Aortic aneyrysm and clinical.pptx0000000

Thoracic Aortic Aneurysm Dr Mohamed Abdelbasit Lecturer of cardiology Zagazig University

Email : [email protected] WhatsApp . +201092791494 Facebook : Mohamed Abd Elbasit YouTube : Mohamed Abd Elbasit

Learning outcomes To understand the definition, causes, and pathophysiology of thoracic aortic aneurysm To know the presentations and complications of thoracic aortic aneurysm To be able to diagnose and manage thoracic aortic aneurysm

Case 35 years old tall male patient Not DM not HPN Presented with sudden severe tearing chest pain referred to back

Case: initial assessment

Case: initial assessment Patent Fine - O2 95% Pulse 60/min BP 80/40 (ABG Alert - RBS 120 O k

Case: initial management IV line Starting noradrenaline IVI Urgent echocardiography

Case: Investigation ABG: PH 7.4 PCO2 40 PHco3 24 Echo Dilated aortic root Flap of aortic dissection

Case: Management Urgent CT A ortogram for u rgent surgical repair with ongoing IVI of Noradrenaline

Case: Big pitfall 2 hours later the patient developed disturbed conscious level Mechanically ventilated

Case: Big pitfall Reassessment BP both arms: 80/50 BP in leg: 250/130

Case: Big pitfall Reassessment CT brain: intracranial hemorrhage Patient died !!!

Case: initial assessment Patent Fine - O2 95% Pulse 60/min BP 80/40 in arms and 180/100 in leg (ABG Alert - RBS 120 O k

Case: initial management IV line Starting Beta-blockers and IV antihypertensive drugs

Thoracic Aortic Aneurysm Aortic dissection

Thoracic Aortic Aneurysm

Thoracic AA: Definition It is a dilatation of the aorta greater than 150 % of its normal diameter for a given segment. For the thoracic aorta, a diameter greater than 4.5 cm would be considered aneurysmal.

Thoracic AA: location Ascending aorta: 60% Arch of aorta: 10% Descending aorta: 40% Thoraco-abdominal: 10%

Thoracic AA: Morphology

Thoracic AA: Etiology Cystic media degeneration Marfan syndrome Genetic Bicuspid aortic valve Familial thoracic aortic aneurysm syndrome Atherosclerosis Vasculitis / infectious

Thoracic AA: Presentation Asymptomatic …… screening Aortic regurge induced S/S Chest pain Pressure signs Acute aortic syndrome Dissection Intramural hematoma Rupture

Thoracic AA: Investigations Chest x ray Echocardiography Transthoracic Transesophageal CT chest / CTA MRI chest Aortography Lipid profile / HbA1C

Thoracic AA: Management Indications of surgical repair Marfan syndrome with Aortic diameter >4.5 cm Bicuspid aorta with aortic diameter >5 cm Any patient with aortic diameter >5.5 cm Severe aortic regurge Rapid expansion (>0.5 cm/year)

Thoracic AA: Management Indications of surgical repair

Thoracic AA: Management Medical management Beta blockers target HR 50-60 BPM ACEI / ARBS / CCB / Diuretic target SBP <120 Avoid heavy lifting Control of DM and dyslipidemia Stop smoking

Learning outcomes To understand the definition, causes, and pathophysiology of thoracic aortic aneurysm To know the presentations and complications of thoracic aortic aneurysm To be able to diagnose and manage thoracic aortic aneurysm

CLINICAL CARDIOLOGY Dr Mohamed Abdelbasit Lecturer of cardiology Zagazig University

Initiate the consultation Infection control Introduce yourself Explain Take his agreement

Build relationship

يا سيدي شكرا عالنصحية عاوز البرشامة

Mitral stenosis Mitral stenosis LA pressure Pulmonary hypertension RVH/RVF AF

Mitral stenosis Presentation: Dyspnoea DD: (Valvular / ischemic / myopathy / COPD) Diagnosis (Etiological / pathological / compensation / complication)

Mitral stenosis History: pulmonary congestion ± systemic congestion ± AF (palpitations / stroke) Past history of Rheumatic fever

Mitral stenosis General examination: Mentality Vital irregular pulse (AF ) ABCD Orthopnic (Pulmonary congestion) Regional ± Congested neck veins ± LL edema (systemic congestion) Other systems lung crepitations (pulmonary congestion)

Mitral stenosis Local examination: Inspection and palpation No LV dilation ± Pulmonary HPN (pulsation / diastolic shock) ± RV dilation Auscultation MS murmur ± pulmonary HPN (accentuated S2) ± RV failure (TR murmur)

