Internal Medicine Board Internal Medicine Board Review (from MKSAP 13) Review (from MKSAP 13)

CardiologyCardiology

June 2006June 2006

Congenital Heart DiseaseCongenital Heart DiseaseIn the AdultIn the Adult

Acyanotic Congenital Heart Acyanotic Congenital Heart DiseaseDisease

(covered in MKSAP)(covered in MKSAP)• Atrial Septal DefectAtrial Septal Defect• Bicuspid Aortic ValveBicuspid Aortic Valve

– Most common congenital anomalyMost common congenital anomaly– More common in menMore common in men– Early systolic ejection click and outflow murmurEarly systolic ejection click and outflow murmur– Diagnosis with echo important because of Diagnosis with echo important because of

endocarditis riskendocarditis risk– Coarctation and bicuspid aortic valve are Coarctation and bicuspid aortic valve are

associatedassociated

• Ventricular Septal DefectVentricular Septal Defect• Patent Ductus ArteriosusPatent Ductus Arteriosus• Valvular pulmonary stenosisValvular pulmonary stenosis• Coarctation of the aortaCoarctation of the aorta

Cyanotic Congenital Heart DiseaseCyanotic Congenital Heart Disease (covered in (covered in MKSAP)MKSAP)

• Most patients with Most patients with unoperatedunoperated cyanotic cyanotic heart disease have developed heart disease have developed Eisenmenger’s syndromeEisenmenger’s syndrome..

• Tetralogy of FallotTetralogy of Fallot– most have had complete intracardiac repair, most have had complete intracardiac repair,

occasionally only aortopulmonary shunt.occasionally only aortopulmonary shunt.– PI leading to right heart dilation is commonPI leading to right heart dilation is common– Yearly mortality increases after 25 years due to Yearly mortality increases after 25 years due to

sudden death, QRS >180ms best predictor, sudden death, QRS >180ms best predictor, apparent interaction between long QRS and apparent interaction between long QRS and right heart dilation, general agreement to right heart dilation, general agreement to replace pulmonary valve when QRS>180.replace pulmonary valve when QRS>180.

• Transposition of Great ArteriesTransposition of Great Arteries– most have had been repaired with atrial switch most have had been repaired with atrial switch

(Mustard, Senning) procedure [now doing (Mustard, Senning) procedure [now doing arterial switch]arterial switch]

– Risk RV failure (survival depends on RV Risk RV failure (survival depends on RV function), sick sinus syndrome, atrial function), sick sinus syndrome, atrial arrhythmiasarrhythmias

• #70 26 y.o. female. Heart murmur as a #70 26 y.o. female. Heart murmur as a child did not outgrow it. Married. Would child did not outgrow it. Married. Would like a child. Mild cough and SOB especially like a child. Mild cough and SOB especially at high altitude. BP 110/70, HR 86. O2 sat at high altitude. BP 110/70, HR 86. O2 sat 99%. Nl JVP. Good carotid upstroke. Lungs 99%. Nl JVP. Good carotid upstroke. Lungs clear. RV lift. S1 normal clear. RV lift. S1 normal S2 wide fixed S2 wide fixed splittingsplitting. 3/6 early to mid peaking systolic . 3/6 early to mid peaking systolic murmur LUSB. Echo RV enlargement, RAE, murmur LUSB. Echo RV enlargement, RAE, and high pulm flow but no ASD on TTE. PA and high pulm flow but no ASD on TTE. PA 45. Valves normal. Next step?45. Valves normal. Next step?– TEETEE– ABX prophylaxis no other treatmentABX prophylaxis no other treatment– Have family and then consider closure of the Have family and then consider closure of the

defectdefect– Cardiac cathCardiac cath– ReassuranceReassurance

# 70 TEE# 70 TEE• Most likely dx is ASD (wide and fixed splitting of S2)Most likely dx is ASD (wide and fixed splitting of S2)• However partial anomalous pulmonary venous However partial anomalous pulmonary venous

drainage is an alternative diagnosis and is suspected drainage is an alternative diagnosis and is suspected when TTE does not show ASD. RV enlargement is when TTE does not show ASD. RV enlargement is consistent with a hemodynamically significant shunt.consistent with a hemodynamically significant shunt.

• Mild elevation of PA pressure is not a contrindication Mild elevation of PA pressure is not a contrindication to closureto closure

• TEE is indicated to define the anatomy and exclude TEE is indicated to define the anatomy and exclude anomalous pulmonary venous drainageanomalous pulmonary venous drainage

• Referral for closure is indicated and if feasible prior Referral for closure is indicated and if feasible prior to pregnancy (CHF sometimes complicates to pregnancy (CHF sometimes complicates pregnancy, risk paradox embolus)pregnancy, risk paradox embolus)

• Closure percutaneous or sugical depending on Closure percutaneous or sugical depending on anatomy and center’s experienceanatomy and center’s experience– Most ostium secundum ASD can be closed percutaneouslyMost ostium secundum ASD can be closed percutaneously– Others require surgical closureOthers require surgical closure

----Closure of ASD and VSD indicated if Closure of ASD and VSD indicated if pulmonary to systemic shunt ratio of 1.7:1 pulmonary to systemic shunt ratio of 1.7:1 or greater with evidence of right or left or greater with evidence of right or left ventricular volume overload respectively.ventricular volume overload respectively.

ASD secondMost commonCongenital defectEncountered in adults(bicuspid AV #1)

Majority are secundumLocation of types of AtrialSeptal Defects

More on ASD’sMore on ASD’s• In absence of pulmonary vascular disease In absence of pulmonary vascular disease

shunt is left to right resulting in RV volume shunt is left to right resulting in RV volume overload.overload.

• With advancing age diminished LV With advancing age diminished LV compliance can lead to increase in shunt compliance can lead to increase in shunt fraction with consequent right heart failurefraction with consequent right heart failure

• A.fib is common in older adults with ASD’s.A.fib is common in older adults with ASD’s.

• Frequency of A.fib and potential for Frequency of A.fib and potential for paradoxical embolism lead to high incidence paradoxical embolism lead to high incidence of embolic stroke.of embolic stroke.

• Before repair prophylaxis for endocarditis is Before repair prophylaxis for endocarditis is not indicated for isolated ASD’s. Following not indicated for isolated ASD’s. Following closure 6 mos of prophylaxis for endocarditis.closure 6 mos of prophylaxis for endocarditis.

• #18 24 y.o. female emigrated from #18 24 y.o. female emigrated from Phillipines eval for murmur. HR 82. O2 sat Phillipines eval for murmur. HR 82. O2 sat 97%. JVP normal. Carotid pulses brisk with 97%. JVP normal. Carotid pulses brisk with rapid upstroke. Lungs clear. Sustained apical rapid upstroke. Lungs clear. Sustained apical impulse in 6impulse in 6thth intercostal space. S1 normal. intercostal space. S1 normal. S2 physiologically split with normal P2. A soft S2 physiologically split with normal P2. A soft S3 is audible. S3 is audible. Continuous murmurContinuous murmur with with crescendo-decresendo quality is heard crescendo-decresendo quality is heard throughout, loudest 3throughout, loudest 3rdrd left intercostal space. left intercostal space. Diagnosis?Diagnosis?– Mitral regugitationMitral regugitation– Mitral stenosis and insufficiencyMitral stenosis and insufficiency– Pulmonary stenosis and insufficiencyPulmonary stenosis and insufficiency– Patent ducts arteriosusPatent ducts arteriosus

#18 patent ductus. #18 patent ductus.

• Patent ductus arteriosusPatent ductus arteriosus – In acyanotic adult with patent ductus In acyanotic adult with patent ductus

communication is usually small. communication is usually small. Murmur soft and confined to systole. Murmur soft and confined to systole.

– Most adults with large patent ductus Most adults with large patent ductus have Eisenmenger’s physiology and are have Eisenmenger’s physiology and are not surgical candidates. not surgical candidates.

