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87 Cards in this Set
- Front
- Back
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What is the most common valvular disease (2% of population)?
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Mitral valve prolapse (primary or secondary)
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Pathogenesis:
Primary form of mitral valve prolapse? Secondary form? |
Primary = genetic defect in connective tissue
Secondary = injury |
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What is the gross pathology of mitral valve prolapse?
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Redundant, billowing, ballooning, hooding, floppy leaflets +/- elongated attenuated chordae tendineae that can rupture
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What is the microscopic pathology of MVP?
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Degeneration and attenuation of outer zona fibrous and expanded myxomatuous inner zona spongiosa (often normal)
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What is the sign of mitral valve prolapse?
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MIDSYSTOLIC CLICK!
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What is on the left?
Right? |
Left = normal valve closed
Right = MVP |
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What is this an image of?
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MVP
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Label the three zones.
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1. Zona atrialis
2. Zona spongiosa 3. Zona fibrosa |
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What is shown here?
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Expanded myxomatous zona spongiosa
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What disease is Libman-sacks endocarditis associated with?
Whatis the pathology? |
LUPUS (of course..)
Gross: small-medium verrucous, berrylike or flat vegetations, commonly on multiple valves, either or both sides Microscopic: necrotic debris, fibrinoid material, degenerating leukocytes, fibroblasts and hematoxylin bodies |
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What is a clinical important fact about Libman-Sacks endocarditis?
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Rarely embolizes
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What is shown on the left? Right?
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Left = most types of endocarditis
Right = Libman-Sacks endocarditis |
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True or false.
The incidence of infection, marantic endocarditis and rheumatic disease on a valve correlate with the resting pressure on the closed valve. |
True
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Infective endocarditis is uncommon (1/1000 hospital admissions), but commonly taught in great detail and tested in great detail. Why?
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100% fatal if undiagnosed
20% fatal if diagnosed and treated (with IV antibiotics and surgery) |
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Where is infective endocarditis most commonly? Describe.
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Valves with vegetations = friable masses of infecting organisms and blood clot
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What is the four step pathogenesis of infective endocarditis?
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1. Valvular endothelial injury
2. Platelet + fibrin deposition 3. Microbial seeding 4. Microbial multiplication |
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What is infective endocarditis more common on?
Mitral valve or aortic valve alone? |
Mitral valve
Then mitral plus aortic |
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What are the two most common etiologic agents of infective endocarditis?
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Staphylococci in general (42%)
Streptococci in general (40%) |
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What are some of the methods of entry for infective endocarditis?
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Central venous catheterization
Mouth (gingivitis, brushing teeth, chewing, dental procedures) |
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What is the gross pathology of the vegetations?
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Large (up to 3 cm), friable, single or multiple; tan, grey, red or brown, usually on line of valve closure, (atrial side atrioventricular valves, ventricular side semilunar valves)
� |
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True or false.
The larger the vegetation, the less likely it is infective. |
FALSE!
Large = more infective |
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What four things can infective endocarditis cause?
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Perforation of valve
Adjacent abcess Fibrotic scarring Calcification |
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Where does infected (septic) embolic from endocarditis commonly go to ?
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Kidneys, heart, spleen, brain
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What are some things commonly seen in the microscopic pathology of vegetations/infective endocarditis?
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Fibrin, platelets, masses or organisms
(possibly necrosis, neutrophils, lymphocytes, mactorphages, fibroblasts, fibrosis) |
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What are the common symptoms of infective endocarditis?
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Most common = fever
Others: Chills, weakness, dyspnea |
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What are some uncommon symptoms of infective endocarditis?
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Cough, sweats, anorexia, weight loss, malaise, skin lesions, nausea/vomiting, stroke, headache, myalgia, arthralgia, edema, chest pain, abdominal pain, delirium/coma, back pain, hemoptysis
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What are the two most common physical signs of infective endocarditis?
What are other common physical signs? |
Fever, heart murmur (MOST COMMON)
Splenomegaly Petechiae |
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What are some uncommon physical signs of infective endocarditis?
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Osler nodes
Subungual splinter hemorrhages Changing heart murmur Others even less common: Janeway lesions (small palm/sole hemorrhages) New heart murmur Roth spots (on retina, white dots with surrounding hemorrhage) |
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What is this? How will the patient feel if you touch them (the nodes that is...)?
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Osler nodes
Ouch! Tender |
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What is this? Is it specific for endocarditis?
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Splinter hemorrhage under fingernail (not specific for
endocarditis, much more commonly due to trauma) |
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What are these?
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Janeway lesions: hemorrhages on palms or soles
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What is this?
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Roth spots: retinal hemorrhages due to endocarditis
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What is THE MOST COMMON lab finding of endocarditis? Others?
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HIGH ESR (most common)
Anemia Proteinuria |
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What are some less common lab findings?
