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230 Cards in this Set

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2 layers of pericardium
Visceral - inner serosal layer, adheres to pericardium

Parietal - outer fibrous layer
3 functions of pericardium
- Fixes the heart within the mediastinum and limits its motion

- It prevents extreme dilatation of the heart during sudden rises of cardiac volume

- Barrier to spread of infection from adjacent structures ( lungs)
Most common cause of acute pericarditis
VIRAL
3 types of infectious pericarditis
- Viral or idiopathic

- Tuberculous

- Pyogenic bacteria
Causes of non-infectious pericarditis
- Post MI

- Uremia

- Neoplastic disease

- Radiation induced

-Connective tissue disease

- Drug induced
2 types of post MI acute pericarditis
Early- first few days after MI

Dresslers syndrome- weeks to months after MI
Name drugs that cause acute pericarditis
- Drugs associated with drug induced lupus syndrome

Procainamide
Methyldopa
Hydrolazine
Isoniazide
Phenytoin

Also minoxidil and anthracycline antineoplastic agents
Name symptoms of acute pericarditis
Chest discomfort - sharp, pleuritic, positional - better with sitting, worse with lying

Dyspnea

Fever
-Auscultatory hallmark of acute pericarditis
-Sometimes heard in subacute or chronic pericarditis
Frictional rub
Describe pericardial friction rub
Can have 3 components - systolic, mid diastolic or late diastolic, evanescent
Where is pericardial friction rub should be heard, in which position?
Left sternal border - ask patient to lean forward, take a deep breath, blow it all out and hold it out
EKG findings of acute pericarditis
-Diffuse, concave-upward ST segment elevation in many of the EKG leads
-PR segment depression in the same leads that have ST segment elevation*
-PR segment elevation and ST segment depression are often seen in lead aVR (& sometimes V1)*
This EKG finding is very useful in differentiating ST segment elevation due to acute pericarditis from ST segment elevation due to other causes
PR segment elevation and ST segment depression are often seen in lead aVR (& sometimes V1)
Is chest x ray useful in diagnosis of acute pericarditis
Usually normal (in idiopathic/ viral pericarditis)
Is echo useful in diagnosis of acute pericarditis
-Usually normal (in idiopathic/ viral pericarditis)
-Should be ordered to evaluate for possible coexisting large pericardial effusion
CBC in patient with acute pericarditis will show _
Mild leukocytosis, with mild lymphocytosis (if viral/ idiopathic)
Is ESR level test useful in diagnosis of acute pericarditis
-Modestly elevated in viral/ idiopathic pericarditis
-If markedly elevated, consider other causes
If cardiac markers are elevated in patients with acute pericarditis what should you consider
Concomitant myocarditis or MI
Treatment for viral/idiopathic acute pericarditis
NSAIDS

Oral corticosteroids

Oral colchicine

Rest

Analgesia
What type of treatment should be avoided in patients with acute pericarditis due to MI
NSAIDS and oral steroids- increase chance of free wall rupture
These drugs are only used for pain refractory to NSAIDS and narcotic analgesia in patients with acute pericarditis (viral/idiopathic)
Oral colchicine and oral corticosteroids
Mainstay of therapy in treatment of acute viral pericarditis
NSAIDS
Treatment for tuberculous acute pericarditis
Prolonged anti TB therapy
Treatment for purulent acute pericarditis
Catheter drainage + antibiotics
Treatment for uremic acute pericarditis
Dialysis
3 complications for acute pericarditis
Pericardial effusion

Pericardial tamponade

Constrictive pericarditis
Accumulation of an abnormally large amount of fluid in the pericardial space
Pericardial effusion
Pericardial space normally contains _ of fluid
15-50 cc of fluid
Differential diagnosis for pericardial effusion
Malignancy

Post cardiac surgery

Post PCI

Complication of pericarditis

Thoracic aortic dissection

Chest trauma
Most useful test for pericardial effusion
Echo
3 determinants of symptom onset/ progression of pericardial effusion
-Rate of accumulation of pericardial fluid
-Volume of pericardial fluid
-Compliance of the pericardium
2 physical findings of large pericardial effusion
Muffled heart sounds

Ewarts sign
Ewarts sign (sign of pericardial effusion)
Dullness to percussion over the angle of the left scapula due to compression of the left lung by the enlarged pericardial sac
What do you see on EKG in large pericardial effusion
Low voltage