– Closure is indicated if associated with a Closure is indicated if associated with a murmur to prevent the complications of murmur to prevent the complications of endarteritis. endarteritis.

– Closure percutaneously with coil.Closure percutaneously with coil.

•PFOPFO — —patent foramen ovalepatent foramen ovale. . – Persist in 20% of people. Persist in 20% of people. – Can be associated with interatrial Can be associated with interatrial

septal aneurysm. septal aneurysm. – Can be diagnosed by contrast echo. Can be diagnosed by contrast echo. – Risk for paradoxical embolism. Risk for paradoxical embolism. – The specific indications for closure of The specific indications for closure of

a patent foramen ovale after a a patent foramen ovale after a cerebral embolic event remain cerebral embolic event remain unclearunclear

• #43 26 y.o. man diagnosed with heart #43 26 y.o. man diagnosed with heart murmur as a baby. Told he would outgrow murmur as a baby. Told he would outgrow it. Participates in sports without problem. it. Participates in sports without problem. 120/80, 64. Lungs clear. Nondisplaced 120/80, 64. Lungs clear. Nondisplaced apical impulse. Normal S1, physio split S2. apical impulse. Normal S1, physio split S2. Thrill in 3 Thrill in 3rdrd left intercostal space and 4/6 left intercostal space and 4/6 holosystolic murmur noted radiating to the holosystolic murmur noted radiating to the right. Echo small perimembranous VSD. right. Echo small perimembranous VSD. Normal chamber size and normal PA Normal chamber size and normal PA pressures.pressures.– Refer to surgeon for closureRefer to surgeon for closure– Treat with amoxicillin 2 gm 1 hour Treat with amoxicillin 2 gm 1 hour

before dental proceduresbefore dental procedures– Refer for percutaneous closureRefer for percutaneous closure– Initiate lisinopril therapyInitiate lisinopril therapy

#43 Treat w/ amoxicillin 2 gm 1 hour before dental #43 Treat w/ amoxicillin 2 gm 1 hour before dental proceduresprocedures

Ventricular Septal DefectVentricular Septal Defect• In acyanotic adult VSD usually smallIn acyanotic adult VSD usually small• Large VSD present in childhood with CHF or Large VSD present in childhood with CHF or

pulmonary hypertensionpulmonary hypertension• Most common location in adults is Most common location in adults is

perimembranous near tricuspid valveperimembranous near tricuspid valve• Indications for closure in adulthood are large Indications for closure in adulthood are large

shunt fraction 1.7:1 or greater or left ventricular shunt fraction 1.7:1 or greater or left ventricular volume overload (LV overload occurs because volume overload (LV overload occurs because shunt is primarily confined to systole and the RV shunt is primarily confined to systole and the RV serves as a reservoir for the shunted blood The serves as a reservoir for the shunted blood The LV diastolic volume is increased because the LV diastolic volume is increased because the stroke volume includes both forward flow and stroke volume includes both forward flow and shunted flow)shunted flow)

• Exam with hemodynamic sig VSD may reveal Exam with hemodynamic sig VSD may reveal displaced apical impulse, mitral diastolic rumble, displaced apical impulse, mitral diastolic rumble, S3. S3.

Endocarditis Risk and Endocarditis Risk and Prophylaxis Prophylaxis

In Congenital Heart DiseaseIn Congenital Heart Disease• Risk of endocarditis is substantial Risk of endocarditis is substantial except inexcept in

operatedoperated patients with pulmonary stenosis, patients with pulmonary stenosis, ASD, VSD, PDA. If residual VSD or PDA leaks ASD, VSD, PDA. If residual VSD or PDA leaks present postoperatively, risk persists.present postoperatively, risk persists.

• Antibiotic prophylaxis is indicated for almost Antibiotic prophylaxis is indicated for almost all patients with all patients with unoperatedunoperated congenital heart congenital heart disease (except isolated ASD)disease (except isolated ASD)

• ASD—before repair no prophylaxis indicated ASD—before repair no prophylaxis indicated unless other coexisting abnormalities. unless other coexisting abnormalities. Prophylaxis for first 6 mos post repair and Prophylaxis for first 6 mos post repair and indefinitely if residual abnormalities.indefinitely if residual abnormalities.

#59#5945 y.o. known Eisenmenger’s b/c of 45 y.o. known Eisenmenger’s b/c of unrepaired VSD. Increased lethargy, unrepaired VSD. Increased lethargy, frontal headache, and difficulty frontal headache, and difficulty concentrating. Previous PMD concentrating. Previous PMD phlebotomized 1 unit every 3 mos. phlebotomized 1 unit every 3 mos. Cyanotic, 95/65, 95, 84%. Clubbing. Cyanotic, 95/65, 95, 84%. Clubbing. Clear lungs, nl JVP. Widely physio split Clear lungs, nl JVP. Widely physio split S2, loud P2. Holosystolic murmur at S2, loud P2. Holosystolic murmur at left parasternal border. High pitched left parasternal border. High pitched diastolic murmur at upper left sternal diastolic murmur at upper left sternal border. Right sided S4.border. Right sided S4.HCT 56%, MCV 72. WBC 5.6. PLT 110.HCT 56%, MCV 72. WBC 5.6. PLT 110.

• Symptoms suggest hyperviscosity, they Symptoms suggest hyperviscosity, they may be caused by iron deficiency. may be caused by iron deficiency. Microcytic erythrocytes are rigid and not Microcytic erythrocytes are rigid and not easily deformed. Thus viscosity easily deformed. Thus viscosity increases paradoxically at lower increases paradoxically at lower hematocrit.hematocrit.

Eisenmenger’s Syndrome and Eisenmenger’s Syndrome and ErythrocytosisErythrocytosis• Seconday erythrocytosis is compensatory Seconday erythrocytosis is compensatory

and usually not associated with symptoms.and usually not associated with symptoms.• Hyperviscosity syndrome can occur when Hyperviscosity syndrome can occur when

HCT >65. Phlebotomy is indicated only to HCT >65. Phlebotomy is indicated only to treat symptoms.treat symptoms.

• Be sure not iron deficient and not volume Be sure not iron deficient and not volume depleted. depleted.

• When phlebotomy is necessary, follow by When phlebotomy is necessary, follow by isovolumic saline repletion (in presence of isovolumic saline repletion (in presence of CHF use 5% dextrose)CHF use 5% dextrose)

• Pregnancy contraindicated. Maternal Pregnancy contraindicated. Maternal mortality excceds 50% with death usually mortality excceds 50% with death usually in early postpartum period.in early postpartum period.

• # 89# 89• 35 y.o. female hypertensive. Told had 35 y.o. female hypertensive. Told had

hypertension at age 20 as well but did not hypertension at age 20 as well but did not follow up. BP 200/100. S1. S2 physio follow up. BP 200/100. S1. S2 physio split. An early systolic ejection sound is split. An early systolic ejection sound is noted and early peaking murmur noted in noted and early peaking murmur noted in second right intercostal space. Short second right intercostal space. Short diastolic murmur along LSB. U/A normal.diastolic murmur along LSB. U/A normal.– Measure TSHMeasure TSH– Measure BP lower extremitiesMeasure BP lower extremities– Order EchoOrder Echo– Order 24 HR urine test for metanephrine and Order 24 HR urine test for metanephrine and

vanillylmandelic acidvanillylmandelic acid– Obtain CXRObtain CXR

#89 Measure BP lower extremities#89 Measure BP lower extremities------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

• Coarctation of the aortaCoarctation of the aorta– Radial femoral delayRadial femoral delay– Lower blood pressure in the legsLower blood pressure in the legs– Rib notching (dilated intercostal arteries Rib notching (dilated intercostal arteries

that provide collateral blood flow)that provide collateral blood flow)– Repair indicated when there is proximal Repair indicated when there is proximal

