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Author: Michael Shea, M.D., 2008 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution – Share Alike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
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Mitral Valve Disease Michael Shea, MD
Fall 2008
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Lecture Outline
• Etiology • Pathophysiology • Clinical features • Diagnostic testing • Differential diagnosis • Management
Mitral Stenosis Mitral Regurgitation
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Mitral Stenosis: Pathophysiology
Etiology: rheumatic; female>male by 6:1
Mitral leaflets: • Large anterior is contiguous to
aorta • Smaller posterior is contiguous to
left atrial endocardium • Normal area: 4-5cm2
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Mitral Stenosis: Pathophysiology
• Fundamental problem: Inability to get blood from left atrium left ventricle
• Stenotic process: – Scarring and fibrosis of leaflets and
chordae tendineae
– Commissural fusion
– Leads to funnel-shaped orifice and pressure gradient across valve
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Mitral Stenosis: Pathophysiology
Source Undetermined
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Mitral Stenosis: Pathophysiology
• Consequences of left atrial pressure: – Left atrial enlargement, blood stasis may
lead to atrial thrombus formation and embolism
– Development of atrial fibrillation • Consequences of pulmonary vein
pressure – Leads to pulmonary artery HTN
– Then RV hypertrophy and dilation
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Mitral Stenosis: Pathophysiology
• Measuring severity: valve area – Severe: < 1.0 cm2
– Moderate: 1.0-1.4 cm2
– Mild: 1.5-4.0 cm2
• Symptoms unusual until area < 1.5 cm but! during unusual flows (eg. exercise) or !tachycardia which left atrial filling time! dyspnea may occur
• Symptoms progress as valve narrows
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Mitral Stenosis: Clinical Features
History
• Long course before sx onset
• Sx worsen with onset of atrial fibrillation
• Typically asx then dyspnea with marked effort then minimal effort
then orthopnea, paroxysmal nocturnal dyspnea
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Mitral Stenosis: Clinical Features
History
• Fatigue is common patient cannot augment cardiac output
• Hemoptysis
• Embolic stroke!. usually when patient is in atrial fibrillation
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Mitral Stenosis: Clinical Features
Physical exam: • Palpation – may be a parasternal lift
(RV) • Auscultation:
1. Accentuated first heart sound (S1) 2. Opening snap sudden stop in
leaflet opening 3. Diastolic rumble
Higher left atrial Po, shorter S2 to OS interval
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Mitral Stenosis: Clinical Features
Diastolic rumble: • Low frequency murmur • Occurs after opening snap (OS) • Decrescendo contour
Pulmonary Hypertension: • " P2 component of S2
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Source Undetermined
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Mitral Stenosis
Diagnostic testing
• Chest radiology
• Electrocardiography
• Echocardiography
• Cardiac catheterization
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Mitral Stenosis: CXR findings
Reflect left atrial HTN
• Double density right cardiac border
• Convexity (LA appendage) just below left PA 4 bump sign: aorta, pulm artery, atrial appendage, left ventricle
• Elevated left main bronchus
• Kerley lines
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Source Undetermined
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Source Undetermined
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Mitral Stenosis: The ECG
Source Undetermined
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Mitral Stenosis
Diagnostic testing
• Chest radiology
• Electrocardiography
• Echocardiography
• Cardiac catheterization
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Echocardiography: Parasternal
Normal Mitral Stenosis
Source Undetermined Source Undetermined
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Echocardiography: Short Axis
Normal Mitral Stenosis
Source Undetermined Source Undetermined
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Mitral Stenosis: Clinical Manifestations and Diagnosis
• Echo: 2D images
– Increased LA size
– Doming of valve leaflets
– Valve stenosis
– Valve area can be planimetered
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Mitral Stenosis: Cardiac Catheterization
• Not required to establish dx in young patients – echo is sufficient
• Cath may be needed if:
– Sx disproportionate to objective evidence
– Other forms of heart disease suspected! eg. CAD
– Mitral regurgitation of uncertain degree
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Mitral Stenosis
• Atrial myxoma
• Cor triatriatum
• Congenital mitral stenosis
Differential Diagnosis
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Mitral Stenosis: Management
Medical • 2° prevention: penicillin years
• Rate control for atrial fibrillation: beta-blockade, digoxin
