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and then thank you for having me for those Keesey and joining this teaching, actually on some important topics that could come up for your medical school finals. My name is Venture comes on the thank you for the introduction on the Characteristics Register and Parts Hospital Monday on the I have a chance on since crabs have let you just finished operating like 20 minutes ago on go before we start just wanting to make a few points a Z, you know, pure characteristic surgeries where topic for Final Seven is that it's quite complex, however you can link up quite well with cardiology wants now. I'm not going to cover some basic cardiology topics, of course, as I'm sure there will be somebody better than me covering them already. I have four much did my presentation and execute base, so it's mostly interactive. And then I was focused learning or some topics that have come up in the past with finals and the damage. It did come up for my finals a few years ago on some points are also want to make sure that you guys aware it's a how are probably going to some more details and some of their management's. That's mostly for completeness on. But you don't need to know that in detail. Of course. Final spite. An overview? Definitely. It's it's required, I would say at your level there will be pulls for each of the questions where you can answer that. What? You discussed ourselves, Onda. Yeah, that's it. So let's get started. Um, so start. Perfect. So question one. Which of these is not a risk factor for ischemic heart disease? Well, smoking be for visit E C for advanced age. Uh, definitely got ridges. Physical activity of minimal You can't see. Ah, we got, uh, S o d for just activity e for female gender and a half for stress. Okay, it's gonna wait a few more seconds. I think the results out and most of the people that would be pretty fantastic are good. So that is the correct answer. Very good of blood about that. So most people said that some few people said stress as well. So let's have a look. Um, so it's given consciousness. Common topic. That's come up, uh, risk factors. Basically, for atherosclerosis on, we can divide it into know modifiable, modifiable. The more known modifiable, obviously older age, family history and mail rather femur. Okay, our male are high risk of getting up from cirrhosis. The modifiable was smoking or consumption with obesity, a poor diet, ABS said. Entry lifestyle up closely and stress as well, actually on in terms of complications for through schools is, um it can affect any. Most body organs were mainly the heart for angina and nature on my card infection the brain with the eyes and then strokes at the vasculature simply for vascular disease. On also the gut for chronic mesenteric ischemia. So very good. Next question. 74 year old man is seen in the cardiac surgery Followup clinic after having a coronary artery bypass graft procedure. On examination, he has a well healed midline sternotomy incision, but you do not see any scars on the arms, legs or abdomen. The consultant asks you which vessel was most likely used for the coronary artery bypass graft surgery. A deep, inferior epigastric artery be lateral traffic artery. See, it's happened in Spain. The radial artery internal mammary artery. Yeah, one step that I would say for finals for sure. Any insecurities for any example would be doing the future or measuring the question carefully, especially the last two lines fit on Daz. You know when you're stressed, store in a hurry. It's very easy to in the stakes, Uh, even if you know in time. So actually Okay, so I've ended the pole and most people have gone for the for the fantastic it. So that is the correct answer. Let me explain why So now the three main options for here for graft vessels consider gee, are the stuffiness day, which is hard. It's from the inner leg, but you couldn't see a scar there. The radial artery, which is another contract but that comes from the forearm and standards, was that there's no scar. The only scar there was available visible. There was the mid lights or not, and that's with the internal mammary artery. It's taken from there. The left or the right internal mammary artery is also known as internal thoracic. Actually, under some people want to go confused with the lateral transit cautery, which is we don't use that at all. Uh, in terms off where there's the internal mammary car, my reaction comes from it comes from the subclavian artery, and the main vessel that we use pretty much on all over a CABG is is a left internal mammary artery, which will be your heart off short of really more for the next plane, you that you can see here will give off the Lima, the Lima. It's best crafted on the L A G, which is the left anterior descending artery, which is the main coronary vessel or the heart, that the reason that's done the best patients. Right now it's 95% Peyton. 10 years. I mean, that's absolutely remarkable on, but we call that progressed a graft. Um, important thing is that we leave it a touched a subclavian. We take harvest all of that and what we have to do. It's the bottom part itself. Extends. Do not come. Nobody close to dark if you have any disease. If your harvesting from the inner leg and then you're taking the long stuffiness, they know the short. We I've never seen the short circuit main being taken. Any short burst of aureus smaller, the exception of every patient, has it unless they've got a strip because of varicose veins. That is also used a lot. For example, let's say, uh, standard CABG times 33 grafts. One will always be the lever. The other two most likely will be the veins from the leg, which is a long stuffiness on the nine year that the 90 of agency for the day in the long substance various, 80% a little bit less. Uh, it doesn't scar in the forearm. Whether your heart is running, that's 98 it seals off 80%. And that's what that's being used as well on dumb. Sometimes we you will see a Squire rare, but you will see ah, total are general vascular ization. So using a radial artery left internal mammary artery and the right and then the memory artery as well to do all the grafting. Of course, arterial revascularization because using only arteries note that the lateral traffic artery is actually a branch off the auxiliary. Actually, which is further now so clear than exhilarate? That's a lot of classic. So, as it says in the name, it's not surprising, not er apart or locks, which is a bit too far to reach the heart itself. Where's the internal mammary? Literally just once belonged sternum and all you have to do. It's part of the settlement I touch. So that's just a little fanatic. Next question, 70 78 year old gentleman went chronic stable angina pretence with nuance and dyspnea on mild exertion. Bilateral basil crepitations and a new loud epical pants. Starlix murmur The chest X ray shows cardiomegaly, um, pulmonary congestion. And the surgeon, like the one below shows ST Elevation or the lot of relief. What is the most likely diagnosis, right? Yeah. Have three. You okay? No. Yeah. Last year. This is I think it is. Yes. You just okay. What? Good. So I think the police be ended early. So as when I was writing this question as I was expecting the split into a half, 45% said my current infection, 40% said mitral regurgitation. Now the before the show The answer itself, the market in function. It is a diagnosis. Absolutely. It does not explain the process started. Murmur doesn't explain. The basic reputations doesn't explain the promote any congestion either. Whereas the correct answer is Marsha regurgitation, which I'll explain a second. That does explain the pansystolic murmur, which is not on. But why is that so When you get every, each alone my kind of fracture localized. It's quiet, bad one, the popular the muscle which are holding the mitral valve in place. You remember from from your not to discriminate myself called a tendon a tendon, the mitral valve itself with the leaflets. If you get to really bad, am I there does. The killer muscle conductor on it has ruptured the mitral valve instead of being nice opening you will just flare up on that will cause question there much regurgitation quite acutely. If you get much relief. Education acutely that were all back fell into the lungs, which will prevent the features of your mother eczema. So, uh, the most likely diagnosis, the correct answer, which meets all the criteria. That question would have been much regurgitation, which is which does happen on quite several studies. So when because our cute much regard station worse is a chronic once a cord oh, rupture, which is the court? A tendon. A doctor discussed infected undercard itis, which is the infection over the valve itself. If you go a quite nasty bug on the mitral valve that can cause within couple of weeks Quiet, bad regurgitation. And as I just discussed a popular monster options. Those are acute findings. Why? Because of chronic much regurgitation. And those are becoming more for months on. The cardiologist probably picked it up and you're keeping an eye on them. Know the GP picked it up and you're keeping an eye on them. Those are from the genetic condition. So much fever myxomatous the generations on. But if you had a previous heart attack and your heart is, you know it's going to scare me cardiomyopathy. So over the months and years, you got much regurgitation. Chronically, in terms of the symptoms are much of a vegetation. Surprisingly, it is actually a symptomatic for many years. It only the symptoms on is that present at the very last, uh, a minute. But you know, the very last few months off weeks, if it's acute setting itself key symptoms would be critical weakness. And you do see that in clinics. That's because of the local, um, display. Answer anything to do with with a long story short of breath or talk now so you can lie flat at night as you used to see people more and more pillows and proximal nocturnal disc that so there, gasping for breath in with a real light because they're getting promoted. Congestion basically. And the hypertension features, of course, the right heart failure. The signs that you see on examination. If you found much regurgitation on an Oscar station, you get the apical frill. The third heart sound on the apex feet would be displaced because it's the volume overloaded, not pressure of a loaded, which is the aortic stenosis on the reasons volume overload away. I remember it's as it's regarding dated. So the blood, instead of going out away from the left ventricle, um, it's all falling back in there. Andahazi basically become distended on as ah said early in the question, that murmur, which has really to the villa on Diffuse You are into severe much regurgitation, and it's, uh, later stages you'll get. I haven't recorded here and especially the pulmonary. Uh, you have an increased Petri sound because now primary body is getting affected because the back flowing into the legs injustice indication to keep us simple as possible for finals on indication for surgery for my trigger vegetation, the key thing is possible scenario we So he has to be severe. We don't operate a barreled moderate mitral regurgitation