1
Q
Define the term auscultation of the heart
A
listening for sounds preduced within the heart during the cardiac cycle using a stethoscope.
2
Q
What is the definition of a heart murmur?
A
a swishy noise produced by blood flow when turbulence is present.
- common in young children as functional
3
Q
What is a funcitonal heart murmur?
A
benign, innocent or normal murmurs
4
Q
how does an ECHO work ?
A
it uses sound waves recorded through a transducer to create a picture of the moving heart. This can determine the servity of the valvular disease, need for surgery, results and follow-up.
its AKA: TTE, TEE, or doppler u/s of the heart
5
Q
How are murmurs graded
A
on a 1-6 scale. Starting point is grade 2 murmur, on just loud enough that its heard on the sethoscope, very loud murmur is 4, and one that can be heard with the naked ear is 6
6
Q
Define a benign systolic murmur
A
a grade 1-2 systolic murmur where a physician is either unaware or aware but not concerned is called a benign systolic murmur.
7
Q
Are the following disorders a concern?
VSD
ASD
mild mitral regurg
A
no
these individuals typically have a normal longetivity in life.
8
Q
Name the organic murmur location in relation to the probable lesions listed below
- aortic stenosis
- aortic regurgitation
- mitral stenosis
- mitral regurgitation
- ventricular Septal Defect
- Mitral valve Prolapse
A
- systolic- upper sternum radiating to carotid
- diastolic- L sternal edge, high pitch, decrescendo
- diastolic- rumbling, apex, with opening snap
- systolic- blowing, apex, radiating to axilla
- systolic- 3rd and 4th intercostal space next to sternum
- late systolic- click, apex-not L sternal border
9
Q
What examinations are included on an ECHO?
A
M-mode to measure sizes of atrial and ventrical chambers and aorta, wall thickness, EF, and valve motion.
In conjuntion with M-mode 2-D imaging provides informaiton on wall motion and anatomic details of valve leaflet structure
10
Q
What does Doppler ECHO evaluate?
A
speed and direction of blood flow thorugh the heart valves as well as through any intra-cardiac shunts.
11
Q
Define TTE known as Trasthoracic Echocardiography- (standard ECH)
A
uses transducer on the chest to direct u/s beams to the heart.
- Used after exercise to assess ventricular function.
- contrast or bubble studies can be used to enhance ventricular borders and to asses atrial R to L shunts
- routine tool- assess valve stenosis, valve regurg, caridac chamber enlargement and function, wall hypertrophy and congenital heart anatomy.
- starting point for aortic root disease
12
Q
What is used to best assess hypertrophy in hypertensive heart disease?
A
TT-
13
Q
What is the focus in a stress echo tests?
A
cardiac wall motion
- incidental findings such as valve abN can be reported but a detailed resting ECHO is needed for full assessment
14
Q
Define Transesophageal Echocardiography (TEE)
A
places u/s transducer on an endoscope and is passed down the esophagus for a close look at heart structures with out lung tissue interference.
15
Q
When would a TTE be used in place of a TEE?
A
- physical factors- indiciduals with barrel-shaped chest- obeses, or poor transthoracic window
- intra-cardiac factors-
- aortic root disease - d/t better visualization
16
Q
What is the important of EJ (ejection fraction measurements)
A
It is a basic measurement of L V function
its a prognostic factor in all types of heart disease
normal LVEF is 55-65%, it increases by 5% in response to exercise.
17
Q
Can EF measures vary between nuclear angiography, contract angiography, and echocardiography?
A
yes, by 20%.
18
Q
Do all valves have regurgitation?
A
yes, the doppler is highly sensitive thus words like ‘trivial’ indicate normal valve function and ‘mild’ signifies an abnormality.
19
Q
In which underwriting situations, would an ECHO not be essential for evaluation?
A
- dx of functional or innocent murmur
- small VSD- clinical diagnosis
- ppossible mild mitral prolapse wiht sysolic click only
- mild mitral regurg with soft apical murmur, normal EKG, CXR and no sxs
- possible mild aortic stenosis >age 60 with normal EKG and soft systolic murmur at base
- most cases of angina pectoris and atypical CP
- arrhhythmias, such as symptomatic extrasystoles or paroxysmal supraventricular tachycardia with a clinically normal heart.
20
Q
Define Valve disease
A
stenosis for narrowing, insufficiency or regurgitation for leaking. Both functional alterations can occur together
21
Q
There has been an increase in reported heart murmurs and valvular heart disease diagnosis’s. Why
A
- more children with examinations and murmurs are now disclosed to pt and parents
- ECHO cardiography and devleopment of tech to identify dx.
