Pulmonic Valvular Ejection Sounds
Pulmonic valvular ejection sounds have identical sound and pressure correlates as aortic valvular ejection sounds.231 Echocardiographic correlations also have shown that the onset of the pulmonary ejection sound occurs at the maximal excursion of the stenotic pulmonary valve. In contrast to the aortic valvular ejection sounds and to most right-sided auscultatory events, the pulmonic sound or ejection click decreases in intensity or disappears with inspiration in mild to moderate pulmonic...
Ventricular Depolarization And Repolarization
Fluxes of ions across the cell membranes cause the differences in voltage between resting and activated myocardial cells. To understand the electrical forces produced by the heart as a whole at the body surface, it has been conventional to first discuss the electrical properties of a hypothetical muscle strip from the free wall of the left ventricle extending from endocardium to epicardium.-5-7 In the resting or polarized state, the charges are at rest. A unipolar electrode facing the...
Examination Of The Arterial Pulse
All major arterial pulses should be examined bilaterally for both patency and waveform characteristics. The thickness and hardness of the arterial walls often can be assessed by rolling the vessel against underlying tissue. A pulse in the foot should not be considered absent unless examined with the foot in a dependent position. Otherwise, the arterial pulses usually are examined with the patient supine and with the trunk of the body slightly elevated. The examiner uses tactile receptors in the...
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Chapter 1 CARDIOVASCULAR DISEASES IN THE UNITED STATES AND PREVENTION APPROACHES View Contents in a Separate Window Figure 1-1 Health expenditures for cardiovascular diseases, United States, 1999 includes expenditures for hospital, home, and nursing home care physician and other professionals and drugs . From the American Heart Association and National Heart, Lung, and Blood Insitute.2 Figure 1-2 Age-adjusted death rates for selected causes of death United States,1950-1997 adjusted to U.S....
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Chapter 1 CARDIOVASCULAR DISEASES IN THE UNITED STATES AND PREVENTION APPROACHES Table 1-1 Incidence of Major Cardiovascular Events Framingham Study, 44-Year Follow-Up of Cohort and 20-Year Follow-Up of Offspringa -H i Table 1-2 Percentage of First Cardiovascular Events by Type of Event Framingham Study, 44-Year Follow-Up of Cohort and 20-Year Follow-Up of Offspring -H i Table 1-3 Incidence of Specified Clinical Manifestations of Coronary Heart Disease Framingham Study, 44-Year Follow-Up of...
Diastolic Regurgitant Murmurs
Holodiastolic Aortic Regurgitant Murmurs The early diastolic murmur of aortic regurgitation is blowing and high-pitched in character and is often more difficult to record than to hear because of its high-frequency content. Since isovolumic relaxation of the left ventricle is very rapid, a large gradient quickly develops between the aortic and LV diastolic pressures, and the murmur builds up to maximum intensity almost immediately after A2. As diastole progresses, the gradient between the two...
Normal Arterial Pulse
The normal carotid pulse has a smooth, rapid upstroke or ascending limb to a smooth, dome-shaped summit see B-hE Fig. 10-42 . Then a downstroke occurs that is somewhat less rapid than the upstroke. The dicrotic notch and secondary diastolic wave usually are not felt but may be palpable in some normal individuals, particularly during fever, exercise, or excitement. The dicrotic notch usually occurs about 300 ms after the onset of the pulse wave when corrected for heart rate. In arteries distal...
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Figure 6-1 Pathways of thrombosis and thrombolysis. Under normal conditions, the endothelium is antithrombotic. Antithrombin III ATIII binds thrombin and serves to clear thrombin from the circulation. Prostacyclin prostaglandin I2, PGI2 inhibits platelet aggregation, and thrombomodulin TM activates protein C, which inhibits plasminogen activator inhibitor I PAI-I and interacts with protein S to inactivate activated factors V and VIII, thus limiting thrombosis. Since PAI-I inhibits the tissue...
Pleura
A right-sided pleural effusion often is present with left-sided heart failure. A bilateral hydrothorax, on the other hand, suggests bilateral heart failure or a noncardiac etiology of the effusion. Congestive heart failure is also known to be associated with a pseudotumor or vanishing tumor, representing an interlobar collection of pleural fluid Fig. 12-17 . As congestive heart failure improves, the tumor disappears. Figure 12-17 Patient with congestive heart failure. Note gross cardiomegaly,...
