Balachander Jayaraman
Professor
Department of Cardiology
Jipmer
Pondicherry, india
11/01/2017
In JIPMER,Pondicherry, India every Friday all DM cardiology residenthave clinical cardiology case discussion which is conducted by Dr
Balachander Jayaraman. I am uploading few important clinical pointswhich were told to us during the case discussion
Bala sir class 4-06-2016
Disease in age of 45 years
ASD
VSD
PDA
Bicuspid aortic valve
Pulmonary valve stenosis
Mitral regurgitation1
Bala sir class 06/01/2017
Dyspnoea at one year of age
LV/RV disease
Dyspnoea in TOF is because of large number of collateral /BT shunt/reverse barhim effect
Absent pulmonary valve syndrome Dyspnoea with wheeze
Agenesis of lung
Absent left or right pulmonary artery
Adults TOF-Mild pulmonary stenosis
Cyanosis is mild in DORV
Loud A2 in TOF-Anterior aorta
Corrected transposition Loud A2
ECG
Precordial R wave transition in anterior lead
Presence of Q wave in V1 -Corrected transposition of great artery
TOF angiogram -AP/LAO 45 for pulmonary artery/PA cranial /PA lateral view
Simultaneous filling of aorta and pulmonary artery is hallmark of TOF
TOF patient develop CVA below 2 year of age because of fetal haemoglobin
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Bala sir class 8-04-2016
Conditions present with Dyspnoea
Valvular heart diseases
Mitral stenosis
Cardiomyopathy
HOCM
Portion of right heart
Infundibuar
Trabacular
Outflow
Inflow tract is always affected most of the time.
Aortic stenosis LV get thickened and prevent after load.
In Pulmonary stenosis there is thickness of interventricular septum. Infundibuar not thicken.
RV contract apicobasal.
Kussmaul's sign absence of fall of JVP is important
Vein in the arm , other sign of constrictive pericarditis
Raised the arm, vein will not empty on raising arm Maiz sign
Femoral artery is best for Pulsus paradoxus.
Presence of x wave tell systolic function is normal.
A wave and S4 are absent in constrictive pericarditis
JVP difference in constrictive pericarditis and restrictive cardiomyopathy
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Bala sir class 8-09-2016
Incidence of angina pectoris in valvular heart disease
10-20% cases of rheumatic fever present as typical angina pectoris
Carditis occur in 40% patient with rheumatic carditis.
Recurrence with carditis is very common. Recurrence episodes lead to mitral stenosis.
Chest pain in valvular heart disease or angina either due to aortic stenosis or Coronary heart disease or dyspnoea equivalent.
Every thing in rheumatic chorea is 20%.
Conduction abnormality in rheumatic fever
Atrial fibrillation
Ventricular tachycardia
Prolongation of PR interval.
Myocardium is least involved in rheumatic fever
Most common involvement is endocarditis.
Aortic root angio RAO/LAO 60*
MAZE four lines required to correct atrial fibrillation
Valvular heart disease with PAH look for mitral stenosis / regurgitation.
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Bala sir class
11/03/2016
AORTIC STENOSIS
Why aortic stenosis doesn't causes increases the LA pressure
Reason LA pressure not increases , LA causes booster effect and LA hypertrophy.
Booster pump is absent in patient with Atrial fibrillation and patient with CHB.
Wall stress in Aortic stenosis
Nothing but afterload.
Sudden increased in wall stress causes LV thickning.
If no LV thickening not than after load mismatch.
Male have more after load mismatch as compared to females in aortic stenosis.
Stage of aortic valve stenosis
Severe symptomatic aortic stenosis stage D
PARTNER Trial
Patient can be symptomatic even after 2 years of syncope.
Aortic stenosis and regurgitation check pulses in the carotid
Angina is due to increased in left ventricular ejection systolic pressure and causes subendocardial ischemia.
Beta blocker causes increased in LV pressure so avoid in aortic stenosis.
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Bala sir class 11-11-2016
LV end systolic pressure ratio to pressure ratio , suga index, high in LV systolic dysfunction.
Hucky equation for mitral valve area
Symptoms in mitral regurgitation depends on Effective regurgitation orifice.
Pulmonary regurgitation murmur is same as aortic regurgitation.
PR murmur is differentiated from aortic regurgitation murmur by the company it keeps with it.