HTN and a gradient exceeding 20 mm HgHTN and a gradient exceeding 20 mm Hg– Discrete coarctation is usually amendable Discrete coarctation is usually amendable

to percutaneous repair while longer to percutaneous repair while longer segments may require surgerysegments may require surgery

Cardiac Disease And Cardiac Disease And PregnancyPregnancy

• #11 25 y.o. pregnant female presents with #11 25 y.o. pregnant female presents with heart murmur noted second trimester. heart murmur noted second trimester. First pregnancy. New murmur. No PMH. First pregnancy. New murmur. No PMH. Asymptomatic. Mild displaced apical Asymptomatic. Mild displaced apical impulse and lower extrem edema. S1 and impulse and lower extrem edema. S1 and S2 normal, S3 at apex. 2/6 early to mid S2 normal, S3 at apex. 2/6 early to mid peaking systolic murmur at left sternal peaking systolic murmur at left sternal border. Likely cause of murmur?border. Likely cause of murmur?– Bicuspid aortic valve with mild to mod ASBicuspid aortic valve with mild to mod AS– Congenitally abnl pulmonary valve with Congenitally abnl pulmonary valve with

mod stenosismod stenosis– Physiologic murmur related to pregnancyPhysiologic murmur related to pregnancy– Bicuspid aortic valve with moderate Bicuspid aortic valve with moderate

regurgitationregurgitation

#11 physiologic murmur#11 physiologic murmur----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

– PHYSICAL FINDINGS AND PREGNANCYPHYSICAL FINDINGS AND PREGNANCY----

• S3 audible in more than 80% of normal pregnant S3 audible in more than 80% of normal pregnant womenwomen

• Early peaking ejection systolic murmur audible in 90%--Early peaking ejection systolic murmur audible in 90%--pulmonary outflow murmurpulmonary outflow murmur

• Increased blood volume during pregnancy Increased blood volume during pregnancy – (CO increases by 30 to 50% during pregnancy and to (CO increases by 30 to 50% during pregnancy and to

about 80% above baseline during labor and delivery)about 80% above baseline during labor and delivery)• Apical impulse displacesApical impulse displaces• Lower extremity edema commonLower extremity edema common

• Abnormal findings-Abnormal findings---S4, loud 3/6 systolic --S4, loud 3/6 systolic murmur, diastolic murmur, fixed splitting of S2.murmur, diastolic murmur, fixed splitting of S2.

• In general, fixed obstructive lesions (MS, AS) poorly In general, fixed obstructive lesions (MS, AS) poorly tolerated in pregnancy—increased blood volume. tolerated in pregnancy—increased blood volume.

Regurgitant lesions well tolerated—decreased SVRRegurgitant lesions well tolerated—decreased SVR

• #20 28 y.o. pregnant female referred for #20 28 y.o. pregnant female referred for eval of persistent dyspnea secondary to MS. eval of persistent dyspnea secondary to MS. 30 weeks pregnant and dyspnea persists 30 weeks pregnant and dyspnea persists after metoprolol, lasix, and digoxin. HR 70. after metoprolol, lasix, and digoxin. HR 70. Echo severe MS, mean grad 14, valve area 1 Echo severe MS, mean grad 14, valve area 1 cm2. Trivial MR. RV systolic 50 mmHg. cm2. Trivial MR. RV systolic 50 mmHg. Crackles and edema. What do you Crackles and edema. What do you recommend?recommend?– Surgical mitral valvotomySurgical mitral valvotomy– Urgent delivery fetus then reassessment of Urgent delivery fetus then reassessment of

maternal cardiac statusmaternal cardiac status– TEE followed by percutaneous mitral balloon TEE followed by percutaneous mitral balloon

valvuloplastyvalvuloplasty– Diagnostic catheterizationDiagnostic catheterization– Fetal EchocardiogramFetal Echocardiogram

# 20 TEE followed by percutaneous mitral # 20 TEE followed by percutaneous mitral balloon valvuloplastyballoon valvuloplasty• Percutaneous valvuloplasty treatment of Percutaneous valvuloplasty treatment of

choice in pregnant women with severe MS choice in pregnant women with severe MS whose sx can’t be controlled with meds.whose sx can’t be controlled with meds.

• TEE to eval Mitral valve aparatus and eval TEE to eval Mitral valve aparatus and eval for LA thrombusfor LA thrombus

• Abdominal shielding to limit radiation to Abdominal shielding to limit radiation to fetus (Avoid during first trimester)fetus (Avoid during first trimester)

• Cardiac surgery can be performed during Cardiac surgery can be performed during pregnancy but should be avoided unless pregnancy but should be avoided unless absolutely necessary (best time 24-28 absolutely necessary (best time 24-28 weeks) (Maternal mortality 1-5%, fetal 15-weeks) (Maternal mortality 1-5%, fetal 15-38%)38%)

• #30 28 y.o. female 29 weeks pregnant #30 28 y.o. female 29 weeks pregnant referred for progressive dyspnea. h/o referred for progressive dyspnea. h/o rheumatic fever and mitral stenosis. 4 wk rheumatic fever and mitral stenosis. 4 wk increase dyspnea. No palpitations. increase dyspnea. No palpitations. Elevated JVP. HR 100. Parasternal Elevated JVP. HR 100. Parasternal impulse present. Opening snap and grade impulse present. Opening snap and grade 2 diastolic rumble….EKG sinus tach, LAE, 2 diastolic rumble….EKG sinus tach, LAE, RAD.RAD.

• What do you recommend?What do you recommend?– DigoxinDigoxin– MetoprololMetoprolol– WarfarinWarfarin– RamiprilRamipril– amlodipineamlodipine

• #30 metoprolol #30 metoprolol – to slow HR, increase diastolic filling to slow HR, increase diastolic filling

time.time.– If sx persist then diureticIf sx persist then diuretic– Note: ACE I, ARB contraindicated in Note: ACE I, ARB contraindicated in

pregnancypregnancy

• #38 35 y.o. female 39 weeks #38 35 y.o. female 39 weeks pregnant comes to office increasing pregnant comes to office increasing dyspnea. No prior PMH. First dyspnea. No prior PMH. First pregnancy. JVP 13, diffuse apical pregnancy. JVP 13, diffuse apical impulse, apical systolic murmur. S3 impulse, apical systolic murmur. S3 and S4. Crackles. EKG tachy.and S4. Crackles. EKG tachy.

• Diagnosis?Diagnosis?– Severe ASSevere AS– Severe TRSevere TR– ASDASD– Peripartum cardiomyopathyPeripartum cardiomyopathy– Pulmonary embolismPulmonary embolism

#38 #38 Peripartum Peripartum CardiomyopathyCardiomyopathy

• 1:1,300 to 1:15,000 pregancies in US, 1:1,300 to 1:15,000 pregancies in US, higher in certain parts of Aftrica higher in certain parts of Aftrica

• Risk increased in: African Americans, Risk increased in: African Americans, multiple gestations, multiparous, women multiple gestations, multiparous, women age >30 years, h/o peripartum age >30 years, h/o peripartum cardiomyopathycardiomyopathy

• Usually occurs during last trimester Usually occurs during last trimester pregnancy or in first 6 mos post partum pregnancy or in first 6 mos post partum (Most commonly diagnosed in first post (Most commonly diagnosed in first post partum month)partum month)

• 50% of women with peripartum 50% of women with peripartum cardiomyopathy will have improvement in cardiomyopathy will have improvement in LV function within 6 mos after delivery.LV function within 6 mos after delivery.

