CVS Flashcards
(182 cards)
1
Q
Examination findings in mitral stenosis
A
- Low volume pulse +/- AF
- Tapping apex beat - not displaced
- Loud first sound (d/t forceful closure of mitral valve)
- Normal second sound
- Opening snap (lost if calcified valve)
- Rumbling mid diastolic murmur in apex louder during left lateral position
- Presystolic accentuation (lost if AF present)
2
Q
Complications to check for in mitral stenosis during examination
A
AF
IE
pulmonary HTN
heart failure
Pronator drift if AF (+)
3
Q
Causes to look for in mitral stenosis during examination
A
MS dt almost always rheumatic
Connective tissue disorder features
4
Q
Ddx of Mid Diastolic Murmur
A
MS, TS
Lf atrial tu/myxoma, Lf atrial thrombus, Cortriatriatum
Carey Coombs murmur (Ac rheumatic fever)
Austin Flint murmur (severe AR)
Flow murmur (Severe MR, VSD, PDA, ASD)
5
Q
Causes of mitral stenosis
A
Rheumatic fever (most common, others are rare)
Congenital mitral stenosis
Rheumatoid arthritis, Systemic lupus erythematosus (SLE)
Carcinoid Syndrome
Mucopolysaccharidoses
Fabry’s disease, Whipples disease
Methylsergide therapy
6
Q
Echo criteria for severity of mitral stenosis
A
classified a/t mitral valve area
-Mild: >1.5 cm2
-Moderate: 1-1.5 cm2
-Severe: <1.0 cm2
7
Q
Clinical criteria for severity of mitral stenosis
A
- Early opening snap (closeness of opening snap to second sound)
- Increasing length of murmur
- Signs of pulmonary hypertension
- Signs of pulmonary congestion
- Graham-Steel murmur (pulmonary regurgitation)
- Low pulse pressure
8
Q
Complications on mitral stenosis
A
Left atrial enlargement
Atrial fibrillation
Left atrial thrombus formation
Pulmonary hypertension
Pulmonary oedema
Right heart failure
Hoarse voice – d/t enlarged Lf atrium compress lf recurrent laryngeal nerve resulting in left vocal cord palsy (Ortner’s S)
- may be d/t amiodarone induced hypothyroidism
9
Q
ECG finding in mitral stenosis
A
Atrial fibrillation may be present
Left atrial hypertrophy (bifid P waves/ P mitrale in lead II)
Left atrial dilatation (inverted or biphasic P waves inV1-V2)
Right ventricular hypertrophy: tall R waves in V1–V3
10
Q
CXR finding in mitral stenosis
A
Straightening of left heart border
Double right heart border (left atrial enlargement)
Splaying of the carina (demonstrate a grossly dilated left atrium)
Pulmonary congestion, Prominent pulmonary arteries (pulmonary hypertension)
11
Q
Echo finding in mitral stenosis
A
Thickened immobile cusps
Mitral stenosis - reduced valve area
Enlarged left atrium
Reduced rate of diastolic filling of left ventricle
12
Q
Coronary angiography findings in mitral stenosis
A
To exclude coronary artery disease before valve replacement
13
Q
Medical treatment of mitral stenosis
A
Diuretics for heart failure
Anticoagulation if AF present or after valve replacement
Digoxin or beta-blocker for rate control of AF
14
Q
Surgical treatment of mitral stenosis
A
Mitral balloon valvuloplasty
Mitral valvotomy (closed or opened)
Mitral valve replacement
15
Q
Indications for surgery in mitral stenosis
A
Pulmonary congestion
Pulmonary hypertension
Haemoptysis
Recurrent thromboembolic events despite therapeutic anticoagulation
16
Q
Criteria for using valvuloplasty or valvotomy
A
Mobile valve (loud first heart sound and opening snap)
Minimal calcification of the valve and subvalvular apparatus
No or trivial mitral regurgitation
Absence of left atrial thrombus (on transoesophageal echo)
17
Q
Examination findings in mitral regurgitation
A
- Apex beat is displaced and thrusting
- Soft first sound
- Blowing pan systolic murmur in apex radiate to axilla
(Mid systolic click followed by late systolic murmur if the cause is d/t MVP) - Normal second sound
- Third & fourth heart sound
(Severe MR — flow murmur MDM can be heard)
18
Q
Complications to look for in mitral regurgitation during examination
A
AF
IE
pulmonary HTN
heart failure
Pronator drift if AF (+)
19
Q
Causes to look for in mitral regurgitation during examination
A
Marfan features, Skin changes, Jt hyperextensible
Blue sclera, hearing aids
CTD features
Ischaemic risk – xanthelesma, arcus, BP, RBS
20
Q
Ddx of Pansystolic Murmur
A
MR, TR, VSD
HOCM
ESM (Gallavardin phenomenon)
Functional TR (in pul HT)
21
Q
Causes of chronic mitral regurgitation
A
Mitral valve prolapse
Papillary muscle dysfunction (ischaemia or degenerative diseases of the chordae)
Rheumatic fever, Infective endocarditis
