Final Exam Lecture Fall '23 Flashcards
What differentiates MAC from rheumatic heart dz?
the leaflet tips in MAC are still thin and mobile
***if you think about it MAC really affects only the annulus, can extend to base of annulus
Associated complications of MAC
left atrial enlargement
left ventricular enlargement
mitral regurg
mitral stenosis
(predisposing factors for MAC) diseases that can cause stress on the annulus by either…
- elevating LV systolic pressure (HTN, Hypertrophic cardiomyopathy, aortic stenosis)
- Causing abnormal mitral motion (MVP, MVR, MR)
2 possible causes of MAC stroke
- MAC can cause LAE, leaders to A-fib, leads to embolic event
- Calcific emboli from MAC lesion
Can MAC extend into membranous portion of IVS? true or false
TRUE!
can cause AV block, intraventricular block , and a-fib
what is a microbial infection of the membrane lining the heart
infective endocarditis
causes of infective endocarditis
bacterial (strep or staph)
yeast infection
fungal infection
perivalvular abscess as what dz advances
infective endocarditis…
forms along mitral and aortic rings as extensions of dz
may cause fistula
infective endocarditis classified as (2)
acute (high grade fever, heart murmur may develop in little as a week)
subacute (AKA SBE subacute bacterial endocarditis) - low-grade fever, fatigue, weight loss, cough, weakness
both are bacterial, both destroy the valve
for acute* - think… “whats acute??? well babies are a-cute. and what sound do babies make???? not “mama” but mur-mur” LOL
Valve destruction of veggies usually result in
valve regurg
Veggies are more common on what side of heart…
LEFT side
affect MV more than AoV
Although not as common, right-sided veggies are seen more with
IV drug use, indwelling catheters, pacer wires
Veggies can exist on all valves… true or false?
They tend to form on what side of affected valves?
TRUE
tend to form on low pressure side
MV and TV on atrial side
AV and PV on ventricular side
“healed veggies” are called such if there is no
no active infection
usu smaller/more echogenic (fibrosis/calcium)
These veggies are the largest
fungal
These veggies have NO positive blood cultures
fungal
what is the predominant clinical sign of acute infective endocarditis
high fever
Subacute Bacterial Endocarditis (aka SBE) is only accurate if
banter is the source of the infection
These will make blood cultures unreliable or impossible
antibiotic therapy
echo appearance of veggie
irregular shape
Can look like a diffuse focal thickening along surface of valve
Can also be pedunculate masses that are highly mobile
Larger veggies more at risk for embolization?
Yes! More likely to break off if bigger
Left sided heart lesions can demonstrate what (4)
- petechiae skin lesions
- purpuric skin lesions
- transient ischemic events
- stroke
right sided heart lesions can display what symptoms
pneumonia like symptoms
valve _______ from veggies usu result in valvular __________.
destruction, regurgitation
NBTE is what… it is in response to what?
refers to formation of platelet and fibrin thrombi on cardiac valves and adjacent endocardium in response to TRAUMA, circulating immune complexes, vasculitis, or a hypercoagulable state
NBTE is caused by infection… true or false?
FALSE!
Caused by trauma!!!!! (physical trauma ie catheter)
Can become the origin for infection
NBTE can become infective endocarditis? True or false
TRUE
can also cause emboli and impair valve function
Systemic Lupus or other circulating immune complexes may result in friable platelet and fibrin veggies along a valve leaflet closure aka
Libman Sacks lesions or endocarditis
Large thrombotic veggies may form on valves and produce significant emboli to the brain, kidneys, spleen, mesentery, extremities, and coronary arteries. A product of _________. These veggies tend to form on congenitally abnormal cardiac valves or those damaged by
Marantic Endocarditis, rheumatic fever
Negative blood cultures and valvular vegetations suggest what diagnosis
NBTE (nonbacterial thrombotic endocarditis)
In noninfective endocarditis, what is often needed but will have the opposite effect in infective endocarditis?
anticoagulant
Definition of mitral valve prolapse
protruding or buckling of one or both MV leaflets into the LA in SYSTOLE in varying degrees
extend ABOVE plane of MV annulus (>or equal to 2mm)
I’m a floppy valve… what am I? I also am histologically identical to what syndrome?
