CARDIOLOGY

Clinical Cases
Page

A.S. & A.R.

M.S. & M.R.
Double Aorta & Double Mitral
T.R.
Valve Replacement Cases
Congenital Heart Diseases
Closed Heart Surgery Cases
Cardiology Scheme

1
3
5
6
7
9
11
12

Aortic Stenosis (A.S.)

Etiology :

Aortic Regurg (A.R.)

Congenital ..
The COMMONEST Cause in Egypt is Rheumatic Fever

Rheumatic Fever ..
Calcification ..
H/O :

Low COP .. up to Syncope (

Palpitation (

then, ANGINAL PAIN .. for a Long Period

* if Left Ventricular FAILURE occur Dyspnea (

General Examination :

*here, its Useless

Peripheral Signs of A.R. (

Local Examination :
(Inspection, Palpation
& Percussion)

*here, its Useless

Apex Sustained Apex (Tension Overload)

Apex Hyper-dynamic Apex (Volume Overload)

Aortic Pulsations

Normal Sound
Murmur

S2 : Muffled (

S1

* if Left Ventricular DILATATION occur Apex will Shifted Outward & Down
Normal (

S1

MURMUR

Dancing Precordium

) it Depends on the Etiology

S2

S1

S1

S2
MURMUR

Auscultation :

Clinical

) but its VERY LATE

MURMUR
Time
Character
Site
Propagation

Mid Systolic (Systolic Ejection)

Harsh
1st Aortic Area
To Carotid & to Apex (

MURMUR
+ Thrill

Early Diastole
Soft Blowing Murmur (
2nd Aortic Area

No Thrill

by

N.B. The SEVERITY of the Disease is Detected by Length of Murmur & Intensity of S2

*Precaution

Additional Sounds
Complication
Investigations
Treatment
Oral Qs

Search for A.F. & Pulmonary HTN in The Cases

by Scheme
by Scheme
The Most Common Cause of A.S. in Egypt is Rheumatic Fever
The Most Common Cause of A.S. in the World is Congenital

How Dose the Case could be Isolated A.R. while the Etiology is Rheumatic Fever ?
- maybe it is One of the Rare % of Rh. Fever
- maybe it is Isolated in Auscultation .. but in ECHO its Double Leision
The Best Investigation is ECHO & DOPPLER
The Best Investigation is ECHO & DOPPLER (N.B. DOPPLER is More Imp. here)
The Assessment of Severity is done by Pressure Gradient (ABP)
The Assessment of Severity is done by its Effect on the Lt. Ventricle
if More than 50 Difference >> its Severe
- for Degree of Dilatation (Dimensions) & for Function (Ejection Fraction)
The Initial Starting Treatment for these Cases is PROPHYLACTIC (Prevention of Rheumatic & IEC)

The Treatment of Angina is Sub-Lingual Nitrate (

)
The Patient Can go for Interventional Treatment with 2 Conditions must be fulfilled
is the Lesion is Isolated & Non-Calcified
Balloon-Aortic-Valvo-Plasty (
)

The Treatment Which Improves the Regurg is Small Dose of Vaso-Dilator (Captopril)
The Patient Can NOT go for Interventional Treatment
The 2 Syndromes Could Cause A.R. are Marfan $ & Ehler-Danlos $
The 2 Infection Diseases Could Cause A.R. are Syphilis & Infective Endocarditis
in A.R. Cases Which Joints Do You Prefer to Exam for Diagnosis ?
Peripheral Joints : - Big Joints .. for Rheumatic
- Small Joints .. for Rheumatoid or Marfan $
Axial Joints : for Ankylosing Spondylitis

-1-

in case of Aortic Regurg (A.R.) :

the Apex :

Heart Sound :

Lt. Vent.
Volume Overload
Lt. Vent. Dilatation

Localized
Hyper-dynamic
Shifted Outward & Down

it Depends on the Etiology

In Rheumatic Fever
Heart Sounds : Muffled

Here,
Heart Sounds : Accentuated

if theres a Patient .. with (A.R. Murmur) + (M.S. Murmur) .. whats the Possibilities for that ?!

