Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
105 Cards in this Set
- Front
- Back
What is Aortic Stenosis?
|
obstruction of LV outflow
pressure gradient between LV and aorta lumen less than 1.0cm2 leads to LVH (then possible dilatation) |
|
In AS, What is Congenital bicuspid AV?
|
asymptomatic, until around 50yo (calcification, rigidity, narrowing)
|
|
In AS, explain rheumatic
|
“childhood febrile illness” usually only seen after mitral stenosis (commissural fusion, calcification, narrowed orifice)
|
|
What are the 4 NYHA Classification?
|
Etiology (congenital, acquired)
Anatomy (valvular, coronaries, muscle) Physiology (arrhythmia, ischemia, CHF) Functional limitation (degree of activity that elicits symptoms) |
|
what is “Senile” Calcific in AS
|
elderly (fibrosis, heavy calcification, fusion of leaflets)
|
|
List 3 signs & symtoms for AS
|
Angina
Syncope Dyspnea |
|
List late findings of AS
|
Left ventricular failure
Severe pulmonary hypertension Resultant right heart failure 15-20% sudden death |
|
On physical exam, what are the findings for AS?
|
Lower B/P with narrowed pulse pressure
Delayed and diminished pulses Prominent “a-wave” on jugular venous exam Palpable S4 with non-displaced, sustained PMI “thrill” at the base |
|
Auscaltation for AS should may hear
|
Apical S4 (plus S3 if CHF present)
“diamond-shaped” murmur (crescendo-descrescendo) Low pitch, rough, “rasping” murmur at the base radiating to the carotids “parodoxical S2 split” from constant late A2 |
|
How will an AS chest xray present?
|
Post-stenotic dilation of the aorta
Calcification of aortic valve on x-ray or fluoroscopy signs of congestion with LVH, dilatation of RV |
|
What will you see on an ECG for an AS?
|
Possible Atrial Fibrillation
Left axis deviation LBBB or intra-ventricular conduction delay (from diffuse myocardial fibrosis) If LAE present, look for MV disease |
|
An ECG/ Doppler may show?
|
LVH
Aortic Valve Calcified Eccentricity, ? Bicuspid Evaluate LV ejection fraction Doppler interrogation allows calculation of AVA additional valvular abnormalities (ie AI, MR, etc) |
|
How can Cardia Catherization help in an AS?
|
Hemodynamics and presence/degree of pulmonary hypertension
Measure LV/Aortic gradient Calculate valve area Evaluate LV ejection fraction Presence/absence of CAD |
|
What is the best management for AS?
|
fix outflow obstruction
plan repair/replacement Medical therapy Endocarditis prophylaxis!!!! CHF stabilization Avoid pre-and after-load therapies Balloon dilation in young bicuspid valve but not in senile calcific |
|
Is valve replacement for AS patients necessary?
|
Yes, surgery is indicated for all symptomatic pts
|
|
What is used to valve replacement and how is it maintained?
|
Either tissue (porcine or human) or mechanical
Anticoagulation always necessary in mechanical With INR 2.5-3.5 normal Tissue valves “wear-out early” Endocarditis prophylaxis always needed Close monitoring for leaks, clot, infection |
|
What is AORTIC INSUFFICIENCY Regurgitation
|
LV end-diastolic volume increases hemodynamic issue
The chamber thickens and dilates to accommodate the regurgitant volume until heart can weigh 4x normal (1000gms) Eventually the LV fails causing pulmonary hypertension and resultant RV failure |
|
what are the causes for AI?
|
Infectious (endocarditis, syphilitic)
Inflammatory (Rheumatic, ankylosing spondylitis, Lupus) Congenital (bicuspid, prolapse associated with VSD, congenital fenestrations) Degenerative (Cystic medial necrosis, Marfan’s) Traumatic |
|
Historically how would an AI pt present?
|
Asymptomatic until middle age
May have history of murmur, bicuspid valve, RHD signs of LV overload and failure (SOB, orthopnea, PND, etc) |
|
what would you see on a physical exam for pt c AI?
|
Wide pulse pressure
Physical findings of Marfan’s Displaced PMI w/palpable S3 and S4 Possible pulmonary congestion Diastolic “blowing” murmur along LSB Ejection click at aortic valve w/systolic murmur Rumbling apical diastolic “Austin-Flint” murmur of early MV closure |
|
What causes Peripheral Manifestations of AI? and list the signs
|
Result from large stroke volume with rapid diastolic runoff:
DeMusset’s sign Corrigan’s pulse Quincke’s sign Duroziez’ murmur Muller’s sign Hill’s sign |
|
what is DeMusset's sign?
