Sunday, 16 February 2020

ACQUIRED HEART DISEASES

EXTRACORPOREAL PERFUSION

- venous cannulae, a venous reservoir, pump, oxygenator, filter, and the arterial
cannula

- 300 to 400 units/kg of heparin

• heparin anticoagulation is reversed with 1 mg protamine per 100 units of heparin

and hemostasis is achieved

- distal ascending thoracic aorta is the most common site of cannulation

- At normothermia, the flow required is approximately 2.4 L/min/m2

- with hypothermia, oxygen consumption is reduced by 50% for every 10°C drop in
temperature, and a flow of only 1 L/min/m2 is required at 18∞C.

- cardioplegic solutions for myocardial protection: potassium-rich solutions

VALVULAR DISEASE

- Diastolic and continuous murmurs are usually pathologic

- gold standard for the evaluation of valvular heart disease is transthoracic

echocardiography

- biological prosthesis is generally preferred in patients without other indications for

anticoagulation therapy who are >60 years of age for the aortic position and >70
years of age for the mitral position

- mechanical valves necessitate systemic anticoagulation = have a target INR of 2 to 3

times normal

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MITRAL VALVE

- Stenosis

• by rheumatic fever

• left atrium becomes dilated and hypertrophied due to increased work in filling the
ventricle against a fixed obstruction

• Atrial fibrillation (AF) may develop

- Regurgitation

• due to myxomatous degenerative disease

• retrograde flow of a portion of the LV stroke volume into the left atrium during
systole due to an incompetent MV or dilated MV annulus

• holosystolic or absent, with a third heart sound and/or diastolic flow murmur

AORTIC VALVE

- Stenosis

• calcification of a normal tri leaflet or congenital bicuspid aortic valve

• harsh, crescendo-decrescendo systolic murmur at the right second or third

intercostal space

- pulsus parvus et tardus

- prolonged heave

- Insufficiency

• produces volume overload with dilation and hypertrophy of the left ventricle and
subsequent dilation of the MV annulus

• fibrous infiltration of the valve cusps and subsequent retraction of the valve

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leaflets, inhibiting apposition of the cusps during diastole and producing a central
regurgitant jet

• angina is the most common complaint

• Corrigan’s water-hammer pulse

TRICUSPID VALVE

- stenosis (TS) is almost always a result of rheumatic heart disease or rarely

endocarditis

- insufficiency secondary to dilation of the tricuspid annulus due to pulmonary

hypertension and/or right heart failure

- jugular venous distention, hepatomegaly, splenomegaly, ascites, and lower extremity

edema

MECHANICAL CIRCULATORY SUPPORT

- IABP

• inflates during diastole and deflates during systole —> augmentation of diastolic
perfusion of the coronary arteries —> decreased afterload —> decreases both
preload and myocardial oxygen consumption.

• incidence of limb ischemia (most common complication)

ATRIAL FIBRILLATION

- most common arrhythmia

- most common complication:

thromboembolism with resultant
stroke

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ACUTE PERICARDITIS

- infiltration of the cellular and fibrous pericardium by inflammatory cells

- pain (sharp and stabbing) may also be positional, with alleviation of pain when the
patient is upright and leaning forward

- pain uniquely radiate to the trapezius ridge due to innervation from the phrenic nerve

- friction rub is at the left lower sternal border

- usually conservative management (NSAIDs + colchicine)

- pericardiectomy for relapsing pericarditis.

CHRONIC PERICARDITIS

- chronic pericarditis vs restrictive cardiomyopathy = non-dilated ventricle with a rigid

myocardium that causes a significant decrease in myocardial compliance

- jugular venous distention with Kussmaul’s sign, diminished cardiac apical impulses,
peripheral edema, ascites, pulsatile liver, a pericardial knock

- CVP is often elevated 15 to 20 mmHg or higher

CARDIAC NEOPLASMS

- left atrium: mimic mitral valve disease with dyspnea and pulmonary edema; syncopal
episodes, hypotension, and sudden cardiac death

- right atrium: hepatomegaly, ascites, and peripheral edema

- malignant (sarcoma): do not demonstrate a gender preference and tend to present

after the fourth decade of life. They are often multifocal within the right atrium, and
intramyocardial invasion

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- benign (myxoma): typically unifocal in the left atrium, have a 3:1 female preference,
and occur in younger patient

- MRI is the gold standard for dx

- in children, rhabdomyomas are the most common primary cardiac tumor

- fibromas are the most commonly resected cardiac tumor