Final Exam Lecture Fall '23 Flashcards
1
Q
What differentiates MAC from rheumatic heart dz?
A
the leaflet tips in MAC are still thin and mobile
***if you think about it MAC really affects only the annulus, can extend to base of annulus
2
Q
Associated complications of MAC
A
left atrial enlargement
left ventricular enlargement
mitral regurg
mitral stenosis
3
Q
(predisposing factors for MAC) diseases that can cause stress on the annulus by either…
A
- elevating LV systolic pressure (HTN, Hypertrophic cardiomyopathy, aortic stenosis)
- Causing abnormal mitral motion (MVP, MVR, MR)
4
Q
2 possible causes of MAC stroke
A
- MAC can cause LAE, leaders to A-fib, leads to embolic event
- Calcific emboli from MAC lesion
5
Q
Can MAC extend into membranous portion of IVS? true or false
A
TRUE!
can cause AV block, intraventricular block , and a-fib
6
Q
what is a microbial infection of the membrane lining the heart
A
infective endocarditis
7
Q
causes of infective endocarditis
A
bacterial (strep or staph)
yeast infection
fungal infection
8
Q
perivalvular abscess as what dz advances
A
infective endocarditis…
forms along mitral and aortic rings as extensions of dz
may cause fistula
9
Q
infective endocarditis classified as (2)
A
acute (high grade fever, heart murmur may develop in little as a week)
subacute (AKA SBE subacute bacterial endocarditis) - low-grade fever, fatigue, weight loss, cough, weakness
both are bacterial, both destroy the valve
for acute* - think… “whats acute??? well babies are a-cute. and what sound do babies make???? not “mama” but mur-mur” LOL
10
Q
Valve destruction of veggies usually result in
A
valve regurg
11
Q
Veggies are more common on what side of heart…
A
LEFT side
affect MV more than AoV
12
Q
Although not as common, right-sided veggies are seen more with
A
IV drug use, indwelling catheters, pacer wires
13
Q
Veggies can exist on all valves… true or false?
They tend to form on what side of affected valves?
A
TRUE
tend to form on low pressure side
MV and TV on atrial side
AV and PV on ventricular side
14
Q
“healed veggies” are called such if there is no
A
no active infection
usu smaller/more echogenic (fibrosis/calcium)
15
Q
These veggies are the largest
A
fungal
16
Q
These veggies have NO positive blood cultures
A
fungal
17
Q
what is the predominant clinical sign of acute infective endocarditis
A
high fever
18
Q
Subacute Bacterial Endocarditis (aka SBE) is only accurate if
A
banter is the source of the infection
19
Q
These will make blood cultures unreliable or impossible
A
antibiotic therapy
20
Q
echo appearance of veggie
A
irregular shape
Can look like a diffuse focal thickening along surface of valve
Can also be pedunculate masses that are highly mobile
21
Q
Larger veggies more at risk for embolization?
A
Yes! More likely to break off if bigger
22
Q
Left sided heart lesions can demonstrate what (4)
A
- petechiae skin lesions
- purpuric skin lesions
- transient ischemic events
- stroke
23
Q
right sided heart lesions can display what symptoms
A
pneumonia like symptoms
24
Q
valve _______ from veggies usu result in valvular __________.
A
destruction, regurgitation
25
NBTE is what... it is in response to what?
refers to formation of platelet and fibrin thrombi on cardiac valves and adjacent endocardium in response to TRAUMA, circulating immune complexes, vasculitis, or a hypercoagulable state
26
NBTE is caused by infection... true or false?
FALSE!
Caused by trauma!!!!! (physical trauma ie catheter)
Can become the origin for infection
27
NBTE can become infective endocarditis? True or false
TRUE
can also cause emboli and impair valve function
28
Systemic Lupus or other circulating immune complexes may result in friable platelet and fibrin veggies along a valve leaflet closure aka
Libman Sacks lesions or endocarditis
29
Large thrombotic veggies may form on valves and produce significant emboli to the brain, kidneys, spleen, mesentery, extremities, and coronary arteries. A product of _________. These veggies tend to form on congenitally abnormal cardiac valves or those damaged by
Marantic Endocarditis, rheumatic fever
30
Negative blood cultures and valvular vegetations suggest what diagnosis
NBTE (nonbacterial thrombotic endocarditis)
31
In noninfective endocarditis, what is often needed but will have the opposite effect in infective endocarditis?
anticoagulant
32
Definition of mitral valve prolapse
protruding or buckling of one or both MV leaflets into the LA in SYSTOLE in varying degrees
extend ABOVE plane of MV annulus (>or equal to 2mm)
33
I'm a floppy valve... what am I? I also am histologically identical to what syndrome?
