CONGESTIVE HEART FAILURE

NYHA II-III ec. MITRAL

STENOSIS
Case Report

Supervisor:
Prof.dr.Peter Kabo,PhD,SpFK,SpJP(K),FIHA,FASCC

Cardiology Department, November 2015

Patients ID
Name

:
DoB (age) :
Sex
:
Job
:
Ward
:
hospital

Mrs. S
15/06/1975 (40 yo)
Female
Housewife
Lontara 1 WS

History
Chief

complaint: Shortness of breath

Experienced since 1 year and progressively
worsening in last 2 days. Shortness of breath
exacerbated by activity and the position of lying
down. She feels comfort by adding 2 or more
pillow and often forcedly awaken because of her
shortness of breath. She also sometimes
experienced left chest pain due to heavy
activity. There was no fever, nausea & vomiting.
Defecation and urination within normal limits.

History
History

of hospitalization due to same

complaintment 1 year ago.
History of HT & DM unknown.
No history of smoking & alcohol consumption.
No history of joint pain.
No history of prematurity or cyanotic at birth.
No history of familial risk.
Risk factor:
Modifiable: lack of physical activity
Non-modifiable: female

Physical Examination
General

condition
Moderate illness / well-nourished / composmentis
Vital signs

BP
HR
RR
Temp.

Head

:
:
:
:

90/60 mmHg
60x/mnt
20x/mnt
37oC

& neck

Anemia (-), icterus (-), cyanotic (-)

JVP R+3 cmH2O

Physical Examination
Thorax

I : symmetric
R=L, normochest
P : mass (-),
tenderness (-), VF
R=L
P : sonor
A : BS: vesicular,
AS: basal ronchi +/
+, wh -/-.

Cor

I : ictus cordis not visible

P : thrill (-), ictus cordis
impalpable
P : dull, enlarged
Right border: right
parasternal line.
Left border: ant. axillary line
5th ICS.

A : HS I/II irregular,
diastolic murmur (+)
apex cordis grade 2/4.

Physical Examination
Abdomen

I : flat and correspond

with breathing
movement
A : peristaltic sound
(+), normal
P : liver palpated 2
fingers below arcus
costa and spleen
impalpable
P : tympani, ascites (-)

Extremities

Edema -/ Warm extremities

ECG

Irregular rhytm
Right axis deviation
Ventricular rate:
60bpm
P wave: fibrillation
(f) wave
QRS complex: lead
V1, R/S ratio >1
ST segment:
depression in lead
V1-V3
T wave: inverted in
lead II, III, aVF, V2-v5
Conclusion:
Irregular rhytm, right
axis deviation, atrial
fibrillation slow
ventricular response

Laboratory findings

Result

Normal

WBC

3,3 [103/mm3]

4.0-10.0

RBC

4,35 [106/mm3]

4.00-5.00

HGB

12,2 [g/dL]

12.0-16.0

HCT

39,3 [%]

37.0-48.0

PLT

205 [10 /mm ]

150-400

Na

141

136-145

3,3

3.5-5.1

Cl

107

CK

38 [U/L]

CK-MB

14 [U/L]

97-111
L(<190),
P(<167)
<25

Result

Norma
l

Troponin-T
GDS

<0,02
72

<0,05
80-180

Ureum

32

10-50

Kreatinin

0,7

SGOT

26

L(<1.3),
P(<1,1)
<38

SGPT

16

<41

PT

78 ctrl 10,4

INR

7,35

APTT

47 ctrl 24,9

Working Diagnosis
Congestive

Heart Failure NYHA IIIII ec. susp. Mitral Stenosis

Atrial Fibrillation Slow Ventricular
Response

Planning & Therapy

Echocardiography

Normal LV systolic fx.; EF 58%

LA, RA, LV, RV dillatation
LVH (-)
Myocard fx: global normokinetic
Decreased RV fx.
Cardiac valve:

Mitral: severe stenosis

Aorta: calcification (+), mild regurgitation
Tricuspid: mild regurgitation
Pulmonal: mild regurgitation

Conclusion:
Normal LV fx
Severe mitral stenosis, mild aorta,
tricuspid, and pulmonal regurgitation
Mild pulmonary HT

Planning & Therapy

Bed rest

O2 2-4 L/mnt via nasal cannula

Fluid restriction

Low salt diet

Furosemide 40mg/12h/IV
Spironolacton 25mg/24h/oral
Fargoxin 0.25mg/24h/oral

Simarc 2mg/24h/oral

Congestive Heart Failure

Mitral Stenosis

Heart Failure
Inability

of the heart to pump

sufficient amount of blood to
fulfill the needs of body
metabolism (forward failure),
The ability to pump can only be
precipitated with high pressure
from the blood entering the heart
(backward failure).

Etiology
Coronary

Artery Disease (CAD)

Cardiomyopathy (dilatated,
obstructed, restricted and
obliterated)
Valvular heart disease
Hypertension

Mitral Valve

Mitral Stenosis
Definition:

Obstruction of mitral valve

that prevents proper left ventricle filling
during diastole
Normal MV Area: 4-6 cm 2
Symptoms begin at areas less than 2 cm 2
Predominantly was a complication of
Rheumatic carditis
Two-thirds of patients with MS are female

Diagnosis (CHF)
Major criteria:
Paroxysmal

nocturnal dyspnea (PND)

or orthopnea;
Distended neck veins (in other than
supine position);
Rales;
Cardiomegaly seen in x-ray;
Acute pulmonal oedema seen in x-ray;
Gallop ventricular S3;
Increased vein pressure > 16 cm H 20;
Hepatojugular reflux;
Pulmonal oedema, visceral congestion,
cardiomegaly found in autopsion;
Decreases body mass.

Minor criteria:
Bilateral

ankle oedema;
Night cough;
Dyspnea on regular activity;
Hepatomegaly;
Pleural effusion seen in x-ray;
Decrease of 1/3 vital capacity
from the maximal record;
Tachycardia (120 bpm or
more);
Engorgement pulmonal
vascularization seen in x-ray.

Diagnosis (MS)
Possible

symptoms and signs of CHF

Cardiac auscultation
Opening snap
Rumbling diastolic murmur best heard at
apex radiating to the axilla
Loud S2: pulmonary hypertension
Additional

clinical presentation

Mitral facies : Pink purple patches on the

cheeks, cyanotic skin changes from low
cardiac output

ECG
Broad

notched P wave
(left atrial enlargement)

Atrial

fibrillation

Echocardiography
The

gold standard for

diagnosis
Anatomy/size of mitral
valve & its opening
Severity of MS (area of
orifice)
Size & function of
ventricles
Estimation of
pulmonary artery
pressure

Management (CHF)
Decrease

the preload
Diuretic, aldosterone receptors antagonist,
nitrat
Increase heart contractility
Digitalis, ibopamin, -blocker
Decrease the afterload
ACE-I, ARB, dihydropiridin CCB
Preventing miocard remodelling
ACE-I, ARB