Cardiology Notes, JIPMER, Pondicherry, India

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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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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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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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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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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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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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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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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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


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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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


Partial closure of tricuspid valve

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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


Myxoma

Tuberculosis

Myocarditis

Takayasu arteritis

Type of fever in rheumatic heart disease

Low grade. 38.5

Intermittent


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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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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0.3% patient develop rheumatic fever after streptococcus infection.

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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


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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Education

Cardiology Notes, JIPMER, Pondicherry, India