Thursday, April 12, 2012

Mitral Valve Proplapse (MVP) Symptoms, Complications and Invesigations

Mitral valve bulging back into the left atrium during systole is called mitral valve prolapse. This is also called floppy mitral valve or or myxomatous mitral valve.

MVP is twice as frequent in women as in men. In the mildest form due to prolapse of mitral valve there is only mid-systolic click but progressively it leads to mitral regurgitation.

MVP exhibits a strong hereditary component and in some patients is transmitted as a autosomal dominant trait.

  • Most commonly it develops due to myxomatous degeneration of mitral valve in which middle layer of valve leaflet composed of loose, myxomatous material is unusually prominent.
  • Second common cause in our country is rheumatic fever.
  • MVP may occasionally result from Marfan syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta, periarteritis nodosa, myotonic dystrophy, von Willebrand disease, hyperthyroidism, Ebstein anomaly of tricuspid valve, hypertrophic cardiomyopathy, ASD II, mitral valve surgery and left ventricular aneurysm.

Clinical Features

  • Most patients with Mitral Valve Proplapse are asymptomatic.
  • In symptomatic patient it presents as chest pain, dyspnea, fatigue, palpitation, syncope and sudden death (reasons of symptoms is unknown). Palpitation may be due to atrial or ventricular premature beats or tachyarrhythmias. Chest pain is similar to angina but may last for hours or days, not related to exertion, and punctuated by brief attacks or severe stabbing pain at apex. This chest pain or discomfort may be due to abnormal tension and papillary muscles.
  • Mitral regurgitation (MR) may develop due to progressive elongation of chordae teninae.
  • Spontaneous rupture of chordae tendinae may cause a sudden worsening of MR that is hemodynamically severe.

On Examination
  • On auscultation there is midsystolic click in mild cases and pansystolic murmur if significant mitral regurgitation. Thoracic deformities are more prevalent in Mitral Valve Proplapse such as loss of normal thoracic kyphosis (straight back syndrome) pectus excavatum and scoliosis.
  • BP may be normal or low.

  • Infective endocarditis
  • Rupture of chordae tendineae causing sudden severe MR.
  • Progressive MR
  • Arrhythmias and sudden death.


ECG may be normal or show arrhythmias such as SVT, atrial or ventricular premature contractions, ventricular tachyarrhythmias, sinus node dysfunction or varying degrees of heart block.

Echocardiography is diagnostic of  Mitral Valve Proplapse (MVP). It shows one or both mitral valve leaflets bulging by at least 2mm into the left atrium during systole. Thickening of the involved leaflet to > 5 mm supports the diagnosis. Doppler echo frequently reveals mild MR that is not always associated with an audible murmur.

  • Asymptomatic patients without arrhythmia on ECG should be reassured about the prognosis and follow up every 3-5 years.
  • Beta-blockers and aspirin

Tuesday, March 27, 2012

Cardiomyopathies – Heart diseases | Types of Cardiomyopathies

Cardiomyopathies are the heart diseases resulting from a primary abnormality in the myocardium. Features of inflammation are minimal. Cardiomyopathy should be suspected in a young normotensive patient who develops heart failure in the absence of congenital, valvular or ischemic heart disease.

Types of Cardiomyopathies

Dilated (congestive) cardiomyopathy: It is characterized by progressive cardiac hypertophy, dilation and contractile (systolic) dysfunction resulting in failure of ventricle to empty in systole. Most cases develop heart failure. Cause is not detectable in most of the cases. A few cases are associated with:
  • Viral infections e.g conxsakievirus B.
  • Metabolie diseases e.g hypothyroidism hyperthyroidism and thiamine deficiency.
  • Alcoholism.

Hypertrophic Cardiomyopathy
It also referred to as asymmetrical septal hypertrophy and idiopathic hypertrophic subaortic stenosis. This condition is characterized by marked hypertrophy of the ventricular muscles with resistance to diastolic filling. Selective hypertrophy of the septum immediately below the aortic valve, obstructing the left ventricular outflow tract. Both ventricles are diffusely involved in most cases. In about 50% cases the disorder is inherited as an autosomal dominant trait. The interventricular septum is substantially thicker than the free lateral wall of the left ventricle.

