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Da da. There we go. Ok guys. Can you all um see my screen and hear me now? Yeah, so just give me a thumbs up please. Ok. Good, good, good. Yes. OK, cool. That's great. So I'm gonna share my um slides here now guys. So um so yeah, so I am Steven, I'm going to quickly talk about aortic disease, infective endocarditis and cardiac tumors tonight. Um And uh hopefully it won't take me as long as it took me to do the last one. It took me about an hour last time. So this will probably be about 40 minutes or so. Hopefully. Um uh hopefully you should all be able to see and hear me. Um If not my um my colleague B is sort of moderate so we can give me a text if there's any issues. Um I've built in a few wee questions guys but um don't feel under pressure to answer them that you can't really be bothered. Um and there's only three of them as we go. So um yeah, if you have any questions as well, put them into the chat as usual, I'll try and answer them at the end when I see them if that's ok. Um, and um, yeah, any issues, um, just let me know. So I'm going to talk about aortic disease first. Hopefully for about 20 minutes, we're going to talk about aneurysms dissections and the coarctation of the aorta. Then I'm going to spend about 10 minutes on infective endocarditis and then less than 15 minutes, probably about 10 minutes or so on cardiac tumors because um, this is all sort of pitched at the medical student level. So, um cardiac tumors, I don't think are that necessarily that uh relevant? Um Whenever you're, whenever you're in university, I suppose it's gonna be just for interest. Um But yeah, hopefully I'll be wrapped up in about 40 minutes max. So that's OK. So, um and as I said, any questions, put them into the chat, um and I'll answer them at the end or attempt to answer them. So, firstly, aortic disease. So, um well, before we talk about aortic disease, talk about the aorta. So, um your heart sits here and from your um uh your left ventricular outflow tract comes your, your aorta through your aortic valve. The first branches of your aorta are these right and left coronary arteries and you have your ascending aorta, your aortic arch, the arch of the aorta and you've got these branches come off. There's anatomical variation with these. They're, they're not always like this, but this is the, the vast majority of people and then as I said, the, the arch loop and it becomes the descending aorta and it moves down through the thorax and then it becomes the abdominal or aorta whenever it passes here through the, um the, the diaphragm at the base of the thorax. So, um it passes through, does anybody want to um, you can, you can think about it, you can put it in the chat you on. But um the uh, where the aorta passes through the, um, the diaphragm, I'll give you the answer at the end of the slide. Uh, um, so when it moves through the diaphragm gives off several branches, the main ones that are important if you're into your anatomy is, are the celiac trunk, which is, um, expanded over here, which is a very complex network of arteries and the inferior mesenteric artery to your midgut and the inferior mesenteric artery which supplies to the organs of the hind gut. Um, there's these other bits and pieces of arteries, lumbar arteries come off at every, um, at every level. You've got gonadal arteries, you've got renal arteries. Um, but I'm not, I'm not talking about the aorta anymore because that's quite enough of that. I think. So, first, I'm going to talk about aneurysms. So, aneurysms, um, was an aneurysm. It's a bulging or a weakened area and open the wall of the blood vessel so it can be arterial or venous. Um, and it results in the abnormal widening or ballooning out of that blood vessel. So you can see in this diagram, there's loads of different kinds um or shapes morphologies. Um And actually what happens pathophysiologically. Um If, if you're interested is um you get degradation of, of collagen and all that and all those sorts of proteins and stuff um don't um fit together as they should. Um It's also um uh attributed to oxidative stress, immune responses, biomechanics, et cetera. Um And this issue, um this pathophysiology is in your um tunica media. So, as you know, you've got three layers of any arterial wall. Um So it's your tunica intima media and adventitia. Um So this is usually a tunica media issue. Um, patients that get aneurysms, risk factors for developing aneurysms include those who are older. So, with age smoking, hypertension, those with a family history, connective tissue disease. CT just means connective tissue disease. So people that have Marfans, for example, um it's actually more common in females interestingly. Um and then patients that um e either use intravenous drugs or um those, those sorts of things or inject intravenous drugs, um the signs and symptoms, symptoms of aneurysms and this is very general, but um it depends on the site. Um obviously the anatomy of that site and um the status, whether it's ruptured or unruptured as you all know, um If somebody has a AAA that's unruptured, it's usually asymptomatic until it ruptures and the person um presents in um in usually in shock. Um not, not, not very well at all. So, um this is uh maybe a bit academic but um there's different ways of classifying aneurysms. Um So it can be