Electrical alternance
What do you see on x ray in moderate to large pericardial effusion
Globular, symmetric enlargement of cardiac silhouette in moderate to large effusions
“Water bottle” heart
Gold standard” test for detection, localization, and quantification of pericardial effusion
Echo
Treatment of pericardial effusion
-Treat underlying cause (if known)
-Observation-If cause is known and patient is asymptomatic
-Pericardiocentesis-If cause is unknown (sample of fluid may be sent for analysis: “diagnostic pericardiocentesis”) or If patient is symptomatic or if there is evidence of pericardial tamponade (“therapeutic pericardiocentesis”)
Cardiac chamber compression caused by pericardial effusion
Pericardial tamponade
Increase in RV volume during inspiration causes a slight shift of the interventricular septum _

Why does this occur?
To the left

This leftward shift of the interventricular septum only occurs to a mild degree, as the compliant pericardium allows outward expansion of the right ventricle to accommodate most of the increased venous return during inspiration
slight decrease in systolic pressure during inspiration which will increase during expiration
Pulsus paradoxus
Measuring pulsus paradoxus
-Apply correct size BP cuff and quickly obtain baseline BP.
-Re-inflate BP cuff to about 20 mmHg above baseline systolic BP.
-Be sure that no sound is heard during expiration or inspiration.
-Slowly deflate the cuff until the first Korotkoff sound can be heard during expiration but not inspiration.
-Note this pressure.
-Slowly deflate the cuff until the sound can be heard during both expiration and inspiration.
-Note this pressure.
-The difference between these two pressures is the pulsus paradoxus
Exaggerated pulsus paradoxus is a sign of _
Pericardial tamponade
Exaggeration (greater than 10 mm Hg during quiet breathing) of the normal decline in systolic arterial pressure during inspiration.
Exaggerated pulsus paradoxus
Is exaggerated pulsus paradoxus diagnostic of pericardial tamponade
Although an exaggerated pulsus paradoxus is considered to be one of the classic physical signs of pericardial tamponade, it is not specific for pericardial tamponade.
Potential causes of exaggerated pulsus paradoxus
Pericardial tamponade Pulmonary embolism
Asthma
Emphysema
Constrictive pericarditis (about one-third of patients)
Hypovolemic shock
Other causes of acute hypotension
Pregnancy
Extreme obesity
Most useful test for pericardial tamponade
Echo
Invasive measurement of intracardiac and intrapericardial pressures
Cardiac catherization
Patient presents with:

Exaggerated pulsus paradoxus
Hypotension*
Jugular venous distension*
Muffled heart sounds*
Tachycardia
Chest discomfort (sometimes)

Diagnosis?
Pericardial tamponade
Becks triad
-Hypotension
-Jugular venous distension (or high central venous pressure)
-Muffled or distant heart sounds
EKG changes of pericardial tamponade
-Sinus tachycardia (unless pharmacologically suppressed)
-EKG signs of large pericardial effusion may or may not be present
Cardiac cath of pericardial tamponade will show _
-Invasive measurement of intracardiac and intrapericardial pressures
-Diastolic equalization of pressures
-All cardiac chambers will have equal diastolic pressures*
-Right atrial pressure tracing
BLUNTED Y DESCENT
Definitive treatment of pericardial tamponade
Pericardiocentesis
Temporizing measure for pericardial tamponade
IV fluids
2nd line temporizing measure for pericardial tamponade
IV inotropes
Pericardial scarring leading to restricted diastolic filling of all four cardiac chambers
Constrictive pericarditis
Phases of impaired ventricular filling for pericardial tamponade
Early, mid and late diastole
Phases of impaired ventricular filling for constrictive pericarditis
Mid and late diastole
Used to be most common cause of constrictive pericarditis; rare cause in industrialized countries today
TB
Causes of constrictive pericarditis
Idiopathic (presumed previous virus)
Post cardiac surgery
Post radiation
Tuberculosis
Patient presents with

-Lower extremity edema
-Abdominal fullness/ discomfort
-Fatigue
-Dyspnea (later)
Constrictive pericarditis
Physical findings for constrictive pericarditis
Hepatomegaly