• Delivery is recommendedDelivery is recommended

• Unless obstetric reasons for c-sec mode Unless obstetric reasons for c-sec mode of delivery should be vaginal because of of delivery should be vaginal because of lower hemodynamic burdenlower hemodynamic burden

• Because risk of recurrence of peripartum Because risk of recurrence of peripartum cardiomyopathy is common repeated cardiomyopathy is common repeated pregnancy is “contraindicated”—pt’s pregnancy is “contraindicated”—pt’s with persistent LV dysfunction and pts with persistent LV dysfunction and pts with h/o serious episode should be with h/o serious episode should be counseled to avoid repeat pregnancycounseled to avoid repeat pregnancy

Cardiomyopathy and PregnancyCardiomyopathy and PregnancyNotes on medical therapyNotes on medical therapy

• NO ACEI, ARB during pregnancy. (in NO ACEI, ARB during pregnancy. (in animals fetal hypotension and death. Also animals fetal hypotension and death. Also early delivery, low birth weight, early delivery, low birth weight, oligohydramnios, neonatal anuria and renal oligohydramnios, neonatal anuria and renal failure)failure)

• DigoxinDigoxin and and hydralazinehydralazine are considered are considered safe during pregnancy and breast feeding. safe during pregnancy and breast feeding.

• Diuretics can be used if sx not controlled by Diuretics can be used if sx not controlled by decreased salt and central venous pressue decreased salt and central venous pressue elevated. Most experience with elevated. Most experience with thiazidesthiazides and and lasixlasix. (diuretics impair uterine blood . (diuretics impair uterine blood flow and placental perfusion). flow and placental perfusion).

• Metoprolol, atenolol, labetalolMetoprolol, atenolol, labetalol have been have been used safely in pregnancy—fetal monitoring used safely in pregnancy—fetal monitoring recommended for risk of intrauterine recommended for risk of intrauterine growth retardation and fetal bradycardia.growth retardation and fetal bradycardia.

• #58#58

• 35 y.o. female who has progressive dyspnea 35 y.o. female who has progressive dyspnea days after delivery. EF 20%. Treated ACEI, days after delivery. EF 20%. Treated ACEI, diuretic, B-blocker. Sx resolve. 12 mos diuretic, B-blocker. Sx resolve. 12 mos after delivery asymptomatic and EF 50% off after delivery asymptomatic and EF 50% off meds. She comes to you for counseling re: meds. She comes to you for counseling re: repeat pregnancy.repeat pregnancy.– Advise her that she may proceedAdvise her that she may proceed– Resume ACE I during pregnancyResume ACE I during pregnancy– Advise her not to become pregnant b/c of risk of Advise her not to become pregnant b/c of risk of

recurrent peripartum cardiomyopathy that may recurrent peripartum cardiomyopathy that may be fatalbe fatal

– Evaluate for another cause of cardiomyopathy Evaluate for another cause of cardiomyopathy b/c diagnosis of peripartum cardiomyopathy is b/c diagnosis of peripartum cardiomyopathy is now in question now in question

#58 Advise her not to become pregnant b/c of risk #58 Advise her not to become pregnant b/c of risk of recurrent peripartum cardiomyopathy that may of recurrent peripartum cardiomyopathy that may be fatalbe fatal

• Because recurrence of peripartum Because recurrence of peripartum cardiomyopathy is common, repeated cardiomyopathy is common, repeated pregnancy is contraindicated.pregnancy is contraindicated.

• Regarding cardiomyopathy in general Regarding cardiomyopathy in general and pregnancy:and pregnancy:– Avoid pregnancy is LVEF is less than 40% Avoid pregnancy is LVEF is less than 40%

or NYHA functional class is higher than II.or NYHA functional class is higher than II.– Bed rest is often required and close cardiac Bed rest is often required and close cardiac

and obstetric monitoring mandatoryand obstetric monitoring mandatory– Treating CHF is more difficult in pregnant Treating CHF is more difficult in pregnant

than in nonpregnant women.than in nonpregnant women.

• #104 28 y.o. female with aortic and mitral #104 28 y.o. female with aortic and mitral mechanical prosthesis. INR therapeutic. mechanical prosthesis. INR therapeutic. Pre-pregnancy consult.Pre-pregnancy consult.– Discontinue warfarin and treat with ASA and Discontinue warfarin and treat with ASA and

dipyridamole during first trimesterdipyridamole during first trimester– Continue warfarin through pregnancy and start Continue warfarin through pregnancy and start

heparin 5000 U SQ TID plus ASAheparin 5000 U SQ TID plus ASA– d/c warfarin and treat with enoxaparin 30 mg d/c warfarin and treat with enoxaparin 30 mg

SQ BID through pregnancySQ BID through pregnancy– d/c warfarin and initiate dose adjusted d/c warfarin and initiate dose adjusted

unfractionated heparin SQ during first unfractionated heparin SQ during first trimester and resume treatment with warfarin trimester and resume treatment with warfarin for rest of pregnancy until shortly before for rest of pregnancy until shortly before deliverydelivery

– Use clopidogrel and ASA for first trimester and Use clopidogrel and ASA for first trimester and warfarin for rest of pregnancy until shortly warfarin for rest of pregnancy until shortly before deliverybefore delivery

initiate dose adjusted unfractionated heparin SC initiate dose adjusted unfractionated heparin SC during first trimester and then resume treatment during first trimester and then resume treatment with warfarinwith warfarin------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Anticoagulation and PregnancyAnticoagulation and Pregnancy

• During pregnancy increased risk of During pregnancy increased risk of thombosis or embolismthombosis or embolism

• Pregnant women with mechanical heart Pregnant women with mechanical heart valve have a 10% risk for development valve have a 10% risk for development of prosthetic valve thrombosis or of prosthetic valve thrombosis or another life threatening complicationanother life threatening complication

• Data are limited on safety of various Data are limited on safety of various anticoagulation regimens and anticoagulation regimens and controversy persistscontroversy persists

Anticoagulation and PregnancyAnticoagulation and Pregnancy• Heparin does not cross the placentaHeparin does not cross the placenta• 12-24% incidence of thromboembolic 12-24% incidence of thromboembolic

complications including valve thrombosis in complications including valve thrombosis in high risk pregnant patients treated with SQ high risk pregnant patients treated with SQ unfractionated heparinunfractionated heparin

• Efficacy of dose adjusted SQ heparin not Efficacy of dose adjusted SQ heparin not established. Dose should be adjusted so established. Dose should be adjusted so that PTT is at lesat 2-3 times control value that PTT is at lesat 2-3 times control value 6 hours after adminstered. 6 hours after adminstered.

• Heparin may not provide sufficient Heparin may not provide sufficient anticoagulation for very high risk patients anticoagulation for very high risk patients (caged-ball or tilting disk--Bjork Shiley--(caged-ball or tilting disk--Bjork Shiley--mechanical prosthesis) mechanical prosthesis)

• Prolonged heparin can lead to Prolonged heparin can lead to thrombocytopenia, osteoporosis, alopeciathrombocytopenia, osteoporosis, alopecia

• Warfarin crosses the placentaWarfarin crosses the placentafetal fetal anticoagulationanticoagulationrisk of spontaneous risk of spontaneous abortion, prematurity, fetal deformity, abortion, prematurity, fetal deformity, stillbirth, retroplacental hemorrhage stillbirth, retroplacental hemorrhage and intracranial hemorrhage. and intracranial hemorrhage.

• Historic reports 30% (more recent data Historic reports 30% (more recent data 4-10%) risk 4-10%) risk warfarin embryopathywarfarin embryopathy— — bone and cartilage abnormalities, nasal bone and cartilage abnormalities, nasal hypoplasia, optic atrophy, blindness, hypoplasia, optic atrophy, blindness, retartdation, seizures--with use in first retartdation, seizures--with use in first trimester.trimester.– risk highest if exposure during 6risk highest if exposure during 6thth to 12 to 12thth

wk.wk.– Low risk if less than 5 mg QD warfarin Low risk if less than 5 mg QD warfarin

dose.dose.

• Warfarin does not enter breast milkWarfarin does not enter breast milk

C-section if labor occurs during warfarin C-section if labor occurs during warfarin anticoagulation due to risk of fetal anticoagulation due to risk of fetal intracranial hemorrhage. intracranial hemorrhage.

