AM ReportTJ O’Neill 3/24/10

Cardiogenic Shock w/ Preserved EF

With pulmonary edema Acute severe aortic regurgitation Acute severe mitral regurgitation

Without pulmonary edema Cardiac Tamponade Acute massive PE Acute RV infarction

Chordae Rupture First described in 1806 Most commonly “primary”, highest association

w/ rheumatic fever, infectious endocarditis Also MVP, collagen vasc disease, trauma,

hypertrophic, but also longstanding hypertension

Chordae classified based on site of insertion

Chordae Rupture

6.6–8.1% of all valvular surgeries, 9.3–20% of all mitral valve surgeries 26% among emergency mitral regurgitation

surgeries P2, P3, or P 2-3 are most likely to flail

Chordal RuptureDiagnosis

Rapid clinical deterioration is frequent w/ associated dyspnea, tachypnea, pulmonary edema

Chordal rupture will usually have associated gallop S3 and S4 w/ hyperactive prechordium and possible thrill

Murmur may radiate upward, posterior as well as apical and compared to chronic MR is early to mid- peaking due to lack of a compliant atrium

Chordal RuptureDiagnosis

Flail mitral leaflet

Chordal RuptureDiagnosis

Because regurgitant jet is asymmetric, pulmonary edema can occur unilaterally

NEJM 361:e6. July 30th 2009, 5.

Acute Mitral RegurgitationTreatment

Afterload reduction if BP tolerates ACE-I, Hydralazine, Sodium nitroprusside Diuretics

Intra-aortic balloon pump

CT surgery consult for any symptomatic patients as mortality is much higher than chronic MR

References

Br Heart J. 1983 October; 50(4): 312–317 Gabbay U, Yosefy C.,Int J Cardiol. 2010 Mar 6. Heart 2009 Jun; 95 (12): 976-9.

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