1-

He is an A.R. Patient .. with an ORGANIC A.R. Murmur , with FUNCTIONING M.S. Murmur .. called [Austin-Flint Murmur]
As the Blood come back from Aortic Valve .. could Prevent Mitral Valve from Opening

2-

He is a Patient with A.R. +

FUNCTIONING M.S. Murmur

M.S. Lesions

This will affect the Peripheral Signs of A.R. & Decrease it

This mean that the Etiology is Rheumatic Fever .. Not a Marfan $ .. & even if you find Marfan Signs in the case this make it (Marfanoid NOT Marfan $)

ORGANIC M.S. Murmur

No Opening Snap
+ No Thrill
Theres Opening Snap

+ Thrill

-2-

Mitral Stenosis (M.S.)

Mitral Regurg (M.R.)

Stages
Introduction for M.S. :

Etiology :

what is the Effect of Pregnancy on M.S. Patient ?

Dyspnea 1- Asymptomatic
M.S. Murmur Only
Low COP 2- Pulm. Congestion
Systemic Venous Congestion (Mainly Edema) 3- Pulmonary HTN
+ P. HTN
+ if Rt. Vent Dilate Retract the Tricuspid Ring
4- Rt. V.F.
T.R. Murmur (may be heard)
Rheumatic Fever in 99% of cases

This the ONLY Disease which ISOLATED LEISION in Rheumatic Fever

H/O :

) Low COP (

DYSPNEA (

General Examination :

Pulse (for A.F.)

+ Malar Flush

Decubitus (for Orthopnea)

what it the Mechanism

its Not Specific

D.D. from Systemic Lupus Butterfly Rash

Local Examination :
(Inspection, Palpation
& Percussion)
Clinical

Normal Sound
Murmur

2nd Rheumatic Fever, 3rd Ischemia (Papillary Muscle Dysfunction)

Palpitation (
)
& After a LONG PERIOD OF TIME L.V.F. may occur (

Stage

Edema in L.L.
(for Rt. Sided H.F.)
Left Atrial Enlargement

will Add +1 Stage in NYHA Classification until the Labour

So, Pregnancy is NEVER Allowed in Patient with NYHA 4

The COMMONEST Cause in Egypt is Mitral Valve Prolapse,

) Systemic Congestion (Edema)

A.F. (

*here, its Useless

Auscultation :

Site
Propagation
by

Left Atrial Enlargement

Right Vent. Enlargement (Never Left Vent.)

Left Vent. Enlargement (Never Right Vent.)

Apex Slapping Apex

S1 : Accentuated

Apex Hyper-dynamic Apex & Shifted Outward and Downward

S1 : Muffled
S1 may be Accentuated in MR if its Double Mitral Only

S1

S1 may be Muffled in MS if theres Calcification or its Double Mitral

Thrill

S1
S2

MURMUR

Mid Diastolic with Pre-systolic Accentuation

Rumbling

Apex
Localized

Effect of A.F. in Auscultation :

Complication
Investigations

Treatment

MURMUR

S2
S1

Pan Systolic
Soft (in 80% of cases) or Harsh
Apex
To Axilla (in Anterior Leaflet Disease) & to Base (in Posterior Leaflet Disease)

- S1 Variable Intensity
- Murmur No Pre-systolic Accentuation
- O.S. it Persist (
)

+ Thrill
*Precaution : its a LOW Pitch Sound .. Heard by the CONE +

Additional Sounds

# if your case is M.R. .. How to Suspect its Double Mitral !

from H/o : starting Dyspnea
from General Exam. : theres A.F.
from H/o : theres Rt. Vent. Enlargement , S1 + (theres 2 Murmurs)

S1
Time
Character

+ Thrill

(& TIME it)

Opening Snap (O.S.)

M.S. is Rare to Complicate with IEC

Search for A.F. & Pulmonary HTN in The Cases

M.R. is Rare to Complicate with A.F.
The Best Investigation is ECHO & DOPPLER
4- Catheter :

- ECHO & DOPPLER

to detect if its Reversible or Ir-reversible P. HTN The Assessment of Severity is done by its Effect on the Lt. Ventricle
- for Degree of Dilatation (Dimensions) & for Function (Ejection Fraction)
- Reversible (due to V.C.)
- while Ir-reversible (due to Fibrosis)

