Cardiology Case 1

Cardiology Case 1

Follow Up Questions/Answers

What are the common indications for aortic valve replacement?

o Severe symptomatic AR/AS.
o Infective endocarditis.
What further investigations would be appropriate in this patient?
o ECG.
o Full blood count, inflammatory markers and blood cultures.
o Chest X-Ray.
o 24 hour tape.
o Echocardiogram.

What are the possible complications of prosthetic valves?

o Infective endocarditis (Early and late) – may present as a new AV
block, acute heart failure or embolic phenomenon.
o Thromboembolism.
o Anticoagulation complications.
o Anaemia (haemolysis, endocarditis, or bleeding).
o Valve failure (heart failure from dehiscence, leaking, calcification or
stiffening of valve leaflets).

What are the types of replacement valves available?

o Tissue valves – xenografts (porcine/bovine) and homografts
(cadaveric).
o Mechanical prosthetic valves.

What are the advantages of tissue valves and mechanical valves:

o Mechanical valves have a longer life span, but require lifelong
anticoagulation, so may be more advantages in an younger patient.
o Tissue valves have a shorter lifespan, so are indicated in older
patients who have a shorter life expectancy. They can be used
when anticoagulation is contraindicated. They can also be
considered in infective endocarditis as tissue valves are more
resistant to infection.
Cardiology Case 1

Cardiology Case 2: Mr Gallagher

Key Words and Phrases

Patients with prosthetic valves are common in the PACES examination,

the candidate needs to identify the relevant important positive findings:

Note the Median sternotomy scar, with no evidence of vein harvesting

from legs or arms, suggesting cardiac surgery for structural heart defects
or valve repair/replacements. Note also the presence of ecchymoses
which could be consistent with anticoagulation therapy.

Timing of heart sounds is important, in this patient there is a metallic

second heart sound, heard after, not with, the pulse, so denoting that the
patient has had a metallic aortic valve replacement.

The patient had a soft systolic flow murmur heard loudest in the aortic
area. The apex is normal, with no signs of LVH, there are no signs of
pulmonary hypertension, or heart failure, which suggests that the valve
may have been replaced due to aortic regurgitation rather than aortic
stenosis.

Importantly there is a second systolic murmur heard loudest at the apex,

radiating to the axilla. The potential differential diagnoses should be
given, in this instance mitral regurgitation is a possible diagnosis for this
murmur.

The pulse has an Irregular rhythm indicative of atrial fibrillation, this is

uncommon in lone aortic valve disease, however is common in patients
with cardiovascular disease, and especially in patients with mitral valve
disease.

In view of a symptomatic patient with SOB, previous valve replacement,

a new murmur, irregular pulse, splinter haemorrhage on examination (but
no further stigmata of infective endocarditis) infective endocarditis
should be excluded. The new murmur needs further investigation also, as
does the atrial fibrillation.
Cardiology Case 1

Management includes blood count, inflammatory markers, INR, Chest X-

ray, ECG, and echocardiogram. A 24 hour tape may also be indicated to
further investigate possible new AF.

Long term management includes adequate anticoagulation, and

monitoring of cardiac function via serial echocardiograms.