Mitral valve prolapse, identical to Marfan's syndrome
34
What are some different names for MVP
1. Degenerative MV disease
2. Myxomatous MV disease
3. Fibroelastic deficiency (mildest form of MVP) - older patients, loss of mechanical integrity, decreased CT production
4. Barlow disease (most severe form of MVP) - younger patients, excess leaflet tissue
35
I'm an anorexic, thin, young, female ballet dancer. I also have Marfan's syndrome. How's my mitral valve?
probably has mitral valve prolapse!!!!!!!
*also, Ehler Danlos syndrome (hyperelastic skin/joint mobility)
36
Most common cause of MR in developed countries
MVP
37
Varying degree of MR can cause
CHF
Pulmonary HTN
Acute pulmonary edema
Bacterial endocarditis from thick leaflets
Flail MV
Ruptured chordae
Sudden death (arrhythmias)
38
Do NOT use this view for MVP
apical!!! MVP OVERDIAGNOSED if view is off axis
use PLAX (2D and m-mode)
39
What's the cure for MVP
none... so reassure the patient!
there are treatments though...
40
I am the mitral valve. One of my chordae has ruptured. I most likely have
mitral valve FLAIL (instead of prolapse)
41
I affect the MV. I am uncommon, am usu associated with endocarditis, and a more common on anterior leaflet... I am
MV aneurysm
42
MS consists of a pressure overload of what
the LA, RV, and pulmonary vasculature tree
43
Most common cause of mitral stenosis worldwide?
rheumatic heart disease
44
3 congenital causes of mitral stenosis
cor triatriatum
supravalvular mitral ring
parachute mitral valve
45
these are becoming the leading cause of non rheumatic heart disease (acquired MS)
age related degenerative MACS
46
one can acquire mitral stenosis (non rheumatic) in many ways (6)
vegetations, thrombus, myxoma (other tumors)
lupus
carcinoid heart disease
rheumatoid arthritis
radiation valvulitis
MACS
47
what is parachute mitral valve (1 of 5 rare causes of what)
rare causes of MS
it is a congenital abnormality
only one papillary muscle or two very close together in LV and chordae of both leaflets attach to single muscle
48
what is cor triatriatum
congenital
membrane (fibromuscular) divides LA into 2 chambers
may or may not cause obstruction
49
rheumatic mitral stenosis, define. may develop after what?
rheumatic fever is systemic inflammatory disease (affects heart, brain, joints, skin, subcutaneous tissue)
may develop after strep
50
echo hallmarks of rheumatic ms
affects both leaflets
leaflet thickening
leaflet calcifications
decreased leaflet mobility
commissural fusions
from tips to base (thickening)
51
chronic elevation of LA pressure
right heart pumps harder
can go into failure over time
TR results
Rt heart failure
52
M-mode of MV
D point: MV opens, beginning of diastole
E point: maximum excursion of valve
F point: lowest point after passive filling phase
A point: atrial contraction
C point: valve closure, systole begins
53
Acute vs Chronic MR
Acute MR - no changes in LA or LV size/function
Chronic MR - increase in LV and LA volume (LV function can become impaired due to volume overload)
54
!isolated rheumatic TV stenosis almost never occurs TRUE OR FALSE
TRUE! occurs only if there is rheumatic MV disease
55
Carcinoid heart disease defined
results from presence of carcinoid tumors found mostly in GI tract
(50% of patients with carcinoid syndrome have cardiac involvement)
56
what are some symptoms of carcinoid heart dz
facial flushing, abdominal pain, diarrhea, renal failure, hepatic failure, hepatomegaly, elevated venous pressure, systolic/diastolic murmur
57
Caval index measures what
right atrial pressures
58
congenital stenosis occurs at the _______level. what 2 kinds.
valvular; both below are congenital
bicuspid valve: doming of valve, fusion of raphe, balloon valvuloplasty to correct
dysplastic pulmonary valve: associated with Noonan's syndrome, immobile cusps from thickened tissue, thickened valve tissue
59
3 types of PV stenosis
valvular
subvalvular
supravalvular
60
Pulmonary HTN is
an increase in pulmonary arterial pressure >30mmHg systolic
61
How does the RV respond FIRST with pulmonary HTN?