Approaches
1 National Heart, Lung, and Blood Institute. Morbidity and Mortality Chartbook on Cardiovascular, Lung, and Blood Diseases, 1998. US Dept of Health and Human Services 1998. 2 American Heart Association. 1999 Heart and Stroke Statistical Update. Dallas American Heart Association, 1999. B H-http www.amhrt.org. 3 Lloyd-Jones DM, Larson MG, Beiser A, Levy D. Lifetime risk of developing coronary heart disease. Lancet 1999 353 89-92. 4 National Center for Health Statistics. Detailed statistical...
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Chapter 11 THE RESTING ELECTROCARDIOGRAM ABNORMAL Q WAVES Abnormal Q waves appearing several hours after total occlusion of a coronary artery result from necrosis secondary to the decreased blood supply. The number of affected cells has to be large enough so as to produce changes reflected at the body surface. In general, the depth of the Q wave is proportional to wall-thickness involvement.7 Thus, in lead aVF a QS complex was said to reflect transmural necrosis. On the other hand, clinical...
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Figure 11-5 A. Nonischemic ST-segment elevation in the right precordial leads in a young patient with the Brugrada syndrome. B. Epsilon wave of a patient with arrhythmogenic right ventricular dysplasia. Figure 11-5 A. Nonischemic ST-segment elevation in the right precordial leads in a young patient with the Brugrada syndrome. B. Epsilon wave of a patient with arrhythmogenic right ventricular dysplasia. Page 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Copyright...
Cardiac Malpositions With Situs Ambiguus
In this group, the patient's heart may be either left- or right-sided. The situs is ambiguous because the aortic arch and the stomach are not on the same side. Under these circumstances, we are dealing with either asplenia or polysplenia syndrome. Patients with polysplenia syndrome tend to be acyanotic, running a milder clinical course, and frequently survive into adulthood. The associated lesions are bilateral left-sidedness, interruption of the inferior vena cava with azygos continuation see...
Nucleic Acids
The human genome is known to contain about three billion base pairs, which contain information that would more than fill a 500,000-page textbook. The DNA is contained in 46 chromosomes consisting of 44 autosomal and 2 sex chromosomes, but each chromosome is one continuous DNA molecule around which is wrapped several proteins. The smallest chromosome, 21, has more than 50 million base pairs, whereas chromosome 1, the largest, has over 250 million base pairs. There is enough DNA to form several...
Table 1010 Third Heart Sound S3 Ventricular Diastolic Gallop Protodiastolic
Physiologic S3-children and young adults Decreased prevalence with increasing age Pathologic S3 Ventricular dysfunction-poor systolic function, in-creased end-diastolic and end-systolic volume, decreased ejection fraction, and high filling pressures Congenital heart disease Systemic and pulmonary hypertension Excessively rapid early diastolic ventricular filling Hyperkinetic states Anemia Thyrotoxicosis Arteriovenous fistula Atrioventricular valve incompetence Left-to-right shunts Restrictive...
Abnormal Arterial Pulses
In hypertension and arteriosclerosis, the pressure pulse amplitude is increased, the tidal wave is prominent, and the diastolic wave is absent. All features of the pulse can be explained by increased wave velocity.162,177 Reflected waves return to the proximal aorta during late systole, augmenting the tidal wave and increasing systolic pressure. With systemic hypotension, the pulse wave velocity is decreased, and the later tidal and diastolic waves are further displaced from the percussion...
Anomalies Jys
Complete persistence of the right venous valve of the embryonic heart produces a septum in the right atrium, separating the intercaval part of the right atrium from the atrial body. The remaining opening may be quite small and restrictive. Persistence of the left common cardinal vein and left sinus horn results in a left superior vena cava draining into the coronary sinus. Septation of the embryonic common atrium involves two distinct mechanisms. 39 The primary atrial septum septum primum forms...
Molecular Development Of The Heart Tube
Morphogenesis of the heart begins with the initial patterning of the embryo that determines the three axes of the embryo anterior-posterior, dorsal-ventral, and left-right. These axes are imprinted onto the cellular program as cell populations expand to form the embryo and extraembryonic tissues. Specific genes have been identified that alter axis determination in a range of species, including the mouse. 2, 3 After determination of the embryo axes, subpopulations of cells are programmed in a...
Extrinsic Control Systems
The best understood, most extensively characterized and important extrinsic control mechanism is modulation of contractility by adrenergic and cholinergic neural discharge and circulating catecholamines.75 81-85 Increased adrenergic stimulation markedly increases contractile strength, relaxation, and HR. These effects on the myocardium may be explained as follows Normal myocytes contain predominantly Pj receptors, with a minority of receptors. Agonist binding to Pj- or P2-adrenergic receptors...