|
Bobbing head
|
|
What is Corrigan’s pulse?
|
Water-hammer pulse, rapidly rising and falling
|
|
What is Quincke’s sign?
|
Arterial pulsations of the nailbeds
|
|
What is Duroziez’ murmur?
|
Systolic and diastolic murmur over femoral artery
|
|
What is Muller’s sign?
|
Rhythmic pulsation of uvula
|
|
What is Hill’s sign?
|
A disproportionate elevation in FA pressure
|
|
How will an AI present on chest xray?
|
Enlarged heart if chronic with signs of pulmonary congestion
Possible Calcified AV Enlarged aorta in connective tissue disorders |
|
What would you see on a pt c AI ECG?
|
LVH
ST depression and T wave inversions Left axis deviation Widened QRS (from patch fibrosis – bad sign!) |
|
What will and ECG/Doppler show on an AI pt?
|
Expanded systolic excursion free wall of LV
“supernormal” velocity of wall motion Rapid, high frequency fluttering of anterior leaflet MV (Austin Flint murmur) Dilated LV, LA, Aortic Root regurgitant flow from aorta into LV during diastole |
|
What is cardia catherization used for in a pt c AI?
|
presence and severity of AI
Assess LV function R/O Coronary artery disease |
|
How can Radionuclide Studies help in AI pt?
|
evaluate LV function at rest and with exercise
A decreased EF w/exercise suggests myocardial impairment |
|
What Medical Treatment are used for pt c AI?
|
Vasodilators
ACE-I B-blockers in Marfans diuretics, salt restriction digoxin Manage arrhythmias SBE prophylaxis Penicillin for syphilitic ?anticoagulation |
|
What do ACE-I do for AI pts?
|
Reduces regurge
|
|
List Vasodialators for AI pts?
|
Hydralazine, nifedipine, ACE-I
|
|
How does diuretics, salt restriction assist pt c AI?
|
Reduce pre-load
|
|
What is digoxin used for in AI pt?
|
Improve inotropy
|
|
When is Surgical Treatment needed for AI pt?
|
Symptomatic pt EF < 55% or LV end-systolic dimension > 5.0 cm on M-mode Echo
Surgery on aortic root for diameter >5.5 cm (or 5.0 in Marfans) |
|
When is it Considerable mortality for AI pt?
|
if LV severely decompensated
“time to operate” sometimes difficult to determine |
|
What is a main characteristic of pt c AI?
|
High pitched "decrescendo diastolic murmur"
Accentuated by sitting up/ leaning forward Austin Flint murmur: Apical low pitched diastolic rumble LVH |
|
What are the Features of the Mitral Valve? (MR)
|
bileaflet (anter and poster)
complex support structure (chordae tendinea,papillary muscles, annulus, wall of LV) on “high pressure” left ventricular contraction plays an active role |
|
What are the signs for Chronic MR?
|
Degenerative
Infectious Structural |
|
Explain the degenerative features of a chronic MR pt?
|
myxomatous degeneration, annular calcification, Marfan Syndrome
|
|
Explain the Infectious features of a chronic MR pt?
|
Infective endocarditis
|
|
Explain the structural signs for a chronic MR pt?
|
ruptured chordae tendineae, papillary muscle dysfunction, increased annulus as result of LV dilatation, prosthetic valve leak
|
|
Explain the degenerative features of an acute MR pt?
|
Myxomatous degeneration with chordal rupture
|
|
Is the feature of an acute and a chronic MR pt the same in the infectious sign?
|
Yes the same Infective endocarditis
|
|
Explain the Structural features of an acute MR pt?
|
rupture of papillary muscle secondary to ischemia, malfunction of prosthetic valve, trauma
|
|
What is the process in chronic MR pt?
|
gradual dilatation of LV and LA with the LA accommodating the volume.
