CARDIOLOGY Clinical Cases Page A.S.
& A.R. M.S. & M.R. Double Aorta & Double Mitral T.R. Valve Replacement Cases Congenital Heart Diseases Closed Heart Surgery Cases Cardiology Scheme
1 3 5 6 7 9 11 12
Aortic Stenosis (A.S.) Etiology :
H/O
:
Congenital ..
Rheumatic Fever ..
Calcification ..
Low COP .. up to Syncope (
Aortic Regurg (A.R.) The
)
COMMONEST Cause in Egypt is Rheumatic Fever
Palpitation (
then, ANGINAL PAIN .. for a Long Period * if Left Ventricular FAILURE occur Dyspnea (
)
General Local
Examination :
Examination :
(Inspection, Palpation & Percussion)
Normal Sound
Murmur
*here, it’s Useless
Peripheral Signs of A.R. (
Muffled (
S1
)
Apex (Volume Overload)
Normal (
S1
MURMUR
Dancing Precordium
Aortic Pulsations * if Left Ventricular DILATATION occur Apex will Shifted Outward & Down
)
) it Depends on the Etiology
S2
S1
S1
S2
l a c i n i l C
Apex Hyper-dynamic
*here, it’s Useless Apex Sustained Apex (Tension Overload)
S2 :
) but it’s VERY LATE
MURMUR
:
n o i t a t l u c s
MURMUR Time
u A
MURMUR
Character
Mid Systolic (Systolic Ejection) Harsh
Site
1st Aortic Area
Propagation
To Carotid & to Apex
+ Thrill
(
Early Diastole Soft Blowing Murmur (
)
2nd Aortic Area
No Thrill
)
by
N.B. The SEVERITY of the Disease is Detected by Length of Murmur & Intensity of S2
Additional Sounds
Complication
Search for A.F. & Pulmonary HTN in The Cases by Scheme
Investigations
by Scheme
Treatment Oral
Qs
*Precaution
The Most
Common Cause of A.S. in Egypt is Rheumatic Fever The Most Common Cause of A.S. in the World is Congenital
How Dose the Case could be
The Best
- maybe it is One of the Rare % of Rh. Fever - maybe it is Isolated in Auscultation .. but in ECHO it’s Double Leision The Best Investigation is ECHO & DOPPLER (N.B. DOPPLER is More Imp. here) The Assessment of Severity is done by its Effect on the Lt. Ventricle - for Degree of Dilatation (Dimensions) & for Function ( Ejection Fraction)
Investigation is ECHO & DOPPLER of Severity is done by Pressure Gradient (ABP)
The Assessment
“if More than 50 Difference >> it’s Severe” The The Treatment The Patient
Isolated A.R. while the Etiology is Rheumatic Fever ?
Initial Starting Treatment for these Cases is PROPHYLACTIC (Prevention of Rheumatic & IEC) “
of Angina is Sub-Lingual Nitrate (
)
Can go for Interventional Treatment with 2 Conditions must be fulfilled
”
The
Treatment Which Improves the Regurg is Small Dose of Vaso-Dilator (Captopril)
The
Patient Can NOT go for Interventional Treatment
is the Lesion is Isolated & Non-Calcified
Balloon-Aortic-Valvo-Plasty (
)
2 Syndromes Could Cause A.R. are Marfan $ & Ehler-Danlos $ 2 Infection Diseases Could Cause A.R. are Syphilis & Infective Endocarditis in A.R. Cases Which Joints Do You Prefer to Exam for Diagnosis ? Peripheral Joints : - Big Joints .. for Rheumatic - Small Joints .. for Rheumatoid or Marfan $ Axial Joints : for Ankylosing Spondylitis The The
-1-
Aortic Stenosis (A.S.) Etiology :
H/O
:
Congenital ..
Rheumatic Fever ..
Calcification ..
Low COP .. up to Syncope (
Aortic Regurg (A.R.) The
)
COMMONEST Cause in Egypt is Rheumatic Fever
Palpitation (
then, ANGINAL PAIN .. for a Long Period * if Left Ventricular FAILURE occur Dyspnea (
)
General Local
Examination :
Examination :
(Inspection, Palpation & Percussion)
Normal Sound
Murmur
*here, it’s Useless
Muffled (
S1
)
Apex (Volume Overload)
Normal (
S1
MURMUR
Dancing Precordium
Aortic Pulsations * if Left Ventricular DILATATION occur Apex will Shifted Outward & Down
)
) it Depends on the Etiology
S2
S1
S1
S2
l a c i n i l C
Apex Hyper-dynamic
*here, it’s Useless Apex Sustained Apex (Tension Overload)
S2 :
) but it’s VERY LATE
Peripheral Signs of A.R. (
MURMUR
:
n o i t a t l u c s u A
MURMUR Time
MURMUR
Character
Mid Systolic (Systolic Ejection) Harsh
Site
1st Aortic Area
Propagation
To Carotid & to Apex
Early Diastole Soft Blowing Murmur (
+ Thrill
(
)
2nd Aortic Area
No Thrill
)
by
N.B. The SEVERITY of the Disease is Detected by Length of Murmur & Intensity of S2
Additional Sounds
Complication
Search for A.F. & Pulmonary HTN in The Cases by Scheme
Investigations
by Scheme
Treatment Oral
Qs
*Precaution
The Most
Common Cause of A.S. in Egypt is Rheumatic Fever The Most Common Cause of A.S. in the World is Congenital
How Dose the Case could be
The Best
- maybe it is One of the Rare % of Rh. Fever - maybe it is Isolated in Auscultation .. but in ECHO it’s Double Leision The Best Investigation is ECHO & DOPPLER (N.B. DOPPLER is More Imp. here) The Assessment of Severity is done by its Effect on the Lt. Ventricle - for Degree of Dilatation (Dimensions) & for Function ( Ejection Fraction)
Investigation is ECHO & DOPPLER of Severity is done by Pressure Gradient (ABP)
The Assessment
“if More than 50 Difference >> it’s Severe” The The Treatment The Patient
Isolated A.R. while the Etiology is Rheumatic Fever ?