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Rheumatoid factor
Hematuria Leukocytosis Leukopenia |
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What is the most common complication of endocarditis? Others
Put in order! |
Heart failure (most common)
Septic embolic (most at autopsy)--> kidneys, heart, spleen, brain |
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What are some uncommon complications?
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Myocardial abscess
Glomerulonephritis Mycotic aneurysm |
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What are two highly sensitive tests for vegetations on endocarditis?
Does the absence of vegetations in these tests exclude the diagnosis of endocarditis? |
Transthoracic echocardiography (60% sensitivity for vegetations)
Transesophageal echocardiography (>90% sensitivity) No! |
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What is shown here?
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Mitral valve endocarditis
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You've heard murmur, got echocardiogram, seen the vegetation...have you made diagnosis?
What do you need? |
No!
Blood cultures! |
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What is continuous low-grade bacteremia characteristic of?
Do you need a lot of blood cultures to make the diagnosis? |
Infective endocarditis
No, but you should alert the micro lab that endocarditis is suspected. |
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Describe how many blood cultures you should get. Where? When?
Why? |
Three fro three different sites 30-60 minutes before starting antibiotics.
Because 86 to 96% of first cultures return positive and 98 to 100% of first two cultures. |
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Why should you alert the microbiology laboratory that endocarditis is suspected?
� |
Because some bacteria causing endocarditis are fastidious or slow-growing or both, so the microbiology laboratory will use extra “special” culture media and hold the cultures longer, but only if you alert them of the need.
� |
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True or false:
Blood cultures are essential for making a specific diagnosis to guide antibiotic therapy for infective endocarditis. |
TRUE!
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What can be life saving with acute disease but provides immediate relief with chronic disease while replacing one chronic disease with another?
Form of treatment for endocarditis. |
Surgical valve replacement.
Mechanical requires lifelong anticoagulation Bioprostheses deteriorate with 50% having structural failing by 10 years, increasing after that. |
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Describe probe-patent foramen ovale.
(Patent foramen ovale) |
20% individuals with flap on FO that can be opened by probe
Higher pressures on left normally keep in place If pressure on right ever gets higher than left, can open between RA and LA, letting deox blood skip the lungs. |
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What are the four types of ASDs?
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Ostium secundum defect
Ostium primum defect Sinus venosus defect Common atrium |
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What are the four components of Tetralogy of Fallot?
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1. VSD
2. Overriding aorta 3. Pulmonic stenosis 4. RV hypertrophy |
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How does tetralogy of fallot come about?
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1. Early embryonic stage aorta takes too much of truncus arteriosus
2. Aorta develops over IVS. 3. As IVS develops, encounter hole in aorta and keeps growing up --> ventricular septal defect (aorta receives blood from both ventricles). 4. Pulmonic outflow is smaller than it should be --> stenosis 5. Right ventricle must hypertrophy to pump through stenosis. |
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What are the cyanotic diseases (think T!)
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Tetralogy of Fallot
Transposition, Arteries Truncus arteriosus Total anomalous pul.. Tricuspid atresia |
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What are the acyanotic disease?
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VSD
ASD Patent ductus arteriosus Pulmonic stenosis Aortic stenosis |
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What is this? Describe.What is the valve? How do you know?
Calcific aortic stenosis Infective endocarditis Libman-sacks endocarditis Nonbacterial thrombotic endocarditis |
Infective endocarditis
Mitral valve = chordae tendinae going to BOTH leaflets Very large, very extensive vegetations involving 80% of the leaflets The bigger the vegetations --> more likely they are infective |
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What would favor a Libman-Sacks diagnosis?
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Medium sized vegetations = on ventricular side or on another valve
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True or false.
Many cases of mitral valve prolapse are microscopically normal. What are the changes in the zones that you typically see in a myxomatous change? |
True
Normal surface Zona spongiosa expanded Zona fibrosa thinned |
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A 45-year-old south Asian female manages a motel in the South. She presents with intermittent fever, chills, weakness and progressive dyspnea on exertion
for 3 months. Her temperature is 38.2, pulse 102 and blood pressure 100/70. On cardiac auscultation she has a grade II/VI holosytolic murmur. |
Blood culture
SPECIFIC! |
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True or false:
Blood cultures are essential for making a specific diagnosis to guide antibiotic therapy for infective endocarditis. |
True!
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What's the answer?
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Viridans streptoccci! MONTHS!
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What's the difference between acute and subacute bacterial endocarditis?
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ABE = highly virulent organisms (staphylococcus aureus)
SBE = insidious onset over weeks, due to less virulent organisms (viridans strep) |
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Why does staph aureus occur on the atrial side of mitral valve and ventricular side of aortic valve?
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What is this?
What should you look for? |
This is mitral valve prolapse at open heart surgery. Note the uniform color of the valve; it looks normal except for being redundant and folded up into mountains and valleys. No vegetations are evident.
