Saturday, May 25, 2013

THE DISEASE COUGHS AND COLDS IN INFANTS AND CHILDREN

THE DISEASE COUGHS AND COLDS
IN INFANTS AND CHILDREN
Babies and young children often experience the illness coughs and colds. Generally children can experience every month and this occurs approximately 1 to 2 weeks. Therefore for mothers should understand this disease, including the use of drugs.

The founders of cough colds in children is difficult because of myriad factors determined who became the founders of cough and colds.  
The following is the cause of the onset of cough and colds:
  1. Use of the fan in the back blew dust all over the room.
  2. The use of air conditioning at night can cause an allergic reaction that made the child's nasal congestion, it becomes difficult to breathe so that the child was breathing through the mouth.
  3. Contracting friends at day care, school, playground. Public area where many children play so lets kids easily infected with cough colds from friends sepermainannya.
  4. Contracting close family members. Parents, caregivers or family members of the other housemates should familiarize yourself immediately using the mask so the flu strikes so as not to rub off on the child.
  5. Less healthy environments, high pollution, there are active smokers in the home.
  6. Consume foodsthat are lesshealthy, such asspendingrecklessly, snacksthat makethe throatitching, etc
 Cough

Causes of cough in infants and children are usually the respiratory syncytial virus, parainfluenza virus (RSV) and influenza viruses. Coughing can also appear because of an increase in the production of phlegm which is triggered by a viral infection or allergy.

Duration of cough hanging from each cause. A cough that is caused by the inveksi virus can take up to 2 weeks. Could be longer if the child is sensitive or allergic to.

Colds

Cold fact is not an illness, but sometimes very disturbing.
Symptoms of colds are typically characterized by:
  1. Blockage of the respiratory tract (nasal congestion)
  2. Body temperature rise or low-grade fever
  3. Sneezing
  4. Liquid mucus out of the nose
  5. Sore throat making it hard to swallow
  6. Hoarseness and coughs.
FIX COUGHS AND COLDS ARE PROPERLY
Coughs and colds in infants and children is mainly caused by a viral infection. Surely no one obatpun that can heal a cough colds, because up to now there are no antiviral drugs for cough and cold. Runny nose cough medicine available in the market are actually only serves to relieve symptoms of colds cough that sometimes can be very annoying, cause a child not able to rest and eat well.

Because it is caused by a virus, then coughs colds in infants and children is self limiting and can heal themselves. That can cause colds cough is cured of the durability of the body of the child itself. Therefore efforts to increase durability of the body of a child is a very important points to speed up the recovery process.

Do the following to improve the durability of the body of the child's cough colds:
  1. BREAST MILK until the age of 2 years. The antibodies found in breast milk is able to fight off viral infections that cause coughs colds.
  2. Balanced and nutritious fruits that contain lots of vitamins such as apples, oranges, kiwi, fruit, etc.
  3. Adequate rest. Help your child to more rest for pain. Subtract the portion of play and select games that are not too drained of energy. If necessary, the child does not need to be studied first.
  4. Dry morning. The sunlight in the morning turned out to be the little immune boost because during exposure to the rays of the morning sun, the body issuing more white blood cells.
Unfortunately, often the symptoms experienced by children in cough colds feels so disturbing. Nasal congestion and coughs constantly make children lazy suckle, lazy and can't sleep well. But as it has been articulated above, the third – BREAST MILK, eat and rest – is indispensable to improve the durability of the body.

In this condition, the attempt to relieve the symptoms of non-pharmacological therapy,/non pharmacological therapy or drugs/medications needed to make the child more comfortable.

