Hi Dr Boris
I have been viewing your discussion with Tlennon. My 5 year old daughter has been diagnosed with mild mitral valve regurgitation after doing an echo. A murmur was detected when she visited the doctor for an umbilical hernia. Also, I have to decide whether to go ahead with the hernia surgery. Seeing now that she has this heart condition I am a bit hesitant. The cardiologist told me that she could ahead with the hernia surgery and advised me about antibiotics and I have to revisit in 3 months time. My daughter was hospitalized on two occasions before and that condition was not detected. The first time she had a wheezing and stayed for 4 days and the doctors said that they can't say it is athsma seeing that it was the first time. She is not on any medication. The second time about three years ago she had a high fever which was diagnosed as pneumonia. She was breast fed only for the first seven months and has always been an over active child even when she is not well. She complains of pain in the hernia area if she wears tight clothes and don't like to wear any clothes touching the area. Is mitral regurgitation a more serious case than mitral valve prolaspe? Does hernia surgery seem necessary?
Allow me to explain the difference between mitral valve regurgitation (MR) and mitral valve prolapse (MVP). MR merely means that the valve leaks. You may also hear the term, “mitral valve insufficiency,” which means the same thing. The valve can leak for one of several various reasons. One of those potential reasons is MVP, which occurs when the valve leaflets not only close but also buckle and bend abnormally as they close. Thus, one is not worse than the other—they’re just different.
We grade MR as trivial, mild, moderate, or severe. Obviously, I can’t assess your child’s clinical condition through this forum, so we have to go with your cardiologist’s evaluation of MR as mild. Typically, this does not cause any problems in the short term for the heart, as long as there are no other structural cardiac defects. Over the longer term, though, depending on the anatomy of the mitral valve as well as several other issues, the degree of MR can progress, so it is a good idea for your daughter to continue to have pediatric cardiac follow-up and surveillance evaluations. I also can’t necessarily assess your daughter’s need for hernia repair based on just the description. But I can say that IF she has only mild MR, it shouldn’t be a problem for her to undergo surgery. Finally, a word about antibiotics: per the latest American Heart Association guidelines, antibiotic prophylaxis for endocarditis (a severe infection of the heart) is no longer recommended for MR, nor is it recommended for gastrointestinal procedures.
Thanks very much for your insight. However I am very concern about the latest guidelines by the American Heart Association. Does it mean that my daughter can have adverse effects from the antibiotics? What is it not recommended and are there any other recommendations?
The American Heart Association has had guidelines out for the prevention of endocarditis for a number of years. Over time, they have assessed the increasing medical evidence, and have reduced the amount of antibiotics needed to prevent endocarditis. It used to be that you had to take antibiotics for a couple of days around a procedure, then it came down to twice in one day, then it was just before the procedure. The latest guidelines demonstrate that the literature does not support the use of antibiotic prophylaxis for most types of heart lesions, nor does it support its use prior to "dirty" gastrointestinal (or genitourinary) procedures anymore. The feeling is that we have bacteria going through our system all the time, such as when we chew, brush our teeth, or have a bowel movement, and that this occurs much more frequently than medical procedures. Plus, it was felt that the risk of "routine" exposure to antibiotics did not outweigh the benefits of it. Finally, repair of a hernia is not considered a dirty procedure, so it would not have qualified for the need for antibiotic prophylaxis, anyway, no matter what the heart defect was. In the end, the surgeons or anesthesiologists often give a dose of IV antibiotics to prevent infection from bacteria on the skin at the time of the surgery, anyway. This should be more than adequate for her needs.
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