Asymmetric hypertrophy is often associated with a significant degree of ventricular outflow obstruction during systole. In this group of patients, the systolic obstruction is caused by abnormal anterior motion of mitral valve leaflet during systole.

Clinical Features: The basic abnormality in hypertrophic cardiomyopathy is an inability to fill a hypertrophic left ventricle. Ejection is forceful but ineffective because the amount of blood in the left ventricle is very small. In addition there is obstruction of the left ventricle outflow. The limitation of cardiac output and a secondary increase in pulmonary venous pressure cause exertional dyspnea. Myocardial ischemia is common and anginal pain is frequent.

Restrictive Cardiomyopathy
It is characterized by a primary disease in ventricular compliance due to fibrosis and stiffness of ventricular walls, resulting in impaired ventricular filling during diastole. Exact cause unknown: myloidosis hemochromatosis and sarcoidosis are involved in some cases.

Clinical Features: The physiologic problem in restrictive cardiomyopathy is a stiff and inelastic ventricle that can be filled only with great effort. Clinically it presents with heart filure and angina.

Monday, March 26, 2012

What is Atrial Septal Defect (ASD)?

Atrial Septal Defect is the most common shunt lesion in adults. It often remains undetected until adulthood because patients are often asymptomatic. The condition remains unnoticed in infancy and childhood till pulmonary hypertension is induced causing late cyanotic heart disease and right-sided heart failure. A large ASD may be associated with growth failure in infants and children. It is more common in women thin in men.

There are three types of Atrial Septal Defect

Ostium Secundum ASD (75%)
It is the most common type (70% of patients) and results from defect in the region of the fossa ovalis. In this type there is no involvement of AV valves.

Ostium Primum ASD (15%)
It results from absence of septum primum at the lower portion of the atrial septum. It is more common in Down’s syndrome. It is more common in Down’s syndrome. In this type there is also involvement of AV valves.

Sinus Venosus Defect (10%)
It is in the upper part of the septum near the entrance of the inferior vena cava and coronary sinus therefore producing communication between coronary sinus and left atrium.

Blood flows from high pressured left atrium to low pressured right atrium (left to right shunt) through ASD. Pulmonary flow is increased and right ventricle is dilated and hypertrophied owing to the volume overload. With time, pulmonary vascular resistance increases resulting in pulmonary hypertension. This pulmonary hypertension in turn causes right heart failure or reversal of the left to right shunt (i.e now blood flows from right atrium to left atrium through this Atrial Septal Defect). Direct mixing of this deoxygenated blood produces cyanosis.
Above the age of 30 years there may be an increase in pulmonary vascular resistance, which gives rise to pulmonary hypertension. Atrial fibrillation is common at this stage.

Clinical Features
  • Asymptomatic for may years if there is small or moderate defect and no pulmonary hypertension. Normal or minimally diminished exercise tolerance may develop.
  • Exertional dyspnea after age 30
  • Palpitations due to atrial arrhythmia
  • Patients are more prone to develop recurrent pulmonary infections.
  • Right ventricular failure with large defect and prolonged pulmonary hypertension may develop later in life.

On CVS Examination
Systolic ejection murmur over the pulmonary area that does not vary with respiration.

X-ray Chest
  • Prominent pulmonary artery
  • Pulmonary plethora (plethora means fullness)
  • Right ventricular hyperthrophy

ECG: Shows incomplete right bundle branch block (RBBB) and right axis deviation.

Echocardiography: It can identify the type of defect, estimates pulmonary artery pressure, demonstrate right ventricular hypertrophy and pulmonary arterial dilation. It also demonstrates paradoxical motion of the interventricular septum. Doppler echocardiography is also required. Transesohageal echocardiography can detect small atrial septal defect that is missed on routine transchoracic 2-D echocardiography.

Cardiac Catheterization
It is performed unless the patient has large defect on echocardiography.
  • It is the definitive diagnostic procedure
  • It quantifies the shunt 
  • It measures pulmonary vascular resistance.

