Right ventricular outflow tract obstruction differential diagnosis: Difference between revisions

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==Overview==
==Overview==
Right ventricular outflow tract obstruction must be distinguished from an [[ASD]],  a small [[VSD]], [[aortic stenosis]], and acyanotic or pink [[tetralogy of Fallot]].


==Differentiating Right ventricular outflow tract obstruction from other Diseases==
==Differentiating Right ventricular outflow tract obstruction from other Diseases==


Right ventricular outflow tract obstruction must be distinguished from several other conditions.
Right ventricular outflow tract obstruction must be distinguished from several other conditions. <ref name="pmid7720297">{{cite journal |vauthors=Waller BF, Howard J, Fess S |title=Pathology of tricuspid valve stenosis and pure tricuspid regurgitation--Part I |journal=Clin Cardiol |volume=18 |issue=2 |pages=97–102 |date=February 1995 |pmid=7720297 |doi=10.1002/clc.4960180212 |url=}}</ref>


1. [[Atrial septal defect]]: Also has a systolic ejection murmur, wide fixed split S2, EKG showing [[RVH]]. In ASD the split of the S2 is fixed, there is no ejection click.
1. [[Atrial septal defect]]: Also has a systolic ejection murmur, wide fixed split S2, EKG showing [[RVH]]. In ASD the split of the S2 is fixed, there is no ejection click. <ref name="pmid14491175">{{cite journal| author=REID JM, STEVENSON JG, BARCLAY RS, WELSH TM| title=Combined aortic and mitral stenosis. | journal=Br Heart J | year= 1962 | volume= 24 | issue=  | pages= 509-15 | pmid=14491175 | doi= | pmc=1017912 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14491175  }} </ref>


2. Small [[Ventricular septal defect]]: [[Amyl nitrate]] increases venous return and increases the murmur of [[pulmonary stenosis]], in VSD the murmur becomes softer.
2. Small [[Ventricular septal defect]]: [[Amyl nitrate]] increases venous return and increases the murmur of [[pulmonary stenosis]], in VSD the murmur becomes softer.
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3. Mild left-sided outflow obstruction: With [[valsalva maneuver]] the murmur of [[aortic stenosis]] becomes softer after about 5 beats, with [[pulmonary stenosis]] it becomes softer within 3 beats.
3. Mild left-sided outflow obstruction: With [[valsalva maneuver]] the murmur of [[aortic stenosis]] becomes softer after about 5 beats, with [[pulmonary stenosis]] it becomes softer within 3 beats.


4. Acyanotic or pink [[tetralogy of Fallot]]: with amyl nitrate and increased venous return the murmur of PS increases, and the murmur of tetralogy decreases because of peripheraldilation and an increase in right to left shunting.
4. Acyanotic or pink [[tetralogy of Fallot]]: with amyl nitrate and increased venous return the murmur of PS increases, and the murmur of tetralogy decreases because of peripheraldilation and an increase in right to left shunting. <ref name="pmid1539731">{{cite journal| author=Shinoda H, Stern PH| title=Diurnal rhythms in Ca transfer into bone, Ca release from bone, and bone resorbing activity in serum of rats. | journal=Am J Physiol | year= 1992 | volume= 262 | issue= 2 Pt 2 | pages= R235-40 | pmid=1539731 | doi= | pmc= | url= }} </ref> 
 
The differential diagnosis of aortic regurgitation includes other valvular abnormalities:<ref name="pmid24603191">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2014 | volume= 63 | issue= 22 | pages= e57-185 | pmid=24603191 | doi=10.1016/j.jacc.2014.02.536 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24603191  }} </ref><ref name="pmid27188578">{{cite journal| author=Lindman BR, Clavel MA, Mathieu P, Iung B, Lancellotti P, Otto CM et al.| title=Calcific aortic stenosis. | journal=Nat Rev Dis Primers | year= 2016 | volume= 2 | issue=  | pages= 16006 | pmid=27188578 | doi=10.1038/nrdp.2016.6 | pmc=5127286 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27188578  }} </ref><ref name="pmid19747723">{{cite journal| author=Chandrashekhar Y, Westaby S, Narula J| title=Mitral stenosis. | journal=Lancet | year= 2009 | volume= 374 | issue= 9697 | pages= 1271-83 | pmid=19747723 | doi=10.1016/S0140-6736(09)60994-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19747723  }} </ref><ref name="pmid14565709">{{cite journal| author=Chockalingam A, Gnanavelu G, Elangovan S, Chockalingam V| title=Clinical spectrum of chronic rheumatic heart disease in India. | journal=J Heart Valve Dis | year= 2003 | volume= 12 | issue= 5 | pages= 577-81 | pmid=14565709 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14565709  }} </ref><ref name="pmid12835667">{{cite journal| author=Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA et al.| title=Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. | journal=J Am Soc Echocardiogr | year= 2003 | volume= 16 | issue= 7 | pages= 777-802 | pmid=12835667 | doi=10.1016/S0894-7317(03)00335-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12835667  }} </ref><ref name="pmid9665226">{{cite journal| author=Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA| title=Long-term follow-up of patients with severe rheumatic tricuspid stenosis. | journal=Am Heart J | year= 1998 | volume= 136 | issue= 1 | pages= 103-8 | pmid=9665226 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9665226  }} </ref>
 