- valve surgery has increased in numbers and is available to people past age 90,
- valvular disease increases with age, and longevity has increased
22
Q
Define Aortic Sclerosis
A
thickening of the aortic valve without significant stenosis or regurgitation.
- may lead to sig stenosis or regurgitation
- ^ risk of CAD and stroke
- 50% of individuals with sclerosis have a bicuspid aortic valve
23
Q
Define Aortic Stenosis (AS)
A
narrowing of the aortic valve, which causes L V outflow obstruction.
- may lead to deformed valve as either unicuspid or bicuspid.
24
Q
What are the most common causes of AS ?
A
- congenital abN valve, either bicuspid or unicuspid with calcification
- normal trileaflet valve with degenerative changes, eventual calcification and fibrosis.
- Rheumatic valve disease
25
How is AS diagnosed>
sxs: dyspnea, decreased exercise tolerance, syncope or dizziness and angina. >> develop with moderate/severe disease
- EKG can show LVH
- ECHO shows aortic valve leaflets thickened and calcified, an abN valve, LVH, aortic regurgitation and mitral regurgitation, and with a bicuspid aortic valve, dilation of aortic root can be present.
26
What happens to the gradient when there is severely impaired L ventricular function?
ventricle is incapable of developing high pressure, thus the gradient may be no more than 25 mmHg, and thus the severity of stenosis can be underestimated.
27
What ventricular heart disorder can be visualized with a CT?
the degree of valve calcification, which correlates with the degree of stenosis on echo.
28
What ventricular heart disorder can be visualized with an MRI?
measure valve area and blood velocity through the stenotic valve.
29
Mild AS gradually leads to what?
progessive fibrosis and calcification
severe AS if accompanied with sxs can lead to severe mortality. When sxs arise surgery is warranted.
Seriel ECHOs are done to follow the progressive narrow of the arter.
30
What is the treatemnet of AS?
there is no satisfactory Rs. Tx is aimed at preventing bacterial endocaditis and preventing rheumatic fevere.
Surgical tx is warranted for the following sxs:
1. sxs of severe AS; CP, dyspnea, heart failure, agina syncope
2. severe AS with hx of CAD bypass grafting
3. severe AS in people having surgery of the aorta or other valves
4. severe AS with LV EJ < 50%
5. aortic dilation >45mm; surgical repair of both valve and aorta
6. heavily calcified aortic root; consider replacement of both valves and aortic root
31
What are some unfavourable features with AS following valve replacement
1. presence of sxs such as angina or synscope
2. ^ BP
3. abN heart rhythm, A fib, LBBB,
4. exercise EKG; very low fitness level and arrhythmnias
5. currench ECHO shows LV wall over 16mm and eJ <50% or mitral disease
32
Define Aortic Regurgitation (AR) ir. Aortic insufficiency (AI)
blood flow from the aorta to the LV during diastrol.
| Backwards blood flow is d/t incompetence and incomplete closure of aortic valve.
33
what causes aortic regurgitation?
1. aortic valve leaflet (cusp) disease
2. deformity of the aortic root and aorta.
most common specific cause is congenital bicuspid valve, bacterial endocarditis and aortic root dilation.
Aortic diease inclues aneurysm of the ascecnding aorta caused by cystic medial necrosis or syphillis and occasionally trauma
34
How is AR diagnosed?
sxs: fatigue, dyspnea, angina, or palpitations - associated with severe diease
abN high-pitched decrescendo diastrolic murmur
increased Pulse pressure
and ECG abN
35
What are some ECHO abnormalities commonly found with A.R.
1. AV leaflets are thickened and calcified
2. abN bicuspid or unicuspid valve can be present
3. severity of regurg
4. EJ with normal LV function should be in excess of 60%
5. measurements of the aortic root and ascending aorta-
6. measurements of LV size- normal AP diameter of LV
36
How is the severity of the regurgitation dx'ed?
doppler area of regurgitation jet graded 1-2, comparison of mitral inflow and aortic outflow, calculation of regurgitant area and dimeter of the aortic jet.
37
What is considered a normal amount of aortic regurgitation?
Trivial amounts, and is not important unless there is associated myocardil weakness or HTN.
38
Why would one use an MRI or CT to evaluate AR?
used to better assess the diameter of the aortic root and ascending aorta, as only the first 3-4cm of the proximal aorta are seen on the ECHO.
39
T or F: calcific aortic valve disease can cause dominant aortic regurgitation rather than aortic stenosis
T
40
What are some indications of aortic valve replacement or repair surgery for AR?
