A 79-Year-Old Man Presents for Evaluation of a Systolic Murmur | Patient Case Quiz

Access related cases on valvular heart disease and earn CME/CE credit by taking The Essentials of Cardiovascular Care for Older Adults (ECCOA).

Case Presentation

A 79-year-old man presents as a referral for evaluation of a systolic murmur. He reports decreased activity level over the last year to an extent that he now feels tired and short of breath walking to the mailbox. He does not report any chest pain at rest or with exertion. He has long-standing diabetes mellitus, hypertension, dyslipidemia, and benign prostatic hypertrophy, all of which have been adequately treated with medications. He is a life-long nonsmoker. He used to work as an accountant, but has been retired for more than 10 years. He lives with and takes care of his wife, who has been undergoing treatment for metastatic breast cancer for the last 8 years. Prior to the current referral, he has not been aware of having a heart murmur. He denies any cardiac evaluation in the past including echocardiography, and denies any history of rheumatic fever.

On physical examination, his blood pressure is 116/70 mm Hg and his heart rate is 89 bpm and irregularly irregular. He has a high-pitched holosystolic murmur that is best heard at the apex and radiates to the left sternal border. The intensity of the murmur is constant from beat to beat. Carotid upstrokes are brisk. Jugular vein pulsation is normal. Peripheral pulses are normal, and there is no edema.

Two-dimensional echocardiography showed mitral regurgitation (MR) with an estimated effective regurgitant orifice of 0.5 cm2. There is inferior hypokinesis and the left ventricular ejection fraction (LVEF) is calculated to be 56% with the biplane Simpson's method. The LV end-diastolic dimension measures 61 mm and end-systolic dimension measures 43 mm. The left atrium is dilated, measuring 41 ml/m2.

Which of the following is the best management option at this time?

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