Mitral stenosis A case of rheumatic mitral stenosis the case is compensated and not complicated Investigations (ECG / CXR / ECHO) TTT (medical / intervention / surgery)

Mitral regurge Mitral regurge Volume overload LV dilatation LV Failure LA pressure / PHT RVH/RVF AF

Mitral regurge Presentation: dyspnoea DD: (Valvular / ischemic / myopathy / COPD) OR If early (palpitations) DD: Valvular / tachy-arrhythmia / Brady-arrhythmia

Mitral regurge History: Regular strong palpitation increase with exertion ± pulmonary congestion ± systemic congestion ± AF (palpitations / stroke) Past history of Rheumatic fever

Mitral regurge General examination: Mentality Vital irregular pulse (AF) ABCD Orthopnic (Pulmonary congestion) Regional ± Congested neck veins ± LL edema (systemic congestion) Other systems lung crepitations (pulmonary congestion)

Mitral regurge Local examination: Inspection and palpation LV dilatation (hyper-dynamic apex) ± Pulmonary HPN (pulsation / diastolic shock) ± RV dilation Auscultation MR murmur ± pulmonary HPN (accentuated S2) ± RV failure (TR murmur)

Mitral regurge A case of rheumatic mitral regurge the case is compensated and not complicated Investigations (ECG / CXR / ECHO) TTT (medical / intervention / surgery)

Aortic stenosis Aortic stenosis Pressure overload LV hypertrophy LV dil. /Failure LA pressure / PHT RVH/RVF

Aortic stenosis Presentation: dizziness / chest pain DD: (Valvular / ischemic / myopathy / CNS / aneurysm / chest ) OR If late (dyspnoea) DD: (Valvular / ischemic / myopathy / COPD)

Aortic stenosis History: Exertional dizziness / syncope / chest pain ± pulmonary congestion ± systemic congestion ± AF (palpitations / stroke) Past history of Rheumatic fever

Aortic stenosis General examination: Mentality Vital small volume ± irregular pulse (AF) ABCD Orthopnic (Pulmonary congestion) Regional ± Congested neck veins ± LL edema (systemic congestion) Other systems lung crepitations (pulmonary congestion)

Aortic stenosis Local examination: Inspection and palpation LV hypertrophy (sustained apex) ± LV dilatation (LV failure) ± Pulmonary HPN (pulsation / diastolic shock) ± RV dilation Auscultation AS murmur ± MR murmur (LV failure) ± pulmonary HPN (accentuated S2) ± RV failure (TR murmur)

Aortic stenosis A case of calcific aortic stenosis the case is compensated and not complicated Investigations (ECG / CXR / ECHO) TTT (medical / intervention / surgery)

Aortic regurge Mitral regurge Volume overload LV dilatation LV Failure LA pressure / PHT RVH/RVF AF

Aortic regurge Presentation: dyspnoea DD: (Valvular / ischemic / myopathy / COPD) OR If early (palpitations) DD: Valvular / tachy-arrhythmia / Brady-arrhythmia

Aortic regurge History: Regular strong palpitation increase with exertion ± pulmonary congestion ± systemic congestion ± AF (palpitations / stroke) Past history of Rheumatic fever

Aortic regurge General examination: Mentality Vital big volume ± irregular pulse (AF) ABCD Orthopnic (Pulmonary congestion) Regional Peripheral AR signs ± Congested neck veins ± LL edema (systemic congestion) Other systems lung crepitations (pulmonary congestion)

Mitral regurge Local examination: Inspection and palpation LV dilatation (hyper-dynamic apex) Pulsations everywhere ± Pulmonary HPN (pulsation / diastolic shock) ± RV dilation Auscultation AR murmur ± MR murmur (LV failure) ± pulmonary HPN (accentuated S2) ± RV failure (TR murmur)

Mitral regurge A case of rheumatic aortic regurge the case is compensated and not complicated Investigations (ECG / CXR / ECHO) TTT (medical / intervention / surgery)

History

Objectives Personal history Complaint Present history Past history Family history Differential diagnosis

Personal history Complaint Present history Past history Family history Differential diagnosis Objectives

Personal History NAS OMRH Name Age Sex Occupation Marital st. Residency Habits

Personal History Mr. Mohamed is 30 years old male patient, carpenter, from Belbes. He is married and has 2 offspring the youngest is 3 years old. He is current moderate cigarette smoker (15 cig./day for 20 years).