which actually surprised by surprising if you you know, if you're if you're serious, echocardiograms you like is moderate, which is gonna keep an eye on them but has to be set there and then Plus, you need to have symptoms for anyway. H a school to before. So it's marked breathlessness on limitation to your daily activities. Basically so mark purposes, which has pain and so on and on echocardiogram as well. The LV is remodeling, so the diameter is increasing because it's volume overloaded or you got a gis injection fractions. Your your healthy, the left ventricle is unable to pump contract as well as there's no contract. Normally anymore, it's it's basically factors for any of those you need to India. You know, it's an indication for surgery dose of like poor prognostic features of march regards. We have symptoms more than what he normally a tribulation if your age about age of 60 as I mentioned earlier perfectionist and 50% which is a mild to moderate and severe impairment of the lien on. And as I just mentioned earlier and increase the never tickle ball, you end of story cause systolic and diastolic and systolic. Next question. A 55 year old gentleman was a lifetime smoker on diabetic presents in a any chest doing on density shows us to the pressure on the lateral leads and the troponin off eight hundreds Patients booked for an inpatient calorie undergo Um, which shows severe is called the artery disease. Before you speak to the cardiac surgeon or call, the cardiologist would like you to refresh from the indication for surgery. Which one? The following is not indication for the region for a good left mainstem coronary artery disease stenoses more than 50% and are symptomatic. Be three muscle Coney Artery disease with chronic, stable angina. See double vessel coronary artery disease, which includes the proximity Lady said, Oh, this was the ejection. Fraction is still 50%. The double vessel disease with proximal a lady statement he stemming with much regurgitation. Yeah, I know this is a little bit more stretching had me. If you think about it, there's no much knowledge actually required for this. It's more just thinking about it and for your knowledge that you have probably from standing. Uh, from when you do pee. See, I see when you just even just keeping a simple a spot. I know it looks big words. I don't purpose because that could come up, You know, big words that you probably haven't seen or we just work it out. Yeah. So we have expected as well. We There's no a winner. We got we as a 35% with then full of I D 23% and the ABC around 15 to 20%. So before should answer now the way I would approach it. Question of this In medical school, it is a hard question possible. Okay, But first of all, remember, it's not an indication for CABG, okay? There's a negation. What that means is that out of these 54 are indications. Right? So, um, we saw the question before stand me with much regurgitation. That is an indication, because, yes, you're gonna deal with the mitral valve itself, But you're also going to do the bypass surgery. True, because you can react three waas blocked, which then led to the popular rupture, which then led to much regurgitation. So, like today, we don't the matter with replace the mitral. And we also did the bypass surgery. So that is an indication going from the top A Are you sure you're in a second? But the left main stem Uh, it is more than 50%. That means that about the, uh, lady, the circumplex are ah, that is used basically because that's where it comes from. So that's already two vessels. Even though you are symptomatic, that's pretty high risk. And we would have let especially even go home. So we keep them is in patient, then I'll create of them treatments a career to disease that's quite standard. You know, that's what we operate on, uh, political, stable angina and double vessel coronary disease. Now, this is when yourself thinking okay, I remember CVG is for the triple vessels of the left mainstem disease for the crazy standards with regurgitation know that the double vessel, I think they can distend it. However, if they are proximal led stenosed or and as a returning here, the LVF, which is the left ventricular ejection fraction, is compromised. So your LV function is not normal. Then you the best indication is actually seeing you. Whereas D, which is the correct answer. A double vessel disease with approximately lady, which is patent, which means the disease it's in to mess ALS, which are not there lady such as the circumplex with the right color, right, they lost consistent. Okay, so it's just about working it in that way with your knowledge dot remember, Stands up or 10 difficult single vessel double that. So triple vessel I remember it's C A B gene left main. That would be CABG as well. Then you can kind of work it out. So we're just going over the natural little bit. So, uh, the right coronary goes on the right by that. Okay, that often gives the process of sending branches left. Main is this part here is normally centimeter, okay. And it's literally as soon as he leaves. They wanted 12, the aortic Sinuses, all right. And that device into the next room complex that left circumflex and the allergy. So if you imagine if the left main stem is diseased more than 50% that means further down you're getting these are they're splitting. You only gained 25% flow down each other's. This is that this is supplying more than two terms of the heart. So, you know, gonna leave that be the other reason we left mainstem are not stent a ball. If this is if this is one centimeter in length, the stent needs a lot off length to be hooked on to be deployed. So if you deploy a stand here which can be done but pretty rare, um, you you you got under blocking the branches itself or you'll be too close to the aortic valve and cause injury. So standing the left main stem, it's it's left mainstem disease. If there is 50% is is a more research is getting both. So, um, that's basically a summary of it. Okay, I know it's beyond, you know, but keeping it as simple as possible and I think will be useful for you guys if you become cardiology. And so, if you come across, went to the PCP. Eyes are seeing bridges for us, um, to medications or patients with mild angina or a stable angina, which is happening for chronically. You do see the gene for left minister notice, as I've explained, because both the a lady in and the circumplex are in danger, Anything which is left mainstem equivalent. So if you go osteo led and we just go back to the previous quite if you go 70% disease here and 70% is is here. That's pretty similar to the left main disease. So again, you, you know, bypassing putting a stent here. It's quite dangerous because you are at bifurcate. So again we get involved for those standard triple vessel disease as it is. But my country disease, the circumplex and the lady that's us, especially if they reject fractures less than 50%. That's even better with the region and BCI for survival benefit. Um, in terms of one or two best oncology rto disease, we do do them. Okay, So, like difficult company after fashion, however we do them if some of the left ventricle is impaired, so less than 50%. And if it's the led, which is a disease because of a showed you earlier. When we do, the, uh, lady is going to get the liver the left internal mammary artery, which is 95% patency, right. At 10 years, that is nothing Beats up. Okay, so, uh, the cardiologist know that. So if if the, uh, lady is diseased severely, especially approximately on dejection functions, just percent we're getting old is well, uh, unstable angina or the instruments again. Priest Similar. A PSA both left main disease. The left, many prevalent disease on do, uh, pretty much similar is that keeping it simple studies. So the problem with stomach is that your troponin is in the thousands, right? If you'll probably have come across patients with duck. Did you come on? Constipation? Where the A celebration. Um, I guess today there will straight up because it is because it's a big am I I this compromise supply to have not supply to the heart. They're gonna go to Catholic priest if they find a culprit will stand if they're a short trip of us. And Dizzy was some left main disease, they're gonna try to stand something which is stent able to help the blood flow going through. Even though they're later on. A couple of days later, they'll have surgery. Just otherwise. They don't, you know. So now when do we get about the reason we don't do straight away surgery often on a stemi? Because the heart is very inflamed. If you go troponin reason thousands Your you know, unless it's a life and death and PCI normally tends to work. Initially, we wait couple of days. So a patient coming with the STEMMING will probably received a stand more of the vessels, which they could have centered. Still go several disease on the other vessels. We keep them in until the troponin. Normally, we say below 1000. Okay, that's when we can talk, right? That means the heart is less inflamed and we can do the operation. Obviously, as an inpatient, we would never let them go home. So assistant stevia on not suitable for PCI, for example, or if PCI failed. Okay, so they're custom out there trying to stand it on depression becoming completely unstable. We need to operate. Doesn't matter that troponin is in. The thousands of the patients are going to make it because PCR they don't work in that stage complications. So as we discussed about that much regurgitation popularly rupture. But if it's pretty bad, um, I see which works. Seen a ventricle septal can rupture on that. We just call it must've vst the every corrupt her. I haven't seen that yet, but we know it does happen. That's what we get involved as well in cardiogenic shock, which means you are on a lot of I know Tropic support, adrenaline or adrenaline and the heart. It's completely not good. Musically, we get involved as well. Or if they're coming with cardiac arrest, the having of introducing relations, anything crazy ventricular arrhythmias, which is caused by a severe stenosis and the left main or a triple vessel disease. That's when we get him or so quite a lot of indications, actually, you know, which is probably surprising for people where we looked into too much because I when I give a lot of talks about how can indicate that surgery always get asked, isn't that special to die while for it to guide nights? Clearly is, there's a lot of work to be done. Still, so again, just comparing a stent is basically a little balloon in there were standing it on. Uh, that's how it looks on The CABG is basically putting graphs, and that's the Lima. Okay, one favors PC. I saw intubation is not fitted for a non operation. Okay, of course, PCI end the disease is stent able. Okay? It's a single vessel, double vessel disease, even if it's triple vessel you tried to stand. The vessels are there, are severely diseased and knock it for in operation. That's better than nothing in there. Very frail, very advanced age. I mean, you know, 75. That's not advanced age. We still do operate on those. I'm talking about the nineties eighties and stuff on every, just like Victor expect. It was quite important If, um