View source for WBR0651

 {{WBRQuestion
|QuestionAuthor=Neeraja Danda M.B.B.S
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|Prompt=A 54 year old male hypertensive patient  presents to his primary care physician’s office for difficulty  breathing when walking 4-5 blocks for the last 2 months. Cardiac auscultation is significant for an apical murmur throughout  systole that radiates to axilla. The murmur increases in intensity on hand grip. Mitral regurgitation is diagnosed on echocardiography.  Ejection fraction, left ventricular end systolic diameter are measured. Operative criteria for mitral regurgitation includes which of the following?
|Explanation=An abnormal backward flow of blood through the mitral valve causes mitral regurgitation. Hypertension, myocardial infarction, papillary muscle rupture or any other condition leading to dilation of the heart causes mitral regurgitation. Mitral regurgitation is characterized by a pansystolic murmur at the cardiac apex that radiates to axilla and increases in intensity on leg raising, squatting and handgrip. Dyspnea on exertion is the most common presentation. Transthoracic echocardiogram is the best initial diagnostic test for all valvular diseases. Angiotensisn converting enzyme inhibitors, angiotenisn receptor blockers and nifedipine are the best initial therapy but surgery is  indicated when ejection fraction drops below 60% and left ventricular end systolic diameter is more than 40mm.

'''Educational Objective'''  In mitral regurgitation angiotensisn converting enzyme inhibitors, angiotenisn receptor blockers and nifedipine are the best initial therapy but surgery is  indicated when ejection fraction drops below 60% and left ventricular end systolic diameter is more than 40mm.

'''References''' Page 65,66 Master the boards step 3  2009 edition, page 89,90 Master the boards step 2 CK second edition. 
|AnswerA=Ejection fraction >80% 
	

|AnswerAExp='''Incorrect''' Ejection fraction should be less than 60% to repair the valve surgically.
|AnswerB=Ejection fraction <75%, left ventricular end systolic diameter < 40mm
|AnswerBExp='''Incorrect''' Ejection fraction less than 75% is not the criteria for surgery in mitral regurgitation
|AnswerC=Ejection fraction <60%, left ventricular end systolic diameter > 40mm
|AnswerCExp=Surgery is indicated when ejection fraction drops below 60% and left ventricular end systolic diameter is more than 40mm.
|AnswerD=Ejection fraction >60%, left ventricular end systolic diameter <40 mm
|AnswerDExp='''Incorrect''' Ejection fraction less than 60% and left ventricular end systolic diameter more than 40mm is the criteria 
|AnswerE=Valve repair is never the treatment of choice in mitral regurgitation.
|AnswerEExp='''Incorrect''' Though the initially preferred treatment is medical in mitral regurgitation if ejection fraction drops below 60% and left ventricular end systolic diameter exceeds 40mm, valve repair should be performed
|RightAnswer=C
|WBRKeyword=Mitral regurgiitation, operative criteria, ejection fraction
|Approved=Yes
}}