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39 Cards in this Set
- Front
- Back
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Aortic stenosis (all)
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*stigmata of endocarditis
low volume, slow rising narrow pulse pressure elevated venous pressure prominent v waves apex heaving, minimally displaced double apical impulse systolic thrill over aortic area S1 normal, P2 soft (*loud with PHT) S4 present ESM aortic area, in expiration and radiates to carotids bibasal crepitations |
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Differential diagnosis of ESM
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Aortic stenosis
Hypertrophic cardiomyopathy Supravalvular stenosis |
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Clinical signs of severe aortic stenosis (11)
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low volume
slow rising pulse narrow pulse pressure signs of pulm hypertension heaving apex beat systolic thrill reversed splitting S2 diminished S4 present late accentuation of murmur signs of cardiac failure |
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Echo criteria of severity by opening area
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normal 3-4 sqcm
mild >1.5 moderate <1.5 severe <1 |
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Echo criteria of severity by pressure gradient
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mean pressure gradient >50mmHg signals severe AS
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Causes of reversed splitting of S2
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Aortic stenosis
Hypertrophic cardiomyopathy Patent ductus arteriosus Left bundle branch block WPW type B |
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Complications of aortic stenosis
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left ventricular failure
syncope ischaemic infarct ventricular arrythmia pulmonary hypertension sudden death infective endocarditis iron deficiency anaemia heyde's syndrome |
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Investigation in Aortic stenosis
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ECG
CXR Echo angiography |
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ECG signs in Aortic stenosis
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LVH
left atrial hypertrophy and dilatation left axis deviation left bundle branch block heart blocks |
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CXR in Aortic stenosis
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post stenotic dilatation of aorta
pulmonary congestion dilated pulmonary artery valve calcification cardiomegaly rib notching (if part of coarcation) |
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indications for aortic valve replacement
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symptomatic pt
asymptomatic pt left ventricular failure valve opening <0.6 ventricular arrythmia BP response to exercise abnormal |
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mitral stenosis
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malar flush
stigmata of endocarditis AF narrow pulse pressure JVP elevated + v-waves -> parasternal heave -> parasternal thrill -> TR -> loud S2 -> Graham-Steel murmur valvotomy scar apex tapping loud S1 opening snap rumbling mid diastolic murmur, with bell, over apex, lateral position, in expiration and with exercise TR murmur Graham-Steel Pulmonary congestion |
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causes of MS
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rheumatic fever
congenital SLE RA carcinoid methysergid Rx Fabry's Mucopolysacharidosis Whipple's |
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clinical severity of MS
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narrow pulse pressure
pulmonary hypertension pulmonary congestion early opening snap longer duration of murmur Graham-Steel |
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echo severity of MS
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normal 4-6 cm^2
mild >1.5 moderate <1.5 severe <1.0 |
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complications of MS
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AF
stroke orthner's syndrome (compression of laryngeal nerve) infective endocarditis pulmonary hypertension congestive heart failure |
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malar flush
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mitral stenosis
SLE hypothyroidism cold weather polycytaemia systemic sclerosis carcinoid syndrome irradiation |
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investigations in MS
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ECG
CXR echo angiogram |
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ECG in MS
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AF
left atrial enlargement/hypertrophy |
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CXR in MS
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calcified mitral valve
left atrial dilatation enlarged pulmonary arteries pulmonary congestion/oedema |
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management of patient with MS
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asymptomatic
-> f/u echos -> endocarditis prophylaxis AF -> AF control + WARFARIN Symptomatic -> diuretics for oedema -> manage AF -> refer for valve replacement once symptoms worsen |
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indications for surgery
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-pulmonary hypertension
-haemoptysis -recurrent thrombembolism not controlled by anticoagulation |
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when can cathether valvuloplasty be used?
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mobile valve, minimally calcified
no mitral regurgitation no left atrial thrombus |
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surgical techniques in MS
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open commisurotomy
mitral valve replacement |
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Prostethic aortic valve
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stigmata of endocarditis
slow rising low volume / collapsing large volume anaemia (jaundice) midline thoracotomy scar saphenous vein/radial artery harvest signs of pulmonary hypertension apex heaving (stenosis) apex thrusting displaced (regurgitation) CLICK shortly after carotid pulse ESM (=normal) aortic regurgitation (? dysfunction) |
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Prosthetic mitral valve
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no stigmata of endocarditis
AF CLICK with the first heart sound midline sternotomy scar / lateral throracotomy scar |
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Dysfunctioning mitral valve
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anaemia
purpura signs of pulmonary hypertension -> TR pansystolic murmur of MR (cave: do not confuse with TR) pulmonary congestion |
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Presenting a prosthetic valve
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- location of the valve
- type of valve - evidence of endocarditis? - functioning/dysfunctioning? - complications of anticoagulation? |
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Mitral regurgitation
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signs of endocarditis ?
AF signs of pulmonary hypertension? left lateral thoracotomy scar? displaced and thrusting apex apical thrill soft S1 S3 loud pansystolic murmur, apex, in expiration, radiating to axilla mid-diastolic flow murmur |
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other causes of short systolic murmur at apex
how differentiated? |
mitral prolapse (posterior leaf)
papillary muscle dysfunction these murmurs radiate up sternal edge |
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causes of acute MR
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infective endocarditis
chordae tendinae rupture trauma |
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causes of chronic MR
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infective endocarditis
rheumatic fever post mitral valvotomy marfan's ehlers-danlos osteogenesis imperfecta RA SLE (libman-sachs endocarditis) left ventricular dilatation cardiomyopathies pseudoxanthoma elasticum papillary muscle dysfunction |
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clinical signs of severity of MR
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displaced apex
precordial thrill soft S1 widely split S2 S3 or S4 mid disastolic flow murmur signs of pulm. hypertension. |
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CXR in MR
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cardiomegaly
double density sign (LA) and splaying of carina prominent pulm. arteries pulmonary congestion |
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ECG in MR
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AF
LA hypertrophy (prom. p in II) LA dilatation (biphasic p in V1) |
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which information from echo in MR
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mechanism
severity LV function PA pressure and RV function |
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management of patient with MR
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asymptomatic
-> endocarditis prophylaxis -> annual echo AF -> rate/rythm control -> WARFARIN symptomatic (heart failure) -> diuretics -> ACE/ARB, spiro, dig -> consider for surgery |
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indication for mitral valve surgery
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asymptomatic pt - if EF <60% or EDD >45mm
symptomatic NYHA III-IV despite full medical Rx |
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Aortic regurgitation
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Head nodding with pulse (De Musset sign)
Fingernail pulsations (Quinke's) ? signs of endocarditis high volume, collapsing pulse visible carotid pulsations in neck (Corrigan's) Systolic pulsations of uvula (Muller's) ? signs of pulmonary hypertension apex displaced and thrusting early diastolic murmur, left sternal, sitting forward and in expiration low pitched mid diastolic murmur at apex (austin flint) ESM (increased flow) |