if your patient was go cancer and difficult life expectancy of one or two years going to a major operation to give them a 10 year survival on, you need to probably think about maybe standing is bad. And obviously, all of these are discussing big cities on a weekly basis. And it's not just a solo decision. Again, Restricted mobility is quite important if you go, somebody was completely wheelchair and bad bound. Remember, after cardiac surgery, the risk of getting chest infections and the duration. After that, it's a normal. So they want they wanted to, with getting over patients up and about their walking straight up. And it's crazy. Just 36 hours ago, they had a major heart operation. So they need to be able to walk around to get the lungs we inflate getting the heart pump it. So again, that's something that would favor PCI favoring CVG diabetes, No doubt on. But if you think about it, most of our patients will be diabetic. A Citgo triple vessel disease, double blasted disease with severa is this pattern and the diabetic own dialysis. You know, we get involved again, reducing of the function as I discussed a recurrent disease in instead, Mr knows what that means is that we do see that, Okay, because ended whether you know, when they were probably 65 years ago, about seven years ago, understand is now narrowing again because of genetics. Because the four lifestyle or whatever, you know, gonna keep stenting again and again. There's only so much you can put through those esa's. I mean, I don't if you guys not these coronary vessels are a millimeter or two in diameter. Okay, the little tiny when we operating, I'm using 3.5 months. If you cation to look at them closely. Okay. So, you know, keep putting stents. It is a millimeter or two vessels in that situation, we get involved, you sleep on. Most important is for concomitant colic surgeries. So, for example, if patients coming with, uh, CABG requirement and also it's double that, so but the aortic valve is completely stenotic for sure. You know, I understand that you're gonna have the best outcome is see veggie plus a VR. Okay, so hopefully that gives you a bit off understanding, cause I used to find this very confusing when I was medical student and also gets a little bit there. Better picture. So question fight you on everyone. Doctor working in the cardiology ward. You have just received the patient who is transfer from the local characteristic centrum. You're going through the list of medication the patient is on which of the following medication would you least prescribe for a patient who is being discharged to the local hospital after coronary artery bypass graft surgery? A restaurant? Be atorvastatin. Ah, CGM spraying the wrong approach. It is a pro air flow. Yeah, uh, strained this question. The last three lines. Very well. Okay, Okay. Okay, good. Okay, So only 50% answered. Maybe the rest weren't too sure. And again in terms off which ones that go. The top two are CJD and spray, 27% and F 25% which is lansoprazole. The rest are below around 10 to 15% equally distributed. So again, there's no you know, uh, large knowledge required for this question. Okay, so it's the key thing is least prescribed again out of all of these. Okay. So close that book on out of all of these, it means that five of them will be prescribed. Okay, so this shot after CABG. Now, why do you see images while patient came with chest pain, right? They had angina or they had a massive heart attack. Most often they would have bean having angina and all that. And while they're waiting for Karachi bypass graft surgery, they would have bean on certain medications to help it just pain. Right. So, uh, that medication normally, if you probably know, is the sublingual GT and spray. They have surgery. Now, the chest pain that is caused by the angina is now gone because that's the whole point of doing the surgery. Getting rid of those angina symptoms. So even see a GED in spray on a patient that CABG just couple of weeks, you know, even months later, on their know, getting chest pain, obviously. And the cardio just been Obviously, that should have been prescribed. Okay, obviously, a couple of years on the line if those graphs are getting, you know, standards together for different story on. So we talked about just the recent transfer which don't search. It just happened few days or weeks ago. Aspirin? Very important. O never. Patients are on aspirin lifelong. Okay, um, they keep just, like extent, they keep the graphs patent and open. It's been proven for that. Trouble started. Well, it's it's, you know, gonna lower the Crestor. Um, I'll explain if next few slides um, Sudan supposed to transfer your ramipril for BP is a problem for the Byetta blocker lansoprazole. I know some people answer that as well. And if you're taking aspirin, you got to protect your gut. So lansoprazole is always gonna be there or omeprazole. But that's opposite is better because of the interactions with cognitive mental. So let's go through these. You probably haven't seen him a call for my college in a long time, so I thought you'd be supporting to quickly go through this stuff and you'll be able to answer all the questions. You know, some of these things are aspirin, the cox inhibitors and decreasing their come back saying a two. The whole point of it just decreases space. Let others signals so it makes the blood. It's an anti platelet, basically right, mix up a little bit. Rainier. The blood primary prevention and secondary prevention with that means that even after having had the operation of the sent, you got to give us problem. We can cause bronchospasm. So if they're severely a smart take on the lot of teenagers with reduced lung function capacity, then you want to be careful about that. Pre actually have. Most of our patients are husband, and I bleed. Hence, for the lung doctors, it's gonna be important. The key doses 75 mg once a day. Atorvastatin is an HMO Geico, a reductase inhibitor that just basically it's involved in the cholesterol's. Into this, And I do remember one of my finest didn't have that question, you know, because most people tend to forget that on how those that, you know, statins work. So, you know, it's important to probably be aware of that's on the whole point. Defend it decreases their aggressive all again primary secondary prevention for cardiovascular events. Not only am I so strokes, you know, uh, your disease and all of that side effects common once a mule job around in my eyes is hepatic dysfunctions. With the liver, functions have gone off. You would hold that or your decrease it a little pain vomiting as well. We put our patients for 80 mg off atorvastatin after surgery. Okay, uh, if they're having any of the senators really registered to 40 mg, But we'll say at least keep it before too. 10 to 20. It's the, you know, really severely affected, and obviously you can change the medications. Then we'll start in problems. Starting the sore on ziprasidone is a PPI proton pump inhibitor. Um, if you need a cigar strikeouts and secretion, it is useful prophylaxis for people who are, or insights and master in, for example, to prevent. Also, it's in the stomach. Basically, side. The next day can cause diarrhea because dry mouth, nose young love a busy um on another common topic that does come up, it does cause osteoporosis. It's in the old people like wrinkles risk factors. You want to be careful about using it as well. The normal dose that we get a starting milligrams on the higher dose per 15 is also finest. The extreme around from December and your ramipril is an under tensing converting enzyme inhibitor. Basic a centimeter and basically events the under 21 to become under tension, too, which is go powerful, basically strict features to increase BP. Right? So if your now preventing all of that renewed getting all of that, you're decreasing the basic constricted a factor friend and also the other standard effect. So it's basically good for treating high BP, so I'll have engine. It's very good for the heart after the operation. So all of our patients, unless the BP is below 100 systolic, there will be on the ramipril 1.25 mg. So we cultured gp to start that if we put it because it it's kind of protective it it, it's maintained, develop pressure bay, even though the other medications has been shown to be very good for the heart on side effects. I've attention, of course. Drinking too much chronic cough again, right? Common. I mean, it does happen. Um, had a cleaner. Of course. That's how it works on, uh, more serena function. So you want to probably hold it if someone's money. Jaafar Torino Kidney function of 30 25%. You probably wanna, uh, just double checking. You want to get high doses effect. Bit of locker. Another very important kind of protective medication that all of our patients are on after cardiac surgery for any kind of surgery. Again, it's beta blocker advice to beat on a receptor. The decreases the I know Tropic and chronotropic effective it again. Primary and secondary prevention of the cardiovascular events and heart failure. It's there's a kind of protective is also good for the heart failure for em eyes and also for a F because it's made controlling it. Problem with that little stripe attention, so you won't decrease the dose if you're too high. Radikal. Because you meet a block too much, you can end up causing heart block if your other medications, such as an order um, it is bronchospastic as well. So again, you want to be careful. It's severe asthma. We started with 1.25 mg can go up to 10 mg once a day. The GT and sprays the one that we don't give after surgery. And I said, It's It's a smooth muscle relaxant. Okay? It basically causes coronary based on a leisurely that lets them up, reduces the spasm of them as well. It has to reduce preload, and after after the heart can call him back. Basically, it reduces the my card in oxygen demand all off the good things so that you don't get chest pain while you're exerting yourself while waiting for surgery resistant. So it's basically for enjoyment. Side effects, Of course. Postural hypertension can cause tachycardia, palpitation and flushing, and the medication that often are it's GTs is great, which is 400 micrograms p r n and you be used to prescribing that information with chest pain while waiting for surgery or stenting. Cardiology. It's okay, like social units, and I said I would rather so avoid a motor nitrate, which is those doses? Good. Next question. 