NON-DRUG THERAPY 
The therapy is done to relieve the symptoms of cough colds in children who do not use medicines and interventions. Non-pharmacological therapy should be kept to its fullest before you decide to use the therapeutic/pharmacological/therapeutic drugs.
Many things that parents can do it at home (home treatment) to help reduce the symptoms of coughs colds suffered. Among Them:
  1. Bathing in the morning. In addition to increasing immune, sunlight will also warm up the respiratory tract the little one so can help thin the mucus.
  2. Mandikan child with warm water
  3. drinking lots of. Increase fluid intake in children by giving him to drink more: ASIP, white water, fruit juice. In this way, children are spared from dehydration, prevent throat not dry as well as more dilute phlegm 
  4. set the position of the pillow. In infants, use higher on pillows while sleeping to help relieve a stuffy nose.
  5. In addition to maintaining the cleanliness of the body though the little one was sick, shower with lukewarm water can increase the moisture of the air and relieve cough.
  6. For children, gargling with salt water can reduce pain in the throat.
  7. Steam Therapy
  8. Vacuum the snot. To help remove mucus, in the market are also available vacuum nose (nasal aspirator/nose cleaner). Its use is still so contentious because it is argued can damage tissue in the nose. If you want to use, select the shape of the bottle with a small rubber plastic to siphon. This Model uses an air pressure of pump rubber to help pull the snot in nose. This Model is better than any vacuum tube model the snot that was equipped with a long hose, vacuum the snot using air pressure of the mouth which may cause displacement of bacteria. Use a special brand of baby products. Read the instructions of use. Sterilkan first before use. Enter the vacuum into the nostrils, but don't be too deep. Do it gently so as not to irritate the baby's nose. Make sure tools are washed clean and sterilized after use.
  9. Can help moisturize the air so as to help relieve the breath and thins mucus so easy, lenders issued. Here's how: put a basin containing hot water in a corner of the room. Tetesi with eucalyptus oil or other oils. Let the steam fills the room and inhaled by the grassroots. Should AIR CONDITIONING turned off or if absolutely necessary, the temperature is regulated in such a way that the steam still feels and effective.
  10. Rinse out
  11. Help your child put out a runny nose. The baby has yet to be requested to be snot nose and breathed out. But it may help the baby breathe more relief. Therefore the baby's runny nose wipe it with a tissue or handkerchief. Press-press gently sticks her nose (not too hard huh). This gentle pressure helps remove phlegm. To clear the mucus dries scars around the nostrils, use a cotton bud and wet wipe it slowly. Don't put cotton bud too deep.
  12. Brush Balsam/oil. Warm your little one with the chest rubbing balm or oil accordingly. This way can help thin the phlegm and relieve respiratory tract. Select the appropriate product age, so that the child is comfortable and not so hot. Examples of balsam which could be used inter alia, Vick Vaprub (adjust with age because the effect is hot enough), Transpulmin BB, etc. While the oil that can be used include: telon oil, eucalyptus oil, and others


PHARMACOLOGICAL THERAPY/DRUGS

Pharmacological/therapeutic drugs can be used if non-pharmacological therapies have resulted in maximum results. There are drug therapies that can be purchased at a pharmacy itself to swamedikasi, there are drug therapy should be based on the prescription or on a discussion with a pharmacist.

For the purposes of swamedikasi, the use of the drug should only if absolutely necessary and adjusted with the symptoms. Some drugs that can moms use is:
  1. physiological NaCl Solution drops 0.9%. Can be bought in pharmacies. Useful to moisturize nasal membranes are dry and inflamed due to colds, allergies or air humidity is low. A solution of NaCl will this work reduces the secretion of the mucous that helps remove mucus from the nose. Squirt 1-2 drops in each nostril. May be repeated a moment later or at least 3 times a day. Although this product can be used for children and babies ages 1 month to the top, its use should remain cautious on a baby who was still very young.
  2. Paracetamol. Antipyretic medication or lowering the heat that is safe to use on infants and children. Should only be used if the child has a fever above 38.5 c. less than the temperature, we recommend that you optimize the non drug therapies to resolve the fever.
THE DRUG OVER THE COUNTER (OTC)  
The use of cough colds which is free should not carelessly. The Food and Drug Administration (FDA) highly recommends that parents avoid using cough colds are sold freely in the market for children under 3 years because of potential side effects that may harm the baby and child < 2 years. In Indonesia alone, the FDA advice to implement with determination the dose starts from the age of 2 years. For security reasons, parents should not violate the rules listed in the dose packaging of drugs with OTC medications give dabble at children aged less than 2 years and modify own dose (dose reduced itself) without a proper basis.

Use Of Antibiotics
Understand the use of antibiotics. Antibiotic use in cough colds caused by the viral infection so has no basis. In addition to antibiotics will not provide therapeutic effects, side effects and the risk of resistance should be a consideration in the use of antibiotics in cough colds due to virus infection.

