CARDIOTHORACIC - Acquired Heart Problems

Question 1

A patient presents with chest pain and episodes of fainting after exertion. He is found to a harsh midsystolic murmur, best heard at the right second intercostal space as well as along the left sternal border.

1. Likely diagnosis
2. Dx
3. Tx

Answer 1

1. Aortic stenosis
   - -> angina, exertional syncope
   - ->harsh midsystolic murmur @ Rt 2nd intercostal space & along LSB
2. Dx Echo
3. Tx: Surgical valve replacement if…
   - gradient >50 mmHg
   - at first indication of CHF, angina, or syncope

Question 2

A patient is found to have a widened pulse pressure and a high-pitched and blowing diastolic murmur. It is loudest at the right second intercostal space, but also heard easily along lower left sternal border, especially when the patient was in full expiration.

1. Likely diagnosis
2. Dx
3. Tx

Answer 2

1. Chronic aortic insufficiency (regurgitation)
   - -> wide pulse pressure (SBP - DBP)
   - -> blowing high-pitched diastolic murmur @ Rt 2nd intercostal space or along lower LSB, best heard during full expiration
2. Dx: Echo
3. Tx:
   - Often followed with medical therapy for years (vasodilators to decrease SVR and therefore LV strain)
   - Valve replacement at 1st echo e/o LV dilatation

Question 3

A young patient with a known history of IVDU presents with shortness of breathe, especially at night, and lower extremity edema. He has a fever, and his family physician notes a new loud diastolic murmur, which is loudest at the right second intercostal space.

1. Likely diagnosis
2. Dx
3. Tx

Answer 3

1. Acute aortic insufficiency 2/2 endocarditis in IVDU
   - -> young drug addicts with development of sudden CHF and a new murmur (loud, diastolic, Rt 2nd intercostal space)
   - -> fever
   - -> petechiae, anemia
   - -> embolic phenomena including Janeway lesions (small, painless, erythematous nodules/macules on palms/soles)
   - -> immune complex phenomena including Osler’s nodes (painful, red, raised lesions on hands/feet) and Roth’s spots (retinal hemorrhages with white/pale centers)
2. Dx: Echo, BCx
3. Tx: IV Abx, Surgical valve replacement
   * Abx PPx required for patients with prosthetic valves to prevent sub-acute bacterial endocarditis

Question 4

A very thin elderly woman presents with exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis. She also complains of occasional heart palpitations. She says that other than occasional sores throats as a child, she has always been healthy and had been putting off coming in. On exam, she is noted to have a low-pitched, rumbling diastolic murmur.

1. Likely diagnosis and developed complications
2. Dx
3. Tx

Answer 4

1. Mitral stenosis 2/2 rheumatic heart dz (many years previously)
   - ->dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, hemotysis
   - -> low-pitched rumbling diastolic apical heart murmur
   - -> as progresses, pt becomes thin/cachectic & develops A Fib
2. Dx: Echo
3. Tx:
   As sxs become more disabling, needs mitral valve repair (surgical commissurotomy or balloon valvuloplasty)

Question 5

A patient presents with exertional dyspnea and orthopnea. When asks, she says she does get occasional palpitations. On exam, a holosystolic murmur is noted; it is high-pitched and loudest at the apex, with radiation to the axilla and back.

1. Likely diagnosis
2. Dx
3. Tx

Answer 5

1. Mitral regurgitation
   - commonly 2/2 valve prolapse
   - -> exertional dyspnea, orthopnea, AFib
   - -> apical, high-pitched, holosystolic murmur radiating to back/axilla
2. Dx: Echo
3. Tx:
   When sxs become disabling, surgically repair valve (annuloplasty)
   *repair preferred over prosthetic replacement

Question 6

A middle-aged accountant with a PMHx of T2DM, hypercholesterolemia, and tobacco use presents with chest pain. He says that for some time he has had chest pains and shortness of breath while exerting himself (such as lifting boxes of computer paper off the shelf or going up stairs when his apartment elevator was broken). These always go away with rest, but he notices that it is increasingly limiting his activity.

1. Likely diagnosis & its risk factors
2. Dx
3. Tx

Answer 6

1. Coronary disease
   - typical patient is middle-aged sedentary man with FHx of CAD and a personal Hx of smoking, T2DM, and HLD
2. Dx:
   If progressive unstable disabling angina, perform cardiac cath & evaluate for revascularization
3. Tx
   Intervention indicated if…
   -1+ vessels have 70+% stenosis with a good distal vessel
   -preferably, still good ventricular fxn (can’t resuscitate myocardium if it is dead)
   Angioplasty & stenting for simpler problems
   =one vessel dz (except Left Main or LAD)
   Surgery (CABG) for more complex situations
   = triple vessel dz
   = Left main or LAD dz
   *CABG uses internal mammary artery to repair most important vessel

Question 7

A patient has just had surgery on his heart. What is the most important parameter to be optimized, & how to go about this?

Answer 7

Cardiac Output

• If well under normal (nl = 5L/min or cardiac index of 3), pulmonary wedge pressure (or LA pressure, or Lt end-diastolic pressure) should be measure
• –if low (0-3), more IVF likely needed
• –if high (20+), likely ventricular failure

Question 8

A patient with a PMHx of breast cancer presents with dyspnea on exertion and a distended belly. On exam, a fluid wave is noted on the belly. US shows hepatomegaly.

Answer 8

1. Chronic constrictive peridcarditis
   - likely 2/2 radiation in breast cancer tx (also may be from previous heart surgery, viral or bacterial pericarditis, etc.)
   - -> dyspnea on exertion, hepatomegaly, ascites
   - -> “square root sign” in RV pressures (elevation of RV diastolic pressure w/early filling & subsequent plateau)
   - -> equalization of pressures (RA, RV diastolic, pulmonary artery diastolic, pulmonary capillary wedge, and LV diastolic) on cardiac cath
2. Dx: echo, cardiac cath, etc.
3. Tx: surgery (pericardial stripping) :(