Collagen d/s - Marfan’s syndrome, Ehlers Danlos Syndrome, Pseudoxanthoma
elasticum, Osteogenesis imperfecta
CTD - Rheumatoid arthritis, SLE (Libman-Sachs endocarditis)
Mitral annular calcification
Left ventricular dilatation (functional mitral regurgitation)
Cardiomyopathies (restrictive, hypertrophic and dilated)
22
Q
Causes of acute mitral regurgitation
A
Infective endocarditis
Rupture of chordae tendinae (acute rheumatic fever and ischaemia)
Trauma
23
Q
Criteria for clinical severity of mitral regurgitation
A
- Soft first heart sound, widely split second heart sound, Third heart sound,
Fourth heart sound (if in sinus rhythm)
-Displaced apex beat (sign of left ventricular enlargement), Precordial thrill - Mid-diastolic flow murmur
- Signs of pulmonary hypertension
- Signs of pulmonary congestion
24
Q
Complications of mitral regurgitation
A
Pulmonary hypertension
Pulmonary oedema
Right heart failure
AF, systemic embolism
25
ECG findings in mitral regurgitation
LAH and LVH
26
CXR findings in mitral regurgitation
Enlarged left ventricle, Enlarged left atrium
Pulmonary venous congestion
Pulmonary oedema (if acute)
27
Echo findings in mitral regurgitation
Dilated left atrium, left ventricle
Structural abnormalities of mitral valve with regurgitation
28
Medical treatment for mitral regurgitation
Diuretics for heart failure
Anticoagulation if AF present or after valve replacement
Digoxin or beta-blocker for rate control of AF
ACEI/ARB to reduce afterload and slow down regurgitation
29
Indications for surgery in mitral regurgitation
Symptomatic, i.e. NYHA Ill or IV despite optimum medical therapy
Asymptomatic patients with echo findings of EF < 60% or when left ventricular
end-systolic diameter is greater than 45mm
30
Cause of MS dominant mixed mitral valve disease
Rheumatic heart disease
31
Cause of MR dominant mixed mitral valve disease
Rheumatic heart disease
Severe MR with flow murmur MDM
32
Examination findings in mitral valve prolapse
- Apex beat usually undisplaced
- Normal first sound
- mid-systolic click followed by a late systolic crescendo-decrescendo murmur
loudest at the lower left sternal edge (no radiation to axilla)
(In mitral valve prolapse involving the posterior leaflet (most commonly affected),
the mitral regurgitant jet hits the left atrial wall adjacent to the aortic root, and
murmur appears to radiate up the sternal edge)
- Normal second sound
33
When is an earlier click (closer to S1) & prolong murmur heard?
Anything that decreases cardiac volume, i.e. standing position and Valsalva
manoeuvre
34
When is a later click (closer to S2) & shorter murmur heard?
Anything that decreases cardiac volume, i.e. standing position and Valsalva
manoeuvre
35
Complications to look for in mitral valve prolapse during examination
Pulmonary HTN
Heart failure
36
Causes of mitral valve prolapse
Primary (most common)
Secondary (associated with other conditions)
Marfan's syndrome, Ehlers--Danlos syndrome, Pseudoxanthoma elasticum,
Osteogenesis imperfecta
Polycystic kidney disease
SLE
37
Complications of mitral valve prolapse
Stroke (embolic phenomena)
Chordal rupture
Endocarditis
Arrhythmias (prolonged QTc interval)
Sudden death
Progression to severe mitral regurgitation
Cardiac neurosis
38
Investigation for mitral valve prolapse
Echocardiogram
39
Management of mitral valve prolapse
Asymptomatic patients - Re-assure
Treat atrial and ventricular arrhythmias
Treat atypical chest pains - simple analgesics or beta blocker
40
Examination findings in aortic stenosis
- Harsh crescendo-decrescendo ejection systolic murmur in aortic area radiate to
both carotids
- Slow rising pulse
- Apex beat displaced & heaving (pressure overload)
- Normal first sound
- Soft second sound
- Fourth heart sound
41
Complications of aortic stenosis to look for during examination
AF
IE
pulmonary HTN
heart failure
42
Causes of aortic stenosis to look for during exaamination
young age
facial dysmorphism
43
Ddx of ejection systolic murmur
AS, PS, Aortic sclerosis
HOCM (LVOT obstruction)
Severe AR (flow murmur)
ASD (flow murmur)
TOF (RVOT obstruction)
Coarctation of aorta (in left sternal border and posteriorly)
44
Causes of aortic stenosis in infants, children and adolescents
Congenital aortic stenosis
Congenital subvalvular aortic stenosis
Congenital supravalvular aortic stenosis (William S – facial dysmorphism, mental
retard, sensorineural hearing defects)
45
Causes of aortic stenosis in young to middle-aged adults
