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31 Cards in this Set
- Front
- Back
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How are Stenotic and Regurgitant Lesions assessed?
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Stenosis: assessed by valve area and pressure gradient
Regurgitation:assessed by volume of leak |
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What is the Law of LaPlace in Pressure Load?
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As pressure increases, tension increases
The heart responds to increased tension If the pressure increases, then the thickness must increase to normalize tension, no effect on radius |
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What is the Law of LaPlace in Volume Load?
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As volume (radius) increases, tension increases
The heart responds to increased tension If the volume increases, then the thickness must increase to normalize tension |
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How does the Diastolic Pressure/Volume Relation change in Concentric and Eccentric Hypertrophy?
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Concentric - up and left
Eccentric - down and right |
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LV Diastolic Pressure/Volume Relation in Eccentric Hypertrophy
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Low filling pressures despite elevated diastolic volume
Later, systolic dysfunction Elevated filling pressures with systolic dysfunction--> Increased work of breathing --> Dyspnea |
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LV Diastolic Pressure/Volume Relation in Concentric Hypertrophy
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High left atrial filling pressure--> High pulmonary venous pressure--> Increased lung water--> Increased work of breathing --> Dyspnea
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Diastolic Pressure/Volume Relation in Aortic Regurgitation
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No change in pressure/volume relation--> Acute LV volume load--> Acute rise in LV diastolic pressure--> Severe pulmonary congestion--> Dyspnea or Pulmonary Edema
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Aortic Stenosis - Etiology
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- Congenital bicuspid valve
- Degenerative calcific aortic stenosis - Rheumatic, not in isolation, but associated mitral disease |
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Aortic Stenosis Pathophysiology
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Concentric LVH, poor LV filling, usually normal systolic function
CHF (dyspnea, exercise intolerance), from elevated diastolic pressure Angina from decreased coronary perfusion pressure and increased myocardial oxygen demand Syncope usually from ventricular arrhythmias |
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Aortic Stenosis:
Physical Exam |
Post PVC beat
Forceful apical impulse, not usually displaced Atrial filling wave and S4 Harsh midsystolic murmur and thrill at right upper sternal border, radiating to carotid Parvus et tardus carotid impulse |
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Aortic Stenosis:
Diagnostic Tests |
ECG: LVH, with large QRS complexes, and also LAE
CXR: not remarkable Echocardiogram: dense, thick, poorly mobile aortic valve, LVH and LAE Doppler: estimate valve area and mean gradient Cardiac Catheterization: valve area, pressures, flows, coronary anatomy |
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Aortic Regurgitation:
Etiology |
-Congenital bicuspid valve
-Rheumatic aortic disease -Infective endocarditis -Inherited connective tissue diseases (Marfan’s) -Inflammatory connective tissue diseases (Ankylosing spondylitis, rheumatoid arthritis) |
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Aortic Regurgitation:
Pathophysiology and Symptoms |
LV volume load
Acute: acute pulmonary congestion, pulmonary edema Chronic: eccentric hypertrophy Eccentric LVH is well tolerated for decades, until the LV systolic function finally begins to deteriorate, then symptoms of CHF appear (dyspnea, fatigue, weakness) Occasional angina: supply/demand imbalance |
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Aortic Regurgitation:
Diastolic Pressure/Volume Relation |
Acute aortic regurgitation-->
No change in pressure/volume relation--> Acute LV volume load--> Acute rise in LV diastolic pressure--> Severe pulmonary congestion--> Dyspnea or Pulmonary Edema |
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Aortic Regurgitation:
Physical Examination |
High systolic pressure, low diastolic, high pulse pressure, Corrigan’s pulse
Apex beat displaced caudal and leftward Dynamic early filling with early filling apex wave and S3 Diastolic decrescendo hi-pitched murmur, may be holodiastolic |
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Aortic Regurgitation: Diagnostic Tests
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-ECG: LVH, frequently without LA enlargement
-Chest X-ray: cardiac enlargement, often dilated ascending aorta -Echocardiogram: confirms eccentric LVH, morphologic valve abnormalities -Doppler: severity of flow abnormality -Catheterization: severity of regurgitation, pressure and flow consequences |
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Mitral Stenosis:
Pathophys and Symptoms |
-Normal mitral valve area 4.0-5.0 cm2, and critical is less than 1.0-1.5 cm2
-Dyspnea on exertion -->increased heart rate means proportionately shorter time in diastole --> increased cardiac output means higher transmitral flow --> LA pressure >25mmHg -Fatigue, attributed to low cardiac output -Atrial fibrillation --> sudden pulmonary congestion/edema --> cardioembolic event |
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Mitral Stenosis
Physical Examination Si/Sx |
-Faint apical impulse
-Loud S1 -Opening Snap, 0.06-0.10 sec after A2 (aortic component of S2) -Diastolic rumbling murmur localized to apex (left lateral decubitus position) presystolic accentuation -Loud P2 (pulmonary component of S2) indicates pulmonary hypertension |
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Mitral Stenosis
Diagnostic Tests |
-ECG: normal, or LA enlargement, or Afib
-Chest X-ray: left atrial enlargement with elevation of left mainstem bronchus, and pulmonary venous congestion -Echocardiogram: thickened doming mitral leaflets, -Doppler shows high velocity flow across the stenosis -Catheterization frequently unnecessary for diagnosis -Treadmill: often useful for objective tolerance |
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Mitral Regurgitation
Etiology |
-Myxomatous degeneration, or MV prolapse
-Infective endocarditis -LV dilation from any cause -Rheumatic heart disease |
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Mitral Regurgitation
Pathophys and Symptoms |
Volume load: LV and LA
--> Acute: dramatic inc in LA pressure, acute pulmonary congestion edema, shock --> Chronic: enhanced LV systolic ejection (into low pressure LA), LA and LV enlargement Chronic LAE may lead to A fib --> not as bad for circulation as mitral stenosis --> risk of cardioembolism -Loss of LV systolic performance - CHF: FATIGUE DYSPNEA |
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Mitral Regurgitation
Physical Examination Si/Sx |
Apical impulse:
--> displaced caudally and leftward --> Hyperdynamic early filling wave --> S3 -Soft S1 -Holosystolic murmur, best at apex -Acute regurgitation: pulmonary edema w/ rales |
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Acute Mitral Regurg
Diastolic Pressure/Volume Relation |
Acute mitral Regurg--> No change in pressure/volume relation--> Acute LV volume load--> Acute rise in LV diastolic pressure--> Severe pulmonary congestion --> Dyspnea or Pulmonary Edema
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Mitral Regurgitation
Diagnostic Tests |
- ECG: LVH and LA enlargement
- Chest X-ray: cardiomegaly - Echocardiogram: LV enlargement, morphology of MR, Doppler can estimate severity of leak - Catheterization: severity of regurgitation, effects on pressure and flow - Radionuclide angiography (MUGA): ejection fraction |
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Tricuspid Disease
Etiology |
- Tricuspid stenosis is rheumatic, rarely carcinoid
- Tricuspid regurgitation is usually due to RV dilation or endocarditis, not rarely a significant complicating factor in left heart disease |
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Pulmonic Disease
Etiology |
- Pulmonary stenosis is congenital, can balloon
-Pulmonary regurgitation is rarely significant |
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IE: Inflammation of endocardial surface
-Etiology -Target -Risk Factors |
MC ethos: infectious, usually bacterial
MC affected target: valve leaflet Risk factors: degenerative valve disease and mitral valve prolapse, also VSD, bicuspid aortic valve, PDA, coarctation, and tetralogy IV drug use: right-sided valvular lesions Indwelling catheters: prosthetic valves |
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Bacterial Endocarditis - Which bacterial types are most commonly found in native valves, valves of IV drug users, prosethic valves?
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- Native valves: most commonly streptococci (alpha-hemolytic, Streptococcus bovis, Enterococcus facealis), then Staph aureus
-IV Drug users: most commonly Staph aureus, also streptococcus -Prosthetic valve endocarditis: Staph aureus, many others, and later alpha-hemolytic streptococcus |
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Rheumatic Fever:
-Definition -Major and minor symptoms - Prevention of primary and secondary RF |
Definition: An inflammatory disease, delayed nonsuppurative sequel to group A streptococcal infection
Major: migratory polyarthritis, Sydenham’s chorea, subcutaneous nodules, erythema marginatum, and carditis Minor: arthralgia, fever, inc. sed rate, CRP, PR interval, acute phase reactant Positive throat culture or rapid streptococcal antigen test, or elevated or rising ASO (streptococcal antibody) titer Prevention of rheumatic fever: penicillin therapy of streptococcal pharyngitis (primary), and penicillin therapy to prevent recurrences (secondary) |
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Color Doppler used for?
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View diastolic flow in aortic regurgitation
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Use of Color Doppler in Tricuspid reguargitation to view___?
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Tricuspid Regurg:
Use Color Doppler to view turbulant flow and large chambers: In Systolic frame note the large RV, LV, and RA |
