1. Internal Medicine Board Review (from MKSAP 13) Cardiology
June 2006

2. Congenital Heart Disease
In the Adult

3. Acyanotic Congenital Heart Disease (covered in MKSAP)
Atrial Septal Defect
Bicuspid Aortic Valve
Most common congenital anomaly
More common in men
Early systolic ejection click and outflow murmur
Diagnosis with echo important because of endocarditis risk
Coarctation and bicuspid aortic valve are associated
Ventricular Septal Defect
Patent Ductus Arteriosus
Valvular pulmonary stenosis
Coarctation of the aorta

4. Cyanotic Congenital Heart Disease (covered in MKSAP)
Most patients with unoperated cyanotic heart disease have developed Eisenmenger’s syndrome.
Tetralogy of Fallot
most have had complete intracardiac repair, occasionally only aortopulmonary shunt.
PI leading to right heart dilation is common
Yearly mortality increases after 25 years due to sudden death, QRS >180ms best predictor, apparent interaction between long QRS and right heart dilation, general agreement to replace pulmonary valve when QRS>180.
Transposition of Great Arteries
most have had been repaired with atrial switch (Mustard, Senning) procedure [now doing arterial switch]
Risk RV failure (survival depends on RV function), sick sinus syndrome, atrial arrhythmias

5. #70 26 y. o. female. Heart murmur as a child did not outgrow it
# y.o. female. Heart murmur as a child did not outgrow it. Married. Would like a child. Mild cough and SOB especially at high altitude. BP 110/70, HR 86. O2 sat 99%. Nl JVP. Good carotid upstroke. Lungs clear. RV lift. S1 normal S2 wide fixed splitting. 3/6 early to mid peaking systolic murmur LUSB. Echo RV enlargement, RAE, and high pulm flow but no ASD on TTE. PA 45. Valves normal. Next step?
TEE
ABX prophylaxis no other treatment
Have family and then consider closure of the defect
Cardiac cath
Reassurance

6. # 70 TEE Most likely dx is ASD (wide and fixed splitting of S2)
However partial anomalous pulmonary venous drainage is an alternative diagnosis and is suspected when TTE does not show ASD. RV enlargement is consistent with a hemodynamically significant shunt.
Mild elevation of PA pressure is not a contrindication to closure
TEE is indicated to define the anatomy and exclude anomalous pulmonary venous drainage
Referral for closure is indicated and if feasible prior to pregnancy (CHF sometimes complicates pregnancy, risk paradox embolus)
Closure percutaneous or sugical depending on anatomy and center’s experience
Most ostium secundum ASD can be closed percutaneously
Others require surgical closure

7. --Closure of ASD and VSD indicated if pulmonary to systemic shunt ratio of 1.7:1 or greater with evidence of right or left ventricular volume overload respectively.
Location of types of Atrial
Septal Defects
Majority are secundum
ASD second
Most common
Congenital defect
Encountered in adults
(bicuspid AV #1)

8. More on ASD’s
In absence of pulmonary vascular disease shunt is left to right resulting in RV volume overload.
With advancing age diminished LV compliance can lead to increase in shunt fraction with consequent right heart failure
A.fib is common in older adults with ASD’s.
Frequency of A.fib and potential for paradoxical embolism lead to high incidence of embolic stroke.
Before repair prophylaxis for endocarditis is not indicated for isolated ASD’s. Following closure 6 mos of prophylaxis for endocarditis.

9. #18 24 y. o. female emigrated from Phillipines eval for murmur. HR 82
# y.o. female emigrated from Phillipines eval for murmur. HR 82. O2 sat 97%. JVP normal. Carotid pulses brisk with rapid upstroke. Lungs clear. Sustained apical impulse in 6th intercostal space. S1 normal. S2 physiologically split with normal P2. A soft S3 is audible. Continuous murmur with crescendo-decresendo quality is heard throughout, loudest 3rd left intercostal space. Diagnosis?
Mitral regugitation
Mitral stenosis and insufficiency
Pulmonary stenosis and insufficiency
Patent ducts arteriosus

10. Patent ductus arteriosus
In acyanotic adult with patent ductus communication is usually small. Murmur soft and confined to systole.
Most adults with large patent ductus have Eisenmenger’s physiology and are not surgical candidates.
Closure is indicated if associated with a murmur to prevent the complications of endarteritis.
Closure percutaneously with coil.

