cardio #8
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- What is Aortic Stenosis?
-
obstruction of LV outflow
pressure gradient between LV and aorta
lumen less than 1.0cm2
leads to LVH (then possible dilatation) - In AS, What is Congenital bicuspid AV?
- asymptomatic, until around 50yo (calcification, rigidity, narrowing)
- In AS, explain rheumatic
- “childhood febrile illness†usually only seen after mitral stenosis (commissural fusion, calcification, narrowed orifice)
- What are the 4 NYHA Classification?
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Etiology (congenital, acquired)
Anatomy (valvular, coronaries, muscle)
Physiology (arrhythmia, ischemia, CHF)
Functional limitation (degree of activity that elicits symptoms) - what is “Senile†Calcific in AS
- elderly (fibrosis, heavy calcification, fusion of leaflets)
- List 3 signs & symtoms for AS
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Angina
Syncope
Dyspnea - List late findings of AS
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Left ventricular failure
Severe pulmonary hypertension
Resultant right heart failure
15-20% sudden death - On physical exam, what are the findings for AS?
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Lower B/P with narrowed pulse pressure
Delayed and diminished pulses
Prominent “a-wave†on jugular venous exam
Palpable S4 with non-displaced, sustained PMI
“thrill†at the base - Auscaltation for AS should may hear
-
Apical S4 (plus S3 if CHF present)
“diamond-shaped†murmur (crescendo-descrescendo)
Low pitch, rough, “rasping†murmur at the base radiating to the carotids
“parodoxical S2 split†from constant late A2 - How will an AS chest xray present?
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Post-stenotic dilation of the aorta
Calcification of aortic valve on x-ray or fluoroscopy
signs of congestion with LVH, dilatation of RV - What will you see on an ECG for an AS?
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Possible Atrial Fibrillation
Left axis deviation
LBBB or intra-ventricular conduction delay (from diffuse myocardial fibrosis)
If LAE present, look for MV disease - An ECG/ Doppler may show?
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LVH
Aortic Valve Calcified
Eccentricity, ? Bicuspid
Evaluate LV ejection fraction
Doppler interrogation allows calculation of AVA
additional valvular abnormalities (ie AI, MR, etc) - How can Cardia Catherization help in an AS?
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Hemodynamics and presence/degree of pulmonary hypertension
Measure LV/Aortic gradient
Calculate valve area
Evaluate LV ejection fraction
Presence/absence of CAD - What is the best management for AS?
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fix outflow obstruction
plan repair/replacement
Medical therapy
Endocarditis prophylaxis!!!!
CHF stabilization
Avoid pre-and after-load therapies
Balloon dilation in young bicuspid valve but not in senile calcific - Is valve replacement for AS patients necessary?
- Yes, surgery is indicated for all symptomatic pts
- What is used to valve replacement and how is it maintained?
-
Either tissue (porcine or human) or mechanical
Anticoagulation always necessary in mechanical
With INR 2.5-3.5 normal
Tissue valves “wear-out earlyâ€
Endocarditis prophylaxis always needed
Close monitoring for leaks, clot, infection - What is AORTIC INSUFFICIENCY Regurgitation
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LV end-diastolic volume increases hemodynamic issue
The chamber thickens and dilates to accommodate the regurgitant volume until heart can weigh 4x normal (1000gms)
Eventually the LV fails causing pulmonary hypertension and resultant RV failure - what are the causes for AI?
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Infectious (endocarditis, syphilitic)
Inflammatory (Rheumatic, ankylosing spondylitis, Lupus)
Congenital (bicuspid, prolapse associated with VSD, congenital fenestrations)
Degenerative
(Cystic medial necrosis, Marfan’s)
Traumatic - Historically how would an AI pt present?
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Asymptomatic until middle age
May have history of murmur, bicuspid valve, RHD
signs of LV overload and failure (SOB, orthopnea, PND, etc) - what would you see on a physical exam for pt c AI?
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Wide pulse pressure
Physical findings of Marfan’s
Displaced PMI w/palpable S3 and S4
Possible pulmonary congestion
Diastolic “blowing†murmur along LSB
Ejection click at aortic valve w/systolic murmur
Rumbling apical diastolic “Austin-Flint†murmur of early MV closure - What causes Peripheral Manifestations of AI? and list the signs
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Result from large stroke volume with rapid diastolic runoff:
DeMusset’s sign
Corrigan’s pulse
Quincke’s sign
Duroziez’ murmur
Muller’s sign
Hill’s sign - what is DeMusset's sign?