73 year old lady has preoperative worker for our hip replacement, the doctor examining the patient Oscar plates the heart, and he has allowed ejection. Systolic murmur radiated to the carotid artery. He proceeds for history. Taking relevant which of the following sentence with this doctor be most worried about for progress. A a China. Be syncope. See shortness, breath and deep palpitations. Okay, Agree. Yeah, yeah, yeah. Concerning these questions that either of the harder but hopefully make you think. And if you understand some of the topics that you will encounter in the future, I think we can end up all here. So I've got be 70% said syncope on C, which is shown it's about 21%. Now. Most people get this question look okay, because they think of syncope. Of course. However, if you think about it, no, obviously, you probably figured out this is the aortic stenosis, right? Three key symptoms of your dexa noses are angina syncopy insurance of breath. Uh, show you in a second that extra sites for basically, uh, syncope is worrying off, of course. Um, but normally it's lost consciousness for a couple of seconds a minute, and they come back again. They're getting investigated and final. It's a scenario. Takes a nose is right, but shortness of breath. That means that The severity of the aortic stenosis is so much that the heart is now failing to pump blood to the less of the body on that blood is now back tracking into the lung again. They're feeling short of breath. So actually, that is the most worrying for prognosis, Of course. Known in terms not in terms off your daily activities. That off for prognostic. Shortness of breath is the worst, because now you are a little bit too late into the aortic stenosis disease itself. Okay, um, now let's go over. The next question is talk about them in a second. So same. Same person, Basically, the person the doctor know decides to call the on call cardiologist for the management plan. Which of the following investigation with the cardiologists have told this orthopedic doctor to order next a cardiac MRI be Korea? Andrea, See, Carotid doctor Ultrasound. The echo Cardio. So we have allowed injections started. Murmur. We get into the carotid arteries. Okay. Yeah, right. Yeah, yeah. Okay. Wait a few seconds. Yeah. Yeah. Okay. Okay. So D, which is a cardiogram. 66% people said that followed by 25% people. Was that carotid Doppler. Now the the most correct answer is I could cardiogram, of course. Um because you want to quantify the severity of the short external is is the carotid Doppler. We will do it. Absolutely. But it's not the next thing because you want to know what's going on. It's, um if I just said there's your hearing a carotid brewing, and that's it, then you know are worrying about carotid artery stenosis. And currently, doctor or somebody number one followed by city, the Arctic arch underground tunnel. That, however, we have a loud murmur here, uh, which is a radiated record it so All right, just telling you, it's quite maybe moderate. Severe aortic stenosis. The hospital. Is this the station? It to be as a captain is an inpatient. Can we let ago? Um, we need to do surgery on you need to do today. And all that stuff. Psychologist. Right. So just going over those two questions about external is a progressive disease. You can remain, uh, symptomatic for lots of years. Okay. On the sentence and the mean survivals are put it here. So if you have a patient, I don't know. This is having chest pain. Their survival prognosis is roughly five years. Okay, Um, and the reason for getting enjoy now is because the as I said earlier, competitive vegetation on stenoses your pushing against a tight valve. So the heart muscle is to adapt to become thicker and stronger to push against a synthetic well. So you have increased allergy pressure, which means increased my Cardura oxygen demand, which now you're getting chest pain when you are trying to push blood to the rest of the body. That's five years followed by syncope, which is so somebody's presenting with seeing company with your dexa nose is normally they will have roughly three years left off life on the reason they get any syncope, obviously, because you're getting insurgent and the brain is not getting enough blood. But, as explained earlier, if they're getting short of breath with aortic stenosis, there's only two years left. And the reason is because there's so much, Um uh, backpressure into the LV, which is now getting even thicker on his own back, uh, back Nashville's into the lungs, so there's heart failure, but more congestion, right left ventricle a failure than funny about a writer political, a failure. Then you go much less time left because you are later stages. Interesting question, Actually, cause most people would say syncope. Well, the most common causes for the aortic stenosis worldwide. So much fever number one in the world. Okay, constipation number two and bicuspid aortic valve. However, it's in the Western world. It depends on the age. If you're somebody less than 70 50% of the aortic stenosis that because of bicuspid aortic bowels Okay, um, they're just more prone. The ways design and the reason they call bicuspid about genetically they're more prone to get your kicks in or this earlier than somebody else going tricuspid or so Okay, But if you're above the age of 70 and 40% of those are due to constipation age degeneration related looking well, the physical science or slow rising balls on Latin for starters, small tablet triples off of us, the usual. Probably remember the question. The Depression, the ejection systolic murmur, which he will get into the karate. It's a single heart second heart sound, which is then diminished because of the stiffening of their boat itself and the fourth heart sound from nature contraction because it's a contractor. The extra kick trying to get more blood pushed in into this very second ventricle. Where's the hot sun? Was for much of regurgitation. Aortic stenosis to the investigation. Off charms for ejection. Starting normal would be your echocardiogram. Or why, to the echocardiogram. First of all, helps us to quantify the severity off the aortic stenosis. We want to know it's mouth moderate or severe on the severity is based on a couple of calculations on. Got a picture here to kind of show it to you. Your blood is trying to go through there. So this is bicuspid about the strike. Hospitable, calcified, uh, constipated. So depending on how big the area is, okay, the areas tiny. Okay, then, um obviously there's gonna be a higher jet, and there's less. Nothing's gonna go to the brain and to rest the body. So the smaller area, the highlights severity mean pressure. Gradient means the month pressure they takes to go through. That signals about the higher the pressure than the higher the severity off the market. And same with peak velocity D. If you go into a s'more the nose area, the velocity of that is going to be very high compared to a bigger area where the las idiots normal. So again, the higher velocity, the higher the severity of the attacks nose is hence where you want to do any credit because that's the only way you'll be able to kind of there. I have all of these things like carrots, particle calculations which we do not need to go into. Then you will also do a calorie angiogram for sure. Unless stay. You know you can't do it for one reason other than you do a CT coriander gram because you want to know Corrie are two disease. Because, I mean, if it's constipation and 72 maybe the coronary arteries also calcified. Do we need to see a GI plus a VR? In fact, 50% of the patient with the yes would have coexisting coronary disease isn't severe enough. However, to intervene was in March moderate. It's multimodal. We leave it. It's more due to severe correct disease. We will have to do it okay, Otherwise you're not going to come off. You know, when a start the heart basically, if you go questionnaire coronary disease, you don't do anything about it. But you did a beautiful valve replacement. The hardest know got mister. It's got struggle. So you're gonna do it coated. Doppler, of course, to check correctly are just the nose is against same disease process which little crosses and calcifications. Um, if it's a bears, I mean it's completely occluded or 70 80% blockages. You probably just wanna get your vascular colleagues to see what they want to do. If they're not symptomatic with the T I s or strokes, then they don't. They get involved later. The heart is number one. Obviously next pressure. You are the cardiologists who have received the referral from the orthopedic surgeon about the 73 year old lady who had previous incumbent, same lady. You have already investigated her with an echocardiogram, and you're demonstrating now its severity or take stenosis. She's normally fit and work very good. While explaining the results to the patient, she interrupts you mention says, Well, I need surgery, Doctor. Which of the following is not an indication for surgery for severe aortic stenosis? A severe areas with syncope be severe ius with angina. See, it's a very it's with significant Call your disease. These several years without any symptoms. All exercise test is very. It's within a year. Complacent percent Again, Little bit Difficult question. But think about it because it's which of these are not an indication. Um, sorry. Ms never comes to make a quick, uh, you guys are ultra ms. Um it's gonna put a link in the trap. Guys, I said this is just a Google form on. I really appreciate. If you fill this out, this will just provide us on further feedback on our collaborative teaching Siris on it will help us improve for the future. So pleased you fill this out. We would really appreciate that. Also missing work. I think it was a question on the chat. Just I think it's related your ticks nose. Is Natalie asked? Is this problem? Nurses with or without aortic repair? Um, without of it? Yep. With repair work with replacement. This about 20 years. I mean, you know, uh, nothing beats stuff off course, So if they are three years, you know, depending again on the valves, which we go later on in next few questions. Are you giving them 10 years? At least they're your sexual. So? So that's without so actually made it clear politics for that Good. I think most people have on any other questions or, uh, from the shot. I know there's a lot off allows anyone so good person. So 50 69% people said deep, so very good because you didn't get scared of all of this, you know, crazy, you know, complex stuff. You've thought about it properly. Okay, on, um, when we talked about, So if it's a very it's they're also got a Yes, aren't they? Is it now the symptomatic. So the syncope off course you got surgery for that, right? Angina? Yes. You got a treat that significant? It is. It's always kind of said that, right? This concomitant surgery, you gotta do operations. Go several. Yes. And your left ventricle? It's impaired. Well, I think even if you're not an extra, but it's you think maybe I should have surgery for that. But, you know, if somebody doesn't have sentence own excess test. Okay, so we get them on a treadmill or bicycle and the sooner getting symptoms. But they're several years as you explain that you don't rush into surgery, you wait and watch. So Well, the so indication for a VR headaches and all this. So it's a matter. Yes, with symptoms as a discussed earlier, serious with undergoing any other cardiac surgery. CABG marketable prosecutor Several. Yes, within in if they are symptomatic. You do an exercise just, uh if now the getting symptoms with excess just But they won't symptomatic because maybe they don't push themselves too much. I mean, you know, you get these six year old six year olds who maybe they don't exert themselves as much anymore. They just watch tell the old days they're like, No, I don't getting symptoms, but actually, have they been walking around? Well, let's do the excess. That's not again sometimes on exertion. Well, of course we can operate. But if they don't have symptoms with the existence, however, this marriage of that, yes, it's so tight. Okay, that you need to do it. I'm not gonna give you numbers to confuse it, but so, so tight they're gonna do it or the ejection fracture is very impaired. So lbs that 30%. 