cardiology notes, jipmer, pondicherry, india
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Bala sir class 8-04-2016Conditions present with DyspnoeaValvular heart diseasesMitral stenosisCardiomyopathyHOCMPortion of right heartInfundibuarTrabacularOutflow
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 cardiomyopathyBroadbent signTell about indrawing of ribs.Indrawing of parasternal area means right ventricular Isovolumetric contractions is not there.Paradoxical splitting of S2 in constrictive pericarditisHepatic pulsations in constrictive pericarditis.Never use the word acquired pericardial disease.Tell severe restrictive physiology heart disease with features of right heart failure.Possiblity areChronic constrictive pericarditisRestrictive cardiomyopathyPrimary tricuspid valve disease.From history and examination my diagnosis is most likely chronic constrictive pericarditisWith possibilities of Similar in eissenminger syndrome always use words severe pulmonary artery hypertension secondary to left to right shunt or primary pulmonary artery hypertension ECGLead I sign of COPD P, QRS and T pointing down ward.Abrupt restrictions of left ventricular posterior wall suggestive of constrictive pericarditis.Inspiratory inward movement of left ventricle wall.Prominent A wave and premature opening of pulmonary valve.ECHO sign of ventricular interdependence Respiratory variationSeptal bouncePulmonary veinRestrictive cardiomyopathy echocardiography huge RA/RV , small ventricle.ManagementConstrictive pericarditis diuretics ethacynic acid AldactoneDigoxin? To be given if there is AF.After doing Pericardiectomy there is myocardial dysfunction.Dopamine and Dobutamine priming prior to surgery.Subtotal Pericardiectomy is the treatment of choice.Two approaches.Most important factor is PT/INR for operations. Derangement indicates progressive disease and liver dysfunction. Operate immediately.Post op recovery difficult predict.
THE ENDBala sir class 8-09-2016Incidence of angina pectoris in valvular heart disease10-20% 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 feverAtrial fibrillationVentricular tachycardiaProlongation 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.
Bala sir class11/03/2016 AORTIC STENOSIS Why aortic stenosis doesn't causes increases the LA pressureReason 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 stenosisNothing 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 stenosisSevere symptomatic aortic stenosis stage DPARTNER TrialPatient 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.
Nitroprusside is good in aortic stenosis patient.
Test to check myocardial stressBNP in aortic stenosisAortic stenosis classification according to flowReduced flow than you can hear P2.Comet sign in lung USG in pulmonary oedema.InvestigationTMT stress testConditions Asymptomatic severe to moderate aortic stenosis.See blood pressure response.Fall in blood pressure suggests severe aortic stenosis.BNPEchocardiography Strain and longitudinal strain.3D echocardiography best.Coronary angiographyCT scan for calcification Dobutamine stress echocardiography.SurgeryBalloon aortic valvuloplasty in young female patient.Open aortic valvotomy in young patient.AVR Patient with eccentric hypertrophic mostly recovery is bad.Diastolic dysfunction bad means bad recovery.Never deny AVR in any symptomatic aortic stenosis patient.PAD pacing was used in the past to assess the AVR need.
Bala sir class 11-11-2016LV 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. How to differentiate Austin flint murmur from mitral stenosis murmur.
Bala sir class 12/05/2015Chest painASDMVPPulmonary stenosis Aortic stenosis Primary pulmonary artery hypertension HOCMCoronary artery anomaly Coronary ostial stenosis(Kawasaki disease,Ankylosing spondylitis,Syphilis)Pericarditis (RA,SLE)Ebstein anomaly Eissenminger syndrome Bicuspid aortic valve ASD with pericarditisVSD with Aortic regurgitation How many coronary supply right ventricleUsually one RCA or LCXAV grove and Diagnostic catheter always tapper in angio view.Pansystolic murmur on right sideGerbode defect Congenital heart disease don't have Pulmonary artery hypertensionVSD with ARIVC type of ASDChest xray LAO at 60 degree for LV enlargement (Best view)View for DORV Minimal four view during angio or cath study.Angio view for TOFPA, Left lateral,RAO, ???DORV rules out coarctation of aorta Bala sir class 15-09-2016Classical point in history which tells you that this episode is rheumatic fever1)Recurrence2)Mitral regurgitation does not need recurrent rheumatic fever. But symptoms start early
Subclinical carditis or indolent carditisComplete cureRebound carditisRecurrent carditisSubclinical carditis -Two type-IndolentSecondDyspnoea 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 LV end systolic volume is more important Amount of regurgitation, forward stroke volume, regurgitation orifice is important Ischemic cardiomyopathy means cardiomyopathy because of ischemia or hibernating myocardium Explosive onset of mitral stenosis murmur indicates good subvalvular apparatus.Severe mitral stenosisExplosive onsetPandiastolicPresence of ThrillManagement
Bala sir class 18-03-2016Conditions present with atypical chest pain since childhoodCoronary artery diseaseMyocarditisAortic stenosisLVOT obstructionRVOT obstructionASD (Most common)Reason Dilated pulmonary arteryAssociated MVPAssociated pericarditisCoronary artery anomalyALPACARCA from opposite sinusHOCM
Dyspnoea alone in a young patient with no fatigueMitral valve disease LVOT obstruction which started with dyspnoeaSubaortic stenosisHOCM primarily present with dyspnoeaAbsence of fatigue rules out pulmonary artery hypertension, Pulmonary stenosis Procedure done in two stagesCoronary artery diseaseLVOT obstructionHOCM with septal ablationPulmonary stenosis with restricted stenosis of Infundibuar to prevent suicidal RVSyncope due to cardiac causes recovered immediatelyAlways remember LVOT obstruction see carotid
Silent mitral stenosis Infundibuar pulmonary stenosis DORV another differentialEjection click in HOCM due to sudden distension of aorta due to blood flow Second type of click is due to venturi effect of blood flowMitral valve buckle.Relationship of intensity of first heart sound with PR interval Increases PR decreases 1st heart sound than again loud due to AV dissociation.Echocardiography in HOCMInterventicular septum doesn't move but posterior wall will move vigorously.Speckled appearanceSAM of mitral valveLV posterior wall abnormality at the site of mitral valve papillary muscle attachmentAortic valve open partially and close partially.LVOT jet is funny.
Bala sir class 19-05-16Complication of closing VSFAneurysm of membrane septumArrhythmiaEmbolismInfective endocarditisDevelopment of PAH/ARNatural history of pulmonary stenosisMild regressModerate VariableSevere ProgressiveNatural history of aortic stenosisPulmonary stenosis murmur is mixed frequency
Bala sir class 22-04-2016Palpitations only present in ASD in eissenminger syndrome. Not in VSD/PDA with eissenminger syndrome.Dyspnoea,Arrhythmia is present in patient with HOCMLutembacher syndrome is associated with cyanosis because of AV fistula DD of Opening snap vs Split S2Split S2 Triple soundOn standing Widening of S2-A2 gap indicates opening snapOpening snap best at low left sternal borderWide 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 studyJL catheterMultiple purpose catheterCournar catheterSwan 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