Initial Starting Treatment for these Cases is PROPHYLACTIC (Prevention of Rheumatic & IEC) “
of Angina is Sub-Lingual Nitrate (
)
Can go for Interventional Treatment with 2 Conditions must be fulfilled
”
The
Treatment Which Improves the Regurg is Small Dose of Vaso-Dilator (Captopril)
The
Patient Can NOT go for Interventional Treatment
is the Lesion is Isolated & Non-Calcified
Balloon-Aortic-Valvo-Plasty (
)
2 Syndromes Could Cause A.R. are Marfan $ & Ehler-Danlos $ 2 Infection Diseases Could Cause A.R. are Syphilis & Infective Endocarditis in A.R. Cases Which Joints Do You Prefer to Exam for Diagnosis ? Peripheral Joints : - Big Joints .. for Rheumatic - Small Joints .. for Rheumatoid or Marfan $ Axial Joints : for Ankylosing Spondylitis The The
-1-
in case of Aortic Regurg (A.R.) : the Apex
:
Lt. Vent. Volume Overload Lt. Vent. Dilatation
Heart
if
Sound :
Localized Hyper-dynamic Shifted Outward & Down
it Depends on the Etiology In Rheumatic Fever Heart Sounds : Muffled
Here, Heart Sounds :
Accentuated
there’s a Patient .. with (A.R. Murmur) + (M.S. Murmur) .. what’s the Possibilities for that ?!
1-
He is an A.R. Patient .. with an ORGANIC A.R. Murmur , with FUNCTIONING M.S. Murmur .. ὠ called [ Austin-Flint As the Blood ὠ come back from Aortic Valve .. could Prevent Mitral Valve from Opening
2-
He is a Patient
Murmur]
FUNCTIONING M.S. Murmur
with A.R. + M.S. Lesions This will affect the Peripheral Signs of A.R. & Decrease it This mean that the Etiology is Rheumatic Fever .. Not a Marfan $ .. & even if you find Marfan Signs in the case this make it ( Marfanoid NOT Marfan $)
ORGANIC M.S. Murmur
No Opening Snap + No Thrill There’s Opening Snap
+ Thrill
-2-
in case of Aortic Regurg (A.R.) : the Apex
Lt. Vent.
:
Localized
Volume Overload
Hyper-dynamic
Lt. Vent. Dilatation Heart
if
Sound :
Shifted Outward & Down
it Depends on the Etiology In Rheumatic Fever Heart Sounds : Muffled
Here, Heart Sounds :
Accentuated
there’s a Patient .. with (A.R. Murmur) + (M.S. Murmur) .. what’s the Possibilities for that ?!
1-
He is an A.R. Patient .. with an ORGANIC A.R. Murmur , with FUNCTIONING M.S. Murmur .. ὠ called [ Austin-Flint As the Blood ὠ come back from Aortic Valve .. could Prevent Mitral Valve from Opening
2-
He is a Patient
Murmur]
FUNCTIONING M.S. Murmur
with A.R. + M.S. Lesions This will affect the Peripheral Signs of A.R. & Decrease it
ORGANIC M.S. Murmur
This mean that the Etiology is Rheumatic Fever .. Not a Marfan $ .. & even if you find Marfan Signs in the case this make it ( Marfanoid NOT Marfan $)
No Opening Snap + No Thrill There’s Opening Snap
+ Thrill
-2-
Mitral Stenosis (M.S.)
Mitral Regurg (M.R.)
Stages
Introduction
for M.S. :
Etiology :
Dyspnea 1- Asymptomatic M.S. Murmur Only Low COP 2- Pulm. Congestion Systemic Venous Congestion (Mainly Edema) 3- Pulmonary HTN + P. HTN + if Rt. Vent Dilate Retract the Tricuspid Ring 4- Rt. V.F. T.R. Murmur (may be heard) Rheumatic
:
General
Local
Examination :
Examination :
(Inspection, Palpation & Percussion) l a c i n i l C
Normal Sound
Murmur
DYSPNEA
(
± A.F. (
)
Pulse (for A.F.)
+ Malar Flush
Decubitus (for Orthopnea)
what
Edema in L.L. (for Rt. Sided H.F.)
Left
(
will Add +1 Stage in NYHA Classification until the Labour So, Pregnancy is NEVER Allowed in Patient with NYHA 4
Fever in 99% of cases
This the ONLY Disease which ISOLATED LEISION in Rheumatic Fever H/O
what is the Effect of Pregnancy on M.S. Patient ?
) Low COP (
COMMONEST Cause in Egypt is Mitral Valve Prolapse, 2nd Rheumatic Fever, 3rd Ischemia (Papillary Muscle Dysfunction) ) Palpitation ( The
) Systemic Congestion (Edema)
& After a LONG PERIOD OF TIME L.V.F. may occur (
Stage it the Mechanism ”
it’s Not Specific D.D. from Systemic Lupus
from H/o :
”
starting è Dyspnea
from General from H/o :
Butterfly Rash
Atrial Enlargement
Exam. : there’s A.F.
there’s Rt. Vent. Enlargement ,
± Right Vent. Enlargement (Never Left Vent.)
± Left Vent. Enlargement (Never Right Vent.) Apex Hyper-dynamic
S1 :
S1
S1
may be Muffled in MS if there’s Calcification or it’s Double Mitral
Thrill
S1 + (there’s 2 Murmurs)
Left Atrial Enlargement
Apex Slapping
Apex Accentuated
)
# if your case is M.R. .. How to Suspect it’s Double Mitral !
*here, it’s Useless
S1 :
Muffled
Apex & Shifted Outward and Downward S1 may be Accentuated in MR if it’s Double Mitral Only
S1 S2
S2
MURMUR
MURMUR
S1
S1
:
n o i t a t l u c s
Time Character
u A
Site
Propagation
Mid Diastolic with Pre-systolic Accentuation Rumbling ” ” Apex Localized
Effect
of A.F. in Auscultation :
by
Additional Sounds
Complication Investigations
Apex To Axilla (in Anterior Leaflet Disease) & to Base (in Posterior Leaflet Disease)
+ Thrill *Precaution : it’s a LOW Pitch Sound .. Heard by the CONE + “
Pan Systolic Soft (in 80% of cases) or Harsh
- S1 Variable Intensity - Murmur No Pre-systolic Accentuation - O.S. it Persist ( )
+ Thrill
”
Opening Snap (O.S.)
