Rapitful Shqip

How would you investigate a patient with atrial septal defect ?  ECG  • Often has right axis deviation and incomplete right bundle branch block. • In ostium primum defects left axis deviation also occurs, whereas a junctional or low atrial rhythm (inverted P waves in inferior leads) occurs in sinus venosus defects. Chest radiography  • Prominent pulmonary arteries (large pulmonary conus). • A peripheral pulmonary vascular pattern of 'shunt vascularity' (in which the small pulmonary arteries are especially well visualized in the periphery of both lungs). • Small aortic knob. • Enlarged right ventricle and right atrium. • 'Hilar dance' on fluoroscopy. Echocardiography  • Transthoracic echocardiography visualizes ostium secundum and primum defects but usually does not identify sinus venosus defects. • Sensitivity can be enhanced by injecting microbubbles into a peripheral vein. after which the movement across the defect can be seen. • Trans-oesophage

What is Fallot's trilogy ?  Atrial septal defect, pulmonary stenosis and right ventricular enlargement.

What is Lutembacher syndrome ?  ASD with an acquired rheumatic mitral stenosis (Arch Mai Coeur 1916; 9: 237).

What do you know about the embryology of atrial septal defect ?  There are seven septa involved in the partitioning of the heart. Three form passively (i.e. when an area of tissue forms a septum because of the rapid growth of con-tiguous tissue); these include the septum secundum at the atrial septum, the mus-cular portion of the ventricular septum and the aorticopulmonary septum. The actively formed portions of the septa of the heart include the septum of the atrio-ventricular canal, the conal septum and the truncal septum. The atrial septum begins as a passively formed septum; however, active growth from the endocardial cushions completes the septum.

In which conditions is an abnormally widely split second sound present ?  • ASD, VSD, pulmonary regurgitation (clue to increased right ventricular volume).  • Pulmonary stenosis (due to increased right ventricular pressure). • Right bundle branch block (due to right ventricular conduction delay). • Mitral regurgitation, VSD (due to premature left ventricular emptying).

What is the mechanism of the fixed split second sound ?  In normal individuals on inspiration there is a widening of the split between the two components of the second sound due to a delay in closure of the pulmonary valve. In ASD the effect of respiration is eliminated due to the communication between the left and right sides of the heart.

At what age does reversal of the shunt occur ?  Usually after the end of the second decade.

What is Holt-Oram syndrome ?  There is an ostium secundum ASD with a hypoplastic thumb and an accessory phalanx. In addition, the thumb lies in the same plane as the other digits (Br Heart J 1960; 22: 236). The inheritance is autosomal dominant and is associated with mutations to chromosome 12q2 (N Engl J Med 1994; 330:885-91 ).

What is the importance of patent foramen ovale ?  The prevalence of patent foramen ovale is significantly higher in patients with stroke (N Engl J Med 1988; 318: 1148 52).

What do you understand by the term 'patent foramen ovale' ?  In the fetus, the right and left atria communicate with each other through an oblique valvular opening, which is called the foramen ovale. The foramen ovale persists throughout fetal life. After birth, the left atrium receives blood from the lungs and the pressure in this chamber becomes greater than that in the right atrium; this causes the closure of the foramen ovale.

What are the types of atrial septal defect (ASD) ?  • Ostium secundum detect accounts for 70% of the cases. The defect is in the middle portion of the atrial septum and is usually 24 cm in diameter (incomplete right bundle branch block pattern, QRS axis rightward). • Sinus venosus type is a defect in the septum just below the entrance of the superior vena cava into the right atrium (leftward P wave axis so that P waves are inverted in at least one inferior lead). • Ostium primum type is a defect in the lower part of the septum, and clefts may occur in the mitral and tricuspid valves (QRS axis leftward). A junctional or low atrial rhythm (inverted P waves in the inferior leads) occurs with sinus venosus defects.

What are the echocardiographic features of mitral valve prolapse ?  • M-mode: abrupt posterior displacement of the posterior or sometimes both valve leaflets in mid or late systole. • 2D: systolic displacement of one or both mitral valve leaflets into the left atrium. John Barlow, South African Professor of Cardiology. Celia Oakley, Professor of Cardiology, Hammersmith Hospital, London (Q J Med 1985; 219: 317)

What are the complications of mitral valve prolapse ?  • Severe mitral regurgitation. • Arrhythmias: ventricular premature contractions, ventricular tachycardia, paroxysmal supraventricular tachycardia. • Atypical chest pain.  • Transient ischaemic attacks (TIAs), embolism. • Infective endocarditis in those with mitral regurgitation. • Sudden death.

What are eponyms for mitral valve prolapse (MVP) ?  Barlow's syndrome (Bt Heart J 1968; 30: 203), click-murmur syndrome, floppy mitral valve.

How would you treat organic tricuspid regurgitation ?  Surgically, by valve plication or annuloplasty, or valve replacement.  J.M.R. Carvallo, Mexican cardiologist who worked in Mexico City (Rivero-Carvallo JM 1946 Signo para el diagnostico de las insuficiencias tricuspideas. Arch Inst Cardiol Mex 16: 531).

What are the causes of tricuspid regurgitation ?  • Functional: pulmonary hypertension, congestive cardiac failure.  • Rheumatic (associated with mitral and/or aortic valve disease). • Right heart endocarditis as in drug addicts. • Uncommon causes: carcinoid syndrome, Ebstein's anomaly, endomyocardial fibrosis, infarction of right ventricular papillary muscles, tricuspid valve prolapse, blunt trauma to the heart.

Which patients should receive a bioprosthetic valve ?  • Those unable to take anticoagulants and those not expected to live longer than the predicted lifespan of the prosthesis.  • Patients over the age of 70 years who require an aortic valve replacement as the rate of degeneration is relatively slow in these patients.

Why are mechanical valves increasingly preferred over bioprosthetic valves ?  Two randomized controlled trials have shown a lower rate of reoperation with mechanical prostheses than with porcine prostheses, and a smaller increased risk of anticoagulant-related bleeding.

What kind of valve would you use to replace the aortic valve ?  Mechanical valves are used in younger patients in whom the risk of porcine valve failure is higher and for whom durability of the valve is of paramount importance. Porcine valves may be considered for elderly patients whose lite expectancy may not exceed that of the prosthesis.

What kind of valve would you use to replace the mitral valve ?  A mechanical prosthesis.  Patients in whom the risk posed by anticoagulants is unacceptably high may receive a bioprosthesis, but at the increased risk of further operation at a later date.