Therefore, parents should prioritize and optimize the non pharmacological therapy in such a way in handling infants and children with coughs colds. If cough colds still ongoing more than 7 days of non-pharmacological therapy though has been attempted, or if symptoms seem heavy and very troubling, should immediately consult a doctor.

FLU AND HOW TO RESOLVE IT ....?


FLU. The Flu is a disease which sucks ... !!!
HOW TO RESOLVE IT. ....?

The Flu is a symptom that occurs due to Influenza or also commonly known as the Flu and is an infectious disease caused by RNA viruses of the family orthomyxoviridae. Cold not only humans but also animals.
SYMPTOMS OF INFLUENZA
Symptoms can start influen quickly, one to two days after infection. Usually the first symptoms are chills or feeling cold, but fever is also common in early infection, with body temperatures ranging from 38-39 ° C (approximately 100-110 ° F). Many people feel so sick that they can't get up from the family's sleep for several days, with aches and pains all over the body, feels heavier on the back and legs. Symptoms of influenza can include:
  1. Fever and a feeling of extreme cold (shivering, shaking)
  2. Cough
  3. Nasal congestion, sneezing and runny
  4. Body aches
  5. Body aches, especially the joints and throat
  6. Fatigue
  7. Dizzy
  8. Irritation of the eyes, watery eyes
  9. Red eyes, red skin (especially face), as well as redness of the mouth, throat, and nose
  10. Petechiae Rash
  11. In children, gastrointestinal symptoms such as diarrhea and abdominal pain (may be severe in children with influenza B)
FOR PEOPLE WITH THE FLU ARE ADVISED :
  1. a lot of rest.
  2. drink plenty of water.
  3. avoid the use of alcohol and cigarettes.
  4. If necessary, taking medications such as acetaminophen (paracetamol) to relieve symptoms of fever and muscle aches associated with the flu.
  5. children and teenagers with flu symptoms (particularly fever) should avoid use of aspirin during influenza infection (especially influenza type B), because doing so can lead to Reye's Syndrome, a rare liver disease but have the potential to cause death. Since influenza is caused by a virus, antibiotics have no effect on the infection; unless provided for secondary infections such as pneumonia bakterialis. Antiviral treatment can be effective, but some strains of inflenza can show resistance to the standard antiviral drugs.

Friday, May 24, 2013

HEMORRHOIDS AND HOW TO TREAT IT ....

 HEMORRHOIDS AND HOW TO TREAT IT ...?

Hemorrhoids are varicose veins which lie around the rectum. When swelling and irritation, hemorrhoids can be extremely painful. Hemorrhoids usually recover alone in one or two weeks. However, if hemorrhoids very painful, you certainly do not want to suffer for it, isn't it?

What can you do to solve it? Here are the 4 steps you can do to relieve hemorrhoids.
  1. Use a painkiller and anti-inflammatory to relieve pain and inflammation. You can take oral tablets, cream or suppository anal oles. Granting of Aloe Vera gel (aloe vera) on the area of the rectum can also help reduce inflammation. Alternatively, you can use natural remedies based on the violet leaf (graptophyllum pictum) against hemorrhoids. Violet leaf is a plant originating from New Guinea and Polynesia. Saponins, alkaloids, glycosides and other substances contained in the violet leaf can inhibit inflammation of hemorrhoids and help the digestive process that make the stool soft. The anti-inflammatory effect of Saponins are strong enough to cope with severe hemorrhoid though.
  2. Clean the anal area with the individual over defecate. You do not need to use SOAP as it may increase irritation. To dry the area around the hemorrhoids, you can use the soft tissue that is commonly used for infants.
  3. Reduce pain by sitting in warm water (sitz bath) three or four times a day for 10 to 15 minutes. You can also apply an ice bag or cold compress on the area of the rectum for about ten minutes, three or four times a day to reduce swelling of the blood vessels.
  4. Prevent or reduce constipation. Choose high-fiber foods (vegetables, fruits and grains) and multiply. Avoid tea and coffee for a while.
If Your hemorrhoids are very painful, even though it's been done the treatment themselves or often recurred, then please consult a doctor.