Calcification and fibrosis of congenitally bicuspid aortic valve
Rheumatic aortic stenosis
46
Causes of aortic stenosis in middle-aged to older adults
Senile degenerative aortic stenosis
Calcification of bicuspid valve
Rheumatic aortic stenosis
47
Severity criteria of aortic stenosis based on echo
classified a/t aortic valve area
-Mild: >1.5 cm2
-Moderate: 1-1.5 cm2
-Severe: <1.0 cm2
mean gradient across the aortic valve > 50mmHg
48
Severity criteria of aortic stenosis based on clinical findings
Low volume pulse, slow rising pulse
Narrow pulse pressure
Heaving apex, Systolic thrill
Reversed splitting of the second heart sound
Soft or absent aortic component of the second heart sound
Fourth heart sound
Late systolic peaking of a long murmur
Signs of pulmonary hypertension
Signs of pulmonary congestion (or cardiac failure)
49
Complications of aortic stenosis
Left ventricular failure
Sudden death (predominantly in symptomatic aortic stenosis)
Pulmonary hypertension
Arrhythmias (AF and ventricular tachycardia)
Heart block (calcification of conduction system)
Infective endocarditis
Systemic embolic complications (disintegration of aortic valve apparatus)
Haemolytic anaemia, Iron deficient anaemia (Heyde's syndrome – AS+Colonic
angiodysplasia)
50
ECG finding in aortic stenosis
LVH with strain pattern
Left axis deviation
51
CXR finding in aortic stenosis
Calcification of aortic valve
Cardiomegaly
Pulmonary congestion
Prominent pulmonary arteries (pulmonary hypertension)
52
Echo finding in aortic stenosis
Narrowed Aortic valve area
Left ventricular size and function
53
Medical treatment of aortic stenosis
Diuretics for heart failure
Anticoagulation if AF present or after valve replacement
Digoxin or beta-blocker for rate control of AF
54
Surgical treatment of aortic stenosis
Transcatherter aortic valve implantation (TAVI)
Aortic balloon valvuloplasty (in cong aortic stenosis)
Aortic valve replacement
55
Indications for surgery in aortic stenosis
Symptomatic patient (angina, syncope, breathlessness)
Symptomatic severe aortic stenosis (mean gradient >5OmmHg)
Asymptomatic patient - -
Moderate/severe aortic stenosis undergoing other cardiac surgery (CABG
or other valve surgery)
Severe aortic stenosis AND any of the following
* Left ventricular systolic dysfunction (EF<50%)
* Abnormal blood pressure response to exercise (on SUPERVISED
exercise treadmill testing)
* Ventricular tachycardia
* Valve area <0.6cm2
56
Examination findings in aortic regurgitation
- High volume pulse, Collapsing pulse
- Peripheral signs of AR (dancing brachial A, hyperactive carotid pulsation (Corrigan’s
sign), head nodding (De Musset’s sign), uvula pulsation (Muller’s sign), visible
capillary pulsation (Quincke’s sign), pistol shot sound (Traube’s S), Duroziez’s murmur - Apex beat is displaced and thrusting
- Normal first sound
- Soft second sound - Decresendo early diastolic murmur in aortic area down to left parasternal edge
louder while sitting & leaning forward
- Third heart sound
(Severe AR --- flow murmur ESM in aortic area, Austin Flint murmur/MDM in
mitral area)
57
Causes to look for in aortic regurgitation
Syphilis – Argyl Robertson pupil, paraparesis, dorsal column sign
Ankylosing spondylitis features, Psoriasis skin lesion
Takayasu – unequal pulse, bruit
Marfan features, Skin changes, Jt change
58
Ddx of End diastolic murmur
AR, PR
Graham Steel murmur
(Functional PR in pul HT)
59
Causes of CHRONIC aortic regurgitation
Bicuspid aortic valve
Aortitis (syphilis, Takayasu's arteritis, ankylosing spondylitis, Reiter's syndrome,
psoriatic arthropathy)
CTD (Rheumatoid arthritis, SLE)
Collagen disorders (Marfan's syndrome, pseudxanthoma elasticum, Ehlers-Danlos
syndrome, osteogenesis imperfecta)
DCM, Hypertension
Rheumatic fever, IE
60
Causes of ACUTE aortic regurgitation
Aortic dissection
Infective endocarditis
Ruptured sinus of Valsalva aneurysm
61
Clinical features determining severity of aortic regurgitation
Wide pulse pressure
Long duration of the decrescendo diastolic murmur
Third heart sound
Austin Flint murmur
Signs of pulmonary hypertension
Signs of left ventricular failure
62
Complications of aortic regurgitation
Left heart failure
Arrthythmia
Infective endocarditis
63
ECG finding in aortic regurgitation
LVH with strain pattern
64
CXR finding in aortic regurgitation
Enlarged left ventricle (cardiomegaly)
Valvular calcification
Pulmonary venous congestion
Pulmonary hypertension
65