true or false. So true is a full thickness. Um, aneurysm, true aneurysms are, are the full thickness of your arterial wall. Um And then in, in contrast, you have also false aneurysms or pseudo aneurysms as they're also called, um which you can see here, it's not a great diagram to describe it, but it shows um blood leaking from an artery in this case. Um but it'll be confined next to the vessel. Um So it's, it's not really, I suppose um it's not really a proper aneurysm health, hence pseudoaneurysm. Um and it forms hematoma. Um And these false aneurysms are associated with trauma or repetitive arterial access. So they're very common in people that are um intravenous drug users. For example, I remember we had a question in, I think it was maybe a third year medicine exam. I think I can't remember really. But um it was about somebody that had a, I think it was a femoral pseudo pseudoaneurysm. Um and they were an intravenous drug user and it was something to do with risk factors or something. So, um yeah, so there's a, there's a, you know, sort of a link there. Um You can classify them by, by morphology. So whether they're saccular. So this is a saccular aneurysm. And you can see you've got this neck, it's pedunculated on this sort of stalk and you've got this ballooning out, it's like a berry aneurysm as you talk about in the brain. And then you've got fusiform aneurysms, which is this sort of no neck, just expansion of your traditional art arterial um lumen. Um There's no, there's no neck associated with it. Um And then obviously you can talk about them in terms of the location. So be it in your aorta or one of the cerebral vessels, the cardiac vessels um or like your coronary arteries, for example, everybody knows, um Kawasaki is associated with um coronary artery aneurysms. Um And then whether the aneurysm is arterial, which we're probably more concerned about than, than venous aneurysms. I've never ever seen a venous aneurysm. Um So, yeah, so I'm just going to very, very briefly talk about um AAA so abdominal aortic aneurysms um because they're most, most frequently examined probably of, of all the different kinds of aneurysms. Um And um I think they're quite interesting as well. They're quite um quite, quite, quite bad to get obviously. Um but um quite, quite interesting um and you can do a lot for them if, if they're caught. So patients will present usually with this terrible abdominal pain which is tearing in its nature, usually radiating to the back. Um Really interestingly, one time I saw a patient in an emergency department um who had come in with really bad abdominal pain. Um, previously, um, it was thought she was just constipated or something like that. But, um, she had this really bad abdominal pain and it did radiate through to her back and she ended up, she got her CT and she actually had a bust a burst AAA. Um, and, um, it was a, it was a terrible, terrible, um, case, unfortunately, she passed away, um, actually within a few hours of arriving in the emergency department because she wasn't deemed suitable for surgery. Um, but she had these typical symptoms. Um, I didn't get to examine her unfortunately, because she was doing well. Um, but I potentially would have felt a pulsation, uh, an abdominal mass with pulsation and, um, in, in most cases of, of presentation, if it ruptures, the patient will present in shock. Um, and because of this, um, it's, it's usually asymptomatic until it ruptures and the patient, it presents very, very unwell. We have a screening program. Um, so the screening program in, um, in, uh, in this country is, um, involves an ultrasound scan for men greater than 65 years of age. Um, uh, it's offered to all men registered with a, with a GP that are over 65. Um, and it's, um, it's actually quite common about one in 80. I think men will be found to have a, a AAA, be it a small, medium or large AAA on their ultrasound. Um, So based on the size of their, their um, aneurysm on ultrasound, you'll take different axons. So small, you'll have a, an annual ultrasound between three and 4.5 centimeters, medium, 4.5 to 5.5. You get three month, three monthly ultrasound surveillance. And then large. It is important to know if it's greater than 5.5 centimeters. They need to be referred for um, surgery, They need to be referred urgently to vascular surgery. Um, or as well as that greater than one centimeter increase over one year, you need to refer them for vascular surgery as well. And this is just what the ultrasound scan looks at. This is, um, this is just AAA few different plans and they put it together. Um, and one so you could see what the, what the aneurysm looked like. Um So yeah, so how do you manage a A AAA? Well, it's an emergency. So, um, they'll present usually to an emergency department and all patients in the emergency department should be, um, especially those in to be managed with an A to E and then they'll be, they'll be treated as necessary. Um, so they'll, you know, treatment ID that involves all your whiteboard Cannulas and um, they might not get fluids or blood in this particular situation if you're thinking about permissive hypotension. But um, all the, all the treatments that go with that including all your chest x rays or ECG S or um giving oxygen et cetera. Um and they need urgently transferred to theater after scanning um for, for um