- Bobbing head
- What is Corrigan’s pulse?
- Water-hammer pulse, rapidly rising and falling
- What is Quincke’s sign?
- Arterial pulsations of the nailbeds
- What is Duroziez’ murmur?
- Systolic and diastolic murmur over femoral artery
- What is Muller’s sign?
- Rhythmic pulsation of uvula
- What is Hill’s sign?
- A disproportionate elevation in FA pressure
- How will an AI present on chest xray?
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Enlarged heart if chronic with signs of pulmonary congestion
Possible Calcified AV
Enlarged aorta in connective tissue disorders - What would you see on a pt c AI ECG?
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LVH
ST depression and T wave inversions
Left axis deviation
Widened QRS (from patch fibrosis – bad sign!) - What will and ECG/Doppler show on an AI pt?
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Expanded systolic excursion free wall of LV
“supernormal†velocity of wall motion
Rapid, high frequency fluttering of anterior leaflet MV (Austin Flint murmur)
Dilated LV, LA, Aortic Root
regurgitant flow from aorta into LV during diastole - What is cardia catherization used for in a pt c AI?
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presence and severity of AI
Assess LV function
R/O Coronary artery disease - How can Radionuclide Studies help in AI pt?
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evaluate LV function at rest and with exercise
A decreased EF w/exercise suggests myocardial impairment - What Medical Treatment are used for pt c AI?
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Vasodilators
ACE-I
B-blockers in Marfans
diuretics, salt restriction
digoxin
Manage arrhythmias
SBE prophylaxis
Penicillin for syphilitic
?anticoagulation - What do ACE-I do for AI pts?
- Reduces regurge
- List Vasodialators for AI pts?
- Hydralazine, nifedipine, ACE-I
- How does diuretics, salt restriction assist pt c AI?
- Reduce pre-load
- What is digoxin used for in AI pt?
- Improve inotropy
- When is Surgical Treatment needed for AI pt?
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Symptomatic pt EF < 55% or LV end-systolic dimension > 5.0 cm on M-mode Echo
Surgery on aortic root for diameter >5.5 cm (or 5.0 in Marfans) - When is it Considerable mortality for AI pt?
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if LV severely decompensated
“time to operate†sometimes difficult to determine - What is a main characteristic of pt c AI?
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High pitched "decrescendo diastolic murmur"
Accentuated by sitting up/ leaning forward
Austin Flint murmur:
Apical low pitched diastolic rumble
LVH - What are the Features of the Mitral Valve? (MR)
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bileaflet (anter and poster)
complex support structure (chordae tendinea,papillary muscles, annulus, wall of LV)
on “high pressure†left ventricular contraction
plays an active role - What are the signs for Chronic MR?
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Degenerative
Infectious
Structural - Explain the degenerative features of a chronic MR pt?
- myxomatous degeneration, annular calcification, Marfan Syndrome
- Explain the Infectious features of a chronic MR pt?
- Infective endocarditis
- Explain the structural signs for a chronic MR pt?
- ruptured chordae tendineae, papillary muscle dysfunction, increased annulus as result of LV dilatation, prosthetic valve leak
- Explain the degenerative features of an acute MR pt?
- Myxomatous degeneration with chordal rupture
- Is the feature of an acute and a chronic MR pt the same in the infectious sign?
- Yes the same Infective endocarditis
- Explain the Structural features of an acute MR pt?
- rupture of papillary muscle secondary to ischemia, malfunction of prosthetic valve, trauma
- What is the process in chronic MR pt?
-
gradual dilatation of LV and LA with the LA accommodating the volume.
Little in the way of transmitted pressure to the lungs till late, then pul HTN and right heart failure - What is the process in acute MR pt?
- instantaneous transmission right thru the normal sized LA into the pulmonary venous system with severely elevated pressures, pulmonary edema and acute right heart strain
- What finding in pt history increases MR?
-
inciting event
Well tolerated chronically until evidence of left heart failure
Findings of Right heart failure - What are the inciting events in a MR pt history?
- childhood rheumatic fever, febrile illness after dental procedure, CHF
- What are the signs for left heart failure in a MR pt?
- DOE, orthopnea
- What are the findings of Right heart failure in a MR pt?