ERITRODERMA

ERITRODERMA
DEFINITION
Skin disorder characterized the Erythema in almost the entire body, usually accompanied by skuama.

SYNONYM
Eksfoliativa Dermatitis


PATHOPHYSIOLOGY
• Depending on the cause.
• At Eritroderma an increase in epidermal turn over, so the form skuama redundant.
• Skuama mainly contain protein, nucleic acid and free amino acids.

CLINICAL SYMPTOMS
• Occurs in a short time
• Fast expand
• Fever, chills, malaise
• The skin looks shiny, eritematus, Peel, palpable heat, itch, rough and thickened.


PATHOPHYSIOLOGY
Erythema: widening blood vessels → blood flow to skin
increased heat loss increases: →
» Cold/chills Sufferers
» Hipotermi (due to an increase in skin perfusion)
» Dehydration (due to increased evaporation of fluid)
» Temperature Setting.
Skuama loss can cause loss of protein (hipoproteinemia) and oedema.

CLINICAL SYMPTOMS
Allergy Medication systemically
     - Anamnesis: a history of medication/herbal medicine.
     - Allergies arising in acute (about 10 days).
     - A universal Erythema without skuama,
     - After recovering recently arising erythema.

Expansion of skin diseases
  Psoriasis:
    - Due to the disease itself or pengobtan is too strong.
    - Erythema is uneven.
      (Erythema has a predilection psoriasis)
  
     Seboroika Dermatitis in infants (Leiner's disease)
     - Dermatitis seboroika which extends
     - Clearly unknown Etiology
     - Age: > > > 4 – 20 weeks.
     - KU patient well.
     - Erythema universal accompanied skuama rough.

Systemic diseases including malignancies
     - Classified in the CTCL (Cutaneous T-Cell Lymphoma)
     - > > > on seniors.
     - Erythema universal meah smoldering + skuama and is very itchy.
     - At 1/3 the sufferer: Lymphadenopathy, splenomegaly
       superficial, alopecia, hyperpigmentation, hiperkeratotik
       distrofia palmoplantar, nails.
     - Laboratory: sezary cells called atipik Lymphoma

DIAGNOSIS
Clinical keradangan eritematus skin found along deskuamasi to ≥ 90% of the surface area of the body.

DIAGNOSIS OF APPEAL
Dermatitis, Psoriasis vulgaris, Drug Eruption, lymphoma/Leukemia, Pityriasis Rubra Pilaris, Pemfigus, Likhen Planus, Dermatofitosis, Skabies

THAT MAKES IT DIFFICULT
• Hipotermi
• Decompensation kordis
• Failure of peripheral circulation
• Tromboflebitis
• Secondary infections of the skin and the lungs

MANAGEMENT
• Fix the fluid body
• Elimination of precipitating factors
• Systemic Corticosteroids "tappering off"
• Antibiotics for secondary infections mencegaf
• Antihistamine/antipruritus
• Topical: coccos (oleum emolient, hydrocortisone 1%)
• High protein Diet

PITYRIASIS RUBRA PILARIS (PRP)

PITYRIASIS RUBRA PILARIS (PRP)

DEFINITION
The chronical disorder:
     - Plaque eritematus
     - Berskuama
     - Papule-follicular keratotik

ETIOLOGY
- HEREDITARY
    - Autosomal dominant
    - Commencement of the child
-OBTAINED
    - All ages
    - Family history (-)
    - Vitamin A deficiency is suspected

CLASSIFICATION
Hereditary
     - Expanding gradually and slowly
     - Settle
Come By
    - Expanding rapidly
    - Remission

CLINICAL SYMPTOMS
  • Erythema and skuama at the beginning on the face and scalp, which can extend to the entire surface of the skin, followed by erythema and thickening in the palms of the hands and feet.
  • Skin Disorders limits firmly with the islands of normal skin.
  • Nail shows thickening.
  • Systemic Disorders (-).

HISTOPATOLOGIS
• Hiperkeratosis
• Parakeratosis
• Akantosis
• Inflammatory cells chronically Sebukan on the upper dermis.

