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Anteroseptal MI give the artery and the ECG Lead you would see changes in
Septal perforators of LAD; V1 and V2
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Anterior MI give the artery and the ECG Lead you would see changes in
LAD; V1-V4
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Anterolateral MI give the artery and the ECG Lead you would see changes in
LAD/Diagonals and Left circumflex; I, aVL, V5 and V6
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Inferior MI give the artery and the ECG Lead you would see changes in
RCA and PDA; II, III and aVF
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Posterior MI give the artery and the ECG Lead you would see changes in
Right circumflex artery; Reciprocal changes in V1 and V2
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Electrocardiology findings in Ischemia
T wave inversion, ST depressions
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Electrocardiology findings in Myocardial injury
ST elevation greater than 1mm in limb leads and greater than 2mm in precordial leads
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Electrocardiology findings in Myocardial infarction
- Pathologic Q waves!!! primary difference between injury and actual infarct
- pathologic when it is greater than one third of the R wave
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What are 4 things that can be determined from Echocardiography?
- Analysis of wall motion abnormalities
- Calculation of ejection fraction
- Detection of inappropriate flow through the valves
- Calculation of valvular stenosis
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What is the Bruce Protocol?
- Protocol followed when performing Exercise ECG
- you increase the treadmill speed and incline every 3 minutes
- Stop if there is hypotension, ECG changes or Chest pain and SOB
- used to induce stress on the heart via activity, can also be done with medication in nonmobile patients
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What is a Stress Echocardiography looking for?
wall motion abnormalities consistent with ichemia
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What is a Myocardial Perfusion Scan?
- SUPER COOL!
- injection of radionuclide during exercise
- defects on scan show where radionuclide was not "taken up" by myocardium
- indicating ischemia and infarction
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What is Coronary Angiography?
- Definitive diagnostic study for CAD
- Indicated only if Percutaneous Transluminal Coronary Angioplasty (PTCA/Stenting) or Coronary Artery bipass surgery is a consideration
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In the US what is the most common cause for acute pericarditis?
Neoplasm
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What is the most common treatment for acute pericarditis?
Anti-inflammatories
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Your patient presents with chest pain. They state that sitting up and leaning forward is the only thing that helps to relieve this pain and that breathing in makes it worse. Upon exam you note that the pain seems to be retrosternal with radiation to the neck and arm on the left side. Upon auscultation you note a rasping, scraping, grating murmur that is heart at the lower left sternal boarder when the patient is leaning forward and holding their breath on exhailation. Finally you note diffuse ST elevations with upward concavity in 2 limb leads as well as V2 to V6 with reciprocal depressions in aVR and V1. You feel confident with a diagnosis of ________ and decide it is best to treat with _____.
Acute pericarditis, Anti-inflammatories
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What is Pericardiocentesis?
- Surgical perforation of the pericardium for the purpose of draining the pericardial space and obtaining pericardial fluid for analysis
- done under the guidance of echo and done most frequently with a subxiphoid approach
- a catheter can be left at the end of the proceedure to allow continual drainage
- Bloody fluid upon drainage is most likely caused by a neoplasm in the US but most likely TB in other countries.
- Fluid that is drained is then sent to be analyzed for cells (WBC, RBCs etc and cultures, TB, etc. ) (transudative fluid may occur in heart failure
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What is Dressler's syndrome?
- A syndrome occuring weeks after MI including pericardial effusion and tamponade with elevated WBCs
- Treat with steroids and NSAIDs
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What are 4 causes of an acute onset pericarditis?
- infectious
- non-infectious
- idiopathic
- post cardiac injury (dressler's syndrome)
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What is the prodrome for pericarditis?
Fever, malaise, myalgia
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Pericarditis will cause elevations in what lab studies?
WBC, ESR, CRP, CPK, CK-MB, Trop-I
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Chest pain is more common with (acute or chronic) pericarditis?
Acute
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What are 3 things that will aggravate a pericarditis chest pain?
inspiration, cough, change in body possition
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If you can't tell the difference between chest pain from an MI and chest pain from an acute pericarditis what would you want the patient to do?
