Clinical Cardiology Update 2010 Course Book Contents List of Contributors v Foreword vii Preface ix 1. GENERAL EXAMINATION OF CARDIOVASCULAR SYSTEM 1 Dr. J. Ezhilan 2. CYANOSIS 27 Dr. J. Ezhilan 3. PULSE 44 Dr. Jaishankar 4. THE ARTERIAL BLOOD PRESSURE 61 Dr. Rajendra Deshmukh, Dr. Mullasari Ajit S. 5. JUGULAR VENOUS PULSE 67 Dr. U. Kalaichelvan, Dr. K. Latchumanadhas 6. EXAMINATION OF THE PRECORDIUM 79 Prof. S. Shanmugasundram 7. AUSCULTATION OF THE HEART 86 Prof. J. Balachandar 8. SECOND HEART SOUND IN CONGENITAL HEART DISEASE 99 Prof. R.J. Manjuran 9. DYNAMIC AUSCULTATION 101 Prof. G. Gnanavelu 10. X-RAY OF HEART 112 Dr. R. Ravikumar 11. ACUTE RHEUMATIC FEVER IN INDIA – A MYTH OR A REALITY AT PRESENT 119 Prof. S. Thanickachalam 12. ASSESSMENT OF MULTIVALVULAR LESIONS 125 Prof. N. Sudhayakumar 13. CLINICAL APPROACH TO CYANOTIC CONGENITAL HEART DISEASE 128 Dr. G. Madhusudan, Dr. R. Suresh Kumar Contents 14. PRESSURE MESUREMENT 130 Dr. Lakshmi Rajagopal 15. PRESSURE TRACINGS IN DISEASED HEART 137 Dr. Sriram Rajagopal 16. CARDIAC OUTPUT 142 Dr. Thomas George 17. VASCULAR RESISTANCE 150 Dr. S.R. Ramkumar 18. DETERMINATION OF VALVULAR STENOSIS 153 Dr. Anand Gnanaraj 19. CARDIAC CATHETERISATION AND ASSESSMENT OF 156 OPERABILITY IN LEFT TO RIGHT SHUNTS Dr. Sreeja Pavithran, Dr. R. Suresh Kumar 20. LEFT VENTRICULAR PRESSURE VOLUME LOOP 167 Prof. G. Gnanavelu 21. CATHLAB HARDWARES 181 Dr. S. Vijayakumar 22. BASIC ELECTROPHYSIOLOGY STUDY 196 Dr. Ulhas M. Pandurangi 23. BIRD’S EYE VIEW OF PEDIATRIC CARDIAC SURGERY 199 Dr. Roy Varghese 24. SURGERY IN CYANOTIC CONGENITAL HEART DISEASE 206 Dr. Krishna Manohar 25. INTRODUCTION TO NUCLEAR MEDICINE IN CARDIOLOGY 209 Dr. K. Thirumurthi 26. ECHO MEASUREMENTS 213 Dr. S.R. Ramkumar 27. RESTRICTIVE PHYSIOLOGY CONSTRICTION OR RESTRICTION ? 216 Dr.S.Shanmugasundaram LIST OF CONTRIBUTORS Dr. Anand Gnanaraj Dr. G. Madhusudan Dr. Sriram Rajagopal Consultant Cardiologist Registrar – Pediatric Cardiology HOD of Cardiology Institute of Cardio-Vascular Diseases Institute of Cardio-Vascular Diseases Southern Railway Headquarters Hospital, The Madras Medical Mission The Madras Medical Mission Chennai Chennai Chennai Dr. Sreeja Pavithran Prof. J. Balachander Dr. Mullasari Ajit S. Associate Consultant – Pediatric Cardiology Prof. & HOD of Cardiology Director – Cardiology Institute of Cardio-Vascular Diseases JIPMER Institute of Cardio-Vascular Diseases The Madras Medical Mission Pondicherry The Madras Medical Mission Chennai Chennai Dr. J. Ezhilan Dr. S. Thanikachalam Senior Consultant Cardiologist Prof. Rajan Joseph Manjuran HOD - Department of Cardiology Institute of Cardio-Vascular Diseases Director Sri Ramachandra Medical College The Madras Medical Mission Pushpagiri Heart Institute & Research Institute Chennai Tiruvalla Chennai Prof. G. Gnanavelu Dr. R. Ravikumar Dr. K. Thirumurthi Prof. of Cardiology Consultant Radiologist Chief – Nuclear Medicine Madras Medical College Institute of Cardio-Vascular Diseases The Madras Medical Mission Chennai The Madras Medical Mission Chennai Chennai Dr. Jaishankar Consultant Cardiologist Dr. Roy Varghese Dr. Thomas George Institute of Cardio-Vascular Diseases Consultant – Pediatric Cardiac Surgery Associate Consultant Cardiologist The Madras Medical Mission Institute of Cardio-Vascular Diseases Institute of Cardio-Vascular Diseases Chennai The Madras Medical Mission The Madras Medical Mission Chennai Chennai Dr. S.R. Krishna Manohar Senior Consultant – Pediatric Cardiac Surgery Dr. S.R. Ramkumar Dr. Ulhas M. Pandurangi Institute of Cardio-Vascular Diseases Consultant Cardiologist Senior Consultant Cardiologist & The Madras Medical Mission Institute of Cardio-Vascular Diseases Electrophysioloigst Chennai The Madras Medical Mission Institute of Cardio-Vascular Diseases Chennai The Madras Medical Mission Dr. U. Kalaichelvan Chennai Registrar - Cardiology Dr. Rajendra Deshmukh Institute of Cardio-Vascular Diseases Registrar - Cardiology Dr. S. Vijayakumar The Madras Medical Mission Institute of Cardio-Vascular Diseases Associate Consultant Cardiologist Chennai The Madras Medical Mission Institute of Cardio-Vascular Diseases Chennai The Madras Medical Mission Dr. K. Latchumanadhas Chennai Senior Consultant Cardiologist Dr. R. Suresh Kumar Institute of Cardio-Vascular Diseases Head, Department of Pediatric Cardiology The Madras Medical Mission Institute of Cardio-Vascular Diseases Chennai The Madras Medical Mission Chennai Dr. Lakshmi Rajagopal Consultant Cardiologist Prof. N. Sudhaya Kumar Dept of Cardiology Professor of Cardiology Southern Railway Headquarters Hospital Amrita Institute of Medical Sciences Chennai Kochi v FOREWORD It gives us great pride in organizing the Clinical Cardiology Update 2010 at the Madras Medical Mission. The Madras Medical Mission