Cardiovascular Disease (Andrews)

Question 1

What represents 2/3 of all valve diseases?

Answer 1

Acquired stenosis of the aortic or mitral valve (LEFT side valve problems)

Question 2

What is the major pathogen of Rheumatic fever

Answer 2

Post Group A Beta-hemolytic streptococcus..

Question 3

Describe what Rheumatic fever is…

Answer 3

It is a post group A Beta-hemolytic Strep pharyngitis, immune mediated, multisystem inflammatory disease

Question 4

Describe the pathogenesis of Rheumatic fever

Answer 4

It’s a hypersensitivity reaction induced by Group A -Beta strep. The M protein on the antibody on the GAS looks like proteins on the heart valve, joints and other tissue. so the immune system gets ‘faked out’ and M protein attacks the proteins on the heart valve. Continued attacks leave lesions and necrosis.

Question 5

What is the morphology of acute Rheumatic fever

Answer 5

The lesions that appear on the heart valve have a bubble gum look called fibrinoid necrosis. Also has ‘Aschoff bodies’, (inflammatory cells). It’s also not just a valvular disease. but a (fibronous) pan-carditis meaning that all 3 layers (endo, myo and pericardium are affected.

Question 6

What is the sound affiliated with pericarditis (pericardial effusion)?

Answer 6

“leather on leather”.

Question 7

What is the endocardial involvement with acute Rheumatic fever?

Answer 7

It’s left sided, the mitral and aortic valves are most commonly affected. Also swollen, edematous and have crusts of fibrin.

Question 8

What are manifestations in the skin that can be seen in acute Rheumatic fever?

Answer 8

Subcutaneous nodules and a maculopapular rash (Erythema marginatum)

Question 9

What is happening with chronic rheumatic heart disease?

Answer 9

You have ongoing alterations of the valve structure (scarring) to the point where the valve becomes thickened and rolled. Commissures of valves leaflets join together (good ddx from others). You also see a thickening and fusing of the chordae tendonae

Question 10

Where does chronic rheumatic heart disease present the most?

Answer 10

About 70 percent of cases are seen in the mitral valve.

Question 11

What can be seen at end stage rheumatic heart disease ?

Answer 11

Right ventricular dilation and hypertrophy due to the back up of flow.

Question 12

What is the lag period for acute rheumatic fever

Answer 12

Usually 10 days to 6 weeks post GAB hemolytic strep pharyngitis it because clinically evident but the peak incidence is about 5-15 years

Question 13

What is the clinical diagnostic criteria for acute rheumatic fever?

Answer 13

The Jones criteria

Question 14

What is the criteria for the Jones criteria

Answer 14

You need to have 2 major or 1 major and 1 minor
Major: PECCS Polyarthritis, Erythema marginatum, Acute Carditis,Chorea (involuntary slow muscle movement) and Subcutaneous nodules
Minor - Fever, arthralgia, prolonged PR interval, previous rheumatic fever and leukocytosis.

Question 15

What are manifestations in chronic rheumatic carditis that could lead to a valve transplant

Answer 15

1) A new murmur
2) Cardiac hypertrophy - CHF
3) Arrhythmia, especially A fib w- Mitral stenosis
4) Thromboembolic complications
5) ineffective carditis

Question 16

What is the claim to fame of Calcific aortic stenosis.

Answer 16

It’s the most common valvular disorder in adults and most common cause of isolated Aortic stenosis in the US

Question 17

Where can Calcific aortic stenosis occur?

Answer 17

It’s commonly associated with bicuspid valves (more congenital) but can develop in normal valves (more due to age).

Question 18

Describe the morphology of Calcific aortic stenosis.

Answer 18

Valves become rigid and deformed by irregular calcified masses but there is no fusion or commisures… they are still distinct but stiff and non-compliant. Due to this they develop a resistance of emptying to the left ventricle, LV becomes hypertrophic and eventually dialated

Question 19

What kind of symptoms would you expect to see in someone who has Calcific aortic stenosis.