M.S. is Rare to Complicate with IEC 1- ECG 2- X-ray 3- ECHO & DOPPLER The Main 4 Points in ECHO Report are : - Valve Area (Assessment of Severity ) (<1cm. = Tight MS.) - Pulmonary Pressure - Mitral Score - is there’s a Thrombus or Not (By TEE)
Treatment
Medically
Search for A.F. & Pulmonary HTN in The Cases
M.R. is Rare to Complicate with A.F. Investigation is ECHO & DOPPLER 4- Catheter : “ ” - ECHO & DOPPLER The Assessment of Severity is done by its Effect on the Lt. Ventricle to detect if it’s Reversible or Ir-reversible P. HTN The Best
- for Degree of Dilatation (Dimensions) & for Function ( Ejection Fraction)
- Reversible (due to V.C.) - while Ir-reversible (due to Fibrosis)
Vaso-Dilator Reversible
The Initial Starting Treatment for these Cases is PROPHYLACTIC (Prevention of Rheumatic & IEC) “
Retention & Diuresis ... for Dyspnea Balloon-Mitral-Valvo-Plasty (Trans-Septal Technique)
”
The Initial Starting Treatment for these Cases is PROPHYLACTIC (Prevention of Rheumatic & IEC) “
Medically
Rest, Salt
Interventional
(& TIME it)
”
Small Dose of Vaso-Dilator (Captopril) Valve Replacement Surgery
Surgery
-3-
Mitral Stenosis (M.S.)
Mitral Regurg (M.R.)
Stages
Introduction
Dyspnea 1- Asymptomatic M.S. Murmur Only Low COP 2- Pulm. Congestion Systemic Venous Congestion (Mainly Edema) 3- Pulmonary HTN + P. HTN + if Rt. Vent Dilate Retract the Tricuspid Ring 4- Rt. V.F. T.R. Murmur (may be heard)
for M.S. :
Etiology :
Rheumatic
:
General Examination :
Local
Examination :
(Inspection, Palpation & Percussion) l a c i n i l C
Normal Sound
Murmur
DYSPNEA
(
± A.F. (
)
Pulse (for A.F.)
+ Malar Flush
Decubitus (for Orthopnea)
what
Edema in L.L. (for Rt. Sided H.F.)
Left
(
will Add +1 Stage in NYHA Classification until the Labour So, Pregnancy is NEVER Allowed in Patient with NYHA 4
Fever in 99% of cases
This the ONLY Disease which ISOLATED LEISION in Rheumatic Fever H/O
what is the Effect of Pregnancy on M.S. Patient ?
) Low COP (
COMMONEST Cause in Egypt is Mitral Valve Prolapse, 2nd Rheumatic Fever, 3rd Ischemia (Papillary Muscle Dysfunction) ) Palpitation ( The
) Systemic Congestion (Edema)
& After a LONG PERIOD OF TIME L.V.F. may occur (
Stage it the Mechanism ”
from H/o :
”
starting è Dyspnea
from General
it’s Not Specific D.D. from Systemic Lupus
from H/o :
Butterfly Rash
Atrial Enlargement
Exam. : there’s A.F.
there’s Rt. Vent. Enlargement ,
± Right Vent. Enlargement (Never Left Vent.)
± Left Vent. Enlargement (Never Right Vent.) Apex Hyper-dynamic
S1 :
S1
S1
may be Muffled in MS if there’s Calcification or it’s Double Mitral
S1 + (there’s 2 Murmurs)
Left Atrial Enlargement
Apex Slapping
Apex Accentuated
)
# if your case is M.R. .. How to Suspect it’s Double Mitral !
*here, it’s Useless
S1 :
Muffled
Apex & Shifted Outward and Downward S1 may be Accentuated in MR if it’s Double Mitral Only
S1
Thrill
S2
S2
MURMUR
MURMUR
S1
S1
:
n o i t a t l u c s u A
Time
Mid Diastolic with Pre-systolic Accentuation Rumbling ” ”
Character Site
Apex Localized
Propagation
Effect
of A.F. in Auscultation :
by
Additional Sounds
Apex To Axilla (in Anterior Leaflet Disease) & to Base (in Posterior Leaflet Disease)
+ Thrill *Precaution : it’s a LOW Pitch Sound .. Heard by the CONE + “
Pan Systolic Soft (in 80% of cases) or Harsh
- S1 Variable Intensity - Murmur No Pre-systolic Accentuation - O.S. it Persist ( )
+ Thrill
”
(& TIME it)
Opening Snap (O.S.)
Complication
Search for A.F. & Pulmonary HTN in The Cases
M.S. is Rare to Complicate with IEC
Investigations
Treatment
M.R. is Rare to Complicate with A.F. Investigation is ECHO & DOPPLER ” - ECHO & DOPPLER The Assessment of Severity is done by its Effect on the Lt. Ventricle to detect if it’s Reversible or Ir-reversible P. HTN The Best
1- ECG 2- X-ray 3- ECHO & DOPPLER The Main 4 Points in ECHO Report are : - Valve Area (Assessment of Severity ) (<1cm. = Tight MS.) - Pulmonary Pressure - Mitral Score - is there’s a Thrombus or Not (By TEE)
4- Catheter :
“
Vaso-Dilator Reversible
The Initial Starting Treatment for these Cases is PROPHYLACTIC (Prevention of Rheumatic & IEC) “
Medically
- for Degree of Dilatation (Dimensions) & for Function ( Ejection Fraction)
- Reversible (due to V.C.) - while Ir-reversible (due to Fibrosis)
Rest, Salt
Interventional
The Initial Starting Treatment for these Cases is PROPHYLACTIC (Prevention of Rheumatic & IEC) “
Medically
”
Retention & Diuresis ... for Dyspnea Balloon-Mitral-Valvo-Plasty (Trans-Septal Technique)
”
Small Dose of Vaso-Dilator (Captopril) Valve Replacement Surgery
Surgery
-3-
Pulmonary Hypertension (P. HTN) Stage 2: Dilatation of Pulmonary Artery withOut Dilatation of Pulmonary Valve
Stage 1: ++ Pressure in Pulmonary Artery
Stage 3: Retract the Pulmonary Valve (Pulmonary Valve Regurg)
++
Accentuated S2
Accentuated S2
Accentuated S2 S1
& Diastolic Shock
S1
± Palpable S2
S1
S1
S1 Diastolic MURMUR
S1
Systolic MURMUR & you can Find a Pulmonary Pulsation & Dullness
Move Your Stethoscope from the Left of the Sternum (Pulmonary Area) to the Right of it (Aortic Area) You will Find S2 ++++ at Pulmonary Area than Aortic Area this = Accentuated S2 with Accentuated Pulmonary Component