repair um with the vascular surgeons. Um So, permissive hypotension for those who don't know what it is. It's um very straightforward basically, if you think about it, um if a person has got low BP, um they're gonna be bleeding out of their leaking aneurysm. Um an awful lot less as they've got a BP of systolic of 200 for example. So a person who has low BP with a AAA, it's probably better to, to keep them or the theoretically it's better to keep them in that, in that lower range. Um And then when they're moved to theaters, they'll either have an open repair with the vascular surgeons or, er, minimally invasive um, stenting or repair. Um, with the, um, vascular surgery or interventional radiology, I think can do it as well. Um, there's advantages and disadvantages of each, but that's probably, that's probably more for uh vascular surgeons and medical students. Um, and this was just a really interesting, a really nice summary sort of document that I found. Um, it's just by the Public Health Authority, it was really, really useful to read through, it just goes through everything very clearly. It's a patient leaflet. Um, but it's um I found it very good if you just want to access that link afterwards. Um, so moving on to dissections. And so is a different thing to aneurysm. Technically, um it's a tear within the wall of an artery and it allows blood to separate the layers of the arterial wall, usually between the intima and the media. As I talked about that forms what we call false lumen. So, between your intima and media, as you can see in this diagram, and what can happen is that blood can flow in uh into the gap. Um And it can create a false lumen. Um And that's, this is a, this is in the aortic dissection. Um So these can be classified as well. Um These are, this is important. Classification is important because it dictates management usually. So there's a couple of different types of um classification systems. Usually the um the Stanford one is, is, is more commonly used, II believe just because it's, it's probably more straightforward to understand. Um you can go through that really in your own time. But um suffice to say a type A Stanford is um one that affects your ascending aorta and these are usually more severe and they need urgent um repair in theater. Whereas those that are type B and they affect the descending aorta, they're usually not as severe, they could be medically managed um for, for some patients. The debate, key thing is um it's just an alternative classification system. Um And as I said, classification is important because it dictates management. Um So risk factors for um, patients that have a dissection. The most common or the, the, the biggest risk factors should they say is um, patients that have got hypertension. So, um, patients with high BP are very, very, very increased or um, have a very, very increased risk. A very large increased risk. I don't know what I'm trying to say. A very high risk of developing uh dissection. Those who smoke, um, older people again, unhealthy diet, all the usual um sort of vascular pa risk factors. And it's also associated with coarcation if you've got aneurysms or connective tissue disease. Again. Um This particular, I don't know how, how true this is, but this is often talked about um dissections um may sometimes happen. Um if, if uh a patient undergoes an event which suddenly causes a really, really massive increase in their BP. Um Traditionally, you would talk about like weightlifting or something like that. Something, there's a lot of strain, um which causes a high BP or a sudden increase in BP can predispose to the development of a dissection. Um very similar presentation in dissection, you get this sudden sudden tearing chest pain again, which may radiate through the person's back. Um They usually present with hypertension though, which is the key difference between dissection and um and uh a burst aneurysm is because an aneurysm usually presents in shock. So, hypotension making a radial pulse deficit, of course, um a diastole murmur which I'm going to talk about um shortly or it might also present with syncope. Um to diagnose this actually need a CT angiogram to just visualize or an aortic dissection, need a CT angiogram to visualize the aorta um and to management to manage it, it's a, it's obviously a surgical emergency if the patient is um unstable. So again, a to e analgesia and um medical management involves controlling heart rate and BP um to make sure they're optimized. And then if, if the patient is for surgery, if it's type A, as I talked about, so type a affecting your ascending aorta, um that's going to require open surgery usually ASAP. Um usually by the cardiothoracic surgeons or um type B, which is um the descending uh the person may opt for a medical management or they may be um deemed more suitable for medical management or endovascular, which can be carried out by the interventional radiologists, um maybe stenting or something like that. So I've got a question or we, if you don't mind if you can activate the we um uh question poll thing in the chat, if that's OK. So the question is why might a patient with an aortic dissection develop a diastolic murmur? So I will give you 30 seconds to go through that and then um I'll check the, the chat if that's OK, you can read through the answers yourself. So 30 seconds