Cardio Flashcards
Signs of AS
Slow rising pulse Wide pulse pressure Heaving apex beat ESM- radiates to carotid Reduced or absent 2nd HS Signs of HF
Causes of AS
Degenerative- around 70
Congential due to bicuspid valve (Turner’s)
Rheumatic (Rare)
Criteria for Severe AS
On Echo
1) Mean valve gradient>40mmHg
2) Valve area <1cm2
Clinical signs of severe AS
Narrow pulse pressure
Absent 2nd sound
Clinical signs of HF
Indications for surgery
1) Symptomatic AS
2) Asymptomatic with gradient >40mmg Hg plus
-LVSD <45%
-Abnormal exercise response
-VT
LVH >15MM
-Valve area <06cm2
Signs of AR
Collapsing pulse Wide pulse pressure Displaced apex beat Early diastolic murmur best heard in left sternal edge Corrigan's pulse
Uncommon signs= DeMusset’s sign- bobbing head with each pulse
Quincke’s sign- pulsing of capillary filling bed of nail
Causes of AR
Acute- IE
Aortic dissection
Prosthetic valve failure
Acute Rheumatic fever
Chronic- Degenerative Marfan's Ehlos Danlos syndrome Seronegative arthropathies Post rheumatic or IE
Clinical signs of severe AR
Dilated heart
Left sided HF
Very wide pulse presure
Short murmur (as so leaky pressure equalises quickly)
Echo signs of severe AR
RF >50%,
LVEDD >70MM
LVESD >50MM
Indications for surgery
Symptomatic Or asymptomatic with - LV dilatation to severe criteria -EF <50% -Significant aortic root dilatation (>45mm in marfans, >50mm in bisucpid valve or >55mm for everyone else)
Signs of MS
Malar Flush Left thoracotomy scar from mitral valvotomy Bruising from warfarin Irregular pulse due to AF Elevated JVP in R HF Tapping apex Left parasternal heave due to RV pressure Palpable p2 (Pulmonary HTN) Signs of HF
Heart sounds are complex and include
Loud S1- closing snap
Loud S2 due to loud P2 from pulmonary HTN
Opening snap after P2
Mid diastolic murmur- low pitched rumbling. best in left lateral decubitus with bell.
May have early diastolic murmer from PR called graham steel murmur
Causes of MS
Rheumatic fever commenest
Degenerative
Congenital
Non valvular (due to LA myoxoma or large thrombus in LA or large vegetation from IE)
Clinical signs of severe MS
Presence of AF Signs of pulmonary HTN Short gap between S2 and opening snap Long mid diastolic murmur Evidence of RHF
Management of MS
Anticoagulate
If symptomatic with evidence of moderate-severe MS then offer Mitral baloon valvuloplasty or surgery if not amenable to valvuloplasty
If asymptomatic treat with valvuloplasty if moderate or severe MS on echo and evidence of raised pulmonary pressure with exercise
Mitral valve baloon valvuloplasty
Assess if suitable based on Wilkin score- which looks at;
1) Leaflet mobility
2) Leaflet thickening
3) Subvalvular thickening
4) Calcification
IF < 8 then likely amenable
Also need to assess severity of MR- as will increase by one grade post procedure.
Cannot perform Valvuloplasty if; moderate-severe MR
Significant calcification
Or a LA thrombus- if this is present anticoagulate. If remains present deSpite this then absolute CI for valvuloplasty,.
Signs of MR
Sternotomy from previous MV replacement
General features of Marfan’s or other syndromes linked to MV prolapse
Stigmata of IE
Bruising from warfarin
In AF on pulse
JVP may be elevated in RHF due tto severe MR
Apex displaced and thrusting in character
Left parasternal heave due to RV pressure overload
Palpable P2 if pulmonary hypertension
On ausultation Soft S1
High pitched pansystolic murmur
S3 sound due to rapid filling
S4 due to forceful atrial contraction against less compliant LV
Auscultation in MV prolapse
Normal S1
Single or multiple mid systolic clicks
Mid to late sytolic murmur occuring as leaflets prolapse
Normal S2
Can increase murmur by getting patinet to squat or stand
Signs of severe MR
AF
Displaced volume overloaded thrusting apex
Signs of pulmonary HTN
Signs of HF
Causes
Degenerative Funtional (due to LV dilatation) Ischaemic MV prolapse- 1-2% ( Can be hereditary, Idiopathic, in Marfan's, CTD and ADPKD) Rheumatic
Indications for Surgery in MR
Replace or repair with chordal preservation in;
Asymptomatic with EF 30-60% and end systolic LV >40mm
Patients with chronic MR and new onset AF or raised pulmonary pressures
If severly dilated and imparied EF- (SF<30%), surgery only recommended if chordal preservation with durable repair is likely in absence of serious comorbidity.
Key to ensure Chordal preservation and loss of chordae tendinae can reduce LV funciton by 20%
Signs of TR
Swelling of pulsatation of neck- CV wave
Parasternal heave
Pansystolic murmur at left sternal edge- louder on inspiration
Pulsatile hepatomegaly
Causes of TR
Pulmonary hypertension Endocarditis Ebstein's abnormnality Rheumatic heart disease Carcinoid syndrome
Signs of Pulmonary hyptertension/Cor pulmonale
Palpable P2 Loud P2 on auscultation Pansystolic murmur of TR louder on inspiration Parasternal heave Raised JVP Signs of RHF
Pulmonary stenosis signs
ESM in pulmonary area loudest on inspitation
Pulmonary thrill
Palpable pulmonary ejection click
prominent a wave in JVP due to RV hyperstrophy
Parasternal heave
RV gallp rhythm (4th HS)
Causes
Congenital- related to Noonan’s syndrome
Also Tetrology of Fallot
Maternal rubella
Rheumatic fever
Management
If mild then may leave with no treatment
Can do balloon valvuloplasty in infants and if severe may need surgical repair or percutaneous replacement.