1. sxs of AR, + LV dysfunction
2. severe AR, with developpment of sxs on exercise testing
3. severe AR, without sxs but LV EF <50%
4. severe AR, in individuals having Coronary arter bypass grafting
5. severe AR in individuals having surgery of the aorta or other heart valves
41
What are the unfavourable features with AR following valve replacement.
1. moderate to severe LV impairment that fails to improve completely
2. continued severe heart enlargement- ECHO LV diameter > 62mm, CXR to CTR ratio >55%
3. EJ <50%
4. co-morbid CAD
5. frequent venticular ectopic beats
6. deteriorating biprosthesis
42
What are some unfavourable features co-related to AR that affect u/w?
1. signs of worsening sxs over last 10 yrs
2. underlying cause- Marfans or Ehlers-Danlos syndrome at risk for aortic rupture
3. multiple valve involvement
4. co-morbid CAD/ significant cardivascular risk factors
6. impaired LV function
43
Define mitral stenosis
is the obstruction of blood flow from the L atrium to the LV caused by narrowing of the mitral valve and creating a pressure gradient across the valve in diastol.
44
What is the main cause of MS?
scaring of the mitral valve from rheumatic fever
less common: infective endocarditis and severe Mitral annular calcification cause MS.
45
How is MS diagnosed?
sxs: dyspnea, decreased exercise tolerance, palpitations, cough and chest pain. A Fib, stroke, p pulmonary edema or pulmonary hemorrhage can also occur.
abN heart sounds,
possibly other murmurs
ECG may show possible A fib and R V hypertrophy
46
What evidence would you see on an ECHO with an MS diagnosis?
1. mitral valve leaflet deformities such as thickening, fibrosis, fusion, and calcification
2. severe cases, the valve becomes funnel-shapped with extreme thickening and immobile leaflets
3. mitral valve area and estimates of extent calcification
4. heart chamber sizes, function and other structures can be assessed
5. doppler ECHO measures the gradient accross the valve and pressures, including estimate of pulmonary artery pressure.
6. associated mitral regurg and abN of other valves can be present
47
What can be assess with a stress EKG or ECHO in terms of MS?
can assess exercise capacity, precipitate sxs and evaluate pulmonary HTN.
48
How does MS develop?
after an episode of acute rheumatic fever. Its a progressive disease with progressive calcification and fibrosis occuring at a variable rate. SXS develop after age 35.
Sxs include exercise dyspnea
49
What complications can change the patients' MS course of action, to acute development?
1. A Fib
2. heavy exercise or pregnany can lead to lead to pulmonary edema with acute episode of severe duspnea
3. thromboembolism-
4. pulmonary hemorrhage-
50
What are the main causes of death for someone with MS
progressive R-sided heart failure
stroke
endocarditis
pulmonary embolism
51
How is MS treated>
medical tx can relieve sxs but surgical intervention will releave obstruction.
rx: abx, fever prevention, DIU, digoxin and beta blockers to tx sxs or anti-coagulants
52
what are the indications for percutaneous or surgical intervential for mitral stenosis?
1. moderate to severe MS with sxs
2. moderate to severe MS without sxs but with pulmonary HTN
```
procedures include"
PMBV
open valvotomy with valve repair
closed valvotomy
mitral valve replacement.
```
53
What is PMBV (percutaneous mitral ballon valvotomy)?
new tx procedure for MS. heart catherization is performed to access the Mitral valve and ECHO can be performed to monitor procedure. A ballon is inflated then rapidly deflated, which opens the stenotic valve by seperating the fused valve leaflets
54
Define Mitral Regurgitation
Blood flow from the LV to the LA during systole. This backwards flow of blood is due to incompetence or incomplete closure of the mitral valve.
- A trivial leak "wiff" of MR can occur accross normal valves
55
What is the main cause of MR>
1. abnormality of the mitral valve apparatus, which involves valve leaflets, annulus, chordae tendineae and papillary muscles.
2. Can also be caused by IHD, with papilalary muscle dysfunciton, LV dysfunction and dilation of any form.
3. systemic diseases: Marfan or Ehlers-danlos syndrome, scleroderma, RA
3. radiation damage, damage at time or surgery, or certain drugs including diet pill Fen-Phen.
56
How is MR diagnosed?
sxs: dyspnea, fatigues, exercise intolerance, palpitations
blowing, high-pitched bolosystolic murmur
ECG shows notched P waves, LVH, ST-T wave abN, A fit.
