A member of DOCS Education writes:
My new patient has requested sedation. His treatment plan consists of four quadrants of scaling and root planing; two extractions and multiple restorations. The man is 34 and he reports a history of hypertension, leaking mitral and tricuspid valves and left ventricular hypertrophy. While the patient has used medications to control his blood pressure in the past, he is not on any drug currently. (Once he lost weight and began eating healthier foods his doctor declared that medication unnecessary.)
Here’s what I obtained during the man’s presedation workup: weight, 200 pounds; smokes one pack of cigarettes each day; pulse is 83 bpm. His blood pressure is 131/86 and oxygen saturation 99 percent. His Mallampati score is Class I. Atlanto-occipital extension and thyromental distance are both good.
I received an echocardiogram from his physician (a two-dimensional, M-mode Doppler with color flow) and much of it registered within normal ranges:
- Right ventricular dimension 2.3
- LV diastole 4.6
- LV systole 3.0
- Post LV wall thickness 1.0
- Septal wall thickness 0.9
- Ejection fraction 67/64
- Aortic leaflet separation 2.5
- Aortic root diameter 3.31
- Left atrial dimension 3.0
The echo is of good quality, and it reveals:
- Normal size aortic root 3.3cm
- Mitral valve prolapse with whiff of mitral insufficiency
- Normal sized left ventricle at 4.6cm with a normal ejection fraction 64%
- Normal left atrium at 3cm
- Normal right ventricle at 2.3cm
- No visible pericardial effusion
- No evidence of atrial or ventricular septal defects.
Conclusion: mitral valve prolapse with mild mitral insufficiency.
How concerned should I be about the heart valves and ventricular hypertrophy?
Dr. John Hexem, DOCS Education faculty, responds:
The patient's description represents some form of valvular heart disease. In his age group this could be either congenital or secondary to rheumatic heart disease. Somewhere along the way the man has had either an ultrasound or angiographic study. You want to make sure he hasn’t abused drugs via IV injection. In that case the valvular heart disease could be the result of endocarditis. You should also make sure this patient lacks any history of congestive heart failure (and establish whether he was ever placed on diuretics due to breathing difficulties).
He appears to have good exercise tolerance, suggesting the heart disease is clinically mild.
I would delay the procedure until you have a coherent description of the man’s cardiac problems. Establish that his physicians have determined “observation” to represent the current treatment plan.
The worst that can happen during sedation is that this patient decompensates into congestive heart failure. Depending on the underlying severity of his heart disease, that could more easily happen without sedation than with it. Once you know his cardiac diagnosis, you might suggest dividing care into separate appointments of short duration and using a single-dose technique including hydroxyzine (because of his smoking). I would encourage efforts to quit smoking.
What you need especially is a copy of his ultrasound study report.
Do let us know what happens.
Dr. Lesley Fang, Medical Director of DOCS Education Faculty, adds:
I agree with Dr. Hexem.
We need more information about the nature of the valvular problems. It may range from minor regurgitation noted on echocardiogram performed for other reasons, to congenital lesions to valvular damage secondary to endocarditis. The last would require antibiotic premedication.
Judging from the medications he is NOT on, I doubt serious problems exist from a hemodynamic standpoint. The residual question revolves around the need for antibiotic premedication.
