Crdiology - Dr Abo-ElAsrar - By El Azhar Medical Students 2012

8/13/2019 Crdiology - Dr Abo-ElAsrar - By El Azhar Medical Students 2012

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( BETA EDITION)

With

Prof. Dr Mohammed Abo El-Asrar

Edited By

El-Azhar Medical students 2012


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Cardiology Dr. Abo El-Asrar

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Cardiology INDEXTotal pages = 74

Total time = 17 hours & 24 minutes

number Pagelecture 18 4 -

introduction ( Page 4 ) lecture 19 10 -

cont. introduction ( page 10 ) lecture 20 17

VSD ( page 17 )

- lecture 21 24 -

PDA ( page 24 )

lecture 22 29

Fallot's ( page 29 )

lecture 23 37

ASD ( page 37 ) + MS ( page 41 )

lecture 24 44

cont. MS ( page 44 ) + MR ( page 46 ) + AS ( page 48 ) + AR ( page 50 )

lecture 25 52

Rheumatic fever ( page 52 )

lecture 26 58

cont. Rheumatic fever ( page 58 ) + IE ( page 63 )

- lecture 27 65

cont. IE ( page 65 ) + HF ( 69 )

- lecture 28 73

cardiomyopathy ( page 73 )


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Cardiology Dr. Abo El-Asrar

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: : : : :

.. .. .. ..

.. Items sub items .. .. ..

.. . .. .. .. . .. .. .. ..

. .. ( ) ./ ..


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Cardiology Prof. Dr. Abo El-Asrar

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8 cardiologyIn Any lesion in congenital heart disease even rheumatic fever

:Definition ()

-ASDDefect in inter atrial septum Etiology

In any rheumatic heart diseaseRF

Hemodynamics

- Abnormalities in blood flow with this lesion..written 3 :- Clinical pictures

symptoms and signs- Complications

- Investigations

Treatment Introduction ....1 :

EtiologyWhat the is the etiology of congenital heart disease ???

Idiopathic :- 50 %idiopathic..

Acquired :-50 % :

N().. ngenital heartdisease

-congenital heart diseaserheumatic heart diseaseHave familial tendency

- - 20.. gene factor


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- congenital heart diseaseGene factor

Environmental factors :

Teratogens factorsmalformation (organogenesis) In the first trimester as :

Drugs malformationheart..:- Aspirin

- .. NB. Aspirin may cause any congenital heart lesion except PDA

- Lethium ( Anti depressant drug(

gene factor-- Warfarine (Oral anti coagulant )

- DVTshiftheparin Irradiations

- .. teratogen -pregnancy test ....

May congenital infections :

-organism placenta Infectioncongenital heart disease is Rubella congenital rubella syndrome

- congenital heat 3 May maternal disease :

-antenatal history DM hyperglycemia 3has teratogenic effect- May hypertensive mother anti hypertensive drug has teratopeneic effect

- Lupus + its drugsAssociated with chromosomal or genetic disorders


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: ommonest congenital heart disease hromosomal and genetic disorder Down syndrome

-congenital heart diseasecommon A-V canal Or called endocardial cushion defect )) Trisomy mid-line defects As PDA, VSD, ASD Turner's syndrome

Co-arctation of the aorta .

- Marfan syndrome

Congenital aortic incompetence .

Nonann syndromeCongenital pulmonary stenosis .

Dijeroge syndrome

Aortic arch anomaly .

Algea syndrome ( )Pulmonary stenosis . yndromesortic lesionsulmonary

syndromefeaturesfeatures() heart

Clinical presentationsSymptoms

-mother complaint Most common asymptomatic .. ECHO

Accidentally discovered Congestive lung symptoms

lung Pulmonary artery..left atriumpulmonary veins Lung congestive lung symptoms :


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pulmonary arterial flow called lung plethora

Congestion( defect in drainage )- & the Net result is congestive lung symptoms tems

- Due to congestion to alveoli & airways

1- Dry cough congestionIrritation of cough receptors dry cough

2- productive cough

- then mucous secretions So, productive cough ()3- Dyspnea

- then O2 to tissues tissue hypoxiaRCtachypneadyspnea

- during effort dyspnea during rest4- orthopnea pathology..

flatstagnation.. 5- paroxysmal nocturnal dyspnea 11 12 .. hypoxia RR during sleep

-18 cycle per min ..10 - 12 arasympathetic

Leading to Mild broncho spasm O2 Hypoxia.. .. :sympathetic + RR

6- Hemoptysis


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- mucosa of airway markedly congested rupture hemoptysis

Palpitation Awareness of heart beats

-Normalheart beats..:certain normal heart H.R. & Certain power of contraction

-..heart beats -

-may low cardiac output symptoms 3.. .. :Brain hypoxia headache + lack of concentration .

cerebellar hypoxia dizziness .

syncopal attacks .

heart anginal pain .

skeletal muscles easy fatigability & muscle cramps .

: .. -RBF oliguria urine output

Cyanosis Peripheral mainly due to peripheral vasospasmcentral + Lips & tongue

- -

Called potential cyanosis

-permanent cyanosisNB. Congestive lung symptoms present in all except Falot tetrology

Examinations ( signs )- local examination of the heart :

- inspection & palpation

1-precordial pulge2-commentapexheart..

Site, size, character and thrill or not

3-other pulsations and thrills:supra sternal notch

pulmonary area


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1st & ( 2nd aortic area =left parasternal area )

Epigastrium

Right parasternal pulsation - urgical anatomyeart: heartaxis..()() heartchest wall.. chest wallapex heartpulsationapex()

apexintra uterine ..rotationheart .pical pulsation-

Dextrocardia

May apex behind rib

Thick chest wall as in obesity

- Pneumothorax or effusions :

-heartchest wall- pericardial or pleural effusion Pneumothorax

- site of the apex normally : during infancy : ( birth 2 years )

-Normally In the 4thleft ntercostals space outsidemidclavicular line

7 years :..thspace- atthe clavicular line

adult..-5thspace insidethe mid clavicular line

- Other areas are :- Suprasternal area above suprasternal notch notchangle of louis..2nd rib2nd

space-2nd spaceleft sidepulmonary area

-2nd spaceright side1st aortic areaJust parallel to sternum2nd aortic arealeft sternal border..3rd space-

-lower end of the sternum Tricuspid areaepigastrium-

3rd and 4thleft parasternal area-


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-right parasternal area3rd and 4th chamber 98- inspection and palpation

Precordial bulge with RV enlargement Comment on the apex :

-commentapexLocalized apical pulse localize in one space ( by one finger )

Diffuse pericardiumpulsating apexthe lower most & outer most..diffuselesion-

1-Tachycardia + power of contraction hyper dynamic apex

2-

heavy sustained apex3-slapping apex.. retrograde .. .. character )

- Vibration sense over pulsationulsationhrill (vibration ) thrill..:

1- Mean organic lesion in the heart 2- severe lesion

Other pulsations thrill


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-areas 1. 1staortic .2. Pulmonary area .3. A2 .4. Left parasternal .5. Right parasternal .6. Tricuspid .7. Epigastrium .8. Supra sternal . ..thrill hambereart chest wallchamberschest wall

chamber Right ventriclepericardiumleft ventricle..apexright ateriumbody of the sternum..

pulmonary arteryP. area A1ascending aorta manubrium sterniarch of aorta aorta..pulsation()A1(Ascending Aorta.. )(ppalmer surface)pulsation

- If pulsation in the supra sternal notchaortic arch dilatation

- If pulsation in pulmonary areapulmonary artery NB. Pulsation on pulmonary area called diastolic shock= palpable pulsation on pulmonary area

- If right atrium pulsation in right parasternal area right sternal bordertip of fingersspaces3rd and 4th- If right ventricle enlarged chest wall.... ..recordial bulge


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ericodiuminspectionPrecordium = Intermammary area

mammary areaPectoralis major precordium bulge.. flat.. pectoralis major (( mammary area

precordiumammaryprecordium MammaryMeans precordial bulge and mean long standing cardiomegalyong standing cardiomegaly

- Due to Right ventricular dilatation or hypertrophy since childhood period ..chest wall

Here apex

in the 5th space (In the same expected space ) Outsidethe midcalvicular line ( Shifted outward apex () axisright ventricleHorizontal..apex

Diffuseright ventriclePulsateOther pulsations

Left parasternal pulsation

Then in epigastrium pulsationleft costal margin..tip of fingers( epigastric pulsation (pulsationxphisternum..

pulsationSo, aortic pulsation

aneurysm.hyper dynamic circulation right edge of the hand..Liver pulsation tricuspid regurge Pulsationheart..tip of my fingers


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N.B. pulsation..supra sternal pulsation

pulsationdilatationHypertrophy dilatation..cavitychamberwall Hypertrophy..wallLumen hypertrophypulsation(lumen)- If left ventricular enlargement anterior

axisobliqueDown and outapexShifted down and out6th space5th :right..

