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