and then if you don't mind voting please. In the poll. If the poll isn't activated, just put the number into the chat, please. Um, so 30 seconds. Ok. I hope people have voted. And so I'm not even gonna go ahead and check the answer to this question. Why might a patient with an aortic dissection have a diastolic murmur is because um, of retrograde extension of the dissection involving the aortic valve, which leads to aortic regurgitation. So, it's a diastolic murmur. So, um if you think about break things down, make it really simple for yourselves. If it's a systolic murmur, it's gonna be a aortic stenosis or mitral regurgitation in um medical school. It's probably not gonna be something much more fancy than that. If it's a diastolic murmur, it's the opposite of that. So, it's aortic regurgitation or mitral stenosis, aortic regurgitation is probably more common and uh especially in the, in the setting of a, of a dissection. Um So this person has got a dissection which as you can see here has torn back the way and actually can cause the aorta, it can do loads of things that can um upset the aortic annulus and then the, the, the valve leaflets won't close over fully and stuff. So you get a bit of regurgitation. Um So we can talk about that later if you want me to. But um that's uh that's why you get a diastolic murmur sometimes with an aortic dissection. Um Yeah, so I'm going to move on to coarctation of aorta, which I think is particularly interesting. Um So it's a congenital disease cot of theta, as you can see here, you can nice ventricle on your aorta here. This would be in an adult heart. Um As you can see here, there's a, there's a narrowing here of your aorta. The lumen is absolutely tiny here. Um So as I said, it's congenital disease, congenital just means present at birth. So, Children will be born with this um where the aorta is narrowed. Um and it's usually in the region of the um the ductus arteriosus or what becomes ligamentum arteriosum um in in life. If you want to revise your ps cardiology, think what causes your ductus to um become your ligamentum arteriosum. What causes that? Um So three different kinds if you want to classify co of theta. Um this is um this is, this is just mostly for interest. So we have preductal ductal, postductal, obviously, relative to where the ductus is at. Um preductal um with Children, it's usually it presents in, in, in, in newborn babies and it usually is a uh a cyanotic issue because um there's, there's not enough blood flow getting through through the um the stenotic area of your aorta. And so that's very, very rapidly life threatening for those Children whenever the um ductal starts to close. Um ductal presents usually in Children. Um it uh it's sort of less severe, I suppose but, um, might, um, present with, um, uh, you know, symptoms in Children and then postductal. That's usually, um, is asymptomatic until adulthood. Um, and, uh, I suppose what are these symptoms? So, there's loads of different symptoms. Um, it depends on the age of the person. So, in a neonate their ductus is, is still potent. If it's still open, it's usually asymptomatic. But as soon as it closes, it can, um, cause the child to develop shock, um, or heart failure. Um, and if you think about it whenever you're doing your, your babies or your baby exams in um, the newborn and then at eight weeks, um, we feel for the femoral pulses and you're feeling for weak pulses in the lower limbs and that's to try and detect if there's a coarcation. Um, because if you've got weak femoral pulses, um, I don't know how sensitive it is or specific for a coarctation, but, um, I suppose it increases your suspicions that this child could have a coarctation um, in the older infant or a child, a coarctation if it's mild can be asymptomatic. But, um, in more severe cases, you'll find discrepancies between the BP in the arms and the legs. Usually that of the arms is higher than that of the legs. You might get a systolic murmur at the, at the left clavicle and usually over your left scapula as well. But, um, I've never, I've never heard that. Um, myself, so II don't really know. Um And then the classical thing that you always look for in your cardiovascular exam, which is your radio radial delay and radiofemoral delay, um which is a difference in the time of the pulsation in those particular pulse areas um in adults that might present with hypertension or differences in blood pressures and limbs. And uh this is something for you to go and look up is what r notching looks like on a chest X ray. So chest X rays with rib notching are associated with coarctation of the aorta. Um It's just one of those things you have to learn. Um And how is it diagnosed? It can actually be diagnosed antenatally and ultrasound scan. Um But then in, in Children or adults, if they start to develop symptoms, um they'll need some sort of, you know, proper imaging of their heartbeat. Um They need an echo or an MRI or a CT most get a chest X ray anyway, looking for this rib, not thing. Um So I've got another question again, if you don't mind activating the, the pole on the chat. So just what genetic condition is associated with coarctation of the AORTA. I've got more fans Turner Syndrome down Syndrome Newman syndrome or this one that nobody knows how to pronounce. I'm going to call it Ehler Danlos syndrome, but that