Mitral valve prolapse, identical to Marfan’s syndrome
What are some different names for MVP
- Degenerative MV disease
- Myxomatous MV disease
- Fibroelastic deficiency (mildest form of MVP) - older patients, loss of mechanical integrity, decreased CT production
- Barlow disease (most severe form of MVP) - younger patients, excess leaflet tissue
I’m an anorexic, thin, young, female ballet dancer. I also have Marfan’s syndrome. How’s my mitral valve?
probably has mitral valve prolapse!!!!!!!
*also, Ehler Danlos syndrome (hyperelastic skin/joint mobility)
Most common cause of MR in developed countries
MVP
Varying degree of MR can cause
CHF
Pulmonary HTN
Acute pulmonary edema
Bacterial endocarditis from thick leaflets
Flail MV
Ruptured chordae
Sudden death (arrhythmias)
Do NOT use this view for MVP
apical!!! MVP OVERDIAGNOSED if view is off axis
use PLAX (2D and m-mode)
What’s the cure for MVP
none… so reassure the patient!
there are treatments though…
I am the mitral valve. One of my chordae has ruptured. I most likely have
mitral valve FLAIL (instead of prolapse)
I affect the MV. I am uncommon, am usu associated with endocarditis, and a more common on anterior leaflet… I am
MV aneurysm
MS consists of a pressure overload of what
the LA, RV, and pulmonary vasculature tree
Most common cause of mitral stenosis worldwide?
rheumatic heart disease
3 congenital causes of mitral stenosis
cor triatriatum
supravalvular mitral ring
parachute mitral valve
these are becoming the leading cause of non rheumatic heart disease (acquired MS)
age related degenerative MACS
one can acquire mitral stenosis (non rheumatic) in many ways (6)
vegetations, thrombus, myxoma (other tumors)
lupus
carcinoid heart disease
rheumatoid arthritis
radiation valvulitis
MACS
what is parachute mitral valve (1 of 5 rare causes of what)
rare causes of MS
it is a congenital abnormality
only one papillary muscle or two very close together in LV and chordae of both leaflets attach to single muscle
what is cor triatriatum
congenital
membrane (fibromuscular) divides LA into 2 chambers
may or may not cause obstruction
rheumatic mitral stenosis, define. may develop after what?
rheumatic fever is systemic inflammatory disease (affects heart, brain, joints, skin, subcutaneous tissue)
may develop after strep
echo hallmarks of rheumatic ms
affects both leaflets
leaflet thickening
leaflet calcifications
decreased leaflet mobility
commissural fusions
from tips to base (thickening)
chronic elevation of LA pressure
right heart pumps harder
can go into failure over time
TR results
Rt heart failure
M-mode of MV
D point: MV opens, beginning of diastole
E point: maximum excursion of valve
F point: lowest point after passive filling phase
A point: atrial contraction
C point: valve closure, systole begins
Acute vs Chronic MR
Acute MR - no changes in LA or LV size/function
Chronic MR - increase in LV and LA volume (LV function can become impaired due to volume overload)
!isolated rheumatic TV stenosis almost never occurs TRUE OR FALSE
TRUE! occurs only if there is rheumatic MV disease
Carcinoid heart disease defined
results from presence of carcinoid tumors found mostly in GI tract
(50% of patients with carcinoid syndrome have cardiac involvement)
what are some symptoms of carcinoid heart dz
facial flushing, abdominal pain, diarrhea, renal failure, hepatic failure, hepatomegaly, elevated venous pressure, systolic/diastolic murmur
Caval index measures what
right atrial pressures
congenital stenosis occurs at the _______level. what 2 kinds.
valvular; both below are congenital
bicuspid valve: doming of valve, fusion of raphe, balloon valvuloplasty to correct
dysplastic pulmonary valve: associated with Noonan’s syndrome, immobile cusps from thickened tissue, thickened valve tissue
3 types of PV stenosis
valvular
subvalvular
supravalvular
Pulmonary HTN is
an increase in pulmonary arterial pressure >30mmHg systolic
How does the RV respond FIRST with pulmonary HTN?