1- ECG
2- X-ray
3- ECHO & DOPPLER
The Main 4 Points in ECHO Report are :
- Valve Area (Assessment of Severity) (<1cm. = Tight MS.)
- Pulmonary Pressure
Vaso-Dilator
- Mitral Score
Reversible
- is theres a Thrombus or Not (By TEE)
The Initial Starting Treatment for these Cases is
PROPHYLACTIC (Prevention of Rheumatic & IEC)
Medically

Interventional

Rest, Salt Retention & Diuresis ... for Dyspnea

Balloon-Mitral-Valvo-Plasty (Trans-Septal Technique)

Medically

The Initial Starting Treatment for these Cases is

PROPHYLACTIC (Prevention of Rheumatic & IEC)

Small Dose of Vaso-Dilator (Captopril)

Surgery

Valve Replacement Surgery

-3-

Pulmonary Hypertension (P. HTN)

Stage 2:
Dilatation of Pulmonary Artery
withOut Dilatation of Pulmonary Valve

Stage 1:
++ Pressure in Pulmonary Artery

Stage 3:
Retract the Pulmonary Valve
(Pulmonary Valve Regurg)

++

S1

Accentuated S2

Accentuated S2

Accentuated S2
& Diastolic Shock

S1

Palpable S2

S1

S1

S1
Diastolic MURMUR

S1

Systolic MURMUR
& you can Find a Pulmonary Pulsation & Dullness

Move Your Stethoscope from the Left of the Sternum (Pulmonary Area)
to the Right of it (Aortic Area)
You will Find S2 ++++ at Pulmonary Area than Aortic Area
this = Accentuated S2 with Accentuated Pulmonary Component

Diastolic MURMUR of Pulmonary Valve Regurg

=
Graham Steell Murmur
[is a heart murmur typically associated with pulmonary regurgitation.
It is a high pitched early diastolic murmur heard best at the left sternal
edge in the second intercostal space with the patient in full inspiration]
This Murmur is in Unstable Patient (so, Actually You will NOT hear it)

-4-

Double Aorta

Double Mitral
Rheumatic Fever ONLY
via Fibrosis

Affect the
Commissures
Stenosis
Affect the
Cusps

Double Lesion

Regurg
Low COP .. up to Syncope (
) + Palpitation (
2 Murmurs should be heard

&Take Care! The Case may be A.R. Only .. Not Double Aorta
in that A.R. Murmur is the Organic Diastolic Murmur
while with Volume Overload
it will produce Functioning Systolic A.S. Murmur
*so you Should Diff. between Functioning & Systolic A.S. Murmur

H/O
Examination

DYSPNEA (
) + Palpitation (
2 Murmurs should be heard
S1:

Double Mitral
M.R.
- by H/O : Dyspnea start very Early before other Symptoms
- by General Exam : A.F., Orthopnea

*N.B. M.R. Produce Orthopnea in Terminal Stage

Organic A.S.
Harsh
Thrill
H/O of Low COP
- by Local Exam : Rt. Vent. Enlargement , Pulmonary HTN

Functioning A.S.
Soft

+ S1 Accentuated
Peripheral Signs of A.R.
S1
Predominance Determined by
*if Marked Signs A.R. is Predominant
*if Accentuated S1 M.S. is Predominant

-5-

 Tricuspid Regurg

(T.R.)

The Only Case for Rt. Sided Lesions

- by H/O : Symptoms of Systemic Venous Congestion

- by General Exam : Signs

of Systemic Venous Congestion :

1 Neck Veins
2 Pulsating Liver
3 Edema + Ascites
- by Local Exam : Rt. Ventricular Enlargement & maybe Rt. Atrial Enlargement + T.R. Murmur

T.R. is NEVER to be Isolated in the Exam ..

its ALWAYS ASSOCIATED with ADVANCED Mitral Valve Disease (MVD)
so, when you have a case of MVD in the Exam .. Search for :

T.R.

Systemic Venous Congestion

- by H/O :
- by General Exam : Edema + Ascites
- by Local Exam : Rt. Ventricular Enlargement

But it Just let you SUSPECT ONLY .. as it may be an ADVANCED MVD reaching the Rt. Vent. Failure Level
N.B. its Similar to M.R. Murmur
Its Only by Hearing a T.R. Murmur by the Stethoscope
Time : Pan Systolic
Character : Soft or Harsh

T.R.

