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12.11.23 Ward notes

Pacemaker infections
  • Sites
    • Lung abscess
    • Under skin
    • Endocarditis
  • Management

Prognostic symptoms in AS
  • Factors
    • Aortic jet velocity 
    • Mean gradient 
    • Aortic valve area
  • Mortality rates from the onset of symptoms are approximately 25% at 1 year and 50% at 2 years
    • More than 50% of deaths are sudden
  • Mortality breakdown (without surgery):
    • CHF : 2 year mortality = 50%
      • Combination of systolic dysfunction (a decrease in the ejection fraction) and diastolic dysfunction (elevated filling pressure of the LV)
    • Syncope : 3 year mortality = 50%
      • Unable to increase output?
      • Vasodepressor response from high LV pressure?
      • Coronary artery insufficiency?
      • Calcification leading to heart block or arrhythmia?
    • Angina : 5 year mortality = 50%
      • Secondary to LVH

Surgical treatments for AF
  • Aortic Valve Replacement
    • In most adults with symptomatic, severe aortic stenosis, aortic valve replacement is the surgical treatment of choice
    • If concomitant coronary disease is present, aortic valve replacement and coronary artery bypass graft (CABG) should be performed simultaneously
    • Aortic valve replacement should be performed in all symptomatic patients with severe aortic stenosis, regardless of LV function, as survival is better with surgical treatment than with medical treatment
    • Aortic valve replacement is also recommended in asymptomatic patients with severe aortic stenosis and LV dysfunction
    • Improvement in EF invariably occurs over the following 6 months, and increased LV mass tends to decrease within 18 months postoperatively
    • Bioprosthetic vs mechanical valves
      • The choice of prosthesis is determined by the anticipated longevity of the patient and his/her ability to tolerate anticoagulation
    • Surgical mortality risk in patients with normal LV systolic function and no other comorbid conditions is less than 5%
    • Overall, the 5-year survival rate in all adults after aortic valve replacement is 80-94%, and the 10-year survival rate is 68-89%
  • Ross procedure
    • Another option in young patients as an initial procedure or for reoperation after prior valvotomy
    • The patient's own pulmonary valve and main pulmonary artery are transplanted to the aortic position, with reimplantation of coronary arteries
    • A homograft is placed in the pulmonary position
    • The Ross procedure is technically demanding and results at different centers have been mixed.
  • Percutaneous transcatheter valve replacement
    • Percutaneous transcatheter aortic-valve replacement (TAVR) with a balloon-expandable bovine pericardial valve is a less invasive option for these high-risk patients
    • Used as a palliative measure in critically ill adult patients who are not surgical candidates or as a bridge to aortic valve replacement in critically ill patients
    • The high rate of restenosis and the absence of a mortality benefit preclude its use as a definitive treatment method in adults with severe aortic stenosis

JVP waveform
  • A wave
    • Right Atrial contraction
    • Ends synchronously with the carotid artery pulse
    • Peak demarcates the end of atrial systole
  • C wave
    • Right ventricular Contraction causing the triCuspid valve to bulge towards the right atrium
  • X descent
    • Corresponds to atrial relaXation and rapid atrial filling due to low pressure
  • X' descent
    • Occurs as a result of the right ventricle pulling the tricuspid valve downward during ventricular systole
    • Used as a measure of right ventricle contractility
  • V wave
    • Corresponds to Venous filling when the tricuspid valve is closed and venous pressure increases from venous return
  • Y descent
    • Corresponds to the rapid emptYing of the atrium into the ventricle following the opening of the tricuspid valve

Pemberton's sign
  • Raise both of the patient's arms above his/her head simultaneously, as high as possible
    • Positive sign = Development of facial flushing, distended neck and head superficial veins, inspiratory stridor and elevation of the JVP
  • Cause - Superior vena cava syndrome
    • Mass in the mediastinum
    • Goiter

JVP Waveform in AF
  • A waves completely absent

  • Ventricular systole is between the peak of the c and v waves