Personal History Smoking severity: Smoking index (cig. Per day x No. of years) (mild…. 200 ….Moderate.… 400 …..Heavy) Pack year (Smoking index/20)

Objectives Personal history Complaint Present history Past history Family history Differential diagnosis

Complaint Shortness of breath of 2 weeks duration In patients words Duration

Objectives Personal history Complaint Present history Past history Family history Differential diagnosis

History of present illness Analysis of complaint Symptoms of same system Symptoms of other systems Present drugs the patient on

Cardiac symptoms Pulmonary congestion Systemic Congestion Low COP Chest pain Cyanosis Cachexia Palpitations Pressure S. Pyrexia Embolic symptoms

Cardiac symptoms: pulmonary congestion Dyspnoea Haemoptysis Cough Recurrent chest infection

Cardiac symptoms: pulmonary congestion Dyspnoea The condition started one month ago with gradual onset progressive course of exertional dyspnea grade III associated with orthopnea ”the patient lies comfortable on three pillows”, paroxysmal nocturnal dyspnea , and dry cough which is exertional and increase on lying flat. The condition was not associated with hemoptysis or evidence of recurrent chest infection

Cardiac symptoms: pulmonary congestion Dyspnoea Grades: NYHA I…… on more than ordinary effort NYHA II….. on ordinary effort NYHA III…. on less than ordinary effort NYHA IV…. at rest

Cardiac symptoms: Systemic congestion LL oedema Dyspepsia Abdominal pain Abdominal enlargement

Cardiac symptoms: Systemic congestion LL oedema The condition started two months ago with gradual onset and progressive course of bilateral pitting painless lower limb oedema extending up to knee increase with standing and decrease by led raising and diuretics associated with dyspepsia related to meals . The condition was not associated with redness , ascitis, or abdominal pain.

Cardiac symptoms: Low cardiac output Syncope Pre-syncope Fatigue Cold extremities Claudications

Cardiac symptoms: Low cardiac output Syncope The condition started one year ago with recurrent brief attacks of fainting of sudden onset that last for few seconds followed by spontaneous recovery . T he attacks occurred once or twice per month and precipitated by emotional stress and prolonged standing and preceded with nausea and sweating. The condition is not associated with convulsions , cyanosis, fatigue, claudications, or cold extremities

Cardiac symptoms: Chest pain

Cardiac symptoms: Chest pain The condition started 3 hours ago with acute onset of severe precordial compressing chest pain referred to the jaw increase with exertion and not relieved with rest or SL nitrates and associated with nausea, vomiting, and sweating

Cardiac symptoms: Palpitations

Cardiac symptoms: Palpitations The condition started 5 months ago with recurrent attacks of rapid regular palpitations of sudden onset and offset that last for 30 minutes . The attacks occur daily and force the patient to stop his activity and is not related to exertion , sleep , or anxiety .

History of present illness Analysis of complaint Symptoms of same system Symptoms of other systems Present drugs the patient on

History of present illness Symptoms of other systems Present drugs the patient on Abdomen Chest Neuro Control Not Cause Cardiac cirrhosis COPD and core pulmonale Bilharizial core pulmonary AF induced thrombo-embolic stroke Duchene myopathy associated DCM

Objectives Personal history Complaint Present history Past history Family history Differential diagnosis

Past history Disease Operation Drugs Similar attacks

Past history Disease Operation Drugs Similar attacks Rheumatic fever / Bilhariziasis / HPN / DM /TB

Past history Disease Operation Drugs Similar attacks Open heart / PCI / chest operation/PPM

Past history Disease Operation Drugs Similar attacks Steroids / CCPs / BB

Objectives Personal history Complaint Present history Past history Family history Differential diagnosis

Family history Similar diseases Common diseases Consanguinity

Menstrual history (females) Endocrine Pregnancy Hemorrhagic anemia

General Exam

Objectives Mentality Vital signs ABCD Regional examination Other system examination

Mentality The patient is fully conscious Well oriented to time, place, and persons With normal memory and mood He is cooperative And of average intelligence

Objectives Mentality Vital signs ABCD Regional examination Other system examination

Vital signs Pulse Blood pressure Temperature Respiration

Vital signs: Pulse Regular pulse 70/minute Average volume Vessel wall not felt No special character Equal on both sides Intact Peripheral pulsations No Radio-femoral delay

Vital signs: Pulse Rhythm Rate V olume Vessel wall S pecial character Equality on both sides Peripheral pulsations Radio-femoral delay

Vital signs: Pulse Pulse rhythm Regular Irregular Regular irregularity Irregular irregularity Pulsus Deficit