RV responds first with hypertrophy followed by RVE, TR, PI, and RAE
Secondary pulmonary HTN can occur due to other abnormalities or pathology taking place elsewhere, such as
mitral stenosis
heart failure with elevated LV end diastolic pressures
cor pulmonale (rt heart failure due to pulmonary dz)
thrombotic emoli to lungs
congenital heart dz with a lt-rt-shunt
Pulmonary HTN M-mode appearance (right heart)
“Flying W”
Midsystolic closure of pulmonic valve
Grading severity of pulmonary hypertension (right heart) method:
AcT/RVET ratio
place sample volume just proximal to PV in center of RVOT
measure AcT (acceleration time)
mesure RVET (right ventricular ejection time)
AcT divided by RVET
normal ratio is 0.45
what is acceleration time a measurement of
measured from onset of systolic flow to peak of velocity
Normal acceleration time for pulmonary arterial pressure in detecting pulmonary HTN is
greater than or equal to 120 msec
With increasing pulmonary pressure the time required for what increases, which delays what?
the time required for RV pressure to exceed PA pressure increases, which delays the opening of the PV
RVH occurs with
PV stenosis at subvalvular or supravalvular level
tetralogy of Fallot
chronic pulmonary HTN
mitral stenosis
Pulmonary emboli
Eisenmenger’s physiology
Normal free wall measurement is
1.9 to 2.9mm
RVVO can result from
INCREASED VOLUME OF BLOOD FROM EITHER WAY!!!
you either have blood increasing from to RV from RA or back flow of blood from the pulmonary system which obstructs RV blood flow from leaving
The tunica _______ composes 80% of aortic wall
tunica media
Elasticity of the AO wall does two things
dampening of force in systole
expulsion of stored energy in diastole
Average diameter for the abdominal aorta is
2cm
What part of the descending thoracic ao is vulnerable to traumatic injury\?
aortic isthmus
ao is fixed to thorax at this point
“obstructive lesion (structural abnormality)” Ao stenosis is VERY RARE
supravalvular ao stenosis
it’s congenital
its a narrowing of asc ao just distal to coronary arteries
supravalvular ao stenosis does have 3 types
- hour glass (most common) above sinuses, may be thicker cusps, assoc. w/williams syndrome, elfin faces, mental retardation, peripheral pulmonic stenosis
- fibrous membrane with narrow opening (aka discrete) - near sinotubular junction
- diffuse narrowing (hypoplasia) of descending ao aka “strand” - often involves origin of brachiocephalic arteries
coarctation (of ao) is
narrowing of desc aorta near origin of ductus arteriosus; associated with other heart defects (bicuspid ao valve, MV malformations)
2 types of subvalvular obstruction
- discrete form (barrier w/in LVOT just below AoV)
- tunnel type of sub aortic obstruction
the MOST COMMON aortic abnormality is
aortic dilation
asc ao dilation usu due to (4)
HTN
Atherosclerosis
Cystic medial necrosis
Post stenotic dilation
Marfan’s
Rheumatoid arthritis
Systemic lupus
Reiter Syndrome (type of arthritis)
Dilation actually becomes an aneurysm when…
when dilation is severe, 50% bigger than it should be
aortic aneurysm criteria (measurements):
is an aneurysm if:
more than 5 cm in ascending aorta
more than 4 cm in descending aorta
6 cm or higher presents higher risk for rupture
aneurysms can be caused by (etiology)
atherosclerosis
Syphilis
trauma
aortic stenosis
Congenital (ao coarctation)
PDA
Aortitis
Types of aneurysms (3)
dissecting
saccular (think “sack-like”)
fusiform (entire circumference, uniform dilation, think fusilli pasta)
aneurysms can have 3 shapes
- annuloaortic: ao root, annulus, sinus of vasalva (SOV)
- annulus, SOV, and part of asc ao
- beginning at sinotubular junction, skipping the annulus and SOV
Aortic sizes measure from a PLAX at what part of cardiac cycle?