RV responds first with hypertrophy followed by RVE, TR, PI, and RAE
62
Secondary pulmonary HTN can occur due to other abnormalities or pathology taking place elsewhere, such as
mitral stenosis
heart failure with elevated LV end diastolic pressures
cor pulmonale (rt heart failure due to pulmonary dz)
thrombotic emoli to lungs
congenital heart dz with a lt-rt-shunt
63
Pulmonary HTN M-mode appearance (right heart)
"Flying W"
Midsystolic closure of pulmonic valve
64
Grading severity of pulmonary hypertension (right heart) method:
AcT/RVET ratio
place sample volume just proximal to PV in center of RVOT
measure AcT (acceleration time)
mesure RVET (right ventricular ejection time)
AcT divided by RVET
normal ratio is 0.45
65
what is acceleration time a measurement of
measured from onset of systolic flow to peak of velocity
66
Normal acceleration time for pulmonary arterial pressure in detecting pulmonary HTN is
greater than or equal to 120 msec
67
With increasing pulmonary pressure the time required for what increases, which delays what?
the time required for RV pressure to exceed PA pressure increases, which delays the opening of the PV
68
RVH occurs with
PV stenosis at subvalvular or supravalvular level
tetralogy of Fallot
chronic pulmonary HTN
mitral stenosis
Pulmonary emboli
Eisenmenger's physiology
69
Normal free wall measurement is
1.9 to 2.9mm
70
RVVO can result from
INCREASED VOLUME OF BLOOD FROM EITHER WAY!!!
you either have blood increasing from to RV from RA or back flow of blood from the pulmonary system which obstructs RV blood flow from leaving
71
The tunica _______ composes 80% of aortic wall
tunica media
72
Elasticity of the AO wall does two things
dampening of force in systole
expulsion of stored energy in diastole
73
Average diameter for the abdominal aorta is
2cm
74
What part of the descending thoracic ao is vulnerable to traumatic injury\?
aortic isthmus
ao is fixed to thorax at this point
75
"obstructive lesion (structural abnormality)" Ao stenosis is VERY RARE
supravalvular ao stenosis
it's congenital
its a narrowing of asc ao just distal to coronary arteries
76
supravalvular ao stenosis does have 3 types
1. hour glass (most common) above sinuses, may be thicker cusps, assoc. w/williams syndrome, elfin faces, mental retardation, peripheral pulmonic stenosis
2. fibrous membrane with narrow opening (aka discrete) - near sinotubular junction
3. diffuse narrowing (hypoplasia) of descending ao aka "strand" - often involves origin of brachiocephalic arteries
77
coarctation (of ao) is
narrowing of desc aorta near origin of ductus arteriosus; associated with other heart defects (bicuspid ao valve, MV malformations)
78
2 types of subvalvular obstruction
1. discrete form (barrier w/in LVOT just below AoV)
2. tunnel type of sub aortic obstruction
79
the MOST COMMON aortic abnormality is
aortic dilation
80
asc ao dilation usu due to (4)
HTN
Atherosclerosis
Cystic medial necrosis
Post stenotic dilation
Marfan's
Rheumatoid arthritis
Systemic lupus
Reiter Syndrome (type of arthritis)
81
Dilation actually becomes an aneurysm when...
when dilation is severe, 50% bigger than it should be
82
aortic aneurysm criteria (measurements):
is an aneurysm if:
more than 5 cm in ascending aorta
more than 4 cm in descending aorta
6 cm or higher presents higher risk for rupture
83
aneurysms can be caused by (etiology)
atherosclerosis
Syphilis
trauma
aortic stenosis
Congenital (ao coarctation)
PDA
Aortitis
84
Types of aneurysms (3)
dissecting
saccular (think "sack-like")
fusiform (entire circumference, uniform dilation, think fusilli pasta)
85
aneurysms can have 3 shapes
1. annuloaortic: ao root, annulus, sinus of vasalva (SOV)
2. annulus, SOV, and part of asc ao
3. beginning at sinotubular junction, skipping the annulus and SOV
86
Aortic sizes measure from a PLAX at what part of cardiac cycle?
