Physical Examination A middle aged man, no sign of distress Vital signs: BP 120/74 mmHg, RR 16 /min, PR 80 /min (irregular rhythm), BT 36.7°C Head&neck : not pale conjunctiva, anicteric sclera, no jugular vein dilatation, no carotid thrill or bruit
Heart : -heaving at Lt. parasternal border -PMI at 6 th ICS, lateral to mid clavicular line, no thrill all of valve area -decreased 1 st sound, normal 2 nd sound, pansystolic murmur grade III at apex, radiate to Lt.axilla Lungs : no chest skin lesion, normal chest contour, equal bronchoalveolar breath sound, no lung crepitation
Abdomen : not distended, soft, not tender, impalpable liver and spleen, active bowel sound Extremities : palpable pulse 2+ all of upper and lower extremities, no pre-tibial pitting edema, no clubbing finger
Echocardiography Report Normal aorta and PA Normal aortic and pulmonic valve Severe MR, ERO 36 mm 2 (grade IV by PISA) with prolapsed PML Moderate TR ( RVSP 62 mm. Hg) Dilated LA, no LA thrombus Impaired LV systolic function, LVEF 40% LV eccentric hypertrophy and hypokinesia of anterior & lateral wall Normal RA & RV
Problem What type of Carpentier’s functional classification of MR in this case? Differential etiological diagnosis ? What is further proper management?
In Our Opinion Echo interpretation: – Severe MR Type II with cardiomyopathy Etiology diagnosis: – Ischemic cardiomyopathy Plan of management: – CAG
CAG Interpretation LM: normal LAD: total occlusion of proximal part, collateral from RCA LCx: 70% stenosis of proximal part RCA: total occlusion of mid part, collateral from acute marginal branch
Plan of operative management ?
In Our Opinion MV repair and CABG ( PDA, LCx, mid LAD)
Operative finding Moderate cardiomegaly, moderate Left atrial enlargement Mitral valve annular ectasia, prolapse posterior mitral leaflet PDA 2 mm Left Cx 2.5 mm LAD 2.5 mm SVG 3-3.5 mm LIMA 2.5 mm