No precordial bulge

No any other pulsation

Only apex shifted down and out + Localized apex ight and left ventricles.. iventricular dilatationApexdiffuse + down and out

Precordial bulge

Left parasternal pulsation apex shifted outprecordial bulge.+ Diffuse. Left parasternal + epigastric

So, right ventricular enlargement precordial bulge(4th spaceapex(. apexshifted down (5thspace) and out sidedown and outapexdiffuseleft parasternal pulsationepigastric pulsationPulmonary pulsation

aortic pulsationsupra sternal pulsation Biventricular , aorta , arch , pulmonaryAs in complicated VSD

- Percussion of the heart :


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percussion of A1 and pulmonary pulmonaryaortawall.. resonant..Lung A1 and Pheavy percussionParallel to space....space left and right sternal border resonantpulmonaryaorta dullnessvessel right border of the heart ( Rt atrium ) on the Right sternal border: heavy percussionmid clavicular lineliver(Upper border) dullness Liverbasal effusion.. liver..resonant One space(parallel to right border)ight sternal border

dullnessright atrium percussion3rd, 4th (and may 5th space)space percussion outside the apex

-percussionapex.. dullnessapex-percussion text )(obsoleteplain X-ray .. clinical sense Investigations..

- Auscultation of the heart

comment 1- heart sound 2- murmurs 3- additional sounds

-heart soundsS1 & S2-murmurs

Timing , Character , Site of maximum intensity & Propagation of murmur heart soundsHeart sounds : best area 1st heart sound S1

-causeclosure of mitral and tricuspid 2 atriadiastole..ventricles2 atria


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timingcarotid pulsation....sternomastoidmedial border- S1carotid

Mitral(apex)tricuspidTricuspid area Lower part of the sternum to the left side

second heart sound S2

causeclosure of Aorta and pulmonary tricuspidmitral..systole - leftright50 Cm

(systole.. )- ..leftright3

-leftrightaortapulmonary-Pressureaorta80..Pressurepulmonary10

aortaPulmonary carotid.. carotidsecond heart sound

..aorticapextricuspidaortic

- pulmonary areapulmonary areaS2comment-

Murmurs :

-Murmurturbulence of flowsystolicdiastolic

(area of maximum intensity)Systolic or diastolictiming


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..ApextricuspidA2PA1..-1 mid axillary area(space( apex

2 - Or start by mid axillary

apextricuspidA2PA1 Site of maximum intensitymurmur-

Additional sounds :

-additional sounds(C/P....)

Complications of congenital heart1. Repeated chest infection . congenital heartFallot2. Heart failure .3. Infective endocarditis . 4. Eisenmenger's syndrome in all except in Fallot .5. Stunted growth chronic

Investigations1. Chest X-rayCardiomegaly or not .Which chamber dilated .Lung vascularity . Oligemia or .

2. ECG ( )3. ECHO .4. Catheterization.

TreatmentSurgical .

Medical . prophylaxis against infective endocarditis 09

..


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VSD clinicalMurmur .. Definition

Defect in inter ventricular septumEtiology50 % idiopathic ( most common ) .

50 % genetic base ( positive family history ) + the mother Gives history of environmental factors

Exposure to irradiation .

Drugs .

Congenital infection as rubella .

Maternal disease . disease Abnormal features chromosomal or genetic disorders As Down's syndrome .

Types-itme..

According to site

-left and right ventricleinter ventricular septumHas lower 2/3part of muscular wall of the ventricle called muscular part of interventricular septu

upper 1/3is a layer of endocardium of Rt. V & a layer of endocardium of Lt. V . the 2 membadhere together Called membranous part

VSD uscularVSDmuscular part of the septum embranousVSDmembranous part of inter ventricular septum

ECHO..diameter : According to size of the VSD

Wide VSD if > 1 cm .

Small VSD if < 0.5 cm .

Medium sized VSD if > 0.5 & < 1 cm .

wide membranous VSDsmall muscular VSD Hemodynamics symptomssigns()

: cardic cyclesystole and diastole


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bloodgradient defect2 ventriclesflow systolediastole direction of flow..symptoms

diastolepressure2 ventriclezeroatrium flowdiastole-flowsystole

-systolezero..pressureventricle-eft sidepressure120 mmHg

25 mmHgight ventriclepressureleft ventricle-systoleA & Pmitraltricuspid

left ventriclepressureleft ventricle..Aorta - LeftrightVSD- VSD ..symptomsitems..

- If small < 0.5 cmasymptomatic :

..clinicallysilentasymptomatic case( (accidentally discovered

- If large > 1 cm ( large defect )

More blood from left to right Congestive lung symptoms : ( ) right ventriclePulmonary artery..Left ventricle

- pulmonarypulmonary artery dilatation(( systole 50 Cm lung.. pulmonary.. 60 CmSo, lung plethora congestive lung symptoms


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MCQThe first presenting symptom in VSD is congestive lung symptoms

Dysphagia :

left atrial dilatationleft atriumlung --posterioresophagus..Left atriumesophagus

( ) dysphagia ..- Palpitation :

-left atrium left ventricle Left ventriclediastole Pressureleft ventriclezero( )So, dilated dilatation of Lt V heartstretchmuscle(dilatation.. ) starling law.. within limits

So, hereDilatationpower of contraction palpitation ( Due to volume overload )

( ) Potential cyanosis :

oxygenatedSo, no cyanosisAorta --defect.. (Central cyanosis on crying)

- Also, if constipation straining on defecationcentral cyanosis

Called potential cyanosis

capillariesalveoliblood..alveolusLung- wall

- - .... .. .... .... tetany)

..- ..100 Cm40 Cm ..alveoli......

Against closed cord

N.B. nspirationxpiration..


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intra alveolar pressure..wallalveolicapillaries LungPressurepulmonaryright ventricle left ventriclepressureleft atrium 80 right ventricleleft ventricle(Aorta.. ) ( )

Central cyanosis due to reversal of the s..intra alveolar pressure- onstipation evacuationbladderrectumlocal reflexwall

contracsphincterrelaxationintra abdominal pressure.... ntraction to abdominal walldiaphragmLung..

vertical diameter and antero posterior diamtere defecation & micturation -

Called potential cyanosis Due toright ventricular pressure Lt. Ventricular pressure .mechanism Low COP symptoms

-pulmonarysection1-serosal2-mucosa

3-muscle pulmonarysystoledilatationdiastole recoil cycle()PulmonaryMuscle-

-pulmonary..lumen(P. stenosis)-chest wall..Pulsation on pulmonary area

Called diastolic shocksignIf percussion on pulmonary areadullnesssign


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-Lumen..Pressurepulmonarypulmonary pressurePulmonaryhypertension congestive lung symptomsLung Lung40Left atriumleft ventricle40( 50

Low cardic output symptoms

- Syncopal attack-..flat ( )

Permanaent central cyanosis ( Eisenminger $ )

-pulmonary pressure..PressureSo, pulmonary component Accentuated S2 ( as a sign )

( )lumenpulmonary..low cardic outputPulmonary hypertension( ..left side(30-Pulmonary hypertension

So, right ventricular hypertrophy ( late) pressureright ventricle..left ventricle..left rightreversal of the shuntso, flow from right to left ventricle(Non oxygenated blood) so, Permanent central cyanosis

Called Eisenminger syndrome (as a complication)

-no role of surgical therapy heart lung transplantation Clinical pictures

symptoms : hemodynamics signs ( examination ) . left atriumleft ventriclePulmonary Aright ventricle right atriumorta

: inspection & palpation- precordial Bulge very very late ( if neglected cases only ) Apex


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Early ( only Lt. V enlargement ) Late ( Lt. & Rt. V enlargement )

Site shifted down & out shifted down & out ( more out )

Size Localized Diffuse

Character * Hyperdynamic ** Heavy sustained

- Thrill May May* Why Hyperdynamic apex ??Due to Volume overload power of contraction hyperdynamic apex .

