Cardio Pathology

• - Communication between the Aorta & Left pulmonary Artery
• - The shunt that is open in the fetus due to the collapsed lung causing higher resistance than systemic resistance.
• - Normally after birth (hours-weeks) the lumen starts to obliterate due to smooth muscle contraction and w/in 12days the Ligamentum Arteriosum forms. 
• CLINICAL FEATURES:
• dyspnea, fatigue, diminished growth & cardiac failure (w/ Lg shunt)
• POSSIBLE FEATURES:
• subacute bacterial endocarditis, aneurysm, noninfectious thrombosis
• Left-to-Right:
• may eventually cause pulmonary hypertension & shunt reversal, surgical correction recommended early
• Right-to-Left:
• cyanosis & fatigue are main complaints, chest pain of pulmonary hypertension may be present

• Four Types:
• - Between the Crista Supraventricularis & Pulmonary Valve
• - Just caudal to the Crista Supraventricularis
• - Beneath the septal leaflet of the tricuspid valve in an area where the         A-V conduction bundle is especially susceptable to injury
• - In the muscular septum near the apex of the right ventricle

• CLINICAL FEATURES:
• - defect size + pulmonary vascular resistance = volume of blood 
• - increase pulmonary blood Q = increase pulmonary vascular R
• **if pulmonary vascular R increases to a level above systemic R, the shunt is reversed from left-to-right -- right-to-left, making surgical therapy uniformly unsuccessful.**

-surgical correction may be carried out with primary closure or, if the defect is large a patch is indicated

• - The name given to a defect which includes hypoplasia or absence of the main pulmonary artery.
• - Pulmonary circulation is dependent upon a patent ductus arteriosus and a ventricular septal defect

• SYMPTOMS:
• - resemble those of tricuspid atresia
• - dyspnea, fatigability, frequent resp infections, cyanosis, hypoxia & cardiac failure are all common

• SURGICAL CORRECTION:
• - involves closing the ventricular septal defect, closing the patent ductus arteriosus and insertion of a dacrom graft betaeen the RV and left main pulmonary artery (RASTELLI PROCEDURE)

• PRIMARY:
• - Extremely rare finding
• SECONDARY:
• - congenital or rheumatic disease, trauma or endocarditis 

• CLINICAL FEATURES:
• - edema and ascites are usually present, as may be hepatomegaly and splenomegaly

**Since it is usually caused by another cardiac defect, the primary defect must be repaired.  Repair of the Tricuspid Valve is usually limited to valvuloplasty.

• ACTIVE CONGESTION:
• SERVERE:
• - left-to-right shunt
• MODERATE:
• - increased speed of circulation
•      - anemia / thyrotoxicosis / beriberi heart disease
• - increased blood volume
•      - pregnancy
• PASSIVE CONGESTION:
• CHRONIC LV FAILURE:
• - severe systolic overload of LV
•    - systemic hypertension / coarctation of aorta / aortic stenosis
• - severe diastolic overload of LV
•    - mitral insufficiency / patent ductus arteriosus / aortic insufficiency 
• - myocardial damage & failure
•    - myocarditis / myocardial fibrosis / myocardial infarction
• - left ventricular aneurysm
• OBSTRUCTION TO FLOW:
• mitral stenosis / LA thrombosis / constrictive pericarditis / amyloidosis / endocardial fibroelastosis / compression of pulmonary veins

- Due to a dietary deficiency of Thiamine.