could be wrong. That's what I've always called it. So again, I'll give you 20 seconds if you don't know, just guess. And, um, yeah, I might actually go and see what you put for this one. So we'll give you 2030 seconds. Ok. So let me see. Did anybody vote? So, uh, nice. So we've got a third went for two, a third one for 31, went for one and one went for five. So the correct answer guys is number what? Number two? So it's number two. So 2206. Got it right. Not bad. Um So it's actually Turner syndrome. So Turner syndrome is associated with co of the AORTA. So if you've done your peds, yep, um Turner syndrome is um very commonly examined, I think or I felt like it was. Anyway, it's a genetic condition that affects females and it's caused by partial or complete absence of one of your X chromosomes. So the the karyotype will be a 45 X instead of it's um in a, in a regular karyotype or a typical karyotype, which is 46 xx or 46 xy. Um And it's very common. It occurs in one in 2500 live female births and it presents usually with this sort of picture. Um Typically people would have talked about like a uh you get broad chest or shield shaped chest with widely spaced nipples and you get this webbing of the neck. Children used to be quite short as well. Um And it's uh associated with um extensive gyne issues and, and fertility and issues around that. Um But as I said, it's, it's reasonably common if you ever do peds cardiology or adult congenital heart disease, you actually might, um come across some people with Turner Syndrome. It's a really, really interesting condition. Um, ok. So that's all my aortic stuff done if that's ok. Um I'm gonna move on to infective endocarditis. Um, now if that's ok, I'm gonna briefly just talk about this. So um it's an infection, infective endocarditis, obviously, infection of the inner surface of the heart, which is known as your endocardium and it usually impacts on your valves, the infection um microbiologically, the most, most of the cases are caused by staphylococcus aureus and um it's associated with intravenous drug use but also people that get repeated access. So people that get dialysis or those sorts of things um because it just, it leaks in from the skin as everybody knows, staphylococcus aureus, it's most common commonly found on, on patients, skin, on people's skin, on the skin of humans. Um Other bacteria that can cause infective endocarditis include the Vidin streptococci which is associated with poor dentition or dentistry. People getting teeth pulled and that sort of stuff ino eye um associated with gi stuff or the, the H A group of um uh uh what's the word bacteria? Um Fungal infections and can also cause infective endocarditis be it can um histoplasma capsulatum. Um And the thing about uh fungal infective endocarditis is, it's particularly, um, high in its mortality. It's usually worse than, um, bacterial infective endocarditis. Um, it's, uh, infective endocarditis. People. Uh, I don't think I appreciate how, um, severe of an infection it actually is. People do be hospitalized for weeks and weeks and weeks with, um, infective endocarditis for antibiotics and they do be quite unwell with it. And, um, just to show you how it happens, so you get colonization epithelial elevation with some sort of bug. Um you get hematogenous dissemination of course and to a heart valve or damaged heart valve or somebody with congenital heart disease or a structural heart disease. Um It's a, that's the perfect site for this bug to, to take root um and to, to cause to, to, to take root, as I said, and grow and vegetate there. Um So it's just commonly found in the valves. Um So what are the risk factors for infective endocarditis? As I said before, people that in inj inject intravenous drugs, patients with CKD. Um Think about why patients with KD might get infective endocarditis. And I'll tell you afterwards or those who are immunocompromised or as I said, structural heart disease in patients with preexisting valve disease or congenital heart disease. Um hypertrophic cardiomyopathy, prosthetic valves or patients with pacemakers. Um in most patients, it will present very nonspecifically, a lot of patients present with ongoing fevers for aids or night sweats and they just be really unwell with it, but until somebody thinks about endocarditis or, um, you know, they've tried several antibiotics and nothing's really worked for them and they still look at this nonspecific sort of presentation. Um, that's when people start to think. Well, maybe we should, maybe we should do an echo here. Um, so there's specific findings. So these are very, very, very commonly examined and they are the things that you talk about in your, um, your, uh acies. Um and your what do you call it your cardiovascular exam. Um And I don't think people, I think people go through the, like the phrases of these all the time, but I don't think they actually understand what they are, what they're looking for. They just know that they're in the hands somewhere. So, splinter hemorrhages, these are just these wee small um hemorrhages you see in the nail beds. Um It's a vascular issue. It's associated with infective endocarditis, gene lesions as you can see here. So these are flat, sort of red, pinkish, purplish lesions usually in the palms and the soles. Um and they're nontender. So they're, they're not going