Sit up and lean forward this should help relieve their pain if it is pericarditis if it is an MI it will hurt no matter what they do
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Pericarditis Friction Rub (where do you listen, what does it sound like? who gets it?)
- 85% of patients with pericarditis
- One two or three components (contraction of atria, filling of ventricles, contraction of ventricles)
- High pitched rasping, scratchign or grating heard best along the LLSB with the diaphragm
- Accentuated by the patient sitting upright and leaning forward and end espiration
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What will see on an ECG of a patient with Pericarditis in stage I
- Widespread ST elevations with ST depressions in aVR and/or V1
- With a concave slope
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What will see on an ECG of a patient with Pericarditis in stage 2
(days later) return of ST segments to baseline
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What will see on an ECG of a patient with Pericarditis in stage 3
(days later) T wave inversion
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What will see on an ECG of a patient with Pericarditis in stage 4
Weeks later, return to baseline
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What do you want to D/C in a patient with pericarditis?
anticoagulant therapy it may lead to a hemopericardium
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What do you treat pericarditis with?
Aspirin, Ibuprofen, selective COX-2 inhibitors, Cochicine, Steroids (last resort), Antibiotics (if bacterial cause)
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"water bottle" heart
Pericardial effusion
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Ewart's sign
Base of the left lung compressed by pericardial fluid in pericardial effusion causing dullness increased fremitus and egophony beneath the angle of the left scapula
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What is the GOLD STANDARD diagnostic test for pericardial effusion
transthoracic echocardiogram
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An echo-free space between the posterior pericardium and the left ventricular epicardium incates (a large or small?) pericaridal effusion
Small
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An Echo-free space between the anterior right ventricle and anterior pericardium indicates a (Large? or Small?) pericardial effusion?
Large
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Which is worse rapid onset cardiac tamponade or chronic slow onset cardiac tamponade?
Rabid onset although both are bad!!!!
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Rapid onset Cardiac tamponade can be caused by as little as ____ mL of fluid
200mL
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Slow onset Cardiac tamponade may take _____ fluid to develope tamponade and may take months to years to accumulate
>2,000mL
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Which Cardiac tamponade (Rapid onset or Slow onset) may have symptoms of dyspnea, orthopnea and hepatic engorgment and look like heart failure?
Slow onset
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Beck's Triad
- hypotension
- Soft or absent heart sounds
- Jugular venous distention
- all signs of Cardiac Tamponade
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A Paradoxical pulse along with Becks triad may indicate
Cardiac Tamponade
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Paradoxical pulse is defined as:
a greater than normal (10mmHg) inspiratory decline in systolic arterial pressure
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Treatment for Cardiac Tamponade
Pericardiocentesis
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Constrictive pericarditis occurs after resolution of acute pericarditis particularly in patients with ____ origin of their pericarditis.
Tuberculous
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What are some causes of constrictive pericarditis?
- Post radiation/cancers esepecially breast, lung and lymphoma
- trauma
- cardiac surgery
- autoimmune disease
- chronic renal failure with uremia
- all resulting in the deposition of granulomatous tissue in the pericardium
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Which pericarditis looks alot like cirrhosis?
Constrictive pericarditis
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Poor forward flow (weakness and fatigue), fluid retention (wt gain, increased abdominal girth, abdominal discomfort, and edema), Kussmaul's sign, and Congestive hepatomegally (impaired hepatic function and possibly jaundice and acites) Are all signs of what condition? Hint: not Cirrhosis
Constrictive pericarditis
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Treatment for Constrictive pericarditis is
pericardial resection
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ECG changes seen with constrictive pericarditis include...
low voltage of QRS, diffuse T wave flattening or inversion
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What is myocarditis?
inflammation of the heart muscle
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Worldwide what is the most common cause of myocardits?
Trypanosoma cruzi (Chagas disease)
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In the western world (specifically US) what is the most common cause of myocarditis?
Viral (Coxsackie virus B, Adenovirus, and Parvovirus B19)
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What are 3 causes of myocarditis?
Infectious, Immune mediated, toxic exposure
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A patient presents with a viral type prodrome of Fever, myalgias and respiratory and GI symptoms about a week ago, they currently have chest pain, fatigue and shortness of breath What would you expect they have?