• Anticoagulation
• Diuretics and rate control for congestion
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Mitral Stenosis
• Closed surgical commissurotomy
• Open surgical commissurotomy
• Valve replacement
• Balloon mitral commissurotomy
Mechanical Relief
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Source Undetermined
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Source Undetermined
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Mitral Regurgitation
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Mitral Regurgitation: Etiology Mitral annulus
- Annular calcification
Leaflets
- Myxomatous degeneration
- Rheumatic disease
- Endocarditis
- SAM (hypertrophic cardiomyopathy)
Chordae tendineae
- Rupture (idiopathic)
- Endocarditis
Papillary muscles
- Dysfunction or rupture
Left ventricle
- Cavity dilatation
Schematic representation of
mitral valve pathologies
removed
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Mitral Regurgitation: Pathophysiology
Acute Mitral Regurgitation:
Pulmonary Edema
High LA Pressure
Chronic Mitral Regurgitation:
Dilated LA with less elevated pressure Brown University
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Mitral Regurgitation: Hemodynamics
Source Undetermined
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Mitral Regurgitation: Pathophysiology
• May be acute or chronic
• Chronic MR:
– Total stroke volume increases
– Blood LA to offload LV
– LV enlarges (ventricular remodeling)
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Mitral Regurgitation: Pathophysiology
Brown University
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Mitral Regurgitation: Clinical Features
• Mild MR no sx • When sx occur
– Fatigue – Dyspnea
• Physical Exam: • Lateral; dynamic LV apex beat • Often diminished S1 (leaflets don’t
coapt); S3 often present • Apical systolic murmur • Holosystolic murmur to axilla
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Mitral Regurgitation: Auscultation
Source Undetermined
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Mitral Regurgitation: Diagnostic Tests
• CXR: LA and LV enlargement
• ECG: Normal initially!then shows LV hypertrophy
• Echo:
– LAE – LV enlargement
– Doppler and color flow allow semi-quantitative estimate (1-4+)
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Source Undetermined
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Source Undetermined
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Mitral Regurgitation: Parasternal
Sources Undetermined
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Severity of Mitral and Tricuspid Regurgitation
Schematic representation of
varying degrees of severity of
regurgitation removed
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Mitral Regurgitation: Clinical Features
Mitral Valve Prolapse: • Protrusion of MV leaflets into LA
during systole; more common in women
• Valve changes leaflets show! - voluminous - thickened - redundant - myxomatous
• Sx: palpitations, dyspnea if severe
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Mitral Regurgitation: Mitral Prolapse
Exam: • Skeletal changes – scoliosis, pectus
excavatum; Marfan’s in some • Midsystolic click; may see late systolic
murmur • Echo: Mid to late systolic prolapse of
posterior leaflet. Doppler or color echo reveals severity of MR
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Mitral Regurgitation: Parasternal
Sources Undetermined
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Mitral Regurgitation: Mitral Prolapse
Complications: • Many patients go thru life without
problems • MR can progress • Chordal rupture can lead to sudden,
severe MR (esp. in men) • Endocarditis in those with murmur • TIA’s rare treat with ASA • Sudden death – very rare
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Mitral Annulus
Schematic representation of heart beat stages
removed
Source Undetermined
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Mitral Regurgitation: Clinical Features
Papillary muscle dysfunction: • Spectrum from intact but poorly
functioning PM to acute rupture • Frequently caused by:
– Ischemia or infarction of papillary muscle or underlying LV myocardium
• Less frequently by LV dilation or infiltrative process
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Mitral Regurgitation: Papillary Muscle Dysfunction
Source Undetermined
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Mitral Regurgitation: Papillary Muscle Dysfunction
Source Undetermined
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Mitral Regurgitation: Differential Diagnosis
Conditions with systolic murmur:
• VSD
• Aortic stenosis
• Tricuspid regurgitation
• Hypertrophic cardiomyopathy
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Mitral Regurgitation: Management
Asymptomatic
• Follow serially with visits and echo
• Recommend repair/replacement if: – Clear sx develop
– LV ejection fraction falls < 60%
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Mitral Regurgitation: Management and Prevention
MR caused by LV dilation from poor LV:FXN
• Diuretics
• Vasodilators
Improves sx!