Diastolic MURMUR of Pulmonary Valve Regurg = Graham Steell Murmur [is a heart murmur typically associated with pulmonary regurgitation. It is a high pitched early diastolic murmur heard best at the left sternal edge in the second intercostal space with the patient in full inspiration] This Murmur is in Unstable Patient (so, Actually You will NOT hear it)
-4-
Pulmonary Hypertension (P. HTN) Stage 2: Dilatation of Pulmonary Artery withOut Dilatation of Pulmonary Valve
Stage 1: ++ Pressure in Pulmonary Artery
Stage 3: Retract the Pulmonary Valve (Pulmonary Valve Regurg)
++
Accentuated S2
Accentuated S2
Accentuated S2 S1
& Diastolic Shock
S1
S1
S1
± Palpable S2
S1
S1
Diastolic MURMUR
Systolic MURMUR & you can Find a Pulmonary Pulsation & Dullness
Diastolic MURMUR of Pulmonary Valve Regurg = Graham Steell Murmur
Move Your Stethoscope from the Left of the Sternum (Pulmonary Area) to the Right of it (Aortic Area) You will Find S2 ++++ at Pulmonary Area than Aortic Area this = Accentuated S2 with Accentuated Pulmonary Component
[is a heart murmur typically associated with pulmonary regurgitation. It is a high pitched early diastolic murmur heard best at the left sternal edge in the second intercostal space with the patient in full inspiration] This Murmur is in Unstable Patient (so, Actually You will NOT hear it)
-4-
Double Aorta
Double Mitral Rheumatic Fever ONLY via Fibrosis “
”
Affect the Commissures Stenosis Affect the Cusps
Double Lesion
Regurg Low COP .. up to Syncope (
) + Palpitation (
)
2 Murmurs should be heard
Functioning A.S.
Harsh
Thrill
DYSPNEA (
Examination
&Take Care! The Case may be A.R. Only .. Not Double Aorta in that A.R. Murmur is the Organic Diastolic Murmur while with Volume Overload it will produce Functioning Systolic A.S. Murmur *so you Should Diff. between Functioning & Systolic A.S. Murmur Organic A.S.
H/O
H/O of Low COP
)
2 Murmurs should be heard S1: Double Mitral M.R. - by H/O : Dyspnea start very Early before other S ymptoms ” - by General Exam : A.F., Orthopnea “ *N.B. M.R. Produce Orthopnea in Terminal Stage “
- by Local Exam : Rt. Vent. Enlargement , Pulmonary HTN “
Soft
Peripheral Signs of A.R. *if Marked Signs A.R. is Predominant
) + Palpitation (
” ”
+ S1 Accentuated Predominance Determined by
S1 *if Accentuated S1 M.S. is Predominant
-5-
Double Aorta
Double Mitral Rheumatic Fever ONLY via Fibrosis “
”
Affect the Commissures Stenosis Affect the Cusps
Double Lesion
Regurg Low COP .. up to Syncope (
) + Palpitation (
H/O
)
2 Murmurs should be heard
Examination
&Take Care! The Case may be A.R. Only .. Not Double Aorta in that A.R. Murmur is the Organic Diastolic Murmur while with Volume Overload it will produce Functioning Systolic A.S. Murmur *so you Should Diff. between Functioning & Systolic A.S. Murmur Organic A.S. Functioning A.S.
Harsh
Thrill
DYSPNEA (
) + Palpitation (
)
2 Murmurs should be heard S1: Double Mitral
M.R. - by H/O : Dyspnea start very Early before other S ymptoms ” - by General Exam : A.F., Orthopnea “ *N.B. M.R. Produce Orthopnea in Terminal Stage “
H/O of Low COP
- by Local Exam : Rt. Vent. Enlargement , Pulmonary HTN “
Soft
” ”
+ S1 Accentuated
Peripheral Signs of A.R. *if Marked Signs A.R. is Predominant
Predominance Determined by
S1 *if Accentuated S1 M.S. is Predominant
-5-
Tricuspid Regurg (T.R.)
The Only Case for Rt. Sided Lesions
- by H/O : Symptoms
of Systemic Venous Congestion
- by General Exam : Signs
?
of Systemic Venous Congestion : 1 Neck Veins 2 Pulsating Liver 3 Edema + Ascites - by Local Exam : Rt. Ventricular Enlargement & maybe Rt. Atrial Enlargement + T.R. Murmur
T.R. is NEVER to be Isolated in the Exam .. it’s ALWAYS ASSOCIATED with ADVANCED Mitral Valve Disease (MVD ) so, when you have a case of MVD in the Exam .. Search for : - by H/O :
T.R.
Systemic Venous Congestion
- by General Exam : Edema + Ascites - by Local Exam : Rt. Ventricular Enlargement
But it Just let you SUSPECT ONLY .. as it may be an ADVANCED MVD reaching the Rt. Vent. Failure Level N.B. it’s Similar to M.R. Murmur It’s Only by Hearing a T.R. Murmur by the Stethoscope Time : Pan Systolic Character : Soft or Harsh
T.R.
1- Non specific 2- Non specific
Tricuspid Area (Lower En of the Sternum to the Left) Propagation : to the Base of Heart ( BUT NEVER Propagate to the Axilla ) Site of Max. Intensity :
by : +++
by Respiration (as any Rt. Sided Lesion) [this called Carvallo's sign]
1 Neck Veins : in T.R. it’s - Level : Congested Pulsating - Wave Form : Systolic Expansion 2 Pulsating Liver : Technique 3
Tenderness
3- Specific
2
1 Rib Costal Margin
-6-
Tricuspid Regurg (T.R.)
The Only Case for Rt. Sided Lesions
- by H/O : Symptoms
of Systemic Venous Congestion
- by General Exam : Signs
?
of Systemic Venous Congestion : 1 Neck Veins 2 Pulsating Liver 3 Edema + Ascites - by Local Exam : Rt. Ventricular Enlargement & maybe Rt. Atrial Enlargement + T.R. Murmur
T.R. is NEVER to be Isolated in the Exam .. it’s ALWAYS ASSOCIATED with ADVANCED Mitral Valve Disease (MVD ) so, when you have a case of MVD in the Exam .. Search for : - by H/O :
T.R.
