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Edinburgh Student Surgical Society FINALS DAY: CARDIOLOGY BONUS EDITION! Dr Laura Clark FY3WHAT WE'LL COVER: Valvular Heart Disease Infective Endocarditis VALVULAR HEART DISEASE Aortic Stenosis Aortic Regurgitation Mitral Regurgitation Mitral Stenosis Tricuspid Valve Pulmonary ValveCase 1 An 80-year-old lady presents with a 2-month history of progressive dyspnoea, exertional chest pain and light-headedness. 1 year ago, she was able to go for walks with her family without issue. She has noticed a gradual reduction in her exercise tolerance since then. PMH: Hypertension Hypercholesterolaemia CKD 3 Penicillins - Rash Amlodipine 10mg OD Simvastatin 20mg NOCTE FH: Mother died of a strokeCase 1 SH: Minimal alcohol Smokes 10 cigarettes per day Lives alone, but well supported by her family. On examination: A - Patient's own B - Breathless on mobilising to the bed, chest clear, RR 20, sats 94% on air C - WWP, low volume carotid pulse, HR 78, BP 156/100 HS I + Ejection systolic murmur, which radiates to the carotids D - GCS 15, afebrile E - Pitting oedema to mid calvesWhich investigations would you order? A - Bloods B - ECG C - CXR D - Transthoracic echo E - Transoesophageal echoWhich investigations would you order? A - Bloods B - ECG C - CXR D - Transthoracic echo E - Transoesophageal echo Essentially the same for all valve diseaseCase 1 Investigations: Bloods: Hb 120, eGFR 50 (baseline), otherwise unremarkable ECG: Sinus rhythm, LVH, nil acute ischaemic changes CXR: Clear Echo is still awaited.What's the main differential diagnosis? A - Mitral stenosis B - Aortic stenosis C - Aortic regurgitation D - Mitral regurgitation E - Tricuspid regurgitationWhat's the main differential diagnosis? A - Mitral stenosis B - Aortic stenosis C - Aortic regurgitation D - Mitral regurgitation E - Tricuspid regurgitationAortic Stenosis Causes: Predominantly due to age-related degeneration/calcification (tricuspid or bicuspid valves) Others - Rheumatic heart disease, congenital causes Symptoms: Syncope/light-headedness Angina Dyspnoea (Aortic stenosis makes you SAD!) Examination Findings: Ejection systolic murmur - harsh murmur, loudest over aortic region (right 2nd intercostal space) and can radiate to carotids. Severe aortic stenosis can lead to absence of second heart sound (aortic valve cannot close) Low volume pulses and narrow pulse pressure Signs of complications - irregular pulse (AF), signs of heart failureWhat's the best management for this lady? A - Commence Furosemide B - Smoking cessation C - Commence ACEi D - Watch and wait approach E - Urgent referral for aortic valve replacementWhat's the best management for this lady? A - Commence Furosemide B - Smoking cessation C - Commence ACEi D - Watch and wait approach E - Urgent referral for aortic valve replacementAortic Stenosis - Management Asymptomatic patients: Generally, watch and wait approach. Mortality significantly increases once patients are symptomatic. Can be offered intervention if meet echo criteria (do not need to know this for finals!) Symptomatic patients: Referral for aortic valve replacement MDT decision re. TAVI vs surgical replacement Generally fit patients will be offered surgical replacement, while elderly, co-morbid* (high risk) patients will be offered TAVI. Younger (<65) patients offered metal valves Treat complications: Diuretics for heart failure Anti-coagulation for AF *Patients will often have angiography as part of their work-up. If they have significant coronary artery disease, they will have a surgical procedure to replace their valve and perform bypass at the same time.Case 2 A 61-year-old male referred by his GP, with a 6 