57
What evidence is revealed on an ECHO, for those with MR
1. cause of the MR
2. severity of regurg
3. calculation of the effective regurgitation orifice (ERO)
4. L arterial size, (usually ^)
5. existence of LV enlargement-
6. EF- should be 70 or 80 with MR, as the ventricle is emptying in two ways, ie to aorta and back to LA
7. LV size and systolic function are usually normal in mild disease
58
What can be determined with a heart cauterization?
confirm echo findings or to identify CAD
59
T or F for valvular diseases- the course of action (ie mortality risk) increases/depends on sxs
T
| once symptomatic, mortality risk increases
60
T or F: 50% of individuals with MR after an attack of acute rheumatic fever will eventually lose their murmur and have midl degrees of residual valve scaring.
T
| they can thereafter have no futher problems or the valve scaring will return MR or the development of MS.
61
MR associated with dilated cardiomyopathy is due to what?
annular dilatation, LV dilation, and dysfunction of papillary muscles and is associated with a high mortality risk
62
how is MR treated
Rx can relieve sxs, but only definitive tx is surgery.
rx includes; abx, DIU, digozin, ACE inhibitors, antiarrhythmic agens for A fib and anti-coagulants
63
What are the indications for valve surgery for chronic MR?
1. severe acute MR, defined by doppler ECHO with sxs
2. severe chronic MR with sxs + LV dysfunction, LVEF < 30%, LVESD
3. severe chronic MR without sxs and with LVEF 30-60%, LVESD >40
4. severe MR without LV dysfunction but with new onset A fib or pulmonary HTN
64
T or F. When feasible and based on anatomy, mitral valve replacement is preferred over mitral valve repair in the majority of cases.
F. Mitral repair is preferred over valve replacement. LV function is better associated with repair and avoids future prosthetic heart valve complications.
65
What are the treatment options for mitral valve replament (type)
mechanical valve- requires life long anti-coagulants
- age <65, with A Fib,
bioprosthetic valve- limited durability
- age >65
66
Describe the characteristics of mild, moderate and severe cases of MR
1. mild- murmur only, normal rhythm, no LV enlargement. Doppler shows only mild regurg; motality is no more than 2x N
2. moderate: LV enlaged slightly, LV diameter on ECHO to 60 mm, LS enlarged on ECHO to 45 mm. The presence of A. Fib increases the mortality risk
3. severe cases- LV and LA are ++ enlarged on ECHO, LV >60mm, LA is >45mm, doppler shows severe regurgitation.
67
Define MVP
Occurs when one or both of the mitral valve leaflets are too large or the chordae tendineae are too long. This results in uneven closure of the valve leaflets, which bulge back or prolapse into the L Atrium. MVP is due to myxomatous degeneration in the mitral valve at the attachment of the chordae.
68
What are other names for MVP?
click-murmur syndrome, balloon, or floppy mitral valve syndrome, and barlows syndrome
69
What causes MVP with myxomatous degeneration?
unknown, but it can be secondary to connective tissue disorder. (marfan, Ehlers-Danlos syndrome, PKD)
- some genetic correlation with autosomal dominant patterns.
- associated with chest wall deformities
- can occur with papillary muscle dysfunction associated with MI, dilated cardiomyopathy and hyperthrophic cardiomyopathy
70
How is MVP diagnosed?
sxs: CP, dyspnea and palpitations
mid-systolic click at the apex
can have an apical murmur
when MR becomes severe murmur of MVP can become pansystolic.
when mid, the MVP clicks and can be intermittent.
71
What are the indications of MVP on an ECHO?
1. redundancy of the mitral valve leaflets
2. degree of prolapse or displacement of vlave leaflets
3. severity of thickening of valve leaflet
4. estimated severity of associated mitral regurgitation,
5. any abN in leaflet length, annual diameter and chordal length
6. LV function
72
What are some favourable features of MVP that are unlikely to progress
1. female
2. apical click- no murmur
3. degree of prolapse on ECHO showing <2.5mm prolapse in the maximal progection
4. valve thicking <4mm on ECHO
5. valve regurg 2+ or less
6. no change in 5 yrs of f/u
7. normal body build and habitus
73
What are some unfavourable features of MVP with likely progression in the next 5-10 years?
1. mitral regurg on ECHO, grade 2-3, and effective regurgitant orifice >0.3cm
2. major degree of prolapse and myxomatous change, valve thickening
3. indication of progression on f.y echo and clinical findings
4. enlarging LV and definite LA enlargement
5. any sxs
6. A fib
7. progression of murmur to pansystolic
8. leaflets described as flail
74
T or F:
| severe myxomatous degeneration leads to major degrees of prolapse and can lead to rupture of the chordae tendineae
T
75
True or False:
Tricuspid stenosis is common, occuring occasionally after rheumatic heart disease or in carcinoid syndrome and tricuspid regurgitation is rare occuring in cases of pulmonary HTN, RV dysfunction and complex congenital anormalities
False.