Systemic Venous Congestion
- by General Exam : Edema + Ascites - by Local Exam : Rt. Ventricular Enlargement
But it Just let you SUSPECT ONLY .. as it may be an ADVANCED MVD reaching the Rt. Vent. Failure Level N.B. it’s Similar to M.R. Murmur It’s Only by Hearing a T.R. Murmur by the Stethoscope Time : Pan Systolic Character : Soft or Harsh
T.R.
1- Non specific 2- Non specific
Tricuspid Area (Lower En of the Sternum to the Left) Propagation : to the Base of Heart ( BUT NEVER Propagate to the Axilla ) Site of Max. Intensity :
by : +++
by Respiration (as any Rt. Sided Lesion) [this called Carvallo's sign]
1 Neck Veins : in T.R. it’s - Level : Congested Pulsating - Wave Form : Systolic Expansion 2 Pulsating Liver : Technique 3
3- Specific
2
Tenderness
1 Rib Costal Margin
-6-
N.B.
Valve Replacement Cases
we done A Replacement Surgeries for the Lt. Sides Valves in a Very Very RARE Conditions .. due to LOW PRESSURE in Rt. Side + if Complications occur After Surgery they are FATAL (as Pulmonary Embolism)
- by H/O :
Valve Replacement Surgery
?
- by Exam : Median
Sternotomy Scar + Metallic Sound (Auscultation)
So, Most Probably it’s Mitral or Aortic Valve Replacement
- by H/O:
- by Examination : - by Local Exam :
Load or Metallic Sound 1
- which Valve is Replaced
?
- by Timing : if Patient Complain from Dyspnea
EARLY
Mitral Most Probably if Patient Complain from Anginal Pain & Palpiataion while Dyspnea is LATE Aortic Most Probably
3
2
- is The New Valve is Functioning or there’s Mal-Function occur
in
S1 = Mitral Valve Replacement
in
S2 = Aortic Valve Replacement - by Local Exam :
?
- hearing a MURMUR Mal-Function occur N.B. there’s may be a Functional Murmur heard [Systolic, Soft, Short, Faint, Localized]
So, Mal-Function occur
- by General Exam : - is there are
3
Complications Occur After Surgery or Not
?
Normal Neural Examination & you feel All Peripheral Pulsations No Pallor or Jaundice No Hyper-Thermia or Clubbing
a- Thrombo-Embolism b- Hemolytic Anemia c- Prosthetic Valve Endocarditis
N.B. there’s No Complicated Pt. will be in Our Exam So, There’s Always No Major - what is the Investigations you want do for this patient - what is the Golden Stander in Investigations - what is the Treatment you want do for this patient
? ? ?
Complications Found
by Scheme
ECHO *esp. TEE (Trans-Esophageal Echo)& DOPPLER by Scheme
*but, we Give Anti-Coagulant Drugs for Life & watch by INR (it should be 2-3 Times of Normal)
-7-
N.B.
Valve Replacement Cases
we done A Replacement Surgeries for the Lt. Sides Valves in a Very Very RARE Conditions .. due to LOW PRESSURE in Rt. Side + if Complications occur After Surgery they are FATAL (as Pulmonary Embolism)
- by H/O :
Valve Replacement Surgery
?
- by Exam : Median
Sternotomy Scar + Metallic Sound (Auscultation)
So, Most Probably it’s Mitral or Aortic Valve Replacement
- by H/O:
- by Examination : - by Local Exam :
Load or Metallic Sound 1
3
2
- which Valve is Replaced
- is The New Valve is Functioning or there’s Mal-Function occur
- by Timing :
?
EARLY Mitral Most Probably if Patient Complain from Anginal Pain & Palpiataion while Dyspnea is LATE Aortic Most Probably if Patient Complain from Dyspnea
in
S1 = Mitral Valve Replacement
in
S2 = Aortic Valve Replacement - by Local Exam :
- hearing a MURMUR Mal-Function occur
?
N.B. there’s may be a Functional Murmur heard [Systolic, Soft, Short, Faint, Localized]
So, Mal-Function occur
- by General Exam : - is there are
3
Complications Occur After Surgery or Not
Normal Neural Examination & you feel All Peripheral Pulsations No Pallor or Jaundice No Hyper-Thermia or Clubbing
a- Thrombo-Embolism
?
b- Hemolytic Anemia c- Prosthetic Valve Endocarditis
N.B. there’s No Complicated Pt. will be in Our Exam So, There’s Always No Major - what is the Investigations you want do for this patient - what is the Golden Stander in Investigations - what is the Treatment you want do for this patient
? ? ?
Complications Found
by Scheme
ECHO *esp. TEE (Trans-Esophageal Echo)& DOPPLER by Scheme
*but, we Give Anti-Coagulant Drugs for Life & watch by INR (it should be 2-3 Times of Normal)
-7-
3 Cage & Ball
Tilting Disk
Bi-Leaflet
Atrium
Atrium
Atrium
Ventricle
Ventricle
You will Know ὠ Valve is Replaced .. - by Anatomical : Vertibral Column Aortic Valve Mitral Valve
Ventricle
Stroke .. Causes after Valve Replacement Surgery : - Valve Replacement Related : Thrombo-Embolism incidence but it will Cerebral Hemorrhage incidence Prosthetic Valve Infective Endocarditis Vegetations Anti-Coagulant “After Surgery” : will
- Non-Valve Replacement Related : e.g. Astherosclerosis
& by the Lesion in the Heart Causes of Un-equal Pulse Volume in Patient with Valve Replacement
A.F.
(sending Thrombus to the Hand)
Valve Replacement Related : - Thrombus .. (if Patient didn’t Receive Anti -Coagulant Regularly) - Vegetation of Bacteria on Prosthetic Valve
Association : - Cervical Rib - Aneurism - Pancoast Tumor
-8-
3 Cage & Ball
Tilting Disk
Bi-Leaflet
Atrium
Atrium
Atrium
Ventricle
Ventricle
You will Know ὠ Valve is Replaced .. - by Anatomical : Vertibral Column
Ventricle
Stroke .. Causes after Valve Replacement Surgery : - Valve Replacement Related : Anti-Coagulant “After Surgery” : will
Thrombo-Embolism incidence
but it will
Aortic Valve
Prosthetic Valve
Mitral Valve
Cerebral Hemorrhage incidence
Infective Endocarditis Vegetations
- Non-Valve Replacement Related : e.g. Astherosclerosis
& by the Lesion in the Heart Causes of Un-equal Pulse Volume in Patient with Valve Replacement
A.F.