11. PFO —patent foramen ovale.
Persist in 20% of people.
Can be associated with interatrial septal aneurysm.
Can be diagnosed by contrast echo.
Risk for paradoxical embolism.
The specific indications for closure of a patent foramen ovale after a cerebral embolic event remain unclear

12. #43 26 y. o. man diagnosed with heart murmur as a baby
# y.o. man diagnosed with heart murmur as a baby. Told he would outgrow it. Participates in sports without problem. 120/80, 64. Lungs clear. Nondisplaced apical impulse. Normal S1, physio split S2. Thrill in 3rd left intercostal space and 4/6 holosystolic murmur noted radiating to the right. Echo small perimembranous VSD. Normal chamber size and normal PA pressures.
Refer to surgeon for closure
Treat with amoxicillin 2 gm 1 hour before dental procedures
Refer for percutaneous closure
Initiate lisinopril therapy

13. #43 Treat w/ amoxicillin 2 gm 1 hour before dental procedures
Ventricular Septal Defect
In acyanotic adult VSD usually small
Large VSD present in childhood with CHF or pulmonary hypertension
Most common location in adults is perimembranous near tricuspid valve
Indications for closure in adulthood are large shunt fraction 1.7:1 or greater or left ventricular volume overload (LV overload occurs because shunt is primarily confined to systole and the RV serves as a reservoir for the shunted blood The LV diastolic volume is increased because the stroke volume includes both forward flow and shunted flow)
Exam with hemodynamic sig VSD may reveal displaced apical impulse, mitral diastolic rumble, S3.

14. Endocarditis Risk and Prophylaxis In Congenital Heart Disease
Risk of endocarditis is substantial except in operated patients with pulmonary stenosis, ASD, VSD, PDA. If residual VSD or PDA leaks present postoperatively, risk persists.
Antibiotic prophylaxis is indicated for almost all patients with unoperated congenital heart disease (except isolated ASD)
ASD—before repair no prophylaxis indicated unless other coexisting abnormalities. Prophylaxis for first 6 mos post repair and indefinitely if residual abnormalities.

15. #59 45 y. o. known Eisenmenger’s b/c of unrepaired VSD
#59 45 y.o. known Eisenmenger’s b/c of unrepaired VSD. Increased lethargy, frontal headache, and difficulty concentrating. Previous PMD phlebotomized 1 unit every 3 mos. Cyanotic, 95/65, 95, 84%. Clubbing. Clear lungs, nl JVP. Widely physio split S2, loud P2. Holosystolic murmur at left parasternal border. High pitched diastolic murmur at upper left sternal border. Right sided S4. HCT 56%, MCV 72. WBC PLT 110.

16. Symptoms suggest hyperviscosity, they may be caused by iron deficiency
Symptoms suggest hyperviscosity, they may be caused by iron deficiency. Microcytic erythrocytes are rigid and not easily deformed. Thus viscosity increases paradoxically at lower hematocrit.

17. Eisenmenger’s Syndrome and Erythrocytosis
Seconday erythrocytosis is compensatory and usually not associated with symptoms.
Hyperviscosity syndrome can occur when HCT >65. Phlebotomy is indicated only to treat symptoms.
Be sure not iron deficient and not volume depleted.
When phlebotomy is necessary, follow by isovolumic saline repletion (in presence of CHF use 5% dextrose)
Pregnancy contraindicated. Maternal mortality excceds 50% with death usually in early postpartum period.