Ascites

Peripheral edema

Pericardial knock

Jugular venous distention

Kussmauls sign
Pericardial knock - early diastolic sound is caused by _
Abrupt cessation of ventricular filling caused by rigid pericardium
Pericardial knock is best heard at _
Left sternal border or cardiac apex
Kussmauls sign
Jugular venous pressure increased during inspiration
Kussmauls sign is the sign of _
Constrictive pericarditis
Increase in jugular venous pressure (distension) during inspiration (normally, JVP decreases during inspiration)
Kussmauls sign - constrictive pericarditis
Differential diagnosis for Kussmauls sign
-Constrictive pericarditis*
-Restrictive cardiomyopathy
-Right ventricular infarction
-Right ventricular failure
-Acute pulmonary embolism
-Pericardial tamponade (occasionally)
What do you see on chest x ray in patients with constrictive pericarditis
-Normal or mildly enlarged cardiac silhouette
-Pericardial calcification seen in about 50 % of patients
What do you see on cardiac cath in patients with constrictive pericarditis
Invasive measurement of intracardiac pressures
Diastolic equalization of pressures
All cardiac chambers will have equal diastolic pressures*
Right atrial pressure tracing
PROMINENT RAPID Y DESCENT*
Exaggerated y descent is a sign of _
Constrictive pericarditis
Cardiac cath

Right and left ventricular pressure tracings
“Dip and plateau” pattern in diastole*
A.K.A.: “square root sign”*


Diagnosis?
Constrictive pericarditis
Definitive treatment for constrictive pericarditis
Pericardiectomy
Symptomatic treatment for constrictive pericarditis ( should NOT delay surgery)
Diuretics and salt restriction
Rise in right atrial pressure due to right atrial contraction - wave?
A wave
Rise in right atrial pressure as the TR valve closes and bulges toward the right atrium - wave?
C wave
Rise in right atrial pressure during ventricular systole when the TR valve is (supposedly) closed- wave?
V wave
2 distinct components of S2 can be heard during inspiration but not expiration
Physiological (normal) spliting of S2
This heart sound is normal in children and young adults
S3
Causes for paradoxical splitting of S2
LBBB

L ventricular obstruction of ventricular outflow - AS, HOCM

R ventricular pacemaker

R ventricular ectopic beat

Systemic HTN
Auscultatory hallmark if ASD
Fixed splitting of S2
Cause of S3 in adults
Sudden limitation of longitudinal ventricular expansion during early rapid ventricular filling
Timing for S3
Early to mid diastole
Frequency of S3
Low (dull thud)
Location for listening to S3
Apex (L), lower LSB/xiphoid (R)
Cause for S4
Late diastolic ventricular distention due to exaggerated active atrial contribution to ventricular filling resulting from reduced ventricular compliance
Timing for S4
Late diastole (presystolic)
Frequency of S4
Low
Location for S4
Apex (L), lower LSB/xiphoid (R)
Altering hemodynamics by a variety of physiological and pharmacological maneuvers and observing their effects on auscultatory finding
Dynamic auscultation
_ increase in intensity (loudness) during inspiration except _
All R sided pathological auscultatory findings

Pulmonic ejection sound (congenital pulmonary stenosis_
What happens when you go from squatting to standing
Decreased venous return

Decreased ventricular preload

Decreased systemic vascular resistance
What happens when you go from standing to squatting
Increased venous return

Increased ventricular preload

Increased systemic resistance
Why do R sided problems increase in intensity on inspiration
Inspiration increases venous return to R side of the heart increasing volume and flow in the right side of the heart
What happens when you passively elevate legs while supine
Increased venous return
What happens in Valsalva maneuver
Decreased venous return

Decreased ventricular preload
What happens in Muller maneuver
Increased venous return

Increased ventricular preload
What happens in PVC in post ectopic beats
Increase contractility (predominant effect)

Increase preload
What happens in isometric exercise
Increased:

- Systemic resistance
- Cardiac output
- Heart rate
- Arterial pressure
- L ventricular filling pressure
- L ventricular volume
Potent vasodilator - used for dynamic auscultation - what happens?
Amyl nitrate