** Why Heavy sustained apex ?? right ventricleagainst pressure(P.Hypertension) other pulsations & thrills Positive...sites

supra sternal no pulsation

A1 never aortaP pulsation if PH

left parasternal may Systolic thrill

- thrill left ventricleright..flowLeftright()wallright ventriclesystole..left parasternal area(Systolic thrill)

right parasternal no ( as in VSD normal right atrium (

may epigastric pulsation if right ventricle

N.B. If Eisenminger is there a Thrill ?? No thrill flow(Right to left)..thrillo, thrill is a good sign

- percussion

- A1 & P dullness on P if pulmonary hypertension .

right border never dullness no enlargement to right atrium .

No dullness outside apex .

Auscultation


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- heart sounds

S1 normal and normal S2

Except if PHS2 ( accentuated )murmur

pansystolic murmur systoleS1 and S2()harsh()soft()-murmurpressure gradient..

25soft murmur25harsh()

-120 - 25 = 95 mmHgSo, harsh() -

-left parasternal areapropagated to all pericordium back

N.B. Area of maximum intensity if Eisenmenger syndrome

back..flowComplication

Repeated chest infection .

Infective endocarditis .

Heart failure .

Right ventricular failureleft ventricular failure - ..

- So Here, left ventricle enlargement early .. And late right ventricular enlargement

So, Left sided heart failure then right sided heart failure

Eiseminger syndrome .

Stunted growth . InvestigationsChest X-ray

Cardiomegaly all except

Lung plethora .

ECG .


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ECHO muscular or membranous .

Catheterization smalllargeTreatment

1. Prevention against IE .2. Surgical : CHOIF membranous :

-membranous.. IF muscular :

wide medium sized or small 106ECHO..pulmonarypressure

-pulmonary pressureEisemenger syndrome -510.. 10

PDA-clinical..Only Fallot and VSD

-Definition

Connection * between arch of Aorta and main pulmonary artery

We have 3 main arteries from arch of Aorta

1- In nominate artery ( ) ..right common carotid And right sub clavian2- Left common carotid

3- Left sub clavian umbilicus..arterial supply to upper segment of the body * Connection after the origin of left sub clavian artery

-ductusIntra uterineintra uterine


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ntrauterine intra uterine intra uterineLungcollapsed.. branchespulmonary- right ventricle pulmonaryLung

-lungcollapsed( placenta) AortaPulmonarypressure- mblical arteryAortaDuctus arteriouspulmonaryAorta placenta..O2

Non oxygenatedD.A. - Intra uterine-D.A.lined by endothelium..O2 sensors

-PO2 endothelium PGE2Relaxation of the smooth muscle around the ductus circular muscle.. PO2DA

- ..Lungpulmonary pressurepulmonaryoxygenated bloodAorta -

PO2No PGE2contraction of the smooth muscle around D.A. -5 alled functional closurefibrosisend arteritis obliteransD.A.Thrombus..- Ligamentus arterious

Etiologys any congenital

50 % idiopathic .

50 % gene + environmental factors .

- Specific factors Aspirin : teratogenAspirinPDA..

As it cause Cycoloxygenase enzyme


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PGE 2( )Premature closure of DA ..DA24endomethacin(.. )contraction of smooth muscle() Congenital rubella :

-congenital rubellaPDA..rubella virusDAProliferation of DA endothelium PGE2 secretion more smooth muscle relaxation

No functional closure

Atopic disease

Maternal disease-As asthma, allergic, rhinitis, dermatitis .

So, PGE2 in mother PGE2 in fetus

(stress)- any cause of neonatal hypoxia after delivery

So, PO2 ( )May apnea (central cause) lungPO2 Aorta..DA 3Also, lung surfactant

So, any cause of neonatal hypoxia

delayed closure of the DAHemodynamics

symtomsitems..VSD- (PDA) ,AortapulmonarySo blood to lower limbs(UL..)- Also, pulmonary artery receive blood from right atrium So,

P.Artery Lung..Lung plethora Asymtomatic : lung..Asymptomatic congestive lung symptoms :

- If large amount of blood congestive lung symptoms dysphagia :

Then blood to left atrium More blood in left atrium Left atrium dilatation dysphagia- Palpitation :

- Then blood to left ventricle volume overload power of contraction


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palpitation( )- Water hammer pulse ( as a sign )

-left ventricular dilatation- Left ventricle500600

- AortadilatationN.B Amount of blood every systole called stroke volume . ( SV )

SV x HR = Cardic output . So, here COP .. & COP affect systolic blood pressure .

-ystolic pressure70(dult-iastole: (80) aorta..pulmonary10.. (systole

diastole) PressureAortaDiastolic blood pressure( )Net result systole & diastole .

So, pulse pressure ( systole - diastole )

-signwater hammer pulse Low COP :

If neglected more and more During systoleulmonary dilatation during and recoil during diastolePulmonary Narrow lumen + hypertrophy in wallPH()so, blood in lungblood to left side

low cardic output(lower part of the body) (COP)+ PDA Potential cynaosis in lower limbs : ..

If straining blood left side aortic pressure pressure in pulmonary So, blood from pulmonary to Ao

reversal of the shunt ) ( ) In the lower part of the bodyCalled potential cyanosis in lower limbs only ( ) .. ...:

Eisemenger syndrome :

- pulmonary artery pressure AorticEisemenger syndrome( .. peripheral cyanosis- not improved by warming

- Clubbing In the lower limbs N.B Central cyanosis in lower part of the body Is Called differential cyanosis


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flowsystole & diastoleo, murmur in both systole and diastolecontinuous murmur

-characterpressure gradient25harsh(murmur)Harsh all time but more in systole called machinery murmur .

Left clavicleJust above the pulmonary areaTo pulmonary and may A1

.... PDApan systolicVSD (Eismeniger syndrome)PH .. :(PHE. syndrome)Systolic pressure -In aorta40 pulmonary70.. 30(pulmonary..ES) diastolieaorta40..pulmonary40

-diastole..systoleharsh-VSD In VSD more in left parasternal

But in PDAbelow left clavicleComplications

Repeated chest infections.

IE as any congenital heart disease .

HF left sided heart failure only .

Eisenmenger syndrome .

Stunted growth . Any systemic disease cause proportional short stature Except one diseaseCause disproportionate short stat

.. What is this disease ?? Lower limbs PDA Investigations

Chest X ray .

Cardiomegaly left ventricle .

Lung plethora .

ECG .

ECHO .


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Catheterization .

Treatment- Medical treatment .

Preventive against IE.If so early diagnosis endomethacin that PGE2

What is the Congenital heart diseaseClosed by medical therapy?? early diagnosed PDA

- Surgical : closure of PDA . 2-3(.. ) 21Fallot's tetraologylinical :

Fallot 1888 tetraology anomalyheart

Definition ....Overriding of the aorta ( occur intrauterine )

-Aortaleftright ventricle No membranous part of inter ventricular septum . ( non functioning )

So, wide membranous VSD ( also , since intrauterine life )

hypertrophy of the infundibulum of the pulmonary artery ( after birth )

-P & AHeart... embryologyorigin- Heart from cardiac tube

- Big vessels ( aporta & pulmonary ) from truncus arteriosis .

