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What is this?

Metastatic pericardial disease


What complication does papillary muscle rupture or dysfunction lead to?

Mitral valve prolapse


What is cor triatriatum?

Cor triatriatum (or triatrial heart) is a congenital heart defect where the left atrium (cor triatriatum sinistrum) or right atrium (cor triatriatum dextrum) is subdivided by a thin membrane, resulting in three atrial chambers (hence the name). Cor triatriatum represents 0.1% of all congenital cardiac malformations.


What is this a picture of?

Cardiac mechanical prosthesis (St Jude)


What is the natural history of a VSD?

Blood from higher pressure LV leaks into RV

Reenters the left ventricle after recirculating

Volume overload of left ventricle

Back leakage into RV due to volume overload

Elevated RVP and volume --> pulmonary hypertension

Eventually PAP = systemic pressure (really bad)

Shunt reverses and goes L-R --> cyanosis


What is the clinical finding of a VSD

Holosystolic (pan systolic) murmur over lower left sternal edge +/- palpable thrill or heave

Smaller = louder + more palpable thrill

Displaced apex if big enough

Normal HS


Three points about VSD

- most common heart defect in children
- most commonly membranous
- most common cause of Eisenmengers syndrome (due to severe overload)


What is the purpose of stress ECG testing?

Stress exercise ECG test indirectly assesses adequacy of supply in periods of increased demand

Other modalities are more sensitive because you can see these abnormalities


What are the factors predicting an adverse outcome in CHD?

        Poor exercise capacity < 5METS

        Exercise induced angina (esp if exercise limiting or occurs at low workload)

        Abnormal low peak systolic BP (<130mmHg) or fall in systolic BP below baseline

        Chronotropic incompetence


What are the stress ECG findings that predict an increased risk of adverse outcome?

≥ 1mm down slopping or flat ST depression

≥ 2mm ischaemic ST depression at low workload (stage 2 or less or ≤130bpm)

Early onset (stage 1) or prolonged duration (>5min) ST depression

Multi leads (>5) with ST depression

Ventricular couplets or tachycardia at low workload or in recovery

SR/HR slope (6microV/beat per min)


What is the significance of early and late onset ST depression in stress testing?

Normally seen in prolonged exercise probably due to atrial repolarisation extending into the QRS.

Much more significant is early onset ST depression in predicting severe coronary artery disease


What is the significance of PVCs in stress testing?

PVC’s occur in about 7-20% of people having exercise testing. 

It is not proven to have an association with CAD but potentially be an indicator of ventricular arrhythmia development risk and is an independent predictor of mortality.


What does this CXR show?

Severe pulm HT

- markedly prominent main pulm artery (MPA)

- RPA enlarged

- prominent right atrial contour (RA dilation due to RVH)


What is pulmonary hypertension?

Resting mean PAP of 25mmHg or more on right heart cath (less than 20 is normal)

Arterial-only hypertension
- high precapillary resistance and normal pulmonary venous pressure (wedge pressure of 15mmHg or less)


What is the clinical presentation of pulmonary hypertension

Combination of:

Dyspnoea - esp with exercise
Right heart failure including peripheral oedema and abdominal distension
ECG - RV strain and hypertrophy


Name the causes of pulmonary hypertension caused by pulmonary vein and left heart pathology

- chronic left heart failure

- mitral valve stenosis

- hypoplastic left heart syndrome


Name the cause of pulmonary hypertension caused by pulmonary capillary and parenchymal pathology

Emphysema of any kind
Bronchiectasis of any kind
Langerhans cell histiocytosis
Pulmonary fibrosis (any cause ie scleroderma, dermatomyositis, rheumatoid, SLE)


Name the cause of pulmonary hypertension caused by pulmonary artery pathology

Chronic pulmonary emboli
Arteritis - PAN, SLE, Takayau, Wegeners
Pulmonary artery stenosis


Name the causes of pulmonary hypertension caused by right heart pathology

Eisenmenger phenomenon (inc ASD, VSD, PDA)


What are the extra-cardiad findings on CT in pulmonary hypertension?

enlarged pulmonary trunk (pulmonary trunk enlargement is a poor predictor of PH in patients with interstitial lung disease (specificity ~40%)

 pulmonary trunk diameter larger than the adjacent ascending aorta

enlarged pulmonary arteries
mural calcification in central pulmonary arteries most frequently seen in patients with Eisenmenger phenomenon 

evidence of previous pulmonary emboli
a segmental artery–to-bronchial diameter ratio of 1:1 or more in three or four lobes in the presence of a dilated (29 mm or more) main pulmonary artery-has a specificity of 100% for the presence of pulmonary hypertension


What are the medical options in pulmonary hypertension?

    calcium channel antagonists
    nitric oxide
    prostanoids, e.g. epoprostenol, treprostinil, iloporst
    endothelin antagonists e.g. bosentan, sitaxsentan, ambrisentan
    phosphodiesterase inhibitors


What are the causes of a split S2?

Normal - splits a little on inspiration, normal on expiration

Wide split and fixed --> ASD

Wide split and varies with inspiration --> Pulmonary stenosis, RBBB

Paradoxical splitting (pulm first instead of a) --> HOCM


3 points about the second heart sound

Splitting of S2 is best heard over the 2nd left intercostal space

The normal P2 is often softer than A2 and rarely audible at apex

Differential Diagnosis of P2 audible at apex- Significant pulmonary hypertension
-Atrial septal defect

(Findings should be present in both upright and supine positions: normal subjects may have expiratory splitting when recumbent that disappears when upright.)


What are the causes of a loud first heart sound?

    Hyperdynamic (fever, exercise)
    Mitral stenosis
    Atrial myxoma (rare)


What are the causes of a soft first heart sound?

Soft First Sound

    Low cardiac output (rest, heart failure)
    Severe mitral reflux (caused by destruction of valve)


What are the causes of variable intensity first heart sound?

Variable Intensity of First Sound

    Atrial fibrillation
    Complete heart block


How do you define a split heart sound?

Audible expiratory splitting means > 30 msec difference in the timing of the aortic (A2) and pulmonic (P2) components of the second heart sound.


What is the significance of a 3rd heart sound?

Low frequency sound in early diastole
Increased atrial pressure --> increased flow rate
CHF is the most common cause but may be normal in people under 40


What is the significance of a 4th heart sound?

Presystolic portion of diastole
Stiff left ventricle - i.e. hypertension, AS, ischemic or HOCM
If the patient has MR, may be due to acute regurgitation following chorda tendinae rupture


What's the best way to hear the 3rd and fourth heart sounds?

Both sounds are low frequency and thus best heard with the bell of the stethoscope.

If originating from LV

    Usually best heard over apex with patient in the left lateral position
    Softer during inspiration

If originating from RV

    Usually best heard over left lower sternal border
    Louder during inspiration