Exam 1 lecture 4 Flashcards
The inferior mediastinum has how many parts
3
Anterior, posterior, middle
How many layers of pericardium do we have?
How many of them are visceral and parietal
3 layers
1 visceral
2 parietal
How many phrenic nerves do we have
2, one on each side of the diaphragm.
Each side of the diaphragm can operate independently of each other
The Esophagus sits next to what main vessel
Descending aorta
Where does the right vagus nerve innervate at
Is it a PNS or SNS comment, and what does that mean
SA node
PNS
Tells the heart to put the brakes on or slow down
Where does the left vagus nerve innervate at
Is it PNS or SNS
AV node
PNS- applies the brakes to the HR
What would the HR be with no PNS involvement and the nodes were allowed to go wild
HR would be around 110
How many layers of pericardial tissues do we have?
Name them
3 layers
visceral pericardium
Parietal layer
Fibrous layer
Which layer of pericardium sits most superficial and is very tough? If blood leaks underneath this layer, it will not expand and not be good for the heart
Fibrous layer
Which layer is considered serous, has a strong attachment to the superior fibrous layer
Pareital layer
Which layer is very thin, sits directly on top of the heart and is considered a serous layer
Visceral pericardium
What is the tendon platform that the heart sits directly on top of
Central tendon
What is the purpose of the ductus arteriosus in the fetus
The ductus arteriosus is a normal fetal artery connecting the aorta and the main lung artery (pulmonary artery). The ductus allows blood to detour away from the lungs before birth.
which valve is the bicuspid valve
Mitral
Label the valves
Weird question I know…….
Can you have a bicuspid aortic valve?
yes 1-2% of people have it
Will you have an increased or decreased valve opening with a bicuspid valve
Decreased opening size
A normal aortic valve comes into contact with what 2 arteries
RCA and LCA
Which cusp of the aortic valve is not connected to a coronary artery?
The posterior cusp also called
NCC non coronary cusp
What is the important electrical insulator between the top and bottom half of the heart
Cartilaginous ring
What rattles during the 3rd heart sound in a sick heart
Cartilaginous ring
Kids’ hearts are able to accommodate _______ compared to adults
Less
They dont handle excess volume to well
What is the opening in the cartilaginous ring that allows communication between the top and bottom parts of the heart
Opening for the bundle of his
How do pediatric hearts compensate for increased venous return? How is that different than adults
Kids will increase HR
Adults increase SV
What is the name of the “fake cusp” that hands out in the mitral valve
Commissural cusp
is a part of the posterior cusp
What does the LCA branch into
LAD- widow maker- on left ventricle
circumflex artery- backside of heart also perfuse LV
In 15% of the population where does the PDA branch from
15% From LCA= higher pressure and can be problematic
85% of people the PDA come from RCA
Coronary blood flow is regulated by what?
Coronary blood flow is relegated to delta P
driven by aortic pressure
also regulated by wall pressure
What side of the heart is mostley to have ischemia
Left side due to pressure
LV has highest wall pressure
What side of the heart is mostly to have ischemia
Left side due to pressure
LV has highest wall pressure
Where are the heart auscultation sites
2nd intercostal site right side- aortic valve- very loud
2nd intercostal left side is the pulmonic valve- blood moving towards the right shoulder
5th intercostal next to sternum left side is tricuspid
5th left side, more lateral is mitral
APTM- order of auscultation
What is the 1st heart sound duration and overall pitch
1st heart sound is 0.14 seconds and low pitch lub
What is the second heart sound duration and overall pitch
2nd 0.11 seconds and high pitch dub
Does high pitch or low pitch have the lowest amount of oscillations per second
Low pitch= low oscillations per second or HZ
What is the normal hearing range in HZ of a young healthy patient
20Hz- 20,000 HZ(20KHZ)
Old people top out around 10,000 HZ
What is a phonocardiogram
Phonocardiogram- low pitch microphones useful for murmur diagnosis
What is the 4th heart sound
4th sound is atrial kick isn’t usually heard in healthy patients
Is aortic stenosis a systolic or diastolic murmur
Systolic
Aortic stenosis is systolic murmur- from narrow valve and increases blood velocity through it and creates more turbulent flow, loudest of all murmurs
Is mitral stenosis a systolic or diastolic murmur
Diastolic murmur- gets louder during rapid filling phase and gets louder the farther it fills and is loudest at atrial contraction
When during the cardiac cycle will you hear mitral regurgitation the loudest
beginning of systole
Is aortic regurgitation a systolic or diastolic murmur
Aortic regurgitation diastolic murmur- lot of regurge at high pressure in aorta and low volume in ventricles, large influx of blood backwards
Is PDA a systolic or diastolic murmur
PDA- is both diastolic and systolic murmur- from blood flow not related to a valve, from aortic pressure 100 and pulmonary pressure of 16 connection between the two, sound will be highest when delta P is highest
What is the term for backward flow
Retrograde flow
What happens to cornonary perfusion with sever aortic stenosis
high resistance valve increase LV pressure to compensate
decreased coronary perfusion since wall pressure is way higher than aortic pressure
How many syllables are in Phonocardiogram?
