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Case Base Cardiology 4.17.2014 kyavar md facc
No 1
A 75 year old woman with Recent orthopnea
• Chronic dyspnea• Fatigue• Recent orthopnea• palpitation• Pedal edema
LA
LV
AO
Diastole
Mitral Stenosis: Physical Exam
First heart sound (S1) is loud and snappingOpening snap (OS)Low pitch diastolic rumble at the apexPre-systolic accentuation (esp. if in sinus rhythm)
S1 S2 OS S!
MS
MR/TR/VSD
AS with ES
PS with ES
AR
MS with OS
PDA
S1 S2
Mitral Stenosis: Investigations
• CXR• ECG• Echo
Mitral Stenosis
• Etiology• Natural history • Symptoms• Physical Exam• Severity• Timing of Surgery
Mitral Stenosis: EtiologyPrimarily a result of rheumatic fever
(~ 99% of MV’s @ surgery show rheumatic damage )
Scarring & fusion of valve apparatusRarely congenitalPure or predominant MS occurs in
approximately 40% of all patients with rheumatic heart disease
Two-thirds of all patients with MS are female.
Mitral Stenosis: Natural History• Progressive, lifelong disease, • Usually slow & stable in the early years.• Progressive acceleration in the later years• 20-40 year latency from rheumatic fever to
symptom onset.• Additional 10 years before disabling
symptoms
Mitral Stenosis:Pathophysiology
Right Heart Failure:Hepatic Congestion
JVDTricuspid Regurgitation
RA Enlargement
Pulmonary HTNPulmonary Congestion
Atrial FibLA Thrombi
LA Enlargement LA Pressure
RV Pressure OverloadRVH
RV Failure LV Filling
Jugular Veins
Add 5 cm
Mitral Stenosis: Symptoms• Breathlessness• Fatigue• Oedema, ascites• Palpitation• Haemoptysis• Cough• Chest painmitral facies or malar flushSymptoms of thromboembolic complications (e.g. stroke, ischaemic limb)Worsened by conditions that cardiac output.
◦ Exertion,fever, anemia, tachycardia,, pregnancy, thyrotoxicosis
Signs of Mitral Stenosis
Palpation:Small volume pulseTapping apex-palpable S1Palpable S2
• Atrial fibrillation• Signs of raised pulmonary
capillary pressure– Crepitations, pulmonary
oedema, effusions• Signs of pulmonary hypertension
– RV heave, loud P2
Auscultation:Loud S1S2 to OS interval inversely
proportional to severityDiastolic rumble: length
proportional to severityIn severe MS with low flow- S1,
OS & rumble may be inaudible
What if you hear something?
• When does it occur? Is it systolic, diastolic, or both?
– What is the pattern?• Where is it loudest?• Where does it radiate?• Who goes with it?Are there other associated
findings? – S2 splitting normal, loud P2, gallop sound?
• How does it respond? Maneuvers
A 75 year old woman with loud first heart sound and mid-diastolic murmer
No 2
70 years old man with PND
•Syncope•Chest pain
LA
LV
AO
Systole
RV
Valve StenosesTwo Catheter Technique
Ejection Murmur
• Mixed frequencies and is moderate-to-marked crescendo-decrescendo
• Caused by forward flow across the left or right outflow
• Aortic stenosis & pulmonic stenosis
No 3
Patient with Purplish lips, hands and feet
• History: 6 week old male with 2 days of clear, nasal
congestion, no fever
Gets bluish after feeding or crying
Previously well, full-term baby
The family history was negative
Tetralogy of Fallot- Clinical Findings squatting
“Tet spells” – due to pulmonary outflow tract spasm
Severe cases ---at birth---severe PS
Mild cases ---- much later---mild PS
Cyanosis usually
ECG reveals right ventricular hypertrophy
Physical Examination Central Cyanosis vs. Peripheral cyanosis
Vital signs
Lung and CNS examination to rule these out
Cardiac Examination Heaves, thrills, abnormal or increased precordial activity Absent or diminished femoral pulses Abnormal first or second heart sound (abnormal splitting) Extra heart sounds (gallop, ejection click, opening snap) Murmurs that are loud, harsh, blowing
Case Presentation cont’d Purplish lips, hands and feet
Grade III/VI systolic murmur loudest at lower left sternal border
Liver was 1.5 cm below right costal margin and a normal spleen
Peripheral pulses equal in upper/lower extremities, 1.5 sec cap refill
Lab/Imaging Studies CBC/Sepsis evaluation
Chest x-ray
Oxygen Saturation (Arterial blood gas, pulse oximetry)
Hyperoxia test
Electrocardiogram
Echocardiography
Hyperoxia test- Cardiac or Pulmonary?
