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Case History :

A 12 year old child with a known history of congenital heart disease presented with dyspnoea on exertion, palpitations, dizziness and syncope. on auscultation there was quiet first heart sound and delayed second heart sound.

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Investigation Reports :

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Discussion :

In general patients with AR of a rheumatic origin need antibiotic prophylaxis to prevent recurrences of rheumatic carditis and patients with syphilitic Ar need a course of antibiotic to treat syphilis. Patients with mild and moderate AR usually need no specific therapy but in asymptomatic patients with severe AR as in this case need some management. A calcium channel-blocking agent, long acting nifedipine, produces a significant reduction in blood pressure in LV end-diastolic volume and mass and major increases in LV ejection fraction at the end of 1 year. Accordingly, all asymptomatic patients with severe AR and normal LV systolic function should be treated with a vasodilator (calcium channel blocking agent, long acting nifedipine) unless there is a contraindication to its use. An acute study showed that nifedipine was superior to an ACE inhibitor and there are no published data to show that ACE inhibitor therapy reduces the need for valve surgery. Digitalis is clearly indicated in patients with these symptoms. In-patient with LV systolic function normal, they can be given long-acting nifedipine and if they have abnormal LV systolic function, they should be treated with Digitalis and ACE inhibitors. Small doses of Hydralazine are without therapeutic effect in AR, and larger doses need to be given only twice daily, sodium nitroprusside is the vasodilator of first choice. Patients with severe chronic AR in some instances need valve surgery. Correct timing of surgical therapy is now better defined but not fully clarified. Recent data indicated that patients with severe AR, LV end-diastolic dimension on echocardiography of >= 80 mm and mild to moderate reduction of LV ejection fraction can obtain benefit from valve replacement.

Dr.C.V.R. Prasad
Kamineni Hospitals