MITRAL INSUFFICIENCYMITRAL INSUFFICIENCYSqn/Ldr GSS PereraMBBS, Flight surgeonSri LankaAAMIMO 2013

Disclosure InformationDisclosure Information8484thth Annual AsMA Scientific Meeting Annual AsMA Scientific Meeting

SQN/LDR GSS PERERASQN/LDR GSS PERERA

I have no financial relationships to disclose.I have no financial relationships to disclose.

I will not discuss off-label use and/or I will not discuss off-label use and/or investigational use in my presentation investigational use in my presentation

Overview Overview

HistoryHistory Clinical examinationClinical examination InvestigationsInvestigations Symptoms of mitral valve regurgitationSymptoms of mitral valve regurgitation USAF ACS evaluationUSAF ACS evaluation ACS recommendationACS recommendation Recommendation for Sri Lanka Air Force Recommendation for Sri Lanka Air Force

HistoryHistory  

54 y/o female flight surgeon 54 y/o female flight surgeon Total of 600 flying hours in fighter wing Total of 600 flying hours in fighter wing 0 flying hours during the last six months 0 flying hours during the last six months ACS evaluation for mitral regurgitation ACS evaluation for mitral regurgitation

annuloplasty repairannuloplasty repair

HistoryHistory

Aug 2010 - while deployed Aug 2010 - while deployed Exertion dyspneaExertion dyspnea Decreased exercise capacity Decreased exercise capacity Near-syncopal episodes during exertionNear-syncopal episodes during exertion Symptoms continued after her return to USSymptoms continued after her return to US

Oct 2010 - The near syncopal episodes Oct 2010 - The near syncopal episodes Cardiology consult - TTE and TEE: moderate-Cardiology consult - TTE and TEE: moderate-

severe mitral regurgitation with preserved left severe mitral regurgitation with preserved left ventricular functionventricular function

HistoryHistory Normal coronary arteries on CTA. Normal coronary arteries on CTA. 2006 - Hospitalized for MRSA with failed 2006 - Hospitalized for MRSA with failed

outpatient therapy, Echo incidentally found outpatient therapy, Echo incidentally found trace mitral and tricuspid regurgitation trace mitral and tricuspid regurgitation

Dec 2010 Dec 2010 Uncomplicated minimally invasive mitral Uncomplicated minimally invasive mitral

annuloplasty annuloplasty 28mm Medtronic Future ring and exclusion of the 28mm Medtronic Future ring and exclusion of the

left atrial appendage surgery left atrial appendage surgery Discharged home Discharged home Uneventful recoveryUneventful recovery

HistoryHistory

Jan 2012 - post-op cardiologic evaluation Jan 2012 - post-op cardiologic evaluation Normal ECG with sinus bradycardia Normal ECG with sinus bradycardia Echocardiogram demonstrating normal LV Echocardiogram demonstrating normal LV

systolic function with an ejection fraction of 60-systolic function with an ejection fraction of 60-65% and only mild mitral valve regurgitation 65% and only mild mitral valve regurgitation and mild tricuspid valve regurgitation and mild tricuspid valve regurgitation

Released by cardiac surgeonReleased by cardiac surgeon

HistoryHistory

Apr 2012Apr 2012 Fitness test score 97.40/100Fitness test score 97.40/100 No recurrence of pre-op symptoms No recurrence of pre-op symptoms Accomplishing sustained aerobic activity and Accomplishing sustained aerobic activity and

weight lifting at the same levels as prior to weight lifting at the same levels as prior to development of symptomsdevelopment of symptoms

ACS - Past Medical HistoryACS - Past Medical History Childhood: no history of rheumatic fever, no Childhood: no history of rheumatic fever, no

family history sudden cardiac deathfamily history sudden cardiac death Adult: MRSA treated inpatient due to failed Adult: MRSA treated inpatient due to failed

outpatient treatmentoutpatient treatment Surgery: Mitral valve annuloplasty, several Surgery: Mitral valve annuloplasty, several

orthopaedic surgeriesorthopaedic surgeries Allergies: Butorphanol - profound parasymp rxnAllergies: Butorphanol - profound parasymp rxn Medications/Supplements: noneMedications/Supplements: none Aeromedical: no history of DCSAeromedical: no history of DCS Deployment: humanitarian deploymentsDeployment: humanitarian deployments Immunization: up to dateImmunization: up to date

ACS - Review of SystemsACS - Review of Systems GeneralGeneral: Pt denies fevers/chills, weight : Pt denies fevers/chills, weight

loss/gain, weakness, fatigueloss/gain, weakness, fatigue EENTEENT: Denies headaches, vision problems, : Denies headaches, vision problems,

eye pain/drainage, ear pain/ringing, nasal eye pain/drainage, ear pain/ringing, nasal congestion, sore throatcongestion, sore throat

