cv 3: valvular heart disease lab september 19, 2011
TRANSCRIPT
![Page 1: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/1.jpg)
CV 3: Valvular Heart Disease LabSeptember 19, 2011
![Page 2: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/2.jpg)
Case 1
![Page 3: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/3.jpg)
Case 1
• A 75 year-old man presents with exertional angina, syncope, and dyspnea.
• The patient also admits to having occasional spells of lightheadedness and fainting on exercise
• On physical examination: – Systolic ejection murmur to right of
sternum radiating to the neck– Weak and delayed carotid pulses
![Page 4: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/4.jpg)
• A chest x-ray shows calcifications of aortic valve leaflets and an enlarged cardiac shadow
• The patient does not have any evidence of significant coronary artery disease on angiogram.
![Page 5: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/5.jpg)
What do you think is the most likely diagnosis?
![Page 6: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/6.jpg)
In a 75 year-old man, what is the most likely etiology of the valvular disease
![Page 7: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/7.jpg)
The patient underwent surgery for aortic valve replacement
The excised valve is shown in image 1B
Image 1A shows a normal aortic valve.
![Page 8: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/8.jpg)
1A
1B
Image 1A, 1B
![Page 9: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/9.jpg)
In a 50 year-old man with similar symptoms and with no evidence of significant coronary artery disease, what would the most likely diagnosis
be?
![Page 10: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/10.jpg)
Image 1C
![Page 11: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/11.jpg)
Image 1D
![Page 12: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/12.jpg)
In a 25 year old-man with similar symptoms, what would be the most likely cause of the
disease?
![Page 13: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/13.jpg)
Image 1E
![Page 14: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/14.jpg)
Image 1F
![Page 15: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/15.jpg)
Case 2• A 25 year old white-male presents to his cardiologist with
complaints of pounding of the heart and angina.• There is no family history of coronary artery disease• The patient denies smoking or drinking and claims to have
had no major illnesses in the past• On physical examination the patient has a bounding pulse,
large in volume and a wide pulse pressure and a diastolic murmur.
• His systolic blood pressure is high and diastolic blood pressure low
• Chest X-ray shows an enlarged left ventricle and dilated ascending aorta.
![Page 16: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/16.jpg)
Why would this patient have a bounding pulse? What is the most likely diagnosis?
![Page 17: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/17.jpg)
On additional questioning the patient mentioned that his older brother died of aortic dissection at the age of 30 years.
Why is this relevant?
A CT angiogram of this patient is shown in image 2A and 2B
![Page 18: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/18.jpg)
2A2B
![Page 19: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/19.jpg)
The next two slides(2C, 2D) demonstrate the pathology in this patient.
![Page 20: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/20.jpg)
Image 2C
![Page 21: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/21.jpg)
Image 2D
![Page 22: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/22.jpg)
Case 3
• A 34-year-old white female is admitted to the hospital with progressively increasing dyspnea and orthopnea
• The patient denies any prior cardiovascular disease, but on additional questioning she reveals that she had rheumatic fever as a child
![Page 23: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/23.jpg)
• On physical examination, the patient has elevated JVP, mid-diastolic murmur
• ECG: Left atrial hypertrophy and atrial fibrillation
• Chest X-ray (Image 3A) shows interstitial and alveolar densities
![Page 24: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/24.jpg)
Image 3A
![Page 25: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/25.jpg)
The patient underwent mitral valve replacement
Excised valve is shown in image 3B
![Page 26: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/26.jpg)
Image 3B
![Page 27: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/27.jpg)
• Image 3C is from another patient with similar history who underwent aortic valve replacement.
• Please describe the gross features.
![Page 28: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/28.jpg)
Image 3C
![Page 29: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/29.jpg)
Images 3D, 3E, 3F & 3G are autopsy images from another patient with
similar clinical history
![Page 30: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/30.jpg)
Image 3D
![Page 31: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/31.jpg)
Thrombus
Image 3E
![Page 32: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/32.jpg)
Image 3F
Image 3G
![Page 33: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/33.jpg)
Case 4
![Page 34: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/34.jpg)
• A 50 year-old with a history of rheumatic fever in childhood presents to the emergency with fever for 10 days
• She has had dyspnea on exertion for the past two years, but says that the dyspnea has become worse since the onset of fever
• On physical examination splinter hemorrhages were seen in his finger nails as shown in image 4A
CASE 4
![Page 35: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/35.jpg)
Image 4A
![Page 36: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/36.jpg)
Blood cultures were positive for staphylococcus aureus
What is the most likely etiology of this patient’s fever and dyspnea?
