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