(sending Thrombus to the Hand)
Valve Replacement Related : - Thrombus .. (if Patient didn’t Receive Anti -Coagulant Regularly) - Vegetation of Bacteria on Prosthetic Valve
Association : - Cervical Rib - Aneurism - Pancoast Tumor
-8-
Congenital Heart Diseases Pulmonary Stenosis (P.S.)
Ventricular Septal Defect (VSD) [The Commonest Heart Disease]
*it’s ALWAYS CONGENITAL .. Rh. Fever Never Affect Pulmonary Valve
1 Anatomy
There are Valvular, Sub-Valvular & Supra-Valvular Lesions
There are Small or Big Lesions
Fallot Tetralogy (F4) [The Commonest Cyanotic Heart Disease]
Congenital Component It’s a Result
2 Hemo-Dynamic
P.S. is Similar to A.S. .. Except in : - Site of Murmur - Chamber Enlargement - ttt of Choice
3 Complications 4 H/O (Symptoms)
Heart Volume Overload in 2 Sides Lung Plethora Systemic Circulation Low COP Infective Endo-Carditis (IEC) & at Late Stage : Eisenmenger's Syndrome
it Depends on the Size of Defect
Low COP Symptoms
if Moderate Lesion Palpitation, Low COP
3 Very Big VDS 4 Very Mild ++ Rt. Vent. Undetected Clinically
Non-Oxygenated Blood in Aorta = Cyanosis
Infective Endo-Carditis (IEC) 1 Cyanosis “almost this is his Complaint”
if Small Lesion Asymptomatic if Very Big Lesion
N.B. Noonan syndrome could be Association: 1- Stunted Growth 2- Sub-normal Mentality 3- Congenital Heart Disease .. esp. P.S. 4- Skeletal Deformities; e.g. Osteo-Arthritis 5- Facial Features
1 Infundibular P.S. “not in the Valve” Dynamic Stenosis 2 Anterior Position Overriding Aorta
It’s Onset : Shortly After Birth (from few weeks to Months) NOT Since Birth “due to presence of PDA”
& Dyspnea
[Cyanosis Shortly After Birth Pathognomonic to F4] 2 Squatting Pathognomonic to F4 ±3 Cyanotic Spells “Only in SEVERE Cases” 3 Main Causes 1 Exaggeration 2 Coldness 3 Infections
Effect Spasm in Infundibular (All Blood in Aorta is Non-Oxygenated)
3 Main Results 1 Deeply Cyanotic 2 Dyspnea 3 Convulsions
ttt of Cyanotic Spells: 1 Put the Patient in Squatting Position 2 O2 Therapy 3 Drugs : β Blockers are the Drug of Choice here
-9-
Congenital Heart Diseases Pulmonary Stenosis (P.S.)
Ventricular Septal Defect (VSD) [The Commonest Heart Disease]
*it’s ALWAYS CONGENITAL .. Rh. Fever Never Affect Pulmonary Valve
1 Anatomy
There are Valvular, Sub-Valvular & Supra-Valvular Lesions
Fallot Tetralogy (F4) [The Commonest Cyanotic Heart Disease]
There are Small or Big Lesions
1 Infundibular P.S. “not in the Valve” Dynamic Stenosis 2 Anterior Position Overriding Aorta
Congenital Component
3 Very Big VDS
It’s a Result
2 Hemo-Dynamic
P.S. is Similar to A.S. .. Except in : - Site of Murmur - Chamber Enlargement - ttt of Choice
3 Complications 4 H/O (Symptoms)
4 Very Mild ++ Rt. Vent. Undetected Clinically
Heart Volume Overload in 2 Sides Lung Plethora Systemic Circulation Low COP Infective Endo-Carditis (IEC) & at Late Stage : Eisenmenger's Syndrome
Non-Oxygenated Blood in Aorta = Cyanosis
Infective Endo-Carditis (IEC)
it Depends on the Size of Defect
Low COP Symptoms
1 Cyanosis “almost this is his Complaint”
if Small Lesion Asymptomatic if Very Big Lesion
N.B. Noonan syndrome could be Association: 1- Stunted Growth 2- Sub-normal Mentality 3- Congenital Heart Disease .. esp. P.S. 4- Skeletal Deformities; e.g. Osteo-Arthritis 5- Facial Features
It’s Onset : Shortly After Birth (from few weeks to Months) NOT Since Birth “due to presence of PDA”
if Moderate Lesion Palpitation, Low COP
[Cyanosis Shortly After Birth Pathognomonic to F4] 2 Squatting Pathognomonic to F4
& Dyspnea
±3 Cyanotic Spells “Only in SEVERE Cases” 3 Main Causes 1 Exaggeration 2 Coldness 3 Infections
Effect Spasm in Infundibular (All Blood in Aorta is Non-Oxygenated)
3 Main Results 1 Deeply Cyanotic 2 Dyspnea 3 Convulsions
ttt of Cyanotic Spells: 1 Put the Patient in Squatting Position 2 O2 Therapy 3 Drugs : β Blockers are the Drug of Choice here
-9-
5 Examination (Signs)
Normal Sound S2 : Muffled
General Exam. : No Cyanosis & No Clubbing
Local Exam. :
Murmur
General Exam. : Cyanosis depends on Severity & Clubbing depends on Duration + if Severe F4 Stunted Growth Local Exam. : Infundibular P.S. P.S. MURMUR 1
By hearing the MURMUR
Systolic Ejection Harsh Site: Pulmonary Area Propagation: To Carotid & to Apex Time:
Character:
(
)
+ Chamber Enlargement (Rt. Vent.)
[
the Defect Size Murmur Sound] Pan-Systolic Character: Harsh Site: Lt. Para-Sternal Area Propagation: To All Au scul tator y Areas (
2 Anterior Position Overriding Aorta 3 Very Big VDS
Time:
1
Rt. Vent.
4
S2
Very Mild ++ Rt. Vent.