Site of Max. Intensity : Tricuspid

Area (Lower En of the Sternum to the Left)

Propagation : to the Base of Heart (BUT NEVER Propagate to the Axilla )
by : +++ by Respiration (as any Rt. Sided Lesion) [this called Carvallo's sign]
1 Neck Veins : in T.R. its - Level : Congested Pulsating
- Wave Form : Systolic Expansion
2 Pulsating Liver : Technique
3
Tenderness

1- Non specific
2- Non specific
3- Specific

1
Rib
Costal Margin

-6-

N.B.

Valve Replacement Cases

we done A Replacement Surgeries for the Lt. Sides Valves

in a Very Very RARE Conditions ..
due to LOW PRESSURE in Rt. Side + if Complications occur After
Surgery they are FATAL (as Pulmonary Embolism)
So, Most Probably its Mitral or Aortic Valve Replacement

- by H/O :

Valve Replacement Surgery

- by Exam : Median

Sternotomy Scar
+ Metallic Sound (Auscultation)
- by H/O:

- by Examination :
- by Local Exam :

Load or Metallic Sound

1

- which Valve is Replaced

- is The New Valve is

Functioning or theres
Mal-Function occur

- by Timing :
if Patient Complain from Dyspnea EARLY
Mitral Most Probably
if Patient Complain from Anginal Pain & Palpiataion
while Dyspnea is LATE Aortic Most Probably

in S1 = Mitral Valve Replacement

in S2 = Aortic Valve Replacement
- by Local Exam :
- hearing a MURMUR Mal-Function occur
N.B. theres may be a Functional Murmur
heard [Systolic, Soft, Short, Faint, Localized]

So, Mal-Function occur

- by General Exam :
- is there are

Complications Occur
After Surgery or Not

Normal Neural Examination

& you feel All Peripheral Pulsations
No Pallor or Jaundice
No Hyper-Thermia or Clubbing

a- Thrombo-Embolism
b- Hemolytic Anemia
c- Prosthetic Valve Endocarditis

N.B. theres No Complicated Pt. will be in Our Exam So, Theres Always No Major Complications Found
- what is the Investigations you want do for this patient

- what is the Golden Stander in Investigations

- what is the Treatment you want do for this patient

?
?
?

by Scheme

ECHO *esp. TEE (Trans-Esophageal Echo)& DOPPLER

by Scheme

*but, we Give Anti-Coagulant Drugs for Life

& watch by INR (it should be 2-3 Times of Normal)

-7-

3
Cage & Ball

Tilting Disk

Bi-Leaflet

Atrium

Atrium

Atrium

Ventricle

Ventricle

You will Know Valve is Replaced ..

- by Anatomical :
Vertibral Column

Ventricle

Stroke .. Causes after Valve Replacement Surgery :

- Valve Replacement Related :
Anti-Coagulant After Surgery : will Thrombo-Embolism incidence

but it will Cerebral Hemorrhage incidence

Prosthetic Valve Infective Endocarditis Vegetations

Aortic Valve
Mitral Valve

- Non-Valve Replacement Related :

e.g. Astherosclerosis

& by the Lesion in the Heart

Causes of Un-equal Pulse Volume in Patient with Valve Replacement

A.F.

(sending Thrombus to the Hand)

Valve Replacement Related :

- Thrombus .. (if Patient didnt Receive Anti-Coagulant Regularly)
- Vegetation of Bacteria on Prosthetic Valve

Association :
- Cervical Rib
- Aneurism
- Pancoast Tumor

-8-

Congenital Heart Diseases

Pulmonary Stenosis (P.S.)
*its ALWAYS CONGENITAL ..
Rh. Fever Never Affect Pulmonary Valve

1 Anatomy

There are Valvular, Sub-Valvular

& Supra-Valvular Lesions

Ventricular Septal Defect (VSD)

[The Commonest Heart Disease]

There are Small or Big Lesions

Fallot Tetralogy (F4)

[The Commonest Cyanotic Heart Disease]

Congenital
Component
Its a Result

2 Hemo-Dynamic

P.S. is Similar to A.S. .. Except in :

- Site of Murmur
- Chamber Enlargement
- ttt of Choice

3 Complications
4 H/O (Symptoms)

Low COP Symptoms

N.B. Noonan syndrome could be Association:
1- Stunted Growth
2- Sub-normal Mentality
3- Congenital Heart Disease .. esp. P.S.
4- Skeletal Deformities; e.g. Osteo-Arthritis
5- Facial Features