• CLINICAL FEATURES:
• - elevated BP
• - bounding pulse (extremely)
• - rapid circulation (extremely)

• COMMON OCCURRENCES:
• - increased venous pressure
• - ascites
• - edema
• - right heart failure

**Responds dramatically to Thiamine therapy.

• 3 common types: 
• 1. Ostium secudum: central portion of the atrial septum
• 2. Sinus Venosum: high in septum, near SVC
• 3. Ostium Primum: low in septum; close to medial leaflet of mitral valve
• Clinical: can cause upper respiratory infections and fatigue; no cyanosis, but can be mild dyspnea and fatigue 
• -increased pulmonary flow resulting in pulmonary hypertension which can reverse shunt to become right to left
• -if it is a primum type defect then severe cardiac failure may be present; this defect should be corrected between the ages 3-5
• -the defect can be repaired by primary closure
• -in the ostium primum defect, the cleft in the mitral vlave is sutured; sometimes a pericardial graft is needed to the bridge the gap in the valve

• -when 4 pulmonary veins return blood to the right side of the heart; most times atrial septal defects are present so blood can circulate to the left side of the heart
• Partial anomalous pulmonary venous return: pulmonary venous returns partially to the right side and partially to the left side
• 3 categories:

• Supracardiac (50%)- most common; pulmonary venous return empties into left SVC, then innominate vein, then SVC
• Cardiac (30%)- pulmonary venous return empties into coronary sinus; occasionally goes into right atrium
• Infracardiac (10%)- pulmonary veins drain into venous trunk that descends and enters IVC or portal vein below diaphragm

• Clinical: can cause cyanosis, cardiac failure, and pulmonary hypertension
• 75% of patients die before age 1
• Surgery tries to aim at rediverting the venous blood to the left side

• -ring of vessels surrounding the esophagus and trachea, most common being the double aortic arch.
• -defect causing the right and left (innominate) aortic arch to form descending aorta
• -another common vascular ring is formed round the right aortic arch joined by the ligamentum arteriosum on the left side; the ring circles the trachea and esophagus causing partial obstruction causing difficulty in respiration
• - surgical correction is directed towards relieving the constriction of the ring around the trachea and esophagus

• -narrowing of the mitral valve; most common valvular defect
• -can impede the flow of blood from the left atrium to the left ventricle during ventricular diastole causing a rise in left atrial pressure 
• -this high pressure can cause increased pulmonary venous, pulmonary arteriolar, pulmonary artery pressures, and right ventricular systolic pressure 
• -pulmonary arteriolar sclerosis or pulmonary fibrosis can occur
• Clinical: palpitations, weakness, orthopnea, dyspnea, pulmonary edema, and hemoptysis are symptoms. Edema and cyanosis appear in advanced stages
• -mitral commissurotomy can be done which opens the mitral valve along its fused commissures 
• -acquired mitral stenosis, esp. calcific mitral stenosis requires valve replacement

• -acute pericarditis accompanied by severe chest pain; may cause pericardial effusion which can result in a cardiac tamponade 
• -adhesive pericarditis is when the pericardium thickens and adheres to the heart itself which can be follow by constrictive pericarditis
• -constrictive pericarditis interferes with the normal function of the heart which may results in the pericardium being surgically removed

• -80-85% of cases
• -predisposing factors include heredity, vascular reactivity, renin-angiotensin-aldosterone , neurogenic factors (sympathetic stimuli causing constriction of renal blood vessels), physiology of circulation (vasoconstriction of efferent glomerular arterioles of kidney, vessels of skin and brain)
• -prolonged hypertension can result from stress (hereditary factor), prolonged emotional strain (physiological factor), acute nephritis, toxemia of pregnancy, etc.
• -secondary changes include renal ischemia and arteriosclerosis 
• -a new equilibrium can be achieved once the pressure restores some disturbed aspect of renal function

• Is the Failure of Development of the MAIN PULMONARY ARTERY.
•           Signs: RHF 
•          Complication: * Subacute Bacterial Endocarditis
•                                    * Brain abcess
•                                     *Embolism
•                                    * Cerebral Vascular Accidents
•       Surgical Correction: depends on the right ventricle
• If the right ventricule chamber is NORMAL in size AS IS pulmonary artery   simple pulmonary valvulotomy  and a closure of the Ductus arterious. 
• If the right ventricule is HYPOPLASTIC with a NORMAL pulmonary artery - Increase pulmonary flow or use the Rashkind procedure. 
• If right ventricular is NORMAL and pulmonary artery is HYPOPLASTIC-- Rastelli procedure.
• If Main pulmonary artery is HYPOPLASTIC - Fontan procedure