Current Recommendationsfor anticoagulation during pregnancy

Anticoagulation and pregnancy … Anticoagulation and pregnancy … Low Molecular Weight HeparinLow Molecular Weight Heparin

• Currently data insufficient to support use Currently data insufficient to support use LMWH during pregnancy. LMWH during pregnancy.

• It does not cross placenta and no It does not cross placenta and no teratogenic effects reported.teratogenic effects reported.

• 66thth ACCP conf supports use of LMWH ACCP conf supports use of LMWH throughout pregnancy except 24 hrs throughout pregnancy except 24 hrs before delivery when recommendation is before delivery when recommendation is IV unfractionated heparin. IV unfractionated heparin.

• However FDA changed labeling to state However FDA changed labeling to state enoxaparin not recommended for enoxaparin not recommended for prosthetic valves during pregnancyprosthetic valves during pregnancy..

More notes on Anticoagulation and More notes on Anticoagulation and pregnancy…pregnancy…

• Dipyridamole should not be used Dipyridamole should not be used during pregnancy (no data on during pregnancy (no data on clopidogrel or ticlopidine)clopidogrel or ticlopidine)

• Information limited on IIbIIIa inhibitors Information limited on IIbIIIa inhibitors during pregnancyduring pregnancy

• 81 mg ASA safe during pregnancy—81 mg ASA safe during pregnancy—recommended for patients with recommended for patients with shunts, cyanosis, or biologic-valve shunts, cyanosis, or biologic-valve prosthesis prosthesis – (A low dose of ASA may also decrease the (A low dose of ASA may also decrease the

incidence of preeclampsia.)incidence of preeclampsia.)

• Thombolytic therapy has been used in Thombolytic therapy has been used in pregnancy in emergencypregnancy in emergency

• #68 26 y.o. female 30 weeks #68 26 y.o. female 30 weeks pregnant murmur noted during pregnant murmur noted during pregnancy. Asymptomatic. Slight pregnancy. Asymptomatic. Slight elevated JVP. Parasternal lift. S1 elevated JVP. Parasternal lift. S1 normal. S2 prominent, fixed split. normal. S2 prominent, fixed split. Grade 2 mid peaking ejection murmur Grade 2 mid peaking ejection murmur LSB. Echo secundum ASD with RV LSB. Echo secundum ASD with RV enlargement. 8 weeks later in labor. enlargement. 8 weeks later in labor. What do you recommend?What do you recommend?– Full anticoagulation in postpartum periodFull anticoagulation in postpartum period– Hemodynamic monitoring during deliveryHemodynamic monitoring during delivery– ABX propylaxis during deliveryABX propylaxis during delivery– Early post partum ambulationEarly post partum ambulation– Delivery by c-sectionDelivery by c-section

•#68 Early post partum #68 Early post partum ambulationambulation– Decrease risk of DVTDecrease risk of DVT paradoxical paradoxical

embolismembolism

• #47 26 y.o. 30 weeks pregnant #47 26 y.o. 30 weeks pregnant murmur during pregnancy and murmur during pregnancy and intermittently in past. Asymptomatic. intermittently in past. Asymptomatic. Slight elevation JVP with an A wave. Slight elevation JVP with an A wave. Parasternal lift is noted. S1 normal S2 Parasternal lift is noted. S1 normal S2 prominent, fixed, split. Grade 2 mid prominent, fixed, split. Grade 2 mid peaking ejection systolic murmur at peaking ejection systolic murmur at LSB. What is most likely Dx?LSB. What is most likely Dx?– Physiologic murmur of pregnancyPhysiologic murmur of pregnancy– ASD with volume overloadASD with volume overload– Pulmonary valve stenosisPulmonary valve stenosis– Aortic regurgitationAortic regurgitation– Mitral stenosisMitral stenosis

# 47 ASD with volume # 47 ASD with volume overloadoverload----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------• Other notes on congenital heart Other notes on congenital heart

disease in pregnancydisease in pregnancy

• Congenital heart disease is the most Congenital heart disease is the most common form of structural heart disease common form of structural heart disease that affects women of childbearing age in USthat affects women of childbearing age in US

• Pregnant cyanotic women have a high risk Pregnant cyanotic women have a high risk of fetal loss. Cyanosis is a recognized of fetal loss. Cyanosis is a recognized handicap to fetal growth, resulting in low handicap to fetal growth, resulting in low birth weigh infantsbirth weigh infants

• The incidence of congenital heart disease in The incidence of congenital heart disease in offspring of women with congenital heart offspring of women with congenital heart disease is about 5 %.disease is about 5 %.

• #91 20 y.o. female in first trimester #91 20 y.o. female in first trimester progressive dyspnea. Acyanotic progressive dyspnea. Acyanotic woman with parasternal lift and loud woman with parasternal lift and loud P2. No S3 or S4. No murmur. EKG P2. No S3 or S4. No murmur. EKG tall P waves II, III, F and tall R in V1 tall P waves II, III, F and tall R in V1 and RAD. What is most likely dx?and RAD. What is most likely dx?– Severe pulmonic valve stenosis resulting Severe pulmonic valve stenosis resulting

in RV pressure overloadin RV pressure overload– Primary pulmonary hypertensionPrimary pulmonary hypertension– Large ASD causing RV enlargement and Large ASD causing RV enlargement and

pulm HTNpulm HTN– Severe mitral stenosisSevere mitral stenosis

• #91 Primary pulmonary hypertension.#91 Primary pulmonary hypertension.– ASD and VSD that result in severe ASD and VSD that result in severe

pulm HTN cause cyanosis. pulm HTN cause cyanosis. – In pulm stenosis P2 would be In pulm stenosis P2 would be

diminished or absent. diminished or absent. – Need to exclude secondary causes Need to exclude secondary causes

pHTN.pHTN.

Severe pulmonary Severe pulmonary hypertension in pregnancyhypertension in pregnancy

• PA pressure >70% systemicPA pressure >70% systemic

• Whether secondary or primary Whether secondary or primary carries 30-50% risk of maternal carries 30-50% risk of maternal death. death.

• If pulmonary hypertension identified If pulmonary hypertension identified counsel against pregnancycounsel against pregnancy

• Termination of pregnancy should be Termination of pregnancy should be considered.considered.

• #98 20 y.o. in first trimester of #98 20 y.o. in first trimester of pregnancy progressive dyspnea. You pregnancy progressive dyspnea. You diagnose severe pulm HTN. TEE diagnose severe pulm HTN. TEE excludes shunt. What is associated excludes shunt. What is associated with lowest risk of maternal with lowest risk of maternal mortality?mortality?– Termination of pregnancyTermination of pregnancy– Initiation of prostacyclin therapyInitiation of prostacyclin therapy– Intiation of bosentan therapyIntiation of bosentan therapy– Initiation of anticoagulationInitiation of anticoagulation– Initiation of ACEI therapyInitiation of ACEI therapy

#98—termination of pregnancy#98—termination of pregnancyCardiac contraindications to Cardiac contraindications to pregnancypregnancy

Severe pulmonary HTN is an absolute contraindication to pregnancy . 30-50% risk maternal death.

“ ”

Indications for C-section in women Indications for C-section in women with Cardiovascular Diseasewith Cardiovascular Disease• Obstetric reasonsObstetric reasons• Anticoagulation with warfarinAnticoagulation with warfarin• Controversial ReasonsControversial Reasons

– Fixed obstructive cardiac lesionFixed obstructive cardiac lesion– Pulmonary hypertensionPulmonary hypertension– Unstable aortic lesionUnstable aortic lesion

• Vaginal delivery is the preferred Vaginal delivery is the preferred mode of delivery in most women with mode of delivery in most women with heart diseaseheart disease..

