Clinical Cases In Cardiology

Clinical case in cardiology

1. Clinical Cases in Cardiology
Dr. Ihab Suliman

2. A 24-year-old man was hospitalized for evaluation. He had a family history of
aortic disease. Physical examination

3. Revealed bifid uvula and pectus excavatum.Dilated aorta 5.5

4. Loeys–Dietz syndrome type 1
•Confirmed by genetic analysis showing a
mutation in exon 7 of the TGFBR2 gene.
•Patients with this autosomal dominant
syndrome are at high risk for aortic
dissection or rupture at an early age

5. A 59-year-old man with a medical history of hypertension,
hyperlipidemia, and coronary artery disease presented with transient,
painless visual obscuration in the left eye,

6. he had undergone placement of a stent in
the left carotid artery for severe stenosis
•Retinal examination of the left eye showed multiple, tiny refractile
retinal arteriolar cholesterol emboli and a saddle embolus superior
to the optic nerve (Panel A, arrow).
•Two months later, repeat examination showed an increase in the
number of cholesterol emboli (Panel B). The patient's visual acuity
was unchanged (20/25 bilaterally).
•Four weeks later, a sudden, painless loss of the left superior visual
field occurred. Examination revealed whitening in the inferior
macular region (Panel C, arrow), a finding that was consistent with
an occlusion at the second major bifurcation of the inferior temporal
branch of the retinal artery. After carotid stenting, ongoing
deposition of retinal emboli may occur. The patient was left with a
deficit in the superior visual field.

7. 83 years old lady chronic AF ,
Dysphagia

8. •An esophagogram obtained to evaluate
dysphagia for solid food revealed a
prominent impression of the left atrium on
the esophagus , without evidence of
obstruction.

9. CXR findings ?

10. •Chest radiography (Panel A) revealed
cardiomegaly (cardiothoracic ratio, 0.86),
splaying of the carina, and an elevated left
main bronchus (arrows). Plus PPM DDD

12. •Echocardiogram showed massive biatrial
enlargement (left larger than right),

13. •An 83-year-old woman with long-standing
atrial fibrillation who had previously
undergone atrioventricular nodal ablation
and pacemaker placement presented with
symptoms of progressive heart failure.
• The patient was discharged home on
medical management after prolonged
diuresis.

14. •What is the mortality for elederly people
with heart failure after first admission ?
•Male ?
•Female ?

15. Mortality Rates After First Hospitalization
for HF

Jong et al. Arch Intern Med. 2002;162:1689-1694.
Age- and Sex-Stratified Case-Fatality Rates 30 Days and 1 Year
After First Hospitalization for HF
Men Women
Mortality, % Mortality, %
Age Group, y No. of Patients 30-Day 1-Year No. of Patients 30-Day 1-Year
20-49
50-64
65-74
≥75
All Ages
655
3048
5923
9310
18,936
4.6
5.5
8.6
15.6
11.4
15.0
20.5
28.8
43.1
34.0
375
1892
4412
13,087
19,766
4.3
5.4
6.8
14.7
11.8
10.9
19.5
23.0
37.9
32.3

16. Type of the valve ?

17. •http://content.nejm.org/cgi/content/full/358/
21/e24/DC1

18. •In 1960, Dr. Albert Starr and Lowell
Edwards, an electrical engineer, achieved
successful implantation of the Starr–
Edwards valve in the mitral position.

19. CXR ??

22. •A biopsy confirmed the presence of
bronchogenic adenocarcinoma, which was
inoperable .

23. •A 56-year-old obese man comes to the emergency department
because of crushing chest pain that has been present for 3 hours.
The pain radiates to his left arm and neck. He also complains of
nausea. On physical examination, the patient is found to be
sweating and his blood pressure is 164/122 mm Hg. Laboratory
analysis reveals that his cardiac enzyme levels are elevated. His
ECG is abnormal with ST-segment depression. Which of the
following is the pathology underlying the correct diagnosis?
•A. Coronary artery vasospasm caused by cigarettes and cocaine
B. Complete occlusion of the coronary arteries by a mural thrombus
C. Increased cardiac demand with coronary arteries that are greater
than 75% occluded
D. Ischemic necrosis of 30% of the ventricular wall
E. Ischemic necrosis of 70% of the venricular wall

24. •The correct answer is D. The patient has a
subendocardial infarction, which is caused by
ischemic necrosis of <50% of the ventricular
wall.
•This area of the myocardium is the last section
of the myocardium to be perfused and, as a
result, is the first to undergo necrosis from
prolonged ischemia. Ischemia is typically due to
diffuse atherosclerosis or a transient thrombosis.

25. •A 62-year-old breast cancer survivor visits her physician because of
weakness, fatigue, fever, and weight gain 5 years following her
radiation therapy. The physician also elicits complaints about
abdominal discomfort and exertional dyspnea. Physical examination
reveals hepatomegaly and jugular venous distention that fails to
subside on inspiration, but shows no evidence of hypotension or
pulsus paradoxus. An echocardiogram shows reduced end-diastolic
volumes and elevated diastolic pressures in both ventricles. Which
of the following is the most likely diagnosis?
•A. Cardiac tamponade
B. Congestive heart failure
C. Constrictive pericarditis
D. Dilated cardiomyopathy
E. Recurrence of breast cancer

26. •The correct answer is C. Constrictive
pericarditis interferes with the filling of the
ventricles because of granulation tissue
formation in the pericardium.
•It can follow purulent viral infections,
trauma, neoplastic diseases, mediastinal
irradiation, and other chronic diseases.
Pericardial thickening and calcification are
sometimes apparent on CT and MRI.

27. •A 76-year-old man receives a pacemaker to treat a
dangerous form of heart block. This form of heart block
is characterized by a constant PR interval with randomly
blocked QRS complexes. The patient’s ECG prior to
treatment is shown in the image. Which of the following
is the abnormality responsible for this type of heart
block?
•
•A. Atrioventricular nodal abnormality
B. Defect in the His-Purkinje system
C. Independently contracting atria and ventricles
D. Retrograde conduction
E. Sinoatrial nodal abnormality

28. •The correct answer is B. This is a Mobitz type II second-degree
heart block. A defect in the His-Purkinje system is responsible for
this type of heart block defect.
•Answer A is not correct. In contrast to this patient’s findings,
atrioventricular nodal abnormalities lengthen the PR interval and are
responsible for first-degree heart block and Mobitz type I second-
degree heart block.
•Answer C is not correct. Independently contracting atria and
ventricles occur in the complete absence or ablation of the His-
Purkinje system, not simply a defect in the system.
•Answer D is not correct. Retrograde conductions would result in an
increase in the number of P waves and a decrease in the PR
interval.
•Answer E is not correct. Sinoatrial nodal abnormalities are
responsible for problems in automaticity and would not result in
randomly dropped QRS complexes.