35% let's say, or if they're going other correct surgery, then you will both like it was surgery for that on. But if they are very yes, a symptomatic and extracts test still do not get symptoms and they do not meet the scratchy that just mention then you're going to follow up with cereal echocardiograms for monitoring every six months, normally or longer. Ondas Soon as it comes symptomatic, Then meet the criteria. Now, just like the PCI CBG probably come across tabbies, which is the transcultural valve implantation transapical from Catherine and Surgical area, which is more we surgeons do. This is basically like a summary off. When did we do one of the other, uh, to keep a simple again on, say, for example, So the less than 75 years of age we were basically proceed for Aviane because normally quite fit well on, but they can withstand the big operation in the low risk of surgery. Of course, if they're suspected and the card I doesn't mean if the valve which they have in it's infected, you know, gonna put a tablet in there. You putting another device, you know? Well, we're going to do it. Open up, take the endocrine etiquette valve there, take it all out, washing nicely and then put it in. Otherwise it's gonna get infected again. And bicuspid aortic mark. Actually, uh, the recaps involved as well. Okay, Uh, which, as I said earlier, 50% of them less than 70 are by custard on morphology, which some therapy? Unfavorable tabby. So they made the credits. Potassium. However the have itself needs to just like that standard me, they need the London so that you can look and see here I went to the A VR, which sets, you know, the smaller space there. There's a lot of landings on this required, and if there's problems with the landings are or a Z know the coronary Sinus is where the coronary arteries arise from a just a few millimeters. So if you put involving their through, the tablet is gonna conclude it, you know, gonna proceed from the light and just got to open up and do it properly under direct vision on TV. For the 80 year old 75 or it's a very high risk of surgery. They look I would stand that there is a very frail but they're musical the criterias porcelain, the autumn Well, that means that the autumn is fully completely calcified to go to do an operation such a cardiac surgery you to participation on a bypass machine. Simply put, basically to stick a big pipe on the bottom and a big pipe of the vital to empty it if they order has fully calcified, you're not gonna get a stick, any pipe in there. So there's no you know, how you gonna do the operation because you can't operate on your devolve opening the heart where the blood is everywhere. You got to empty the heart so that, you know tablet will be involved and Savella just radiation because everything's completely stuck there recently. More radio 65 year old lady. Next question is like 65 year old lady presents with worsening shortness of breath, fatigue and dizziness the last six weeks. When examination she spell in the middle. It's not in this car, and the left leg scar is noted. On a quotation, you hear a mechanical click to replace the ass to south. You check the hemoglobin, which is 86. Normal is between 1 21 60 and see, which is 85 which is in the middle of the normal range. Right cell is normal platelet is normal. What is the most likely cause for low hemoglobin? A G I blood loss? B B 12 deficiency. See him on it, says the ER and efficiency. A plastic? Really? Uh huh. Few more seconds. Okay, good. So seeing, which is 67% people, said Hemolyzes. On that is the correct ones on. The reason is so just working through the question itself. Midlands. They're not truly scar and mechanical click. Basically the clicking, which it is. It's because of a mechanical valve, and it's in the restroom sound. Plus, you're getting a lex car. Been harvesting supervision. Most basically had mechanical aortic valve replacement. Plus every gee, if the clicking of the mechanical valve is on s one, so the first heart sound then it's a matter of all many mechanical mitral. Or if it's on the second heart sound, which kind of makes sense, will have to be an aortic right. The three major complications of that nearly put, you know, the mechanical heart valve one you can get from us because, you know, taking your anticoagulation properly so you end up getting strokes effective and the colitis it's getting infected basically or free humanise is because, um, you are you know, the blood is going through the metal every time the blood doesn't really like that will start humanizing especially this time of the more reason you would be a normal city. Columbia. In fact, the station had a normal and city. And why that kind of help? It's anemic and his normal city Now, couple of other points warfrin is required lifelong for mechanical valve. It can cause dry bleed. Absolutely. We do tell them, okay, you to be carefully to be aware of those things, but it would've course iron deficiency. And you're right on that. Therefore, we're having a microcytic anemia. So no, I'm city. If it was a B 12 deficiency would have been microcytic so gray's density and it was a plastic anemia. Then you're having normal setting. But also obviously low platelets and white cell count is what we can do is work it out expression. You've been asked to discuss prosthetic bad choices between tissue and mechanical to a patient who is awaiting mitral valve replacement. Which one? The following should not be considered during this discussion. A patient age. Be patient choice. See if female patient would like to child there. Deep rooted difference to medication. He patients profession as a patient ethnicity to discussing valves, issue and mechanical. And basically, it kind of understand which of these you become centering, which will these you would not be. Concentrate. You're in a discussion. Get a few more seconds. Okay. So me and so So if you call and tell you I'm sorry on so, um, the top two choices were 35% said patient profession F 49% people majority, nearly 50%. People said, uh, patient density. Now, the correct answer is patient necessity. Okay. What that means is that all of the others you would consider during the discussion okay, so that's a common topic that does come up. Okay. Um, I you know, it's an ascetic hard balls and all of that. So that's a beautiful tissue, but that we put in and that's the mechanical. How about what the president called? Basically, when I explained it to the patients, as simple as possible tissue about is less durable. I caught anything between eight years to 15 years. It's variable. It could happen before as well, obviously. But the average Okay. You did good thing. The benefit of it. So you do not need it. You don't need any blood in the medication. Maybe you need aspirin a couple of months just to get fitted. Then you don't need anything like warfarin. Make money, carbamazepine. See, it's completely made of metal. These are rings. Okay. People ask me. These are just made a Teflon. This is what we suture. Okay, this is where the blood is going to go through the other the leaflets. Okay, so, um, the mechanical valve will last you a lifelong, I mean, 20 plus years. Okay, But you got it more afraid for the rest of your life on duller, if you know, but more friend. It's a regular eye in our checks. Ionize this, uh, it's a blood test. You have to do to make sure that the warfarin level it's correct on day because you don't want war free mix blood in. You don't want your levels to be such a way that your blood is too thin. It's random bleeding very easily or too thick. They're undercutting this Arctic well. And I've seen that people that stopped taking warfarin the leaflets will get from most the least that is not gonna open anymore. It's gonna just do this and then you're in trouble basically on. So you know you can eat to tell them about like like this. When you are counseling that before doing surgery and the target for the mechanical loss, it's again. I'm going to keep your simple It's possible I looked through the latest guidelines, but previously I were said for your tick. Mechanical valve is a target between 23 and they're now saying you wanted to actually be at 2.5 s close. It's possible 2.5 and same with the mitral before we say to perpetuate secret five. Basically around three s o Keep that a simple again. It's possible again, with more for completeness. Okay, for your understanding again. So prosthetic hard balls of mechanical bob more durable patient's desire. It is. They're important, actually, especially today that age. So when I discussed the hard balls, I get the patient, I tell them is biological and this tissue benefits and risks, and I actually get the next talking on the phone as well or physically recovered to make sure they're listening in because, you know, at the dates there is that about right on. So if they're well informed Okay, uh, the patient and there's no contraindications that for a long time were free news. So, for example, the patient doesn't have any bleeding disorders, Doesn't have severe comorbidities. Doesn't have any issues with a deer. It's that's very important. As I just explained, If you go a patient who you know that or you, you know, they're telling you they're not gonna take the warfarin every day there for get full, uh, or, you know, you know, going, you know, going to give them a mechanical valve, you know, to get get them in trouble so you can discuss those things. Occupation. That's very important, actually, because if there's somebody who's a resting or somebody who does a lot of cutting okay, gardening, for example, you're gonna cut themselves very easily on they're gonna bleed very easy so you can lead to consider those things as well. Okay, lifestyle, Same thing. You know, if they're doing a lot of three know high level activities, my box anger or, you know they like to play a lot of football or rugby, you going to cancel them. You know that mechanical but might not be for you. Maybe let's discuss this further or if they're This cough was known as a celebrated structure or about it. Orations. For example, the less than 40 with pretty much one that drive a mechanical valve because it will give them 20 plus years so they don't need to have a reoperation until they're late to the sixties. Also or never if they're on hemodialysis or hyper para terrorism, because that there's a father generation happens. Quit carrying those conditions, uh, mechanical, but should be considered in the less than 60 for 80 hour Lesson 65. So when I was sitting exams, it was kept quite simple. The guidelines changed recently, and that's why I'm going a little bit more details. Normally, people decide if you're less than 65 or less than 60 you should go for mechanical. If you're above that tissue is pretty much, you know, black and white. Other. There is no any more