18. # 89
35 y.o. female hypertensive. Told had hypertension at age 20 as well but did not follow up. BP 200/100. S1. S2 physio split. An early systolic ejection sound is noted and early peaking murmur noted in second right intercostal space. Short diastolic murmur along LSB. U/A normal.
Measure TSH
Measure BP lower extremities
Order Echo
Order 24 HR urine test for metanephrine and vanillylmandelic acid
Obtain CXR

19. Coarctation of the aorta
#89 Measure BP lower extremities
Coarctation of the aorta
Radial femoral delay
Lower blood pressure in the legs
Rib notching (dilated intercostal arteries that provide collateral blood flow)
Repair indicated when there is proximal HTN and a gradient exceeding 20 mm Hg
Discrete coarctation is usually amendable to percutaneous repair while longer segments may require surgery

20. Cardiac Disease And Pregnancy

21. #11 25 y.o. pregnant female presents with heart murmur noted second trimester. First pregnancy. New murmur. No PMH. Asymptomatic. Mild displaced apical impulse and lower extrem edema. S1 and S2 normal, S3 at apex. 2/6 early to mid peaking systolic murmur at left sternal border. Likely cause of murmur?
Bicuspid aortic valve with mild to mod AS
Congenitally abnl pulmonary valve with mod stenosis
Physiologic murmur related to pregnancy
Bicuspid aortic valve with moderate regurgitation

22. PHYSICAL FINDINGS AND PREGNANCY--
#11 physiologic murmur
PHYSICAL FINDINGS AND PREGNANCY--
S3 audible in more than 80% of normal pregnant women
Early peaking ejection systolic murmur audible in 90%--pulmonary outflow murmur
Increased blood volume during pregnancy
(CO increases by 30 to 50% during pregnancy and to about 80% above baseline during labor and delivery)
Apical impulse displaces
Lower extremity edema common
Abnormal findings---S4, loud 3/6 systolic murmur, diastolic murmur, fixed splitting of S2.
In general, fixed obstructive lesions (MS, AS) poorly tolerated in pregnancy—increased blood volume.
Regurgitant lesions well tolerated—decreased SVR

23. # y.o. pregnant female referred for eval of persistent dyspnea secondary to MS. 30 weeks pregnant and dyspnea persists after metoprolol, lasix, and digoxin. HR 70. Echo severe MS, mean grad 14, valve area 1 cm2. Trivial MR. RV systolic 50 mmHg. Crackles and edema. What do you recommend?
Surgical mitral valvotomy
Urgent delivery fetus then reassessment of maternal cardiac status
TEE followed by percutaneous mitral balloon valvuloplasty
Diagnostic catheterization
Fetal Echocardiogram

24. # 20 TEE followed by percutaneous mitral balloon valvuloplasty
Percutaneous valvuloplasty treatment of choice in pregnant women with severe MS whose sx can’t be controlled with meds.
TEE to eval Mitral valve aparatus and eval for LA thrombus
Abdominal shielding to limit radiation to fetus (Avoid during first trimester)
Cardiac surgery can be performed during pregnancy but should be avoided unless absolutely necessary (best time weeks) (Maternal mortality 1-5%, fetal 15-38%)

25. #30 28 y. o. female 29 weeks pregnant referred for progressive dyspnea
# y.o. female 29 weeks pregnant referred for progressive dyspnea. h/o rheumatic fever and mitral stenosis. 4 wk increase dyspnea. No palpitations. Elevated JVP. HR Parasternal impulse present. Opening snap and grade 2 diastolic rumble….EKG sinus tach, LAE, RAD.
What do you recommend?
Digoxin
Metoprolol
Warfarin
Ramipril
amlodipine

26. #30 metoprolol to slow HR, increase diastolic filling time.
If sx persist then diuretic
Note: ACE I, ARB contraindicated in pregnancy

27. # y.o. female 39 weeks pregnant comes to office increasing dyspnea. No prior PMH. First pregnancy. JVP 13, diffuse apical impulse, apical systolic murmur. S3 and S4. Crackles. EKG tachy.
Diagnosis?
Severe AS
Severe TR
ASD
Peripartum cardiomyopathy
Pulmonary embolism

28. #38 Peripartum Cardiomyopathy
1:1,300 to 1:15,000 pregancies in US, higher in certain parts of Aftrica
Risk increased in: African Americans, multiple gestations, multiparous, women age >30 years, h/o peripartum cardiomyopathy
Usually occurs during last trimester pregnancy or in first 6 mos post partum (Most commonly diagnosed in first post partum month)
50% of women with peripartum cardiomyopathy will have improvement in LV function within 6 mos after delivery.