6 maybe…..
Anything that increases wall pressure does what to coronary perfusion
Decreases perfusion
Does Bradycardia have increased or decreased coronary perfusion
Increased
Spends more time in diastole
What is the resting coronary blood flow per minute in 100 grams of heart tissues
70ml/min/100 grams
What is the normal resting coronary blood flow in an adult heart per minute
225ml/minute
10-20% of patients with CAD have what valve issues
Mitral Regurgitation
What are the values of blood in ml for mild,medium, severe mitral regurgiation
10-20% of people with CAD have this
<30ml=mild
30-60ml= medium
>60ml=severe end stage mitral regurgitation
What type of axis deviation will we see with mitral stenosis
Right axis
What happens to our P wave with mitral stenosis
Prolonged p wave from LA strecth
What two common heart rhythms are really, really really bad for mitral stenosis
A fib- no atrial kick not swell for MS
Tachycardia- less time in filing, not swell
What bacterial agent is most common to cause mitral stenosis
Strep
If we have an elevated P wave, what does that mean
Something is wrong with the Right side of the heart
Do you want high afterload or low afterload for our mitral regurgitation patients
Low
Lower afterload will have lower BP overall and low intraventricular pressure.
High afterload increases LV pressure and push more blood into LA and further back.
Want to reduce afterload if you can be careful in severe regurge and patient with severe CAD
What happens to LVEDV in aortic regurgitation
It increases
Can get above 200ml
What type of hypertrophy occurs in aortic stenosis
Concentric hypertrophy
What type of hypertrophy occurs with aortic regurgitation
eccentric hypertrophy
How are the sarcomeres arranged in concentric hypertrophy
On top of each other
“you need consent to be on top”
How are the sarcomeres arranged in eccentric hypertrophy
Arranged end to end in a series
What type of hypertrophy is mitral regurgitation
Eccentric hypertrophy
How many parts does the mediastinum have?
how many sections are in each section and name them.
2 parts
1 in the superior mediastinum
3 in the inferior mediastinum.
Superior, Anterior, Middle and Posterior mediastinum.
what section of the mediastinum is the heart contained in?
inferior middle mediastinum
how many layers of pericardium do we have?
how many of these layers are visceral?
how many of these layers are parietal?
3 layers
1 Visceral Layer
2 Parietal Layers.
how many phrenic nerves do we have?
which section of the mediastinum are the phrenic nerves?
2 phrenic nerves
Middle mediastinum.
what do the phrenic nerves control?
diaphragm
what structure does the Esophagus sit next to?
descending aorta
what super important nerve sits in the posterior mediastinum?
vagus nerve
what area of the heart does the Left Vagus nerve control?
the right?
Left Av node
Right SA node
what is the resting heart rate with NO parasympathetic stimulation
For our class about 110 BPM
how many pericardial layers are “serous”
which 2 layers?
2
the visceral and the first parietal layer
what is the outermost pericardial layer called?
fibers pericardium
what part of the diaphragm does the heart sit on?
the central tendon.
true or false, breathing will cause the heart to shift up and down?
True. The heart rises and falls with the diaphragm as we breathe.
what is formed when the ductus arteriosus closes
ligamentum arteriosum
a patent ductus arteiosus will allow blood to flow from where to where?
Aorta to the pulmonary artery- in the adult circulation.
how many bicuspid valves do we have?
1 between the left atrium and the left ventricle.
When electrical impulses reach the papillary muscles what happens?
They tense up and give us a nice tight closed valve when everything is working appropriately.
dilated cardiomyopathy can effect closure of the AV valves how?
they displace the Chordae Tendineae, as well as the papillary muscles and prevent the valve from closing as well as it could (mitral regurgitation)
What anchors the AV valves in place?
Chordae Tendineae, and Papillary Muscles
What will turbulent blood flow cause?
“Noise” Murmmur
What percent of the population has a bicuspid Aortic Valve?
Will all of these people need to have these valves replaced?