end diastole
Most common aneurysm is
atherosclerotic aneurysm
25% are thoracic
rest are abdominal aneurysms
symptoms of aneurysms
wheezing
cough
dyspnea
hemoptysis (esophagus compression)
hoarseness (laryngeal nerve compression)
dysphagia
the gold standard in diagnosing aneurysm is
angiography… but even they can STILL MISS if aneurysm is layered with thrombus
complications of
LSOVA
NCSOVA
RSOVA
THE MOST COMPLICATIONS OCCUR IN the RIGHT!!!!
LSOVA
1. LA/RA rupture
2. cause LA compression
NCSOVA
1. may rupture into LA, RA, LV, or ventricular septum
RSOVA
1. may rupture into RA, RV, or adjacent main pulmonary artery
2. can cause RVOT obstruction
3. May result in RCA dissection or compression and acute MI
4. May compress conduction system and cause heart block
5. may rupture into pericardium and cause tamponade
What is aortitis
general term that refers to a broad group of conditions which causes inflammation of aortic wall
infectious or not
radiation induced
idiopathic
acute aortic syndrome
several life threatening entities overlap
aortic dissection what is
catastrophic event initiated by a sudden tear of intimacy and resulting cleaving of media
column of blood enters aortic wall and destroys the media while stripping the intimate from adventitia
classified by location
Ao Dissection classified by location…. two names… what are they… describe the locations
Standford classification:
Type A: asc aorta (tamponade most common cause of death)
Type B: all as long asc ao not included
Debakey classification
Type 1: ascending, transverse, descending ao involved (70%)
Type 2: ascending ao, stops proximal to brachiocephalic
Type 3: descending ao and may extend into abd ao
Ao dissection causes
HTN
atherosclerosis
Marfan’s
aging
pregnancy
trauma
iatrogenic injury
inflammatory dz
cocaine use
renal dz
strenuous physical exercise
patient symptoms of ao dissection
excrutiating pain
severe at onset
radiate in path of dissection
clammy (acute)
shock
hypertensive or hypotensive
In dissection, contrast agents opacify the _______ lumen FIRST.
TRUE
trauma normally occurs with
high speed deceleration injuries from MVA
bioprosthetic valve is
heterograft, xenograft, stented, scentless, homograft, autograft
*as long as it comes from live tissue
valve of choice for TV and PV is
bioprosthetic valve
porcine valve comes from what animal
“P” for pig
Ross procedure is
pulmonary AUTOGRAFT
Valved conduit is used to repair
congenital heart disease (done in kids/young adults, GROWS WITH PATIENT!)
least stenotic mechanical prosthetic valve
St Jude
3 orifices
(think, st Jude… 3… the trinity…) 3 peaks, 3 orifices
Most common ball and cage valve is
Starr Edwards
Classic type of mitral ring and tricuspid ring is
CARPENTIER EDWARDS
Most common tilting disc valve is
Bjork Shiley and Medtronic Hall
2 orifices
the higher the pressure in the pulmonary artery, the higher the
RVSP
elevated pressure in the pulmonary artery can lead to pulmonary artery HTN, so it must be monitored
RVSP is a good estimate of
pulmonary artery pressure
RVSP equation is
4(Vsquared) + RAP
RAP obtained from caval index
TR is the max velocity jet or (V) in the equation
RAP or right atrial pressure is determined by
caval index
in the absence of RVOT obstruction, RSVP actually =
SPAP
Cutoff for a normal RVSP is
35 mmHg
40-50 mild
>50 moderate
>60 severe
Both deep vein thrombosis (DVT) and pulmonary embolism fall under what category of dz
thromboembolic dz
When putting information in The Bernoulli equation, you need to look and see if the value of the Pressure gradient needs to be adjusted value-wise… for example
change 291 cm/s to m/s… so it would be 2.91 m/s instead for Vmax… THEN plug into Bernoulli equation
Flattening of the EF slope and/or decreased/absent A wave indicates
Mitral stenosis