29. Delivery is recommended
Unless obstetric reasons for c-sec mode of delivery should be vaginal because of lower hemodynamic burden
Because risk of recurrence of peripartum cardiomyopathy is common repeated pregnancy is “contraindicated”—pt’s with persistent LV dysfunction and pts with h/o serious episode should be counseled to avoid repeat pregnancy

30. Cardiomyopathy and Pregnancy Notes on medical therapy
NO ACEI, ARB during pregnancy. (in animals fetal hypotension and death. Also early delivery, low birth weight, oligohydramnios, neonatal anuria and renal failure)
Digoxin and hydralazine are considered safe during pregnancy and breast feeding.
Diuretics can be used if sx not controlled by decreased salt and central venous pressue elevated. Most experience with thiazides and lasix. (diuretics impair uterine blood flow and placental perfusion).
Metoprolol, atenolol, labetalol have been used safely in pregnancy—fetal monitoring recommended for risk of intrauterine growth retardation and fetal bradycardia.

31. #58
35 y.o. female who has progressive dyspnea days after delivery. EF 20%. Treated ACEI, diuretic, B-blocker. Sx resolve. 12 mos after delivery asymptomatic and EF 50% off meds. She comes to you for counseling re: repeat pregnancy.
Advise her that she may proceed
Resume ACE I during pregnancy
Advise her not to become pregnant b/c of risk of recurrent peripartum cardiomyopathy that may be fatal
Evaluate for another cause of cardiomyopathy b/c diagnosis of peripartum cardiomyopathy is now in question

32. Regarding cardiomyopathy in general and pregnancy:
#58 Advise her not to become pregnant b/c of risk of recurrent peripartum cardiomyopathy that may be fatal
Because recurrence of peripartum cardiomyopathy is common, repeated pregnancy is contraindicated.
Regarding cardiomyopathy in general and pregnancy:
Avoid pregnancy is LVEF is less than 40% or NYHA functional class is higher than II.
Bed rest is often required and close cardiac and obstetric monitoring mandatory
Treating CHF is more difficult in pregnant than in nonpregnant women.

33. #104 28 y. o. female with aortic and mitral mechanical prosthesis
# y.o. female with aortic and mitral mechanical prosthesis. INR therapeutic. Pre-pregnancy consult.
Discontinue warfarin and treat with ASA and dipyridamole during first trimester
Continue warfarin through pregnancy and start heparin 5000 U SQ TID plus ASA
d/c warfarin and treat with enoxaparin 30 mg SQ BID through pregnancy
d/c warfarin and initiate dose adjusted unfractionated heparin SQ during first trimester and resume treatment with warfarin for rest of pregnancy until shortly before delivery
Use clopidogrel and ASA for first trimester and warfarin for rest of pregnancy until shortly before delivery

34. Anticoagulation and Pregnancy
initiate dose adjusted unfractionated heparin SC during first trimester and then resume treatment with warfarin
Anticoagulation and Pregnancy
During pregnancy increased risk of thombosis or embolism
Pregnant women with mechanical heart valve have a 10% risk for development of prosthetic valve thrombosis or another life threatening complication
Data are limited on safety of various anticoagulation regimens and controversy persists

35. Anticoagulation and Pregnancy
Heparin does not cross the placenta
12-24% incidence of thromboembolic complications including valve thrombosis in high risk pregnant patients treated with SQ unfractionated heparin
Efficacy of dose adjusted SQ heparin not established. Dose should be adjusted so that PTT is at lesat 2-3 times control value 6 hours after adminstered.
Heparin may not provide sufficient anticoagulation for very high risk patients (caged-ball or tilting disk--Bjork Shiley--mechanical prosthesis)
Prolonged heparin can lead to thrombocytopenia, osteoporosis, alopecia

36. Warfarin does not enter breast milk
Warfarin crosses the placentafetal anticoagulationrisk of spontaneous abortion, prematurity, fetal deformity, stillbirth, retroplacental hemorrhage and intracranial hemorrhage.
Historic reports 30% (more recent data 4-10%) risk warfarin embryopathy— bone and cartilage abnormalities, nasal hypoplasia, optic atrophy, blindness, retartdation, seizures--with use in first trimester.
risk highest if exposure during 6th to 12th wk.
Low risk if less than 5 mg QD warfarin dose.
Warfarin does not enter breast milk

37. Current Recommendations
for anticoagulation
during pregnancy
C-section if labor occurs during warfarin anticoagulation due to risk of fetal intracranial hemorrhage.

