cardiac

Acquired Heart Disease

Mitral Stenosis (MS)
Etiology :

Rheumatic fever.

Congenital mitral stenosis

Clinical features :

Symptoms :
Exertional dyspnea,Orthopnea, and PND: result from pulmonarycongestion,
Easy fatigability, weakness, weight loss and cardiac cachexia due to decreased cardiac output.
Hemoptysis: in severe MSdue to rupture of pulmonary microvasculature 2ry to pulmonary HT, or dueto bronchitis causedby the pulmonary edema.
AF, LA thrombus formation with or without Systemic embolization due LA dilatation and stasis
RV failure with peripheral edema, and hepatic congestion,
Signs :
Thin and cachectic with peripheral cyanosis and mitral faces characterized by flushed cheeks.
Rhythm : AF may be present
Auscultation : normal apex beat with an opening snap and a mid-diastolic rumbling murmur
Investigations :
Chest X-ray :
double contourright sided heart border (LA enlargement seen visible behind RA shadow).
Mitralizationof left heart border:Enlargement of LA appendage& pulmonaryvasculature obliterates the normal concavity bet. The aorta & LV → straight Left border of the heart .
Pulmonary edema and Kerley B-lines seen
ECG : prominent large p-wave (P-mitrale) , AF , RVH, (Normal LV)
echocardiography: usually diagnostic.
Cardiac catheterization : only indicated before surgery for patients alder than 40 years old to exclude concomitant coronary artery disease.
Treatment:
I- Medical treatment :
Prophylaxis for Bacterial Endocarditis.
Diuretics to decrease pulmonary congestion.
treatment of AF : by antiarrhythmic agents and/or electrical cardioversion to convert AF to sinus rhythm.
Chronic anticoagulation (indicated in those with a history of embolism, known left atrial thrombus, and chronic AF.)
II- Surgical treatment :surgical options include:
Percutaneous balloon mitral valvotomy (BMV).
Operative treatment of mitral stenosis. (Open or closed mitral valvotomy or mitral valve replacement)
Indications of surgery :-
Moderate to severe mitral stenosis with a mitral valve area less than 1 Cm2


The onset of atrial fibrillation.
worsening pulmonary hypertension.
LA thrombus ± systemic embolization.
bacterial endocarditis.

Mitral Regurgitation (MR)

Causes :
Rheumatic fever: due to previous rheumatic fever with calcification and valve destruction. This is probably the most common cause in our country..
Mitral valve prolapse.
Ischemic heart disease ( MI or Ischemia ): causing acute MR
Bacterial endocarditis :
Hypertrophic Cardiomyopathies
Clinical features :
Symptoms :
Mild MR cause no disability & the patient may remain well for many years with LV adapting adequately to the increased work load. As MR progress the most common symptoms are :

Exertional dyspnea.

Palpitation.
Orthopnea.
Paroxysmal nocturnal dyspnea


Acute MR: acute onset pulmonary edema with left ventricular failure

Signs :heaving (forceful) laterally displaced apex beat with a pansystolic blowing murmur heard all over the heart maximum at the apex and radiating to the lungs.
Investigations :
CXR : LA & LV enlargement, Kerley B-lines, and pulmonary edema.
ECG:P-mitrale, LVH or biventricular hypertrophy, with or without AF.
Echocardiography is diagnostic
Cardiac catheterization only when in doubt or patient over 40 years old.
Treatment :
Medical treatment: prophylaxis for endocarditis, Diuretics & vasodilators : to reduce LV afterload and to increase cardiac output. control heart rate in atrial fibrillation
Surgical treatment : mitral valve repair, or Replacement with another synthetic or natural valve.
Indications for operation:
Moderate to severe MR with NYHA Class III or Class IV
Onset of AF.
LA enlargement
Evidence of impaired LV function
Acute MR following MI. (Cardiac surgical emergency).