end diastole
87
Most common aneurysm is
atherosclerotic aneurysm
25% are thoracic
rest are abdominal aneurysms
88
symptoms of aneurysms
wheezing
cough
dyspnea
hemoptysis (esophagus compression)
hoarseness (laryngeal nerve compression)
dysphagia
89
the gold standard in diagnosing aneurysm is
angiography... but even they can STILL MISS if aneurysm is layered with thrombus
90
complications of
LSOVA
NCSOVA
RSOVA
THE MOST COMPLICATIONS OCCUR IN the RIGHT!!!!
LSOVA
1. LA/RA rupture
2. cause LA compression
NCSOVA
1. may rupture into LA, RA, LV, or ventricular septum
RSOVA
1. may rupture into RA, RV, or adjacent main pulmonary artery
2. can cause RVOT obstruction
3. May result in RCA dissection or compression and acute MI
4. May compress conduction system and cause heart block
5. may rupture into pericardium and cause tamponade
91
What is aortitis
general term that refers to a broad group of conditions which causes inflammation of aortic wall
infectious or not
radiation induced
idiopathic
92
acute aortic syndrome
several life threatening entities overlap
93
aortic dissection what is
catastrophic event initiated by a sudden tear of intimacy and resulting cleaving of media
column of blood enters aortic wall and destroys the media while stripping the intimate from adventitia
classified by location
94
Ao Dissection classified by location.... two names... what are they... describe the locations
Standford classification:
Type A: asc aorta (tamponade most common cause of death)
Type B: all as long asc ao not included
Debakey classification
Type 1: ascending, transverse, descending ao involved (70%)
Type 2: ascending ao, stops proximal to brachiocephalic
Type 3: descending ao and may extend into abd ao
95
Ao dissection causes
HTN
atherosclerosis
Marfan's
aging
pregnancy
trauma
iatrogenic injury
inflammatory dz
cocaine use
renal dz
strenuous physical exercise
96
patient symptoms of ao dissection
excrutiating pain
severe at onset
radiate in path of dissection
clammy (acute)
shock
hypertensive or hypotensive
97
In dissection, contrast agents opacify the _______ lumen FIRST.
TRUE
98
trauma normally occurs with
high speed deceleration injuries from MVA
99
bioprosthetic valve is
heterograft, xenograft, stented, scentless, homograft, autograft
*as long as it comes from live tissue
100
valve of choice for TV and PV is
bioprosthetic valve
101
porcine valve comes from what animal
"P" for pig
102
Ross procedure is
pulmonary AUTOGRAFT
103
Valved conduit is used to repair
congenital heart disease (done in kids/young adults, GROWS WITH PATIENT!)
104
least stenotic mechanical prosthetic valve
St Jude
3 orifices
(think, st Jude... 3... the trinity...) 3 peaks, 3 orifices
105
Most common ball and cage valve is
Starr Edwards
106
Classic type of mitral ring and tricuspid ring is
CARPENTIER EDWARDS
107
Most common tilting disc valve is
Bjork Shiley and Medtronic Hall
2 orifices
108
the higher the pressure in the pulmonary artery, the higher the
RVSP
elevated pressure in the pulmonary artery can lead to pulmonary artery HTN, so it must be monitored
109
RVSP is a good estimate of
pulmonary artery pressure
110
RVSP equation is
4(Vsquared) + RAP
RAP obtained from caval index
TR is the max velocity jet or (V) in the equation
111
RAP or right atrial pressure is determined by
caval index
112
in the absence of RVOT obstruction, RSVP actually =
SPAP
113
Cutoff for a normal RVSP is
35 mmHg
40-50 mild
>50 moderate
>60 severe
114
Both deep vein thrombosis (DVT) and pulmonary embolism fall under what category of dz
thromboembolic dz
115
When putting information in The Bernoulli equation, you need to look and see if the value of the Pressure gradient needs to be adjusted value-wise... for example
change 291 cm/s to m/s... so it would be 2.91 m/s instead for Vmax... THEN plug into Bernoulli equation
116
Flattening of the EF slope and/or decreased/absent A wave indicates
Mitral stenosis