to be sore at all. Whereas by contrast, osler nodes, this is sort of an osler node up here. Um Again, it's this tender red, raised lesion, again, palms and soles, but it tends to be more tender than the g eye lesions. And then finally, raw spots. Now, people often say, look at hands and say, yeah, there's no raw spots, but you actually can't see raw spots because raw spots are on patients retinas. So you actually have to look in the patient's eye with um uh uh what we call it a fundoscope in order to see the, the raw spots. And as you can see, this is a raw spot here. So it's basically this red area, there's a bit of bleeding with this white bit in the center, which is a bit of fibrosis. So you've got this red area with a pale center, that's a raw spot. So say these in your cardiovascular exam and look in the eyes. And um so as you know what infective endocarditis is, these are called, have you ever heard of the peripheral stigmata of infective endocarditis? Um That's a nice phrase to use if you're ever doing your, your ays or, and whatever. So, in order to investigate invasive endocarditis, um you need blood cultures, you usually do three of them um before you give any sort of antibiotics and you need echocardiography because you actually need to visualize the vegetation on the valve or in the endocardium somewhere. And you preferably you would do a transesophageal echocar echocardiogram. But um transthoracic is often easier to um easier to order, easier to access. Um and it's diagnosed using the modified dukes criteria. So I'm gonna go through this in very, very, very brief detail. You have two major criteria, blood culture positive for infective endocarditis and evidence of endocardial involvement, ie and echo. Um And then you've got minor criteria. So these five minor criteria. So somebody that's predisposed like a heart condition or um drugs, somebody with a um persistent fever vascular phenomenon. As we just talked about all those things like the J lesions, the um all those sorts of um embolic things, the immunologic phenomenon, which includes all your oar nodes, raw spots and those sorts of things. And then microbiological evidence. Again, positive blood culture is not meeting major criteria else up here and you put it all together, you can either have a diagnosis of definite infective endocarditis. In which case, you would treat possible, you usually treat as well, but um you might get rejected infective endocarditis, which means the patient doesn't have it um by the laws of average. And um this is the Duke's criteria, the modified Duke's criteria you can read through yourselves for medical school. I don't really think you would need to know it, but it, it all makes sense. It's very easy to learn, but it's um just quite an awful lot of words. Um So whenever you have a diagnosis, how do you management, you need to give intravenous broad spectrum antibiotics. Um you always um prescribe based on whether they've got a native valve or a prosthetic valve or it also depends on where you're from, obviously. So, um you're prescribed in accordance with your local guidelines. Usually something like uh it depends on the valve, but they'll have a gentamicin in there and, um, some sort of, they do flucloxacillin or something like that as well. Um, some patients actually might need surgery. Um, but there's, there's different indications for it if they're, you know, really unstable, unwell with heart failure or, um, those sorts of things. There's, there's other reasons I can't remember now, but, um, some patients actually might need debulking surgery for their infective endocarditis. So, here's another question. If um a we if you don't mind again, just activate in a wee pole. So I'll read through it and then you can um answer the question. So we've got a 60 year old man with a history of prosthetic aortic valve replacement and he's presenting with a two day history of fever, chills and fatigue, maybe, maybe more than two days on exam. He's got a new murmur, a rash on his arms and a palpable splenic infarct, which is seen on imaging and his blood cultures grow with ver and streptococci after 48 hours, he has an echo because somebody thinks this man might have ie and uh it remains a 1.5 centimeter mass and it's attached to his prosthetic aortic valve. So, if he goes through his Duke's criteria, he's got indefinite infective endocarditis. His valve was replaced six months ago, which of the following is the most likely cause of him having this infective endocarditis. So if you just wanna read through the options and answer. I'll give you 30 seconds. Ok. So the answer to this question, this is my last question. By the way, guys, I think the answer to this is number one. So indulging has spread from the oral cap due to poor dental hygiene. Now, I don't know what you went for. Um I'll not go out and check, but um I would, I think I tried to make discussions so people would go for number two, because he had a valve replacement and I thought, let's try and make it so that it'll think contamination during the procedure. Um But he had the procedure six months ago and he's only developed this, in fact of endocarditis clearly recently and his blood culture. So this particular strain of streptococci, um which is associated with poor dentition, as II said a few slides ago. So that's why number one, excuse