1-2 %
According to the Miller text yes; however, Schmiddy isn’t convinced that this is the case.
2 of the cusps of the Aortic valve are connected to what? (crappy question sorry)
The L and R Coronary Artery.
The left coronary artery connects to the Left cusp
The right coronary artery connects to the Right cusp.
what is the function of the L and R Coronary artery sitting in the cusps of the Aortic valve
During diastole there is retrograde blood flow. These cusps act as funnels directing blood flow into the Coronary artery.
what does the NCC stand for?
where is this located?
Non coronary cusp.
This is the third cusp of the Aortic Valve.
what is the cause of noise associated with a non compliant ventricle?
rattling of the cartilaginous ring structure.
what is the one connection point through the cartilaginous ring that connects the atria and the ventricles?
the bundle of His.
why is a 3rd heart sound more likely in peds than in adults
the heart of pediatrics is less compliant when compared to an adult heart.
how would a pediatric heart compensate for an increase in venous return?
increase the heart rate
do we typically see more problems associated with the tricuspid valve or with the mitral valve?
why is this the case?
mitral valve. This is due to it functioning at higher pressures.
what is the false cusp of the bicuspid valve called?
Commissural cusp.
how many splits does the Left coronary make and what are they called?
2
LAD
Left circumflex
what 2 areas does the circumflex artery supply perfusion to?
posterior of the heart as well as some to the left ventricle.
what does the right coronary artery feed into 85% of the time
the posterior descending artery
in what percentage of the population is the Posterior depending artery connected to the left coronary artery?
15%
what are the pressures that drive coronary perfusion?
aortic pressure
wall pressure
will high wall pressure make coronary perfusion easy or more difficult?
more difficult probably.
why is Left heart coronary ischemia more prevalent than right heart coronary ischemia?
wall pressures are higher in the left heart walls.
where would you auscultate the aortic valve?
2nd intercostal space on the right sternal boarder.
where would you auscultate the pulmonic valve?
2nd intercostal space on the left sternal boarder .
where would you auscultate the tricuspid valve
5th intercostal space left sternal boarder
where would you auscultate the bicuspid valve.
5th intercostal space mid clavicular line.
when auscultating chest wall looking for a murmur, would you want to place your stethoscope above or below the level of the valve associated with the murmur (crappy question sorry)
ideally for this class you want the stethoscope above the valve and in the direction that the valve will be ejecting blood.
for this class one of the heart valves will probably be the loudest. which one of the valves would it be?
the aortic valve.
how long is the 1st heart sound
what causes this sound
will the pitch for this hear sound be high or low.
0.14 seconds (LUB)
closure of the AV valves
Low pitch
how long is the 2nd heart sound
what causes this sound
will the pitch for this hear sound be high or low.
0.11 (DUB)
Closure of the aortic and pulmonic valves
Slightly higher than the first but still low
when we are young what is our hearing range
20 Hz - 20 kHz
the lowest of low subwoofers is about 20 Hz
if we hear the 3rd heart sound what is causing it and when would we hear it?
rattling of the cartilaginous rings occurring during rapid ventricular filling.
if we were to hear the 4th heart sound what is casing it and when would we hear it?
Atria Kick
Atrial contraction. (DUH)
Aortic stenosis, systolic or diastolic murmur?
Systolic murmur
mitral regurgitation, systolic or diastolic murmur?
Systolic murmur loudest at the beginning of systole.
Aortic Regurgitation, systolic or diastolic murmur?
Diastolic murmur, loudest at the beginning of diastole
Mitral stenosis, systolic or diastolic murmur?
Diastolic murmur should be loudest during atrial contraction.
Schmiddy disagrees and says he thinks it should be loudest in the beginning of the filling phase…. So I guess take your pick on what you choose to believe, I am sure that both of them will be answer choices on the exam…..
what is one way discussed in lecture that we can artificially create a murmur that is not being caused by a pathologic heart valve.
what are causes of this?
Increased Cardiac Output.
Hyperthyroidism, Prego,
With patent ductus artereosus, is this a systolic or diastolic murmur?
Trick Question! its both….. Schmiddy got you again!!!
coronary perfusion is driven by ______ and resisted by______?
Aortic pressure
Wall pressure.
at the earliest point in diastole is coronary blood flow normal or retrograde?
Retrograde because the wall pressure is sigher than the aortic pressures.
With aortic stenosis will delta P between aortic pressure and wall pressure be greater or less than normal?
Larger pressure gradient and by extension this will increase retrograde blood flow.
what is the standard blood flow per minute for the coronary blood flow?