month history of fatique and exertional dyspnoea. Over the last couple of weeks, he has been sleeping with more pillows than previously. PMH: Hypertension T2DM NKDA Amlodipine 10mg OD Metformin 500mg BD FH: Father had MI in his 50sCase 2 SH: Works as an electrician Drinks 6 pints on a weekend Non-smoker On examination: A - Patient's own B - Nil dyspnoea at rest, bibasal creps, RR 20, sats 94% on air C - WWP, normal volume carotid pulse, HR 84, BP 145/96 HS I + II + Pansystolic murmur, radiating into the axilla D - GCS 15, afebrile E - Pitting oedema to mid calvesWhat's the main differential diagnosis? A - Mitral stenosis B - Aortic stenosis C - Aortic regurgitation D - Mitral regurgitation E - Tricuspid regurgitationWhat's the main differential diagnosis? A - Mitral stenosis B - Aortic stenosis C - Aortic regurgitation D - Mitral regurgitation E - Tricuspid regurgitationMitral Regurgitation Causes: Post-MI, dilatory heart disease, Marfan's, infective endocarditis, Symptoms: Fatigue, dyspnoea, palpitations Examination Findings: Pansystolic murmur, soft murmur loudest over the apex, radiates into the axilla Can have soft S1 and/or third heart sound Signs of complications - irregular pulse (AF), signs of heart failureMitral Regurgitation - Management Asymptomatic patients: Generally, watch and wait approach. Can be offered intervention if meet echo or pulmonary artery pressure criteria (do not need to know this for finals!) Symptomatic patients: Referral to MDT Decision re. valve repair or replacement Patients offered mechanical vs tissue valve - Generally patients <65 are given metal valves Treat complications: Diuretics for heart failure Anti-coagulation for AFCase 3 A 23-year-old man presents with 1 month history of dyspnoea and lightheadedness. Describes palpitations for a while before hand, but put this down to exam stress. PMH: Nil known NKDA Nil regular medications FH: Nil knownCase 3 SH: Finished university last year. Works in finance Non-smoker Alcohol within recommended limits On examination: Tall, slim male. Wears glasses. A - Patient's own B - Breathless on mobilising, chest clear, RR 20, sats 94% on air C - WWP, collapsing pulse, HR 66, BP 130/64, pectus excavatum HS I+II+ early diastolic murmur D - GCS 15, afebrile E - Abdo SNT, nil peripheral oedemaWhat's the main differential diagnosis? A - Mitral stenosis B - Aortic stenosis C - Aortic regurgitation D - Mitral regurgitation E - Tricuspid regurgitationWhat's the main differential diagnosis? A - Mitral stenosis B - Aortic stenosis C - Aortic regurgitation D - Mitral regurgitation E - Tricuspid regurgitationAortic Regurgitation Causes: Aortic root disease - Marfan's, congenital, aortic dissection, infective endocarditis, rheumatic fever Symptoms: Palpitations, dyspnoea, angina, orthopnoea, PND, lightheadedness Examination Findings: Early diastolic murmur, accentuated by leaning forwards Can have 4th heart sound Collapsing pulse, increased pulse pressure, Quincke's sign (pulsating nails), femoral bruit, head nodding, heave, displaced apex beat Treatment: Treat endocarditis if cause Aortic valve/root replacementMatch the murmurs 1.IVDU with pansystolic murmur at left sternal edge 2.Mid-diastolic murmur, low pitched and rumbling 3.Ejection systolic murmur, radiates into the carotids 4.Early diastolc murmur, accentuated by sitting forwards 5.Pansystolic murmur, loudest at the apex A - Mitral stenosis B - Aortic stenosis C - Aortic regurgitation D - Mitral regurgitation E - Tricuspid regurgitationMatch the murmurs 1.IVDU with pansystolic murmur at left sternal edge 2.Mid-diastolic murmur, low pitched and rumbling 3.Ejection systolic murmur, radiates into the carotids 4.Early diastolc