The Dilemma of the Octogenarian With Severe Mitral Regurgitation | Patient Case Quiz

You are asked to consult on an 82-year-old woman with a long history of mitral valve prolapse and regurgitation for thoughts on further management. She reports worsening dyspnea on exertion and is limited to walking one block. She denies chest pain, orthopnea, or paroxysmal nocturnal dyspnea.

Medical History: Her comorbidities include obesity, stage 3 chronic kidney disease, obstructive sleep apnea, hypertension, hyperlipidemia, and mild dementia. She needs assistance with activities of daily living, and she lives with her granddaughter, who is her primary caregiver.

Negative History: She has no history of coronary disease, valve surgery, peripheral vascular disease (PVD), cerebrovascular disease, diabetes, hemodialysis, endocarditis, or immunosuppression.

Medications: Aspirin 81 mg daily, metoprolol 50 mg BID, furosemide 20 mg daily, hydralazine 10 mg BID, and simvastatin 10 mg daily.

Height - 4 feet, 7 inches
Weight - 63 kg (body mass index [BMI] 32.5 kg/m2)
Heart Rate - 58 beats per minute (BPM)
Blood Pressure - 132/60 mm Hg
Oxygen Saturation - 100%

Physical Exam:
General Appearance - Pleasant, cooperative Romanian female, appearing her stated age, and in no acute distress.
Neck - Jugular venous pressure of 12 cm measured with the patient reclined at 45 degrees.
Cardiovascular - Regular rhythm, III/VI blowing holosystolic murmur heard best at the apex, no gallops.
Extremities - Trace pedal edema.
Neurological - She is oriented to person, place, time, and situation.

Laboratory Data:
B-Natiuretic Peptide (BNP) - 586 pg/mL
Creatinine - 1.2mg/dL
White Blood Cell - 6.8 K/uL
Hemoglobin - 11.3 g/dL
Hematocrit - 33%
Platelet Count - 203 K/uL
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were within normal limits.

Transthoracic Echocardiogram: Mild left ventricular (LV) enlargement with an indexed LV diastolic volume of 112 mL/m2. LV ejection fraction is 60% by biplane with no regional wall motion abnormalities. Right ventricular size and systolic function are normal. The left atrium is severely enlarged with an indexed left atrial volume of 40 mL/m2. There is mitral valve prolapse with a prominent eccentric, anteriorly-directed jet of mitral regurgitation (MR). The peak E wave velocity is 1.5 m/sec, effective mitral valve regurgitant orifice area is 59 mm2, and mitral regurgitant volume is 105 mL – all values consistent with severe MR. The estimated pulmonary artery systolic pressure is at least 39 mm Hg plus central venous pressure.

Transesophageal Echocardiogram: There is an anteriorly-directed, wall-hugging jet of severe MR. Systolic flow reversal is seen in the right upper pulmonary vein. The etiology of MR is degenerative valve disease (primary MR). There is bileaflet prolapse with severe prolapse of the P2 scallop and mild prolapse of P1. There is myxomatous thickening and mild prolapse of A2.

Cardiac Catheterization: LV end diastolic pressure is elevated at 18 mm Hg and pulmonary capillary wedge pressure is elevated at 15 mm Hg. The mean pulmonary artery pressure is 23 mm Hg with V waves to 45 mm Hg. Angiography shows right dominant coronary anatomy with 95% stenosis of the mid left anterior descending artery and 70% stenosis of the proximal right coronary artery.

Her case was reviewed by two cardiac surgeons. The mitral valve was felt to be amendable to mitral valve repair. However, her Society of Transthoracic Surgeons (STS) Surgical Risk Sore for mitral valve repair with two vessel bypass was elevated as follows:

Mortality - 7 %
Morbidity or Mortality -   30 %
Long Length of Stay - 15 %
Short Length of Stay - 12 %
Permanent Stroke -  3.5 %
Prolonged Ventilation - 18 %
Deep Sternal Infection - 0.2 %
Renal Failure - 8 %
Reoperation - 11 %

Additionally, the patient and her family express concerns about the recovery period after open surgery; they favor a less invasive option, if possible.

Which of the following statements describes your choice for this 82-year-old female with severe degenerative MR and two-vessel coronary artery disease?

Show Answer