Stenosis is rare, and regurgitation is common.
Trivial TR is present in 80% of normal individuals.
it is most commonly found with cardiac arrhythmias or congested heart dailyre.
76
How is heart rhythm affect the survival outcome after valve replacement surgery
a fib is unfavourabke
those with LA enlargement are greater risk of recurrent a fib.
high-grade ventricular ectopic activity is also unfavourable
77
How does Left Ventricular Function affect the survival outcome after valve replacement surgery
impaired pre-op EF and persistent EF <45% are associated with adverse outsomes.
Persistent heart enlargement by x-ray is another sign of poor LV function
78
How is anticoagulant use affect the survival outcome after valve replacement surgery
any hx of major bleeding or thromboembolism is unfavourable.
those wirh a fib and valvular disease should be on warfarin
79
How does the valve type and matched size affect the survival outcome after valve replacement surgery
valve size matches patient size
| if small - called prosthesis-patient mismatch leads to increase risk of heart failure
80
How valve type and mechanics affect the survival outcome after valve replacement surgery
mechanical valves used from 1970-1885 are prone to failure with unacceptable failure rate.
81
How valve type and bioprosthesis affect the survival outcome after valve replacement surgery
early tissue valves had limited long-term longevity, replacement usually needs to be done 10-20 yrs. Repeat surgery is associated with operative mortality.
82
How is associated coronary disease affect the survival outcome after valve replacement surgery
individuals with coronary artery stensois >60^ often will have had angioplastic of CABG at the time of valve surgery.
83
How functional capacity affect the survival outcome after valve replacement surgery
functional capacity and return to a productive life are markers for better long-term outlook. Associated with depression is an adverse factor
84
How multiple valve disease affect the survival outcome after valve replacement surgery
surgical strategy can be to only correct the most severe lesion, associated tricuspid valve disease is an adverse sign.
85
How does aortic dilatation affect the survival outcome after valve replacement surgery
often associated with dialtion of the ascending aorta. If the diameter exceeds 45mm, it is felt to be better repaired with a sleeve or graft
86
How does pulmonary HTN affect the survival outcome after valve replacement surgery
R ventricular pressure >40 mmHg by ECHO is an adverse finding
87
How do comorbidity factors affect the survival outcome after valve replacement surgery
COPD, DM, smoking make mortality predictions more difficult.
88
What are the causes of death after valve surgery that are valve related?
1. mechanical heart failure
2. biological valve failure
3. blood clots on valve
4. paravalvular leaks
5. valve/patient size mismatch
6. endocarditis on valve
7. surgery for valve replacement
8. failure to replace other dysfunctional valves
89
What are the causes of death after valve surgery that are heart related
worsening Myocardial funciton and heart failure
a fib
ventricular arrhythmias
uncorrected aortic aneurysm or aortic dilation
associated CAD not fully approciated and corrected
development of new CAD or progression
90
What are the causes of death after valve surgery that are associated with blood clotting disorders
clots on valves
embolism primarily to brain
major hemorrhage from warfarin
anticoagilant complications with other surgeries
91
What are the causes of death after valve surgery that are not related to cardiac condition
COPD
DM
Stroke
Cancer
92
What is Ross operation for Aortic Valve disease also known as Pulmonary Autograph
it is an alternative to mechanical or bioprosthetic valve.
aortic valve is replaced with client's own pulmonary valve (autograft) which is a 3-cusp structure very similar to the normal aortic valve, with another tissue valve (homograft) is then used to replace pulmonary valve
93
What are the advantages to preforming the Ross operation?
1. anticoagulation is not required
2. hemodynamics were better with very low gradients at rest or exercise
3. longevity of the transplanted new aortic valve
4. growth of the aortic autograph in children
94
What is the impetus of the Ross opertation
avoiding embolization or bleeding related to anticoagulation.
it is technically complex with complications with both the pulmonary autograph in the aortic posision and the homograft in the pulmonary position and there are now better techniques anyways.
95
What is TAVR (transcatheter aortic valve replacement)
new catheter-based technique currently reserved for individuals with severe symptomatic calcific aortic stensosi who are considred unacceptably high surgical risk.
not used with bicuspid or noncalcified valve.
these cases are uninsurable
ALU 201
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