Symptomatic MR with preserved LV:
• Mitral repair or replacement before progressive LV dysfunction occurs
• B-Blockers
• Digitalis
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Schematic representation of
mitral valve removed
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Aortic Valve Disease
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Lecture Outline
Aortic Stenosis Aortic Regurgitation
Etiology
Pathophysiology
Clinical Features
Diagnostic Testing
Differential Diagnosis
Management
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Aortic Stenosis: Pathology Normal Congenital Acquired
Sources Undetermined
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Aortic Stenosis
Pathophysiology
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Aortic Stenosis: Pathophysiology
Measuring severity: valve area – Severe # 1.0 cm$ – Moderate 1.0 – 1.4 cm$ – Mild > 1.5 cm$
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Left Ventricular Pressure Overload
Global gene activation
Concentric hypertrophy
Gradient between LV and Aorta
Source Undetermined
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Source Undetermined
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Aortic Stenosis: Clinical Findings
• Dyspnea • Angina pectoris • Syncope
Heart Rate
(bpm)
Systemic Arterial
Pressure (mmHg)
Pulmonary Arterial
Pressure (mmHg)
Pre
ssur
e
Aortic stenosis
Volume
Normal
Source Undetermined
M. Shea
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Aortic Stenosis: Clinical Findings
• Dyspnea • Angina pectoris • Syncope
Heart Rate
(bpm)
Systemic Arterial
Pressure (mmHg)
Pulmonary Arterial
Pressure (mmHg)
Pre
ssur
e
Aortic stenosis
Volume
Normal
Source Undetermined
M. Shea
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Normal
Parvus et tardus pulse
Carotid Pulse
Sources Undetermined
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Source Undetermined
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Aortic Stenosis
Laboratory Evaluation
! Chest radiology
! Electrocardiography
! Echocardiography
! Stress testing
! Catheterization
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Aortic Stenosis: Chest radiology
Sources Undetermined
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The Electrocardiogram
Source Undetermined
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Echocardiography: Parasternal
Normal Aortic Stenosis
Source Undetermined Source Undetermined
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Echocardiography: Short Axis
Normal: Aortic Stenosis
Source Undetermined Source Undetermined
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Aortic Stenosis: Continuity Equation
Source Undetermined
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Aortic Valve Stenosis: Echo Findings
Leaflet changes: • Thickening
• Calcification
• Mobility
Ventricular changes: • Left ventricular hypertrophy
Doppler changes: • valve gradient / valve area
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Aortic Stenosis
Laboratory Evaluation
! Chest radiology
! Electrocardiography
! Echocardiography
! Stress testing
! Catheterization
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Aortic Stenosis: Differential Diagnosis Any systolic murmur
Adapted by University of Michigan, Gray’s Anatomy, wikimedia commons
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Natural History of Aortic Stenosis
Braunwald, Circulation, 1968
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Source Undetermined
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Schematic representation of
pulmonary autograph removed
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Aortic Stenosis: Management
• Young patient – Balloon valvotomy – Ross procedure
• Adults – Valve replacement
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Cribier-Edwards Percutaneous Valve
medGadget Source Undetermined Source Undetermined
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Aortic Regurgitation
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Aortic Regurgitation: Etiology
Abnormalities of valve leaflets
• Rheumatic • Endocarditis • Bicuspid valve
Dilatation of aortic root
• Aortic aneurysm/dissection • Annulo-aortic ectasia • Marfan syndrome • Syphilis
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Normal Valve Function: • Total cusp area > aortic root area by 1.8 x • Allows leaflets to overlap/abut • Helps prevent prolapse in diastole
Impact of Diseases: • Rheumatic: Cusp area central defect • Endocarditis: Destroys cusp by tears • Aortic root: Dilation central defect
Aortic Valve Regurgitation: Pathophysiology
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Dominant Hemodynamics: LV volume overload • Critical determinant of severity - area of