Myocarditis
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Describe fulminant heart failure due to myocarditis
severe hemodynamic compromise, distingct onset of heart failure symptoms, fever, viral illness within the last two weeks, severe and acute heart failure, bad presentation and these patients tend to die right or away or live without complications
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Describe actue (Non-fulminant heart failure) due to myocarditis
hemodynamically stable, indistinct onset of heart failure symptoms, no fever, have had a viral infection in the last 2-3 weeks, progress to dialated cardiomyopathy and tend to die later from the cardiomyopathy
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What are 4 things you would find on an echocardiography of a patient with myocarditis?
- Impaired left ventricular systolic performance
- absence of left ventricular dilatation
- regional wall motion abnormalities
- ventricular thrombus
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What is the gold standard diagnostic test for myocarditis?
Endomyocardial biopsy
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What indications in a patient with myocarditis would make you want to do an endomyocardial biopsy?
- Fulminant myocarditis
- Giant-cell myocarditis
- HF symptoms for less thatn two weeks with normal size or LV dilatation and hemodynamic compromise
- HF of 2wks to 3 months with LV dilatation and ventricular arrhythmias or type two or 3 heart block
- patients unresponsive to care within 2-3 weeks
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Dallas Criteria
grading criteria for pathological diagnosis of myocarditis from endomyocardial biopsy
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How would you manage a patient with myocarditis?
- supportive thereapy for left ventricular dysfunction: ACEI or ARB, B-blocker, Diuretic
- Mechanical circulatory support: Left ventricular assist device, ECMO
- Cardiac transplant
- Immunosuppression (giant cell myocarditis)
- antiarrhythmics if arrhythmias are present
- temporary pacemaker
- NO AEROBIC ACTIVITY!
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What drugs would you give for giant cell myocarditis?
Immunosuppression with steroids
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3 ways a HIV patient can get myocarditis from their disease
Viral directly from the HIV, Drug induced from HARRT, Coinfection (CMV) b/c low helper T
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Sarcoid Myocarditis
- rare (5% of sarcoid patients)
- Features: chronic dilated cardiomyopathy, new ventricular arrhythmias, second or third degree AV heart block, poor response to optimal care,
- Treatment: aggressive medical therapy including corticosteroid therapy
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Giant Cell myocarditis
- rapidly progressive CHF and ventricular tachyarrhythmias that most commonly occurs in the 3rd and 4th decade of life.
- Features: cardiac enlargment, ventricular thrombi, microscopic evidence of giant cells, Chest pain, fever, acute dialated cardiomyopathy
- treatment: corticosteroids but usually fatal without cardiac transplantation
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Name the Acyanotic congenital heart defects
atrial septal defect, patent foramen ovale, ventricular septal defect, patent ductus arteriosus, coarctation of the aorta, bicuspid aortic valve, pulmonic stenosis
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What is the most common classification of ASD?
Ostium secundum
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ASD is more common in (males? females?)
Females
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Describe the pathophysiolgy of an ASD
Oxygenated blood is displaced from the lefts side to the right side of the heart through a defect in the atrial septum. This increases the flow through the pulmonary circuit which increases pulmonary pressures
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ASD shunt volume is dependant on what three factors?
Size of the defect, pressure gradient between the atria, peripheral outflow resistance
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"Wide fixed split of S2 heart sound"
ASD
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Systolic ejection murmur at the LUSB, Diastolic murmur at the LSB, RV heave and wide fixed S2 split indicate _____
ASD
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When will you see cyanosis with ASD?
When right sided pressure exceeds left sided pressure (eisenmenger syndrome)
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What are some physical exam findings in ASD?
- prominent RV impulse and palpable pulmonary artery pulsation
- dyspnea on exertion, fatigue, palpitations, near syncope,
- wide fixed split of S2, systolic ejection murmur at LUSB, diastolic murmur at LSB, RV heave, cyanosis, atrial fibrillation, systemic embolizations
- ostium primum- apical thrill and holosystolic murmur (ASD with VSD or mitral regurg)
- cyanosis and clubbing
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ASD Chest X ray will have what two findings
prominent right heart, prominent pulmonary arteries
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ASD ECG will have what findings?