Echo finding in aortic regurgitation
Assess valve morphology (bicuspid or tricuspid valve), severity of regurgitation
Assess aortic root size and dilatation
Establish aetiology of aortic regurgitation
Assess left ventricular size (left ventricular end-systolic diameter) & left
ventricular function
66
Computerized axial tomography (magnetic resonance imaging (MRI) finding in aortic regurgitation
Assess aortic root and ascending aorta
67
Medical treatment for aortic regurgitation
Diuretics for heart failure
Anticoagulation if AF present or after valve replacement
Digoxin or beta-blocker for rate control of AF
ACEI/ARB to reduce afterload and slow down regurgitation
68
Surgical treatment of aortic regurgitation
Aortic valve replacement
69
Indications for surgery in aortic regurgitation (Symptomatic patients)
Severe aortic regurgitation and symptoms of heart failure
Severe aortic regurgitation with angina
70
Indications for surgery in aortic regurgitation (Asymptomatic patients)
Left ventricular systolic dysfunction (ejection fraction <50%)
Left ventricular dilatation (left ventricular end-systolic diameter >55mm or
end-diastolic diameter> 75mm)
Aortic root dilatation >50mm (irrespective of the degree of aortic
regurgitation)
71
Causes of AS dominant mixed aortic valve disease
Bicuspid Aortic valve
Rheumatic ht disease
72
Causes of AR dominant mixed aortic valve disease
Bicuspid Aortic valve
Rheumatic ht disease
Severe AR with flow murmur ESM
73
Causes of MR/AR (regurgitant lesions only)
Collagen t/s disease (Marfan’sS, Ehlers-Danlos S, Osteogenesis imperfecta,
Pseudoxanthoma elasticum)
Connective t/s d/s (SLE, RA)
Dilated Cardiomyopathies
74
Causes of tricuspid stenosis
Rheumatic heart disease
Carcinoid Syndrome
75
Causes of primary tricuspid regurgitation
- Rheumatic heart disease
- Right sided IE in IVDU
- Ebstein’s
- Congenital anomaly
- Carcinoid Syndrome
76
Causes of secondary tricuspid regurgitation
Right ventricular failure
Right ventricular infarction,
Pulmonary hypertension secondary to chronic pulmonary disease
77
Causes of valvular pulmonary stenosis
Congenital
Rheumatic heart disease
Carcinoid syndrome
Noonan's syndrome
78
Causes of supravalvular pulmonary stenosis
Congenital rubella
William's syndrome
79
Causes of subvalvular pulmonary stenosis
Fallot's tetralogy
80
Causes of primary pulmonary regurgitation
IE
Rheumatic heart disease
Carcinoid syndrome
Balloon valvuloplasty for pulmonary stenosis (iatrogenic)
Swan-Ganz catheter insertion (iatrogenic) Marfan's syndrome (dilatation of the pulmonary trunk)
Syphilis
Congenital absence of pulmonary valve
Idiopathic
81
Causes of secondary pulmonary regurgitation
Pulmonary hypertension
82
Examination findings in hypertrophic cardiomyopathy
- Jerky pulse
- Heaving apex beat with double apical impulse
- ESM in left sternal edge
- PSM in mitral area
83
Complications to look for in hypertrophic cardiomyopathy during examination
Heart failure
AF
IE
84
Association to look for during examination of hypertrophic cardiomyopathy
Friedrich ataxia
85
Hallmark feature of hypertrophic cardiomyopathy
Myocardial hypertrophy with marked asymmetrical septal hypertrophy
Systolic anterior motion of the mitral valve
86
Genetics of hypertrophic cardiomyopathy
Autosomal dominant
200 distinct mutations in genes encoding for sarcomeric proteins (troponin T,
troponin I, myosin binding protein C, myosin light chains, Beta myosin heavy chain)
87
Complications of hypertrophic cardiomyopathy
Heart failure
Atrial fibrillation
Ventricular arrhythmias
Sudden death
Angina
Infective endocarditis
88
Markers of poor prognosis in hypertrophic cardiomyopathy
Younger age of presentation
History of syncope
Family history of sudden death
Non-sustained VT on Holter monitoring
Marked left ventricular wall thickness (>30mm)
Drop in blood pressure during exercise
Particular genetic mutations. e.g. myosin binding protein C and troponin T
89
ECG findings in hypertrophic cardiomyopathy
Left ventricular hypertrophy +/- strain,
Left axis deviation
Left atrial dilatation
ST/T waves changes
90
CXR findings in hypertrophic cardiomyopathy
Normal heart size (with left ventricular hypertrophy and diastolic dysfunction)
Cardiomegaly (in late stages with systolic dysfunction)
91
Echo findings in hypertrophic cardiomyopathy
Left ventricular hypertrophy
Asymmetrical septal hypertrophy
Dynamic left ventricular outflow obstruction
Systolic anterior motion of mitral valve