THERAPY
• Vit A 200.00 units per day.
• Retinoat Acid 0.05%
• Topical Kortkosteroid + Asidum salisilikum 3 – 20%

THE PROGNOSIS
Hereditary: bad
Come by: good


Tuesday, May 14, 2013

VALVE DISEASE


VALVE DISEASE

CARDIAC ANATOMY 101
 

CARDIAC PHYSIOLOGY 101












Systole                        AV/PV – opens
 S1-S2              MV/TV – closes

Diastole           AV/PV – closes
 S2-S1              MV/TV – opens

NORMAL VALVE FUNCTION NORMAL VALVE FUNCTION
         Maintain forward flow and prevent reversal of flow.
         Valves open and close in response to pressure differences (gradients) between cardiac chambers.



















ABNORMAL VALVE FUNCTION
  • Valve Stenosis
    • Obstruction to valve flow during that phase of the cardiac cycle when the valve is normally open.
    • Hemodynamic hallmark -“pressure gradient”  ~ flow// VA
  • Valve Regurgitation, Insufficiency, Incompetence
    • Inadequate valve closure --→ back leakage
  • A single valve can be both stenotic and regurgitant; but both lesions cannot be severe!!
  • Combinations of valve lesions can coexist
    • Single disease process
    • Different disease processes
    • One valve lesion may cause another
    • Certain combinations are particularly burdensome (AS & MR)

MITRAL VALVE COMPETENCE:
















  • Integrated function of several anatomic elements
  1. Posterior LA wall
  2. Anterior & Posterior valve leaflets
  3. Chordae tendineae
  4. Papillary muscles
  5. Left ventricular wall where the papillary muscles attach
 MITRAL VALVE DISEASE:  ETIOLOGY
  • Mitral Stenosis
v     Rheumatic  - 99.9%!!!
v     Congenital
v     Prosthetic valve stenosis
v     Mitral Annular Calcification
v     Left Atrial Myxoma
  •  Acute Mitral Regurgitation
v     Infective endocarditis
v     Ischemic Heart disease
-     Papillary ms rupture
v     Mitral valve prolapse
-     Chordal rupture
v     Chest trauma
  •  Chronic Mitral Regurgitation
v     Ischemic Heart disease
-     Papillary ms dysfunction
-     Inferior & posterior MI
v     Mitral Valve prolapse
v     Infective endocarditis
v     Rheumatic
v     Prosthetic
v     Mitral annular calcification
v     Cardiomyopathy
-     LV dilatation
-     IHSS


MITRAL REGURGITATION-PATHOPHYSIOLOGY




















MITRAL REGURGITATION-PATHOPHYSIOLOGY




















MITRAL REGURGITATION-PATHOPHYSIOLOGY

















MITRAL REGURGITATION-PATHOPHYSIOLOGY
















  • MR: Leakage of blood into LA during systole
  • 10 Abnormality -Loss of forward SV into LA
  • Compensatory Mechanisms
1        Increase in SV (& EF)
2        Forward SV + regurgitant volume
3        LV (LA) dilatation
4        Left Ventricular Volume Overload (LVVO)

MITRAL REGURGITATION : SYMTOMS & PE
Symptoms
         Fatigue and weakness
         Dyspnea and orthopnea
         Right sided HF
         MVP Syndrome (if present)

Physical Exam
          Holosystolic Apical Blowing Murmur
          Laterally displaced apical impulse
          Split S2 (but is obscured by the murmur)
          S3 Gallop (increased volume during diastole)
          Radiation depends on the etiology


















MITRAL REGURGITATION : SURGICAL INTERVENTION












MITRAL STENOSIS

































MITRAL STENOSIS














MITRAL STENOSIS-PATHOPHYSIOLOGY
  • MV gradientè Incr LA pr
  • Pulmonary HTN
    • Passive
    • Reactive- 2nd stenosis
  • RV Pressure Overload
    • RVH
    • RV failure
    • Tricuspid regurgitation
    • Systemic Congestion
  • Paradoxes of MS
    • Disease of Pulm Arts & RV
    • LV unaffected (protected)
    • As RV fails, pulmonary symptoms diminish




















MITRAL STENOSIS : CLINICAL SYMPTOMS
  • Symptoms related to severity of MVA reduction-
  • Symptoms unrelated to severity of MS-
    • Atrial fibrillation
    • Systemic thromboembolism
  • Symptoms due to Pulmonary HTN and RV failure-
    • Fatigue, low output state
    • Peripheral edema and hepato-splenomegaly
    • Hoarseness –recurrent laryngeal nerve palsy


