)
by: Exercise
+ Thrill
2
6 Investigations
Additional Sounds
Ejection Click Best Investigation is : ECHO-Doppler & Assess the Severity by Pressure Gradient
7 Treatment
Balloon-Pulmonary-Valvo-Plasty is the ttt of Choice
Rt. Vent. or Lt. Vent. or BOTH Chamber Enlargement
For Eisenmenger's Syndrome Pulmonary Pressure as Pulmonary HTN ECHO-Doppler .. it will show : The Defect Any Chamber Enlargement *Pulmonary Pressure
3
Medical ttt : Prevention of IEC (Antibiotics Before & After Any minimal Procedures) Interventional ttt : Closure by Umbrella (via Catheter) Definitive ttt : Open Heart Surgery .. Indicated to : Patient who are Liable to Develop Eisenmenger's Syndrome (Detected by Measuring Pulmonary Pressure) [if Pulmonary Pressure = ½ Systemic Pressure Close the Defect]
E.C.G. X-ray ECHO-Doppler
Medical ttt : Prevention of IEC (Antibiotics Before & After Any minimal Procedures) & for Cyanotic Spells give β Blockers Interventional ttt : Useless
Definitive ttt : Closed Heart Surgery Open Heart Surgery
Shunt OperationS .. Shunt from Aorta to Pulmonary The most Famous is Blalock-Taussig Operation Total Correction Operation 1 Infundibular P.S. Resection 2 Overriding Aorta Closed in Rt. Vent. 3 Very Big VDS Very Big Patch 4 Very Mild ++ Rt. Vent.
Onset of Cyanosis & its Relation to Diagnosis : TGA Birth F4 Shortly after days “Weeks to Month” F3 during Childhood (3-5 Years) Eisenmenger's Syndrome Teenage (13-19 Years Chest Causes Older than that
since
N.B. TGA usually die after short period of birth .. unless it’s associated with Lt. to Rt. Shunt e.g. VSD
-10-
Normal Sound S2 : Muffled
5 Examination (Signs)
General Exam. : No Cyanosis & No Clubbing
Local Exam. :
Murmur
General Exam. : Cyanosis depends on Severity & Clubbing depends on Duration + if Severe F4 Stunted Growth Local Exam. : Infundibular P.S. P.S. MURMUR 1
By hearing the MURMUR
Systolic Ejection Harsh Site: Pulmonary Area Propagation: To Carotid & to Apex Time:
Character:
(
+ Chamber Enlargement (Rt. Vent.)
[
the Defect Size Murmur Sound] Pan-Systolic Character: Harsh Site: Lt. Para-Sternal Area Propagation: To All Au scul tator y Areas (
1
Rt. Vent.
)
2 Anterior Position Overriding Aorta 3 Very Big VDS
Time:
4
S2
Very Mild ++ Rt. Vent.
)
by: Exercise
+ Thrill
2
6 Investigations
Additional Sounds
For Eisenmenger's Syndrome Pulmonary Pressure as Pulmonary HTN ECHO-Doppler .. it will show : The Defect Any Chamber Enlargement *Pulmonary Pressure
3
Ejection Click Best Investigation is : ECHO-Doppler & Assess the Severity by Pressure Gradient
7 Treatment
Rt. Vent. or Lt. Vent. or BOTH Chamber Enlargement
Balloon-Pulmonary-Valvo-Plasty is the ttt of Choice
E.C.G. X-ray ECHO-Doppler
Medical ttt : Prevention of IEC (Antibiotics Before & After Any minimal Procedures) Interventional ttt : Closure by Umbrella (via Catheter) Definitive ttt : Open Heart Surgery .. Indicated to : Patient who are Liable to Develop Eisenmenger's Syndrome (Detected by Measuring Pulmonary Pressure) [if Pulmonary Pressure = ½ Systemic Pressure Close the Defect]
Medical ttt : Prevention of IEC (Antibiotics Before & After Any minimal Procedures) & for Cyanotic Spells give β Blockers Interventional ttt : Useless
Definitive ttt : Closed Heart Surgery Open Heart Surgery
Shunt OperationS .. Shunt from Aorta to Pulmonary The most Famous is Blalock-Taussig Operation Total Correction Operation 1 Infundibular P.S. Resection 2 Overriding Aorta Closed in Rt. Vent. 3 Very Big VDS Very Big Patch 4 Very Mild ++ Rt. Vent.
Onset of Cyanosis & its Relation to Diagnosis : TGA Birth F4 Shortly after days “Weeks to Month” F3 during Childhood (3-5 Years) Eisenmenger's Syndrome Teenage (13-19 Years Chest Causes Older than that
since
N.B. TGA usually die after short period of birth .. unless it’s associated with Lt. to Rt. Shunt e.g. VSD
-10-
Closed Heart Surgery Cases
What Happen in M.S. ?!
For Mitral Stenosis ONLY
(Closed Mitral Valvotomy or Commissurotomy)
Fibrosis in Rh. Fever
- by H/O : Severe
?
Indications Prerequisites Contra-Indications
? ?
Symptoms (Dyspnea) Not Controlled Medically or Dangerous Symptoms (Hemoptysis) - by Investigations : ECHO-Doppler .. if Valve Area LESS than 1 Cm.
Opening Snap S1 & Both are Disappear with Calcification # Murmur Caused by the Stenosis itself in Valve Opening : it Give in Valve Closure : it
Isolated Lesion (No M.R.) & Not Calcified If Double
Rigid Cusps but Liable in the Center
Lesion or Calcified - by H/O:
1
-
Closed Commissurotomy
Give
- by Examination : - by Lateral
?
(Infra-Mammary) Thoracotomy Scar
3
1- for Follow-up
3
2 & 3
-
?
:
No Murmur .. but still there are Opening Snap & 2- for Complications After Surgery (e.g. converted into M.R.) Palpitation Systolic Murmur 3- for Recurrence .. (Re-Stenosis - M.S.) Dyspnea Diastolic Murmur
- in case of Re-Stenosis .. what is the Causes
?
- in case of Failed Commissurotomy what is the Treatment
?
- is Incidence of Commissurotomy
or
?
S1
99% it’s Recurrent Rheumatic Activity (Re-Fibrosis) even if Patient didn’t give a H/O of Rheumatic Activity [Subclinical Attack] 1% Under-Correction from Surgeon
Valve Replacement or Open Heart Surgery N.B. Commissurotomy is useless now due to Balloono-Plasty is now Considered the ttt of Choice
-11-
What Happen in M.S. ?!
