Case Base Cardiology 4.17.2014 kyavar md facc

No 1

A 75 year old woman with Recent orthopnea

• Chronic dyspnea• Fatigue• Recent orthopnea• palpitation• Pedal edema

LA

LV

AO

Diastole

Mitral Stenosis: Physical Exam

First heart sound (S1) is loud and snappingOpening snap (OS)Low pitch diastolic rumble at the apexPre-systolic accentuation (esp. if in sinus rhythm)

S1 S2 OS S!

MS

MR/TR/VSD

AS with ES

PS with ES

AR

MS with OS

PDA

S1 S2

Mitral Stenosis: Investigations

• CXR• ECG• Echo

Mitral Stenosis

• Etiology• Natural history • Symptoms• Physical Exam• Severity• Timing of Surgery

Mitral Stenosis: EtiologyPrimarily a result of rheumatic fever

(~ 99% of MV’s @ surgery show rheumatic damage )

Scarring & fusion of valve apparatusRarely congenitalPure or predominant MS occurs in

approximately 40% of all patients with rheumatic heart disease

Two-thirds of all patients with MS are female.

Mitral Stenosis: Natural History• Progressive, lifelong disease, • Usually slow & stable in the early years.• Progressive acceleration in the later years• 20-40 year latency from rheumatic fever to

symptom onset.• Additional 10 years before disabling

symptoms

Mitral Stenosis:Pathophysiology

Right Heart Failure:Hepatic Congestion

JVDTricuspid Regurgitation

RA Enlargement

Pulmonary HTNPulmonary Congestion

Atrial FibLA Thrombi

LA Enlargement LA Pressure

RV Pressure OverloadRVH

RV Failure LV Filling

Jugular Veins

Add 5 cm

Mitral Stenosis: Symptoms• Breathlessness• Fatigue• Oedema, ascites• Palpitation• Haemoptysis• Cough• Chest painmitral facies or malar flushSymptoms of thromboembolic complications (e.g. stroke, ischaemic limb)Worsened by conditions that cardiac output.

◦ Exertion,fever, anemia, tachycardia,, pregnancy, thyrotoxicosis

Signs of Mitral Stenosis

Palpation:Small volume pulseTapping apex-palpable S1Palpable S2

• Atrial fibrillation• Signs of raised pulmonary

capillary pressure– Crepitations, pulmonary

oedema, effusions• Signs of pulmonary hypertension

– RV heave, loud P2

Auscultation:Loud S1S2 to OS interval inversely

proportional to severityDiastolic rumble: length

proportional to severityIn severe MS with low flow- S1,

OS & rumble may be inaudible

What if you hear something?

• When does it occur? Is it systolic, diastolic, or both?

– What is the pattern?• Where is it loudest?• Where does it radiate?• Who goes with it?Are there other associated

findings? – S2 splitting normal, loud P2, gallop sound?

• How does it respond? Maneuvers

A 75 year old woman with loud first heart sound and mid-diastolic murmer

No 2

70 years old man with PND

•Syncope•Chest pain

LA

LV

AO

Systole

RV

Valve StenosesTwo Catheter Technique

Ejection Murmur

• Mixed frequencies and is moderate-to-marked crescendo-decrescendo

• Caused by forward flow across the left or right outflow

• Aortic stenosis & pulmonic stenosis

No 3

Patient with Purplish lips, hands and feet

• History: 6 week old male with 2 days of clear, nasal

congestion, no fever

Gets bluish after feeding or crying

Previously well, full-term baby

The family history was negative

Tetralogy of Fallot- Clinical Findings squatting

“Tet spells” – due to pulmonary outflow tract spasm

Severe cases ---at birth---severe PS

Mild cases ---- much later---mild PS

Cyanosis usually

ECG reveals right ventricular hypertrophy

Physical Examination Central Cyanosis vs. Peripheral cyanosis

Vital signs

Lung and CNS examination to rule these out

Cardiac Examination Heaves, thrills, abnormal or increased precordial activity Absent or diminished femoral pulses Abnormal first or second heart sound (abnormal splitting) Extra heart sounds (gallop, ejection click, opening snap) Murmurs that are loud, harsh, blowing

Case Presentation cont’d Purplish lips, hands and feet

Grade III/VI systolic murmur loudest at lower left sternal border

Liver was 1.5 cm below right costal margin and a normal spleen

Peripheral pulses equal in upper/lower extremities, 1.5 sec cap refill

Lab/Imaging Studies CBC/Sepsis evaluation

Chest x-ray

Oxygen Saturation (Arterial blood gas, pulse oximetry)

Hyperoxia test

Electrocardiogram

Echocardiography

Hyperoxia test- Cardiac or Pulmonary?

