Cardio

Question 1

Signs of AS

Answer 1

Slow rising pulse
Wide pulse pressure
Heaving apex beat
ESM- radiates to carotid
Reduced or absent 2nd HS
Signs of HF

Question 2

Causes of AS

Answer 2

Degenerative- around 70
Congential due to bicuspid valve (Turner’s)
Rheumatic (Rare)

Question 3

Criteria for Severe AS

Answer 3

On Echo

1) Mean valve gradient>40mmHg
2) Valve area <1cm2

Question 4

Clinical signs of severe AS

Answer 4

Narrow pulse pressure
Absent 2nd sound
Clinical signs of HF

Question 5

Indications for surgery

Answer 5

1) Symptomatic AS
2) Asymptomatic with gradient >40mmg Hg plus
-LVSD <45%
-Abnormal exercise response
-VT
LVH >15MM
-Valve area <06cm2

Question 6

Signs of AR

Answer 6

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

Question 7

Causes of AR

Answer 7

Acute- IE
Aortic dissection
Prosthetic valve failure
Acute Rheumatic fever

Chronic- Degenerative
Marfan's
Ehlos Danlos syndrome
Seronegative arthropathies 
Post rheumatic or IE

Question 8

Clinical signs of severe AR

Answer 8

Dilated heart
Left sided HF
Very wide pulse presure
Short murmur (as so leaky pressure equalises quickly)

Question 9

Echo signs of severe AR

Answer 9

RF >50%,
LVEDD >70MM
LVESD >50MM

Question 10

Indications for surgery

Answer 10

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)

Question 11

Signs of MS

Answer 11

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

Question 12

Causes of MS

Answer 12

Rheumatic fever commenest
Degenerative
Congenital
Non valvular (due to LA myoxoma or large thrombus in LA or large vegetation from IE)

Question 13

Clinical signs of severe MS

Answer 13

Presence of AF
Signs of pulmonary HTN
Short gap between S2 and opening snap
Long mid diastolic murmur
Evidence of RHF

Question 14

Management of MS

Answer 14

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

Question 15

Mitral valve baloon valvuloplasty

Answer 15

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,.

Question 16

Signs of MR

Answer 16

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

Question 17

Auscultation in MV prolapse

Answer 17

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

Question 18

Signs of severe MR

Answer 18

AF
Displaced volume overloaded thrusting apex
Signs of pulmonary HTN
Signs of HF

Question 19

Causes

Answer 19

Degenerative
Funtional (due to LV dilatation)
Ischaemic
MV prolapse- 1-2% ( Can be hereditary, Idiopathic, in Marfan's, CTD and ADPKD)
Rheumatic

Question 20

Indications for Surgery in MR

Answer 20

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%

Question 21

Signs of TR

Answer 21

Swelling of pulsatation of neck- CV wave
Parasternal heave
Pansystolic murmur at left sternal edge- louder on inspiration
Pulsatile hepatomegaly

Question 22

Causes of TR

Answer 22

Pulmonary hypertension
Endocarditis
Ebstein's abnormnality
Rheumatic heart disease
Carcinoid syndrome

Question 23

Signs of Pulmonary hyptertension/Cor pulmonale

Answer 23

Palpable P2
Loud P2 on auscultation
Pansystolic murmur of TR louder on inspiration
Parasternal heave
Raised JVP
Signs of RHF

Question 24

Pulmonary stenosis signs

Answer 24

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)

Question 25

Causes

Answer 25

Congenital- related to Noonan’s syndrome
Also Tetrology of Fallot
Maternal rubella
Rheumatic fever

Question 26

Management

Answer 26

If mild then may leave with no treatment

Can do balloon valvuloplasty in infants and if severe may need surgical repair or percutaneous replacement.