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Transcript
Teaching Handout – Cardiology 1 twitter.com/njfawcett http://users.ox.ac.uk/~magd3786 Essential in black. Optional in grey Midline Sternotomy Scar 1. CABG (look for vessel harvest – saphenous vein, radial artery, LIMA) 2. Valve replacement 3. Correction of congenital cardiac abnormality 4. Heart/Lung transplant 5. Anterior approach to Pneumonectomy Aortic Stenosis Causes: 1. Degenerative/Calcification 2. Congenital bicuspid 3. Infective endocarditis 4. Rheumatic Fever Narrow pulse pressure/slow rising pulse “anacrotic” – low volume, flat Soft 2nd HS ESM Aortic Area/LSE, louder on expiration, radiating to carotids Lifting but nondeviated apex Symptoms: Progressive SOBOE Atypical Chest Pain Syncope Echo criteria: Gradient Area <15 Mild 1.5-2 15-50 Moderate 1-1.5 50+ Severe <1cm2 Aortic sclerosis Aortic sclerosis is a thickening of the aortic valve, without flow limitation. Classically it will give an ejection systolic murmur, but no radiation to the carotids. It is usually a degenerative process of calcification, and can progress to aortic stenosis. Aortic Regurgitation Causes: 1. Infective endocarditis 2. Rheumatic Fever 3. Congenital connective tissue disease (Marfan’s, Ehler Danlos) 4. Ankylosing Spondylitis 5. Syphilis/aortitis Wide pulse pressures and hypertension Waterhammer/collapsing pulse. Corrigan – dancing carotid Carotid pulsus bisiferens DeMusset- Nodding head Quinke- pulsating nail beds Duroziez – regurgitant femoral murmur Traube’s -Pistol Shot Femorals Early Diastolic murmur heard in endexpiration at the LSE with the patient sitting forward Hyperdynamic apex deviated laterally Symptoms: SOBOE LVF/CCF Progression to RHF Echo Regurgitant fraction Progressive left ventricular hypertrophy and LV dysfunction Differential for systolic murmur Aortic stenosis / Aortic sclerosis Mitral regurgitation / Mitral valve prolapse VSD HOCM Pulmonary stenosis – only really seen in corrected Tetralogy of Fallot (with residual pulmonary outflow tract obstruction) Management of Valvular Heart Disease *MULTIDISCIPLINARY* 1.Therapy Minimise the effect on the patient’s life with the aid of physiotherapy, occupational therapy 2. Support Arrange support from community heart failure nurses and relevant support groups 3. Medical – symptom control: diuretic therapy - long term survival benefit – ace inhibitors (reducing cardiac remodelling) 4. Surgical - valvotomy/valvuloplasty - bioprosthetic valve (last 10 years) - metallic valve replacement (last longer but require anticoagulation) (note – angiogram prior to surgery for ?CABG) Random points Always listen at the LSE in end expiration sitting forward Loud AS may radiate all around the praecordium Listen lower down in the neck for aortic stenosis, behind the ear for carotid stenosis Take the pulse rate! – Pulse: character, rate, regularity. General Advice Metallic valves – L sided only (mitral/aortic) – tricuspid/pulmonary valves are rarely replaced and when they are they are tissue valves Pulmonary valve lesions only usually occur in the context of a congenital cardiac abnormality eg. Tetralogy of Fallot = pulmonary outflow tract obstruction/pulm.stenosis Tricuspid regurg – often difficult to hear, and usually only audible when significant TR and accompanying systemic signs (v waves, pulsatile liver, peripheral oedema) Types of AV node block 1st Degree - prolonged PR interval, delayed AV node conduction 2nd Degree – Type I Mobitz or Wenkebach – variable, prolonging PR then missed beat Type II Mobitz – occasional nonconduction of p wave 3rd Degree – complete HB