Diastolic dysfunction & Systolic dysfunction (late stages)
92
Medical treatment of hypertrophic cardiomyopathy
Beta blockers or verapamil for symptoms
Amiodarone for arrhythmias (AF, VT)
Anticoagulation for paroxysmal AF or systemic emboli
93
Surgical treatment of hypertrophic cardiomyopathy
Septal myomectomy (surgical or chemical ablation with alcohol) - Implantable defibrillator to prevent arrhythmia related sudden death in
high risk patients
94
Examination findings in ASD
Apex beat not displaced
- Normal first sound
- Ejection systolic murmur in pulmonary area
- Wide fixed split second sound (early A 2 and late P2)
- Flow murmur MDM in tricuspid area (if hemodynamic significant)
95
What to check for during examination of ASD
Check direction of shunt (shunt reversal from Right to Left - cyanosis & clubbing
reduced intensity or disappearance of murmur)
Check for haemodynamic significance (pulmonary HT, Flow murmur MDM)
Check other complications – AF, pronator drift, IE, heart failure
96
Types of ASD
1. Ostium secundum ASD (ECG – RBBB with RAD) – commonest 70%
2. Ostium primum ASD (ECG – RBBB with LAD)
3. Sinus venosus ASD
4. Coronary sinus ASD
97
Congenital risk factors for ASD
Genetics
Rubella infection during pregnancy
Certain medications, drug treatments (such as cocaine), alcohol and tobacco use
during pregnancy
Maternal diabetes, lupus, phenylketonuria
Conditions such as down syndrome
Holt-Oram syndrome – Autosomal dominant
Ostium secundum ASD + hypoplastic thumb with accessory phalanx
98
Acquired risk factors for ASD
Iatrogenic ASD d/r mitral valvotomy
>> Lutembacher S – cong ASD + acquired rheumatic mitral stenosis
99
Complications of ASD
Atrial arrhythmias (AF is the most common)
Pulmonary hypertension
Eisenmenger 's syndrome
Paradoxical embolism
Stroke
Infective endocarditis
Recurrent pulmonary infections
100
CXR findings in ASD
Increased pulmonary vascular markings with prominent main pulmonary arteries
Decreased pulmonary markings in outer third of lung fields (oligaemic lung fields)
Enlarged left & right atrium (left atrial appendage and double right-heart border)
101
ECG findings in ASD
RBBB with Right Axis Deviation (RAD)(secundum) or LAD (primum)
Right ventricular hypertrophy
Right atrial hypertrophy (P pulmonale)
Left atrial enlargement (Biphasic P waves in V1-V2)
102
Echo findings in ASD
Location, size and direction of shunt
Pulmonary artery systolic pressure
Pulmonary: Systemic flow (QP: QS ratio)
103
Role of cardiac catheterization in ASD
can determine the magnitude and direction of shunting and determine the severity
and reversibly of pulmonary hypertension
104
Medical treatment of ASD
Diuretics for heart failure
Treatment of pulmonary HT
105
Surgical treatment of ASD
ASD closure (open surgical or device)
106
Indications for surgery in ASD
Increasing pulmonary:systemic blood flow (QP:QS > 2:1)
107
Contraindications for surgery in ASD
Eisenmenger’s syndrome with irreversible pulmonary hypertension
108
How to check reversibility of pulmonary hypertension
How to check reversibility of pulmonary hypertension
109
Examination findings in VSD
- Apex beat may be displaced
- Normal first sound
- Pan systolic murmur in left sternal edge
- Normal second sound
- Flow murmur MDM in mitral area (if hemodynamic significant)
110
What to check for during examination of VSD
- Check direction of shunt (shunt reversal from Right to Left - cyanosis & clubbing
reduced intensity or disappearance of murmur)
- Check for haemodynamic significance (LVH, pulmonary HT, Flow mur2 MDM)
- Check other complications – IE, heart failure
111
Types of VSD
1. Perimembranous (infracristal) – commonest 80%
2. Muscular
3. Supracristal
4. AV canal/endocardial cushion type
112
Which types of VSD have spontaneous closure
Muscular and peri-membranous type
113
Congenital risk factors for VSD
-Maternal factors – diabetes, phenylketonuria, alcohol consumption (fetal alcohol syndrome)
-Aneuploid syndromes
- Down's syndrome (Trisomy 21), Edward's syndrome, (Trisomy 18), Patau's syndrome (Trisomy 13), Di George syndrome
114
Acquired risk factors for VSD
-Ischaemia (post myocardial infarction)
-Iatrogenic (RV pacing with septal puncture, complication of alcohol septal ablation)
115
Complications of VSD
Infective endocarditis
Pulmonary hypertension
Left ventricular dysfunction
Aortic regurgitation (perimembranous or supra-cristal defects)
Ventricular arrhythmias
Eisenmenger's syndrome