38. Anticoagulation and pregnancy … Low Molecular Weight Heparin
Currently data insufficient to support use LMWH during pregnancy.
It does not cross placenta and no teratogenic effects reported.
6th ACCP conf supports use of LMWH throughout pregnancy except 24 hrs before delivery when recommendation is IV unfractionated heparin.
However FDA changed labeling to state enoxaparin not recommended for prosthetic valves during pregnancy.

39. More notes on Anticoagulation and pregnancy…
Dipyridamole should not be used during pregnancy (no data on clopidogrel or ticlopidine)
Information limited on IIbIIIa inhibitors during pregnancy
81 mg ASA safe during pregnancy—recommended for patients with shunts, cyanosis, or biologic-valve prosthesis
(A low dose of ASA may also decrease the incidence of preeclampsia.)
Thombolytic therapy has been used in pregnancy in emergency

40. #68 26 y. o. female 30 weeks pregnant murmur noted during pregnancy
#68 26 y.o. female 30 weeks pregnant murmur noted during pregnancy. Asymptomatic. Slight elevated JVP. Parasternal lift. S1 normal. S2 prominent, fixed split. Grade 2 mid peaking ejection murmur LSB. Echo secundum ASD with RV enlargement. 8 weeks later in labor. What do you recommend?
Full anticoagulation in postpartum period
Hemodynamic monitoring during delivery
ABX propylaxis during delivery
Early post partum ambulation
Delivery by c-section

41. #68 Early post partum ambulation
Decrease risk of DVT paradoxical embolism

42. #47 26 y.o. 30 weeks pregnant murmur during pregnancy and intermittently in past. Asymptomatic. Slight elevation JVP with an A wave. Parasternal lift is noted. S1 normal S2 prominent, fixed, split. Grade 2 mid peaking ejection systolic murmur at LSB. What is most likely Dx?
Physiologic murmur of pregnancy
ASD with volume overload
Pulmonary valve stenosis
Aortic regurgitation
Mitral stenosis

43. # 47 ASD with volume overload
Other notes on congenital heart disease in pregnancy
Congenital heart disease is the most common form of structural heart disease that affects women of childbearing age in US
Pregnant cyanotic women have a high risk of fetal loss. Cyanosis is a recognized handicap to fetal growth, resulting in low birth weigh infants
The incidence of congenital heart disease in offspring of women with congenital heart disease is about 5 %.

44. #91 20 y. o. female in first trimester progressive dyspnea
#91 20 y.o. female in first trimester progressive dyspnea. Acyanotic woman with parasternal lift and loud P2. No S3 or S4. No murmur. EKG tall P waves II, III, F and tall R in V1 and RAD. What is most likely dx?
Severe pulmonic valve stenosis resulting in RV pressure overload
Primary pulmonary hypertension
Large ASD causing RV enlargement and pulm HTN
Severe mitral stenosis

45. #91 Primary pulmonary hypertension.
ASD and VSD that result in severe pulm HTN cause cyanosis.
In pulm stenosis P2 would be diminished or absent.
Need to exclude secondary causes pHTN.

46. Severe pulmonary hypertension in pregnancy
PA pressure >70% systemic
Whether secondary or primary carries 30-50% risk of maternal death.
If pulmonary hypertension identified counsel against pregnancy
Termination of pregnancy should be considered.

47. #98 20 y. o. in first trimester of pregnancy progressive dyspnea
# y.o. in first trimester of pregnancy progressive dyspnea. You diagnose severe pulm HTN. TEE excludes shunt. What is associated with lowest risk of maternal mortality?
Termination of pregnancy
Initiation of prostacyclin therapy
Intiation of bosentan therapy
Initiation of anticoagulation
Initiation of ACEI therapy

48. #98—termination of pregnancy Cardiac contraindications to pregnancy“ ”
Severe pulmonary HTN is an absolute contraindication to pregnancy % risk maternal death.