1st 30 seconds- decreases systemic arterial pressure

After 30-60 seconds- Increased heart rate and increased cardiac output
Cause hemodynamic effects opposite of amyl nitrite - should be avoided in CHF or systemic HTN
Vasopressors - methoxamine and phenylephrine
Murmurs result from _
Turbulent flow
What is grading system of murmurs based on?
Loudness/intensity of murmur
Grades _ murmurs have NO palpable thrill
1-3
Grades _ murmurs have palpable thrill
4-6
Very faint murmur, not usually heard during the first few seconds of listening - grade?
1/6
Faint murmur but heard immediately - grade?
2/6
Prominent but not loud murmur - grade?
3/6
Loud murmur usually associated with a palpable thrill - grade?
4/6
Very loud murmur, associated with palpable thrill audible with only one edge of stethoscope on the chest - grade?
5/6
Way loud murmur, associated with palpable thrill, audible with stethoscope removed slightly from contact with chest - grade?
6/6
What type of murmur begins with or after S1 and ends at or before S2
Systolic
What type of murmur begins with or after S2 and ends before the next S1
Diastolic
What type of murmur begins in systole and continues without interruption through the S2 into all or part of diastole
Continuous
What is more reliable in elucidating murmurs cause
Timing, quality as well as associated findings ( NOT anatomical location)
Which valves are open in diastole
Mitral and Tricuspid
Which valves are open in systole
Aortic and Pulmonary
Name systolic murmurs
MR

TR

AS

PS
Name diastolic murmurs
AR

PR

MS

TS
Name causes for systolic murmurs
- Outflow obstruction from either ventricle - AS, PS, HOCM, any stenosis
- Insufficiency of either AV valve - MR, TR
- VSD
- Ventricular ejection in non compliant great vessel - aortic sclerosis
- Ventricular ejection in high flow states - innocent murmurs (child, young adult), pregnancy, anemia, hyperthyroidism
2 types of systolic murmurs
Systolic ejection murmurs - crescendo-decrescendo, midsystolic, AS, PS, HOCM, most innocent murmurs

Holosystolic murmurs - TR, MR, VSD
Name holosystolic murmurs
TR, MR, VSD
Patient presents with classic holosystolic murmur - diagnosis
Chronic mitral regurgitation
Patient presents with early systolic crescendo-decrescendo murmur - diagnosis
Acute mitral regurgitation
Patient presents with midsystolic click, late systolic murmur - diagnosis
Mitral valve prolapse
- Holosystolic murmur
- DOES NOT get louder during inspiration
- Best heard at apex, sometimes radiating to L axilla
- Gets louder during isometric grip, sudden squatting or vasopressor administration
Chronic mitral regurgitation
Chronic mitral regurgitation murmur gets louder with _
Isometric handgrip

Sudden squatting

Vasopressor administration
Which murmur do you have with acute mitral regurgitation
EARLY systolic CRESCENDO-DECRESCENDO murmur
Which murmur do you have with MVP
Midsystolic click, late systolic murmur
Patient with MVP is standing, what happens to murmur
Click occurs earlier - murmur is longer
Patient with MVP is squatting - what happens to the murmur
Click occurs later - murmur is shorter
_ makes click later and murmur shorter (and louder) in MVP
Squatting
_ makes click earlier and murmur longer (and softer)
Standing (or Valsalva)
- Holosystolic murmur
- Gets LOUDER DURING INSPIRATION (Carvallos sign)
Tricuspid regurgitation
Classic triad of severe TR
Carvallos sign

Pulsatile jugular venous distention (JVD)

Pulsatile liver
Holosystolic murmur

Doesnt get louder with inspiration

Best heard at lower LSB

Often HARSH in quality
VSD
Auscultatory hallmark of bicuspid aortic valve
Aortic ejection sound (click)
Crescendo decrescendo murmur

Often heard best at 2nd RSB radiating to carotids

Pulsus parvus et tardus (diminished and delayed carotid upstroke)
Aortic stenosis
Paradoxical splittins of S2 + diminished or absent A2 (aortic component of 2nd heart sound)
Aortic stenosis
Crescendo decrescendo murmur that gets louder with Valsalva maneuver, standing (from squatting or lying) and amyl nitrite inhalation

Gets softer with isometric handgrip and squatting
Hypertrophic cardiomyopathy
Murmur of HOCM gets louder with _
Valsalve maneuver

Standing (from squatting or supine)