Aortic Stenosis (AS)

Causes of AS:
Congenital AS and a congenital bicuspid aortic valve may become stenotic with time
Acquired aortic AS:due to rheumatic fever ordegenerative (senile) aortic stenosis


Symptoms:
Once AS is symptomatic the patient survival is limited. There are 3 principal symptoms of AS:
Angina: on exertion
Syncope on exertion and AS is one of the causes of sudden death
LVF (pul. edema) &RVF (congestive HF) presenting symptom in nearly 1/3 of patients.
Signs :
Arterial pulsation: slow, prolonged rising arterial pulse.
Auscultation: ejection systolic murmur, best heard at 2nd intercostal space to right of the sternum, radiates into carotid arteries & to the cardiac apex.
Investigations
ECG:LVH, T-wave inversion and ST-segment depression are common (ischemia).
CXR: usually normal. but may show post-stenotic dilation of ascending aorta or calcification of the AV.
ECHO is diagnostic
Cardiac catheterization : (The most accurate measure of AS) when in doubt or older than 40.
Management:-
The only effective therapy is operative therapy because AS is a mechanical obstruction to flow from LV.
Indications
The existence of symptoms .
congestive heart failure mandates urgent intervention.
Transvalvular gradient across the aortic valve more than50 mmHg.
Percutaneousaorticballoonvalvuloplasty :has been preserved for elderly high risk patients with degenerative AS


Aortic Insufficiency (AI or AR)
AI (AR) :is failure of coaptation of the aortic leaflets during diastole and causes a central leak.
Etiology :-
Rheumatic fever.
AV degerative disease e.g.; Annuloaorticectasia (with Marfan's syndrome.), Myxoid degeneration, Congenital bicuspid aortic valves may become incompetent.
Infective endocarditis.
Aortic dissection.
Diagnosis:
Angina on exertion and Nocturnal angina : due to low diastolic pressure, leading topoor coronary flow.
Dyspnea on exertion, Orthopnea, and paroxysmal nocturnal dyspnea.
Symptoms of CHF occur later on
The physical examination:
The peripheral pulses rise and fall abruptly (Corrigan's or water-hammer pulse),
Blood pressure : wide pulse pressure.
The head may nod with each systole (de Musset's sign),
The capillaries visibly pulsate (Quincke's sign).
(pistol shot ) sound heard on the femoral artery pulsation .
Auscultation : high pitched early diastolic regurgitant murmur.
Investigations :
ECG: LV hypertrophy and LA enlargement.
CXR: an enlarged cardiac silhouette. enlarged left atrial shadow.
echocardiography :most accurate noninvasive technique to determine the severity of AI
Cardiac catheterization:The severity of the AR may be visualized angiographically.
Management :-
Medical treatment :
Indicated for : asymptomatic or mildly symptomatic patient.
Diuretics and vasodilators (afterload reduction)
Careful follow up with serial Echo ,because significant irreversible LV systolic dysfunction may develop before clinical evidence of congestive HF.
Surgical treatment :
Indications of surgery:
All symptomatic patients.
Asymptomatic patient with increased LV size (LV dilatation ) on echo
Pt with AI undergoing CABG or surgery for other heart valves disease.
Acute AR in: ♦endocarditis or ♦acute aortic dissection.


Coronary Artery Diseases (CAD)
Almost always the result of atherosclerosis of the coronary arteries.
Clinical Presentation:
Angina
Unstable angina
Myocardialinfarction:
Sudden death: Caused by: acute infarction , or arrhythmia ( usually VF).
Invistigations:
CXR:
ECG:q-waves, S-T and T wave changes
Exercise stress test: ( treadmill test) for patients with normal rest ECG
Echo: determining the EF% and cardiac wall motility.
Myocardial enzymes CK,LDH&troponin:
Coronary arteriography: (the gold stadered test)
Nuclearcardiography:(sensitive and specific) assess EF% & myocardial perfusion.
MRA: (magneticresonanceangiography)

Management Of CAD:

Medical management :
Alteration of life style and modification of risk factors /
Drugs.
PTCA (percutaneous transluminal coronary angioplasty) or recently called PCI (percutaneous coronary intervention)
CABG (coronary artery bypass grafting)


Indications for CABG:
Critical left main stem disease (more than 50% stenosis)
Critical proximal LAD stenosis (more than 70% stenosis)
All three main coronary artery disease (triple vessel disease)
Poor left ventricular function with coronary artery disease
Coronary artery disease with diabetes mellitus
Combined coronary artery disease with valvular heart disease.
Failed PCI or development of complications during PCI
Surgery for complications of MI.
Contraindications to CABG:
Small diffusely diseased coronary arteries
Advanced heart failure
Acute myocardial infarction

Choice of conduit:

Venous grafts:
Long saphenous vein: is the most common vein used as a conduit as it is easy to harvest and provides good length. 10 year patency graft is 50-60%. Alternative vein conduits include the short saphenous vein and veins of the upper limb
Arterial grafts:
The left internal mammary artery (LIMA), or internal thoracicartery, is the conduit of choice for the LAD. Its 10-year patency rates is 90%. Bilateral internal mammary can be used as well (BIMA). Alternative artery conduits include the radial artery, right gastro-epiploic artery and others.

Surgical Complications Of Acute MI :

occur due to tearing of myocardial tissue, and include:
rupture of the ventricular free wall.
ventricular septal defect.
rupture of a papillary muscle with severe mitral regurgitation.
Ventricular aneurysm


Rupture of the ventricular free wall:due to necrosis and rupture of the infarcted area
C/F:hemopericardium and tamponade. (It form 10% of hospital deaths due to acute MI.
Dx:Pericardiocentesis can confirm diagnosis & provide temporary hemodynamic relief. Echo provides definite diagnosis.
Rx:Urgent surgical therapy with ventricular reconstruction can lead to survival.
Post infarction VSD:due to infarction and necrosis of interventricular septum
C/F: New onset of a harsh pansystolic murmur, often with a thrill. Hemodynamic compromise (shock) with ventricular failure occurs early.
Dx:echocardiography,and cardiac catheterization
Rx:unstable patients: IABP (intra-aortic balloon pump which is a cardiac assisted device) to provide hemodynamic support followed by emergency CABG & patch closure of the VSD.
stable patient's → the operation can be delayed, allowing the infarct tissue to heal.

Papillary muscle rupture:(acute MR): due ruptured papillary muscle

C/F:severe acute MR & rapid development of pulmonary edema & hypotension.pansystolic murmur is usually present.
Dx:Echocardiography is diagnostic.
Rx:IABP with Early surgeryincluding mitral valve replacement plus CABG is indicated.
Ventricular aneurysm;occurs following partial-thickness necrosis of the ventricular wall and the necrotic wall is replaced with non-contractile fibrous tissue.
C/F: heart failure because the fibrous wall balloons out during systole and reduces the actual stroke volume.
Dx: echo and catherterixation
Rx; Surgical repair is indicated.

PERICARDIAL DISEASE

Pericardial effusion
Disturbance balance between production & resorption of pericardial fluid → pericardial effusion may develop. If the intrapricardial pressure > pressure in the atria → tamponade& compression will occur, venous return will fall and the circulation will be compromised. (Cardiogenic shock)
Acute tamponade(from penetrating trauma, during coronary angiography or post-operatively) may occur in minutes with small volumes of blood. The clinical features are low BP with a ↑ JVP & paradoxical pulse. Kussmaul's sign is a characteristic pattern (↑ JVP with inspiration ).
Emergency treatment → needle Aspiration of the pericardial space (pericardiocenthesis)
Penetrating wounds of the heart →exploration by median sternotomy.
Chronic tamponade → malignant infiltration of the pericardium (usually secondary carcinoma from breast or bronchus) or, very occasionally, uraemia or connective tissue disease. Treated by dealing with the underlying cause, repeated needle or catheter aspiration and sometimes requires creating a pericardial window between the pericardial space and the pleural or peritoneal space.