like doctors. You can kind of tell now, so that's what they should be considered. Okay, say, with the tissue that's durable. If the patient wants it and really want said and knows that it's less durable. And they are 55 they do not want to take more friend us to the reason Well, you know, as long to say, counseled, Well, they're very well informed. Then you you tend to go towards stuff you do give your expert opinion. Of course, Um uh, again, tissue about if their deal is to offer it's unlikely. As I you know, for the other one. I've leading risk, obviously of lifestyle creation, as we discussed, um, a villages, then you probably want prefer the tissue. So if the life expectancy is low work, then the presumed your abilities hasn't said a tissue all the nasty anything to 15 years, depending. What about are They are, um so if the patient is no gonna be alive in five years because of severe comorbidities, Um, you know, you need to kind of think about that as well. If you know that the patient you know, it's not gonna be alive, you know, in 10, 15 years on the line, then you need to put a mechanical valve and give them water on top of it. Which probably is gonna you know, affect their lifestyle and all of that. So there's a little discussions about that, of course, again, a tissue or should be considered that more than 65 5 years or more than 70. So basically the age group, which is the most combination between 60 to 65 maybe our 65% of envy are much more replacement. You could consider about it. Um uh, but, um, according to the current guidelines of both acceptable, but they need to become very well. And they used to be a proper discussions. Of course, there's no just about a judge as it used to be. Maybe something surprising if you weren't aware of this expressions. A 55 year old homeless man presents with letter jeep and weight loss for the last two months. More visibly, she has been developing intermittent fevers and has noted feeling breathless could minimal exertion. You also take it out and here and murmur, but you are unable to define it. It happens, you know, on what are you most suspicious Off a matrix summer? Be interested in different see rheumatic heart disease. The investment Could I just eat more confidence is Oh, I'm just giving her 20 seconds. Maybe you're running a little bit. Make sorry. End up all now. Good. So that you have 72% people said, In fact, in the car I just which is correct the next people serve you, Martic Heart disease. Remember, It's rheumatic heart disease. Normal Matic fever, rheumatic few minutes weapons. When you are as a child with destructive caucus infection, the market card is is is what happens decades later. You don't get few months with that. Yes. Impacted. Recognize It is. This is again common question. Do come up and Azilect very, very soon. Basically the key symptoms here. Well, letter gym, weight loss, fever. And then you murmur You've got to think of my victory colitis. Absolutely. So these are the symptoms. Couple of pictures is also this is again from the guidelines again. 90% of these people with effector courageous will present with fever, poor appetite and weight loss. 85% of them will have had new basically heart murmur. The ones that we really well know which are. These generations also know that you know, very common only See him. I mean, I see them a little bit more than you would see them in a known carotid Lansing unit one unknown if actually correct his unit. So things like basketball with only touch of seven. Same with the Enbrel to the brain. Longer speed. So on a touch of present so considerable it's like vascular phenomenon. Are mycotic aneurysms? Generalizations? The general lesions are these ones at the bottom. They are popular stuff, and they are basically on the palms and soles on the flop on. They're not painful, whereas the immunological phenomenon, which is Osler notes, which is this one here. They tend to happen on the digits on the pope's of the fingers or the toes. They are no Jill's and that pain, Uh, and you can find various best to remember how to describe them. Obviously gonna fight is another one right spot. It's well, it's something in diverticula bridges and I. If neurological symptoms, most of them will be skimming, less than 10% will be bleeds or upsets. My contact you and your is um's in the brain. Next question. 42 year old man who presented with fever about area degrees has been a mental, worsening shortness of breath, address that break for the month of condition You're here, remember and proceed for urgent transthoracic echocardiogram, which does not show any vegetation. However, two separate blood cultures have grown streptococcus office to meet the criteria for a definitive infected and a collector's. Which of the following diagnostic criteria would not be relevant? A note. Be generalization. See peripheral edema, the previous heart condition. He IV drug user. Yes, As you probably figure out, I'm trying to find out if you know your Dukes criteria, which again is something that does, can come up, does come up for finals, and you should be a welcome. So again, you just explained the question that you know there's not. You don't purpose okay on so which are different. I would not be about it. So you see, 54% of the people said secret for Dema, followed by 70%. Is that IV drug user? The correct answer is, See, that's It's not in the Duke white area. The rest are okay. As I explained in the next few side, So oscal a note generalizations the's of minor criterias, his heart condition IV drug use is that also minor bacterials, So this is a summary. I'm sorry. It's Ah, it's, you know, busy, but try to simplify it. This is from the latest 11 15 guidelines, when I will. So I said my finest around 17. 16. Um, he was still dull criteria, basically. So things have changed a little bit, As you can see now, the two major criterias are a blood culture, and then imaging, which are positive. Okay. Eso the blood culture keeping the simple again. They have to be from two separate blood cultures. Not a one, you know. But after the two on a separate occasion, most of the bugs, which, you know, you probably come across on and they're positive for that. The second major criteria. It's an imaging finding. This guy had no vegetation on in on the echocardiogram, which can happen, Okay, especially with a transthoracic. And they're very large. Be in my left side, you know, gonna be able to scan them very well. It's operated dependent as well, right? But if you do see a vegetation abscess and pseudoaneurysm a fistula and valvular perforation and aneurysm, previous valve that was in certain was the highest. Okay, Any of those kind of things you know that's the second major criteria. So to mention to you is called Just imagine the minor Pretty. Is this life them? One If they have a previous heart conditions and the child or the night it Peters operation for cardiac or devices Base maker. Second self injection of drug use five. You drug use is a minor criteria Number two. It's fever about 38 degrees as number three is the vascular phenomenon as we discussed it. So, for example, your interest in your hemorrhages, your embolize, you contractible Amerasians, you're generally lesions. Okay, then before is your immunity immunological ones so globin If I just also knows what sports any of these on five. If it's the microbiological evidence, which is positive cultures but doesn't meet the criteria, for example, it's one positive culture for expert. But then he was not positive anymore. And so these are the criteria, and then the waist divided. Now it's definitely shows, and the cardiologist wants to be sent it. But I just And yet it's not in a collector's. So a definitive endocarditis. It's well, this that's correct, you know, basically means you got a piece of vials where this vegetation. You look into the microscope, you say. Yes, definitely. That's quite obvious. But most often is gonna be clinical criteria. Then that's where you are combining these. So if you go both major criterias blood culture, positive end and echocardiogram finding vegetation, it's definitely and the colitis. Or if it's one major criteria. So like another guy, we had one more culture. I mean, we're the blood culture positives. Another station, then you want to look for three mile a criterias. He had fever. He had something. A storm, a busy. You're looking for the others. Is it IV? Drug user is a principle sing heart condition. Does he have basket? You know, you you know it's perfect or five minute procedure. So none of these are met. All five of these. Um but again, that's definite. Defender Correct. Possible. So you kind of like in the middle. If you go one major criteria in one minute criteria or three minor pretty, it's rejected. If anything else, obviously, or if the symptoms and numbers don't do the time to go to therapy less than four days, nobody. That wouldn't happen. Endocrinologist. It takes six weeks, So the antibiotics treatment despite having surgery as well. Okay, um, or it doesn't meet any criteria. So So hopefully that kind of simplifies that how the modifying drug criteria works in them. Imaging haven't asked questions about it, so I'm just going to tell you about it. So the echocardiogram, it's your modality of choice. Obviously, it's good for diagnosis, as we said and management and three key things that are meeting in the major criteria for my credit. And you want to look for vegetations for abscesses pseudoaneurysms. And if it's a previously in certain about, you want to make sure there's no deficits, we got 2000. I go cardiograms we go a transthoracic, which is done when the jealous come on your chest in the teary, which is transesophageal between the probe patients asleep on you looking at it, and you can see if you have a native bowels your own both. Okay, The sensitivity often echocardiogram transthoracic a 70% by the teariness 96%. One that means is that if you don't see a vegetation, an echocardiogram on them on transthoracic, you know, and you're still suspicious about while you probably want to consider it, you're right. with presenting Well, it's very interesting because often it's a mechanical bar, for example, is gonna be a lot of a kristic. Shadows and all of us have lots of interference, right? So the sensitive is only 50% so teary. It's best for the prosthetic credence in certain pathetic boat. And now you're suspicious of endocarditis. That part of the Prius it was in surgery. Teary is recommended as well. It's getting suspicious on Do you go a prosthetic hard marble previous of the chronic devices. If you, um, think suspicious, remains high on your still negative findings, you can always repeat in ICU cardiogram within 5 to 7 days. That's recommended, cause maybe you didn't pick it up. Initially, you were repeated. Next question. 58 year old gentleman who presented with persistent fevers letter G recent shortness of breath is admitted to hospital. He's got two separate blood cultures which, of course, people stuff Oreos and echocardiogram shows an aortic abscess of the level of your itching. But great. This is interconnected. Seem it's pork. Major fractures is awaiting urgent cardiac surgery. Apart from these, which of the following is the least likely to be an indication for surgery again. Little bit difficult. But again, you know what that means. Out of the 654 indications one will not will be the least likely to be an indication. But few more seconds. Okay, so we have a bit of a spritz. We go 37 Muslim people said the fun game fracture. It's not an indication. 