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Acquired Heart Disease Edited2
Acquired Heart Disease Edited2
Acquired Heart Disease Edited2
Disease
Dr. Aulia janer
Supervised by :
Dr. Juli Ismail, Sp.B, Sp.B TKV
Cardiac Assesment
History
Symptoms
:
Chest
discomfort,
fatigue,
edema,
dyspnea,
palpitations, and syncope
paying particular attention
to
onset,
intensity,
radiation, duration, and
exacerbating/alleviating
factors
Beware
diabetics,
females, and the elderly
silent angina
Functional
Disability and
Angina
Physical Examination
General appearance : pale, diaphoretic, and
obviously uncomfortable patient
Vital sign, mental status, skin
Palpation : deviation punctum maximum
Auskultation: murmur, rubs, gallop
Extracardiac manifestations and examination of the
other organ systems should not be neglected
for
further evaluation and risk
management
risk factors are:
history of ischemic heart
disease
history of prior or
compensated heart
failurehistory of
cerebrovascular disease
diabetes mellitus
renal insufficiency
Diagnostic Studies
Electrocardiogram
and Chest X-ray
Echocardiography
Radionuclide Studies
myocardial
perfusion imaging
Magnetic Resonance
Imaging
Cardiac
Catheterization
Cardiac Computed
Tomography
Diagnostic Studies
ECG & Chest xray
Non invasive, simple
useful in detecting old myocardial infarction, dilation or hypertrophy of
cardiac chambers, arrhythmias, and conduction Abnormalities
Xray detect pulmonary pathology, sequelae of heart failure (e.g.,
pulmonary edema, cardiac enlargement, pleural effusions)
Echocardiography
Diagnostic Studies
Magnetic Resonance Imaging
global chamber function and valvular pathologies
contrast agents such as gadolinium can enhance scar
tissue and are very useful in viability assessment
Cardiac Catheterization
access to the cardiac chambers and great vessels with a peripherally inserted catheter under
fluoroscopic guidance
the gold standard for the assessment of coronary artery disease
cardiac chamber pressures, valvular abnormalities, wall motion assessment, and coronary artery
anatomy
LH percutaneous access of the femoral, or less commonly, the radial artery
RH Pheripheral vein, Jugular
Opportunity for interventional therapy
EXTRACORPOREAL PERFUSION
History
John
Gibbons
cardiopulmonary bypass
(CPB) 1953 repair a
large atrial septal defect
in an 18-year-old female
Bubble oxygenators
Now a day search for
minimal
inflammatory
effect
Technique CPB
The basic CPB circuit consists of the venous cannulae, a
venous reservoir, pump, oxygenator, filter, and the arterial
cannula
Anticoagulation is required during CPB, and 300 to 400
units/kg of heparin CT 450
Distal ascending aorta, femoral artery, axillary artery, or the
distal aortic arch
Arterial cannulation is performed through a purse-string
suture, or through a side graft which is sewn on to the
native artery
Venous cannulation Purse-string sutures right atrium
single cannula or for two separate cannulae extending into
the superior and inferior vena cava, respectively
Alternative : femoral vein and right atrium
Technique CPB
Flow 2,4L/min/m2 Normothermia
with hypothermia, oxygen consumption is reduced by
50% for every 10C drop in temperature, and a flow of
only 1L/min/m2 is required at 18C.
The oxygenator PaO2 150 mmHg and normocarbia
After procedur : rewarm, lung ventilated, heart
defibrillated.
venous return to the CPB machine is gradually
reduced allowing the heart to fill
Inotropic and vasopressor support
The heparin anticoagulation is reversed with
protamine and hemostasis is achieved
Adverse Effects
Derangements in hemostasis Anticoagulation prior to
the commencement of CPB is required
Generation of thrombin plays a major role in both thrombotic and
bleeding phenomena during CPB
heparin induced thrombocytopenia and thrombosis (HITT)
Myocardial Protection
Pharmacologic agents cardioplegic cardioplegia consists
of potassium-rich solutions that can be mixed with
autologous blood and are delivered into the coronary
circulation
Antegrade cardioplegia is delivered into the root of a crossclamped aorta or directly into the individual coronary ostial
via specialized catheters.
Retrograde cardioplegia catheter is a balloon-cuffed catheter
that is placed through the right atrium into the coronary
sinus and is used to perfuse the coronary circulation in the
opposite direction through the venous circulation
Most surgeons in the United States favor cold blood
potassium cardioplegia
Clinical Manifestations
Spectrum of presentations:
angina pectoris pain or discomfort substernal radiate to
left upper extremity, left neck, or epigastrium
myocardial infarction
ischemic heart failure
Arrhythmias
sudden death
Intervention vs.