� |
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Pregnancy can cause mitral regurgitation from prolapse to go into remission. Why?
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Pregnancy --> 45% increase in blood volume --> left ventricle dilation that allows mitral leaflets to coapt without regurgitation
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What is the answer?
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Young Asian, syncope at bedtime => BRUGADA!!
"Coved" ekg at rest = ST SEGMENT ELEVATION |
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What is ventricular tachycardia in ARVC triggered by?
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Exercise
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THROMBUS FORMATION!
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True or false.
Any condition causing stasis of blood in the left atrium predisposes to clot formation. What is one disease that causes impaired outflow of blood from the left atrium? What is Virchow's triad? |
TRUE!
Rheumatic heart disease Endothelial injury, abnormal flow, hypercoagulability |
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A 24-year-old white male medical student in Memphis, TN, presents in February with the abrupt onset of fever, chills, weakness, dyspnea, cough, nasal congestion, sore throat, myalgias and malaise.
What is differential diagnosis? He most likely has what? |
Influenza
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He appears “toxic” (ill). His BMI is 25, temperature 39.5, pulse 120, blood pressure 110/70, respirations 22 and saturation 97%. He has a grade III/VI pansystolic high pitched “blowing” murmur and a grade I/IV mid-late diastolic low pitched rumbling murmur. His lungs are clear, abdomen normal and extremities without edema, but he has a few petechiae on his soles.
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Infective endocarditis from previous rheumatic valvulitis.
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What does carcinoid syndrome result from?
What are the systemic manifestations? |
Bioactive compounds (serotonin) released by carcinoid tumors.
Flushing, diarrhea, dermatitis, and bronchoconstriction |
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What parts of the heart are commonly affected by carcinoid heart disease?
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Endocardium and valves of the right heart
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What is shown here?
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Carcinoid heart disease
Distinctive, glistening white intimal plaquelike thickenings |
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What is shown here?
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Carcinoid heart disease
Smooth muscle cells Embedded in acid mucopolysaccharide-rich matrix |
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What causes it?
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Septic embolism --> to the spleen in this case.
Splenic infarct (wedge shape with base at capsule, exudate on surface and wispy projection = fibrinous adhesion) |
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What is shown here?
What is the treatment? |
Splenic abscesses
Drainage, if too many = splenectomy |
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What is the best diagnosis for his condition?
Atrial septal defect Infective endocarditis Libman-sacks endocarditis Marantic endocarditis Mitral valve prolapse Nonbacterial thrombotic endocarditis |
Infective endocarditis
Infective endocarditis is destructive. It can eat a hole in a heart valve. If you see a hole in a heart valve, think infective endocarditis. |
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What distinct shape do you notice about the heart?
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Boot shaped!
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What does the asterisk identify?
atrial septal defect atrial septal defect with overriding aorta perforation due to infective endocarditis ventricular septal defect ventricular septal defect with overriding aorta |
Ventricular septal defect with overriding aorta
Tetralogy of Fallot |
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What are the four components of TOF?
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VSD, overriding aorta, pulmonic stenosis, RV hypertrophy
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A 22-year-old white female college student unaware that she was born with a probe-patent foramen ovale and with heterozygous factor V Leiden mutation has her leg mauled by a wolf, while on a camping trip in a remote area of Wyoming. Half a day later, she suddenly turns blue.
What happened? |
Eisenmenger syndrome
Wounds --> DVT (from congenital hypercoagulable state) --> thromboembolus from leg obstructed right ventricular outflow --> increase in right atrial pressure became higher than left atrial pressure --> tissue flap over foramen ovale to open and let deoxygenated blood into left atrium (CYANOSIS) |
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What is Eisenmenger syndrome most often seen in?
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Children with congenital heart diseases with holes between left and right heart (ASD, VSD, etc) and chronic left to right shunt that causes progressive pulmonary hypertension until one day the shunt reverses.
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What is it?
calcific aortic stenosis infective endocarditis Libman-Sacks endocarditis marantic endocarditis mitral valve prolapse |
Calcific aortic stenosis
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What are the buzz words for MITRAL VALVE PROLAPSE?
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Buzzwords for marantic endocarditis?
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Buzzwords for Libman-Sacks endocarditis?
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Buzzwords for infective endocarditis?
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Buzzwords for calcific aortic stenosis?
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This 47-year-old white male had a history of alcohol and cocaine abuse and mitral valve prolapse. He was brought to the ER nearly unresponsive with flaccid right side, fever of 40.3, pulse 136, blood pressure 189/98, respirations 30, diffuse pulmonary rhonchi
and “no murmurs” specifically dictated by the admitting physician. Admission blood cultures all yielded Staphylococcus aureus. He died 36 hours later and this is what his heart showed: |
Inadequate physical examination!
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