Vital signs: Pulse Rhythm Rate V olume Vessel wall S pecial character Equality on both sides Peripheral pulsations Radio-femoral delay

Vital signs: Pulse Pulse rate Normal (60 – 100) BPM <60 ? 100-250 ? 250-400 ? >400 ? Causes

Vital signs: Pulse Rhythm Rate V olume Vessel wall S pecial character Equality on both sides Peripheral pulsations Radio-femoral delay

Vital signs: Pulse Average volume Big volume Small volume Variable volume Causes

Vital signs: Pulse Rhythm Rate V olume Vessel wall S pecial character Equality on both sides Peripheral pulsations Radio-femoral delay

Vital signs: Pulse Normally not felt Cord like vessel? Causes

Vital signs: Pulse Rhythm Rate V olume Vessel wall S pecial character Equality on both sides Peripheral pulsations Radio-femoral delay

Vital signs: Pulse Pulse special character

Vital signs: Pulse Pulse special character plateau pulse

Vital signs: Pulse Rhythm Rate V olume Vessel wall S pecial character Equality on both sides Peripheral pulsations Radio-femoral delay

Vital signs: Pulse Normally equal on both sides Unequal pulse? Acute Chronic Causes

Vital signs: Pulse Rhythm Rate V olume Vessel wall S pecial character Equality on both sides Peripheral pulsations Radio-femoral delay

Vital signs: Pulse Peripheral pulsations

Vital signs: Pulse Rhythm Rate V olume Vessel wall S pecial character Equality on both sides Peripheral pulsations Radio-femoral delay

Vital signs: Pulse Normally no radio-femoral delay Radio-femoral delay? Femoro-Radial delay Causes

Vital signs: Blood pressure Right hand Setting palpatory SBP 120 mmHg Setting auscultatory BP 130/80 mmHg Standing auscultatory BP 120/80 mmHg Left hand Setting palpatory SBP 120 mmHg Setting auscultatory BP 130/80 mmHg Leg Auscultatory BP: 140/80

Vital signs: Blood pressure 5 min rest Stop talking Bare arm Appropriate cuff Arm/Back supported Leg supported uncrossed

Vital signs: Blood pressure

Vital signs: Temperature Axillary temperature: 36.5 ̊

Vital signs: Respiratory rate Adequate chest movement Equal on both sides RR 14/minute

Objectives Mentality Vital signs ABCD Regional examination Other system examination

ABCD Appearance Built Colour Decubitus

ABCD: Appearance The patient looks: Good Toxic Cachectic .........

ABCD: Built Average Built OR Overweight Underweight Dwarf Giant

ABCD: Color Pallor Jaundice Cyanosis

ABCD: Color: cyanosis Central cyanosis Peripheral cyanosis Distribution Limbs and tongue Iimbs only Hands Warm Cold Clubbing Present Absent Warming No effect Improve

ABCD: Color: cyanosis Central cyanosis Peripheral cyanosis O2 inhalation Improve No effect Polycythemia May be No ABG O2 sat. Low Normal

ABCD: Decubitus The patient lie flat free OR Orthopnic Platypnic Trepopnic Prayer position Squatting

Objectives Mentality Vital signs ABCD Regional examination Other system examination

Regional Head Neck Upper limb Lower limb

Regional: head

Regional: Neck

Regional: Neck: neck veins Congested pulsating Neck veins Congestion reach ear lobule Congestion decrease with inspiration With hepato -jugular reflux There is systolic expansion JVP 15 CVP 20

Regional: Neck: neck veins

Regional: Upper Iimb

Regional: Lower Iimb

Regional: Lower Iimb Bilateral Pitting Painless LL edema Reach level of the knee Not associated with redness, hotness, or ulcerations Not associated with ascites

Objectives Mentality Vital signs ABCD Regional examination Other system examination

Other systems examination Chest Neurology Abdomen

Other systems examination Chest Neurology Abdomen Bilateral fine basal crepitations in HF

Other systems examination Chest Neurology Abdomen Duchenne myopathy with DCM Previous stroke (AF)

Other systems examination Chest Neurology Abdomen Ascites /Hepatomegally in systemic congestion

Local exam Inspection & Palpation

Objectives Steps of inspection and palpation Normal comment Mitral stenosis Mitral regurge Aortic stenosis Aortic regurge Pulmonary hypertension and tricuspid regurge

Steps Patient feet Right side: Tangential Shape of the chest / Precordial bulge Scars/dilated veins/pigmentations Pulsations Confirm by palpation