MITRAL STENOSIS :  PHYSICAL FINDINGS
  • Auscultatory findings
    • S1 – variable intensity; increased early, progressively decreases
    • OS –opening snap, variable intensity
    • A2-OS interval – varies inversely with severity of MS; shortens as MVA diminishes
    • Low-pitched diastolic rumble @ apex
      • Duration of murmur correlates with severity of MS
      • Pre-systolic accentuation
    • Increased P2
  • Body habitus – thin, asthenic, female
  • Low BP
  • LA lift & RV tap

MITRAL VALVE DISEASE : TREATMENT
    • Medical Rx for Class I & II
      • HR control – Dig & BB
      • Anticoagulation
        • Afib, >40yrs, LAE, MR, prior  embolic event
    • Surgical Rx -Class III &IV
      • Balloon Mitral Valvuloplasty
      • Commissural fusion
      • pliable, noncalcified leaflets
      • No MR of LA thrombus
      • Mitral Valve Surgery
      • Open commissurotomy
      • MV replacement

MEDICAL MANAGEMENT - MS
  • CHF
    • Salt restriction and intermittent diuretics
    • See MD immediately if sudden onset SOB
      • May have A-fib with flash pulmonary edema 
  • Exertional symtpoms
    • Consider –ve chonotropic agents (BB,CCB) 
  • Atrial fibrillation
    • Rate control and anticoagulation
    • May consider anticoagulation if stroke w/o Afib
BALLOON MITRAL COMMISSUROTOMY













AORTIC VALVE DISEASE:  ETIOLOGY
  • Aortic Stenosis
    • Degenerative calcific (senile)
    • Congenital – Uni or bicuspid
    • Rheumatic
    • Prosthetic
  • Acute Aortic Insufficiency
    • Infective endocarditis
    • Acute Aortic Dissection
      • Marfan’s Syndrome
      • Chest trauma
  • Chronic Aortic Insufficiency
  • Aortic leaflet disease
    • Infective endocarditis
    • Rheumatic
    • Bicuspid Aortic valve
    • Prolapse & congenital VSD
    • Prosthetic
  • Aortic root disease
    • Aortic aneurysm/dissection
    • Marfan’s syndrome
    • Connective tissue disorders
    • Syphilis
    • HTN
    • Annulo-aortic ectasia
 AORTIC STENOSIS - PATHOPHYSIOLOGY
  • Normal AVA 2.5-3.0cm2
    • Severe AS <1.0cm2
    • Critical AS <0.7cm2; <0.5cm2/m2
  • Hemodynamic Hallmark
    • Systolic pressure gradient
    • AV grad ~ AV flow//AVA
      • AV flow = CO/SEP (systolic ejection period)
    • 50-100mmHg gradients are common in severe AS




















RELATIONSHIP BETWEEN AV GRADIENT AND FLOW FOR DIFFERENT AORTIC VALVE AREAS
  • Like Mitral Stenosis – as flow increases so does the gradient.
  • Unlike Mitral Stenosis –
    • Resting flows are higher
      • smaller AV area
      • shorter SEP
    • Larger gradients
    • Significant (>50mmHg) gradient can be present at rest in asymptomatic individuals.
 

Aortic Stenosis: Natural History & Clinical Symptoms
  • Asymptomatic for many years
  • Symptoms develop when valve is critically narrowed and LV function deteriorates
    • Bicuspid AV  5th - 6th decade
    • Senile AS  7th-8th decades
  • Classic Symptom Triad
    • Angina pectoris – 5 years
    • CHF   1-2 years
    • Syncope 2-3 years
    • Sudden Death
  • Natural History Studies-
    • Pts grad 25mmHg –20% chance of intervention in 15 years
    • Pts with asymptomatic severe AS require close f/u
    • Gradient progression
      • 6-10mmHg/yr
    • Risk Factors
      • Age > 70
      • CAD, hyperlipidemia
      • Chronic renal failure
 AORTIC STENOSIS: NATURAL HISTORY