-cardiac tubetruncus arterious infandibulumAortaLeft ventricle...pulmonaryright ventricleInfandibulum is the Muscular part of the ductus arteriousus valve allot..

- Within 1st six months hupertrophy of infandibulum of pulmonary artery (infandibulum)


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6variable -So, pulmonary stenosis Due to subvalvular cause ( subvalvular pulmonary stenosis)

- Right ventricular hypertrophy : right ventricle Aortaleft ventricle..Pressure..So, here .. VSD is non functioning

N.B. All Fallots occur intrauterine , except hypertrophy of pulmonary artery Infandibulum Etiology

1- 50 % idiopathic 2- 50 % Hemodynamic ymptomstems right ventricle: systole

tricuspidMitral valve.... right ventricleTo Aorta Pulmonary(pulmonary artery(Aorta.. -

- Then from pulmonary small amount of blood to lung

LungSo, oligemia in lungSo, no congestive lung symptoms

central cyanosis :

Less blood to left side AortaNon oxygenated.. AortaMixed central cyanosis central cyanosis5 gram%un oxygenated hemoglobin5clinically

- central cyanosisAs un oxygenated hemoglobin > 5 gm % Fallotcyanotic congenital heart disease as TGA

central cyanosis -So, onset of cyanosis in Fallot shortly after birth ..

(.2.....) ..


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: -Fallot

So, at birth No hypertrophy in infandibulum

bloodright ventricle..Pulmonary LungOxygenatedLeft ventricleaorta

So, mixed blood in aorta mainly oxygenated ( un oxygenated blood < 5 gram % ) So, no central cyahypertrophypulmonary.. ductus Arterious delayed closure of DA

As mixed blood in aorta then Through DA PO2

- PGE 2Delayed closure of DA15 PulmonaryLungleft sideSo, more oxygenated blood in aorta So, no cyanosis nfandibulumypertrophyAyanosis

Squatting position : - Fallot Squatting position

( ..IschemiaLower limbs) - femoralpopletial arteryPressureAorta

pulmonary..oxygenated blood..hypoxia cyanosis

-.. ( ) abdominal wall intra abdominal pressure venous return..squeezing of abdomenLower limbs-blood ..blood to right ventricle

- Pulmonary oxygenated blood() - Aorta ... orta..pulmonaryaortaRt V...

clubbing :


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So, hypertrophy of nail bedperipheral hypoxiacentral cyanosis..- (clubbing (cyanotic type..clubbing- cyanotic spells : : ..

(more deep cyanosis(syncopal attack -

- ...cyanotic spells() (hypoglycemiaviral ( - spasm of infandibulum of pulmonary..pulmonary.. AortaSo, all aortic blood is non oxygenated..:

Anoxia of brain syncopal attackAll art blood non oxygenated More cyanosis ( )Brain hypoxia anerobic metabolism

MetaboliteirritationconvulsionhypoxiaMusclesrelaxation of the infandibulum.. .. 5

ExaminationGeneral

Squatting position Central cyanosis .

Clubbing .

Local examination (wall..right ventricle)

Inspection and palpation normal .

Percussion normal .

Auscultation : usculation Heart sounds

-M & TSo, normal S1S2 single accentuated S2


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:Aortapressure80..Pulmonary10.. pulmonary area(?? :Why accentuated S2 Aorta2chambers..wallsystole recoildiastole.. wall..Pulmonary

diastole(pressure80)So, aortic component of S2Why single S2 ??

-Pulmonary.. So, diastolic pressure (< 10)pulmonary component..

So, S2 only one component

So, single S2 accentuated Murmur

NB. No murmur of VSD ( VSD is one of fallot components) pulmonary arterySo, murmur of pulmonary stenosis

So, systolic murmur EjectionWhy Ejection ?? pressure gradientejection systolic phase

single S2..accentuated..single or double( Harsh ejectionharshejectionMurmur ..jection

- Normally In Rt. Sidetricuspid(Rt. VzeroRt atrium5)Pulmonary

(10)


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& the pressure in Rt. Side as the following :

- Rt. atrium 5 - Rt. V 0 ( zero ) - pulmonary 10 atrium.. 2(zerovenous return )....systolein systole : VentriclecontractionSo, pressure3(0diastole)..ricuspid 2atriumS1

-valvesPressureRt. V10Called isometric contraction phase

- Rt. V11pulmonary(p10) P..ejection phase(Pulmonary)S2..systole

-pulmonary stenosis..murmurejection phaseSo, P. stenosis cause ejection systolic murmur

NB. But in VSD pan systolic murmurpulmonary 6(10...stenosis) right ventricle120(left) (

(25 25harsh...114..very harsh murmurOn pulmonary area

Complications as any cong. But :NB. NO Repeated chest infection

High incidence of pulmonary T.B. - congenitalFallot T.B. bacilliIs micro aerobic bacteria(O2)

mixed blood(fallot) manifestations of T.B. toxemia in Fallot tetraology ???

- Night fevernight sweating night(night../)


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PO2 acitivityT.B. respiratory ratetidal volumeSo, PO2..T.B. ay and night fever and sweating

Due to PO2 all the time .

Tissue hypoxia erythropiotein polycythemia incidence of thrombosiscerebral thrombosisincidence of brain abscess

-functionslung......phagocytic function(filtration )

Aortalung()3 branches ArchbrainSo, may brain abscess- May right ventricular failure .

May IE but rare .

N.B. no Eisenmenger

Cyanotic spells Investigations

- Chest X - ray

Cocur en sabot specific configuration of heart .

Oligemic lung .ECG . 3 ECHO . 4 - Cathetrization .

Treatment- Medical treatment .

As any congenital prophylaxis against IE .

If cyanotic spells .

squatting position oxygen canula..IV indral ( B blocker)Relaxation of infandibulumNaHCO3acidosistissue hypoxia Indralmorphinelife threatening drug()


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Iron & folic acid

folic acid- ironDue to hyperactive bone marrow- Surgical :

Palliative surgery .

NB) graft) Infandibulum PDA:Shunt between right subclavian and left pulmonary

Aortapulmonary 22 32ASD

DefinitionDefect in inter atrial septum

EtiologyAs any congenital heart disease

Types- Patent foramen ovale :

embryologyinteratrial septum:- Septum secondum - Septum primum secondumprimumembryology primum secondum line..secondumprimum:

2 septaCalled foramen ovale Intra uterine...Oxygenated bloodumblical vesselsright side. oxygenated Leftforamen ovale

primumsecondum ntra uterine right side pressureleft side pressure..secondum .. foramen ovale :-right side pressureLeft side pressure..secondum


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lineprimumforamen ovale(Immediately after delivery)secondumfixed( .. )foramen ovale ASDPatent foramen ovale ECHO

- Ostium secondum defect :

- secondum.. defectby ECHOAppears as defect in upper part of the septum .