Amyl nitrite
Murmur of HOCM gets softer with _
Isometric handgrip

Squatting
Crescendo-decrescendo murmur which gets louder with squatting ( or lying, from standing) and amyl nitrite inhalation

Gets softer with standing, valsalva maneuver or isometric handgrip
Aortic stenosis
Crescendo decrescendo murmur

- Increases during inspiration
- often heard best at 2 LSB
- Doesnt radiate to carotids
- If ejection sound (click) is present (congenital PS), it gets softer during inspiration
Pulmonic stenosis
Which R sided problem gets softer during inspiration
Congenital pulmonic stenosis (ejection sound - click)
Causes of diastolic murmurs
Insufficiency of either ventricular outflow - AR, PR

Stenosis of AV valves - MS, TS
Early diastolic murmur, decrescendo, high pitched, " blowing" murmur, best heard with diaphragm of sthethoscope at 3 L or RSB with patient leaning forward, during held, deep end-exhalation
Aortic insufficiency (regurgitation)
Diastolic rumble, best heard with bell of stethoscope at apex - can be present in people with aortic insufficiency
Austin Flint murmur
Patients with aortic insufficiency in addition to primary murmur can have_
Systolic ejection murmur - due to high flow states across aortic valve - from high stroke volume

Austin Flint murmur
What is the cause of Austin Flint murmur
Due to " functional" mitral stenosis resulting from aortic regurgitant jet forcing the anterior mitral leaflet into partially closed position ( also have been proposed that it results from fluttering of anterior mitral leaflet caused by aortic regurgitant jet)
Duroziez sign
Systolic murmur over femoral artery when stethoscope is compressed proximally and diastolic murmur over femoral artery when stethoscope is compressed distally
Most predictive sign of severe aortic insufficiency
Duroziez sign
Signs associated with high stroke volume (aortic insufficiency)
Wide pulse pressure

Quinckes pulse - phasic blanching of the nail bed

Hills sign - lower extremity SP exceeds upper extremity SP by > 20 mm Hg

Corrigan (water hammer) pulse - palpable abrupt upstroke and rapid fall of arterial pulsation

Traube sign - pistol shot sound over femoral artery

Mueller sign - pulsating uvula
2 causes of pulmonic insufficiency (regurgitation)
Pulmonary HTN - in absence of pulmonic valve deformity - GRAHAM STEEL MURMUR

- Deformity of pulmonic valve- congenital, acquired
Early diastolic murmur
Begins with loud pulmonic component of S2
Decrescendo
High pitched
"blowing"
Gets louder during inspiration
Best heard at 2nd to 4th ICS, LSB
Graham Steel Murmur - pulmonic insufficiency in absence of deformity of pulmonic valve
Mid diastolic murmur
Begins AFTER pulmonic component of S2
Crescendo decrescendo
Low pitched
Gets louder during inspiration
Best heard at 3d-4th ICS, LSB
Pulmonic insufficiency due to deformity of pulmonic valve
Mitral stenosis is almost always a sequela of _
Rheumatic fever
Mid diastolic murmur (pre systolic accentuation if rhythm is sinus), holodiastolic if severe

LOW PITCHED

Best heard if patient is in left lateral position with the bell of stethoscope at apex
Mitral stenosis
This type of murmur has opening snap - high pitched sounds, occurs after S2 EARLY in diastole, as severity increases will move closer to S2
Mitral stenosis
Which R sided problem gets softer during inspiration
Congenital pulmonic stenosis (ejection sound - click)
Causes of diastolic murmurs
Insufficiency of either ventricular outflow - AR, PR

Stenosis of AV valves - MS, TS
Early diastolic murmur, decrescendo, high pitched, " blowing" murmur, best heard with diaphragm of sthethoscope at 3 L or RSB with patient leaning forward, during held, deep end-exhalation
Aortic insufficiency (regurgitation)
Diastolic rumble, best heard with bell of stethoscope at apex - can be present in people with aortic insufficiency
Austin Flint murmur
Patients with aortic insufficiency in addition to primary murmur can have_
Systolic ejection murmur - due to high flow states across aortic valve - from high stroke volume