30% said I'd be drug user. It's not an indication for surgery on, but then it was reflected community. Now I the surprisingly again, this is awfully close. This so come So you before mystified fungal infection is actually indication. I v e d u drug user. It's a diagnostic criteria. It doesn't mean it's, uh it's not an actual indication for doing surgery. Okay, everything else is so obviously if your heart is failing and you're going to correct, you got to operate in cardiogenic shock. You interview later, you got lots of support. You know, Tropic adrenaline adrenaline you got operate the vegetation, which is a centimeter went stroke. You got operated. You're getting embolisms, fungal infection. The reason for guys because a very hard to treat okay with antibiotic Well, anti fungal. Sorry. It's quite difficult to get rid of them. You got to operate to get rid off it. The natural source, refractory form or a demon means that you got from your demon you're treating. Yet it's not working because coming back you got operate because you're probably going into heart failure. Why did you drive? Use itself? It's not indication so, keeping it simple again for you guys and for completeness again. Okay, my know, come up in the finance. That's more for understanding. Ah, heart failure. It's an indication. So due to severe acute vegetation, an obstruction of the valves because of the vegetation, this distal a forming. I mean, you know, this severe infection we're talking about or all of these are causing refractory formula. The month, No country and I'm controlled infection. There's an abscess setting there. You gotta give it off that system of infection due to form guy, because that's not easy to treat without the fungals or persisting positive cultures. Despite being on a couple of weeks of antibiotics is not control the infection you got, operate and prevent embolism certificate vegetation, which is more than a centimeter and getting strokes, septic, embolized, spleen, liver, cooperate or the vegetation is causing such a severity education or a valve stenosis, which is gonna the's literally a vegetation was like sitting on the valve, and they're literally just moving. All it takes is one piece to fly off. You get a stroke. So you got operated. Those a couple of more questions left. So 35 year old old gentlemen presents to his GP with worsening shortness of breath on exertion. The GP auscultate says heart and notices that diastolic murmur. We're exploring his background. The GP elicits that the patient's father certainly passed away at a young age, often uncertain coast. The cheap people like to perform a full body examination to have with the potential differential diagnosis, which is the foot doing signs is less likely to be relevant. A scoliosis be this location lenses see long paper fingers, the perfusion off the no job be high arched palates. Probably no more condition. We're referring to just taking it to a step further. That's how questions in the values are. Uh, they're they're not? No, all of them opposite. But they are a two step, three step question for you know, the diagnosis. If that was a question was diagnosis 100% of people, 90% people would probably be like, uh, it's about thinking the next step. All right. Okay. Couple more seconds. Okay. So, yes. So it's a split. We go tide 31%. Because scoliosis and over the 31% said protrusion of the lower job, then the rest of around 17%. So it's Marfan's syndrome. Okay, wise, the Marfan's under. Well, okay, couple of things is young has toe. He's having problems for the breathing. Okay, you could have diastolic murmur. Okay. Um, father passed away for genetic. Okay on. So you think about Marfan's syndrome now the patrician of the lower joke. That's acromegaly basically. And that's where people often get confused between the two. So that's not, you know, in the It's not Marfan's syndrome. Basically the rest. You will see them in Marfa Lloyd patients. So what smarts syndrome? This can come up on. Did that come up actually from our skin itself by the patient with Marfan's syndrome? Okay, for the skin. So, uh, you know that if you know what I mean. So orders are dominant. It's a mutation of the several in gene problems and 15 little condition. Well, the clinical features possible of the right ear that told the thing they got this arachnodactyly. I don't want to say that, obviously, because everybody knows that as a textbook to memorize it. What the flavor mean. The long taper fingers because high arched palates Because scoliosis told and all that effective excavatum it's present ago happen. Mobility of the joints as well. They don't have the patrician off the job, which is called, uh, pregnant is, um, on Think of conditions is spontaneous pneumothorax because a toll they're gonna have a long, you know, big long story often get article bull is, ah, pocket A very busy which the top, then, Because the muscle, you know, talks Ectopic Lantus, which is a port dislocation of the lens, is seen they to keep things loss surgeons much about prolapse. So the motorized hopefully nicely. It's prolapsing because off the genetic of scene on assisted media necrosis, so that cause much in vegetation and called a rupture and a lot of your top of things, which is basically because of the features such as cystic meeting the cross off the vessel wall. They're more prone to getting validation of the walls so they're more prone to get good education because of the where they oughta. About six, which we call the root, is dilating. So the what involves getting stretched out and it's leakier prosecuting aneurisms. They don't that's actually that's stuff that Martin single patients can end up having a young age. Pretty supposing, factors for traffic, your take aneurysm. So, uh, it's kind of a B C D, which is what it stands for. So age arthrosclerosis uh uh can cause you know, the core principles and features for aneurysms. That's conspicuity. 12 are. It's another your top. It's basically a so you know, there are more like to get Your sister knows this but also get aneurysms. Very high BP, which is uncontrolled opposite It's going to get stretched. The autumn constitutions or the Marfan's syndrome discussed about elidel is that as well. They're sections, obviously trauma, your titers infections off the order syphilis. They also do pretty simple stuff again. This is again for completeness. For those people who are interested, you shouldn't get his question. Hopefully, no. But to give you an idea, when do we do surgery for that on your results. Okay. That's an aortic aneurysm you're looking at. This is the head of the bottom feeder there. We're looking from the anesthetic. You basically it's very large. Okay, so it's all about size. Uh, sending your 10 years and more than 5.5 centimeters. You can operate on that. On down here is a more than 4%. Because end, you're doing other operations. You dropped by one centimeter. Um, on do you drop another sentence between 45 centimeters? Integral corrected vision is order because you know, that's what's going to get bigger or at the art itself is more than 5% meters. Other indications of the conservatives the usual chest pain, back pain, breathlessness, dysphagia because, especially the esophagus. Most business because off the left of the recurrent laryngeal nerve, which is no arching at the Arctic arches, its you know, massive thing is gonna press enter. You marked. It is because it's the wrong kind of locals. A rapid rate of expansion just explaining so quickly, which is more than some Demetria. If they get recurrent embolize. Next question. Last two questions. Sorry. 65 year old gentleman presents with Southern Onset of back pain and dizziness in any is. Jesus is 12 out of 15. Heart rate is tachycardia. BP is 80/50 and you're getting rid your speed. A pulse is once the patient is hemodynamically stable. What investigation? Off choice. Would you consider doing a CT? Just be a city. Be a primary angiogram. See? City autograph, the echocardiogram, MRI, heart. But most people should be able to get this any few seconds. Okay, so, uh, if you so you're getting a sudden out of the back pain. You go. No. GCS your cologne. BP. You could reduce Peter pulses You obviously worry about in the article section because you're perfusing on your tee. That section you want to know? Couple of things like you want to know whether that section starting from it started for where the heart start, where they order starts happening halfway down is affecting the well. Pinter posters are reduced. His affect the femoral artery is affecting the arch. The neck vessels. Well, Jesus has reduced navy. It is, um, the best way to find out all those answer is going to be a CT aortogram. Okay. What that means is, um inject contrast, and you literally getting a picture of the whole day or two from a sort of start from the aorta about old way down to Ah, the femoral arteries. Get bifurcate. Okay. See teachers. Yes, you can, incidentally, find it. But you know, that's no your modality of choice, CPA. I mean, you know, you know, gonna order that, Um it has happened the past that people do find the present that's a little bit differently on, uh, bit more stable of the high suspicion would be actually a little section, You know, we get a call. Uh, echocardiogram definitely want to do it because you want to know Is the valve competent journey to replace the valve as well? They ought about MRI heart. You don't want it so out in a section. Quick topic. So basically, it's an intimate tear or something slipped in the aortic wall itself between the internal and the external laminas off the media. Okay, which is the middle ear off the off the rest of the aorta. The city or 2 g is the 95% sensitivity. You can sit here. This is a contrast force. Lumen. True, Lumen and you're you consider sending yours doesn't have their section. I know it's a mobile. It's static picture, but here you can see. Maybe it's only going up to dodge. That's important things to remember. It's quick. It's easily available. Any unit in the country can do that. You can imagine important. But as you can imagine, the head, the neck, the arch ascending, the sending your water down to the femoral, the pericardium. You want to look old support that are sexually active. And the point is the Vistaril organ. So the program is it Derek Poetry driven into the country. See your trunk? All of these, you know it's trying to got Are they monitor fuels on And for surgical planning, of course. So that's your best moderated T. O. E. Is the next available best availability. It's Ah, Mr Vicious asleep Transesophageal. Oh, you will check the degree of the aortic regurgitation. You can't get that from the city or to cram. It is operated dependent, but you're unable to do old other visual profusion, all of that. This is an SSRI flap. Looks like