Little in the way of transmitted pressure to the lungs till late, then pul HTN and right heart failure |
|
What is the process in acute MR pt?
|
instantaneous transmission right thru the normal sized LA into the pulmonary venous system with severely elevated pressures, pulmonary edema and acute right heart strain
|
|
What finding in pt history increases MR?
|
inciting event
Well tolerated chronically until evidence of left heart failure Findings of Right heart failure |
|
What are the inciting events in a MR pt history?
|
childhood rheumatic fever, febrile illness after dental procedure, CHF
|
|
What are the signs for left heart failure in a MR pt?
|
DOE, orthopnea
|
|
What are the findings of Right heart failure in a MR pt?
|
peripheral edema, increased JVD, hepatomegaly
|
|
What are the findings on a Physical Examination of Chronic MR pt?
|
Increased “a” wave
Carotids with early sharp upstroke, then normal Laterally and inferiorly displaced PMI with palpable S3 and S4 Holosystolic (Pansystolic) diastolic murmur at apex radiating to axillae Pulmonary Ejection sound from pul HTN Left atrial lift late systole behind RV, “rocking motion |
|
What will chest xray show for a Chronic MR pt?
|
left atrial, left ventricular and right ventricular enlargement
|
|
What will chest xray show for an Acute MR pt?
|
pulmonary edema without chamber enlargement
|
|
What are the secondary findings on ECG to the chamber's of a MR pt?
|
Increased voltage of LA and LV in chronic MR
Atrial arrhythmias LAD until right heart failure then may shift rightwards |
|
What shows on Echocardiography of a MR pt?
|
Assessment of MV leaflet motion and directional doppler flow helps with mechanism of the MR
TEE allows precise MV detail Chamber size of LA, LV and RV Ejection fraction of LV always “over-estimation” as unloading into low pressure LA makes the LV “look good”… |
|
Why is Cardiac Catheterization used in Mr pt?
|
Hemodynamics with degree of pulmonary HTN measured and PCWP
LV angiogram to assess EF, LVEDP and quantitate degree of regurgitation (1+ mild to 4+ severe) LA size Presence of coronary artery disease |
|
Why do MR pt undergo Exercise Testing?
|
assessing severity of MR and timing of surgery
May have echo for transplant candidates |
|
What are the Medical Treatment to prevent LV failure and delay need for MV surgery for pt c MR?
|
Relieve LV wall stress
ACE inhibitors B/P control Prevent or treat ischemia Maintain sinus rhythm, treat arrhythmias Consider anticoagulation |
|
What are ACE inhibitors used for in MR pt?
|
first line therapy to allow easier LV emptying and reduce regurgitant volume, especially when LV dysfunction present
|
|
In MR pt at what level should Bp control?
|
to levels of <139 sys and <89 diastolic
|
|
In relieving LV wall stress we are really preventing _ in MR pt?
|
prevention of adverse remodeling
|
|
When should Surgical Intervention be considered for MR pt?
|
Symptomatic pt
EF <60% or marked LV dilation Repair vs replacement |
|
When is surgery considered for an acute MR?
|
endocarditis, MI, rupture chordae usually emergency surg
|
|
In a pt c MR when will you consider repair vs replacement?
|
Try to repair if at all possible, but if replace try to use patients own annular papillary structure
|
|
What are the causes of Mitral Stenosis MS and what are some of the signs?
|
DOE, Orthopnea, PND, hemoptysis (rupture of pul-bronch venous)
Causes: Rheumatic Fever Congenital disease |
|
What other symptoms may precipitate signs of MR?
|
Sx precipitated by Afib, pregnancy
|
|
What are the 2 syndromes for a MR pt?
|
Moderate: pulm edema
Severe: pulm HTN, low CO |
|
How does a MR sound?
|
Prominent mitral 1st sound, opening snap, apical diastolic rumble
|
|
Which bacteria found in Rheumatic Fever?
Found in what age group? |
strep pharyngitis (Group A)
age 5-15yrs |
|
How does the body react to Rheumatic fever, to develop MR?
|
Antibodies form in response to the strep antigen
These antibodies mistakenly attack host tissues! Special propensity for connective tissue, like valve collagen Inflammation occurs and repeated attacks with intermittent attempts at healing create fibrous thickening, adhesion of valve commissures |
|
What step may be taken to Prevent RF?
|
Treat strep pharyngitis aggressively!!!
Penicillin G or Penicillin V Oral sulfadiazine Oral erythromycin azithromycin |
|
What are the dosages for the prevention of RF?
|
IM injection of 1.2 million units of Penicillin G once a month or Penicillin V 250 mg BID (less effective)
Oral sulfadiazine 1 g daily for penicillin allergic patients Oral erythromycin 250 mg BID or azithromycin for both penicillin and sulfadiazine allergic patients |
|
What are the Major Jones Criteria in MS pt?
|
Migratory arthritis
Carditis Sub-cutaneous nodules Erythema marginatum Sydenham’s chorea |
|
What are the Minor Jones Criteria in Ms pt?
|
Fever
Elevated sedimentation rate/C-reactive protein Arthralgias Increased PR interval Prior RF or RHD |
|
What are the Criteria Needed for RF?