49. Indications for C-section in women with Cardiovascular Disease
Obstetric reasons
Anticoagulation with warfarin
Controversial Reasons
Fixed obstructive cardiac lesion
Pulmonary hypertension
Unstable aortic lesion
Vaginal delivery is the preferred mode of delivery in most women with heart disease.
____________________________

50. Valvular Heart Disease

51. #15
21 y.o. female, murmur on screening exam. No PMH. Runs 3-8 miles daily for cross country. No syncope. SOB with windsprints. No FH sudden death. HR 52. BP 98/60. 2/6 cresendo decresendo murmur loudest LUSB. Which would suggest need for echo?
Murmur decreases in intensity with valsalva
SOB with unusual exercise
Soft S3
Murmur peaks in intensity in the latter half of systole
A split S1

52. #15 Murmur peaks in intensity in the latter half of systole
Late-peaking suggests LV outflow obstructionfurther testing.
Murmur of dynamic subvalvular LV outflow obsturction (hypertrophic cardiomyopathy) increase with valsalva.
AS and PS and MR and TR diminish during valsalva.
Intensity of innocent flow murmurs also diminish during valsalva.
Flow murmurs peak in the first half of systole
An S3 is common in children and young adults

53. Echo for evaluation of murmurs

54. Murmurs…. VSD: pansystolic, palpable thrill may be associated
PDA: continuous, machinery-like
Increase with Inspiration
TR, TS, PS (right sided murmurs)
Increase with Handgrip
Mitral regurgitation
Aortic Stenosis
Decrease with handgrip, decrease with standing, decrease during valsalva
Hypertrophic Obstructive Cardiomyopathy
Decrease with handgrip, increase with standing, increase during valsalva

55. 63 y.o. male farmer. 3/6 holosystolic murmur at apex heard throughout and louder at left sternal border. LV displaced laterally. HR 94. BP 136/80. ASYMPTOMATIC. Echo--myxomatous degeneration MV with partial flail posterior leaflet. LV enlarged. LV EF 52%.
Surgery if LV dilated 8 weeks after ACEI
Surgery if MIBI normal
Surgery if TEE shows repairable valve
Surgery despite lack of symptoms
Surgery contraindicated based on presence of LV dysfunction

56. Chronic severe MR w/ LV dysfunction --Surgery despite lack of symptoms
Indications for surgery in chronic severe mitral regurgitation
Symptoms
Left ventricular systolic dysfunction (EF<60%, endsystolic diameter>45mm)
Atrial fibrillation
Pulmonary hypertension
Intervention for chronic severe MR should be considered earlier if successful mitral valve repair is likely

57. Chronic Mitral regurgitation
Organic: Myxomatous degeneration, rheumatic, infective endocarditis …
“Functional”: Dilated cardiomyopathy, ischemic (prior MI)
Chronic left ventricular volume overload
Forward CO preserved by LV dilation at expense of increased wall stress

58. Chronic Mitral regurgitation
Vasodilators improve hemodynamics in acute MR, role in chronic MR not adequately studied. Thus routine use in asymptomatic pts not recommended. If HTN present, then vasodilator. And, in pts with functional MR complicating cardiomyopathy, afterload reduction is indicated.
In anorectic drug (fenfluramine and dexfenfluramine) induced MR (or AR) regurgitation appears to regress in the first year after discontinuation of exposure.

59. # 51. 54 y. o. female evaluated for exertional dyspnea
# y.o. female evaluated for exertional dyspnea. Orthopnea for mos. Rheumatic fever as a child. No palpitations. HR 86, BP 124/76. JVP 14. Bibasilar rales. Regular rhythm, diminished S1, widely split S2. 3/6 holosystolic murmur at apex radiating to axilla. 2/6 holosystolic murmur at LLSB increases with inspiration. 2/6 decresendo diastolic rumble at apex. EKG sinus, RVH, BAE. Echo-- BAE, normal LV size and fxn. RVE, normal fxn. Mitral leaflets thickened and restricted. Minimal leaflet Ca++ and mild to mod subvalvular thickening. Mean grad 11 and valve area 0.9 cm2. Severe MR and TR noted. RV systolic 62 mmHg. Best course of action?
Digoxin
ASA
Anticoagulation INR 2-3
Percutaneous balloon mitral valvotomy
Refer for mitral valve repair or replacement