A mitral valve replacement was performed. The next image is from the
mitral valve from an autopsy patient with similar findings
![Page 37: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/37.jpg)
Image 4B
![Page 38: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/38.jpg)
Image 4C
![Page 39: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/39.jpg)
Image 4D
![Page 40: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/40.jpg)
Case 5
![Page 41: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/41.jpg)
• A 50 year-old-man died of bleeding complications following surgery for adenocarcinoma of the pancreas
• He was diagnosed with disseminated intravascular coagulation shortly before his death
• An autopsy was performed – The heart showed vegetations on his mitral valve and
aortic valve– Blood cultures were negative for microorganisms
![Page 42: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/42.jpg)
Image 5A
![Page 43: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/43.jpg)
![Page 44: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/44.jpg)
Libman-Sacks Disease
-- Seen in patients with SLE
– No predilection for lines of closure
– Circulating antiphospholipid antibodies
![Page 45: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/45.jpg)
Libman-Sacks Disease
![Page 46: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/46.jpg)
Rheumatic valvulitis
![Page 47: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/47.jpg)
Rheumatic valvulitis LSENBTEInfective endocarditis
![Page 48: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/48.jpg)
Case 6
![Page 49: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/49.jpg)
Case 6
• A 50 year-old man with known mitral regurgitation due to myxomatous degeneration presents in the ER with acute shortness of breath
• There is no fever. • A coronary angiogram performed 2 months prior did
not show any evidence of coronary artery disease. • Prior echo showed normal left ventricle and an
enlarged left atrium
![Page 50: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/50.jpg)
What are the diagnostic possibilities in this patient?
![Page 51: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/51.jpg)
The patient underwent emergent mitral valve replacement.
![Page 52: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/52.jpg)
The gross and microscopic features of the excised mitral valve are shown in
kodachrome 6A and 6B.
What is your diagnosis?
![Page 53: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/53.jpg)
Image 6A
![Page 54: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/54.jpg)
Image 6B
![Page 55: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/55.jpg)
In a patient with history of coronary artery disease the probable cause of acute mitral regurgitation is shown in the next kodachrome (6C)
What is your diagnosis?
![Page 56: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/56.jpg)
Image 6C
![Page 57: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/57.jpg)
Case 7
![Page 58: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/58.jpg)
Case 7
• A 35 year-old-man presents with complaints of flushing, cramps, nausea, vomiting, diarrhea and wheezing.
• On physical examination: patient has increased jugular venous pressure, hepatomegaly, ascites and bilateral lower leg edema.
![Page 59: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/59.jpg)
The patient underwent right tricuspid valve replacement.
Image 7B is from an autopsy heart of another patient with similar history.
![Page 60: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/60.jpg)
Image 7B
![Page 61: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/61.jpg)
Case 8
![Page 62: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/62.jpg)
Case 8• A 40 year old man underwent mitral valve
replacement for mitral stenosis. • A year later the patient presented to the emergency
department with an acute surgical abdomen. • On examination the patient had generalized
peritonitis. • On urgent laparotomy a ruptured spleen was found.
The spleen was infarcted at the site of rupture. • An echo was performed.
![Page 63: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/63.jpg)
The patient subsequently underwent a redo heart valve replacement
The pathologic abnormality of the valve is shown in image 8A which is from an autopsy
heart
![Page 64: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/64.jpg)
Image 8A
![Page 65: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/65.jpg)
• Another 40 year-old-man underwent mitral valve replacement for mitral stenosis.
• Four years later he developed mitral regurgitation.
![Page 66: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/66.jpg)
The valve was excised and is shown in image 8B.
What is the possible etiology?
![Page 67: CV 3: Valvular Heart Disease Lab September 19, 2011](https://reader034.vdocuments.net/reader034/viewer/2022051115/56649ea95503460f94badf92/html5/thumbnails/67.jpg)
Image 8B