Right axis deviation, right ventricular hypertrophy, IVCD (interventricular conduction delaY) or RBBB
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When do you treat an ASD?
- when pulmonary flow ratio exceeds systemic flow by 50% (QP:Qs > 1.5:1)
- Or... if there is infective endocarditis, ischemic heart disease, TIA or stroke, Arrhythmias
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3 ways to close an ASD
suture, pericardial patch, percutaneous device
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What is the most common CHD defect in infants and children?
VSD
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What is the most common variety of VSD?
membranous
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What are some symptoms of a large VSD?
failure to thrive, congestive heart failure, tachypnea, tachycardia
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Why are VSDs not often picked up at birth>?
initial pulmonary vascular resistance is high at birth causing right and left sided pressures to be similar lessening the shunt
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A harsh holosystolic murmur at LLSB that is inversly proportional to the size of the defect
VSD
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3 findings on a chest x-ray of a patient with VSD
- congestive heart failure
- cardiomegaly
- prominent pulmonary arteries
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Most small VSDs close spontaneously by ___ years old
2
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Three methods of VSD repair
suture close, pericardial patch, percutaneous device closure
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When do you treat VSD?
Qp:Qs > 1.5;1
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You have a baby with cough*, difficulty feeding, dyspnea, tachycardia and symptoms of CHF what do you suspect?
PDA
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Lower extremity cyanosis occurs with what congenital heart defect?
Eisenmenger syndrome in a patient with PDA
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"Lower extremity cyanosis"
PDA, coarctation of the aorta (preductal)
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Describe the pathophysiology of a PDA
shunting of blood from the aorta to the pulmonary artery which creates increased pulmonary volume without RV involvement leading to LV and LA enlargment
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Is spontaneous closure of a PDA more common in premature infants or full term infants?
premature
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What are some symptoms of PDA in adults?
dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue
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You have a 6 month old who you see for difficulty feeding upon physical examination you note the following: a continuous "machinery" murmur best heart at the LUSB to infraclavicular area that is continuous between systole and diastole. also: tachycardia, bounding pulses, widened pulse pressure and chest heave what congenital defect do you suspect?
PDA
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What 3 things will you see on an echocardiogram of a patient with PDA?
PDA visible, left atrial enlargement, doppler flow through PDA
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What is the treatment of PDA?
- IV indomethacin for premature infants; suture ligation or percutaneous device closure
- treat CHF and pulmonary hypertension
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Describe the pathophysiology of Coarctation of the Aorta
Discreet narrowing of the aortic lumen increased left ventricular pressure load, preserved blood flow to the head, neck and upper extremities, decreased blood flow to the trunk and lower extremities
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Does coarctation of the aorta cause a murmur?
no
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Physical exam findings of coarctation of the aorta include...
no murmur, femoral pulses that are weak and delayed compaired to brachial pulses, upper vs lower BP differential, may have a higher BP in the right arm if lesion is prior to left subclavian artery, lower extremity cyanosis atrophy hairloss and weakness
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What are 2 CXR findings in coarctaiton of the aorta
- Notching of the inverior rib surface (caused by dilation of the thoracic arteries and colateral vessels that arise to help keep the thorax adequately profused past the narrowing)
- indented aorta
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What radiological study best shows the length and severity of a coarctation of the aorta?
MRI
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What is the radiologic test of choice for all congenital heart defects?
Echocardiogram
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What is the treatment for coarctation of the aorta?
- IV prostaglandin infusion to keep PDA open
- Surgical repair with end to end anastamosis
- synthetic graft repair
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Explain the pathophysiology of a Bicuspid aortic valve
two leaflet aortic valve causes significatn narrowing of the aortic outflow tract which leads to increased left ventricular pressures and left ventricular hypertrophy
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Bicuspid aortic valves are more common in (males? females?)