CVCV: Denies chest pain, SOB, palpitations, : Denies chest pain, SOB, palpitations, always had normal lipid levelsalways had normal lipid levels

RespResp: Denies cough, bloody sputum, : Denies cough, bloody sputum, wheezing, night sweatswheezing, night sweats

ACS - Review of SystemsACS - Review of Systems GIGI: Denies stomach pain, bloody stools: Denies stomach pain, bloody stools GUGU: Denies painful urination, increased : Denies painful urination, increased

urgency or frequencyurgency or frequency MSMS: Denies muscle or joint pain or : Denies muscle or joint pain or

swellingswelling SkinSkin: No rashes: No rashes NeuroNeuro: Denies lightheaded/dizziness: Denies lightheaded/dizziness

Family HistoryFamily History Mother:Mother: 75 Alive healthy75 Alive healthy Father: Father: 75 Alive DM, HTN, HLP, 75 Alive DM, HTN, HLP,

obesityobesity Siblings: Siblings: 57 Alive Brother - DM, obesity 53 57 Alive Brother - DM, obesity 53

Alive Sister - DM, obesity 51 Alive Sister, Alive Sister - DM, obesity 51 Alive Sister, healthyhealthy

Maternal Grandmother: Maternal Grandmother: 86 Dead stroke86 Dead stroke Maternal Grandfather: Maternal Grandfather: 90 Dead COPD90 Dead COPD Paternal Grandmother: Paternal Grandmother: 70s Dead stroke70s Dead stroke Paternal Grandfather: Paternal Grandfather: 75 Dead 75 Dead

prostate cancerprostate cancer

Social HistorySocial History

Caffeine:Caffeine: Coffee: Coffee: 1/d, no tea or colas1/d, no tea or colas Smoking: Smoking: NeverNever Alcohol:Alcohol:

Beer: Beer: 1-2/mo1-2/mo Glasses of Wine:Glasses of Wine: 1-2/mo 1-2/mo Mixed Drinks: Mixed Drinks: NoneNone

Exercise: Exercise: 3-4x/wk aerobic - treadmill, rowing 3-4x/wk aerobic - treadmill, rowing machine and swimmingmachine and swimming

Diet: Diet: infrequent red meat, mainly lean white infrequent red meat, mainly lean white meat, increased fruits/vegetablesmeat, increased fruits/vegetables

ACS - Physical ExaminationACS - Physical Examination BMIBMI: 24.0 : 24.0 GenGen: Alert & Oriented x3, no acute distress, : Alert & Oriented x3, no acute distress,

very pleasantvery pleasant HEENTHEENT: No carotid bruit with normal upstroke, : No carotid bruit with normal upstroke,

no JVDno JVD RespResp: Symmetric, clear, no wheezes, rales, : Symmetric, clear, no wheezes, rales,

crackles crackles CVCV: RRR no murmurs, rubs: RRR no murmurs, rubs, , gallops, nl S1/S2 gallops, nl S1/S2

no S3 or S4no S3 or S4 AbdAbd: Soft, non-tender, non-distended, good : Soft, non-tender, non-distended, good

BSBS ExtExt: No cyanosis, clubbing, edema, normal 2+ : No cyanosis, clubbing, edema, normal 2+

radial, dosalis pedis, post-tibial pulsesradial, dosalis pedis, post-tibial pulses

ACS - Physical ExaminationACS - Physical Examination

Height: Height: 68 in/172cm 68 in/172cm Weight: Weight: 158158 lbs/71.67 kglbs/71.67 kg

(in uniform)(in uniform) Blood Pressure:Blood Pressure: 139/87 139/87 Pulse:Pulse: 7878 Lab: Lab: Non-contributoryNon-contributory 3 Day Blood Pressure: 3 Day Blood Pressure: NormalNormal

RadiologyRadiology

Chest: Chest: NLNL KUB:KUB: NL NL Fluoroscopy:Fluoroscopy: NL NL

ACS Branch EvaluationsACS Branch Evaluations Flight Medicine:Flight Medicine:

- Audio: - Audio: NLNL

- Clinical:- Clinical: NLNL

NeuropsychiatryNeuropsychiatry

History and Exams:History and Exams: NL NL Neurophysiological Studies Neurophysiological Studies

(EEGs/NCSs/EPs):(EEGs/NCSs/EPs): NLNL Psychiatry: Psychiatry: NLNL Psychology:Psychology: NL NL

Internal MedicineInternal Medicine

12 Feb 2013 - Treadmill test12 Feb 2013 - Treadmill test Exercised for 13 minutes (15.2 METS) to Exercised for 13 minutes (15.2 METS) to