- Ostium primum defect

by ECHOAppears as defect In lower part of the septum

- commom AV canal :

- primumleafletmitralleaflettricuspid membranous part of inter ventricular septumSo, ASD + VSD + MR + TR

endocardial cushing defectcommom AV canal- ommonest congenital heart disease in Down's syndrome clinically.. VSDcommon AV canal( ( Hemodynamicsclinical ((as a symptomsitems

SD ressureeft atrium56)mmHg)diastole (43)43ight atrium-leftright

6 - 3 = 3 mmHg

-3... Leftright right atrium So, mild right atrial dilatation

May cause palpitation and may not : right ventriclepower of contraction

May cause palpitation and may not

congestive lung symptoms :

Then to pulmonary to lung Then congestive lung symptoms

To left atrial .. So, mild left atrial dilatation ( no compression symptoms )

maimly asymptomatic :


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complaint normalMostly asymptomaticExamination

Inspection & palpation

May apex shifted downward .May hyperdynamic apex ()

- Auscultation

S1 Murmur

pressure gradientMay functional pulmonary stenosis murmur

ASDSoft ejection systolic murmur S2() -

professional ( ... - )Basics

- We have inspiration , expiration and inter respiratory period

inter respiratory..Inspirationexpiration-S2Aortic componentpulmonary componentAorticbeforehigher thanpulmonary

-Inter respiratory phase rightleft sides of the heart (hamber during deep inspiration : negative intra thoracic pressurectioninspirationdeep inspiration...

of blood from whole body

venous return6right side :Left sideLu left side right...Left

- conclusion : during inspiration in normal persons :6 liter of blood in Rt. Ventricle

4 liter of blood in Lt. Ventricle

left..Aortic component..pulmonary


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S2 component..splitting of 2ndheart soundduring full expiration : Full expiration

VR blood to right side4 Left6..Aorta6Pulmonar.. single S2 during expiration ormalulmonary area

SD Wide fixed spliting of S2

- during inspiration

-tem..ide 6.. 4() right atrial pressure4(.. )left atrial pressure5 mmHg(Pressure gradient1 mmHg(1=4-5) mmHg.5 Rt...0.5Lt . atrium..6.5Rt. atriumto Rt.

vent

Left atrium3.5(4... )left ventricle- conclusion : during inspiration in ASD :

6.5 liter of blood in Rt. Ventricle

3.5 liter of blood in Lt. Ventricle

So, during inspiration

AortaPulmonarySo, wide spiltting of second heart sound

- during expiration

-tem..fixed 6.. 4() right atrium3(.. ) left atrium6()

Pressure gradient3 mmHgo, 1.5 liter from Lt. to Rt

Leftright


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So, right ventricle5.5 liter..left ventricle4.5 liter AortaNormal5..4.5Pulmonary5..5.5

So, here spiltting of S2 during expiration

CONCLUSIONSo, wide fixed splitting of S2

What is the meaning of fixed splitting ??means splitting during inspiration & expiration

ComplicationsRepeated chest infection ( rare )

Heart failure (rare )

IE ( rare )

Eisenmenger syndrome ( rare )

Stunted growth ( rare )

Lutembacher syndrome ( ) ( mitral valve disease in ASD patient )rheumatic fever15 -

mitral valve diseaseASDInvestigations

Chest X - ray

-Left ventricle-lung plethora

ECG just association right bundle branch block .

etc ) other investigation (

TreatmentProphylaxis against IE + surgical closure

Mitral valve lesionsvalve..valve

all caused by rheumatic fever .

Mitral stenosisHeodynamics & symptoms

3 stages+end stage diastole))stenosis atriumventricle70 %pressure gradient30 %atrial contraction


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silent MS : asymptomatic

-mild mitral stenosisSo, 50 % pressure gradient...50 %atrial contraction mitral stenosisasymptomatic mitral stenosis

ilent mitral stenosis2 Congestive MS : congestive lung symptoms

- Moderate stenosisatrial contraction70 %pressure gradient30 %-

atrium..So, left atrial hypertrophypressure.. LungStagnation of blood

symptoms of pulmonary congestionHypertensive MS : low COP symptoms + dysphagia + may orthopnea & hemoptysis 20 %pressure gradient80 %atrial contraction

diastole.. 80%0%

70 %(20+50)to left ventricleto aortaow cardic outputsymptoms

-atria30 %So, dilatationSo, dysphagia( )-PressureLt atriumlungMore blood in lung

rthopneaemoptysis - Stagnation in pulmonary pulmonary hypertension Pulmonary hypertension + low cardic output

Called Hypertensive mitral stenosis

MS with Rt. V failure ( end stage MS ) systemic venous congestion symptoms :Right ventricular hypertrophy Right ventricluar failure Stagation of blood in superior vena cava

Systemic venous congestionend stage Examination

- General examination Asymptomatic


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Lung congestion

inelastic wall of alveoli fine crepitationHyper tensive mitral stenosis malar flush erythema

()With no any explanation(( -Right sided failureCongested pulsating neck vein

Enlarged tender liver

Pitting odema

Ascites

- Local examination ..right ventricular failureInspection and palpation

Precordial bulge if right ventricular failure

Apex normal except if Right ventricular enlargement :Shifted out

Diffuse

slapping apex

diastolic as blood pass through stenotic mitral valve during diastole .

Other pulsations

No Supra sternal

NO Aortic

Pulmonary if hypertensive stage

Right parasternal , left parasternal & epigastric Percussion

Pulmonary dullness if pulmonary hypertension

Auscultation

Heart sounds

S1 : S1 A-V valvemembrane.. valve .. ..membrane...atriumvalv()Accentuated S1


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& may palpable S1 ( ) called slapping apex- S2 :

S2Normal...Except in pulmonary hypertensionS2 -Murmur

in diastole ( filling phase ) pressureLeft ventricle120Left atrium5Aorta80 systole...mitral..ventriclepressure

Aorta S2() mitral...ventriclePressure5 isometric relaxation phase...Mitralmurmur mitralfilling phase

Interruptedy pressure gradient..trium- () .. ()So , Rumbling murmur

-Then atrial contraction (S1(So, presystolic accentuation at apex

Localized and may be propagated to the medial of the apex .

one 23 43 mitral stenosis Additional sounds

- Opening snap ( ) valveCalled opnening snapAt the end of isometric relaxation & begining of filling

the wall of the leaflet is still healthy NO Calcification .. 2 - Means isolated mitral stenosis NO

Complications of mitral stenosisComplications on the valve itself


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Rheumatic fever activity

Caused by streptococcal -susceptible - rheumatic feverFor another timeCalled rhematic activity

May IE

May pathological calcifications No opening snap Left atrium

Pressure manifestations due to enlargement

Dysphagia Press on bifurcation of trachea Irritative cough ( brassy cough )

Hoarsness of voice compression of left recurrent laryngeal nerve

,,,,heart lesion with hoarsness of voiceAtrium

atriumventriclevolume overloadcontractionBut within limits atriumover dilatationleading to Failure of contraction of atriumSo,:low COP symptoms 2- Aslo, no presystolic accentuation

rumbling murmurcharacter over dilatation -S.A.nodeA.V. nodeventricle

left atriumright atriummuscle fiberssignalsormal atrium ((from both Lt. & Rt. atria .V. nodeeft and right atrium ( ..Left atriumOverstretched muscle

) signalsventricle5 sginals()AFSo, heart rate

-5A.V. noderefractory period:Irregular irregularity Irregular heart rate

-Heart raterhythm.. palpaitation ( irregular ) irregular..VSD & PDAStagnation of blood liable to form thrombus thrombo ebolism .. thrombusAorta..sudden death Lung


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Repeated chest infection lung congestion hemoptysisMay pulmonary embolism

right ventricular failuresystemic venous congestionay DVT or systemic embolizationembolusright ventriclepulmonaryMay pulmonary infarction

What is the most common causes of hemoptysis in children ???Chest infection T.B.

Tight mitral stenosis

Malignancy

InvestigationsChest X - ray Lung congestionAorta+left ventricleECG

ECHO

TreatmentMedical prophylaxis against IE & Rheumatic fever activity

Surgical treatment

- May ballon dilatation calcifiedisolated mitral stenosis -calcificationMRvalve replacement

Mitral regurgeHemodynamics & symptoms

-valve..So, appear in systolePalpitation : AortaMitral.. To aorta and left atrium

Left atriumpulmonary veins..volume overloadLeft atrial dilatation Left ventricledilatation..Power of contractionPalpitation complaint...earliest complaintMR..MSpalpitationlate

Congestive lung system :


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palpitation..Left ventricle..lung congestionCongestive lung symptoms

Lt. V failure : Left ventricular failureMore congestive lung symptoms and low COP ( both so late MS )

- May pulmonary hypertension + right ventricular failure :

-May pulmonary hypertension + right ventricular failure(Rt. V failure(

Local ExaminationInspection & palpation :

No precordial bulge

Apex

Down and out , Localized , hyperdynamic ( volume overload )

May systolic thrill due to flow of blood during systole through m. valve.

