CLINICAL PRESENTATION
38-year-old women presented with recurrent symptoms of congestive heart
failure, including dyspnea, lower-extremity edema, and ascites due to
idiopathic dilated cardiomyopathy diagnosed two years ago, complicated
with functional mitral and tricuspid regurgitation. Both coronary
angiography and cardiac magnetic resonance were performed at the time
with no significant abnormality.
Her past medical history revealed permanent atrial fibrillation.
In view of her worsening heart failure symptoms with recurrent
hospitalizations despite optimal heart failure treatment, the decision
of surgical management of her biventricular dilated cardiomyopathy was
taken and the patient was admitted in our department for a mitral and
tricuspid valve repair surgery.
On admission, initial physical exam reveals temperature 37 °C, heart
rate 87 bpm, blood pressure 101/70 mmHg, Cardiac physical examination
revealed irregularity of heart sounds S1 and S2, holosystolic murmur
(grade 4/6) radiating to the axilla and holosystolic murmur (grade 3/6)
at the left lower sternal border. Other physical checks were within
normal limits.
Electrocardiography (ECG) examination revealed atrial fibrillation, and
chest X-rays showed cardiomegaly.
Transthoracic echocardiography revealed global severe left ventricular
dysfunction, ejection fraction (EF) of 25%, severe left ventricular
dilatation with left ventricular end diastolic diameter (LVEDD) 68 mm,
severe functional mitral valve regurgitation (MR) with central jet
(effective regurgitation orifice 0.30 cm2, regurgitation volume 63 ml),
and concomitant systolic dysfunction of dilated right ventricle (low
TAPSE of 15 mm) with severe tricuspid valve regurgitation grade (TR).
Bi-atrial enlargement was also noted (figure 1).
Results of complete blood count, inflammatory markers (C-reactive
protein), electrolytes, serum creatinine, liver enzymes, and thyroid
hormones were in normal ranges. Heart failure therapy was optimal.
She underwent a mitral valve restrictive annuloplasty with a Carpentier
ring N°28 (figure 3)in addition to annuloplasty ring N° 30 mm.
The patient was discharged from the hospital on day 14 after an
uneventful post operative course.
At the 6-month postoperative follow-up, the patient showed continuous
improvement of her symptoms, besides, repeat transthoracic
echocardiography also showed an improved of left ventricle dimensions
and function with left ventricle EF increased to 40% (figure 2).