Answer 19

Angina pectoris (due to increased demand and decreased aortic outflow), syncope, a harsh systolic murmur Eventually can get CHF

Question 20

What is the age of onset for both types of Calcific aortic stenosis.?

Answer 20

Normal valve - in 70s- 80s

Bicuspic valve - in 40s-50s

Question 21

What is the general treatment for someone with Calcific aortic stenosis?

Answer 21

Surgical valve replacement (if not 50% mortality in 2 years)

Question 22

What is the most common cause of isolated mitral valve regurgitation?

Answer 22

Myxomatous degeneration or Mitral valve prolapse.

Question 23

Who is most likely to get Myxomatous degeneration or Mitral valve prolapse

Answer 23

Peak age 20-40, Females outnumber males 7:1. Associated with those with Marfans and other connective tissue diseases but many who don’t get it.

Question 24

What is the morphology of Myxomatous degeneration or Mitral valve prolapse?

Answer 24

Its the ballooning of redundant cusps especially the posterior leaflet. Chordae tendonae can get elongated and fragile (can rupture) due to polysaccharide mucus build up on valves.

Question 25

What are the possible symptoms of Myxomatous degeneration or Mitral valve prolapse?

Answer 25

Palpations, Fatigue, chest pain, click murmur syndrome (click is chordae tendonae pulled tight

Question 26

What does Myxomatous degeneration or Mitral valve prolapse increase the risk of?

Answer 26

1) Ineffective endocarditis
2) Stroke from emboli
3) Arrythmias and sudden death

Question 27

What are the two types of prosthetic heart valves?

Answer 27

1) Bioprosthetic - From pigs or other humans

2) Mechanical - Artificial (no tissue component)

Question 28

What are the 2 types of mechanical heart valves

Answer 28

1) Star Edwards - “Ping-Pong ball in a birdcage” - Fills and floats ball that gets sucked in annulus and closes valve
2) Tilting disc - has 2 trap doors. Hydrodynamic valve, reach a critical volume it opens up.

Question 29

What are some complications that can happen with prosthetic heart valves?

Answer 29

1) Gradual wear - more of a problem in bioprosthetic, can stiffen
2) Thrombi- more with mechanical
3) Ineffective endocarditis (bioprosthetic)
4) Paravalvular leaks (both)
5) Hemolysis - more in mechanical (tilting disc)

Question 30

What are the two types of pericarditis?

Answer 30

Primary - (usually viral) uncommon

Secondary - Most

Question 31

What are the causes of secondary pericarditis?

Answer 31

1) MI
2) Cardiac surgery
3) Mediastinal radiation
4) Systemic disorders (Rhu fever, uremia)

Question 32

What is morphology of secondary pericarditis?

Answer 32

Shaggy fibrinous membrane

Question 33

What are the clinical features of pericarditis

Answer 33

1) atypical chest pains (worsened by reclining)
2) Friction rub
3) Tamponade (faint distant heart sounds, distended neck veins, reduced CO)

Question 34

What are the 3 types of pericardial effussion

Answer 34

1) Serous - CHF, hypoalbuminemia
2) Serosanguineous - d/t blunt chest trauma and malignancy
3) Chylous - d/d mediastinal lymphatic obstruction.

Question 35

Where do you find metastatic cardiac tumors and (what do they metastasized from)

Answer 35

Most commonly in the pericardium

Metastasized from lung, breast, melanoma, lymphoma/leukemia most common primaries

Question 36

Are primary cardiac tumors rare?

Answer 36

Yes

Question 37

What are 3 types of primary cardiac tumors

Answer 37

1) Myxoma - on the valve. Ball valve AV obstruction
2) Rhabdomyoma - associated with tuberous sclerosis and may see polygonal spider cells
3) Lipoma - on interatrial septum