• It’s a complete transposition of the great vessels as the AORTA arises from RIGHT VENTRICLE (anterior to pulmonary artery) and the PULMONARY ARTERY arises from LEFT VENTRICLE (posterior to aorta).
• What happens??  Blood circulates around and around in the systemic circulation WITHOUT passing through the pulmonary circulation. Likewise,
• The pulmonary circulation is recirculated WITHOUT passing to systemic. 
• How patient survive?
• INTRACARDIAL SHUNTS are presented which will permits mixing of both circulations. 
• Patent foramen ovale and Ductus arteriosus are presented in most of the cases. 
• Most commonly associated defect is the VENTRICULAR SEPTAL DEFECT. 
• Symptoms:  Cynosis, Respiratory Infection, Hypoxia, MI, pulmonary hypertention, CF. 
• Surgical correction: 
• Blalock Hanlon technique (DON’T NEED CPB) involves excising a portion of the ATRIAL SEPTUM.  
• MUSTARD PROCEDURE which involves rearranging the arterial septum so that the blood in arterial chamber will empty into the ventricular  pulmonary artery arise. The chamber receiving blood from pulmonary veins will empty into  the ventricular  aorta arises

• This type of Aneurysm develops in the SINUS VALSAVA IN THE AORTA at its junction with the annulus fibrosus. 
• Right Coronary Sinus is the mostly involved. 
• Rupture of this Aneurysm is into the RIGHT VENTRICLE, Occasionally into the RIGHT ATRIUM. 
• An Aneurysm of the posterior cusp ruptures into the RIGHT ATRIUM. 
• An Aneurysm of the left cusp ruptures the LEFT or RIGHT ATRIUM or into LEFT VENTRICLE (This type is rare). 
• The cause of this defect is usually congenital. -  There may be an associated VENTRICULAR SEPTAL DEFECT. 
• Rupture of the Aneurysm may be marked by  ACUTE ONSET OF LEFT VENTRICULAR FAIURE.
• Symptoms: Heart failure, Cardiomegaly ( Enlarged Heart)
• Surgical correction: Direct Suture of the Defect

• It occurs when the AORTIC VALVE fails to close completely immediately AFTER SYSTOL.
• There is an INCREASE in pulse pressure.
• LEFT  VENTRICLE  becomes Dilated  and Hypertophied
• Pulmonary Congestion and Edema are common.
• Symptoms: Cerebral Insufficiency, Dizziness, Pulsating Headaches, Dyspnea, Increased Pulse Pressure, Pulmonary congestion and Edema. 
• Coronary Insufficiency may occur.  As well Left Heart Failure may occur followed by a Right Heart Failure. 
• Treatments : Surgical replacement with a PROSTHETIC VALVE.

• Core pulmonale is a HEART DISEASE which is caused by HYPERTENTION in the PULMONARY CIRCULATION. 
• HAPPENS DUE to abnormal resistance of blood flow from the RIGHT VENTRICLE. 
• ACUTE COR PULMONALE is caused by PULMONARY EMBOLISM. 
• CHRONIC COR PULMONALE is caused by one of the four general categories pulmonary disease:
• Chronic obstruction Lung Disease. 
• Pulmoary Fibrosis.
• Musculoskeletal or Mechanica disorders or the Thoracic Cage. 
• Primary Disease of the Pulmonary Vessels. 
• In addition to one of the pulmonary manifestations for a Chronic Cor pulmonale RIGHT HEART FAILURE. 
• Treatment: Is Directed toward the pulmonary component. 

Hypertension is the elevation of the basal blood pressure above the normal limits of 145/90 mmHg.

Physiological Vasoconstriction or an increase of cardiac output due to Emotion, Cold or other causes that will give us a reading higher than 160/90mm.