chapter 11 Flashcards
Define the term auscultation of the heart
listening for sounds preduced within the heart during the cardiac cycle using a stethoscope.
What is the definition of a heart murmur?
a swishy noise produced by blood flow when turbulence is present.
- common in young children as functional
What is a funcitonal heart murmur?
benign, innocent or normal murmurs
how does an ECHO work ?
it uses sound waves recorded through a transducer to create a picture of the moving heart. This can determine the servity of the valvular disease, need for surgery, results and follow-up.
its AKA: TTE, TEE, or doppler u/s of the heart
How are murmurs graded
on a 1-6 scale. Starting point is grade 2 murmur, on just loud enough that its heard on the sethoscope, very loud murmur is 4, and one that can be heard with the naked ear is 6
Define a benign systolic murmur
a grade 1-2 systolic murmur where a physician is either unaware or aware but not concerned is called a benign systolic murmur.
Are the following disorders a concern?
VSD
ASD
mild mitral regurg
no
these individuals typically have a normal longetivity in life.
Name the organic murmur location in relation to the probable lesions listed below
- aortic stenosis
- aortic regurgitation
- mitral stenosis
- mitral regurgitation
- ventricular Septal Defect
- Mitral valve Prolapse
- systolic- upper sternum radiating to carotid
- diastolic- L sternal edge, high pitch, decrescendo
- diastolic- rumbling, apex, with opening snap
- systolic- blowing, apex, radiating to axilla
- systolic- 3rd and 4th intercostal space next to sternum
- late systolic- click, apex-not L sternal border
What examinations are included on an ECHO?
M-mode to measure sizes of atrial and ventrical chambers and aorta, wall thickness, EF, and valve motion.
In conjuntion with M-mode 2-D imaging provides informaiton on wall motion and anatomic details of valve leaflet structure
What does Doppler ECHO evaluate?
speed and direction of blood flow thorugh the heart valves as well as through any intra-cardiac shunts.
Define TTE known as Trasthoracic Echocardiography- (standard ECH)
uses transducer on the chest to direct u/s beams to the heart.
- Used after exercise to assess ventricular function.
- contrast or bubble studies can be used to enhance ventricular borders and to asses atrial R to L shunts
- routine tool- assess valve stenosis, valve regurg, caridac chamber enlargement and function, wall hypertrophy and congenital heart anatomy.
- starting point for aortic root disease
What is used to best assess hypertrophy in hypertensive heart disease?
TT-
What is the focus in a stress echo tests?
cardiac wall motion
- incidental findings such as valve abN can be reported but a detailed resting ECHO is needed for full assessment
Define Transesophageal Echocardiography (TEE)
places u/s transducer on an endoscope and is passed down the esophagus for a close look at heart structures with out lung tissue interference.
When would a TTE be used in place of a TEE?
- physical factors- indiciduals with barrel-shaped chest- obeses, or poor transthoracic window
- intra-cardiac factors-
- aortic root disease - d/t better visualization
What is the important of EJ (ejection fraction measurements)
It is a basic measurement of L V function
its a prognostic factor in all types of heart disease
normal LVEF is 55-65%, it increases by 5% in response to exercise.
Can EF measures vary between nuclear angiography, contract angiography, and echocardiography?
yes, by 20%.
Do all valves have regurgitation?
yes, the doppler is highly sensitive thus words like ‘trivial’ indicate normal valve function and ‘mild’ signifies an abnormality.
In which underwriting situations, would an ECHO not be essential for evaluation?
- dx of functional or innocent murmur
- small VSD- clinical diagnosis
- ppossible mild mitral prolapse wiht sysolic click only
- mild mitral regurg with soft apical murmur, normal EKG, CXR and no sxs
- possible mild aortic stenosis >age 60 with normal EKG and soft systolic murmur at base
- most cases of angina pectoris and atypical CP
- arrhhythmias, such as symptomatic extrasystoles or paroxysmal supraventricular tachycardia with a clinically normal heart.
Define Valve disease
stenosis for narrowing, insufficiency or regurgitation for leaking. Both functional alterations can occur together
There has been an increase in reported heart murmurs and valvular heart disease diagnosis’s. Why
- more children with examinations and murmurs are now disclosed to pt and parents
- ECHO cardiography and devleopment of tech to identify dx.