Other pulsation

May pulmonary pulsation if reach pulmonary hypertension

Percussion

- If pulmonary hypertension dullness on pulmonary

- Auscultation

-leaflet..:H. sounds :

So, hereS1muffled S1() Murmur

systolic ( all phases isometric contraction + ejection ) so, pansystolic .

The Pressure gradient left atrium6left ventricle120..murmurvalve :a- if narrow harsh b- if wide may soft

So, variable intensity according to severityof maximum intensisty propagation :

Here, mitral valve has two leaflets :

-site of maximum intensityLeaflet Anterior or posterior leafletPropagated to axilla if anterior leaflet incomptenance the commonestPropagated to left parasternal if posterior leaflet incomptenance

Propagated to axilla and left parasternal if double leaflet MR


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ComplicationsSValve

heumatic fever ..etc as MS

Atrium as MSLung as MS

investigationsas MS

treatmentMedical as MS

Surgical valve replacement

Aortic stenosisystoleTypes

ay :

Valvular leaflet Congenital or rheumatic

Subvalvular hypertrophy of the infandibulum called idiopathic hypertrophic sub aortic stenosis IHSS()congenital ( not common )

Hemodynamics symptoms-left ventricleMild stenosis ..()

Left ventricluar hypertrophy ( not dilatation )

Low COP symptoms : Aortic stenosis..left ventricle..ejection .. left ventricle(30 %)70 % in Aortaw cardic output symptoms may anginal pain : Left ventricleDue to hypertrophy + dilatation

30 %..Left atriumVolume overloadmuscle..O2May left ventricular ischemiaanginal pain N.B.0nginal painalled premature angina 12.. anginatypical anginal pain.

(.. )sudden death Lt. v failure & congestive lung symptoms :


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As before

TreatmentAs before + if IHSS give propronalol elaxation

Aortic regurge valvediastole..diastoleHemodynamics & symptoms

palpitation :

ventriclepressure..leafletAscending Aortaeftventricle..Left atrium..left ventricle

Volume overload power contraction

palpitation-..

very late Lt. v failure & congestive lung symptoms . regurgeleft ventricular failureLung congestion ( very very very verylate )

Examination- General .R.water hammer pulse :

ystole ventricle5..5.5..stroke V..rdicouptutsystolic blood pressure :diastole

pressureAorta80Left ventricleAortaPressure

- So, pulse pressure water hammer pulse ( Diastolic pressure may reach zero )

suprasternal pulsation

-supra sternal pulsation Aorta corrigan's sign- Also, prominent carotid pulsation called corrigan's sign

- Demussiet sign : Demussiet sign() ..


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A.R... A.R. ..() prominent capillary pulsation :

-nailsystole..diastoleCalled prominent capillary pulsation

Pistol shots :

- femoralradialpistol shotsarterydiastolecollapsedsystole( psitol shots)

Pendol sign :

-pendol sign( )poplieteal artery diastolesystolesystolic & diastolic Bl. Pressure

& (systole - diastole)- Local examination

inspection & palpation :

No precordial buge

Apex

Shifted down and out

Localized

Hyperdynamic

May diastolic thrill on apex

Auscultation

S1 normal & S2 muffled

Murmurs y pressure gradientiastole diastolic - character : soft

: A2 & On leaning forward

Localized on apex

peripheral signsComplications, investigations and treatments before 24 54


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Rheumatic fever ver diagnosis..Definition & introduction

an auto immune disease (Antibodies against own body )

.. Not geneticrheumatic feverstreptococcal infectionWhich is a common infection .. rheumatic fever

but it has familia tendency ( ..( )cross infectionene factor with environmental factor

So, rheumatic fever has genetic basistreptococcal infectionheumatic fever toxinsanitgenicitytissues()

ost accepted theorycross similarity Between cells of the body and streptococcal strains antibodies antigenisity

Rheumatic fever: carditis..choreaarthritiscarditis & chorea.. So, variable clinical pictures, but same in the same family

Epidemiology- Age : ..15age..5 (autoimmune(( )

not mature enough3immune system.. ( gene strepto cocci)

25 Rheumatic fever


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As streptococcal infection is a common So, persons Who reach 25 years , mainly exposed to all strains

streptococci ( as it is a very common infection ) although, no antibodies were formed Againt their tiss

So, there is no genetic factor present

60.. auto immune disease 60..Diagnosis of Rheumatic fever

Rheumatic fever is a clinical diagnosis(( mainly clinical over diagnosis ..( ..)Rheumatic fever until proved

othe

myalagiageneralized bone ache( ) CBCleucocytosis..ESR C- reactive protein..ASOT ..Rheumatic fever .. .. Jone's criteria( Jone) ..5 major criteria5 minor :inor

History of Rheumatic feverArthralagia ( with no limitation ) only pain + Fever

Acute phase reactant (ESR, C reactive protein and leucocytes )

ECG prolonged PR interval

In Jone's 2 major only or

1 major and 2 minors ( ) carditis.. prolonged PR intervalarthritismajor( arthalagiaminor any child has chorea ( ONLY

Rheumatic fever ..Rheumatic feverother collagendisease(Rheumatoid arthritisSLE)

both may affect the heart, the joints, neurological and other skin manifestations

- vidence of previous streptococcal infection


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(criteria) videnaceSure history of scarlet fever (sore throat.. ) strept or Throat culture Pathogenic streptococci ( as a history ) or Antibodies against streptococci

-one'odified Jone's criteria- 2 major only or

1 major and 2 minors ( ) carditis.. prolonged PR intervalarthritismajor arthalagiaminor+ Evidence of previous streptococcal infection ( for both 1 2 )

- criteriachorea..

As it Occurs after streptococcal infection

34 acute phase reactant or evidence of previous stept. infection riteriaajor :1 - Arthritis

has the following 4 criteria :

Joint are Red, hot, swollen, tender with complete loss of function

() .. But more in In big joints ( hip, shoulder, knee, ankle, elbow and wrist )

Has fleeting character ( (.. - Therapeutic test : criteria :Give Asprin as anti inflammatory .. complete cure ( dramatic response to salicylate Indicate rheum

fever ) Without any residual damage joint complete normal antibodiesInflammationsynovial membrane..salicylate

good excretion in synovial fluid Complete anti inflammatory action Complete cure

Rheumatic feverfleeting arthritis


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So, early treatmentaffectionjoint N.B. May 2 joints at same time

2 - Rheumatic carditis

Carditis in Rheumatic fever is a pancarditis means any layer of the heart may affected ..pericarditisendomyoPericardium pericarditis ( dry )

ymptoms :

- Inflamation Between parietal and visceral surfaces So, are both rough

parietal layerpain receptorSo, pain retrosternal, stitching painD.D. from dry pleurisy

Here, not related to respiration or cough ( in dry pleurisy )

n examination pericardial rub

- Both systolic and diastolic As PDA murmur

but PDA maximum below left clavicle but here all over the percordium

- Myocarditis ( atria and ventricle )

entricle..yocardium-myocardiumtria ventricles heart

Criteria of myocarditis:..tems

tachycardia disproportionate to fever

-neuronal fibersHeart:called Conductive system of the heart ( S.A. node, conductive of atrium, A.V. node etc (

myocarditisH.R.tachycardia disproportionate to fever- pulse1015 5Normal pulse90 ..febrile state

38 Pulse 100-105..105Tachycardia out of feverNB Rever pyrogensfeveractivationS.A. node.. InfectionheartAs in diphtheria

muffled H. sounds :