regurgitant orifice area • End diastolic volume increases & stroke
volume increases • Dilation and hypertrophy of LV • Diastolic burden reaches critical point
leading to heart failure • Low diastolic blood pressure: incomp. valve
and vasodilation
Aortic Valve Regurgitation: Pathophysiology
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Aortic Valve Regurgitation: Pathophysiology - Acute vs. Chronic
Pulmonary
Congestion
Pressure
Pressure
N-
Pressure Pressure N-
Brown University
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Aortic Regurgitation: Clinical Features
• Long course • Palpitations • Dyspnea • Fatigue • Angina pectoris
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The Arterial Pulse and Blood Pressures in Aortic Regurgitation
Mild Moderate Severe
132/76
144/67 152/58
Blo
od P
ress
ure
(mm
/Hg
160
140
120
100
80
60
40
M. Shea
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Hyperkinetic pulse
Carotid Pulse
Source Undetermined
Source Undetermined
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• LV apex impulse: displaced laterally, downward, dynamic, enlarged
• Systolic murmur: may or may not imply valve stenosis!rapid ejection of stroke volume across aortic valve
• Diastolic murmur: decrescendo murmur; valvular AR - louder LUSB. Aortic root disease - louder RUSB
Aortic Valve Regurgitation: Physical Examination
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Source Undetermined
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Aortic Regurgitation
Laboratory Evaluation
• Chest radiology
• Electrocardiography
• Echocardiography
• Exercise testing
• Cardiac catheterization
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Aortic Regurgitation: Chest X-ray
Source Undetermined
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The Electrocardiogram
Source Undetermined
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Source Undetermined
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Aortic Regurgitation
Laboratory Evaluation
• Chest radiology
• Electrocardiography
• Echocardiography
• Exercise testing
• Cardiac catheterization
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Aortic Regurgitation: Differential Diagnosis
• Mitral stenosis
• Pulmonic regurgitation
• Patent ductus arteriosus
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Aortic Regurgitation Management
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Aortic Regurgitation: Management
Medical Therapy
• Noninvasive follow-up
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100
80
60
40
20
0
Asy
mto
mat
ic p
atie
nts
with
no
rmal
LV
func
tion,
%
0 2 4 6 8 10 12
Time, y
Sudden death
Onset of symptoms
Onset of asymptomatic left ventricular dysfunction
Severe Aortic Regurgitation: The Asymptomatic Patient
M. Shea
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Aortic Regurgitation: Management
Surgical Therapy
Repair • Aortic valve
Replacement
• Aortic root replacement
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Slide 14: Source Undetermined Slide 17: Source Undetermined Slide 18: Source Undetermined Slide 19: Source Undetermined Slide 21: Sources Undetermined Slide 22: Sources Undetermined Slide 28: Source Undetermined Slide 29: Source Undetermined Slide 32: Brown University, http://www.brown.edu/Courses/Bio_281-cardio/cardio/handout2.html Slide 33: Source Undetermined Slide 35: Brown University, http://www.brown.edu/Courses/Bio_281-cardio/cardio/handout2.html Slide 37: Source Undetermined Slide 39: Source Undetermined Slide 40: Source Undetermined Slide 41: Sources Undetermined Slide 45: Sources Undetermined Slide 47: Source Undetermined Slide 49: Source Undetermined Slide 50: Source Undetermined Slide 57: Sources Undetermined Slide 60: Source Undetermined Slide 61: Source Undetermined Slide 62: Michael Shea; Source Undetermined Slide 63: Michael Shea; Source Undetermined Slide 64: Source Undetermined Slide 65: Source Undetermined Slide 67: Sources Undetermined Slide 68: Source Undetermined Slide 69: Sources Undetermined Slide 70: Sources Undetermined Slide 71: Source Undetermined Slide 74: Adapted by University of Michigan, Gray’s Anatomy, Wikimedia Commons, http://commons.wikimedia.org/wiki/File:Heart-and-lungs.jpg Slide 75: Braunwald, Circulation, 1968 Slide 76: Source Undetermined Slide 79: Sources Undetermined; medGadget, http://medgadget.com/archives/2005/06/edwards_lifesci.html
Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy
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Slide 84: Brown University, http://www.brown.edu/Courses/Bio_281-cardio/cardio/handout2.html Slide 86: Michael Shea Slide 87: Sources Undetermined Slide 89: Source Undetermined Slide 91: Source Undetermined Slide 92: Source Undetermined Slide 93: Source Undetermined Slide 98: Michael Shea