Brief Answer:
please provide more details.

Detailed Answer:
Dear Sir
1. I have gone through your reports and understood the pathology on ECHO. Kindly upload the documents where doctor has suggested surgery, So that we can discuss that what are the options. Please also mention that what is status of her symptoms now?
Waiting for your reply
Sincerely
Sukhvinder

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Brief Answer:
please see details below.

Detailed Answer:
Dear Sir
Thanks for the update.
1. The reports of 20th September 2016 and 2-9-2016 are very different from each other. The report of 20th September 2016 says that there is Moderate MS, Mild MR, Normal LV systolic function and Mild AR. Report of 2-9-2016 (which was done just 18 days prior) says that there is Mild MS, Moderate to severe MR, Moderate AR and LV systolic dysfunction.

2. Treatment options for these two reports are very different. i would request you to tell me which report should I discuss? Second, If you can not decide on that, then I will ask you to repeat the ECHO from a reliable cardiologist and then consider further management. She may have to undergo diagnostic cardiac catheterization for ascertaining exact lesion severity if ECHO remains inconclusive.

3. I can elaborate management on the basis of both type of reports separately but that will be too confusing for you.

Waiting for your further input.
Sincerely
Sukhvinder

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Brief Answer:
please see details

Detailed Answer:
Dear Sir
1. I have gone through the new attachment. It has abnormal blood glucose level which needs further evaluation by HbA1c / Postprandial / random blood glucose estimation.

2. I have not seen the two reports in isolation. Considering them together, I told you that there are differences which are not explainable. For example Chronic Moderate to severe MR of 2nd September can not become Mild MR on 20th September. Similarly, Moderate AR can not change to mild AR and LVEF becomes normal from abnormal, Unless the patient on 2nd September had a major heart attack which improved; which is not the case. Hence, If not impossible, then highly improbable that these changes occur in a span of 18 days. One of the reports or some of the findings are not correct. A decision based upon wrong report, obviously, can not be correct.

3. I remember your question and all my supplementory queries are for detailed answering of same. When a patient has worsening shortness of breath as stated by Dr Lim tian and in your current question, with atrial fibrillation, mostly the patient requires an intervention. Considering the report of 2nd september, guidelines suggest a double valve surgery (aortic valve replacement along with mitral valve replacement). The reason for same is that patient has Moderate AR along with Mitral valve disease. When replacement of mitral valve is indicated and there is associated moderate AR, aortic valve is replaced too. However, this decision is jointly taken by heart team in each case which includes cardiac surgeon, cardiologist and echocardiographer and they decide upon merit of each case. As per guidelines, reduced ejection fraction of 45% is an absolute indication of surgery. Mitral valve repair in case of mitral valve regurgitation associated mitral stenosis is very very difficult and in presence of significant aortic valve disease is done very uncommonly .

4. If we consider the report of 20th september, such cases can be dealt with mitral valvotomy or mitral valve replacement. It depends upon the morphology of the mitral valve, which has not been decribed in detail. A Wilkin score of 8 or less favours valvotomy, provided there is not much calcification/ subvalvular disease/ LA clot.

5. I hope that now you understand that why a good echo examination is foremost in decision making. Why we can not consider two reports in continuum and why I told you that she reuires further evaluation. I hope this provides you much more insight. Please feel free to discuss , if there are more questions. I will be glad to clarify.

Sincerely

Sukhvinder

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