60. Interventions Mitral Valve
# 51 mitral valve repair or replacement
Interventions Mitral Valve
Percutaneous balloon mitral valvotomy:
Pliable, non-calcified valve, </= 2+ MR, no other cardiac intervention required
(3 or 4+ MR, LA thrombus contraindications)
Open commissurotomy
Relatively pliable noncalcified valve, any amount MR, no other cardiac intervention required
MVR
Calcified nonpliable valves
In pregnant women, ballon valvotomy associated with fewer fetal complications than open commussurotomy

61. Mitral Stenosis Often due to previous rheumatic heart disease
Normal MVA Mod MS 1-1.5, Sev MS<1cm2.
MS exacerbated by a.fib, exercise, stress, fever, pregnancy (b/c increased HR leads to shorter diastolic filling period)
Abx prophylaxis against endocarditis and rheumatic fever (at least 10 yrs after last episode or until age 40, lifetime in high risk (ie. teachers), salt restriction, diuretics, negative chronotropic (prolong filling period) agents. Anticoagulation if a.fib or prior thomboembolus.
Echo if change in symptoms. Mild to mod pHTN (PASP >40) may be indication for more frequent follow up.

62. #80
36 y.o. with substernal chest pressure. 2 mos progressive fatigue, dysnea, palps. 2 hours began CP to jaw, SOB. BP 110/90. HR 110 and irregular. Elevated JVP, crackles, irregular, accentuated P2. diastolic rumble at apex. EKG a.fib, RBBB, RAD, ST elevation V2-5. Cause?
CAD plaque rupture
Coronary thromboembolism from LV thrombus
Coronary thromboembolism from LA thrombus
Coronary arteritis
Coronary vasospasm

63. # 80 Coronary embolism from LA thrombus

64. # y.o. female with palpitations (heavy beat then pause) no associated sx. HR 72 BP 108/68. Mid systolic nonejection click. EKG sinus no preexcitation. Echo posterior leaflet prolapse with mild late systolic MR. Holter multiple PVC’s. Next step?
History and PE in 1-2 yrs
TEE
Lisinopril
Echo in 6 mos
Propafenone therapy

65. Mitral Valve prolapse Most patients with MVP have a good prognosis
#75 History and PE in 1-2 years
Mitral Valve prolapse
Most patients with MVP have a good prognosis
Patients with myxomatous disease are at risk for valve degeneration with MR
Endocarditis prophylaxis in patients with MR or leaflet thickening
MVP syndrome—palpitations and atypical chest pain

66. #23
76 y.o. male to your office for yearly exam. Over 6 mos decreased exercise tolerance—dyspnea and CP uphill. No SOB at rest. No syncope. CAD. Lipids. h/o stent. ASA. Lipitor. HR 82. BP 142/82. 3/6 cresendo decresendo systolic RUSB to carotids. Delayed upstroke of pulse. Echo LVH, nl fxn. Peak aortic 86, mean 44. Mid RCA 70% cm2.
What is the best course of action?
Refer AVR and CABG
Refer valvotomy and PTCI
DP MIBI
Exercise testing
No intervention

67. # 23 AVR plus CABG
# y.o. male CHF. LV impulse enlarged and lateral. Late peaking cresendo decresendo systolic murmur. Echo global LV dysfunction. EF 20-25%. AV calcified decreased opening. Peak grad 26 mean 16. What test next?
TEE
Exercise stress test with EKG
Dobutamine stress echo
Adenosine MIBI

68. Aortic valve gradients depend on flow
# 116 Dobutamine stress echo
Low gradient Aortic Stenosis
Aortic valve gradients depend on flow
Patients with LV dysfunction have increased perioperative risk
An increase in aortic gradients in setting systolic augmentation of LV suggests AS is severe. (AVR better long term survival than med if severe AS and contractile reserve)
Contractile reserve without an increase in gradients suggest that stenosis is not severe.
Lack of contractile reserve suggest a poor prognosis after AVR. (AVR worse long term survival than meds if no contractile reserve)

69. More notes on Aortic Stenosis …
Asymptomatic patients with severe AS have a good prognosis
Severe AS valve area <1.0cm2, mean gradient >50 mmHg.
Consider patient size. Valve area of 0.45cm2/m2 is severe.
Echo follow up in asymptomatic AS
Every 5 years mild
Every 2 years moderate
Every year severe (to detect development asymptomatic LV dysfunction)