116
CXR findings in VSD
Cardiomegaly (LVH, RVH)
Increased pulmonary vascular markings with prominent main pulmonary arteries
Decreased pulmonary markings in outer third of lung fields (oligaemic lung fields)
117
ECG findings in VSD
Left ventricular hypertrophy
Right ventricular hypertrophy
118
Echo findings in VSD
Location, size and direction of shunt
Right ventricular size and function
Left ventricular size and function
Pulmonary artery systolic pressure
Pulmonary:systemic flow (QP:QS ratio)
119
Medical treatment of VSD
Diuretics for heart failure
Treatment of pulmonary HT
120
Surgical treatment of VSD
VSD closure (open surgical or device)
121
Indications for surgery in VSD
Increasing pulmonary:systemic blood flow (QP:QS > 2:1)
Left ventricular dilatation & dysfunction
Recurrent endocarditis
Development of aortic regurgitation (at least, mild) through prolapse of right
coronary cusp of the aortic valve in supra-cristal defects
Acute rupture of interventricular septum. i.e following myocardial infarction
122
Contraindications for surgery in VSD
Eisenmenger’s syndrome with irreversible pulmonary hypertension
123
Examination findings in PDA
- High volume pulse, Collapsing pulse
- Normal first & second sound
- Continuous machinery murmur in left infraclavicular area +/- thrill
- Flow murmur MDM in apex (if haemodynamic significant)
124
What to check for in examination of PDA
- Check direction of shunt
(shunt reversal from Right to Left – differential cyanosis & clubbing
reduced intensity or disappearance of murmur)
- Check for hemodynamic significance (LVH, pulmonary HT, flow murmur MDM)
- Check other complications – IE, heart failure
125
What is the usual site for PDA
Connection between the main pulmonary artery to the proximal descending aorta,
just after the origin of the left subclavian artery
126
Ddx of continuous murmur
PDA
Aortopulmonary window
Ruptured sinus of valsava
Pulmonary arterio-venous ·fistula
Coronary arterio-venous fistula
Mitral regurgitation AND aortic regurgitation
Ventricular septal defect AND aortic regurgitation·
Pulmonary arterio-venous shunt (Blalock Taussig shunt)
Venous hum
127
Risk factors for PDA
Prematurity, Low-birth weight
Maternal used of prostaglandin antagonists, i.e. NSAIDs
Maternal rubella (first trimester)
High altitude
Maternal hypoxia
Fetal alcohol syndrome
Maternal amphetamine use
Phenytoin use
128
Complications of PDA
Left ventricular dysfunction (volume overload)-most common
Infective endocarditis
Pulmonary hypertension
Eisenmenger's syndrome
Ductal aneurysm and calcification
Ductal rupture
129
ECG findings for PDA
RVH, LVH, pul HT
130
Treatment of PDA
Definitive management – ductal closure (percutaneous using device or surgical)
131
Examination findings in Eisenmenger syndrome
- cyanosis, clubbing
- signs of pulmonary hypertension – LPSH, palpable P2, loud P2
- signs of right heart failure – raised JVP, hepatomegaly, pedal & sacral oedema
*Murmur of underlying causes (ASD, VSD, PDA) disappear
*In PDA, murmur first shorten to systolic murmur and later disappear
*Functional TR, Functional PR murmur can be heard in severe case
132
What to check during examination of Eisenmenger syndrome
SpO2
polycythemia evidence
focal neuro deficit
IE
133
Underlying causes of Eisenmenger syndrome
ASD
VSD (Eisenmenger's complex)
PDA
A-P window
134
Complication of Eisenmenger syndrome
Haemoptysis
Right ventricular failure
Paradoxical embolism
Infective endocarditis
Sudden death
Polycythemia
Thrombosis
Bleeding
135
ECG findings in Eisenmenger syndrome
RAH, RVH, Right axis deviation
136
Echo findings in Eisenmenger syndrome
RV dilatation & hypertrophy
can detect underlying valvular
causes
137
Management of Eisenmenger syndrome
Avoid dehydration, Oxygen therapy
Contraception, avoid pregnancy
Anticoagulation
Diuretic therapy for right heart failure
Phlebotomy for polycythemia and hyperviscosity symptoms (Hct >65%)
Pulmonary vasodilator therapy (CCB)
Surgical repair of primary cardiac defect if reversible pulmonary HT
Heart-lung transplantation
138
Components of Tetralogy of Fallot
ventricular septal defect
overriding aorta
pulmonary stenosis
right ventricular hypertrophy
139
Examination findings in ToF
cyanosis and clubbing
- Apex beat not displaced
- LPSH dt RVH
- Normal first sound
- Ejection systolic murmur in pulmonary area
- Single second sound (absent P2)
- No pulmonary HT (no palpable P2, Loud P2)
140
What is Blalock Taussig shunt?