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Source Hatle L, Angelsen B. Doppler Ultrasound in Cardiology, 2d ed. Philadelphia Lea amp Febiger 1985. Doppler Assessment of Diastolic Function in recent years, there has been a great deal of interest in using mitral inflow velocity patterns to evaluate LV diastolic properties.6474-74a Transmitral filling velocities reflect the pressure gradient between the LA and LV during diastole65 Fig. 13-34 . In early diastole, pressure in the LV normally falls below that in the LA, producing an increase...
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Figure 13-117 A. Transesophageal image transverse plane from a patient with persistent left superior vena cava. The coronary sinus CS is dilated. B. After injection of agitated saline into the left antecubital vein, contrast is seen entering the right atrium RA via the CS. TV tricuspid valve RV right ventricle LV left ventricle. From Blanchard DG, DeMaria AN. Cardiac and extracardiac masses Echocardiographic evaluation. In Skorton DJ, Schelbert HR, Wolf GL, Brundage BH, eds. Marcus' Cardiac...
Patent Ductus Arteriosus
The ductus arteriosus originates just to the left of the PA bifurcation and inserts into the aorta slightly distal to and opposite from the ostium of the left subclavian artery. Given this posterior location, it is difficult to image a patent ductus arteriosus PDA itself with 2D TTE alone, and TEE is usually superior for direct visualization of the lesion574 Fig. 13-115 4 and B, Plate 71 . In most cases, 2D imaging of the communication is not essential, as color-flow Doppler reliably detects...
Atrial Septal Defect
Most secundum and primum atrial septal defects ASD are easily visualized by echocardiography, although sinus venous defects are often difficult to detect without TEE.559,560 Apical echocardiographic views often show artifactual dropout in the region of the fossa ovalis, since the interatrial septum is thin in this area and runs parallel to the ultrasound beam. Therefore, the subcostal view provides the optimal imaging plane to detect lesions of the atrial septum.561 Ostium secundum defects are...
Myogenic Properties Of Vascular Smooth Muscle
Arterial constriction to increased perfusion pressure was first described by Bayliss in 1902. Since then, myogenic responses have been documented in arteries, arterioles, and veins. The fundamental question of how a vessel is able to sense intravascular pressure and or flow has proven difficult to answer. The identity of the myogenic sensor-the structure s that convert physical force into VSM contraction-has thus far eluded investigators. Some putative candidates are integrins molecules...
Diastolic Movements
Cardiac ape systolic movement may be inconspicuous diastolic movements. F and A correspond to 3rd and 4tli heart sounds. which may merge in tachycardia tu torn a Aummatirtn qslinp Figure 10-61 Graphic representation of apical movements in health and disease. Heavy line indicates palpable features. P2, pulmonary component of second heart sound A, atrial wave, corresponding to a fourth heart sound S4 or atrial gallop F, filling wave, corresponding to third heart sound S3 or ventricular gallop....
Table 1011 Fourth Heart Sound S4 Atrial Diastolic Gallop and Presystolic Gallop
Physiologic-recordable rarely audible Left or right ventricular outflow obstruction Excessively rapid late diastolic filling secondary to Acute atrioventricular valve incompetence An audible S4 with a palpable presystolic impulse is common in patients with ischemic heart disease during an acute episode of angina and in the early phases of transmural MI. Its prevalence is also increased with prior MI however, audible fourth heart sounds in patients with ischemic heart disease without prior...
Auscultation
1 Vanden Belt RJ. The history. In Chizner M, ed. Classic Teachings in Clinical Cardiology A Tribute to W. Proctor Harvey. Cedar Grove, NJ Laennec 1996 41-54. 2 Hurst JW, Morris DC. The history Symptoms and past events related to cardiovascular disease. In Schlant RC, Alexander RW, O'Rourke RA, et al., eds. The Heart, 8th ed. New York McGraw-Hill 1994 205-216. 3 O'Rourke RA. Chest pain. In Schlant RC, Alexander RW, O'Rourke RA, et al., eds. The Heart, 8th ed. New York McGraw-Hill 1994 459-467. 4...
Excitation System
This system is also discussed in Chap. 23. The cellular AP consists of a transient, local transsarcolemmal depolarizing current that raises the transmembrane potential from its normal resting value of negative 80 to 90 mV to slightly positive values, followed by a depolarizing current that returns the potential to its resting value4-6 Fig. 3-4 . The AP is initiated within the specialized conduction tissue and is propagated to individual myocytes. It results from a series of coordinated changes...