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Bala sir class 12/05/2015
Chest pain
ASD
MVP
Pulmonary stenosis
Aortic stenosis
Primary pulmonary artery hypertension
HOCM
Coronary artery anomaly
Coronary ostial stenosis
(Kawasaki disease,Ankylosing spondylitis,Syphilis)
Pericarditis (RA,SLE)
Ebstein anomaly
Eissenminger syndrome
Bicuspid aortic valve
ASD with pericarditis
VSD with Aortic regurgitation
How many coronary supply right ventricle
Usually one RCA or LCX
AV grove and
Diagnostic catheter always tapper in angio view.
Pansystolic murmur on right side
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Bala sir class 15-09-2016
Classical point in history which tells you that this episode is rheumatic fever
1)Recurrence
2)Mitral regurgitation does not need recurrent rheumatic fever. But symptoms start early
Subclinical carditis or indolent carditis
Complete cure
Rebound carditis
Recurrent carditis
Subclinical carditis -Two type-Indolent
Second
Dyspnoea in aortic valve is very rare.
ASD can be possible with dyspnoea with fatigue
Pulmonary stenosis
Pulmonary artery hypertension
Berheim effect of severe aortic stenosis
Mitral regurgitation begats mitral regurgitation
LA good compliance lead to late dyspnoea in mitral regurgitation
LV contractility is very important
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Bala sir class 18-03-2016
Conditions present with atypical chest pain since childhood
Coronary artery disease
Myocarditis
Aortic stenosis
LVOT obstruction
RVOT obstruction
ASD
(Most common)
Reason Dilated pulmonary artery
Associated MVP
Associated pericarditis
Coronary artery anomaly
ALPACA
RCA from opposite sinus
HOCM
Dyspnoea alone in a young patient with no fatigue
Mitral valve disease
LVOT obstruction which started with dyspnoea
Subaortic stenosis
HOCM primarily present with dyspnoea
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Bala sir class 19-05-16
Complication of closing VSF
Aneurysm of membrane septum
Arrhythmia
Embolism
Infective endocarditis
Development of PAH/AR
Natural history of pulmonary stenosis
Mild regress
Moderate Variable
Severe Progressive
Natural history of aortic stenosis
Pulmonary stenosis murmur is mixed frequency
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Bala sir class 22-04-2016
Palpitations only present in ASD in eissenminger syndrome. Not in VSD/PDA with eissenminger syndrome.
Dyspnoea,Arrhythmia is present in patient with HOCM
Lutembacher syndrome is associated with cyanosis because of AV fistula
DD of Opening snap vs Split S2
Split S2 Triple sound
On standing Widening of S2-A2 gap indicates opening snap
Opening snap best at low left sternal border
Wide split best heard at Pulmonary area.
S1S2S3 in Pulmonary hypertension,COPD,
Pseudo R wave pattern Severe RA enlargement
Which catheter you will use for RV study
JL catheter
Multiple purpose catheter
Cournar catheter
Swan ganz catheter
Measure PCWP,RPA,LPA,MPA,Infundibuar,RV,RA,High SVC,IVC, Hepatic vein,LA,LV,Femoral artery sample.
15,10,5 ASD,VSD,PDA without flushing you get oxygen setup.
With flush
10,7,3 ASD,VSD,PDA
Even small amounts of bidirectional shunt in ASD indicates irreversibility. So do not do surgery.11
Bala sir class 23-05-16
Dyspnoea in ASD
LV dysfunction
Lutembacher syndrome
Mitral regurgitation
Femoral puncture complication are due to sheath
Angina-AS,ASD,MVP
MVP causes embolization in coronary artery and causes angina
MVP causes posteroseptal ischemia
Bicuspid aortic valve -AS/AR
Cardiomyopathy HOCM/DCMP
Aortoarteritis
Natural history of mitral regurgitation
Acute phase of acute rheumatic fever gone to develop mitral stenosis
Chronic mitral regurgitation begats mitral regurgitation
Recommended guidelines to measure blood pressure
Oscillator method for measuring blood pressure
Blood pressure in lower limb is high but still blood flow because mean pressure is low and area under blood pressure curve is low.
Single S2
Tell about both pulmonary and aortic component
Tell always whether murmur frequency, systolic,early or late,grade,
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Bala sir class 26-08-2016
Dr Praveen Kumar Gupta
Causes of earliest cyanotic spell
TOF
Pulmonary atresia
SVR in TOF determined the amount of shunt.
