Cardiovascular Flashcards
What are the indications for mitral valve replacement surgery?
- Mitral regurgitation
- Mitral stensis
- Infective endocarditis
How does S2 splitting vary between ASD and other forms of congenital heart diseases?
In ASD there is fixed splitting of S2 not affected by respiration while in other forms of congenital heart disease S2 splitting is variable with respiration
What are the signs associated with severe mitral regurgitation?
- Displaced, thrusting apex beat
- Right ventricular heave
- S3 gallop rhythm
- Evidence of pulmonary hypertension (loud P2, raised JVP)
What are key features of the JVP waveform?
‘a’ wave = atrial contraction
- large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
- absent if in atrial fibrillation
Cannon ‘a’ waves
- caused by atrial contractions against a closed tricuspid valve
- are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing
‘c’ wave
- closure of tricuspid valve
- not normally visible
‘v’ wave
- due to passive filling of blood into the atrium against a closed tricuspid valve
- giant v waves in tricuspid regurgitation
‘x’ descent = fall in atrial pressure during ventricular systole
‘y’ descent = opening of tricuspid valve
What are the different types of heart sounds?
- S1: Closing of the tricuspid and mitral valves at the end of ventricular filling
- S2: Closing of the aortic and pulmonary valves at the end of systole
- S3 (gallop): Occurs immediately after S2 and signifies end of rapid ventricuular filling. Normal in small children and pregnancy but can indicate severe LV dysfunction
- S4 (gallop): Occurs immediately before S1 and signifies decreased ventricular compliance, usually due to ventricular hypertrophy
What are the indications for aortic root replacement in patients with Marfan’s syndrome?
- Dilation of >50mm or >45mm in patients with family history of aortic dissectioon
- Root expansion at >3mm/year
What are the causes of pulmonary stenosis?
Supra-valvular obstruction:
- Tetralogy of Fallot
- Noonan syndrome
- Alagille syndrome
- LEOPARD syndrome
Valvular obstruction:
- Noonan syndrome
- Alagille syndrome
- Carcinoid syndrome
- Infective endocarditis
- Rheumatic heart disease
Sub-valvular obstruction:
- Tetralogy of Fallot
How is severity of pulmonary stenosis classified?
- Mild stenosis (valve gradient <36mmHg)
- Moderate stenosis (valve gradient 36 - 64mmHg)
- Severe stenosis (valve gradient >64mmHg)
What are the causes of mittral valve prolapse?
- Primary myxomatous degeneration of the valve
- Secondary non-myxomatous degeneration of valve caused by:
1. Marfan’s syndrome
2. Ehlers-Danlos syndrome
3. Osteogenesis imperfecta
4. ADPKD
What are the clinical signs of severe aortic stenosis?
- Slow-rising pulse
- Narrow pulse pressure
- Evidence of left ventricular dysfinction (displaced apex, pulmonary oedema due to L-sided heart failure)
What are the indications for closure of a patent ductus arteriosus in adult patients?
- Left ventricular failure
- Evidence of pulmonary hypertension if pulmonary artery pressure <2/3 systemic pressure or pulmonary vascular resistance <2/3 systemic resistance
What are the causes of Eisenmenger’s syndrome?
- Atrial septal defect
- Ventricular septal defect
- Patent ductus arteriosus
What are the indications for closure of a VSD?
- Significant left to right shunting (pulmonary:systemic blood flow >2)
- Cardiac surgery for any other indications
- Endocarditis
- Significant aortic regurgitation caused by prolapse of one or more aortic valve leaflets through defect
What are the causes for cyanotic congenital heart disease?
- Truncus arteriosus (1 vessel)
- Transposition of great arteries (2 vessels)
- Tricuspid/ pulmonary atresia (Tricuspid – 3)
- Tetralogy of Fallot (Tetralogy – 4)
- Total anomalous pulmonary venous return (5 words)
Other:
- Ebstein’s anomaly
- Eisenmenger’s syndrome
What are the causes of acyanotic congenital heart disease?
- ASD
- VSD
- PDA
- Coarctation of the aorta
- Aortic stenosis
What are the key features of Tetralogy of Fallot?
- Large ventricular septal defect
- Overriding aorta
- Right ventricular outflow tract obstruction
- Right ventricular hypertrophy
What are the long-term complications following corrective surgery for Tetralogy of Fallot?
- Pulmonary regurgitation
- Endocarditis
- Coagulopathy
- Polycythaemia
- Paradoxical emboli
- Arrhythmias
- Hearet failure
What are the causes of restrictive cardiomyopathy?
Primary:
- Loffler’s endocarditis
- Endomyocardial fibrosis
Secondary:
- Cardiac amyloidosis
- Cardiac sarcoidosis
- Haemochromatosis
- Radiation therapy
What are the ESC indications for aortic valve replacement surgery in aortic stenosis?
- Symptomatic (so long as no contraindications to surgery and there is likely to be significant quality of life improvement post-surgery)
- Asymptomatic, severe AS (mean gradient >/= 40mmHg) and:
1. LVEF <50%
2. Reduced exercise tolerance
What are the ESC indications for mitral valve replacement surgery in mitral regurgitation?
- Symptomatic
- Asymptmatic and:
1. LVESD >/= 40mm
2. LVEF </=60%
3. AF
4. Pulmonary hypertension
What are the components of the modified Duke’s criteria for diagnosis of infective endocarditis?
Major criteria:
1. 2x positive blood cultures showing typical organisms responsible for IE including S. virdans, HACEK, S. aureus or S. epidermidis
2. Evidence of endocardial involvement including positive echo findings or new valvular regurgitation
Minor criteria:
1. predisposing heart condition or intravenous drug use
2. microbiological evidence does not meet major criteria
3. fever > 38ºC
4. vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
5. immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots
Diagnosis of IE requires 2x major criteria, 1x major & 3x minor criteria or 5x minor criteria
What are the interventions for mitral stenosis and what are their indications?
- Percutaneous mitral commissurotomy (PMC) is preferred over surgery for mitral stenosis unless it is contraindicated
Indications for PMC:
- Symptomatic
- Asymptomatic with:
1. High thromboembolic risk (history of VTE, AF)
2. High risk of haemodynamic compromise (systolic pulmonary pressure >50mmHg)
