06 CT Flashcards
A 6-month-old baby has occasional stridor, and episodes of respiratory distress with “crowing” respiration during which he assumes a hyperextended position. The family has also noted mild difficulty in swallowing.
The combination of pressure on the esophagus and pressure on the trachea identifies a vascular ring. Barium swallow will show a typical extrinsic compression from the abnormal vessel. Bronchoscopy confirms the segmental tracheal compression and rules out diffuse tracheomalacia. Surgical repair is done by dividing the smaller of the double aortic arches.
A patient who has prosthetic aortic and mitral valves needs extensive dental work.
Antibiotic prophylaxis is needed to protect those valves from bacterial contamination. Pretty brief vignette, but the point is that somewhere along the line, you might be expected to remember that these patients need antibiotic prophylaxis for subacute bacterial endocarditis.
During a school physical exam, a 12-year-old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognizes that she indeed has a pulmonary flow systolic murmur, but he also notices that she has a fixed split second heart sound. A history of frequent colds and upper respiratory infections is elicited.
What is it? Atrial septal defect.
Management. Echocardiography to establish the diagnosis. Closure of the defect by open surgery or cardiac catheterization.
A 3-month-old boy is hospitalized for “failure to thrive.” He has a loud, pansystolic heart murmur best heard at the left sternal border. Chest x-ray shows increased pulmonary vascular markings.
What is it? Ventricular septal defect.
Management. Echocardiography and surgical correction.
Because of a heart murmur, an otherwise asymptomatic 3-month-old baby is diagnosed with a small, restrictive ventricular septal defect located low in the muscular septum.
This particular variant has a good chance to close spontaneously within the first 2 or 3 years of life.
A 3-day-old premature baby has trouble feeding and pulmonary congestion. Physical examination shows bounding peripheral pulses and a continuous, machinery-like heart murmur. Shortly thereafter the baby goes into overt heart failure.
What is it? Patent ductus arteriosus.
Management. Echocardiography and surgical closure. In premature infants, surgery is usually reserved for patients who did not close their ductus with indomethacin, but with overt heart failure there is no time to wait. In full-term infants, closure can be achieved with intraluminal coils or surgery.
A premature baby girl has mild pulmonary congestion, signs of increased pulmonary blood flow on x-ray, a wide pulse pressure, and a precordial machinery-like murmur. She is not in congestive failure.
Same diagnosis of patent ductus, but with no urgency, and being premature, she is a clear candidate for medical treatment with indomethacin.
A 6-year-old boy is brought to the United States by his new adoptive parents from an orphanage in Eastern Europe. The boy is small for his age and has a bluish hue in the lips and tips of his fingers. He has clubbing and spells of cyanosis relieved with squatting. He has a systolic ejection murmur in the left third intercostal space. Chest x-ray shows a small heart and diminished pulmonary vascular markings. ECG shows right ventricular hypertrophy.
What is it? Tetralogy of Fallot. Cyanotic kids could have any of the five conditions that begin with the latter “T”: tetralogy or transposition of the great vessels, which are common, or truncus arteriosus, total anomalous pulmonary venous connection, or tricuspid atresia, which are rare. If the baby went home after birth, and later was found to be cyanotic, bet on tetralogy, if he was blue from the moment of birth, bet on transposition.
Management. Even if all you can recognize in the vignette is that a child has cyanosis, start with an echocardiogram as a good diagnostic test. The intricate details of surgical correction are bound to be beyond the level of knowledge expected of you.
A 72-year-old man has a history of angina and exertional syncopal episodes. He has a harsh midsystolic heart murmur best heard at the right second intercostal space and along the left sternal border.
What is it? Aortic stenosis with the triad of angina, dyspnea, and syncope.
Management. The diagnostic test is echocardiogram. Surgical valvular replacement is indicated if there is a gradient of more than 50 mm Hg., or at the first indication of congestive heart failure, angina, or syncope.
A 72-year-old man has been known for years to have a wide pulse pressure and a blowing, high-pitched, diastolic heart murmur best heard at the right second intercostal space and along the left lower sternal border with the patient in full expiration. He has had periodic echocardiograms, and in the most recent one there is evidence of beginning left ventricular dilatation.
What is it? Chronic aortic insufficiency.
Management. Aortic valve replacement.
A 26-year-old drug-addicted man develops congestive heart failure over a short period of a few days. He has a loud, diastolic murmur at the right, second intercostal space. A physical examination done a few weeks ago, when he had attempted to enroll in a detoxification program, was completely normal.
What is it? Acute aortic insufficiency caused by endocarditis.
Management. Emergency valve replacement, and antibiotics for a long time.
A 35-year-old lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis. She has had these progressive symptoms for about 5 years. She looks thin and cachectic and has atrial fibrillation and a lowpitched, rumbling diastolic apical heart murmur. At age 15 she had rheumatic fever.
What is it? Mitral stenosis.
Management. Start with echocardiogram. Eventually, surgical mitral valve repair (mitral commissurotomy), or balloon valvuloplasty.
A 55-year-old lady has been known for years to have mitral valve prolapse. She now has developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back.
What is it? Mitral regurgitation.
Management. Start with the echocardiogram, eventually surgical repair of the valve (annuloplasty), or possibly valve replacement.
A 55-year-old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type 2 diabetes mellitus, and has high cholesterol.
What is it? It’s a heart attack waiting to happen—but the point of this vignette is the management: this man needs a cardiac catheterization to see whether he is a suitable candidate for coronary revascularization.
A 55-year-old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type 2 diabetes mellitus, and has high cholesterol. Cardiac catheterization demonstrates 70% occlusion of three coronary arteries, with good distal vessels. His left ventricular ejection fraction is 55%.
Management. He is lucky. He has good distal vessels (smokers and diabetics often do not) and enough cardiac function left. He clearly needs coronary bypass, and with triple-vessel disease he is clearly not a good candidate for angioplasty.
