Tag Archives: Cardiology

Aortic stenosis – 12/4/17

Most common etiologies of AS

  • Calcification of a normal aortic valve overtime with age
  • Bicuspid aortic valve
  • Rheumatic heart disease (usually associated with mitral valve disease)


  • Dyspnea (most common)
  • Angina
  • Syncope


  • Physical exam
    • Systolic ejection murmur at RUSB with radiation to the carotids
    • Any maneuver that decreases blood flow across the valve will cause a decrease in the sound of murmur (e.g. valsalva, handrip, or standing) whereas anything that increases blood flow across the valve will increase the sound of the murmur (e.g. squatting)
  • Transthoracic echo
    • Severe AS is AVA < 1 cm2, mean gradient greater or equal to 40, or max velocity greater than 4 m/s

Low-flow, low-gradient AS

  • If patient has an AVA < 1 cm2 but has a mean gradient < 35 mmHg, consider low-flow, low-gradient AS
  • To determine whether there is an intrinsic problem with the valve versus a pseduo-aortic stenosis due to myocardial dysfunction, do a dobutamine stress echo
  • If AVA remains unchanged and the mean gradient increases with dobutamine, the etiology is severe AS and the patient would benefit from valve replacement
  • If the AVA increases and the mean gradient doesn’t increase, this is a pseudo-aortic stenosis and the patient can be managed medically

When to treat?

  • Any patient who is symptomatic
  • An asymptomatic patient with EF < 50 or who is getting another cardiac surgery


  • AVR > TAVR if the patient is a surgical candidate
  • TAVR is good for high risk patients and has similar survival to AVR in high-risk patients
  • AV balloon valvuloplasty is a short-term bridge to TAVR as it only lasts a few months
  • Medical management is usually not beneficial if a patient has severe AS

Heart Block 07/24/2017

Heart Block 1Heart Block 7

Heart Block 8

  • Two General Indications for permanent pacemaker (PPM) implantation 
    • 1) Symptomatic sinus bradycardia with rate <40bpm
    • 2) High grade or symptomatic AV block
  • Pacing is generally not indicated in asymptomatic sinus bradycardia

Heart Block 2

Heart Block 3

  • There are Four main rhythms that are seen with DDD
    • 1) Normal sinus rhythm
      • pacemaker is totally inhibited due to acceptable intrinsic sinus rate and AV conduction
    • 2) Atrial sensing and ventricular pacing
      • Sinus rate is above the set rate (inhibited atrial pacing) with prolonged AV conduction (triggered ventricular pacing)
    • 3) Atrial pacing, normally conducted to the ventricle with native QRS
      • Atrial pacing is triggered by sinus bradycardia in the setting of normal AV conduction (inhibited ventricular pacing)
    • 4) AV sequential pacing
      • Both atrial and ventricular pacing are triggered due to sinus brady and prolonged AV conduction

Heart Block 4Heart Block 5Heart Block 6

Endocarditis – 7/17/17

Risk Factors for developing Endocarditis

  • Dental procedure that penetrates the gums
  • Prior endocarditis
  • Prosthetic valves
  • IVDU
  • Immunosuppression

Common Organisms

  • Staph
  • Strep
  • Enterococcus


  • Fever (most common)
  • Murmur
  • Splinter hemorrhages
  • Janeway lesions (non-tender erythematous macules on palms and soles)
  • Osler nodes (tender, subcutaneous nodules, on pads of fingers and toes)
  • Roth spots (exudative edematous hemorrhages in the retina)

Indications for surgical repair

  • New heart failure
  • Perivalvular abscess/extension
  • Conduction abnormalities
  • Persistent bacteremia
  • Prosthetic valves
  • Septic emboli
  • Large vegetation > 10-15 mm
  • Resistant organisms