Elevated Venous Pressure
The most common cause of an elevated jugular venous pressure is an increased RV pressure such as occurs in patients with pulmonic stenosis, pulmonary hypertension, or RV failure secondary to left-sided heart failure or RV infarction. The venous pressure also is elevated when obstruction to RV inflow occurs, as with tricuspid stenosis or RA myxoma, or when constrictive pericardial disease impedes RV inflow. It also may result from vena cava obstruction and, at times, an increased blood volume....
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Figure 13-28 A. Pulsed-wave Doppler tracing from a patient with aortic regurgitation. The transducer is in the apical position and the sample volume is in the left ventricular outflow tract. A laminar envelope is seen during systole, while aliased flow is present during diastole because of high-velocity flow. B. Continuous-wave Doppler tracing through the left ventricular outflow tract with transducer in the apical position . The maximal velocity of the aortic regurgitation is now measurable,...
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Chapter 10 THE HISTORY, PHYSICAL EXAMINATION, AND CARDIAC AUSCULTATION HEART SOUNDS Heart sounds are of two types high-frequency transients associated with the abrupt terminal checking of valves that are closing or opening and low-frequency sounds related to early and late diastolic filling events of the ventricles. Sounds related to closing and opening of the AV valves include mitral and tricuspid closing sounds M1, T1 , nonejection sounds, and the opening snaps sounds related to closing and...
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Chapter 11 THE RESTING ELECTROCARDIOGRAM ELECTROLYTE IMBALANCES Because multiple factors can affect ventricular repolarization in diseased hearts, the finding characteristic of a specific electrolyte abnormality may be modified, and even mimicked, by various pathologic processes and the effects of certain drugs. In practice, the major problem with the ECG diagnosis of electrolyte imbalance is not the negative ECG with abnormal serum values but the production of similar changes by other...
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Chapter 2 FUNCTIONAL ANATOMY OF THE HEART CORRELATIVE ANATOMY This section in this chapter is an illustrated review of applied cardiac anatomy. The clinical significance of the anatomy described is highlighted in italics. The fibrous parietal pericardium is a resilient sac that envelops the heart and attaches onto the great vessels. 5 Almost the entire ascending aorta and main pulmonary artery and portions of both venae cavae and all four pulmonary veins are intrapericardial Fig. 2-19 . These...
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View Contents in a Separate Window Chapter 13 THE ECHOCARDIOGRAM PERICARDIAL DISEASE In normal subjects, the pericardium is difficult to visualize since the pericardial cavity is only a potential space and visceral and parietal pericardial layers appear as a single echo.696 In the setting of pericardial effusion, the fluid appears as a sonolucent area or clear space separating epicardium from pericardium.697 Pericarditis may be unaccompanied by pericardial effusion and in such cases may be...
The Ventricle As A Muscle
For convenience, it is useful to consider contraction systolic performance as distinct from relaxation and filling diastolic performance . This distinction is arbitrary, however. The two aspects of function overlap and interact. Systolic performance of the ventricle traditionally is characterized in terms of loading conditions preload, afterload and contractility.112 Although contractility is a term that is employed frequently and often perfectly reasonably, it is difficult to define. We use it...
Excitationcontraction Coupling System
ECC is accomplished by the sarcotubular system, an arrangement of specialized sarcolemmal and intracellular membranes that functions to control and amplify the ability of the AP to switch the activity of the contractile system on and off. It does so by creating electrochemical signals between the sarcolemma and intracellular organelles these signals occur much more rapidly than would be possible by simple diffusion of the signaling molecule in this case, Ca ions . The sarcotubular system...
Peripheral Resistance And Its Determinants
Pressure, flow, and resistance are related most often through Poiseuille's equation, which was first formulated in 1842. Based on a series of careful observations of water flowing through rigid tubes, Poiseuille demonstrated that the resistance to flow R through a tube is proportional to tube length L and fluid viscosity h and inversely proportional to the tube radius to the fourth power r4 . These variables can be related to each other in the following way Poiseuille's equation applies to the...
Bisferiens Arterial Pulse
The bisferiens from the Latin, meaning twice beating pulse has a waveform characterized by two positive waves during systole see Fig. 10-42B . The pulse wave upstroke rises rapidly and forcefully, producing the first systolic peak percussion wave . A brief decline in pressure is followed by a smaller and somewhat slower-rising positive pulse wave tidal wave . Abnormalities of LV ejection and reflected waves from peripheral arteries contribute to the prominence of the second systolic wave in the...
The Standard Mmode Examination
Although largely supplanted by 2D imaging, M-mode echocardiography remains a useful part of a complete ultrasound examination. Figure 13-6 A through D shows the typical views obtained when the transducer is placed at the left parasternal area and rocked through the heart from apex to base. Tissue typically reflects ultrasound at its surface specular reflectors and from internal inhomogenicity backscatter , while blood is homogenous and does not produce reflections. Thus, blood is free of...