Aortic Stenosis | Symptoms, Treatment and Investigations

Obstructed left ventricular outflow due to aortic stenosis leads to increased left ventricular pressure and compensatory left ventricular hypertrophy. To maintain cardiac output large pressure gradient across the valve is required. Cardiac output at rest is maintained within normal limits in most patients with severe aortic stenosis, it often fails to rise normally during exertion. Late in the course of the disease, the cardiac ouput and stroke volume decline (due to LV dysfunction). Decreased flow of blood through the aortic valve causes decreased cardiac output, hypotension and syncope (fainting), myocardial ischemia and angina.

Ischemia in aortic stenosis : Due to hypertrophy, heart requires more blood for oxygenation that may be not be possible in severe aortic stenosis resulting in myocardial ischemia even in the absence of coronary artery disease. High left ventricular pressure may compress the coronary arteries in systole and shorten the diastole phase may lead to reduced coronary blood flow manifesting as myocardial ischemia, angina, arrhythmias and left ventricular failure. This ischemia becomes more severe on exercise.

  • Rheumatic heart disease
  • Congenital bicuspid aortic valves
  • Calcification of valves in old age

Clinical Features

  • Long asymptomatic phase
  • Symptomatic aortic stenosis manifests as angina, exercise induced syncope, exertional dyspnea and ultimately heart failure and sudden death. These symptoms appear when the aortic orifice in reduced to one-third of its normal size.
  • On auscultation there is an ejection systolic murmur at aortic area.


Xray Chest
  • Chest X-ray may be normal in critical aortic stenosis
  • The heart is usually normal in size or slightly enlarged
  • Post-stenotic dilatation of ascending aorta on PA view is commonly seen.

  • Left ventricular hypertrophy.
  • Left ventricular strain due to pressure overload. Left atrial enlargement.

  • This shows thickened, calcified and immobile aortic valve cusp.
  • Detects left ventricular hypertrophy, its systolic and diastolic function.
  • Droppler echocardiography demonstrates the pressure gradient across the valve and the valve area.


Medical treatment is not effective for aortic stenosis, any patient who develop any of the three symptoms (angina, syncope or heart failure) is the candidate for valve replacement.
Surgery is not indicated for asymptomatic patients except those with declining left ventricular function, very severe left ventricular hypertrophy and very high gradient (>80 mmHg) or severely reduced valve area (<0.7 cm2).

Mitral Regurgitation (MR)

Mitral Regurgitation

  • Rheumatic heart disease (most common cause).
  • Mitral valve prolapse.
  • Chronic left ventricular failure with dilatation of the mitral valve ring may cause functional mitral regurgitation.
  • Connective tissue disorders e.g. SLE, rheumatoid arthritis.
  • Hypertrophic cardiomyopathy.
  • Collagen abnormalities such as Marfan’s syndrome, Ehlers-Danlos syndrome.
  • Acute MR may occur due to rupture of chordae tendineae a complication of infective endocarditis or rupture of papillary muscles due to myocardial infarction.

  • Regurgitation of blood from left ventricle to the atrium occurs throughout systole. During diastole, regurgitant blood flows back across the mitral valve. Left ventricular volume is greatly increased, being the sum of cardiac output plus the regurgitant flow; the left ventricle is thus dilated and hypertrophied.
  • The left atrium, which accepts both the pulmonary venous return and regurgitent flow is also dilated in chronic cases. Left arterial pressure and pulmonary venous pressure are increased. In chronic ases, there is pulmonary fibrosis, pulmonary arterial hypertension and right ventricular hypertrophy followed by failure. Acute mitral valve regurgitation produces pulmonary edema and acute left heart failure.

Clinical Features
  • Features of left heart failure such as exertional dyspnea.
  • Palpitation due to atrial fibrillation.
  • On auscultation there is soft first heart sound, a loud third heart sound and pansystolic murmur at apex.


X-ray Chest: This shows cardiomegaly due to left atrial and left ventricular enlargement. Pulmonary hypertension may be evident, pulmonary edema and pleural effusion in case of heart failure.

  • Bifid P wave due to left atrial hypertrophy
  • Left ventricular hypertrophy occurring in about 50% of cases and manifests as:
  • Right ventricular enlargement in some patients.