-cardic musclePressurechambersLeft atrium . 5 6 mmHg


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Right atrium .. 3 4 mmHg

Right ventricle .. 25 0 mmHg

Left ventricle 120 0 mmHg

Aorta .. 120 80 mmHg

Pulmonary . 25 10 mmHg pressurevlavesHeart soundsSo,here pressure so, muffled heart soundpressurevalves

may Heart faliure gallop rhythm

rate.. - heart failureBiventricular heart failure..congestive heart failure-additional sound( )Gallop rhythm

- multiple regurge leaflets

cardic muscle( : .. () (failure Heartcircular muscle ()valvesOn mitral area MR

On tricuspid area TR

On A2 AR

On P PR

Called multiple regurge leaflets

- ultiple regurge leaflets cardiomegaly & HB :

- X- ray cardiomegaly , If ECG prolonged PR interval Why ????

s P-R interval From beginning of P (atrial systole)to beginning of R (Ventricular systole) P-R repre

conduction bet. Atria & ventricles 5prolongedeans time between atrial and ventricular contraction due to odema (from inflammation in myocard

Odema around A-V node delay AV conduction Cause heart block ( 1stdegree heart block )

tachycardia refractory periodS.A.nodeinflammationHeart( shortness of RF ) RF.. heart rate(tachycardia)

Due to excitation of S.A.node

Endocarditis : Affect left side more than right side


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Inflammationleafletmitral valveodema mitral stenosis)Criteria items..

muffled hart sounds :

- S1 & S2muffled leflaets Called transient mitral stenosis Called Carey comb's murmur

Mid diastolic murmur Rumbling without presystolic accentuation, weak, localized on apex

odemaCalled transient mitral stenosisCalled Carey comb's murmur Permenant mitral stenosis :

-()Permenant mitral stenosis- Also, in Aorta may AS

- single valve regurge : valveChorda tendenaePapillary muscle.. (prolapse)

-inflammatory reactionleafletregurge(In one valve only))irreversible.. ) (reversible)

-V. lesion..Change of previous murmur3 - Chorea

Inflammation in Caudate lobe of basal ganglia

-- Occur after streptococcal infection

34 acute phase reactant or evidence of previous stept. infection:Sudden jerky, semi purposeful movement

- ( )(ms. Weakness).... ((Emotional instability abnormal movement(NB abnormal movement) Dancing gait .. .. (criteria:

1- Ms weakness 2- emotional instability 3- abnormal movement

- aggressive ..igns

piano sign :


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- () small muscle of the handCalled piano sign forking sign : :()

- Semi flexion in wrist + Metacarbophalangeal extension + Interphalangeal flexionchoreaic handforking sign( ) !!!! milk maid sign :

Chorea here is a self limited 65254- Subcutaneous nodules

(Lymph node) Nodules On extensor surface of bony prominent as in elbow, tibial tuberosity, chin of the tibia, mastoid process

(mastoid process)lymph node....( Lymph node )

5- Erythema marginatumErythema= redness + Marginatum= margin

Due to inflammatory reaction

()clear .. trunk 2-3.. ( )

D.D. enia circinata

-teniaitchingNon itching-tineascales..non scales

Both erythema marginatum and subcutaneous nodules are very rare ones Investigations

Acute phase reactant

CBC WBCs

ESR more than 100

C- reactive protein positive


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X- ray cardiomegaly

ECG PR interval

- Evidence of previous streptococcal infection

Swab and culture ( throat pathogenic streptococci )

Antibodies ASOT-333(/)250 333contaminated area(300active

Treatment- Prophylaxis ( prevention )

3 1ry prevention Prevent the 1st attack

proper hygiene & avoid over crowdness

streptococcal infectiondroplet infectionSo, proper hygiene , avoid crowding , Good nutrition, avoid contacts ..etc.

- proter ttt of any upper resp. tract infection ( proper antibiotics , dose & duration ) Upper respiratory tract

infection..( symptoms..1ry etiology)

- :- proper antibiotics + in a proper dose ( ) ( gm or mg / kg )

+ In proper duration of therapy 0.. .. 48 (antibiotic) : ..:: : 500 :

ntibiotics( -- (!!(10: :


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streptococcisore throat culture.. sore throatgram positiveanti gram +ve..48anti gram negative..viral

broad spectrum

- if no availabe culture & there is upper respiratory tract infection 48amoxacillin..gram positive gram negativecephalosporin..bacteria partial improvement gram positive and gram negative..antibiotic gram negative 2ry prevention straininfection( genetic susceptibility..(

Rheumatic attack

-antibiotics So, give long acting penicillin 1,200,000 IU 6 6 ..

-erum55(N.B.

Long acting penicillinsensitivity test 1000( penicillinbenzathin)

-sensitiveOral penicillin..12(250,000)-oral penicillinGive erythromycin (250 mg)

Or Sulphadiazine -5last attack

oral compliance..daily ..15


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3ry prevention preventcomplicationsIE( )- Curative treatment Immune system- Eradication of streptococci

procain penicillingram positive ttt of manifestations :

If arthritis only + ( 2 minors ) Give salicylate

Why ??? ( mechanism ) arthritisinflammatory mediatorPGE2, throboxane A2, prostacycline arachidonic acidcyclo oxygenase enzyme- So, asprincyclo oxygenase

dose 100 - 120 mg / kg / day gastritisdose - Complete clinical cure.. ESR..

- If there is a Contraindiaction of aspirin use in rheumatic arthritis Give corticosteroids

arachidonic acid- spirinheumatic arthritis aspirin contraindications of aspirin therapy when give steroids in arhritis

If any manifestations of viral infection Reye syndromemassive liver cell failurecattarahalUpper respiratory...

Bleeding tendency Bronchial asthma

s aspirin may induce asthma IF aspirin is CI Give predinosolone 2 mg /kg / day

ESRNormal1-2


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If carditis only as a major

arditisspirineukotriensarditis- COXarachidonic acidLOXleukotriens- ..arthritisaspirincarditis

sub clinical carditisaspirinaspirincortisoneif carditis only Give cortisonesame dose as above

4-6till ESR normal-cortisone

So, gradual stop of steroid over 2 weeks under umberlla of aspirin ( if no CI of aspirin )(contraindications)

Why under umberlla of salicylate cortisonerebound arthritis permenant suppressioncyclo oxygenase ( COX )cortisone permenant suppressionlipo oxygenase ( LOX )( )..(COX)early recovery

convert all arachidonic acid to PGE2 etc.( as there is suppression of LOX for long period )Aff

joints ( called reboun arthritis )salicylate 6 cortisone..22(cortisonecircadian-1(22 22..21(3)

( Gradual tappering till reach 1/2 dose of steroids )

ow add aspirin ( after reach hace dose of cortisone ) (If not contraindicated)

75 mg / kg /day cortisone dosecortisonesuppressioncyclo oxygenase aspirinTo suppress cyclo oxygenase

If carditis + arthritis

- As carditis only


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Chorea

chorea)stress (sedative( )-As diazepam ..etc.To abnormal movementelf limited

anti leukotriens ..side effects( Infective endocarditis

Types

May acute or sub-acute

Acute Highly virulent organism + Affect normal or diseased heart acute

Sub-acute type Cardic lesion ( congenital or rheumatic ) +

Bacteremia nfectionndocardium..-normal heartPapillary muscle fibers of chorda tendenea

endocardiumvery smooth membrane..flow.. stagnation

flowcellsbacteria- cardic lesion roughness to endocardium rouhgnesslesionabnormal flow..endocardiumrough( )

-rough surfacebacteremia Gram +ve :

strep. Viridansoral mucosaBacterial flora-..blood vesselsbacteremia( )

Or streptococcal fecalis after surgical removal of anal polyp

Or sever abrasion in skin staph albus enter and cause bacteremia

Or contaminated catheterization


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staph. Aureus-gram positive

May gram negative as H. influenza

May fungal as Aspergellius canula VSDimmunityeonates-1

contaminationMay bacteremiaIE

Heartddictcontaminated injection-2Immuno compromised-3

- Heartflowroughnesslocal inflammation activationplatelets) coagulation cascadecoagulation( for localization of infectionInfected thrombus