Steps Examine the apex Site Rate / Rhythm Localized/Diffuse Character Palpable sound/Thrill Rocking

Steps Palpate other areas for Palpable pulsations Palpable sounds Palpable thrills ( time/posture)

Objectives Steps of inspection and palpation Normal comment Mitral stenosis Mitral regurge Aortic stenosis Aortic regurge Pulmonary hypertension and tricuspid regurge

Normal comment Normal shape of the chest No precordial bulge No dilated veins No pigmentations No scar of cardiac surgery

Normal comment Regular apex 70/min lies in the left 5 th intercostal space MCL. It is localized with normal character with no thrill or rocking movement

Normal comment Weak epigastric pulsations most probably arising from aorta No other visible nor palpable pulsations No palpable heart sounds No palpable thrills

Objectives Steps of inspection and palpation Normal comment Mitral stenosis Mitral regurge Aortic stenosis Aortic regurge Pulmonary hypertension and tricuspid regurge

Mitral stenosis Mitral stenosis LA pressure Pulmonary hypertension RVH/RVF

Mitral stenosis Normal shape of the chest No precordial bulge No dilated veins No pigmentations No scar of cardiac surgery

Mitral stenosis Regular apex 70/min lies in the left 5 th intercostal space MCL. It is localized slappy apex with diastolic thrill and no rocking movement

Mitral stenosis Weak epigastric pulsations most probably arising from aorta No other visible nor palpable pulsations No other palpable sounds No other palpable thrills

Objectives Steps of inspection and palpation Normal comment Mitral stenosis Mitral regurge Aortic stenosis Aortic regurge Pulmonary hypertension and tricuspid regurge

Mitral regurge Mitral regurge Volume overload LV dilatation LV Failure PHT RVH/RVF

Mitral regurge Normal shape of the chest No precordial bulge No dilated veins No pigmentations No scar of cardiac surgery

Mitral regurge Regular apex 70/min lies in the left 6 th intercostal space Anterior Axillary line. It is localized hyper-dynamic apex with systolic thrill and counter clock wise rocking movement

Mitral regurge Weak epigastric pulsations most probably arising from aorta No other visible nor palpable pulsations No palpable heart sounds No other palpable thrills

Objectives Steps of inspection and palpation Normal comment Mitral stenosis Mitral regurge Aortic stenosis Aortic regurge Pulmonary hypertension and tricuspid regurge

Aortic stenosis Aortic stenosis Pressure overload LV hypertrophy LVF/dilatation PHT RVH/RVF

Aortic stenosis Normal shape of the chest No precordial bulge No dilated veins No pigmentations No scar of cardiac surgery

Aortic stenosis Regular apex 70/min lies in the left 5 th intercostal space MCL. It is localized sustained apex with no thrill or rocking movement

Aortic stenosis Weak epigastric pulsations most probably arising from aorta No other visible nor palpable pulsations No palpable heart sounds Palpable systolic thrill over the first aortic area and neck

Objectives Steps of inspection and palpation Normal comment Mitral stenosis Mitral regurge Aortic stenosis Aortic regurge Pulmonary hypertension and tricuspid regurge

Aortic regurge Aortic regurge Volume overload LV dilatation LV Failure PHT RVH/RVF

Aortic regurge Normal shape of the chest No precordial bulge No dilated veins No pigmentations No scar of cardiac surgery

Aortic regurge Regular apex 70/min lies in the left 7 th intercostal space Mid Axillary line. It is localized hyper-dynamic apex counter clock wise rocking movement and no thrill

Aortic regurge Epigastric pulsations most probably arising from aorta Palpable supra- sternal pulsations No palpable heart sounds Palpable systolic thrill on carotid arteries

Objectives Steps of inspection and palpation Normal comment Mitral stenosis Mitral regurge Aortic stenosis Aortic regurge Pulmonary hypertension and tricuspid regurge

PHT/TR Normal shape of the chest No precordial bulge No dilated veins No pigmentations No scar of cardiac surgery

PHT/TR Regular apex 70/min lies in the left 5 th intercostal space Anterior Axillary line. It is diffuse hyper-dynamic apex with clock wise rocking movement and no thrill

PHT/TR Epigastric pulsations most probably arising from right ventricle Palpable pulmonary pulsations Palpable diastolic shock in pulmonary area No palpable thrills

Objectives Steps of inspection and palpation Normal comment Mitral stenosis Mitral regurge Aortic stenosis Aortic regurge Pulmonary hypertension and tricuspid regurge

Local exam Auscultation

René- Théophile - Hyacinthe Laennec 1826