- valve surgery has increased in numbers and is available to people past age 90,
- valvular disease increases with age, and longevity has increased
Define Aortic Sclerosis
thickening of the aortic valve without significant stenosis or regurgitation.
- may lead to sig stenosis or regurgitation
- ^ risk of CAD and stroke
- 50% of individuals with sclerosis have a bicuspid aortic valve
Define Aortic Stenosis (AS)
narrowing of the aortic valve, which causes L V outflow obstruction.
- may lead to deformed valve as either unicuspid or bicuspid.
What are the most common causes of AS ?
- congenital abN valve, either bicuspid or unicuspid with calcification
- normal trileaflet valve with degenerative changes, eventual calcification and fibrosis.
- Rheumatic valve disease
How is AS diagnosed>
sxs: dyspnea, decreased exercise tolerance, syncope or dizziness and angina. »_space; develop with moderate/severe disease
- EKG can show LVH
- ECHO shows aortic valve leaflets thickened and calcified, an abN valve, LVH, aortic regurgitation and mitral regurgitation, and with a bicuspid aortic valve, dilation of aortic root can be present.
What happens to the gradient when there is severely impaired L ventricular function?
ventricle is incapable of developing high pressure, thus the gradient may be no more than 25 mmHg, and thus the severity of stenosis can be underestimated.
What ventricular heart disorder can be visualized with a CT?
the degree of valve calcification, which correlates with the degree of stenosis on echo.
What ventricular heart disorder can be visualized with an MRI?
measure valve area and blood velocity through the stenotic valve.
Mild AS gradually leads to what?
progessive fibrosis and calcification
severe AS if accompanied with sxs can lead to severe mortality. When sxs arise surgery is warranted.
Seriel ECHOs are done to follow the progressive narrow of the arter.
What is the treatemnet of AS?
there is no satisfactory Rs. Tx is aimed at preventing bacterial endocaditis and preventing rheumatic fevere.
Surgical tx is warranted for the following sxs:
- sxs of severe AS; CP, dyspnea, heart failure, agina syncope
- severe AS with hx of CAD bypass grafting
- severe AS in people having surgery of the aorta or other valves
- severe AS with LV EJ < 50%
- aortic dilation >45mm; surgical repair of both valve and aorta
- heavily calcified aortic root; consider replacement of both valves and aortic root
What are some unfavourable features with AS following valve replacement
- presence of sxs such as angina or synscope
- ^ BP
- abN heart rhythm, A fib, LBBB,
- exercise EKG; very low fitness level and arrhythmnias
- currench ECHO shows LV wall over 16mm and eJ <50% or mitral disease
Define Aortic Regurgitation (AR) ir. Aortic insufficiency (AI)
blood flow from the aorta to the LV during diastrol.
Backwards blood flow is d/t incompetence and incomplete closure of aortic valve.
what causes aortic regurgitation?
- aortic valve leaflet (cusp) disease
- deformity of the aortic root and aorta.
most common specific cause is congenital bicuspid valve, bacterial endocarditis and aortic root dilation.
Aortic diease inclues aneurysm of the ascecnding aorta caused by cystic medial necrosis or syphillis and occasionally trauma
How is AR diagnosed?
sxs: fatigue, dyspnea, angina, or palpitations - associated with severe diease
abN high-pitched decrescendo diastrolic murmur
increased Pulse pressure
and ECG abN
What are some ECHO abnormalities commonly found with A.R.
- AV leaflets are thickened and calcified
- abN bicuspid or unicuspid valve can be present
- severity of regurg
- EJ with normal LV function should be in excess of 60%
- measurements of the aortic root and ascending aorta-
- measurements of LV size- normal AP diameter of LV
How is the severity of the regurgitation dx’ed?
doppler area of regurgitation jet graded 1-2, comparison of mitral inflow and aortic outflow, calculation of regurgitant area and dimeter of the aortic jet.
What is considered a normal amount of aortic regurgitation?
Trivial amounts, and is not important unless there is associated myocardil weakness or HTN.
Why would one use an MRI or CT to evaluate AR?
used to better assess the diameter of the aortic root and ascending aorta, as only the first 3-4cm of the proximal aorta are seen on the ECHO.