Question of the Week

For February 21, 2017

A 67-year-old man with type 2 diabetes reports new-onset mild dyspnea on exertion during the past several months. He has rheumatoid arthritis and moderate mitral regurgitation, for which he has been followed with a yearly echocardiogram. His only medications are aspirin, simvastatin, and hydroxychloroquine.

On examination, the patient has normal vital signs, normal jugular venous pressure, clear lungs, a grade 3/6 holosystolic murmur at the apex that radiates to the axilla, and trace lower-extremity edema. His electrocardiogram shows normal sinus rhythm at 70 beats per minute, with nonspecific ST-segment and T-wave abnormalities.

A transthoracic echocardiogram reveals severe mitral regurgitation, which has worsened since the previous study. There is bileaflet mitral valve prolapse and a new flail posterior leaflet segment. The left ventricular ejection fraction is 60%. Given the patient’s symptoms and echocardiographic findings, he is referred for mitral valve repair.

Which one of the following preoperative tests is indicated for this patient?

Pharmacologic stress testing with myocardial perfusion imaging
Exercise stress testing
Coronary angiography
Transesophageal echocardiography
MRI of the heart