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

Notes

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