____________________________

Valvular Heart DiseaseValvular Heart Disease

#15#15• 21 y.o. female, murmur on screening exam. 21 y.o. female, murmur on screening exam.

No PMH. Runs 3-8 miles daily for cross No PMH. Runs 3-8 miles daily for cross country. No syncope. SOB with windsprints. country. No syncope. SOB with windsprints. No FH sudden death. HR 52. BP 98/60. 2/6 No FH sudden death. HR 52. BP 98/60. 2/6 cresendo decresendo murmur loudest LUSB. cresendo decresendo murmur loudest LUSB. Which would suggest need for echo?Which would suggest need for echo?– Murmur decreases in intensity with Murmur decreases in intensity with

valsalvavalsalva– SOB with unusual exerciseSOB with unusual exercise– Soft S3Soft S3– Murmur peaks in intensity in the latter half Murmur peaks in intensity in the latter half

of systoleof systole– A split S1A split S1

#15 Murmur peaks in intensity in the latter #15 Murmur peaks in intensity in the latter half of systolehalf of systole

• Late-peaking suggests LV outflow Late-peaking suggests LV outflow obstructionobstructionfurther testing.further testing.

• Murmur of dynamic subvalvular LV outflow Murmur of dynamic subvalvular LV outflow obsturction (hypertrophic cardiomyopathy) obsturction (hypertrophic cardiomyopathy) increase with valsalva.increase with valsalva.

• AS and PS and MR and TR diminish during AS and PS and MR and TR diminish during valsalva.valsalva.

• Intensity of innocent flow murmurs also Intensity of innocent flow murmurs also diminish during valsalva.diminish during valsalva.

• Flow murmurs peak in the first half of systoleFlow murmurs peak in the first half of systole

• An S3 is common in children and young adultsAn S3 is common in children and young adults

Echo for evaluation of Echo for evaluation of murmursmurmurs

Murmurs….Murmurs….• VSD: pansystolic, palpable thrill may be VSD: pansystolic, palpable thrill may be

associatedassociated• PDA: continuous, machinery-likePDA: continuous, machinery-like• Increase with InspirationIncrease with Inspiration

– TR, TS, PS (right sided murmurs)TR, TS, PS (right sided murmurs)

• Increase with HandgripIncrease with Handgrip– Mitral regurgitationMitral regurgitation

• Aortic StenosisAortic Stenosis– Decrease with handgrip, decrease with Decrease with handgrip, decrease with

standing, decrease during valsalvastanding, decrease during valsalva

• Hypertrophic Obstructive CardiomyopathyHypertrophic Obstructive Cardiomyopathy– Decrease with handgrip, increase with Decrease with handgrip, increase with

standing, increase during valsalvastanding, increase during valsalva

• 63 y.o. male farmer. 3/6 holosystolic 63 y.o. male farmer. 3/6 holosystolic murmur at apex heard throughout murmur at apex heard throughout and louder at left sternal border. LV and louder at left sternal border. LV displaced laterally. HR 94. BP displaced laterally. HR 94. BP 136/80. ASYMPTOMATIC. Echo--136/80. ASYMPTOMATIC. Echo--myxomatous degeneration MV with myxomatous degeneration MV with partial flail posterior leaflet. LV partial flail posterior leaflet. LV enlarged. LV EF 52%.enlarged. LV EF 52%.– Surgery if LV dilated 8 weeks after ACEISurgery if LV dilated 8 weeks after ACEI– Surgery if MIBI normalSurgery if MIBI normal– Surgery if TEE shows repairable valveSurgery if TEE shows repairable valve– Surgery despite lack of symptomsSurgery despite lack of symptoms– Surgery contraindicated based on Surgery contraindicated based on

presence of LV dysfunctionpresence of LV dysfunction

Chronic severe MR w/ LV dysfunctionChronic severe MR w/ LV dysfunction--Surgery despite lack of symptoms--Surgery despite lack of symptoms----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

•Indications for surgery in chronic Indications for surgery in chronic severe mitral regurgitationsevere mitral regurgitation

SymptomsSymptoms

Left ventricular systolic Left ventricular systolic dysfunction (EF<60%, endsystolic dysfunction (EF<60%, endsystolic diameter>45mm)diameter>45mm)

Atrial fibrillationAtrial fibrillation

Pulmonary hypertensionPulmonary hypertension

•Intervention for chronic severe MR Intervention for chronic severe MR should be considered earlier if should be considered earlier if successful mitral valve repair is likelysuccessful mitral valve repair is likely

Chronic Mitral regurgitation Chronic Mitral regurgitation

• Organic: Myxomatous degeneration, Organic: Myxomatous degeneration, rheumatic, infective endocarditis …rheumatic, infective endocarditis …

• ““Functional”: Dilated Functional”: Dilated cardiomyopathy, ischemic (prior MI)cardiomyopathy, ischemic (prior MI)

• Chronic left ventricular volume Chronic left ventricular volume overloadoverload

• Forward CO preserved by LV dilation Forward CO preserved by LV dilation at expense of increased wall stressat expense of increased wall stress

Chronic Mitral regurgitationChronic Mitral regurgitation• Vasodilators improve hemodynamics Vasodilators improve hemodynamics

in in acuteacute MR, role in chronic MR not MR, role in chronic MR not adequately studied. Thus routine use adequately studied. Thus routine use in asymptomatic pts not in asymptomatic pts not recommended. If HTN present, then recommended. If HTN present, then vasodilator. And, in pts with functional vasodilator. And, in pts with functional MR complicating cardiomyopathy, MR complicating cardiomyopathy, afterload reduction is indicated.afterload reduction is indicated.

• In anorectic drug (fenfluramine and In anorectic drug (fenfluramine and dexfenfluramine) induced MR (or AR) dexfenfluramine) induced MR (or AR) regurgitation appears to regress in the regurgitation appears to regress in the first year after discontinuation of first year after discontinuation of exposure.exposure.

• # 51. 54 y.o. female evaluated for exertional # 51. 54 y.o. female evaluated for exertional dyspnea. Orthopnea for mos. Rheumatic fever as dyspnea. Orthopnea for mos. Rheumatic fever as a child. No palpitations. HR 86, BP 124/76. JVP a child. No palpitations. HR 86, BP 124/76. JVP 14. Bibasilar rales. Regular rhythm, diminished 14. Bibasilar rales. Regular rhythm, diminished S1, widely split S2. 3/6 holosystolic murmur at S1, widely split S2. 3/6 holosystolic murmur at apex radiating to axilla. 2/6 holosystolic murmur at apex radiating to axilla. 2/6 holosystolic murmur at LLSB increases with inspiration. 2/6 decresendo LLSB increases with inspiration. 2/6 decresendo diastolic rumble at apex. EKG sinus, RVH, BAE. diastolic rumble at apex. EKG sinus, RVH, BAE. Echo-- BAE, normal LV size and fxn. RVE, normal Echo-- BAE, normal LV size and fxn. RVE, normal fxn. Mitral leaflets thickened and restricted. fxn. Mitral leaflets thickened and restricted. Minimal leaflet Ca++ and mild to mod subvalvular Minimal leaflet Ca++ and mild to mod subvalvular thickening. Mean grad 11 and valve area 0.9 cm2. thickening. Mean grad 11 and valve area 0.9 cm2. Severe MR and TR noted. RV systolic 62 mmHg. Severe MR and TR noted. RV systolic 62 mmHg. Best course of action?Best course of action?– DigoxinDigoxin– ASAASA– Anticoagulation INR 2-3Anticoagulation INR 2-3– Percutaneous balloon mitral valvotomyPercutaneous balloon mitral valvotomy– Refer for mitral valve repair or replacementRefer for mitral valve repair or replacement

# 51 mitral valve repair or # 51 mitral valve repair or replacementreplacement------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Interventions Mitral Valve• Percutaneous balloon mitral valvotomy:Percutaneous balloon mitral valvotomy:

– Pliable, non-calcified valve, </= 2+ MR, no Pliable, non-calcified valve, </= 2+ MR, no other cardiac intervention required other cardiac intervention required

– (3 or 4+ MR, LA thrombus contraindications)(3 or 4+ MR, LA thrombus contraindications)

• Open commissurotomyOpen commissurotomy– Relatively pliable noncalcified valve, any Relatively pliable noncalcified valve, any

amount MR, no other cardiac intervention amount MR, no other cardiac intervention requiredrequired

• MVRMVR– Calcified nonpliable valvesCalcified nonpliable valves

• In pregnant women, ballon valvotomy In pregnant women, ballon valvotomy associated with fewer fetal complications associated with fewer fetal complications than open commussurotomythan open commussurotomy

Mitral StenosisMitral Stenosis• Often due to previous rheumatic heart diseaseOften due to previous rheumatic heart disease• Normal MVA 4-5. Mod MS 1-1.5, Sev MS<1cm2.Normal MVA 4-5. Mod MS 1-1.5, Sev MS<1cm2.• MS exacerbated by a.fib, exercise, stress, fever, MS exacerbated by a.fib, exercise, stress, fever,

pregnancy pregnancy (b/c increased HR leads to shorter diastolic filling period)(b/c increased HR leads to shorter diastolic filling period)

• Abx prophylaxis against endocarditis and Abx prophylaxis against endocarditis and rheumatic fever (at least 10 yrs after last rheumatic fever (at least 10 yrs after last episode or until age 40, lifetime in high risk (ie. episode or until age 40, lifetime in high risk (ie. teachers), salt restriction, diuretics, negative teachers), salt restriction, diuretics, negative chronotropic (prolong filling period) agents. chronotropic (prolong filling period) agents. Anticoagulation if a.fib or prior thomboembolus.Anticoagulation if a.fib or prior thomboembolus.

• Echo if change in symptoms. Mild to mod pHTN Echo if change in symptoms. Mild to mod pHTN (PASP >40) may be indication for more (PASP >40) may be indication for more frequent follow up.frequent follow up.

• #80#80• 36 y.o. with substernal chest pressure. 2 36 y.o. with substernal chest pressure. 2

mos progressive fatigue, dysnea, palps. 2 mos progressive fatigue, dysnea, palps. 2 hours began CP to jaw, SOB. BP 110/90. hours began CP to jaw, SOB. BP 110/90. HR 110 and irregular. Elevated JVP, HR 110 and irregular. Elevated JVP, crackles, irregular, accentuated P2. crackles, irregular, accentuated P2. diastolic rumble at apex. EKG a.fib, RBBB, diastolic rumble at apex. EKG a.fib, RBBB, RAD, ST elevation V2-5. Cause?RAD, ST elevation V2-5. Cause?– CAD plaque ruptureCAD plaque rupture– Coronary thromboembolism from LV Coronary thromboembolism from LV

thrombusthrombus– Coronary thromboembolism from LA Coronary thromboembolism from LA

thrombusthrombus– Coronary arteritisCoronary arteritis– Coronary vasospasmCoronary vasospasm

• # 80 Coronary embolism from LA # 80 Coronary embolism from LA thrombusthrombus

• #75 28 y.o. female with palpitations #75 28 y.o. female with palpitations (heavy beat then pause) no associated (heavy beat then pause) no associated sx. HR 72 BP 108/68. Mid systolic sx. HR 72 BP 108/68. Mid systolic nonejection click. EKG sinus no nonejection click. EKG sinus no preexcitation. Echo posterior leaflet preexcitation. Echo posterior leaflet prolapse with mild late systolic MR. prolapse with mild late systolic MR. Holter multiple PVC’s. Next step?Holter multiple PVC’s. Next step?– History and PE in 1-2 yrsHistory and PE in 1-2 yrs– TEETEE– LisinoprilLisinopril– Echo in 6 mosEcho in 6 mos– Propafenone therapyPropafenone therapy

#75 History and PE in 1-2 years#75 History and PE in 1-2 years--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

– Mitral Valve prolapseMitral Valve prolapse• Most patients with MVP have a good Most patients with MVP have a good

prognosisprognosis

• Patients with myxomatous disease are Patients with myxomatous disease are at risk for valve degeneration with MRat risk for valve degeneration with MR

• Endocarditis prophylaxis in patients Endocarditis prophylaxis in patients with MR or leaflet thickeningwith MR or leaflet thickening

• MVP syndrome—palpitations and MVP syndrome—palpitations and atypical chest painatypical chest pain

#23#23• 76 y.o. male to your office for yearly 76 y.o. male to your office for yearly

exam. Over 6 mos decreased exercise exam. Over 6 mos decreased exercise tolerance—dyspnea and CP uphill. No SOB tolerance—dyspnea and CP uphill. No SOB at rest. No syncope. CAD. Lipids. h/o at rest. No syncope. CAD. Lipids. h/o stent. ASA. Lipitor. HR 82. BP 142/82. stent. ASA. Lipitor. HR 82. BP 142/82. 3/6 cresendo decresendo systolic RUSB to 3/6 cresendo decresendo systolic RUSB to carotids. Delayed upstroke of pulse. Echo carotids. Delayed upstroke of pulse. Echo LVH, nl fxn. Peak aortic 86, mean 44. Mid LVH, nl fxn. Peak aortic 86, mean 44. Mid RCA 70%. 0.7 cm2.RCA 70%. 0.7 cm2.

• What is the best course of action?What is the best course of action?– Refer AVR and CABGRefer AVR and CABG– Refer valvotomy and PTCIRefer valvotomy and PTCI– DP MIBIDP MIBI– Exercise testingExercise testing– No interventionNo intervention

# 23 AVR plus CABG# 23 AVR plus CABG--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

• # 116 71 y.o. male CHF. LV impulse # 116 71 y.o. male CHF. LV impulse enlarged and lateral. Late peaking enlarged and lateral. Late peaking cresendo decresendo systolic cresendo decresendo systolic murmur. Echo global LV dysfunction. murmur. Echo global LV dysfunction. EF 20-25%. AV calcified decreased EF 20-25%. AV calcified decreased opening. Peak grad 26 mean 16. opening. Peak grad 26 mean 16. What test next?What test next?– TEETEE– Exercise stress test with EKGExercise stress test with EKG– Dobutamine stress echoDobutamine stress echo– Adenosine MIBIAdenosine MIBI

# 116 Dobutamine stress echo# 116 Dobutamine stress echo------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

– Low gradient Aortic StenosisLow gradient Aortic Stenosis

• Aortic valve gradients depend on flowAortic valve gradients depend on flow

• Patients with LV dysfunction have increased Patients with LV dysfunction have increased perioperative riskperioperative risk

• An increase in aortic gradients in setting An increase in aortic gradients in setting systolic augmentation of LV suggests AS is systolic augmentation of LV suggests AS is severe. severe. (AVR better long term survival than med if severe AS (AVR better long term survival than med if severe AS and contractile reserve)and contractile reserve)

• Contractile reserve without an increase in Contractile reserve without an increase in gradients suggest that stenosis is not gradients suggest that stenosis is not severe.severe.

• Lack of contractile reserve suggest a poor Lack of contractile reserve suggest a poor prognosis after AVR. prognosis after AVR. (AVR worse long term survival than (AVR worse long term survival than meds if no contractile reserve)meds if no contractile reserve)

More notes on Aortic Stenosis …More notes on Aortic Stenosis …

• Asymptomatic patients with severe Asymptomatic patients with severe AS have a good prognosisAS have a good prognosis

• Severe AS valve area <1.0cm2, Severe AS valve area <1.0cm2, mean gradient >50 mmHg.mean gradient >50 mmHg.

• Consider patient size. Valve area of Consider patient size. Valve area of 0.45cm2/m2 is severe.0.45cm2/m2 is severe.

