure, pulmonary edema and CHF
 Acute MR may cause a volume overload of the left ventricle and atrium.
This is because each time pumping blood, the blood flow not just toward
the aorta (forward stroke volume), but regurgitant flow into the atrium
(regurgitant volume) is also pumped. Total stroke volume of the left
ventricle is a combination of the forward stroke volume and the regurgitant
volume.
 In acute left ventricular stroke volume increased, but the forward cardiac
output decreased. The mechanism that causes the increased total stroke
volume is called the Frank-Starling Mechanism. Regurgitant volume causes
the volume and pressure overload in the left atrium. This pressure rise will
lead to congestive lung, due to the drainage of blood from the lungs is
inhibited
Chronic MR

 There is a longer time interval from mid to end systolic rise

 With decrease in cardiac output, there is left ventricular failure because of
a volume overload
 The severity can be judged because left atrial and ventricular enlargement
at end diastolic dimensions due to stretching of the annulus and
enlargement of the left ventricle during the pushing of large volumes of
blood into the left ventricle
 A mild degree of regurgitation produce little derangement in LV function
 In chronic severe MR, LV volume overload occurs as the LV becomes
hyperdynamic
 The LA undergo compensatory changes to accommodate the volume
overload
 Increase in LV and LA chamber sie allow for accommodation of the
regurgitant volume at a lower filling pressure that limits pulmonary
congeation
 LA dilation can be mild to severe and predispose to atrial fibrillation
 Prolonged LV volume overload results in L contractile dysfunction and
increase LV end systoliv volume
 As this cycle continue along with an increase in LV filling pressures
 This hemodynamic changes eventually results in decrased cardiac output
and pulmonary vascular congestion
CLINICAL MANIFESTATION

Acute MR
 Rest dyspnea
 Orthopnea
 Paroxysmal nocturnal dyspnea
 Sincope
Chronic MR
 Fatique
 Weakness
 Decrease exercise tolerance
 Dyspnea
 Orthopnea
 Paroxysmal nocturnal dyspnea
Physical examination

 Carotid upstroke is brisk.

 Palpation-laterally displaced, diffuse, and brief apical impulse with
enlarged LV.
 An apical thrill
 Systolic expansion of the enlarged left atrium causes a late systolic thrust in
the parasternal region
 S1 is included in the murmur and is usually normal but may be increased in
rheumatic disease.
 Wide splitting of S2 due to the shortening of LV ejection and an earlier A2
due to reduced resistance to LV ejection.
 MR who have severe pulmonary hypertension, P2 is louder than A2.
 The abnormal increase in the flow rate across the mitral orifice during the
rapid filling phase is associated with an S3, (not due to heart failure) ; may
be accompanied by a brief diastolic rumble.
 Midsystolic clicks are markers of valve prolapse
 systolic murmur, most often holosystolic, including 1st and 2nd heart sounds.
 blowing type but may be harsh(MVP)
Chest x-ray:
 1. Left atrial enlargement, LV enlargement
 2. Possible pulmonary congestion, although most often normal

ECG:
 1. Left atrial enlargement
 2. LV hypertrophy
 3. Atrial fibrillation
Echocardiography:
 dilated left atrium
 hyperdynamic left ventricle
 color flow Doppler will show evidence of MR.
 The most important aspect of the echocardiographic examination is the
quantification of the severity of MR
Cardiac catheterization:
 to confirm severity of MR, or to rule out presence of coronary artery disease
in patients being evaluated for surgical replacement
Treatment

 Diuretics to improve pulmonary edema,

 vasodilators to improve cardiac output,
 AF rate control with digoxin and beta blockers
 anticoagulan in case of atrial fibrillation,
 treatment for heart failure as diuretics, beta blockers, ACE inhibitors, and
digitalis can handle mitral regurgitation experienced cardiomyopathy
Indications for Surgery for MR. *Mitral valve repair is preferred over MVR when
possible. AF, 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