This shows dilated left atrium and left ventricle. It confirms the diagnosis of mitral regurgitation. Severity of Mitral Regurgitation can also be assessed.

Medial treatment in mild to moderate cases. Mitral valve repair or replacement in severe cases.

Causes, Pathogenesis, Morphology of Acute Myocardial Ischemia and Myocardial Infarction (MI)

  1. Thrombosis superimposed on a complicated stenosing atheroma is the basic cause of acute myocardial ischemia and myocardial infarction.
  2. The risk factors of atherosclerosis are hypercholesterolemia, cigarette smoking, diabetes mellitus, physical inactivity and use of oral contraceptives. Checkout risk factors.
  3.  Myocardial necrosis begins within approximately 20-30 minutes after coronary artery occlusion.
  4. Subendocardial region of myocardium is the most poorly perfused region of the ventricular wall and therefore myocardial infarct typically begins in the subendocardial region. The infarct usually reaches it full size within a period of 3-6 hours (During this period of infarction in evolution lysis of thrombus by administration of thrombolytic agents e.g. streptokinase or tissue plasminogen activator may limit the size of the infarct.
  5. Location of infarct depends on the coronary artery involved e.g.
    1. Occlusion of anterior descening artery (LAD) leads to infarction in anterior and apical areas of left ventricle and adjacent anterior 2/3 of interventricular septum.
    2. Occlusion of right coronary artery (RCA) leads to infarction in posterior wall of left ventricle, posterior 1/3 of interventricular septum.
    3. Occlusion of left circumflex artery (LCx) leads to infarction in lateral wall of left ventricle.
  6. Size of infarct depends on the following factors:
    1. Which segment of artery is blocked: Occlusion of proximal segments of the coronary arteries produces larger infarcts, involving the full thickness of the myocardium. Conversely, occlusion in more distal arterial branches tend to cause smaller infarcts.
    2. Degree of collateral circulation: In patients with long-standing coronary atherosclerosis, collateral circulation may develop over time in response to chronic ischemia. Such collateral vessels may limit the size of the infarct.

Consequences of Acute Myocardial Ischemia
The Acute myocardial ischemia has four possible consequences:
1.      It may only induce an attack of angina.
2.      More severe ischemia may result in myocardial infarction limited to inner 1/2  some portion or the entire circumference of the left ventricular wall to produce subendocardial foci of ischemic necrosis, also called subendocardial infarct.
3.      The ischemic necrosis (infarction) may traverse the entire thickness of some portion of the left ventricular wall, creating transmural infarct.
4.      Sudden cardiac death.

1.      Transmural infarct: Greater than 2.5 cm and traverses from endocardium to subepicrdial myocardium. It is more common than subendocardial one.
2.      Subendocardial infarct: Multifocal area of necrosis confined to inner 1/3 – 1/2 of the left ventricular wall.
3.      Sequence of Morphologic Changes in Transmural Infarct

Morphologic changes in myocardial infarction depend on the time passed from onset. There is coagulation necrosis and inflammation followed by formation of granulation tissue, resorption of necrotic material and finally organization of the granulation tissue to form a fibrous scar.

Friday, January 20, 2012

Right-Sided Heart Failure

Reduction of right ventricular output for an increased atrial pressure is called right-sided heart failure.

MORPHOLOGY (Right-sided heart failure)
Organs affected: Liver, spleen, kidneys, subcutaneous tissues, brain, portal area of venous drainage.

Liver: Changes in the liver tissue are the following:

Chronic passive congestion:
It has two components as following:
  • Nutmeg pattern: The central region of hepatocytes become congested appearing red while the peripheral region is uncongested appearing yellow. This red and yellow mottling gives the liver a characteristic appearance called nutmeg pattern.
  • Ischemic atrophy: Congestion of the central vein causes diminished rate of blood flow through the lobule, leading to chronic oxygen  deficiency in the liver cells in the central region of the lobule which results in ischemic atrophy of the liver cells in the congested central region of the lobule.

Central hemorrhagic necrosis:
In severe congestive cardiac failure, hemorrhages into the hepatic cords occur producing necrosis of the liver cells, this is called central hemorrhagic necrosis.