70. More notes on Aortic Stenosis …
AVR in symptomatic patients with severe AS.
Consider AVR in asymptomatic patients with severe stenosis AND left ventricular dysfunction, marked LVH, hypotension on exercise testing, or moderate or greater valve calcification and a rapid increase in aortic jet velocity.
Added risk for noncardiac surgery in severe symptomatic AS (mortality rate as high as 10%)
if elective AVR first,
if not surgical (AVR) candidate percutaneous valvuloplasty may be considered
If severe AS but asymptomatic noncardiac surgery can be performed with close intraoperative monitoring with only slightly increased risk.

71. # 66 36 y. o. man to ICU with abrupt hypotension and hypoxemia
# y.o. man to ICU with abrupt hypotension and hypoxemia. Intubated , 121, 88/30, pulm edema. Regular with summation gallop. No murmur. TTE inadequate. TEE bicuspid AV partially destroyed with vegetations. Severe AI. Normal LV fxn. You start abx. Which is indicated?
B-blocker
Nitroprusside
Intraaortic balloon pump
Cath and coronary arteriography
Transfer for surgery for emergent AVR

72. (#66 Nitroprusside)
After load reducing therapy with or without inotropic support to optimize forward cardiac output
IABP contraindicated in aortic regurg
Depending on response to intensive medical intervention patient may require urgent surgery. If surgery can be deferred to allow a period of therapy with ABX early postop infection after AVR is less likely.

73. Notes on acute valve regurgitation
Patients with acute severe AR or MR are symptomatic and may present with cardiogenic shock
Many physical findings of chronic severe regurgitation are NOT present in patients with acute severe regurgitation
Diagnosis is with echo
IABP useful in acute severe MR but contraindicated in AR
Urgent or emergent surgical intervention is usually indicated in acute mitral or aortic regurgitation

74. # 85 86 y. o. female evaluated for recent abrupt onset dyspnea
# y.o. female evaluated for recent abrupt onset dyspnea. She had a bioprosthetic AV placed 16 years ago for calcific AS. No fever. Harsh cresendo decresendo systolic murmur at RUSB to carotids. What is cause of SOB?
Prosthetic valve failure
Paraprosthetic leak
Thrombus formation
Mitral stenosis and mitral regurgitation
Infective endocarditis

75. #85 Prosthetic valve failure After 16 yrs valve at risk for failure, cuspal calcification and then fracture leading to acute AR. Intuitively should expect diastolic murmur. However murmur of AR may not be prominent whereas the increase in stroke volume across calcified bioprosthesis is more audible. Thombosis not likely in bioprosthetic valve placed years earlier.
KEY POINT—In patients with prosthetic valves and new/changed cardiac symptoms, need to evaluate valve.

76. # y.o. female for f/up AVR 3 mos ago for congenital bicuspid aortic valve. No a.fib or thromboembolism. Echo shows normal mechanical aortic valve.
Coumadin INR 2-3
INR
INR 2-3 plus ASA 100 mg
INR plus ASA 100 mg
ASA 650 mg QD

77. #100 INR 2-3. Prosthetic Valves

78. Preoperative Cardiac Evaluation

79. ACC/AHA Guidelines.
The need for preoperative testing is determined by:
1)Clinical predictors of the patient (minor/intermediate/major).
2)Risk of the surgery (low/intermediate/high).
3)Patient’s functional status (</> 4 METS).
Remember that all patients requiring emergent surgery go to the OR immediately regardless of cardiac risk.
Don’t forget benefit of Beta-blockade to goal HR 60

80. Patient Clinical Predictors

81. Risk of Surgery

82. Functional Capacity

86. Shortcut to noninvasive testing in preop patients if any two factors are present
Intermediate clinical predictors (class 1 or 2 angina, prior MI based on Q’s, compensated or prior heart failure, diabetes, or renal insufficiency)
Poor functional capacity
High risk surgery (emergency—may not have a choice---,aortic repair, peripheral vascular surgery, prolonged surgical procedures with large fluid shifts or blood loss)