Heart Volume Overload in 2 Sides

Lung Plethora
Systemic Circulation Low COP

Infective Endo-Carditis (IEC) & at Late Stage : Eisenmenger's Syndrome

it Depends on the Size of Defect
if Small Lesion Asymptomatic
if Very Big Lesion
if Moderate Lesion Palpitation, Low COP

& Dyspnea

1 Infundibular P.S. not in the Valve Dynamic Stenosis

2 Anterior Position Overriding Aorta
3 Very Big VDS
4 Very Mild ++ Rt. Vent. Undetected Clinically
Non-Oxygenated Blood in Aorta = Cyanosis

Infective Endo-Carditis (IEC)

1 Cyanosis almost this is his Complaint
Its Onset : Shortly After Birth (from few weeks to Months)
NOT Since Birth due to presence of PDA
[Cyanosis Shortly After Birth Pathognomonic to F4]
2 Squatting
Pathognomonic to F4
3 Cyanotic Spells Only in SEVERE Cases
3 Main Causes
1 Exaggeration
2 Coldness
3 Infections

Effect
Spasm in Infundibular
(All Blood in Aorta is
Non-Oxygenated)

3 Main Results
1 Deeply Cyanotic
2 Dyspnea
3 Convulsions

ttt of Cyanotic Spells:

1 Put the Patient in Squatting Position
2 O2 Therapy
3 Drugs : Blockers are the Drug of Choice here

-9-

5 Examination
(Signs)

Normal Sound
S2 : Muffled

Murmur
Time: Systolic Ejection
Character: Harsh
Site: Pulmonary Area
Propagation: To Carotid & to Apex

+ Chamber
Enlargement
(Rt. Vent.)
Rt. Vent.

Ejection Click
Best Investigation is : ECHO-Doppler
& Assess the Severity by Pressure Gradient

7 Treatment

General Exam. : Cyanosis depends on Severity

& Clubbing depends on Duration
+ if Severe F4 Stunted Growth

Local Exam. :

Local Exam. :
1
Infundibular P.S. P.S. MURMUR

By hearing the MURMUR

Additional Sounds

6 Investigations

General Exam. : No Cyanosis & No Clubbing

Balloon-Pulmonary-Valvo-Plasty is the ttt of Choice

[ the Defect Size Murmur Sound]

Time: Pan-Systolic
Character: Harsh
1
Site: Lt. Para-Sternal Area
Propagation: To All Auscultatory Areas (
by: Exercise
+ Thrill
Rt. Vent. or Lt. Vent. or BOTH
2 Chamber Enlargement
For Eisenmenger's Syndrome
3 Pulmonary Pressure
as Pulmonary HTN
ECHO-Doppler .. it will show :
The Defect
Any Chamber Enlargement

*Pulmonary Pressure
Medical ttt : Prevention of IEC (Antibiotics Before & After Any minimal Procedures)
Interventional ttt : Closure by Umbrella (via Catheter)
Definitive ttt : Open Heart Surgery .. Indicated to :
Patient who are Liable to Develop Eisenmenger's Syndrome
(Detected by Measuring Pulmonary Pressure)
[if Pulmonary Pressure = Systemic Pressure Close the Defect]

2 Anterior Position Overriding Aorta S2

3 Very Big VDS
4
Very Mild ++ Rt. Vent.
)

E.C.G.
X-ray
ECHO-Doppler
Medical ttt : Prevention of IEC (Antibiotics Before & After Any minimal Procedures)

& for Cyanotic Spells give Blockers

Interventional ttt : Useless
Definitive ttt :
Closed Heart Shunt OperationS .. Shunt from Aorta to Pulmonary
Surgery
The most Famous is Blalock-Taussig Operation
Open Heart
Total Correction Operation
Surgery
1 Infundibular P.S. Resection
2 Overriding Aorta Closed in Rt. Vent.
3 Very Big VDS Very Big Patch
4 Very Mild ++ Rt. Vent.

Onset of Cyanosis & its Relation to Diagnosis :

TGA
since Birth
Shortly after days Weeks to Month
F4
during Childhood (3-5 Years)
F3
Eisenmenger's Syndrome
Teenage (13-19 Years
Chest Causes
Older than that
N.B. TGA usually die after short period of birth .. unless its associated with Lt. to Rt. Shunt e.g. VSD

-10-

 Closed Heart

Surgery Cases

What Happen in M.S. ?!