- peripheral edema, increased JVD, hepatomegaly
- What are the findings on a Physical Examination of Chronic MR pt?
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Increased “a†wave
Carotids with early sharp upstroke, then normal
Laterally and inferiorly displaced PMI with palpable
S3 and S4
Holosystolic (Pansystolic) diastolic murmur at apex radiating to axillae
Pulmonary Ejection sound from pul HTN
Left atrial lift late systole behind RV, “rocking motion - What will chest xray show for a Chronic MR pt?
- left atrial, left ventricular and right ventricular enlargement
- What will chest xray show for an Acute MR pt?
- pulmonary edema without chamber enlargement
- What are the secondary findings on ECG to the chamber's of a MR pt?
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Increased voltage of LA and LV in chronic MR
Atrial arrhythmias
LAD until right heart failure then may shift rightwards - What shows on Echocardiography of a MR pt?
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Assessment of MV leaflet motion and directional doppler flow helps with mechanism of the MR
TEE allows precise MV detail
Chamber size of LA, LV and RV
Ejection fraction of LV always “over-estimation†as unloading into low pressure LA makes the LV “look goodâ€â€¦ - Why is Cardiac Catheterization used in Mr pt?
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Hemodynamics with degree of pulmonary HTN measured and PCWP
LV angiogram to assess EF, LVEDP and quantitate degree of regurgitation (1+ mild to 4+ severe)
LA size
Presence of coronary artery disease - Why do MR pt undergo Exercise Testing?
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assessing severity of MR and timing of surgery
May have echo for transplant candidates - What are the Medical Treatment to prevent LV failure and delay need for MV surgery for pt c MR?
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Relieve LV wall stress
ACE inhibitors
B/P control
Prevent or treat ischemia
Maintain sinus rhythm, treat arrhythmias
Consider anticoagulation - What are ACE inhibitors used for in MR pt?
- first line therapy to allow easier LV emptying and reduce regurgitant volume, especially when LV dysfunction present
- In MR pt at what level should Bp control?
- to levels of <139 sys and <89 diastolic
- In relieving LV wall stress we are really preventing _ in MR pt?
- prevention of adverse remodeling
- When should Surgical Intervention be considered for MR pt?
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Symptomatic pt
EF <60% or marked LV dilation
Repair vs replacement - When is surgery considered for an acute MR?
- endocarditis, MI, rupture chordae usually emergency surg
- In a pt c MR when will you consider repair vs replacement?
- Try to repair if at all possible, but if replace try to use patients own annular papillary structure
- What are the causes of Mitral Stenosis MS and what are some of the signs?
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DOE, Orthopnea, PND, hemoptysis (rupture of pul-bronch venous)
Causes:
Rheumatic Fever
Congenital disease - What other symptoms may precipitate signs of MR?
- Sx precipitated by Afib, pregnancy
- What are the 2 syndromes for a MR pt?
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Moderate: pulm edema
Severe: pulm HTN, low CO - How does a MR sound?
- Prominent mitral 1st sound, opening snap, apical diastolic rumble
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Which bacteria found in Rheumatic Fever?
Found in what age group? -
strep pharyngitis (Group A)
age 5-15yrs - How does the body react to Rheumatic fever, to develop MR?
-
Antibodies form in response to the strep antigen
These antibodies mistakenly attack host tissues!
Special propensity for connective tissue, like valve collagen
Inflammation occurs and repeated attacks with intermittent attempts at healing create fibrous thickening, adhesion of valve commissures - What step may be taken to Prevent RF?
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Treat strep pharyngitis aggressively!!!
Penicillin G or Penicillin V
Oral sulfadiazine
Oral erythromycin
azithromycin - What are the dosages for the prevention of RF?
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IM injection of 1.2 million units of Penicillin G once a month or Penicillin V 250 mg BID (less effective)
Oral sulfadiazine 1 g daily for penicillin allergic patients
Oral erythromycin 250 mg BID or azithromycin for both penicillin and sulfadiazine allergic patients - What are the Major Jones Criteria in MS pt?
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Migratory arthritis
Carditis
Sub-cutaneous nodules
Erythema marginatum
Sydenham’s chorea - What are the Minor Jones Criteria in Ms pt?
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Fever
Elevated sedimentation rate/C-reactive protein
Arthralgias
Increased PR interval
Prior RF or RHD - What are the Criteria Needed for RF?