anastomosis between the subclavian artery (usually the left)
to the pulmonary artery
141
Examination findings in TOF with Blalock Taussig shunt
- cyanosis and clubbing
- lateral thoracotomy scars (+)
- unequal pulse, unequal BP (+) (reduced in lf arm)
- continuous murmur in left infraclavicular area (over shunt)
142
What to check during examination of ToF
SpO2
polycythemia
IE
heart failure
focal neurological deficit
143
Causes of ToF
Fetal hydantoin syndrome (phenytoin exposure)
Fetal carbamazepine syndrome
Fetal alcohol syndrome
Maternal phenylketonuria
144
Complications of ToF
Cyanotic spells – precipitated by exercise, fever, stress, hypoxia, dehydration
(d/t infundibular stenosis)
Endocarditis
Right heart failure
Polycythaemia
Systemic thrombosis
Paradoxical embolism
Cerebral abscess
145
ECG findings in ToF
RAH, RVH, Rt axis deviation
146
CXR findings in ToF
RVH – boot shaped heart
Decreased pulmonary vasculature
147
Management of ToF
Total corrective surgery
Shunt operation – Blalock-Taussig shunt, Waterston shunt (ascending aorta & Rt
pulmonary A), Potts shunt (descending aorta & Lt pulmonary A)
148
Ddx of cyanosis + clubbing
TOF
Eisenmenger’s S
149
Examination findings in coarctation of aorta
- Radio-femoral delay (radio-radial delay/unequal pulse if origin before lf subclavian A)
- Apex beat displaced & heaving (pressure overload)
- Harsh Ejection systolic murmur in left sternal edge & posteriorly (over coarctated
segment)
- Bruits are heard over collaterals (over scapula, anterior axilla & left sternal border)
- ESM +/- EDM in aortic area if associated with bicuspid aortic valve (50%
150
Examination findings after repair of coarctation of aorta
- left lateral thoracotomy scar
- unequal pulse, unequal BP
- bruits still present
- disappearance of ESM over coarctated segment
151
Complications to look for during examination of coarctation of aorta
BP
TOD of HT (retinopathy, nephropathy ..)
left heart failure
152
Associated conditions to look for during examination of coarctation of aorta
Turner feature
Abd exam for PCKD
Berry aneurysm – neck stiff, 3rd CN
153
Usual site of CoA
distal to origin of left subclavian artery
154
Complications of CoA
Hypertension
Hypoplastic limbs (legs +/- left arm)
Left ventricular dysfunction
155
ECG findings in CoA
Left ventricular hypertrophy +/- strain
156
CXR findings in CoA
Rib notching
Prominent aortic knuckle
Characteristic '3 sign'; the upper bulge is formed by dilatation of the left subclavian
artery and the lower bulge is formed by post-stenotic dilatation of the aorta
Cardiomegaly and pulmonary congestion
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Echo findings in CoA
Left ventricular hypertrophy
Left ventricular function
158
Role of MRI in CoA
Sensitive for location and extent of coarctation
Involvement of adjacent vessels
Presence of collaterals
159
Treatment of CoA
Surgical repair (preferably before 5 yr of age)
Balloon dilatation with stenting
160
Causes of unequal pulse
- Aortic dissection
* Coarchtation of aorta (proximal to origin of subclavian artery)
* Takayasu’s arteritis
* Subclavian artery stenosis or abnormality
* Artherosclerosis
* Arterial Thromboembolism
* Vasculitis
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Examination findings in Pulmonary hypertension
LPSH (dt RVH), Palpable P2, Loud P2
- Functional TR (PSM left sternal edge – louder dr inspiration – Carvallo’s sign)
- Functional PR (EDM pul area – Graham Steel murmur)
- Features of right ht failure – raised JVP, hepatomegaly, sacral & pedal edema
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Causes of pulmonary HTN
Secondary to valvular heart diasease
Secondary to chronic pul thromboembolism
Secondary to pulmonary vasculitis – connective t/s d/s (SLE, Systemic sclerosis)
Secondary to chronic hypoxia (eg COPD, OSA, ILD, high altitude, kyphoscoliosis)
If no cause is found ----- Primary pulmonary HTN
163
ECG findings in pulmonary HTN
Right ventricular hypertrophy with Right ventricular strain
Right atrial hypertrophy (P pulmonale)
Incomplete or complete right bundle branch block
In addition, look for evidence of underlying valvular ht d/s.
