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Cardiovascular Notes compiled for Pediatrics Cardiovascular (Med I, Block 3, CV) Contents CV 036 Valvular Heart Disease A CV Dr. J Tam CV 042 Valvular Heart Disease II T1 CV Dr. J Tam CV 044 Development of the Heart and Lung L AN Dr. M Torchia CV 045 Valvular Heart Disease III T5 CV Dr. J Tam CV 046 Congenital Heart Disease I A PD Dr. R Soni CV 048 Development of the Heart and Lung A AN Dr. M Torchia CV 049 Congenital Heart Disease II L PD Dr. R Soni CV 050 Congenital Heart Disease III T1 PD Dr. R Soni CV 075 Genetic Aspects of Cardiomyopathy L GN Dr. A Chudley CV 076 Acquired Pediatric Heart Disease L PD Dr. R Soni CARDIOVASCULAR COURSE: MED I BLOCK III Valvular Heart Disease I & II (CV036) OBJECTIVES: Assigned Reading to be completed prior to CV042 University of Manitoba –Faculty of Medicine Instructor: Dr. J. Tam Objectives: At the completion of these sessions, the student will be able to: 1. Describe the common etiology, pathology and pathophysiology of: a) aortic stenosis b) aortic regurgitation c) mitral stenosis d) mitral regurgitation e) tricuspid regurgitation 2. Apply the above knowledge to describe the clinical manifestations and physical findings of the above valvular abnormalities. 3. Describe the laboratory findings (chest x-ray, ECG, echocardiogram) that assist in the diagnosis of the above entities. 4. Relate the pathophysiology to therapeutic approaches (both medical and surgical). 5. Briefly discuss the indications for surgical intervention of valvular heart disease. 6. List the various surgical options – repair, mechanical replacement, bioprosthetic replacement, homograft replacement, autograft replacement. 7. Describe the acute and chronic pathologic changes with rheumatic heart disease. 8. Describe the common features of acute rheumatic fever. Knowledge from these sessions will be integrated with the Clinical Skills Program to allow students to: 1. Differentiate between innocent and pathologic murmurs. 2. Distinguish between regurgitate murmurs, flow murmurs and obstructive murmurs. 3. Assess the severity of valvular heart disease based on physical examination findings alone. References: Please feel free to find your own page references within Lilly, Cecil‟s and Harrison‟s textbook and any other sources of information that you feel are appropriate to allow you to understand the subject material. Also see notes for Valvular Heart Disease I. 1. Kirklin and Barratt-Boyes, Cardiac Surgery, 1993. 2. Glenn‟s Thoracic and Cardiovascular Surgery, 1996. 3. L. Henry Edmunds, Jr. Cardiac Surgery in the Adult, 1997. 4. Pascoe, Teskey, Bhattacharya. Surgical Treatment of Valvular Heart Disease. Manitoba Medicine; 1989: 59(2). 1 CARDIOVASCULAR COURSE: MED I BLOCK III Valvular Heart Disease I & II – CV042 OBJECTIVES University of Manitoba –Faculty of Medicine Instructor: Dr. J. Tam (2006) Objectives: NB: See assigned study CV036 At the completion of the sessions, the student will be able to: 1. Describe the common etiology, pathology and pathophysiology of: f) aortic stenosis g) aortic regurgitation h) mitral stenosis i) mitral regurgitation j) tricuspid regurgitation 2. Apply the above knowledge to describe the clinical manifestations and physical findings of the above valvular abnormalities. 3. Describe the laboratory findings (chest x-ray, ECG, echocardiogram) that assist in the diagnosis of the above entities. 4. Relate the pathophysiology to therapeutic approaches (both medical and surgical). 5. Briefly discuss the indications for surgical intervention of valvular heart disease. 6. List the various surgical options – repair, mechanical replacement, bioprosthetic replacement, homograft replacement, autograft replacement. 7. Describe the acute and chronic pathologic changes with rheumatic heart disease. 8. Describe the common features of acute rheumatic fever. Knowledge from these sessions will be integrated with the Clinical Skills Program to allow students to: 1. Differentiate between innocent and pathologic murmurs. 2. Distinguish between regurgitate murmurs, flow murmurs and obstructive murmurs. 3. Assess the severity of valvular heart disease based on physical examination findings alone. References: Please feel free to find your own page references within Lilly, Cecil‟s and Harrison‟s textbook and any other sources of information that you feel are appropriate to allow you to understand the subject material. Also see notes for Valvular Heart Disease I. 1. Kirklin and Barratt-Boyes, Cardiac Surgery, 1993. 2. Glenn‟s Thoracic and Cardiovascular Surgery, 1996. 3. L. Henry Edmunds, Jr. Cardiac Surgery in the Adult, 1997. 4. Pascoe, Teskey, Bhattacharya. Surgical Treatment of Valvular Heart Disease. Manitoba Medicine; 1989: 59(2). 