50-150mm Hg Truncus Arteriosus ( No restricted pulmonary blood flow)
<50 mm Hg Tetralogy of Fallot, Tricuspid Atresia ( Reduced pulmonary flow)
<150 mm HgCardiac disease or PPHN (SHUNT)
>150mm HgPulmonary disease (V/Q mismatch)
On 100% oxygenpaO2
TOF - ECG
Brickner, M. E. et al. N Engl J Med 2000;342:334-342
Tetralogy of Fallot
• 5/10k births• Ventricular septal
defect• Narrowing of the
pulmonary outflow tract
• Over riding aorta • right ventricular
hypertrophy
Hypoxemia Differential Right-to-Left Shunt
INTRACARDIAC, Great Vessels, pulmonary AV malformation
V/Q Mismatch Pneumonia, atelectasis, aspiration, pulmonary hypoplasia
Hypoventilation CNS depression, Neuromuscular disease, Airway obstruction
Diffusion Impairment Pulmonary edema, pulmonary fibrosis
Hemoglobinopathy
No4
A 41-year-old man was initially evaluated 6 years previously by his family physician, found to be hypertensive, and managed with pharmacologic agents. Over the next several years, control of his BP became increasingly difficult, requiring multiple agents. He was referred to a cardiologist for further evaluation. Throughout the entire period, he has remained asymptomatic.
Physical examination disclosed a BP of 160/94 mm Hg and a heart rate of 75 beats/min. Precordial pulsations were normal. Auscultation disclosed a late-peaking systolic murmur heard well at the apex; however, it was also heard over the entire thoracic cage and upper back (Fig 1 ). No diastolic murmurs were audible. Simultaneous palpation of the radial and femoral pulses disclosed a significant delay of the latter. The systolic pressure in the lower extremities was 130 mm Hg, determined with a Doppler probe over the pedal vessels, yielding an ankle/brachial index of 0.85. The remainder of the examination was normal.
Graphic recording of murmurs as heard at two locations over the chest.
Varma C et al. Chest 2003;123:1749-1752
©2003 by American College of Chest Physicians
Rib notching
Coarctation of the Aorta
• Grade II or III murmur• Heard posteriorly & over base of the heart• Hypertension in the arms, but not in the legs• Decreased or absent femoral arterial pulsation
Coarctation of Aorta
• Narrowing in proximal descending aorta
• May be long/tubular but most commonly discrete ridge
• Natural hx: poor prognosis if unrepaired– Aortic Aneurysm/dissection– CHF– Premature CADz
Coarctation Repair
Edmunds’ Cardiac Surgery in the Adult, Ch 47
• Surgical correction1) Patch aortoplasty with removal of segment and end to end anastomosis or subclavian flap repair 2) bypass tube grafting around segment
Coarctation of Aorta
• Residual or recoarctation may be seen in 3% to 41% of patients and can occur with any surgical technique or after angioplasty (seen in 8% to 11% of patients undergoing angioplasty for native coarctation)
No5
Dyspnea & Chest Pain
• The patient was a 33 year old housewife who had acute cardiac failure on the sixteenth day after the onset of the disease
• Physical examination revealed a pale thin female with tachycardia (107 beats/minute), tachypnea (22 breaths/minute), hypotension (blood pressure 86/50 mmHg), jugular venous distension with rapid “×” descent, and distant heart sounds. While the patient was being evaluated in the emergency room, she suddenly had a cardiopulmonary arrest
Myocarditis• Myocarditis is an inflammation of the myocardium, the thick
muscular layer making up the major portion of your heart. • Often follows URI• May present with chest pain (either pleuritic or non-specific) or signs
of heart failure• ECG may show sinus tachycardia, nonspecific repolarization
abnormalities, and intraventricular conduction abnormalities• Echocardiography documents cardiomegaly & contractile
dysfunction• Myocardial biopsy, although not sensitive, may reveal characteristic
inflammatory pattern (ex. Giant Cell)
Myocarditis basics
• Wide spectrum of clinical consequences– Mild & self-limited with few symptoms or severe
with progression to CHF & dilated CM– Very localized or diffuse– Clinical involvement can be limited to the heart or
be part of widespread systemic disorder
Electrocardiogram showing PQ-segment depression and diffusely elevated ST-T-segments at presentation (A)
and evolution after 1 day (B).
ECG & CXR
• ECG - nonspecific ST-T changes and conduction delays are common– Ventricular ectopy may be only clinical finding
• CXR - cardiomegaly is frequent, may have evidence for pulmonary venous hypertension & pulmonary edema
Diagnostics
• Wbc’s often elevated• ESR increased• Troponins elevated in 1/3• CK-MB elevated in 10%• Echocardiogram helps evaluate cardiac
function & exclude other causes• Cardiac MRI improving in ability to see
abnormalities in myocardium
Endomyocardial Bx
• Pathologic exam may reveal lymphocytic inflammatory response with necrosis, but this is not sensitive b/c of the patchy areas of distribution.
• “Dallas” criteria for histopathologic dx• May see “Giant cells”
No6
65 years man with sever chest pain
•History• DM • Hyperlipidemia• smoking
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