70 mL of blood per 100 grams of cardiac muscle mass of 225 mL/minute
will bradycardia increase or decrease coronary artery perfusion time.
For this class we can probably say that if tachycardia will decrease coronary perfusion time, then bradycardia will probably increase the coronary perfusion time.
what is being depicted in the red Schmidt drawing
coronary perfusion driven by Delta P
According to this graph when is peak coronary perfusion noted
very beginning of diastole.
Is continuous coronary perfusion seen in the left or right coronary artery?
why is this?
Right.
This is due to lower wall pressures on the right side.
how do we compensate for mitral stenosis
why is this compensation mechanism not super swell
is there remodeling changes in the left ventricle during mitral stenosis?
in mitral stenosis, does the pressure volume loop shift to the left or right
increase preload to the left side of the heart.
increasing pulmonary venous pressure (right heart after load) and CVP
No the left ventricle is spared.
shift the the left.
will mitral stenosis cause a left or right axis deviation?
Right axis deviation due to hypertrophy of the right side of the heart
due to mitral stenosis the left aria is likely to become stretched and blown out… what can this cause
delayed p wave conduction.
please note the right atria might stretch as well, but the left stretch is more important apparently.
what are 2 arrhythmias (non leathal) that would worsen prognosis of mitral stenosis?
Why are these 2 arrhythmias bad? (other than the fact that they are arrhythmias of course)
a fib- the heart looses the atrial filling help
Tachycardia – you end up shortening the filling time of the left ventricle.
you might end up using all of diastole to fill the left ventricle instead of just the first 1/3 of diastole as would be normal.
what are three of the most common reasons for mitral regurgitation discussed by Schmiddy in lecture
rheumatic fever
bad strep infection
remodeling following an MI
will the stroke volume increase or decrease with mitral regurgitation?
increase
in regards to the left atria what can happen with mitral regurgitation
Blood being pushed in to the atria from the ventricle during systole combines with the 70 mL of blood the atria would normally get. This will cause a dilation of the left atria and can produce a prolonged P wave, or potentially a fib.
In crayon please break down the rating system for mitral regurgitation.
< 30 mL in reverse per beat = mild
30-60 mL of blood in reverse per beat = mid grade
> 60 mL of blood in reverse per beat = end stage, not swell, you gonna die
what percentage of CAD patients will end up with Mitral Regurgitation
10-20 % this is due to left ventricular wall wear down from past ischemia.
what is a good Tx for mitral regurgitation.
when would this Tx probably not be great?
after load reducer – this decreases the amount of blood that goes back into the atria because the heart doesn’t take as much force to put blood into the aorta.
CAD patients, reduced after load might decrease coronary perfusion and put them in a place where they are most happy.
is Bradycardia good or bad for mitral regurgitation?
For this class Bradycardia is not great. More time is systole will mean that more blood is regurgitant into the atria…. Tachycardia would be best for this.
In what way does the body compensate for aortic regurgitation?
Peripheral vasoconstriction to keep BP adequate. this will cause SVR to increase.
increased SVR will increase the amount of Aortic regurgitation we have.
Catch 22
True or false Aortic regurgitation will cause remodeling of the Left ventricle?
True that ventricle is gonna be blown out.
What would be a treatment for Aortic regurgitation.
After load reducer if they can tolerate?
what are 3 variables that will be decreased in Aortic Valve Stenosis
Coronary perfusion
Peripheral pulse pressure
SV (with no compensation)
If the stroke volume is decreased due to Aortic stenosis… what is the bodies response to try and increase the peripheral pulse pressure?
Tachycardia, this will cause a decrease in diastolic filling time, and by extension decreased the time for coronary perfusion.
what type of heart wall thickening happens with aortic stenosis?
Concentric hypertrophy that ventricle gets THICCCCCC
Sarcomeres stack on top of each other. please enjoy this Schmiddy drawing.
what type of hypertrophy occurs with aortic regurgitation?
eccentric hypertrophy the walls get blown out and super thin… something like dilated cardiomyopathy…
Additional Sarcomeres are stacked end to end and not on top of each other
Please enjoy this Schmiddy drawing.
What is Schmiddy pointing out in the bottom right corner of this graph? (the area he has circled)
the bottom right hand corner of the loop is higher than it normally is… this is due to thicker and less compliant wall of the ventricles.
This requires more preload to get the appropriate amount of volume into the ventricle.
The same thing is essentially being represented on this graph as well. (moving form C to E will require more pressure to expand against something that is less compliant)