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Two major
One major, two minor - Which valves are affected in Rheumatic Heart Disease?
- Mitral>aortic>tricuspid (almost never involves pulmonic)
- What happens to the valves in Rheumatic Heart Disease?
- Stenosis, regurgitation or combination of the two
- When does the diagnosis of “RF†(where there is a “pancarditisâ€, arthritis, etc) change to “RHDâ€?
-
when there is residual evidence of cardiac impairment characteristic of this disease long after the acute illness has passed:
20 yrs after the acute illness (4th decade) - what is the time frame for Acute rheumatic fever?
- typically begins as polyarthritis 2-6 weeks after streptococcal pharyngitis
- The Acute rheumatic fever disease involves what parts?
- heart, joints, central nervous system (CNS), skin, and subcutaneous tissues
- What might you expect on Mitral Stenosis Physical Exam?
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Large “a†waves on JVP
Normal to Low blood pressure
? Palpable S1
Possible RV lift
Diastolic “thrill†left apex in left lateral decubitus position - Auscultation
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S1 “snapping†and accentuated
Increased P2 with Ejection Click
“Opening snap†of MV after S2
“diastolic rumbleâ€, low-pitched at apex in LLD position, accentuates towards end
Severity gauged by the closeness of “OS†to S2 and the duration of the murmur - What else may be Associated findings on auscultation of MS pt?
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Aortic stenosis/regurgitation
Tricuspid stenosis/regurg
Mitral regurgitation
Graham-Steell murmur of Pulmonic Insufficiency secondary to severe pulmonary hypertension - What may be seen on chest Xray of MS pt?
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Small LV
Straightened left heart border
Prominent PA
Dilatation of pulmonary veins upper lobes
Kerly “B†lines of congested interlobular septa and lymphatics
Esophagus displaced posteriorly secondary to LAE - Electrocardiogram will show in a MS pt?
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LAE
With pulmonary hypertension: RAE, RVH, Right axis deviation
Atrial Fibrillation - Echocardiogram will show in a MS pt?
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Ant and poster leaflets of mitral valve do not separate fully
Decreased E-F slope
Calcifications and thickening with shortening of the chords
Decreased MV orifice
LAE - What may a Cardiac Catheterization advise in MS pt?
-
measure pressure
Calculate MVA
Assess hemodynamics, severity of pulmonary hypertension
Presence of MR
Evaluate LV ejection fraction
Evaluate for CAD - Cardiac catherization approach is?
- trans-septal approach to enter LA
- What are the Treatments for asymptomatic patients c MS?
-
SBE prophylaxis
Limit strenuous physical activity
MAINTAIN SINUS RHYTHM!!!
Convert A-fib - What are the SBE prophylaxis for asymptomatic MS pt?
- Penicillin for prophylaxis of Beta-hemolytic strep
- What are the Treatment for symptomaic patients c MS?
-
Limit Na+, use diuretics
Digoxin , beta-blocker
Detect and treat anemia
Consider anticoagulation
Bedrest if hemoptysis present
MAINTAIN SINUS RHYTHM!!! -
Digoxin is used for?
Beta-blocker used for? -
for Afib
to control rate - When is Surgery needed for MS pt?
-
MVA <1.0cm2 and symptoms
If concurrent MS & MR
Balloon valvuolplasty for lesser calcified MS without regurgitation
Valve repair may be possible
Ultimately replacement - Which procedure not done much anymore in pt c MS?
- Intra-operative “valvotomyâ€
- When will replacement valves needed in MS pt?
- first procedure in presence of heavy calcification or regurgitation
- What kind of Post-surgical Care needed for MS pt?
-
Anticoagulation
maintain NSR
SBE prophylaxis
Good valve surveillance - What is the most common cause of Mitral Stenosis?
- Rheumatic Fever from Group A Beta-Hemolytic Strep
- Where is Mitral Stenosis heard?
- heard best at the apex in the left lateral decubitus position
- Low pitched diastolic rumble best accentuated by which movements in Ms pt?
- squatting (valsalva) or expiration
- What other informative occurences may not be strep?
- Occasional pts have hoarseness due to recurrent laryngeal nerve compression b/t aorta and pulmonary artery
-
What sounds upon auscultation
for pt c MS? - Loud (Crisp) S1 , Increased P2