me is the correct answer. Um, hematology has spread due to previous skin infection. He doesn't have any signs of neck fash or anything traumatic. Like, so he wouldn't have infective endocarditis from that fungal infection secondary to immunosuppression. He's not immunosuppressed or hemodialysis related infection. He hasn't got him but he's not on dialysis. Um So that's that question. So now I'm gonna very quickly speak through cardiac tumors because I don't think they're necessarily that relevant for our medical students. Um But nonetheless, they're a bit interesting if you, if you have an interest at all. Um in, in cardiology or cardiothoracic. So I'm gonna talk about an atrial myxoma, which is the type of benign tumor. I'm gonna talk about a sarcoma, which is just any connective tissue tumor. But I'm gonna talk about um uh cardiac sarcomas. And then I'm gonna talk about metastatic diseases very briefly, but just to say that cardio oncology, um cardio oncology is sort of a region or a branch of cardiology in and of itself. Um And the cardio oncology is not really involved necessarily with the treatment of these diseases of cardiac tumors. It's more involves um the prevention and managing of cancer patients who've had cardiotoxicity as a result of their chemotherapy, for example, or their radiotherapy. Um It's a, it's a, it's a really um big sort of emerging topic at the minute is cardiotoxicity. And due to um chemotherapy, anthracycline, chemotherapy and different kinds of radiotherapy and stuff like that. Um Cardiac tumors themselves usually are managed by um the cardiothoracic surgeons and oncology because the patient obviously will need it removed. Um If they're amenable to surgery at all. And um that's beyond the remit of the cardiologist, they need something surgical. Um But usually it's an MDT thing, they'll have cardiology, cardiothoracic oncology, radiology, et cetera. Um So, firstly, atrial myxoma. So it's a rare benign tumor and it usually affects the left atrium and you'll see a smooth, pale, soft and rounded mass, it's usually attached by a pedicle to the endocardium. It's the most common primary cardiac tumor and 75 to 80% of them, as I said, are going to be in the left atrium. So, um very rare, but the most common of these rare group of diseases, um, it can be asymptomatic. Some people might just find one incidentally and then have it after treated thereafter. But it can also present with these sorts of either um, fever, cough, breathlessness or apnea, failure, sort of symptoms, palpitations, chest pain, all the usual stuff are then the constitutional symptoms as well. Um This is just what one, what one might look like. Um This is obviously somebody's left atrium and um this is a very big mass inside their left atrium. So um the left atrium isn't gonna be filling to, to max capacity, obviously, because of this, this lesion that's occupying this bit of space. Um Risk factors are, are caused, I suppose 10% are actually inherited. Interestingly, there's loads of different symptoms that can lead to the development of myxomas anywhere in the body. But um atrial myxomas in, in particular, more common in females, usually between 30 or 4060 more common in those with the family history, apparently. Um to diagnose them, you need to do a cardiac exam, obviously. Um And what you're listening for is a tumor plop. So I've never heard a tumor plop, I have to say, but apparently it's heard at the end of diastole, um whenever you have the tumor um hitting up against the wall of your atria in this case. Um Interestingly, and then obviously they'll get the full, um, walk of cardiac investigations. They get ECG S and chest X rays echos, potentially CT potentially um uh cardiac MRI as well. Um And for anybody that likes histology, that what it looks, this is what it looks like on histology. So you get hypocellular myxoid stroma, which I presume is this vaguely pink stuff with scattered stellate or polygonal cells if that means anything to you. Um It doesn't mean much to me to be honest, but that's what, that's what you're looking for on um if you get it removed on um what's called histopathology, um complications, it can obstruct. So a left atrial myxoma, if you think about it can obstruct your mitral valve and it'll mimic mitral stenosis. Whereas a right atrial myxoma can obstruct the tricuspid valve and that can lead to rightsided heart failure because it blocks your right ventricular out flow tract. Sorry. Um your um right ventricular inflow tract, if you, if you want to imagine um your uh uh it can also embolize so it can break off and cause strokes or ischemia of limbs or it can lead to arrhythmias as well. The management is surgical resection. It needs to be removed surgically. You're not gonna be able to medically manage it because it's a uh a benign tumor but it's, it's not that it wouldn't respond to a beta blocker. Unfortunately. Um, it's associated with this thing. I've never heard of it. It's called Carney Complex. I was just reading about it, which is a genetic syndrome. Interestingly, it's associated with multiple myxomas. Um, as you can see here, um, pigmented skin lesions and endocrine overactivity like cushing's or acromegaly. Um, it was caused by mutations in this particular gene. Um So I just thought it was interesting. I did a bit of reading about it. Um So, yeah, so