50-150mm Hg Truncus Arteriosus ( No restricted pulmonary blood flow)

<50 mm Hg Tetralogy of Fallot, Tricuspid Atresia ( Reduced pulmonary flow)

<150 mm HgCardiac disease or PPHN (SHUNT)

>150mm HgPulmonary disease (V/Q mismatch)

On 100% oxygenpaO2

TOF - ECG

Brickner, M. E. et al. N Engl J Med 2000;342:334-342

Tetralogy of Fallot

• 5/10k births• Ventricular septal

defect• Narrowing of the

pulmonary outflow tract

• Over riding aorta • right ventricular

hypertrophy

Hypoxemia Differential Right-to-Left Shunt

INTRACARDIAC, Great Vessels, pulmonary AV malformation

V/Q Mismatch Pneumonia, atelectasis, aspiration, pulmonary hypoplasia

Hypoventilation CNS depression, Neuromuscular disease, Airway obstruction

Diffusion Impairment Pulmonary edema, pulmonary fibrosis

Hemoglobinopathy

No4

A 41-year-old man was initially evaluated 6 years previously by his family physician, found to be hypertensive, and managed with pharmacologic agents. Over the next several years, control of his BP became increasingly difficult, requiring multiple agents. He was referred to a cardiologist for further evaluation. Throughout the entire period, he has remained asymptomatic.

Physical examination disclosed a BP of 160/94 mm Hg and a heart rate of 75 beats/min. Precordial pulsations were normal. Auscultation disclosed a late-peaking systolic murmur heard well at the apex; however, it was also heard over the entire thoracic cage and upper back (Fig 1 ). No diastolic murmurs were audible. Simultaneous palpation of the radial and femoral pulses disclosed a significant delay of the latter. The systolic pressure in the lower extremities was 130 mm Hg, determined with a Doppler probe over the pedal vessels, yielding an ankle/brachial index of 0.85. The remainder of the examination was normal.

Graphic recording of murmurs as heard at two locations over the chest.

Varma C et al. Chest 2003;123:1749-1752

©2003 by American College of Chest Physicians

Rib notching

Coarctation of the Aorta

• Grade II or III murmur• Heard posteriorly & over base of the heart• Hypertension in the arms, but not in the legs• Decreased or absent femoral arterial pulsation

Coarctation of Aorta

• Narrowing in proximal descending aorta

• May be long/tubular but most commonly discrete ridge

• Natural hx: poor prognosis if unrepaired– Aortic Aneurysm/dissection– CHF– Premature CADz

Coarctation Repair

Edmunds’ Cardiac Surgery in the Adult, Ch 47

• Surgical correction1) Patch aortoplasty with removal of segment and end to end anastomosis or subclavian flap repair 2) bypass tube grafting around segment

Coarctation of Aorta

• Residual or recoarctation may be seen in 3% to 41% of patients and can occur with any surgical technique or after angioplasty (seen in 8% to 11% of patients undergoing angioplasty for native coarctation)

No5

Dyspnea & Chest Pain

• The patient was a 33 year old housewife who had acute cardiac failure on the sixteenth day after the onset of the disease

• Physical examination revealed a pale thin female with tachycardia (107 beats/minute), tachypnea (22 breaths/minute), hypotension (blood pressure 86/50 mmHg), jugular venous distension with rapid “×” descent, and distant heart sounds. While the patient was being evaluated in the emergency room, she suddenly had a cardiopulmonary arrest

Myocarditis• Myocarditis is an inflammation of the myocardium, the thick

muscular layer making up the major portion of your heart. • Often follows URI• May present with chest pain (either pleuritic or non-specific) or signs

of heart failure• ECG may show sinus tachycardia, nonspecific repolarization

abnormalities, and intraventricular conduction abnormalities• Echocardiography documents cardiomegaly & contractile

dysfunction• Myocardial biopsy, although not sensitive, may reveal characteristic

inflammatory pattern (ex. Giant Cell)

Myocarditis basics

• Wide spectrum of clinical consequences– Mild & self-limited with few symptoms or severe

with progression to CHF & dilated CM– Very localized or diffuse– Clinical involvement can be limited to the heart or

be part of widespread systemic disorder

Electrocardiogram showing PQ-segment depression and diffusely elevated ST-T-segments at presentation (A)

and evolution after 1 day (B).

ECG & CXR

• ECG - nonspecific ST-T changes and conduction delays are common– Ventricular ectopy may be only clinical finding

• CXR - cardiomegaly is frequent, may have evidence for pulmonary venous hypertension & pulmonary edema

Diagnostics

• Wbc’s often elevated• ESR increased• Troponins elevated in 1/3• CK-MB elevated in 10%• Echocardiogram helps evaluate cardiac

function & exclude other causes• Cardiac MRI improving in ability to see

abnormalities in myocardium

Endomyocardial Bx

• Pathologic exam may reveal lymphocytic inflammatory response with necrosis, but this is not sensitive b/c of the patchy areas of distribution.

• “Dallas” criteria for histopathologic dx• May see “Giant cells”

No6

65 years man with sever chest pain

•History• DM • Hyperlipidemia• smoking