this is a work of you, and that's basically the fuck itself, Ondo yes, place cabin. Actually, things for you to be aware for. Finals. It's the classification. Okay, keeping it simple. That's basically that you could you hear of the Stanford? Get the debate with Stanford. Simple Type A A for sending so it a zongs ascending aorta is involved. Doesn't matter if it's extending old redound you're descending. It's a type of used to confuse me. Actually, it was only ascending is going to type it. But if you think Cruces ascending and it's called ascending typing, if it's only descending so after left subclavian on, it doesn't matter how far down it is going, then it's the time and is different. Type A. Re operate straightaway tight be. It's more sleep pressure management on If you're stable, we we keep an eye on them and then they can have further operations later, all standing and all that, the baking constipation will be more complex. You got the type of by the holy water is involved with the Type two, where only the sending orders involvement. Type 383 B where Onley the descending a water with the traffic part which is involved whereas ah, type three B, it's classic descending and I don't understand it. And as a book features, you know, she has to be a lot of tearing retrosternal chest pain that you know your immediate thing. Come on, that back pain neck pain on Say think about that. Any organ a profusion, Am I stroke? Abdominal pain would usually not put increase lactate. All of these things are gonna be thinking off sections, shortness of breath because the ghost a very good education that tamponade ing hemothorax No BP, high BP to the pressures you know, 118. You're worried the publishers 80. You also worried on depression. Difference is obviously between the right left off noted regurgitation murmur because the body's become incompetent on the section started from there. Absent, personable. So Lantus is moderate. Last question. 36 year old man is brought to any after suffering a single stab wound it to the left side of the chest. On examination, patient is to keep Nick distended neck veins. That's good BP of 88 or 55 despite intravenous IV fluids, with the most likely diagnosis for your to that section. In with their Dema can take company out pneumothorax and worry embolism. Couple more seconds. Onda. Nearly 80% people said carry company out, which is the correct answer. Um, because a Z we'll see. Basically, it meets the back. Try it. Okay, so while you go stab wound on the left side of the chest, that's for the hardest thing, right? Vicious To kept me. Okay, but it's distended neck veins for increase JVP The blood pressure's very low. Uh, temperate is, you know, something that you worry about on features off that So apparently intro to the very cardio will fill up the particular space. But a lot of blood the heart is unable to push against all of it's not gonna cause stamp about the try it off. The next ride is muscle heart sounds high potential radiology people just they understand it. Other features to get exposed to products Is that the cells here? Basically Ah, vertical inspiration expiration. We called a fall in the system pressure more than 10 millimeter off, three on inspiration. You can't get there for even then I make a compromise. So they are kept make short of breath. And so I only go your area because the heart's not pumping. Very well. So are the investigations for Company institute Sexually neck. Oh, well, you know, you shouldn't be doing them if you're high suspicion that you put a probe, Kartika. You see, the blood got drained, all right? Especially the compromise. But if you're because during the process where your Clarkin them know that you see in a CGM often you see at electrical terms and basically, which means, you know, the spikes are alternating. Basically, chest X ray was quite globular heart. You're doing that because I researched you quickly. Check on this new material for other things On best offices, echocardiographic can put a probe. You can see this is the heart left ventricle, and this is the fluid. And that would be the diet. So that and the keys features would be RV collapse. Because it's pushing our guests RV at a time, working just for the medical students when you come in to see the heart for the first time open in front of them. The first chamber that they see when you know if somebody had to stop you is the right ventricle. Okay, so, uh, you know, it does collapse off that metrical that after because more lateral. Then you know you're struggling with beating of the heart and being kind of carpet or that so those are important sign so you can act quickly, which is basically treatment. If it's a known cardiac surgical patient submission, resident cardiac surgery, they present to a temperament. You gotta do this. 74 pericarditis diseases. Basically, what that means is that sticking a needle into the particulate states under the ultrasound guided and you're taking all that fluid out. But if there is, you know, if there's a stab wound and the puncture the RV that I have seen that the blood in the bag will feel a little better will come in seconds, like within a minute. Um, you're gonna operate? Basically, open up your total colectomy. It's clamshells. You could have stopped that bleeding somehow. Otherwise, bag, which is keep filling. It is official that cardiac surgery very different. Okay, people who don't drink it is for chronic surgery on it. For patients go Tampa Not after a heart operation which can happen, you know, gonna stick it Very curious and decent. Drain the best thing to do. Still want the sternal wires with still present Superfresh within the last couple of days. You just gotta get them apart, open the heart, open the sternum, which has already been open before, and then do internal carotid massage. And Gary does everything. All the clocks. That's the best way to treat kind of jumping up pasta colic. Surgeon on that said I'm sorry. Over on a little bit, Um, we covered a lot of topics. A lot of these do come up in finals, some off the topics. I want to be more detail for completeness. Okay, So don't be worried. It's, you know, hopefully like, um, useful for your future careers. Um, a lot of it, you know, it comes in one way or another. So we talked for a carotid disease. Much regurgitation. Your exynos is their eye. And ask them, you know, the war friends, the mechanical tissue boss, and a keratosis, which is common thing that does come up. You find us more for center of the dust, come up aneurysms, defections. And then lastly, Tampa. So thank you very much for listening. And hopefully the number you too much. Thank you so much. Uh, Mr No Ruka. There was a really, really comprehend, even amazing session. Okay, thank you. And I think everyone in the chatter also saying It's excellent session. Thank you so much. That's okay, too. I'm glad about that. That's under you know, if you anybody's go questions, feel free to ask me on. You know, you can always find answers from books from Google. You know, we're looking about that these days. If you're not too sure about it, you know, don't go for finals. The tips you know, thinking that's where most of knowledge you've already got from your last 56 years of medical school now just wrapping it up and building medical school dramatical school. But it's not uncommon to have questions that are some anatomy, for example, or questions. They're the clinical, but asking something about physiology because they don't they they are finals and trying to wrap it up your knowledge. Basically, we're not trying to catch you out. Always. You probably been told the million times, read the question, probably read the last line or two because that one not or least can really change. And it makes the question silly, very easy. Even, he said. The beginning we looked pretty daunting. Thanks. Just one question is, Well, um, someone has asked her on a C s. When do you go from cabbage over? Yeah. Yes. And that's That's basically the indications which I went over. I can quickly go through them again, but, um, let me just go back and doctor, if I went through quickly. Um, sorry. There we go. No, no, they're so so in a C s. So occasional presents. Classically divisions that we get. We're the last result for the patient, basically the Michigan's. We just met anybody. They're getting a CSR getting ST elevations said troponin. It's in the thousands or less. It's an instrument. Okay, Disaster, depression, the chest pains. Resolving now, you know, for angina in the past few months, so getting recalled the correctness factors, they said yes, and oppression. Troponin is, let's say 600. What would happen within a day or two or three days? You know, they don't have kept us an impatient. You can start on all those medications that would kind of went over there. Gonna have a coriander gram if they're completely stable. That can happen as elective, uh, within couple off weeks. If there are not so stable or going chest pain or troponin is very high. We'll have an inpatient coriander gram. The angiograms only shows goodness me. Not so left mainstem disease or triple vessel disease. That's when the cardiologist from capsule, um, they give us a call like please come and see this patient communication we think is a surgical disease. Otherwise they wouldn't bother calling us. If they see on the single vessel, which is 70% stenosed, they will just go ahead and stand it, and we will never know about it. Um, it is never vessel and they're not. You know, l a t Austin disease not left main stem. It's a vessel which is know, approximately deal. The injection fracture is normal. The heart's not beating nice and pumping than the constant it is where we'll never know about it. But suddenly, if the pictures diabetic young fit for an operation, they go next instant disease. They go on triple vessel disease, they give us a call, and then what happens is we discussed. Okay, So if the completely stable, uh, they can go home and come back, okay? Or go back to the local hospital and come back to us within couple off days. Um, papers urgent, urgent. So left mainstem, you know, if you know what I mean. The left Mr means that both the lady in osteo as circumflex have gone pretty much That's not of the heart tissue, which is it's chemical, uh, potentially can become ischemic. We keep them is in patient on, um, until we get them done. And sometimes it doesn't happen the day after the day after that. Uh, because of various reasons, personally, be accepted. A patient. The patient is a smoker. You want your lung function death? The patients got some Currently bruitt you want to do an ultrasound? Corrupt. It's the patient. You haven't done an echocardiogram fully. Do they have a valve problem? You're gonna do that tower that will take a couple of days once at the overall picture when I cook will go for CABG times three. We don't need to do anything else or okay, it's changed a CABG between through the valve as well. So that's how the journey off the patient basically happens. I used to confuse me a lot, actually. But obviously being on this side now it's make a note of it is just Sometimes the end of the patient starts off in a any basically