murmur, accentuated by sitting forwards 5.Pansystolic murmur, loudest at the apex A - Mitral stenosis B - Aortic stenosis C - Aortic regurgitation D - Mitral regurgitation E - Tricuspid regurgitationINFECTIVE ENDOCARDITISInfective endocarditis Disclaimer: Image not mine, but taken from previous presentation and cannot find the original sourceWhat are the major Duke criteria? A - Temperature >38 degrees B - Positive blood cultures C - Pre-disposing heart conditions D - Splinter haemorrages E - Endocardial involvementWhat are the major Duke criteria? A - Temperature >38 degrees B - Positive blood cultures C - Pre-disposing heart conditions D - Splinter haemorrages E - Endocardial involvementDuke Criteria Major: Positive blood culture - Typical organism in two separate blood cultures; persistently positive blood culture more than 12 hours apart; more than 3 positive cultures in 1 hour Endocardial involvement - Positive echo findings and vegetations, or new valve regurgitation Minor: Vascular or cardiac abnormality IV drug use Pyrexia >38 degrees Emboli or vasculitis Classic sequelae e.g. splinter haemorrhages, oslers nodes etc. Positive cultures with atypical/non-specific organisms Suggestive echo without major criteriaWhen does someone definitely have endocarditis? A - 1 major and 1 minor criteria B - 2 major criteria C - 1 major and 3 minor criteria D - 5 minor criteria E - 3 minor criteriaWhen does someone definitely have endocarditis? A - 1 major and 1 minor criteria B - 2 major criteria C - 1 major and 3 minor criteria D - 5 minor criteria E - 3 minor criteriaInfective Endocarditis Causes: Staph. and strep. predominant Steph aureus is most common Know which organisms are associated with certain presentation e.g. strep. mitis associated with dental extraction Sub-Acute: Persistent fever, tirednes, night sweats, weight-loss Splinter haemorrhages, Osler's nodes, Janewqay lesions, clubbing Acute: Severe, febrile illness Heart murmur, petechiae Embolic features, haematuria Absess on echoInfective Endocarditis Treatment MDT: involving cardiologists/physicians, microbiologists, surgeons Antibiotics usually as per micro advice IV antibiotics up to 4 weeks for natural valve; up to 6 weeks if prosthetic valve May need surgical removal of source of infection e.g. valve However, there are some general antibiotic regimes for finals ....Which antibiotics do you give for subacute infection? A - Flucloxacillin B - Benzyl penicillin C - Flucloxacillin and Gentamicin D - Benzyl penicillin and Gentamicin E - Vancomycin, Gentamicin and oral RifampicinWhich antibiotics do you give for subacute infection? A - Flucloxacillin B - Benzyl penicillin C - Flucloxacillin and Gentamicin D - Benzyl penicillin and Gentamicin E - Vancomycin, Gentamicin and oral RifampicinWhich antibiotics do you give for acute infection? A - Flucloxacillin B - Benzyl penicillin C - Flucloxacillin and Gentamicin D - Benzyl penicillin and Gentamicin E - Vancomycin, Gentamicin and oral RifampicinWhich antibiotics do you give for acute infection? A - Flucloxacillin B - Benzyl penicillin C - Flucloxacillin and Gentamicin D - Benzyl penicillin and Gentamicin E - Vancomycin, Gentamicin and oral RifampicinWhich antibiotics do you give with a prosthetic valve? A - Flucloxacillin B - Benzyl penicillin C - Flucloxacillin and Gentamicin D - Benzyl penicillin and Gentamicin E - Vancomycin, Gentamicin and oral RifampicinWhich antibiotics do you give with a prosthetic valve? A - Flucloxacillin B - Benzyl penicillin C - Flucloxacillin and Gentamicin D - Benzyl penicillin and Gentamicin E - Vancomycin, Gentamicin and oral RifampicinGood Luck!Contact Details: Twitter: @L_eClark Email: laura.clark8@nhs.scot