Cardiac sclerosis:
It is a complication of severe cardiac failure and is characterized by fibrosis of the central areas of hepatic lobules and is termed as cardiac sclerosis or cardiac cirrhosis.


Acute right ventricular failure:

Acute right ventricular failure occurs in:
  • Massive pulmonary embolism: Acute right ventricular failure occurs when massive pulmonary embolus becomes impacted in and obstruct the outflow tract of the right ventricle and main pulmonary artery. This results in arrest of the circulation and sudden death.
  • Cardiac temponade: Acute right ventricular failure occurs when fluid accumulates in pericardial cavity that interferes the right ventricular diastolic filling, resulting in decreased right ventricular output; the condition called cardiac temponade.

Chronic right ventricular failure:
Most commonly occurs secondary to left ventricular failure and is manifested clinically by systemic venous congestion such as:
  • Liver is enlarged and tender: Enlargement due to congestion and tenderness due to stretching of liver capsule.
  • Peripheral edema: Occurring in dependent areas – the ankles in ambulatory patients and the sacrum in recumbent ones.
  • Pleural effusion, pericardial effusion or ascites.


ECG: ECG may show:
  • Right or left ventricular hypertrophy
  • Myocardial ischemia or infarction
  • Arrhythmia

X-ray Chest:
  • Hilar congestion
  • Bat’s wings appearance in acute pulmonary edema (opacities tend to spread in a butterfly manner from the hilum, periphery is usually clear)
  • Cardiomegaly
  • Evidence of pulmonary hypertension
  • Pleural effusion
  • Pneumonia as a precipitating factor may be evident.

Echocardiography is a very important tool for the diagnosis and cause of heart failure. It may demonstrate:
  • Systolic or diastolic impairment of left or right ventricle.
  • Valve disease.
  • Regional wall motion abnormalities in ischemic heart disease.
  • Cardiomyopathy
  • Intracardiac thrombus
  • Ejection fraction

  • Diuretics e.g. frusemide.
  • Vasodilators e.g. ACE inhibitors 
  • Digitalis

Thursday, January 19, 2012

Symptoms of Left Heart Failure and Signs

Left Heart Failure Symptoms are:

A sense of breathlessness, initially on exertion then on rest also. The dyspnea is maximal when congestion of the lung is greatest as in exercise and lying flat.

Dyspnea on exertion
In early stage syspnea is noticeable during physical activity and is called dysnea on exertion. It results from increased venous congestion during physical activity.

Dyspnea on lying flat is called orthopnea. It results from increased amount of venous return to thorax from lower extremities when patient is in lying position. Heart is unable to pump all of this venous return that leads to lung congestion and dyspnea.

Paroxysmal nocturnal dyspnea
Dyspnea during sleep which awakens the patient with severe breathlessness, accompanied by a choking sensation and coughing is called paroxysmal nocturnal dyspnea. It also results from increased venous congestion as the patient is lying on bed.

Signs of Left Heart Failure:

Tachycardia, cardiomegaly, third heart sound, and fine crepts at the lung bases. Chronic dilation of left atrium may also occur which may be associated with atrial fibrillation.

Low Versus High Cardiac Output Failure

Low output failure
Low cardiac output at rest or during exertion characterizes heart failure caused by common conditions such as congenital, valvular, rheumatic, hypertensive, coronary and cardiomyopathic diseases. Low output failure presents with evidence of systemic vasoconstriction such as cold, paler or cyanotic extremities. Pulse pressure is low.

High cardiac output failure
Conditions that are associated with a very high cardiac output such as anemia, beriberi, paget’s disease of bone and thyrotoxicosis may lead to or precipitate heart failure.

To understand basic pathogenesis of heart failure of each side of the heart is studied separately.

Reduction in the left ventricular output for a given pulmonary venous pressure is called left sided heart failure.

The clinical changes associated with left ventricular failure depend on whether failure is acute or chronic.

Acute left ventricular failure:
  • Acute forward failure: An acute severe decrease in cardiac output leads to cardiogenic shock.
  • Acute backward failure: Failure of the left ventricle to pump the pulmonary venous return causes increased hydrostatic pressure in pulmonary capillaries with transudation of fluid into the alveolar space, called pulmonary edema. Clinically, pulmonary edema is manifested as dyspnea with cough productive of pink frothy sputum. Edema fluid produces crepitations on auscultation.

