Cardiac Flashcards
Indications for aortic root replacement in Marfans
Aortic root diameter >50mm (or 45mm if FHx of dissection)
Rate of dilatation >3mm/yr
Causes of AF
Age related
Cardiac related IHD and MI Sick sinus syndrome Valvular - MR/MS Dilated LA Rheumatic heart disease Htn Cardiomyopathy
Driven Sepsis Alcohol Thyrotoxicosis Drugs - stimulants
Mx of AF
Assess for anticoagulation
Rate vs rhythm control
What does a fourth heart sound indicate
Atria contracting against a stiff LV - pressure overload
Follow up ix for coarctation repair
MRI, not echo
Complications of mitral prolapse
Progression to MR
Infective endocarditis
Arrhythmias
Indications for surgical repair of mitral regurg
Valve repair preferred to valve replacement
Repair of valve = valvuloplasty
Repair of ring - annuloplasty
Indications:
Increasing LV dilatation (volume overload) - LVED dimension >45mm -> heart failure
Acute MR post CT rupture or infective endocarditis
Heart unable to tolerate acute MR - decompensates
Mx of aortic stenosis
Medical mx
TAVI
Valvotomy if young adult or child (delays need for valve replacement)
Valve replacement - bioprothetic or metallic
Four classic peripheral signs of infective endocarditis
Janeway lesions (non tender macules, blanching, typically on palms) Osler nodes - raised tender lesions on finger pulps Splinter haemorrhages Petechiae
What does a third heart sound indicate
Rapid ventricular filling in a dilated ventricle - volume overload
Eisenmengers syndrome
Def
Causes
Longstanding L->R shunt causing pul htn and reversal of shunt direction
Large VSD - Fallots tetralogy
Primary pul htn
ASD
PDA (normal splitting of S2, widening on inspiration due to delay in P2; only lower limbs cyanosed)
Indications for mitral valve replacement for mitral stenosis
Symptoms limiting normal activity - heart failure
Pulmonary oedema
Recurrent emboli
Pulmonary oedema in pregnancy (emergency transcatheter valvuloplasty)
Main presentation of coarctation
Htn
Features of Tetralogy of Fallot
Overriding aorta
VSD
Pulmonary stenosis
RVH
Causes of pul stenosis
By level:
Supra-valvular - Tetralogy of Fallot
Valvular (commonest)
Sub-valvular - Tetralogy of Fallot, congenital Rubella syndrome
Congenital heart disease - Tetralogy of Fallot (treated with shunt rather than correction or post surgical correction)
Infection - Rubella, infective endocarditis, rheumatic fever
Turners, Downs and Noonan’s syndromes
Carcinoid syndrome
Causes of mitral prolapse
Primary myxomatous degeneration (commonest)
Connective tissue disease - Marfans, Ehlers Danlos, Osteogenesis imperfecta
PKD
Cardiomyopathy
Causes of tricuspid regurgitation
Commonest - RV dilatation / failure due to:
Left sided heart disease - MV disease
Cor pulmonale (RHF due to lung resistance) - Primary pul htn
RV infarction
Causes of primary TR:
Infective endocarditis (esp IVDU)
Congenital heart disease
Carcinoid syndrome
Causes of mitral incompetence / regurg
Primary - Valve degeneration
Functional regurgitation - widening of LA/LV - cardiomyopathy, htn
Progression of mitral valve prolapse
Papillary muscle dysfunction - ischaemia, infarction, degeneration
Infective endocarditis
Iatrogenic Post valvotomy for mitral stenosis
Connective tissue disorders - SLE, RA, ank spond
Congenital - Marfans, ED, pseudoxanthoma elasticum
Causes of a raised JVP
CCF - ischaemic, valvular, hypertensive, cardiomyopathy
Cor pulmonale (RHF due to lung resistance)
Pul htn
Constrictive pericarditis
Pericardial effusion
Complications that can arise following coarctation repair
Recurrence
Aortic valve degeneration (tends to be bicuspid)
Aneurysm at the site of repair (+/- infection +/- rupture)
Aortic dissection in later life
What are the causes of acute MR (3)
Trauma, MI, endocarditis
Causes of aortic stenosis
Degenerative calcification
Rheumatic heart disease
Bicuspid aortic valve
Indications for aortic valve replacement
Aortic stenosis
Symptomatic (angina, syncope, dyspnoea) in the presence of normal LV function
Aortic regurg - LV dysfunction (EF <50%), widening of LV (LV dimension >50mm in systole, LVED dimension >70mm)
Acutely in infective endocarditis
Both can be combined with coronary artery grafting
Causes of aortic incompetence
Infection - Rheumatic fever and infective endocarditis
Long standing htn -> aortic dilatation, aneurysm and dissection
Marfans
Ankylosing spondylitis
Indications for valvotomy in mitral stenosis (valve widening)
Mobile valve
Absence of incompetence (no MR)
Cardiac features of Noonan syndrome
Septal defects - Atrial and ventricular Hypertrophic cardiomyopathy Pulmonary stenosis (commonest)