• Echo follow up in asymptomatic ASEcho follow up in asymptomatic AS– Every 5 years mildEvery 5 years mild– Every 2 years moderateEvery 2 years moderate– Every year severe (to detect Every year severe (to detect

development asymptomatic LV development asymptomatic LV dysfunction)dysfunction)

More notes on Aortic Stenosis …More notes on Aortic Stenosis …• AVR in symptomatic patients with severe AS.AVR in symptomatic patients with severe AS.• Consider AVR in asymptomatic patients with Consider AVR in asymptomatic patients with

severe stenosis AND left ventricular severe stenosis AND left ventricular dysfunction, marked LVH, hypotension on dysfunction, marked LVH, hypotension on exercise testing, or moderate or greater exercise testing, or moderate or greater valve calcification and a rapid increase in valve calcification and a rapid increase in aortic jet velocity.aortic jet velocity.

• Added risk for noncardiac surgery in severe Added risk for noncardiac surgery in severe symptomatic AS (mortality rate as high as symptomatic AS (mortality rate as high as 10%) 10%) – if elective AVR first,if elective AVR first,– if not surgical (AVR) candidate percutaneous if not surgical (AVR) candidate percutaneous

valvuloplasty may be consideredvalvuloplasty may be considered• If severe AS but asymptomatic noncardiac If severe AS but asymptomatic noncardiac

surgery can be performed with close surgery can be performed with close intraoperative monitoring with only slightly intraoperative monitoring with only slightly increased risk.increased risk.

• # 66 36 y.o. man to ICU with abrupt # 66 36 y.o. man to ICU with abrupt hypotension and hypoxemia. hypotension and hypoxemia. Intubated. 38.1, 121, 88/30, pulm Intubated. 38.1, 121, 88/30, pulm edema. Regular with summation edema. Regular with summation gallop. No murmur. TTE inadequate. gallop. No murmur. TTE inadequate. TEE bicuspid AV partially destroyed TEE bicuspid AV partially destroyed with vegetations. Severe AI. Normal with vegetations. Severe AI. Normal LV fxn. You start abx. Which is LV fxn. You start abx. Which is indicated?indicated?– B-blockerB-blocker– NitroprussideNitroprusside– Intraaortic balloon pumpIntraaortic balloon pump– Cath and coronary arteriographyCath and coronary arteriography– Transfer for surgery for emergent AVRTransfer for surgery for emergent AVR

(#66 Nitroprusside)(#66 Nitroprusside)• After load reducing therapy with or After load reducing therapy with or

without inotropic support to optimize without inotropic support to optimize forward cardiac outputforward cardiac output

• IABP contraindicated in aortic regurgIABP contraindicated in aortic regurg

• Depending on response to intensive Depending on response to intensive medical intervention medical intervention patient may patient may require urgent surgeryrequire urgent surgery. If surgery . If surgery can be deferred to allow a period of can be deferred to allow a period of therapy with ABX early postop therapy with ABX early postop infection after AVR is less likely.infection after AVR is less likely.

Notes on acute valve Notes on acute valve regurgitationregurgitation• Patients with acute severe AR or MR are Patients with acute severe AR or MR are

symptomatic and may present with symptomatic and may present with cardiogenic shockcardiogenic shock

• Many physical findings of chronic severe Many physical findings of chronic severe regurgitation are NOT present in patients regurgitation are NOT present in patients with acute severe regurgitationwith acute severe regurgitation

• Diagnosis is with echoDiagnosis is with echo

• IABP useful in acute severe MR but IABP useful in acute severe MR but contraindicated in ARcontraindicated in AR

• Urgent or emergent surgical intervention Urgent or emergent surgical intervention is usually indicated in acute mitral or is usually indicated in acute mitral or aortic regurgitationaortic regurgitation

• # 85 86 y.o. female evaluated for # 85 86 y.o. female evaluated for recent abrupt onset dyspnea. She recent abrupt onset dyspnea. She had a bioprosthetic AV placed 16 had a bioprosthetic AV placed 16 years ago for calcific AS. No fever. years ago for calcific AS. No fever. Harsh cresendo decresendo systolic Harsh cresendo decresendo systolic murmur at RUSB to carotids. What is murmur at RUSB to carotids. What is cause of SOB?cause of SOB?– Prosthetic valve failureProsthetic valve failure– Paraprosthetic leakParaprosthetic leak– Thrombus formationThrombus formation– Mitral stenosis and mitral regurgitationMitral stenosis and mitral regurgitation– Infective endocarditisInfective endocarditis

• #85 Prosthetic valve failure#85 Prosthetic valve failureAfter 16 yrs valve at risk for failure, cuspal After 16 yrs valve at risk for failure, cuspal calcification and then fracture leading to calcification and then fracture leading to acute AR. Intuitively should expect diastolic acute AR. Intuitively should expect diastolic murmur. However murmur of AR may not murmur. However murmur of AR may not be prominent whereas the increase in be prominent whereas the increase in stroke volume across calcified bioprosthesis stroke volume across calcified bioprosthesis is more audible. Thombosis not likely in is more audible. Thombosis not likely in bioprosthetic valve placed years earlier.bioprosthetic valve placed years earlier.

• KEY POINT—In patients with prosthetic KEY POINT—In patients with prosthetic valves and new/changed cardiac valves and new/changed cardiac symptoms, need to evaluate valve.symptoms, need to evaluate valve.

• #100 35 y.o. female for f/up AVR 3 #100 35 y.o. female for f/up AVR 3 mos ago for congenital bicuspid mos ago for congenital bicuspid aortic valve. No a.fib or aortic valve. No a.fib or thromboembolism. Echo shows thromboembolism. Echo shows normal mechanical aortic valve.normal mechanical aortic valve.– Coumadin INR 2-3Coumadin INR 2-3– INR 2.5-3.5INR 2.5-3.5– INR 2-3 plus ASA 100 mgINR 2-3 plus ASA 100 mg– INR 2.5-3.5 plus ASA 100 mgINR 2.5-3.5 plus ASA 100 mg– ASA 650 mg QDASA 650 mg QD

#100 INR 2-3. #100 INR 2-3. Prosthetic Prosthetic ValvesValves

Preoperative Cardiac Preoperative Cardiac EvaluationEvaluation

• ACC/AHA Guidelines.ACC/AHA Guidelines.– The need for preoperative testing is determined The need for preoperative testing is determined

by:by:•1)Clinical predictors of the patient 1)Clinical predictors of the patient

(minor/intermediate/major).(minor/intermediate/major).

•2)Risk of the surgery (low/intermediate/high).2)Risk of the surgery (low/intermediate/high).

•3)Patient’s functional status (</> 4 METS).3)Patient’s functional status (</> 4 METS).

– Remember that all patients requiring emergent Remember that all patients requiring emergent surgery go to the OR immediately regardless of surgery go to the OR immediately regardless of cardiac risk.cardiac risk.

• Don’t forget benefit of Beta-blockade to goal HR 60Don’t forget benefit of Beta-blockade to goal HR 60

Patient Clinical Predictors

Risk of Surgery

Functional Capacity

Shortcut to noninvasive testing Shortcut to noninvasive testing in preop patients if any two in preop patients if any two factors are presentfactors are present

– Intermediate clinical predictorsIntermediate clinical predictors (class 1 or 2 angina, prior MI based on (class 1 or 2 angina, prior MI based on Q’s, compensated or prior heart failure, Q’s, compensated or prior heart failure, diabetes, or renal insufficiency)diabetes, or renal insufficiency)

– Poor functional capacityPoor functional capacity– High risk surgeryHigh risk surgery (emergency—may (emergency—may

not have a choice---,aortic repair, not have a choice---,aortic repair, peripheral vascular surgery, prolonged peripheral vascular surgery, prolonged surgical procedures with large fluid surgical procedures with large fluid shifts or blood loss)shifts or blood loss)