Which of the following is the most appropriate management for this patients problem?
A 50-year-old woman is hospitalized for an acute inferior myocardial infarction for which she has undergone angioplasty to the right coronary artery. On day 4, she develops acute shortness of breath and hypotension. She does not have any chest pain. On examination, she is tachycardic with a 3/6 holosystolic murmur at the apex and bibasilar crackles. An electrocardiogram shows sinus tachycardia, and a chest x-ray shows pulmonary edema.
A. Prompt surgical repair B. Left heart catheterization C. Right heart catheterization D. Anticoagulation
Prompt surgical repair -key concept/objective: to recognize the signs, symptoms, and treatment of acute mitral regurgitation mitral regurgitation may result from injury to any of the components of the mitral valve apparatus, including the papillary muscles and ventricular walls to which they attach. mild mitral regurgitation is common in acute myocardial infarction and is present in nearly 50% of patients. severe mitral regurgitation caused by acute myocardial infarction is rare and generally results from partial or complete rupture ofa papillary muscle. the characteristic murmur of severe chronic mitral regurgitation may not be present with acute rupture of a papillary muscle. instead, a decrescendo systolic murmur is often present, extending less throughout systole as systemic arterial pressure falls and left arterial pressure rises. in many cases, the signifi cance of the murmur is not recognized. the blood supply of the anterior papillarymuscle arises from branches of both the left anterior descending and the circumfl ex arteries; therefore, rupture of the anterior papillary muscle is rare. however, the posterior papillary muscle receives blood only from the dominant coronary artery (the right coronary artery in nearly 90% of patients); thrombotic occlusion of this artery may cause rupture of the posterior papillary muscle, resulting in severemitral regurgitation. severe mitral regurgitation is 10 times more likely to occur with inferior infarction than with anterior infarction. acute severe mitral regurgitation is poorly tolerated and generally results in pulmonary edema, often with cardiogenic shock. prompt surgical repair is recommended. although the mortality associated with mitral valve surgery is high in this setting, approaching 50%, survivalappears to be greater than with medical therapy alone. therapy aimed at reducing left ventricular afterload, such as use of iv nitroprusside and an intra-aortic balloon pump, reduces the regurgitant volume and increases forward blood fl ow and cardiacoutput and may be helpful as a temporizing measure.