Indications for treatment of pulmonary stenosis
Pressure gradient across valve >64mmHg or >4m/s
Valvular area <1cm2
Signs of RHF
Balloon valvuloplasty
Valve replacement
Red flags in the presence of a PDA
Ix
Indications for intervention
Collapsing pulse
RV heave (pressure overload) - pul htn
Cyanosis = pul htn
Evidence of LV failure - due to Eisenemgers
Systolic / continuous murmur loudest in pulmonary region in expiration, radiating to the back
Ix:
Cardiac MR/CT
Echo
R heart catheterisation
Indications for intervention:
Raised pulmonary artery pressure - pul htn
LV volume overload
PA pressure or vascular resistance >2/3 systemic vascular pressure / resistance
Follow up only at 6mths if no adverse features, or regularly if persistent post intervention
Causes of aortic regurg
Primary myxomatous disease Rheumatic heart disease Htn Ankylosing spondylitis CTD - SLE, Osteogenesis imperfecta, Marfans, Ehlers Danlos
Acute AR - infective endocarditis, trauma, dissection
Ix for aortic stenosis
Echo
Exercise testing
Angiography for CAD
Causes of secondary htn
Renal - Renal artery stenosis, diabetic nephropathy, GN, PKD
Phaeochromocytoma
Endo - Hyperthyroidism, Cushings, Conns, Acromegaly
Cardiovascular - coarctation
Drugs - steroids, OCP
Changes seen on hypertensive retinopathy
Gr1 - Silver wiring
Gr2 - AV nipping
Gr3 - Flame haemorrhages, cotton wool exudates, Microaneurysms
Gr4 - Papilloedema
Mx of malignant htn
Hypertensive emergency - BP >180/110 and end organ damage
Hypertensive urgency - BP >180/110, no end organ damage
End organ damage - stroke, encephalopathy, renal impairment, ACS, acute LVF, dissection
Hypertensive emergency - IV labetalol / GTN in ITU/HDU setting
Hypertensive urgency - oral agents - CCB, ACEi, diuretics
Correct BP over 24hrs to <160 systolic
Causes of a widely split S2
Delay in P2 - pul stenosis, RBBB, deep inspiration
Early A2 - MR, VSD, causing LV to empty quickly
Cause of a split S2 not varying with inspiration (fixed split)
ASD - no pressure differential between the atria, so no change wit respiration pattern
Causes of reversed split S2
Early P2 closure - pul htn, Eisenmengers
Late A2 - LBBB, aortic stenosis
Causes of Eisenmenger’s syndrome
VSD (commonest)
ASD
PDA
Indications for closure of a VSD
Significant L->R shunt
Pt undergoing cardiac surgery for another indication
Endocarditis
Aortic regurgitation with prolapse of valve leaflet through VSD
Complications of Eisenmenger’s syndrome
Significant shunting of blood (R->L) with systemic:pulm ratio >2 Cyanosis and hyperaemia Paradoxical embolus RV failure Infective endocarditis Haemoptysis LV dysfunction Acute septal rupture post MI
Causes of congenital cyanotic heart disease
Tetralogy of Fallot Transposition of the great arteries Pulmonary atresia Pulmonary stenosis Ebsteins anomaly Tricuspid atresia Eisenmengers
Complications post surgery for correction of Tetralogy of Fallot
Pulmonary regurg
Infective endocarditis
Coagulopathy
Polycythaemia (due to chronic cyanosis)
Causes of diastolic heart failure
Ix
Constrictive disease - constrictive pericarditis, restrictive cardiomyopathy
Ix: Echo, CXR, cardiac CT, cardiac MR, cardiac catheterisation
Causes of a restrictive cardiomyopathy
Amyloidosis (commonest)
Sarcoidosis
Haemachromatosis
Scleroderma
Endocardial or pericardial fibrosis
Radiotherapy
Drugs - hydroxychloroquine
Idiopathic
Causes of constrictive pericarditis
Features
Ix
TB
Connective tissue disease - RA, scleroderma, SLE
Trauma / post-surgery
Radiotherapy
Evidence of bi-atrial dilatation / right and left heart failures
Ix - cardiac catheterisation - left and right atrial diastolic pressures are raised
Diagnosis of infective endocarditis
Dukes criteria
2 major and 5 minor criteria
Either both major, 1 major and 3 minor, or all 5 minor
Major:
Blood culture - typical bug in 2 samples
Echo - vegetation or abscess
Minor:
Fever >38
Risk factors / predisposition
Vasculitic signs - Osler nodes, haematuria, petechiae, raised ESR/CRP
Embolic signs - Roth spots, splinter haemorrhages, Janeway lesions
Abnormal echo or blood culture not meeting major criteria
Ddx of midline sternotomy
CABG
Open valve replacement
Open repair of congenital heart disease
Heart +/- lung transplant
Symptoms of aortic stenosis is worsening order
ASD
Angina, syncope, dyspnoea
Complications of aortic valve replacement
Surgical complications - infection, bleeding, pain, scarring, failure, recurrence
Specific - valve regurgitation / leak, infective endocarditis, microangiopathic haemolytic anaemia