Austin Flint murmur
What is the cause of Austin Flint murmur
Due to " functional" mitral stenosis resulting from aortic regurgitant jet forcing the anterior mitral leaflet into partially closed position ( also have been proposed that it results from fluttering of anterior mitral leaflet caused by aortic regurgitant jet)
Duroziez sign
Systolic murmur over femoral artery when stethoscope is compressed proximally and diastolic murmur over femoral artery when stethoscope is compressed distally
Most predictive sign of severe aortic insufficiency
Duroziez sign
Signs associated with high stroke volume (aortic insufficiency)
Wide pulse pressure

Quinckes pulse - phasic blanching of the nail bed

Hills sign - lower extremity SP exceeds upper extremity SP by > 20 mm Hg

Corrigan (water hammer) pulse - palpable abrupt upstroke and rapid fall of arterial pulsation

Traube sign - pistol shot sound over femoral artery

Mueller sign - pulsating uvula
2 causes of pulmonic insufficiency (regurgitation)
Pulmonary HTN - in absence of pulmonic valve deformity - GRAHAM STEEL MURMUR

- Deformity of pulmonic valve- congenital, acquired
Early diastolic murmur
Begins with loud pulmonic component of S2
Decrescendo
High pitched
"blowing"
Gets louder during inspiration
Best heard at 2nd to 4th ICS, LSB
Graham Steel Murmur - pulmonic insufficiency in absence of deformity of pulmonic valve
Mid diastolic murmur
Begins AFTER pulmonic component of S2
Crescendo decrescendo
Low pitched
Gets louder during inspiration
Best heard at 3d-4th ICS, LSB
Pulmonic insufficiency due to deformity of pulmonic valve
Mitral stenosis is almost always a sequela of _
Rheumatic fever
Mid diastolic murmur (pre systolic accentuation if rhythm is sinus), holodiastolic if severe

LOW PITCHED

Best heard if patient is in left lateral position with the bell of stethoscope at apex
Mitral stenosis
This type of murmur has opening snap - high pitched sounds, occurs after S2 EARLY in diastole, as severity increases will move closer to S2
Mitral stenosis
Opening snap of mitral stenosis softens or disappears with _
Calcification (loss of mobility) of the body of mitral leaflets
This type of murmur is associated with loud (accenuated) S1
Mitral stenosis
Name mitral stenosis - like murmurs
Austin flint (AI)

Carey- Coombs murmur - active mitral valvulitis associated with acute rheumatic fever

Left atrial myxoma

Tricuspid stenosis
This murmur sounds just like mitral stenosis except it gets louder during inspiration and best heard along lower LSB
Tricuspid stenosis
Most common cause of tricuspid stenosis
Rheumatic heart disease
Continuous murmurs causes
PDA

Cervical venous hum

Mammary soufle

Hepatic venous hum

Arteriovenous connections

Ruptured aneurysm of sinus of Valsalva
Congenital causes of aortic valve stenosis
Unicuspid aortic valve

Bicuspid aortic valve

Tricuspid aortic valve
Acquired causes of aortic valve
Degenerative (senile) calcific

Rheumatic (post inflammatory)
Causes severe obstruction to left ventricular outflow IN INFANCY, most common cause of fatal valvular aortic stenosis IN INFANCY
Unicuspid aortic valve
Most common congenital cardiac defect (1-2% of population), 4: 1 male to female, often not detected until adulthood
Bicuspid aortic valve
In people with bicuspid aortic valve obstruction develops after childhood due to _
Turbulent flow (causes fibrosis and calcification of aortic cusps)
If you have coarctation of aorta you have high chance of which congenital cardiac defect
Bicuspid aortic valve
Risk factors for degenerative (senile) calcific aortic stenosis
- Hypercholesterolemia

- DM

- Pagets disease of bone

- End stage renal disease
3 classic symptoms of aortic stenosis
Angina

Syncope

CHF symptoms
For aortic stenosis when will mortality increase dramatically
With development of symptoms
50% mortality for angina with aortic stenosis
5 years
50% mortality for syncope with aortic stenosis
3 years
50% mortality for CHF symptoms with aortic stenosis
2 years
Most common physical finding in acute stenosis
Systolic ejection murmur that radiates to the neck
Which heart sound would you hear in patient with aortic stenosis
S4
What would you see on EKG in patient with aortic stenosis
LVH