males
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Childhood symptoms of bicuspid aortic valve include
tachycardia, tachypnea, failure to thrive, poor feeding
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Adult symptoms of bicuspid aortic valve include
fatigue, dyspnea on exertion, angina, syncope
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Harsh, crescendo-decrescendo murmur that is loudest at the RUSB and radiates to neck. Present from birth (not aortic stenosis)
Bicuspid aortic valve
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What is the treatment for a Bicuspid aortic valve
watchful waiting in mild or asymptomatic cases; balloon dilitation in moderate or symptomatic, or surgical revision in severe or worsening cases
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Describe the pathophysiology of pulmonic stenosis
obstruction of the right ventricular systolic ejection leads to progressively increased right ventricular pressure and eventually right ventricular hypertrophy
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A patient presents to you with dyspnea on exertion and progressing right sided heart failure. upon physical examination you note a prominent JV wave and a Loud late-peaking crescendo-decrescendo systolic ejection murmur at the LUSB. the murmur increases with inspiration. You also note right heart enlargment on CXR what do you suspect?
Pulmonic stenosis
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Treatment for pulmonic stenosis
transcatheter balloon valvuloplasty
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What are the four primary abnormalities that develope in response to abnormal development of the outflow tract of the intraventricular septum?? ie the 4 abnormalities of tetralogy of Fallot
- VSD
- RV outflow obstruction (in effect a pulmonic stenosis)
- RVH
- Overriding aorta
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What is the most common additional defect to tetrology of fallot?
Right sided aortic arch
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Describe the Pathophysiology of the Tetralogy of Fallot
- 1. There is an obstruction to blood pumping out of the right ventricle usually caused by a pulmonic stenosis. The degreee of stenosis
- An aortic valve with biventricular connection, that is, it is situated above the ventricular septal defect and connected to both the right and the left ventricle. The degree to which the aorta is attached to the right ventricle is referred to as its degree of "override." The aortic root can be displaced toward the front (anteriorly) or directly above the septal defect, but it is always abnormally located to the right of the root of the pulmonary artery. The degree of override is quite variable, with 5-95% of the valve being connected to the right ventricle
- A hole between the two bottom chambers (ventricles) of the heart. The defect is centered around the most superior aspect of the ventricular septum (the outlet septum), and in the majority of cases is single and large. In some cases thickening of the septum (septal hypertrophy) can narrow the margins of the defect.[8]
- The right ventricle is more muscular than normal, causing a characteristic boot-shaped (coeur-en-sabot) appearance as seen by chest X-ray. Due to the misarrangement of the external ventricular septum, the right ventricular wall increases in size to deal with the increased obstruction to the right outflow tract. This feature is now generally agreed to be a secondary anomaly, as the level of hypertrophy generally increases with age.
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What is a tet spell?
Tet spells are characterized by a sudden, marked increase in cyanosis followed by syncope, and may result in hypoxic brain injury and death. Older children will often squat during a tet spell, which increases systemic vascular resistance and allows for a temporary reversal of the shunt. Usually occur with exertion, feeding or crying
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Which congenital heart defect will cause clubbing?
Tetralogy of Fallot
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"boot shaped" heart
Tetralogy of Fallot
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2 year old from Ghana with Profound cyanosis, RV heave, systolic ejection murmur at LUSB, Right axis deviation, right ventricular hypertrophy and a slightly boot shaped heart with deceased pulmonary markings. Dx??
Tetralogy of Fallot
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What are some treatments for a "tet" spell?
Knee to chest position, oxygen, infuse prostaglandin E1 if under 6 wks old, morphine, phenylephrine or epinephrine (increases vasoconstriciton, increases afterload and decreases shunting) Beta blockers
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What is surgical repair for Tetralogy of Fallot
Palliative shunt, Complete repair (at 3-6 months) closure of VSD, relief of the RVOT obstruction
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What are 4 chronic complications of Tetralogy of Fallot?
perioral and mucosal cyanosis, digital clubbing, erythrocytosis, hyperviscosity (stroke)
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Symptoms of Transpostion of the great vessels
rapid deterioration after birth
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Physical exam findings for transpostion of the great vessels
blue baby, cyanosis worsens as PDA closes, RV heave
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"Egg shaped" heart
Transpostion of the great vessels
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Treatment for Transpostion of the great vessels
- Maintain PDA with infused prostaglandin E1
- Rashkind procedure creation of an ASD
- Permanent arterial switch Jatene proceedure
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