For Mitral Stenosis ONLY

(Closed Mitral Valvotomy or Commissurotomy)

- by H/O : Severe Symptoms (Dyspnea) Not

Indications
Prerequisites

Contra-Indications

?
?

Controlled Medically
or Dangerous Symptoms (Hemoptysis)
- by Investigations : ECHO-Doppler .. if Valve Area LESS than 1 Cm.
Isolated Lesion (No M.R.) & Not Calcified
If Double Lesion or Calcified

Closed Commissurotomy

Rigid Cusps but Liable in the Center

in Valve Opening : it Give Opening Snap
in Valve Closure : it Give S1

& Both are Disappear with Calcification

# Murmur Caused by the Stenosis itself

- by H/O:

Fibrosis in Rh. Fever

- by Examination :
- by Lateral (Infra-Mammary)

Thoracotomy Scar

1- for Follow-up

2
&
3

No Murmur ..
but still there are Opening Snap & S1
2- for Complications After Surgery (e.g. converted into M.R.)
Palpitation
Systolic Murmur
3- for Recurrence .. (Re-Stenosis - M.S.)
Dyspnea
Diastolic Murmur
99% its Recurrent Rheumatic Activity (Re-Fibrosis)
even if Patient didnt give a H/O of Rheumatic Activity [Subclinical Attack]
1% Under-Correction from Surgeon

- in case of Re-Stenosis ..
what is the Causes

- in case of Failed Commissurotomy

what is the Treatment

Replacement or Open Heart Surgery

? Valve
N.B. Commissurotomy is useless now
? due to Balloono-Plasty is now Considered the ttt of Choice

- is Incidence of Commissurotomy or

-11-

Cardiology Scheme
# How to Reach the Diagnosis ?!
from H/O 1 Dyspnea (

) from the Start M.S.

) in the course of Disease A.F. most probably with M.S.

2 Ir-regular Palpitation (

) T.R. (have to be associated with MVD)

3 Systemic Venous Congestion Symptoms (

) Angina Pain from the Start A.S.

4 Low COP Symptoms (

) from the Start Regurge (M.R. or A.R.)

5 Regular Palpitation (
6 Cyanosis (

) + Squatting (

) from the Start F4

) Etiology is Congenital

7 Young Onset Complain (

from

General
Exam

1 Blood Pressure : Systole / Diastole = Pulse Volume > 60 A.R. (& search for Other Peripheral Signs of A.R.)
2 Pulse : Ir-regular A.F. M.S. (& Revise the between A.F. & Extra-Systole)
3 Orthopnea (
) M.S. (
)
4 L.L. Edema or Ascites T.R. (have to be associated with MVD)
5 Cyanosis or Clubbing F4
6 Very Tall & Thin Patient Marfan $ (& search for Other Signs of Marfan $) A.R.
7 Stunted Growth (
) Congenital (either its The Cause esp. if Sever, or its Association as Down $ or Noonan $)

from

Local Exam

1st Auscultation

1st Put the Stethoscope on 2nd Aortic Area :

If you Hear a Murmur

Systolic Murmur
Then you have to move in the 4 Directions to get the SITE OF MAX. INTENSITY

Apex
M.R. (Posterior Leaflet)
if Site of Max. Intensity is Pulmonary Area P.S.
if Site of Max. Intensity is
Tricuspid Area T.R. (associated with MVD)
if Site of Max. Intensity is
1st Aortic Area + reaching the Carotid A.S.
if the Sound is wherever you Move VSD
if Site of Max. Intensity is

Diastolic Murmur
Then its A.R.
+ Peripheral Signs
will lead you

2nd Put the Stethoscope on Apex :

If you Hear a Murmur = MVD
Now, Search if it Localized or Propagated .. by moving the Stethoscope to the Axilla

Propagated to Axilla

Localized

M.R. (Anterior Leaflet)

M.S.

+ its Systolic

+ its Diastolic

P.S.

+ A.S.

3
2nd Aortic Area
4

MVD

Apex

T.R.
then Inspection +

to Detect Any Chamber Enlargement

Palpation
& Percussion

-12-