|
Two major
One major, two minor |
|
Which valves are affected in Rheumatic Heart Disease?
|
Mitral>aortic>tricuspid (almost never involves pulmonic)
|
|
What happens to the valves in Rheumatic Heart Disease?
|
Stenosis, regurgitation or combination of the two
|
|
When does the diagnosis of “RF” (where there is a “pancarditis”, arthritis, etc) change to “RHD”?
|
when there is residual evidence of cardiac impairment characteristic of this disease long after the acute illness has passed:
20 yrs after the acute illness (4th decade) |
|
what is the time frame for Acute rheumatic fever?
|
typically begins as polyarthritis 2-6 weeks after streptococcal pharyngitis
|
|
The Acute rheumatic fever disease involves what parts?
|
heart, joints, central nervous system (CNS), skin, and subcutaneous tissues
|
|
What might you expect on Mitral Stenosis Physical Exam?
|
Large “a” waves on JVP
Normal to Low blood pressure ? Palpable S1 Possible RV lift Diastolic “thrill” left apex in left lateral decubitus position |
|
Auscultation
|
S1 “snapping” and accentuated
Increased P2 with Ejection Click “Opening snap” of MV after S2 “diastolic rumble”, low-pitched at apex in LLD position, accentuates towards end Severity gauged by the closeness of “OS” to S2 and the duration of the murmur |
|
What else may be Associated findings on auscultation of MS pt?
|
Aortic stenosis/regurgitation
Tricuspid stenosis/regurg Mitral regurgitation Graham-Steell murmur of Pulmonic Insufficiency secondary to severe pulmonary hypertension |
|
What may be seen on chest Xray of MS pt?
|
Small LV
Straightened left heart border Prominent PA Dilatation of pulmonary veins upper lobes Kerly “B” lines of congested interlobular septa and lymphatics Esophagus displaced posteriorly secondary to LAE |
|
Electrocardiogram will show in a MS pt?
|
LAE
With pulmonary hypertension: RAE, RVH, Right axis deviation Atrial Fibrillation |
|
Echocardiogram will show in a MS pt?
|
Ant and poster leaflets of mitral valve do not separate fully
Decreased E-F slope Calcifications and thickening with shortening of the chords Decreased MV orifice LAE |
|
What may a Cardiac Catheterization advise in MS pt?
|
measure pressure
Calculate MVA Assess hemodynamics, severity of pulmonary hypertension Presence of MR Evaluate LV ejection fraction Evaluate for CAD |
|
Cardiac catherization approach is?
|
trans-septal approach to enter LA
|
|
What are the Treatments for asymptomatic patients c MS?
|
SBE prophylaxis
Limit strenuous physical activity MAINTAIN SINUS RHYTHM!!! Convert A-fib |
|
What are the SBE prophylaxis for asymptomatic MS pt?
|
Penicillin for prophylaxis of Beta-hemolytic strep
|
|
What are the Treatment for symptomaic patients c MS?
|
Limit Na+, use diuretics
Digoxin , beta-blocker Detect and treat anemia Consider anticoagulation Bedrest if hemoptysis present MAINTAIN SINUS RHYTHM!!! |
|
Digoxin is used for?
Beta-blocker used for? |
for Afib
to control rate |
|
When is Surgery needed for MS pt?
|
MVA <1.0cm2 and symptoms
If concurrent MS & MR Balloon valvuolplasty for lesser calcified MS without regurgitation Valve repair may be possible Ultimately replacement |
|
Which procedure not done much anymore in pt c MS?
|
Intra-operative “valvotomy”
|
|
When will replacement valves needed in MS pt?
|
first procedure in presence of heavy calcification or regurgitation
|
|
What kind of Post-surgical Care needed for MS pt?
|
Anticoagulation
maintain NSR SBE prophylaxis Good valve surveillance |
|
What is the most common cause of Mitral Stenosis?
|
Rheumatic Fever from Group A Beta-Hemolytic Strep
|
|
Where is Mitral Stenosis heard?
|
heard best at the apex in the left lateral decubitus position
|
|
Low pitched diastolic rumble best accentuated by which movements in Ms pt?
|
squatting (valsalva) or expiration
|
|
What other informative occurences may not be strep?
|
Occasional pts have hoarseness due to recurrent laryngeal nerve compression b/t aorta and pulmonary artery
|
|
What sounds upon auscultation
for pt c MS? |
Loud (Crisp) S1 , Increased P2
|