HR of 147 (90% of target HR) and BP of HR of 147 (90% of target HR) and BP of 180/84 limited by fatigue and knee pain. 180/84 limited by fatigue and knee pain. Frequent PVC`s and occasional PAC`s Frequent PVC`s and occasional PAC`s with no ST-T changes. with no ST-T changes. Clinically and Clinically and electrically negativeelectrically negative

Thallium:Thallium: NL NL

EchocardiogramEchocardiogram

Normal appearance and function of the left Normal appearance and function of the left ventricleventricle

Normal left ventricular sizeNormal left ventricular size Normal left ventricular systolic functionNormal left ventricular systolic function Normal septal wall thicknessNormal septal wall thickness Left ventricular diastolic parameters were normalLeft ventricular diastolic parameters were normal Normal appearance and function of the aortic valveNormal appearance and function of the aortic valve

Trace aortic insufficiency (Normal Variant)Trace aortic insufficiency (Normal Variant)

EchocardiogramEchocardiogram

Tri-leaflet aortic valveTri-leaflet aortic valve Normal appearance and function of the mitral valve Normal appearance and function of the mitral valve

with trace physiologic regurgitationwith trace physiologic regurgitation There is mild mitral valve regurgitation (normal There is mild mitral valve regurgitation (normal

variant)variant) The mitral regurgitation jet was eccentric and The mitral regurgitation jet was eccentric and

directed posteriorlydirected posteriorly The mitral valve leaflets are status post repair. A The mitral valve leaflets are status post repair. A

mitral annuloplasty ring is present (abnormal)mitral annuloplasty ring is present (abnormal)

Stress EchocardiogramStress Echocardiogram

Normal appearance of the tricuspid valveNormal appearance of the tricuspid valve There is trace tricuspid regurgitation There is trace tricuspid regurgitation

(normal variant)(normal variant) There is trace pulmonic insufficiency There is trace pulmonic insufficiency

(normal variant)(normal variant)

Comments: Comments: Normal Stress EchoNormal Stress Echo

HolterHolter

12 Feb 13: 24-hour Holter monitor: 12 Feb 13: 24-hour Holter monitor: HR 51-115 HR 51-115 Average 70Average 70 Rare PAC's (29) and PVC's (22), all singles, no Rare PAC's (29) and PVC's (22), all singles, no runs, no symptomsruns, no symptoms

CONCLUSION: CONCLUSION: Normal variant HolterNormal variant Holter

Neuroimaging Studies (MRI/CT): Neuroimaging Studies (MRI/CT): NLNL

Mitral Valve Regurgitation  Mitral Valve Regurgitation   Symptoms typically manifest as heart valve Symptoms typically manifest as heart valve

disease developsdisease develops Typical progression over a period of many years Typical progression over a period of many years Common mitral regurgitation symptoms:Common mitral regurgitation symptoms:

Shortness of breath, especially during exercise or Shortness of breath, especially during exercise or when laying stillwhen laying still

Fatigue, especially during exerciseFatigue, especially during exercise Cough, often during the night, when in bedCough, often during the night, when in bed Heart palpitations, fluttering heart beats, atrial Heart palpitations, fluttering heart beats, atrial

fibrillationfibrillation Swollen feet or anklesSwollen feet or ankles Heart murmur, muffled heart beatHeart murmur, muffled heart beat Excessive urinationExcessive urination

Risk AssessmentRisk Assessment 54-year old female flight surgeon assigned to a 54-year old female flight surgeon assigned to a

Fighter WingFighter Wing Dec 2010 - Diagnosed symptomatic moderate Dec 2010 - Diagnosed symptomatic moderate

to severe primary mitral valve insufficiency (no to severe primary mitral valve insufficiency (no MVP)MVP)

Dec 2010 - Treated surgically with mitral Dec 2010 - Treated surgically with mitral annuloplasty with a partial semi-rigid prosthetic annuloplasty with a partial semi-rigid prosthetic ringring

Post-op course satisfactory, uncomplicated, Post-op course satisfactory, uncomplicated, with good surgical resultswith good surgical results

Feb 2013 - Evaluated at ACS for the first timeFeb 2013 - Evaluated at ACS for the first time

ACS Evaluation Summary ACS Evaluation Summary

No cardiovascular symptomsNo cardiovascular symptoms Physical examination was normalPhysical examination was normal ECG was normalECG was normal Resting Echo showed normal LV and LA size Resting Echo showed normal LV and LA size

and functionand function The prosthetic mitral annular ring was The prosthetic mitral annular ring was

visualized with no evidence of mitral stenosisvisualized with no evidence of mitral stenosis

ACS Evaluation Summary ACS Evaluation Summary There was mild mitral regurgitation with an There was mild mitral regurgitation with an

eccentric jet directed towards the posterior eccentric jet directed towards the posterior atrial wallatrial wall