Coronary Artery Bypass
Grafting
The New York State Study (2005) CABG
was associated with higher adjusted rates of longterm survival than PCI
Stent or Surgery Trial (2008) The median
follow-up was extended to 6-years, and a survival
advantage persisted in the CABG group over the
PCI group
(ASCERT Study, 2012) PCI. There was no
difference in adjusted mortality at 1 year, but
there was a significantly lower mortality with
CABG than PCI at 4 years
Operative Techniques
Bypass Conduit Selection
Conventional Coronary Artery Bypass
Grafting
Off-pump Coronary Artery Bypass
Total Endoscopic Coronary Artery Bypass
Hybrid Coronary Revascularization
Transmyocardial Laser Revascularization
Surgical Options
valve replacement can be accomplished with
either mechanical or biological prostheses
Current options for mechanical valve replacement
include tilting disc valves and bileaflet valve
Mechanical vs biological ?
MS
Clinical manifestation
The first clinical signs of MS are those associated
with pulmonary venous congestion, namely
exertional dyspnea, decreased exercise capacity,
orthopnea, and paroxysmal nocturnaldyspnea
Hemoptysis,
jugular
venous
distention,
hepatomegaly, ascites, and lower extremity
edema
Diagnostic Studies
The diagnostic tool of choice is TTE
EKG, chest x-ray should perform
treatment
balloon valvuloplasty,
surgical commissurotomy or repair,
MV replacement may be indicated for the
treatment of MS
Mitral Regurgitation
Etiology :
myxomatous degenerative disease of the MV 2,4 %
rheumatic heart disease, infective endocarditis, ischemic
heart disease, and dilated cardiomyopathy
Pathology
Type I annular dilatation or leaflet perforation
Type II mitral valve prolapse
Type III restricted leaflet motion
Pathophysiology
basic pathophysiologic abnormality of MR is the
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
Clinical Manifestations
Exertional dyspnea, decreased exercise capacity,
orthopne
Pulmonary Congestion
cardiogenic shock
systolic murmur of MR may be holosystolic or absent
a third heart sound and/or diastolic flow murmur
Diagnostic Studies
Doppler TTE
EKG and chest X-ray
Coronary angiography should be performed prior to valve
surgery
Commissurotomy
Mitral commissurotomy is used to repair mitral
stenosis associated with rheumatic disease. The
commissuresopenings between the valve leaflets
are manually separated by the surgeon. Fused
chordae tendineae (cords of connective tissue that
connect the mitral valve to the papillary muscle of
the heart's left ventricle) are separated, along with
papillary muscles. Calcium deposits may be
removed from the valve leaflets. The left atrial
appendage is removed to reduce the risk of future
thromboemboli (blood clot) generation.
Treatment
Short course of nonsteroidal anti-inflammatory
agents (NSAIDs)
Steroid
Antibiotics
Surgical exploration and drainge
Pericardiocentesis if occure tamponade
Relapsing Pericarditis
one-third of patients with acute pericarditis will
develop at least one episode of relapse
Recurrence may develop either from the original
etiology or from an autoimmune process that
occurs as a consequence of damage from the
initial episode
Can be treated by NSAID (colchicine) and steroid
for rapid response
Even pericardiectomy if relapse with severe
symptom and no response to medication, also
have recurrence tamponade
Chronic Constrictive
Pericarditis
Can occur after any pericardial disease process,
idiopathic and after cardiac surgery, mediastinal
radiation, and pyogenic infectio. Tuberculosis in
immunocompromise patient
It resulted when chronic pericardial scarring and
fibrosis cause adhesion of the visceral and parietal
layers and resultant obliteration of the pericardial
space
Clinically pericardial contriction limits diastolic
filling of ventricel rise filling pressure mimic
RHF
Surgical Treatment
Transient constrictive pericarditis self limiting
only medical therapy
If hemodynamic was stable conservative
managemet for 2-3 months prior to a
pericardiectomy
Surgery approached in patients :
Very advanced end stage constrictive pericarditis
Mixed constrictive restrictive disease
Surgical result
following pericardiectomy, symptomatic relief may
take several months
Between 1970 and 1985, the operative mortality
was reported to be 12%
but a lower mortality of approximately 4% to 8%
was noted between 1977 and 2006 at several
experienced centers
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