Eustachian Valve
View Contents in a Separate Window Chapter 13 THE ECHOCARDIOGRAM CARDIAC MASSES, THROMBI, AND TUMORS Normal Variants and Masses of Uncertain Significance When an abnormally localized accumulation of dense reflectances appears on the echocardiogram, it is said to represent a mass. Echocardiographic masses may be caused by technical artifacts or anomalous structures, but they are of greatest significance in representing true lesions of the heart such as tumors, thrombi, and vegetations....
Visualization Of Subepicardial Fat Stripes
The subepicardial fat lines are important landmarks in the diagnosis of heart disease. The fat stripe is a cushion-like structure separating the myocardium from the pericardium. Normally, it is difficult to see the fat line because of the adjacent similar radiolucency of the air-filled lung. The in-between hairline density of the normal pericardium is delicate and also difficult to see except in the left lateral view Fig. 12-10M . In the presence of pericardial effusion or thickening, the...
Anomalies Aos
Atrial Septal Defect at the Fossa Ovalis This defect, which often is referred to as a secundum-type atrial septal defect, is due to malformation of the primary atrial septum, resulting in an oversized ostium secundum. Frequently, the atrial defect is further enlarged by a hypoplastic septum secundum. Total absence of both the septum primum and the septum secundum common atrium is rare and almost always is associated with a form of persistent AV canal. Anomalous Pulmonary Venous Connection The...
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Figure 12-1 Practical application of four-view cardiac series. A. Posteroanterior view in a patient with coarctation of the aorta showing areas of rib notching bilaterally and left ventricular enlargement in the inferior and leftward direction. B. Magnified view of the left upper thorax of the same patient showing multiple areas of rib notching arrows . The sclerotic margin of each represents a reparative process by which new bone is laid down in the defect. C. Posteroanterior view of another...
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Figure 10-34 Hyperlipidemia xanthomata associated with coronary artery disease. A. On the extensor tendons of the hand. B. On the Achilles tendon arrow . In Werners syndrome, the skin is tightly stretched over the underlying bones.112 There is marked loss of subcutaneous tissue, and ulcerations occur over the legs. Severe coronary atherosclerosis often results in MI at an early age. Physical findings in diabetes mellitus may include tight skin and necrobiosis diabeticorum, an atrophy of the...
The Physical Examination
Important information concerning the patient with definite or suspected heart disease is often obtained by a careful and deliberate physical examination, which includes a general inspection of the patient, an indirect measurement of the arterial blood pressure in both arms and one or both lower extremities, an examination of central and peripheral arterial pulses, an evaluation of the jugular venous pressure and pulsations, palpation of the precordium, and cardiac auscultation. Based on the...
Parvus Et Tardus Pulse
Patients with moderate or severe valvular aortic stenosis often have an arterial pulse that is small and has a delayed systolic peak.184,186 Occasionally, there may be a detectable shoulder on the upstroke of the carotid pulse, referred to as anacrotic184 see Fig. 10-42D . Palpable coarse vibrations often are present as a systolic thrill over the slowly rising carotid pulse. The parvus et tardus pulse is much easier to detect in the carotid arteries than in more distal arteries. Most...
Holosystolic Regurgitant Murmurs
The murmur of chronic mitral regurgitation is the prototype of the holosystolic regurgitant murmur, as shown in Fig. 10-77. It begins with or replaces S1 and continues throughout systole in a plateaulike fashion beyond A2, finally terminating when the LV pressure drops to the level of the left atrial pressure during isovolumic relaxation.287 In contrast to the systolic ejection murmur, there is little variation in its intensity with varying cycle lengths.288 It is heard best at the apex and...
Dextrocardia With Situs Solitus
This represents an anomaly with normal situs but a right-sided heart. Radiographically, normal situs situs solitus is a certainty when both the aortic knob and the gastric air bubble are on the left side. Situs soJitus also means that both the abdominal viscera and the atria are in the normal position. Under these circumstances, if the ventricles fail to swing from the primitive right-sided position to the normal left-sided position, abnormal relationships between the ventricles and the rest of...
Inspection And Palpation Of The Precordium
Inspection and palpation of the cardiac pulsations of the anterior chest have been practiced by physicians since ancient times and have a solid scientific basis. The results of precordial inspection and palpation have been correlated with noninvasive studies, hemodynamic data, and surgical and autopsy studies202,203 and remain an important part of the cardiovascular examination. Their usefulness depends on an understanding of cardiovascular physiology, the proficiency of the examiner, and his...
The Heart Wml
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