Sinus rhythm
If you see LVH in patient with atrial fibrillation - what should you consider
Aortic stenosis with concomitant mitral disease
What would you see on chest x ray in patient with aortic stenosis
LV prominence

Dilation of ascending aorta

Calcification of aortic valve (lateral projection)
This test allows localization of aortic stenosis, assessing LV size and function, coexisting mitral disease and assesment of severity - mean aortic valvular gradient and calculated aortic valve area
Echocardiogram
Coronary angiography should be performed in patients prior to aortic valve replacement EXCEPT
Males < 40 years old without CAD risks

Females < 50 without CAD risk factors
3 types of treatment of aortic stenosis
Medical

Surgical

Percutaneous
Is medical therapy a definitive treatment of AS
NO
Medical management of As
SBE prophylaxis

Heart rate control - use negative chronotropes

Symptomatic treatment

Avoid physical exertion and extreme heat
Which medications should be used with caution in patients with AS
Nitrates

Diuretics

ACE inhibitors

ARB's

Hydralazine
Only definitive treatment of aortic stenosis
Aortic valve replacement
Indications for aortic valve replacement
Symptomatic severe AS

Severe AS with progressive LV dysfunction (regardless of symptoms)
What should be performed in patients with significant mitral regurgitation before AVR
Intraoperative TEE
Indications for percutaneous (Balloon aortic valvuloplasty) intervention in patients with AS
Bridge to AVR

Emergency non cardiac surgery

Palliation in non surgical candidate
2 main causes of aortic insufficiency
Valvular - structural valve problem

Aortic - dilated aorta
2 causes of valvular aortic insufficiency
Congenital - bicuspid aortic valve, VSD

Acquired - infective, rheumatic, degenerative
2 causes of aortic AI
Dissection - trauma, cystic medial necroiss

Dilation - systemic HTN, age, cystic medial necrosis
Connective tissue diseases make you prone to which valvular problems
Aortiic insufficiency
Causes of acute AI
Dissection

Infective endocarditis

Trauma
Symtoms of acute AI
Severe dyspnea

Weakness
Physical findings of acute AI
Hypotension

Tachycardia

Pulmonary edema
Why dont you have classic findings of chronic AI in acue AI
due to elevated LV end diastolic pressure
Patient presents with severe dyspnea, weakness. Physical exam reveals hypotension, tachycardia and pulmonary edema - peripheral arterial signs are absent, pulse pressure is not widened and there is soft and short diastolic murmur
Acute AI
What would you see on EKG in patient with acute aortic insufficiency
Sinus tachycardia

LVH may be absent
What would you see on chest x ray in patient with acute aortic insufficiency
Pulmonary edema (usually)

LV size is normal

Ascending aorta MAY be dilated (depending on the cause)
Diagnostic test of choice in patient with acute aortic insufficiency
Echo
Patient presents with exertional dyspnea, reduced exercise tolerance, fatigue and uncomfortable"forceful" heartbeat
Chronic AI
Double systolic impulse in carotid or brachial artery
Bisferiens pulse
What would you see in patient with chronic AI on EKG
LVH
What would you see on chest x ray in patient with chronic AI
LV enlargement

Ascending aorta MAY be dilated
Excellent modality for long term follow up and timing of surgery in patient with chronic AI
Echo
Indicator of poor prognosis in patients with chronic AI
- Presence of symptoms

- LVEF< 55%

- Significant LV dilation

LV end systolic dimension > 55

LV end diastolic dimension > 75
Treatment for AI
Prompt surgical intervention for hemodynamically unstable patients

Medical treatment while awaiting surgery
Medical treatment while awaiting surgery for acute AI may include
POSITIVE IV inotropic agents

IV vasodilators
Which treatment is contraindicated in patients with acute AI
Beta blockers

IABP
Patient with acute AI secondary to active infective endocarditis is hemodynamically stable - treatment?
Surgery deferred for 5-7 days of intensive antibiotic therapy
Medical treatment of chronic AI
- Antibiotic infective endocarditis prophylaxis
- Nifedipine - may delay the need for AVR surgery in asymptomatic patients with severe AI and normal LV systolic function
Surgical indications for chronic AI
- Decline in LV systolic function (rule of 55, LVEF< 55%)
- Increase in LV (end systolic>55, end diastolic > 75)

- Symptoms - significant fatigue, worsening exercise tolerance, CHF