moving on to sarcoma, I'm nearly finished now. Um it's a a cardiac sarcoma in particular, it's very, very rare, but it's a malignant primary tumor of the heart. Um and it rises from me mesenchymal tissue. Um They're aggressive and they've got a very poor prognosis. Um and they make up less than 1% of all your primary cardiac tumors and there's several different subtypes as you can see all ending in sarcoma. Um Angio sarcoma I think is the most common and I also think it's got the worst prognosis associated with it. Again, it presents it can present very similarly to the um atrial myxoma, which is benign. Obviously, sarcoma is malignant um with obstructive symptoms with the constitutional oncology, symptoms, embolic phenomenon. Arrhythmia is again spelt wrong by the way, heart failure, pericardial effusion, et cetera. Um and this is just what it looks like grossly. So I just um got this off this particular paper. So you can see here where this is um this hashtag is, is the uh your um the mass in the left atrium, which is probably a sarcoma. And um this is a, the um ventricular wall as you can see down here. And these different colored deposits. Very interestingly. The asterisk here are um mets within the left ventricular wall interestingly. So this person had an awful lot of disease in their heart on autopsy. Um Again, diagnosis, you need to image it, you need to actually see it. So echo um MRI or CT to manage it. If it's appropriate, you can surgically resect it. But unfortunately, they usually present at such a late stage that palliative care is the only option. Um including ads, therapies like palliative radiotherapy, for example, um for symptom control. Um and as I said, prognosis is very poor, usually only 6 to 12 months from diagnosis. Unfortunately, angiosarcoma is with the worst prognosis. Um and then early diagnosis and aggressive treatment may improve outcomes, but it's often limited by the tumor's advanced stage at presentation. And this is just what it looks like on um CT here. So, unfortunately, not a not um not very good and then very, very, very finally guys, I'm going to talk about cardiac meths. So these are the most common of all the sort of cardiac thing, cardiac oncology, tumor things you're gonna get. So they're secondary cardiac deposits. Um the signs of card are more common than primary cardiac tumors. So, as I said, they're, they're the most common cancer of the heart you're going to find. And they found, actually, I didn't know this, they're found in 10 to 20% of all patients with metastatic cancer in autopsy. Um, but they're usually clinically asymptomatic. They don't present with any sort of, um, symptoms at all until the person is, um, until unfortunately they pass away And it, it just so happens that they have um Mets in their heart in an autopsy. It can involve any bit of the heart at all. Uh Again, similar diagnosis with echo CMR CT um or an autopsy and management is usually palliative obviously because it's metastatic disease at this stage. And again, prognosis is per if they at the stage that they've got diagnosed cardiac Mets. Um, unfortunately, prognosis is um going to be quite poor at that stage. The primaries most commonly originate in lung cancer. Um, lung primaries will result in cardiac meds. But also you can get with breast melanomas, leukemias or lymphomas. Um There's several other different cancers that are associated with cardiac meds as well. But um, I think what's important to think about is cardiac meds are um most common or the most common like cardiac um, cancer you're going to get. Um, if, if, if somebody has cardiac cancer, it's usually probably gonna be met and that's all I have to talk about. Um, if you have any questions, please put it in to chat, I'll attempt to answer, but I can't guarantee I'll be correct. Um, and please fill in the feedback form this, hopefully that should, um, er, er, let you go to the feedback form. If you don't mind filling in the feedback, it's just useful for ourselves. Um, so we know going forward, I think this was the eighth um, teaching session in this series that we're doing, we're doing one every Tuesday or roughly every Tuesday. Um So we did a good few in the first semester of this academic year and we're doing more um into into this next semester as well. Um And hopefully you'll be able to, to come and join authors um in future um and support us because um we've had good support so far and hopefully that's been useful. So, um we just want to fill in the wee form. Let me see. Now. Uh I'll just double check. Is there any questions? But it doesn't seem to be any questions? OK, if you want a fee, better fill in the feedback form guys. And um yeah, if you wanna fill in the feedback form, um No problem, Fatima, uh that would be very much appreciated. And um other than that, I think you're, you're free to go, you should get a wee certificate and I think this was recorded and I'll put up the slides on the um on the medal afterwards. If you want access to them uh, afterwards. So, um, yeah, you can continue filling out the form or leave, do whatever you want now. Um But, um, yeah, thanks. I hope that was, hope that was useful. No problem. Have a good day then. Heel, I'm glad you were able to join in the end the on the broadcast in about three seconds or so. That sounds all right. Yeah, I don't, I don't know.