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| * forever, gunny.al.. i missed this one |
| | #531356 |
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A 22-year-old female student is evaluated for a rapid heartbeat that builds over the course of the day and is not associated with chest pain or shortness of breath. She adds that she has been drinking a lot of coffee lately to finish term papers and study for finals. She is one of the best players on an intramural soccer team. The patient’s medical history is significant for tetralogy of Fallot repair that she underwent at age 2 years. She received a patch closure of the ventricular septal defect and a transannular patch to relieve pulmonic stenosis. She last saw her pediatric cardiologist 4 years ago, who told her everything was “OK.”
On physical examination, she is afebrile, her blood pressure is 110/60 mm Hg, pulse is 92/min, and respiration rate is 16/min. Estimated central venous pressure is 8 cm H2O. She has a mild right ventricular heave, a single S2, and a soft diastolic murmur at the base that increases in intensity with inspiration. She has clear lungs and no peripheral edema. The results of a hematocrit and thyroid function tests are within normal limits.
An echocardiogram shows a repaired tetralogy of Fallot and a mildly enlarged aorta and no residual ventricular septal defect. Left ventricular systolic function is normal. The right ventricle is moderately enlarged with normal systolic function. The pulmonic valve is not easily viewed, but regurgitation is present.
Which of the following is the most appropriate management option?
A-Cardiac magnetic resonance imaging
B-Chest CT
C-Counsel her to avoid pregnancy
D-Endocarditis prophylaxis for dental procedures
E-Reassurance
I always pick the wrong one when I have to choose between 2 optionssssss urgggggggg what to do? |
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| * Re:forever, gunny.al.. i missed this one |
| #2188534 |
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Answer: A
The best option for this patient is to undergo cardiac magnetic resonance imaging. Although repaired tetralogy of Fallot is associated with a higher risk of cardiac arrhythmias, the slow onset and offset and persistent nature of this patient’s symptoms, in conjunction with excess caffeine intake and stress, are most consistent with sinus tachycardia. Many young adults with congenital heart disease mistakenly believe they no longer need regular evaluation and, like this patient, present to a primary care physician with unrelated symptoms. However, the finding of a diastolic murmur consistent with pulmonic regurgitation and right ventricular enlargement requires further evaluation because these findings would not be present if the pulmonic valve was still competent after surgical repair. In adults with repaired tetralogy of Fallot, the most common long-term adverse outcome is severe pulmonic regurgitation leading to right ventricular dilation and systolic dysfunction.
Surgical repair for tetralogy of Fallot includes closure of the ventricular septal defect and relief of right ventricular outflow obstruction. Usually, outflow obstruction is relieved by surgically opening fused valve leaflets or by placement of a patch to enlarge the pulmonic annulus (transannular patch). This approach avoids placement of a prosthetic valve because a prosthesis will not grow with the child and is prone to rapid degeneration in children. However, this approach often results in pulmonic regurgitation, which is initially well tolerated, but eventually results in right ventricular volume overload and systolic dysfunction. Cardiac magnetic resonance imaging is the most accurate method for quantitation of right ventricular volumes and ejection fraction, and can also provide quantitative measures of pulmonic regurgitant severity. Repeat pulmonic valve surgery will eventually be needed in this patient to prevent progressive right heart dysfunction.
Chest CT is useful for evaluation of coronary anomalies and aortic dimensions, but these are not the primary concern in this patient. Mild aortic root dilation is typical of tetralogy of Fallot and is rarely associated with progressive dilation.
There is no reason to discourage pregnancy in this patient because she has no high-risk features—she is not cyanotic, her left ventricular function is normal, she does not have severe left-sided valve obstruction, and she has an excellent functional status.
Endocarditis prophylaxis is no longer recommended for native valve disease. In persons with congenital heart disease, endocarditis prophylaxis is recommended only with cyanotic disease or in the first 6 months after implantation of prosthetic material.
Reassurance alone is inappropriate for this patient. Although her presenting symptoms are likely benign, she needs further diagnostic evaluation of her structural heart disease and should also be referred to an established center for management of adult congenital heart disease. |
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| * Re:forever, gunny.al.. i missed this one |
| #2188544 |
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Take home:
Endocarditis prophylaxis is no longer recommended for native valve disease or most case of repaired congenital heart disease.
Endocarditis prophylaxis is recommended only with cyanotic disease or in the first 6 months after implantation of prosthetic material. |
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