IEcommon in right sideleft sideCommon in left side

..curve.. ()-roughnessHigh pressureLeft (mitral(regurgestenosis

IEregurgeAs in stenosispressure gradient is 6 - 0 = 6 mmHg

Butin regurge pressure gradient is 120-2 = 118 mmHgregurge flow ARAS ASAR stenosisflow(( ventricle ASDVSDVSDASD..mall VSDarge VSD -Heart failurerare IEpressure gradient

26 76


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- Jane way nodule :

On theaner eminenance & hypo theaner blue not tender nodule

Spleen may splenomegaly

N.B. If severe toxemia toxic heart failure

B Emolic manifestations vegitationsfraible detatchment..Infected emboliNon infected emboli :

-Occlusionend arteryInfarction

end arteryischemia(collaterals) infected :

Also, if infective emboli cause infarction ischemia may mycotic aneurysm & Hge : artery branches..embolusartery

If infected ..Inflammationwall of vessel..artery pressure inflammationwallherniation before site of obstruction

& form what is called mycotic aneurysm asymmetrical bulge

(mycoticfunguscolonyirregulary)May rupture severe bleeding IC He

Kidney : idney1- If non infective emboli

-massive renal infarction Massive hematuria Acute renal failure then chronic renal failure

2- May small embolus -small arteriole Cortical infarction ( not medulla) Then fibrosis ( micro infarction ) (

Flea bitten kidney

depressed(flea) 3- May GN : -Immune complexglomerulonephritis

C - Underlying cardic lesion :If the cardiac lesion was MR :


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vegitationsMR (Inferior surface of the valve.. ) chorda tendinea...leafletmurmur(Musical character)

Due to rupture of chorda tendinea

if the lesion was MS :

If MSleaflet..stenosisouble mitral(Apperance of new murmur)MRMS...IE

Investigations ECHO to see vegitations

Blood culture for bacteremia intermittent() ..culture:4 )febrile --3 culture-33If positive + vegitations = IE investigationInfectionESR.....etc RFidney(

Urine analysis ( for hematuria ) + renal functions

Complications

complications3 -Embolization In coronaries brainHeart failure

Renal failure

Treatment- Specific anti - microbial therapy According to culture and senstivity bacterocidal.. parenteral form dosemaximum dose.. 4 - 6clinical improvement Parenteral(IV or IM) 72 broad spectrum antibiotic ( gram positive and gram negative )

N.B. curecomplications preventionPrevention of IE ardic lesionactor (acteremia

early proper ttt of any infection :


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Heart failure ..ardiomyopathy

definitionMeans failure of the cardic muscle to supply the tissues with their requirments of blood flow

It is a clinical syndrome in which the heart cant maintain sufficient cardic output to meet the metabo

needs of the body inspite of normal venous return

Causes May deue to congenital heart disease

VSD left 1stthen right late

ASD right ventricular failure

PDA left ventricular failure ,,, rare right VFFallot if heart failure right VF

AS ( congenital ) left VF

Coarctation of Aorta left VF

If Rheumatic disease

MS right only

MR left and rare right

AS or AR left ventricular failure

Cardic muscle itself

Cardiomeglay

Rheumatic carditis

Infective endocarditis

Toxic or viral myocarditis ( as viral bacterial pneumonia )

- May activity or activity

Tachyarrhythmia Or bradyarrhythmia due to block High cardic output failure ( as in thyrotoxicosis thyroxin severe tachycardia )

Or anemia make compensatory tachycardia if severe anemia

Anemic heart failure

Arterio venous fistula venous return congestive heart failure

May Cor pulmonale obliterate pulmonary vessels pulmonary hypertension right sided heart failu

Systemic hypertension

Left ventricular contract against pressure


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Left ventricular hypertrophy then failure

Pulmonary embolism pulmonary hypertension right sided heart failure

Over hydration by IV fluids

congestive heart failure due to volume overload of blood Clinical manifestations cardic muscle low COP :

-right ventricular failureblood in pulmonaryin lungto left sideblood in Aorta(low COP)

- Also, if left VFblood in Aorta ( low COP )

So, all heart failure low cardic output ventricle stagnation stagnation of blood :

if Rt VF manifestations of ststemic congestion

-rightstagnation in right atriumstagnation in SVC and IVC- So, manifestations of systemic congestions .. congested pulsating neck veins

+ enlarged tender liver + shifting dullness(ascites) + Odema lower limb

No lung congestionso, no dyspnea , no orthopnea etc.

If left sided heart failure congestive lung symptoms :

Stagnation in left atriumstagnation in lung congestive lung symptoms

If neglectedstagnation in pulmonary Rt V F ( ) ..LtRt..Rtlt(Lt VF)eart failure

Low cardic output symptoms + auscultations + 2 variables systemic venous congestion manifestations right sided heart failure

or manifestations of pulmonary venous congestion left sided heart failure

And if both( 2&3)biventricular failure =congestive heart failureuscultation- In alltachycardia As a compensation(stroke volume heart rate to keep COP )ventricle.. ..vibrationchorda tendenea


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ventriclediastole- & at end of diastole atrial contraction another sound

So, either 3rd or 4th additional sound- Tachycardia with 3rd or 4thcalled gallop rhythm

If best heard on tricuspidright ventricular failureIf best heard on mitralleft ventricular failure

If all throughbiventricular failure

low cardic output+congestive lung symptoms tricuspidgallop

So, right ventricular failure low cardic output+systemic venous congestion+congestive lung symptoms+ gallop on mitral Lt V F

3- If all biventricular F ( congestive heart failure )ow cardic outputung or systemic..

symptoms :dyspneacongestive lung symptoms -

Or refuse feedingpoor feeding So, poor Wt gain- ()

tachypnea -signs signs

Generalized odema even puffiness

Tender hepatomegaly if right VF

Pitting odema + ascites

- Crepitation in chest if left side VF+ gallop , tachycardia ..etc.


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InvestigationsOnly to know underlying etiology .. But, heart failure itself is a clinical diagnosis only

Chest X -ray may pneumonia

ECG enlargement or not

ECHO- Blood gases as distressed

Serum electrolytes

TreatmentRest + 3 D + SAVO

Rest heart rate Diet

Small frequent meales ..dyspepsia

Low salt diets load on heart + Low in fat ( ) Diuretics

o Lasix should give K with it o May aldactone ( without K )

(acute stage)o May combination of both if severe

- Digitalis

- Dose ..digitalization(Loading)Single dose0.05 mg / kg single dose( ( rapid digitalization (( ..20 Kg0.05 X 20=1 mg digitalis- At first Give 1/2 mg ( 1/2 dose )slowly IV

- Thengive 1/4 mg after 8 hours ..

- Thengive 1/4 mg after another 8 hours ( after 16 Hrs of the 1 st dose )

Thenafter another 8 hours give maintenance dose ( any maintenance = 1/5 loading dose )

o, here in our Ex. 1/5 X 0.05 = 0.01 mg / kg / day ollow upKigitalis toxicity


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Cardiology Prof. Dr. Abo El-Asrar ( )Inter ventricular septum( (lumenventricle limitation of movement

- in diastole pressure never reach 0 so, Bl. Volume received by Lt. Ventricle from atrium- during systole contraction of both septum & ventricle ..valve..Aortaclosure of infandibulum of Aorta

Sub valvular stenosislow COP + all other manifestations of HF

( notropic..o tachycardia and no gallop Beta blocker -

- Restrictive cardimyopathy Limited contraction & limited relaxation diastole ..Pressurezero no good filling systoleNo full contraction heart-lung transplantation ardio ardio..enetics

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Crdiology - Dr Abo-ElAsrar - By El Azhar Medical Students 2012

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