Tricuspid atresia
TAPVC Present with cyanosis and recurrent respiratory infections
History of cyanotic spell with squatting indicates decreased pulmonary blood flow.
CVA occur because of paradoxical embolism in TOF.
Brain infection occur during dentition.
Early cyanosis
Large VSD with eissenminger syndrome
Severe PAH
Causes of failure in TOF
Anemia
Infective endocarditis
Partial closure of tricuspid valve
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Bala sir class 28-05-16
Supracistal VSD develop late pulmonary artery hypertension
Early PAH in VSD
VSD with PDA
Atrioventricular cushion defect
Always says Severe pulmonary artery hypertension most likely because of intracardiac shunt.
DD of PAH in female
Primary pulmonary artery hypertension
Chronic pulmonary thromboembolism
Pulmonary artery hypertension mean pulmonary artery pressure more than 25 mmHg with PCWP less then 12.
VSD ECG with counter clockwise loop rotation suggestive of multiple vascular VSD.
Management of eissenminger syndrome
Contrast echocardiography
Bubble comes through the mitral valve into LVOT then ASD.
Bubble comes in LVOT without mitral valve than VSD.
LA size regress very fast once eissenminger syndrome develop in VSD/PDA.
Use swan ganz catheter, go to pulmonary artery.
RA take blood sample.
RV take blood sample. Fill the balloon.
Push the catheter to pulmonary artery.
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Bala sir class
29-04-2016
Cyanosis at Day 3
PDA depending circulation,
e.g. Tricuspid atresia
Pulmonary atresia
TGA
Cyanotic spell means TOF physiology.
Determinant of cyanosis in TOF
Impedance of pulmonary circulation
Systemic vascular resistance
Things lowering SVR
Crying
Fever Defecation
Large PDA with TOF-
PVR is highso cyanosis is high.Prevent left to right shunt. So cyanosis is there.
Which decreases Pulmonary vascular resistance
Recruitment of alveoli.
Factor causing decreases in lung alveolar
Congenital diaphragmatic hernia
Increases in lung blood flow.
Modified BT shunt can be done on any site.
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Bala
Sir class
Chest pain more than 20 min suggests either Myocardial infarction or non anginal.
Chest pain occur at night in myocardium infarction ?Why
At night increased platelet aggregation
Coronary vasomotion
Parasympathetic withdrawal not sympathetic activation so give aspirin even at night time
Coronary vasospasm because of alpha receptor activation
Diminition of heart chambers than increases in the wall stress so it causes Subendocardial infarction so angina occur
What are the predictor of the myocardial infarction on clinical examination ?
Precodial dyskinesia
Unstable angina patient develop collateral so only 5% developed acute myocardial infarction
Nitrate promote collateral formation
But patient developed tolerance
Drug given in night to prevent myocardial infarction
Beta blocker increases myocardial infarction at night
Nikorandial
Statin 80 mg
Relief in angina occur by preconditioning
Fatty acids oxidation inhibitors e.g Trimetazidine and Pfox inhibitors,Ranolazine
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Bala sir
14 05 2016
Causes of heart failure in infancy
Post tricuspid shunt
VSD
ALCAPA
AV cannal malformations
Pure right heart failure- PPH or critical stenosis
Symptoms of heart failure in pediatric population
Pedal oedema in Pediatric population
Periorbital odema
Increased in the liver span in the infancy first sign of LVF in the child.
Cause of resolving in heart failure in children
Development of Pulmonary hypertension
Development of pulmonary stenosis
Change in fetal haemoglobin
Decreases in the size of the shunt
LV maturation
Development of L to R shunt at atrial level
Unleger - Lakes of blood in right ventricle in ALCAPA.
LAD drain into pulmonary artery
Congenital mitral regurgitation with CC-TGA
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Bala sir 15-04-2016
Chronic fever with dyspnoea
Causes
Chronic rheumatic heart disease
Infective endocarditis
Myxoma
Tuberculosis
Myocarditis
Takayasu arteritis
Type of fever in rheumatic heart disease
Low grade. 38.5
Intermittent
Infective endocarditis
High grade, with chills/rigor
Tricuspid regurgitation classification
Mild -Only murmur
Mod-Murmur /JVP/Liver with pulsations increases on inspiration
Sever Tricuspid regurgitation -
Pre A wave tell you RVEDP. (V wave)
Mean gradient between RA/RV 1.7 Mild Tricuspid stenosis
2.6 Mod stenosis
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Bala sir 26/02/2016
Restenosis in mitral stenosis is mostly due to subvalvular disease.