AORTIC STENOSIS














AORTIC STENOSIS:  PHYSICAL FINDINGS
Severity of AS
Mild
Moderate
Severe
Carotid pulse
normal
Slow rising
Parvus et Tardus
LV apical impulse
normal
heaving
Heaving & sustained
Auscultation



S4 gallop
 -
+/-
++
Systolic ejection Click
+
+/-
-
SEM, peaking
Early systole
midsystole
mid-to-late systole
S2
normal
Normal or single
Single or paradoxical


AORTIC STENOSIS: MEDICAL THERAPY   
  • No medical therapy prolongs life
    • Theoretical benefit of statins, but trials –ve so far 
  • Treatment of CHF can reduce symptoms
    • Diuretics, ACEi, Digoxin have all been used 
  • Atrial fibrillation worsens symptoms
    • Needs aggressive rate control or cardioversion 
  • All patients should be considered for OR
    • Age is NOT a contraindication to surgery, but increases risk of complications

AORTIC STENOSIS: WHEN TO OPERATE?
Indication for Aortic Valve Repair
Class
Severe AS (AVA <1.0cm2) with symptoms
I
Severe AS undergoing CABG or CVS surgery
I
Severe AS and impaired LV function (LVEF < 50%)
I
Moderate AS undergoing CABG or CVS surgery
IIa
Asymptomatic patients:
 - critical AS if operative mortality very low (<1%)
 - severe AS with exercise induced hemodynamic changes
 - severe AS and risk of rapid progression (age, calcified, CAD)

IIb
IIb
IIb

REMINDER
  • Class I: There is evidence and/or general agreement that a given procedure or treatment is useful and effective
  • Class II: There is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment
-     IIa:  Weight of evidence/opinion is in favor of usefulness/efficacy
-      IIb:  Usefulness/efficacy is less well established by evidence/opinion.
  •  Class III: There is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful.
AORTIC INSUFFICIENCY- PATHOPHYSIOLOGY
  • 10 abnormality – LVVO
  • Severity of LVVO
    • Size of regurgitant orifice
    • Diastolic pressure gradient between Ao & LV
    • HR or duration of diastole
  • Compensatory Mechanisms
    • LV dilatation & eccentric LVH
    • Increased LV  diastolic compliance
    • Peripheral vasodilation





















LV VOLUME VS PRESSURE OVERLOAD

Feature

LVPO (AS)
LVVO (MR,AI)
LV Volume

normal
Dilated**
Wall thickness

Conc. LVH
Normal to slightly increased
LV compliance

“stiff” noncompliant
Increased compliance
LV diastolic Pr

increased
Normal to slightly increased
LV systolic Pr

Increased**
Normal to slightly increased
LVEF

normal
increased

CHRONIC AORTIC REGURGITATION: 
PHYSICAL FINDINGS
         Widened Pulse Pressure  > 70mmHg   (170/60)
         Low diastolic pressure  <60mmHg
         Hyperdynamic LV
         DeMusset’s signs
         Corrigan’s pulse
         Quincke’s pulsations,
         Durozier’s murmur
         Auscultation:
         Diminished A2
         Descrescendo diastolic blowing murmur @ LSB
         Austin-Flint murmur – diastolic flow rumble @ apex
         Due to interference with trans-mitral filling by impignement from aortic regurgitant jet.
         DDx - mitral stenosis(increases intensity with amyl nitrite)

AORTIC REGURG – AUSTIN FLINT MURMUR



















Due to the vibration of the anterior leaflet of the mitral valve as it is buffetted simultaneously by the blood jets from the left atrium and the aorta.

AORTIC REGURGITATION
Treatment of Asymptomatic Aortic Regurg

Medical Therapy – treats the symptoms not the cause
  1. Serial Check ups with Echos (eval EF, Severity AR)
  2. SBE Prophylaxis
  3. Vasodialators (Nifedipine, ACE-I)
  4. Diuretics

Treatment of Symptomatic Aortic Regurg
            Aortic Valve Replacement
                        Bioprosthetic vs Mechanical AVR

CONCLUSION
  • Normal valves : maintain forward flow and prevent reversal of flow.
  • Aortic, mitral, tricuspid and pulmonal valves.
  • Treatment : medical and intervention (non surgical and surgical.