Chronic left ventricular failure:
  • Chronic forward failure: Decreased cardiac output results in decreased tissue perfusion. Decreased renal blood flow stimulates rennin-angiotensin system and aldosterone formation which causes sodium and water retention from kidney. This sodium and water retention increase blood volume, therefore increasing venous return to already weak heart, resulting in congestion of lungs.
  • Chronic backward failure: Inability of heart to pump all the venous return leads to passive venous congestion in the lung which if prolonged induces fibrous thinking of alveolar septa. The thickened alveolar septa intern increases resistance to lung expansion, causing dyspnea.

Types of Heart Failure and Causes

The heart failure may be classified in several ways.
  1. Acute versus chronic
  2. Left versus right and biventricular or congestive heart failure (CCF)
  3. Forward versus backward
  4. Systolic versus diastolic
  5. low output versus high output

Acute heart failure
Heart failure developing suddenly in hours a days in a previously asymptomatic patient is called acute heart failure.

The causes of acute heart failure occur when a previously normal person suddenly develops a serious anatomical or functional abnormality and time is not sufficient for compensatory mechanisms to operate such conditions are:
  • Massive acute myocardial infarction.
  • Tachyarrhythmias with very rapid heart rate.
  • Rupture of valve secondary to infective endocarditis.

Chronic heart failure
Heart failure developing gradually is called chronic heart failure. In this type of failure a variety of compensatory changes may take place in early phase to improve cardiac function. These adoptive mechanisms allow the patient to adjust and tolerate not only the anatomic abnormality but also a reduction in cardiac output with less difficulty.


Left sided heart failure
The left sided heart failure is characterized by a reduction in effective left ventricular output for a given pulmonary venous or left atrial pressure.
An acute increase in left atrial pressure may cause pulmonary congestion or pulmonary edema, while chronic increase in left atrial pressure leads to reflects pulmonary vasoconstriction which protects the patient from pulmonary adema at the cost of increasing pulmonary hypertension (as a compensatory mechanism).

Causes of left heart failure
  • Ischemic heat disease (commonest)
  • Systemic hypertension
  • Mitral and aortic valve disease
  • Cardiomyopathies

Right side heart failure
Right-sided heart failure in characterized by reduction in right ventricular output for any given right atrial pressure.
Causes of right heart failure
  • Secondary to left heart failure (most common)
  • Chronic lung disease (Causing cor-pulmonale)
  • Pulmonary embolism or pulmonary hypertension
  • Tricuspid and pulmonary valve disease
  • ASD & VSD
  • Right ventricular cardiomyopathy

Biventricular or congestive cardiac failure (CCF)
When both sides of heart are involved, features of both right and left heart failure are present. In most of the patient right heart failure is a result of preexisting left heart failure.


Forward failure
In some patients with cardiac failure predominant problem is an inadequate cardiac output that leads to diminished perfusion of vital organs, leading to ischemia of these organs this is called forward failure. Ischemia of brain causes mental confusion, ischemia of skeletal muscles leads to weakness, ischemia of kidneys causes sodium and water retention leading to symptoms of heart failure.

Backward Failure
In some patients cardiac failure presents mainly with features of damming of blood into venous system such as lung congestion in left heart failure and congestion of liver, spleen and other areas in right heart failure.


In majority of patients heart failure is due to combine systolic and diastolic dysfunction, however isolated systolic or diastolic dysfunction may be present.

Systolic Failure
Heart failure may develop as a result of impaired myocardial contraction (systolic dysfunction). The most common cause of systolic ventricular dysfunction is ischemic heart disease usually after myocardial infarction. The left ventricle is usually dilated and fails to contract normally resulting in symptoms of predominantly forward failure.

Diastolic Failure
Heart failure may develop due to poor ventricular filling caused by impaired ventricular relaxation (diastolic dysfunction). The most common cause is left ventricular hypertrophy as a result of hypertension and coronary artery disease. Other causes of diastolic dysfunction are hypertrophic and restrictive cardiomyopathy, diabetes and pericardial disease.