For Mitral Stenosis ONLY
Closed Heart Surgery Cases
(Closed Mitral Valvotomy or Commissurotomy)
Fibrosis in Rh. Fever
- by H/O : Severe
?
Indications Prerequisites Contra-Indications
? ?
Symptoms (Dyspnea) Not Controlled Medically or Dangerous Symptoms (Hemoptysis) - by Investigations : ECHO-Doppler .. if Valve Area LESS than 1 Cm.
Opening Snap S1 & Both are Disappear with Calcification # Murmur Caused by the Stenosis itself in Valve Opening : it Give in Valve Closure : it
Isolated Lesion (No M.R.) & Not Calcified If Double
Rigid Cusps but Liable in the Center
Lesion or Calcified - by H/O:
1
-
Closed Commissurotomy
Give
- by Examination : - by Lateral
?
(Infra-Mammary) Thoracotomy Scar
3
1- for Follow-up
2 & 3
3
-
?
:
No Murmur .. but still there are Opening Snap & 2- for Complications After Surgery (e.g. converted into M.R.) Palpitation Systolic Murmur 3- for Recurrence .. (Re-Stenosis - M.S.) Dyspnea Diastolic Murmur
- in case of Re-Stenosis .. what is the Causes
?
- in case of Failed Commissurotomy what is the Treatment
?
- is Incidence of Commissurotomy
99% it’s Recurrent Rheumatic Activity (Re-Fibrosis) even if Patient didn’t give a H/O of Rheumatic Activity [Subclinical Attack] 1% Under-Correction from Surgeon
Valve Replacement or Open Heart Surgery N.B. Commissurotomy is useless now
?
or
S1
due to Balloono-Plasty is now Considered the ttt of Choice
-11-
Cardiology Scheme # How to Reach the Diagnosis ?! from H/O 1 Dyspnea (
) from the Start M.S. ) in the course of Disease A.F. most probably with M.S.
2 Ir-regular Palpitation (
) T.R. (have to be associated with MVD)
3 Systemic Venous Congestion Symptoms ( 4 Low COP Symptoms (
) ± Angina Pain from the Start A.S. ) from the Start Regurge (M.R. or A.R.)
5 Regular Palpitation ( 6 Cyanosis (
) + Squatting (
) from the Start F4 ) Etiology is Congenital
7 Young Onset Complain ( from
General Exam
1 Blood Pressure :
Systole /
Diastole = Pulse Volume > 60 A.R. (& search for Other Peripheral Signs of A.R.)
2 Pulse : Ir-regular A.F. M.S. (& Revise the between A.F. & Extra-Systole) 3 Orthopnea (
) M.S. (
)
4 L.L. Edema or Ascites T.R. (have to be associated with MVD) 5 Cyanosis or Clubbing F4 6 Very Tall & Thin Patient Marfan $ (& search for Other Signs of Marfan $) A.R. 7 Stunted Growth ( from
Local Exam
) Congenital (either it’s The Cause esp. if Sever, or it’s Association as Down $ or Noonan $)
st
1st Put the Stethoscope on 2nd Aortic Area :
1 Auscultation
If you Hear a Murmur
Systolic Murmur Then you have to move in the 4 Directions to get the SITE OF MAX. INTENSITY if Site of Max. Intensity is
Apex
M.R. (Posterior Leaflet)
if Site of Max. Intensity is
Pulmonary Area
P.S.
Tricuspid Area T.R. (associated with MVD) if Site of Max. Intensity is 1st Aortic Area + reaching the Carotid A.S. if the Sound is wherever you Move VSD if Site of Max. Intensity is
2nd Put the Stethoscope on Apex : If you Hear a Murmur = MVD
Diastolic Murmur Then it’s A.R. + Peripheral Signs will lead you
Cardiology Scheme # How to Reach the Diagnosis ?! from H/O 1 Dyspnea (
) from the Start M.S. ) in the course of Disease A.F. most probably with M.S.
2 Ir-regular Palpitation (
) T.R. (have to be associated with MVD)
3 Systemic Venous Congestion Symptoms ( 4 Low COP Symptoms (
) ± Angina Pain from the Start A.S. ) from the Start Regurge (M.R. or A.R.)
5 Regular Palpitation ( 6 Cyanosis (
) + Squatting (
) from the Start F4 ) Etiology is Congenital
7 Young Onset Complain ( from
General Exam
1 Blood Pressure :
Systole /
Diastole = Pulse Volume > 60 A.R. (& search for Other Peripheral Signs of A.R.)
2 Pulse : Ir-regular A.F. M.S. (& Revise the between A.F. & Extra-Systole) 3 Orthopnea (
) M.S. (
)
4 L.L. Edema or Ascites T.R. (have to be associated with MVD) 5 Cyanosis or Clubbing F4 6 Very Tall & Thin Patient Marfan $ (& search for Other Signs of Marfan $) A.R. 7 Stunted Growth ( from
Local Exam
) Congenital (either it’s The Cause esp. if Sever, or it’s Association as Down $ or Noonan $)
st
1st Put the Stethoscope on 2nd Aortic Area :
1 Auscultation
If you Hear a Murmur
Systolic Murmur Then you have to move in the 4 Directions to get the SITE OF MAX. INTENSITY if Site of Max. Intensity is
Apex
M.R. (Posterior Leaflet)
if Site of Max. Intensity is
Pulmonary Area
Diastolic Murmur Then it’s A.R. + Peripheral Signs will lead you
P.S.
Tricuspid Area T.R. (associated with MVD) if Site of Max. Intensity is 1st Aortic Area + reaching the Carotid A.S. if the Sound is wherever you Move VSD if Site of Max. Intensity is
2nd Put the Stethoscope on Apex : If you Hear a Murmur = MVD Now, Search if it Localized or Propagated .. by moving the Stethoscope to the Axilla
Propagated to Axilla
Localized
M.R. (Anterior Leaflet)
M.S.
+ it’s Systolic
+ it’s Diastolic
2
P.S.
+ A.S.
3
2nd Aortic Area 4
5
MVD
Apex
T.R. then Inspection +
to Detect Any Chamber Enlargement
Palpation & Percussion
-12-