2 Objectives • 1) Describe the common etiology, pathology and pathophysiology of : – aortic stenosis (we will cover today) VALVULAR HEART DISEASE – aortic regurgitation (we will cover today) – mitral stenosis (this is in your notes!!) – mitral regurgitation (we will cover today) – tricuspid regurgitation (do this on your own) James W. Tam, MD, FRCP(C), FACC • 2) Apply the above knowledge to describe the clinical manifestations and physical findings of Associate Professor of Medicine the above valvular abnormalities. (today and [email protected] on own) Objectives Objectives • 3) Describe the laboratory findings (chest X-ray, • 7) Describe acute and chronic changes with ECG, echocardiogram) that assist in the diagnosis of the above entities. (today and PR sessions) rheumatic heart disease • 4) Relate the pathophysiology to therapeutic • 8) Describe the common features of acute approaches (both medical and surgical). (today) rheumatic fever (read on your own) • 5) Briefly discuss the indications for surgical intervention of valvular heart disease. (later today) • 6) List various surgical options: repair, mechanical replacement, bioprosthetic replacement, homograft replacement, autograft replacement. (read this on your own) References History • Lilly, Pathophysiology of Heart Disease, 3rd Edition, • 54 year old man Chapter 8, pages 185 - 209; Chapter 2 pages 29 - 43 • • Cecil’s Essentials of Medicine, 4th edition Shortness of breath and chest pain on exertion. pages 10 - 19; 45 - 52 • Began 2 years ago symptoms after running 2k • Berne and Levy, Physiology, 2nd edition, • Progressed to the symptoms now at about 400m pages 249 - 255 Supplemental Sources: • WHAT IS THE DIFFERENTIAL DIAGNOSIS? Harrison’s Principles of Medicine Braunwald’s Heart Disease • WHAT ADDITIONAL INFORMATION WOULD YOU Supino PG et al, Am J Cardiol 2007; 100: 1274-81. NEED? 1 Differential Diagnosis More History • Heart Disease – Coronary artery disease • Central tightness without radiation – Myocardial disease – Valvular heart disease • Duration is short, min after slowing or stopping – Pericardial disease • Pulmonary Disease • Increases with further walking or running – Obstructive Airways disease • Not worse with breathing, eating or a change in – Pulmonary interstitial disease – Pulmonary arterial disease body position • Other • Shortness of breath felt as an inability to – Gastroesphageal spasm “catch his breath” – Acid Reflux – Peptic Ulcer Disease More History Refined Differential Diagnosis • No orthopnea, PND, fainting, wheezing, • Heart Disease cough or bitter taste in the mouth (pyrosis) – Coronary artery disease – Myocardial disease – Valvular heart disease • Still able to carry out his usual activities but is – Pericardial disease unable to participate in weekend sporting • Pulmonary Disease events such as basketball or tennis. – Obstructive Airways disease – Pulmonary interstitial disease • CAN WE REFINE THE DIFFERENTIAL Dx? – Pulmonary arterial disease More History Take a Poll of Likely Diagnosis • Previously healthy, without known hypertension, • A) Coronary artery disease diabetes or abnormal cholesterol • B) Obstructive valvular heart disease • Never smoked • C) Regurgitant valvular heart disease • No known history of asthma, previous lung infections or allergies to medications or • D) Primary pulmonary hypertension (primary environmental elements pulmonary arterial disease) • No history of rheumatic fever • E) Pulmonary fibrosis • Brother with a heart condition in his 50’s, which required open heart surgery; ?? details 2 Physical Examination Physical Examination • Average build, normal appearance • Apex beat is prominent and sustained • No apparent distress • S1 normal. S2 is single. S4 • HR 72 and regular. BP 150 / 90 both arms • Loud late peaking systolic ejection murmur heart • Jugular venous pressure is normal and does not everywhere, radiating well to the base of the neck increase with abdominal compression • No increase with handgrip or with standing • Carotid pulse is delayed and diminished • No diastolic murmur is heard • Chest exam is normal • Remainder of physical exam also normal Murmurs http://www.blaufuss.org/tutorial/ • “The noise of bloodflow in motion” • May or may not be related to valvular disease # (eg. “flow” murmur) • May or may not represent PATHOLOGY I just found this tutorial site! • May or may not represent ABNORMAL VALVE • Characteristics of murmur and association with Author won educational award for this other cardiac findings ESSENTIAL in diagnosis • Essential to have an “approach” to murmurs Murmurs Re-order Differential Diagnosis Systolic murmur Ejection Regurgitant or flow Left sided Right sided Right sided Left sided ?? (? valvar PS subvalvar PS supravalvar PS) "Flow" Obstructive Tricuspid Mitral Ventricular Regurgitation Regurgitation Septal Defect Fixed Dynamic Valvar Supravalvar Muscular
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