W10: Valvular Heart Disease Infective Endocarditis; RHD; DVT

Question 1

MITRAL STENOSIS PRESENTATION

Answer 1

• exertional dyspnoea + palpitations
• pulm oedema
• haemoptysis (pressure backflow & pulm vasc. rupture)
• systemic embolism
• infective endocarditis
• Ortner’s Syndome (laryngeal compression d/t posterior cv enlargement = hoarseness)
• ↑JVP, mitral facies, taping apex, RV heave, 1 + 2 +1, peripheral cyanosis

Question 2

MITRAL STENOSIS aetiology

Answer 2

RHD (commonest),

systemic, Rheumatoid Arthritis,

Congenital

Question 3

Mitral Disease Diagnosis

Answer 3

ECG: prolong P, RV hypertroph. (V1, V2)

ECHO: id hypertrophy and peak velocity

Question 4

MITRAL REGURG. (aetiology + presentations)

Answer 4

aetiology: rhd, valve prolapse, IEndo, degenerative, ANNULAR DILATAION

ACUTE: ↑ESPressure ES Vol = cardiogenic shock
d/t valve perforation, pap muscl.

CHRONIC: ↑EDV ESV norm., HYPERTROPHY; palpitation/AF
d/t reduced Co RH failure

Question 5

ACUTE & CHRONIC MITRAL REGURG. Tx

Answer 5

ACUTE

=> nitrates (vasodilator), dobutamine (contract.), intraaortic balloon pressure

CHRONIC

=> follow-up, valve repair + replacement

Question 6

AORTIC STENOSIS (pathophys + signs; heart sounds present?)

Answer 6

long asympt. and rapid deterioration:
** angina syncope SOB **

↑↑LV systolic pressure = ↑LV EDP = ↑O2 consumption => ischaemia

S1 radiates, S2 less audible

Question 7

AORTIC REGURG. (aetiology + presentations)

Answer 7

d/t annulus dilatation and enlargement.

• Leaflets: biscuspid (congenital), RHD, endocard., degenerative
• Ao root: dissection, connetive tiss disease, aortitis

*HF; angina;

ACUTE: exertional

CHRONIC: long asypt. and exert. tachypnoea

Question 8

AORTIC VALVE DISEASE DIAGNOSIS

Answer 8

ECG: ST/T changes

CXR: clacification (stenosis) or megaly (regurg.)

ECHO: id hypertrophy and peak velocity

Question 9

Aortic valve Tx

Answer 9

valve replacement

vasodilator Rx

Question 10

what is the commonest cause of mitral stenosis?

Answer 10

1. chronic rheumatic heart/valve disease (rheuma. fever predisposing)
2. rheumatoid arth.
3. congenital

Question 11

CABG

Answer 11

for L Main stenosis, and 3 vessel coronary art. disease

• long saphenous vein, IMA, radial art.

=> lifestyle, alleviation of symptoms,

Question 12

Signs of Tamponade

Answer 12

low BP, elevated JVP, oliguria, raised O2 demand, metabolic acidosis

Question 13

Sternotomy Risk & Mgmt

Answer 13

risk of stroke; death, wire infection (osteomyelitis of sternum), isolated granuloma); painful wires, sternal dehiscence

• drains to avoid tamponade
• anti pl. + thinners

Question 14

Most common valvular surgeries in adults and children?

Answer 14

Adult: Ao and mitral

Paed: pulmonary and tricuspid

Question 15

Rheumatic Fever common aetiological agents

Answer 15

strept. viridans

s. aureus

Question 16

surgery options in rheumatic fever

Answer 16

endocard. surgery: severe valvular regurg. , lARGE VEGETATIONS, persistent pyrexia, progresive renale failure

=> post-surgery abx for 6w and pre-abx course

Question 17

Presentation & nature of Rh. Fever + Tx

Answer 17

recurring

• pancarditis (imm-mediated: inflamm.)
• skin rash
• joint paint

=> aspirin and bedrest

Question 18

Valve prosthesis

Answer 18

1. BIO. VALVES: 70y/o+ Pt. via wire valve replacement
   no warfarin, 15y wearout
2. MECHANICAL VALVES: <50y/o Pt.
   permanent warfarin, INR monitoring, 40y wearout (more durable)

*infective risk
* thrombo-emboli. risk
therefore valve repair > replacement

Question 19

Procedure & Risks for Cardiopulmonary bypass

Answer 19

Requires SYSTEMIC ACOAG. (heparin); bedside RA and Ao drain.

• induced hypothermia: protective and slows metab.
• 12 hours max.
• RISK OF AIR EMBOLIM

Question 20

Epidemiology of Infective Carditis

Answer 20

• worse in females
• older Pt.: degenerative nature
  ↑incidence d/t ↑cardiac procedures therefore ↑complications

RF: IVDU, alcoholic cirrhosis, DM, septal hypertrophy, RHD, congenital (8%), mitral valve disease

Question 21

Pathophy. of IE

Answer 21

1. MECHANICAL DISRUPTION & INSULT
2. FIBRIN + PL. DEPOSITION (NON-BACT. THROMB.)
3. BACTERIAL ADHERENCE
4. VEGETATION
   * bacteraemia: DENTAL AND GI PROCEDURES, extra-acardiac infections

Question 22

Investigation of IE

Answer 22

(+) Duke’s

• cultures x3, 1hr apart (viridians; s. aureus; enterococci)
• ECHO or CT

+ Duke’s

• CRP, ESR, Renal funct. (U+E)
• urinanalysis: haematouria
• ECG: PR prolongation (1 block)
• CXR: pulm congestion, abcesses

Question 23

Typical Presentation of IE

Answer 23

• BACTERAEMIA w/ MURMUR or new/worsening murmur (regurg.)
• ACUTE FEVER
• EMBOLIC RISK

Question 24

IE Tx

Answer 24

COMMUNITY, NATIVE, OR PROSTHETIC
> ampicillin, FLUCLOX., gentamycin
> vancomycin, gentamycin

EARLY P(rosthetic)VE or HAI/non ENDOCARDITIS
> vanco, genta, RIFAMPIN

*PVE: 6W VS NON PVE 2-6W

SURGICAL:

• HF, aortic > mitral
• uncontrolled infection
• migrating infection for vegetation removal

Question 25

IE Prophylaxis

Answer 25

for prosthetics Pt.,
past IE
congenital

> valve repair
oral hygiene
prophylactic abx in invasive procedures: amoxicillin d/t risk of bacteraemia

Question 26

DVT

Answer 26

Arterial vs Venous THROMBOSIS

• venous: red thrombus (rbc + fibrin)
• arterial: white thrombus (fibrin + PL)
• female > male, ↑risk in ↑age
• D-DIMER

Question 27

DVt Tx

Answer 27

> VASCULAR SURGERY

> THROMBOLYSIS: alteplase for massive pe

> acoag:
(1) apixiban/rivaroxaban5mg tw/24
(2) LMWH (5days) > dabigatran, edoxaban
or LMWH with vitamin K antagonist for 5 d

PROVOKED: 3mos~
UNPROVOKED: 3mos+ (d/t likely recurrence)

Question 28

PE signs and symptoms

Answer 28

pleuritic pain, dyspnosea, haemoptysis, TACHY (RH ecg strain), pleural rub

?malignancy

RH ecg strain = T inv. (V1-4) +/- II, III, aVF

Question 29

PE Tx

Answer 29

DOAC
> RIVAROXABAN
> DABIGATRAN
* no review needed
* renal funct. d/t bleeding risk

LMWH
IOA Inhibitor
DALTEPARIN