Advanced Education In General Dentistry

Patient Case: Rheumatic Heart Disease

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P.R. is a 74 year old woman referred to the Oral Surgery Clinic for evaluation and treatment of a retained canine root and mandibular tori removal prior to denture fabrication.

PMHx: Rheumatic Heart Disease affecting the Mitral Valve -> Mitral Valve Replacement 85', Arthritis, Osteoporosis, GERD, HTN
Medications: Coumadin, Celebrex, Oscal, Prilosec, Lasix
Allergies: Penicillin

Questions For The Patient

  1. Do you have chest pain? If yes, is frequency quality, location, duration of pain, associated with exercise or at rest? Does it respond to Nitrogylcerin tablets? Are there any associated GI symptoms?
  2. Do you have shortness of breath? If yes, with or without exercise.? How much exercise prior to SOB?
  3. Do your legs swell?
  4. How many pillows do you sleep with?
  5. How well is you blood pressure controlled?
  6. Any recent changes in your medications?
  7. When was your last Echocardiogram? What were the results? How is your artificial valve functioning?
  8. Have you had a recent stress test? What were the results?

Implications For Sedation

As with Cardiac Disease Patient Case, it is essential to determine the patient's current cardiac status and how well the patient will tolerate the planned procedure. This patient has the additional problem of being on anticoagulation therapy and will need to be converted to heparin for the perioperative period. Furthermore, patients that have heart valve replacement must receive antibiotic prophylaxis according to American Heart Association Guidelines of Antibiotic Prophylaxis.

Summary Of Treatment

  1. Supplemental Oxygen
  2. BP Monitoring
  3. EKG Monitoring
  4. Light Sedation
  5. Oxygen Saturation Monitoring
  6. Good Local Anesthesia - limit epinephrine
  7. Emergency Drugs Available - Nitroglycerin!
  8. Admitted to hospital for change from coumadin to heparin for anticoagulation
  9. Stop heparin infusion 4 to 6 hours prior to procedure and restart heparin 6 hours after the procedure.
  10. Pre and Post Operative lab values including CBC, PT/INR/PTT
  11. Pre-Operative Medical Evaluation***
  12. Antibiotic Prophylaxis - Clindamycin 600mg IV 30 minutes prior to procedure

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