has been in the forefront of teaching, training and therapeutics in cardiology over the last 25 years. This Cardiology Update has been an effort by the cardiology group at the Madras Medical Mission to provide candidates in training in cardiology an opportunity to interact with best of teachers and updating their skills in clinical cardiology. I thank the entire faculty and wish all delegates a useful and interactive update. This would be an annual programme at the Madras Medical Mission. Dr. Mullasari Ajit S. Course Director vii Preface Cardiology is the fastest developing superspeciality in medicine due to introduction of high gadget investigative tools along with advanced interventional and surgical treatment. However clinical cardiology is losing its charm and importance in the examination of a cardiac patient. To improve clinical skills in cardiology, we at the Madras Medical Mission decided to hold a Clinical Cardiology Update for the benefit of cardiology postgraduates across the country. We are also coming out with a course book, which will primarily focus on improving clinical cardiology skills and strengthening your preparation for the clinical cardiology examinations. I am thankful to my Director of Cardiology at the Madras Medial Mission, Dr.Ajit Mullasari for giving me the responsibility of organizing this conference. I am also thankful to Dr. R. Suresh Kumar, Head of Pediatric Cardiology Department for his guidance and support. I will be failing in my responsibilities if I do not thank my colleagues, Dr.Latchumanadhas and Dr. Ulhas Pandurangi and all other faculty members, residents and secretaries for their immense support. I appreciate the enthusiasm and cooperation of all the postgraduates who attended and made the 2009 Update a grand success. We are confident that at the end of the update you will be more confident than before to face the challenge of clinical cardiology examination. We also welcome suggestions from you to improve the course book and the update sessions for the future. Dr. J. Ezhilan Organising Secretary ix Acknowledgements: We thank all Registrars and Ms. Sujatha K. for their assistance in successfully bringing out this book. GENERAL EXAMINATION OF CARDIOVASCULAR SYSTEM Dr. J. Ezhilan Physical signs are objective indications of disease whose significance is enhanced when they confirm a disease already suggested by the patients history. At times the physical sign may be the only evidence for the disease. The physical examination should be performed methodically and thoroughly also taking into consideration the patients comfort and modesty. The examination must extend from head to foot in an objective search for abnormalities. Skill in physical diagnosis is acquired with experience and knowledge, for the eye sees only what the brain knows. A good history taking, detailed symptom analysis and thorough general examination is half way through to the diagnosis of a cardiovascular disorder. However a meticulous general examination in a cardiovascular case is inadequately utilized. A common pitfall in cardiovascular medicine is the failure by the cardiologist to recognize that a patient’s heart disease is part of a systemic illness and failure of the noncardiologist to recognize the presence of a cardiac disorder accompanying the systemic illness. Hence it is imperative to do detailed general examination of a cardiovascular patient Cardiovascular Disorders With Findings In General Examination Cardiovascular disorders with findings in general examination can be broadly classified as follows 1) Chromosomal abnormalities 2) Heritable conditions 3) Connective tissue disorders 4) Inborn errors of metabolism 5) Sporadic disorders 6) Teratogenic disorders 7) Endocrine disorders 1) Chromosomal Abnormalities Chromosomal abnormalities and mutation of single genes accounts for less than 10% of cardiac malformations. The common chromosomal abnormalities are a) Trisomy (Additional chromosome) b) Monosomy (Missing chromosome) c) Triploidy (1 additional set of chromosome) d) Tetraploidy (2 additional set of chromosomes). Of the above abnormalities Trisomy is the commonest abnormality. Trisomy occurs for all chromosomes but only trisomy 13, 18, 21 and sex chromosome are compatible with survival to term. GE CVS Down’s Syndrome (Triosomy 21) Flat facial profile Single atrium Oblique palpaberal fissure Endocardial cushion defect Epicanthus fold Abundant neck skin 1 Protruding tongue Low set ears Poorly formed nasal bridge Hypoplastic mandible Edward’s Syndrome (Triosomy 18) Micrognathia VSD Rocker bottom feet PDA Polyvalvular dysplasia Patau’s Syndrome (Triosomy 13) Microcephaly VSD Microophthalmia PDA Cleft lip DORV Mid facial defects Cri Du Chat Syndromme (5P-) Microcephaly VSD Antimongoloid slant