Her treadmill test was negative for Her treadmill test was negative for inducible ischemia and demonstrated inducible ischemia and demonstrated normal functional capacity normal functional capacity

The stress Echo was normalThe stress Echo was normal The 24 hour Holter showed no significant The 24 hour Holter showed no significant

arrhythmiasarrhythmias

Aeromedical Concerns Aeromedical Concerns Thrombo-embolic eventsThrombo-embolic events Infective endocarditis Infective endocarditis Progression to ventricular dysfunction and Progression to ventricular dysfunction and

heart failureheart failure Residual or progressive post-procedure Residual or progressive post-procedure

issuesissues Mitral regurgitation Mitral regurgitation Iatrogenic mitral stenosis produced by the Iatrogenic mitral stenosis produced by the

prosthetic annulus prosthetic annulus Short and long-term durability of the procedureShort and long-term durability of the procedure

Aeromedical Concerns Aeromedical Concerns Can be monitored with periodic Echo exam & Can be monitored with periodic Echo exam &

surveillance for redevelopment of symptomssurveillance for redevelopment of symptoms Risk for sudden incapacitation due to sudden Risk for sudden incapacitation due to sudden

cardiac death, syncope & sustained cardiac death, syncope & sustained tachyarrhythmias is quite lowtachyarrhythmias is quite low

ACS experience with moderate and severe ACS experience with moderate and severe primary MR limitedprimary MR limited

In the absence of hypertrophy, chamber In the absence of hypertrophy, chamber enlargement & ventricular dysfunction, moderate enlargement & ventricular dysfunction, moderate MR or less maybe eligible for unrestricted FC-II MR or less maybe eligible for unrestricted FC-II waiverwaiver

ACS Final Diagnoses ACS Final Diagnoses

History of moderate to severe History of moderate to severe symptomatic primary mitral insufficiencysymptomatic primary mitral insufficiency

History of minimally invasive mitral valve History of minimally invasive mitral valve annuloplasty repair surgery with left atrial annuloplasty repair surgery with left atrial appendage exclusionappendage exclusion

History of transient post operative heart History of transient post operative heart block, resolvedblock, resolved

ACS RecommendationsACS Recommendations Disqualified for FC-II dutiesDisqualified for FC-II duties Recommend FC-II waiver for diagnoses #1 and #2, Recommend FC-II waiver for diagnoses #1 and #2,

valid for two years (Jan 2015), waiver authority Air valid for two years (Jan 2015), waiver authority Air National GuardNational Guard

Diagnosis #3 is clearly secondary to a reversible Diagnosis #3 is clearly secondary to a reversible cause and has resolved and is an exception to cause and has resolved and is an exception to disqualification and does not require a waiverdisqualification and does not require a waiver

ACS Internal Medicine review in two years (Jan ACS Internal Medicine review in two years (Jan 2015)2015)

Prior to waiver expiration submit Aeromedical Prior to waiver expiration submit Aeromedical Summary, ECG, Echo (CD copy of images) to ACS Summary, ECG, Echo (CD copy of images) to ACS for review and recommendationsfor review and recommendations

SLAF Medical CategoriesSLAF Medical Categories AA Air dutiesAir duties GG Ground duties Ground duties

A1G1 Fit to fly any type of aircraftA1G1 Fit to fly any type of aircraft A2G1 Fit to fly transport or rotary co-pilot A2G1 Fit to fly transport or rotary co-pilot

onlyonly A3G1 Fit to fly as navigator, load master A3G1 Fit to fly as navigator, load master A4G1 Fit to fly as passenger onlyA4G1 Fit to fly as passenger only A5G2 Unfit for flying, fit for ground duties A5G2 Unfit for flying, fit for ground duties

Sri Lanka Air ForceSri Lanka Air Force

One senior medical officer (Gp/Capt) conducts One senior medical officer (Gp/Capt) conducts all aircrew medical exams every 6 monthall aircrew medical exams every 6 month

He/She is the final authority for fitness to fly He/She is the final authority for fitness to fly determinations and sends evaluations directly determinations and sends evaluations directly to Chief of Air Staff, Director Air Operation, to Chief of Air Staff, Director Air Operation, and Director Health Service.and Director Health Service.

Policy on MVPPolicy on MVP

MVP found in pilot applicants disqualifies MVP found in pilot applicants disqualifies for any military dutiesfor any military duties

If found in initial flying training ground him If found in initial flying training ground him and give change of branch not in aircrewand give change of branch not in aircrew

If found in pilots given A2G1 category that If found in pilots given A2G1 category that mean he is not fit for flying fighter air craft mean he is not fit for flying fighter air craft but he can fly with transport or rotary wing but he can fly with transport or rotary wing aircraft as co-pilotaircraft as co-pilot