164
CXR finding in pulmonary HTN
Classical findings of pulmonary hypertension are:
Prominent pulmonary vasculature (enlargement of central pulmonary arteries)
Attenuation of peripheral vessels (Oligaemic lung fields)
In addition, look for cardiomegaly and evidence of lung diseases
165
Echo findings in pulmonary HTN
Right ventricular size and function (right ventricular hypertrophy or dilatation)
Degree of tricuspid regurgitation
Pulmonary artery systolic pressure
166
Treatment of pulmonary HTN
Diuretics for congestive symptoms
Long-term oxygen therapy
Anticoagulation
Vasodilator therapy – CCB (nifedipine and diltiazem)
Prostacyclin analogues (epoprostenol, iloprost)
Phosphodiesterase 5 inhibitors (sildenafil)
Endothelin antagonists (bonsentan)
Treatment of underlying causes in secondary pulmonary hypertension
Surgical Tx – Atrial septostomy
Combined Heart-lung transplant
167
Examination findings in prosthetic heart valve
- midline sternotomy scar
- metallic click + in mechanical valve but no click in bioprosthetic valve
Decide MVR / AVR / Dual VR
- features of valve dysfunction – leaking murmur (EDM in AVR, PSM in MVR)
heart failure signs
- features of IE +/-
- side effects of anticoagulations +/-
- harvest scars (radial A or saphenous V) if CABG is carried out together for
associated CAD
- pacemaker scars
168
Types of mechanical prosthetic valves
Starr-Edwards valve (ball and cage valve) – produce both opening & closing clicks
Medtronic Hall valve (titling disc valve)
Bjork-Shiley valve (single tilting disc valve/monoleaflet)
St Judes valve (double-tilting disc valve/bileaflet)
169
Types of bioprosthetic/biological valves
Xenograft - Porcine valve, Bovine pericardial valve
Homograft - cadaveric valve
170
Complications of prosthetic valves
Thromboembolism
Complications of anticoagulation, i.e. bleeding
Valve dysfunction, i.e. leakage, dehiscence, and obstruction due to thrombosis,
fibrosis, and clogging
Infective Endocarditis
Haemolysis due to mechanical valve
Anaemia (d/t blood loss secondary to anticoagulation, Haemolysis, Endocarditis)
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Contraindications for biological valve
In pt who has high risk of anticoagulation
- If patient’s expected life expectancy less than valve lifespan \
- Patient >70 yr of age
- Woman of reproductive age who have plan for pregnancy (because warfarin
cannot use during pregnancy)
(Drawback is high risk of reoperation for further valve replacement)
172
Choice of anti-coagulation in valve replacement
Warfarin
173
Target INR in valve replacement
- 2.5 – 3.5
- varies depending on AVR or MVR (AV - 2.5 to 3 , MV - 3 to 3.5)
- varies depending on types of prosthesis used
Ball and cage (e.g. Starr–Edwards)
INR 3-4
Tilting disc (e.g. Bjork–Shiley)
INR 3-4
Bi-leaflet (e.g. St Jude)
INR 2.5–3
Biological valves with atrial fibrillation
INR 2-3
174
Indications for valve replacement
Patients who fulfilled criteria for valve replacement in AS, AR, MS, MR
Infective endocarditis with failed medical therapy or with complications
Enlarging aortic root diameter (50mm) irrespective of degree of AR
Acute severe aortic regurgitation (IE, ruptured sinus of Valsalva aneurysm)
Acute severe MR (IE, Post MI)
175
Examination findings in CABG
- midline sternotomy scar without metallic click - harvest scars (radial A or saphenous V) present (but no harvest scar found if
internal mammary A is used for grafting) - risk factors for coronary artery disease
Xanthelesma, Corneal arcus, Xanthoma
Raised BP, LVH
Check RBS
Evidence of old stroke
Evidence of peripheral vascular d/s
176
Midline sternotomy scars with metallic click indicates?
Mechanical valve replacement
177
Midline sternotomy scars without click indicates?
Bioprosthetic valve replacement - -
CABG (harvest scars m/b present)
Other cardiothoracic surgeries (eg ht transplant, correction of cong ht defects)
178
Lateral thoracotomy scar indicates?
Blalock Taussig shunt for TOF
Repair for coarctation of aorta
Repair of some congenital heart disease (ASD, VSD, PDA)
Other (eg. Lung surgeries, Oesophageal operations)
179
Submammary scar indicates?
Mitral valvotomy or repair
Operations for pericardial disease
Open lung biopsy
180
Left infraclvicular scar indicates?
Pacemaker or ICD insertion
181
High risk procedures for IE
-Dental procedures involving manipulation of gingival tissue or periapical region of
teeth or perforation of oral mucosa.
-Procedures involving manipulation of infected/septic focus like draining empyema, abscess
182