During Isovolumic contractions anticlockwise wise motion causes valve closure. Called lock and key mechanism. After that papillary muscle start contracting.
If subvalvular disease means left atrial pressure is much lower so symptoms are lower. (After surgery). Subvalvular disease prevent mitral regurgitation.No orthopnoea, PND.
PAH pre-existing prevent symptoms.
Onset of LV dysfunction gives orthopnoea and PND.
Tricuspid stenosis murmur usually occurs in late diastolic but lately it becomes mid diastolic. The gradient is less. So you have to put two catheter in RA and RV. Reverse the transducer and during inspiration measure pressure.
Long diastolic murmur with presystolic accentuation tell mitral stenosis is severe.Presence of PAH.
Clinical signs of severe TR
JVP
Murmur
Pulsatile Liver
CV wave, TR murmur, palpable liver with no change with respiration suggests severe Tricuspid regurgitation.
Organic TR means associated tricuspid stenosis.
Leads V3,4R lead post mitral valve surgery.
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Bala sir class 1/04/2016
Definition of failure to thrive
Height is normal but weight gain is low
E.g Large pulmonary blood flow
Differential body parts development
Coarctation of aorta
Congenital heart disease causing delayed miles stone
E.g Pulmonary atresia,TAPVC, TOF
Deoxygenated blood reached to the body, there is insufficient collateral. Increased desaturation, causes delayed miles stone.
RV in TOF
RV pressure is systemic. RV out put depends on systemic ventricular obstruction. Wall stress of RV.
If systemic vascular pressure is low than RV is protective.
RV failure in anemia is because of decreases flow.
RV coronary blood flow is largely during systole not during diastole.During RV hypertrophy decrease in right coronary blood flow.
Causes of decreases in SVR
Aortic regurgitation.
Structure of body getting maximum blood is Liver and kidney.
Restrictive RV physiology.
Decreases in RV systolic pressure,?diastolic pressure,RV regression.
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Bala sir class 1/06/16
0.3% patient develop rheumatic fever after streptococcus infection.
21
Bala sir class 2-09-2016
NYHA Class III is associated with PCWP of 18 mmHg.
Palpitations is associated with either volume overload
Sinus tachycardia normally don't produce palpitations
Palpitations occur due to AV resynchronization.
Palpitations occur with junctional rhythm or sick sinus syndrome
Mitral stenosis palpitations are associated with fatigue
Aortic regurgitation palpitations with volume overload.
Angina
Remember Pneumonic PQRSTPrecipitated factor
Relieving factor
Temporal factor, most important
Aortic stenosis association not relived with oral medication , angina is prolonged
MVP typical angina with atypical features
HOCM Atypical angina
Aortic stenosis IVRT is affected , first because of diastolic dysfunction
HOCM give rise to dyspnoea, orthopnoea,PND.
Supraclavicular is the best place to ausculate S4.
Hypertrophy myocardium in aortic stenosis revascularization is not successful. Always do stress induced ischemia demonstration in myocardium via stress MPI or TMT.
PAD PACING produce ectopy in ventriculograpgy /CAG22
Bala sir class 4/03/16
Nitrate only drug which promotes collateral vessel.
Coarctation of aorta there is pain in the leg as collateral are not adequate.
Internal mammary, superior epigastric artery, thyroxcervical trunk give blood collateral in coarctation of aorta.
In collateral blood supply the femoral artery pulsations is replaced by gradual upstroke. In radialartery there is large upstroke.
Disease of aorta is best seen in abdominal aorta.
Fatigue indicates left ventricular outflow tract obstruction.
Superficial temporal artery to dorsal pedis artery.
Ejection click in aortic regurgitation indicates large blood flow, bicuspid aortic valve, dilated ascending aorta.
Back examination is very important in patient with coarctation of aorta Upper scapular, mid scapular, infrascapular area.
Peripheral pulmonary artery stenosis causes continuous murmur. Rubella syndrome.
Lateral thoracic jerk of bern
Definitive sign of coarctation of aorta
Continuos murmur restricted to suprascapular area.
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