* [[Aortic stenosis]]: The murmur of [[aortic stenosis]] is harsh and best heard at the right second intercostal space.
* [[Mitral regurgitation]]: The murmur of [[mitral regurgitation]] is blowing, soft and best heard at the apex.
* [[Mitral stenosis]]: The murmur of [[mitral stenosis]] is mid-diastolic, rumbling, and best heard after the opening snap.
* [[Tricuspid regurgitation]]: The murmur of [[tricuspid regurgitation]] is blowing, holosystolic, and  best heard over the fourth intercostal area at the left sternal border.
* [[Tricuspid stenosis]]: The murmur of [[tricuspid stenosis]] is characterized by a mid diastolic murmur best heard over the left sternal border with rumbling character and tricuspid opening snap with wide splitting of S1.
 
Aortic regurgitation should also be differentiated from other diseases that might cause similar clinical presentation, such as:<ref name="pmid10376577">{{cite journal| author=Choudhry NK, Etchells EE| title=The rational clinical examination. Does this patient have aortic regurgitation? | journal=JAMA | year= 1999 | volume= 281 | issue= 23 | pages= 2231-8 | pmid=10376577 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10376577  }} </ref><ref name="pmid27443437">{{cite journal| author=Elkayam U, Goland S, Pieper PG, Silverside CK| title=High-Risk Cardiac Disease in Pregnancy: Part I. | journal=J Am Coll Cardiol | year= 2016 | volume= 68 | issue= 4 | pages= 396-410 | pmid=27443437 | doi=10.1016/j.jacc.2016.05.048 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27443437  }} </ref><ref name="pmid15476566">{{cite journal| author=Lozano HF, Sharma CN| title=Reversible pulmonary hypertension, tricuspid regurgitation and right-sided heart failure associated with hyperthyroidism: case report and review of the literature. | journal=Cardiol Rev | year= 2004 | volume= 12 | issue= 6 | pages= 299-305 | pmid=15476566 | doi=10.1097/01.crd.0000137259.83169.e3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15476566  }} </ref><ref name="pmid27470456">{{cite journal| author=Anand IS| title=High-Output Heart Failure Revisited. | journal=J Am Coll Cardiol | year= 2016 | volume= 68 | issue= 5 | pages= 483-6 | pmid=27470456 | doi=10.1016/j.jacc.2016.05.036 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27470456  }} </ref>
 
* [[Acute coronary syndrome]]
* [[Anemia]]
* [[Heart failure]]
* [[Infective endocarditis]]
* [[Patent ductus arteriosus]]
* [[Pregnancy]]
* [[Thyrotoxicosis]]
* [[Volume depletion]]
* [[Wet beriberi]]
 
Following are the cardiac conditions having similar presentation as Aortic regurgitation:<ref name="pmid22379596">{{cite journal| author=Nassar PN, Hamdan RH| title=Cor Triatriatum Sinistrum: Classification and Imaging Modalities. | journal=Eur J Cardiovasc Med | year= 2011 | volume= 1 | issue= 3 | pages= 84-87 | pmid=22379596 | doi=10.5083/ejcm.20424884.21 | pmc=3286827 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379596  }} </ref><ref name="pmid17170355">{{cite journal| author=Roudaut R, Serri K, Lafitte S| title=Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations. | journal=Heart | year= 2007 | volume= 93 | issue= 1 | pages= 137-42 | pmid=17170355 | doi=10.1136/hrt.2005.071183 | pmc=1861363 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17170355  }} </ref><ref name="pmid19604402">{{cite journal| author=Apostolakis EE, Baikoussis NG| title=Methods of estimation of mitral valve regurgitation for the cardiac surgeon. | journal=J Cardiothorac Surg | year= 2009 | volume= 4 | issue=  | pages= 34 | pmid=19604402 | doi=10.1186/1749-8090-4-34 | pmc=2723095 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19604402  }} </ref><ref name="pmid3805524">{{cite journal| author=Alboliras ET, Edwards WD, Driscoll DJ, Seward JB| title=Cor triatriatum dexter: two-dimensional echocardiographic diagnosis. | journal=J Am Coll Cardiol | year= 1987 | volume= 9 | issue= 2 | pages= 334-7 | pmid=3805524 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3805524  }} </ref><ref name="pmid4412638">{{cite journal| author=Gibson DG, Honey M, Lennox SC| title=Cor triatriatum. Diagnosis by echocardiography. | journal=Br Heart J | year= 1974 | volume= 36 | issue= 8 | pages= 835-8 | pmid=4412638 | doi= | pmc=458901 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4412638  }} </ref><ref name="radiopedia">Cor triatrium https://radiopaedia.org/articles/cor-triatriatum (2016) Accessed on November 29, 2016 </ref><ref name="pmid17258606">{{cite journal| author=Sosland RP, Vacek JL, Gorton ME| title=Congenital mitral stenosis: a rare presentation and novel approach to management. | journal=J Thorac Cardiovasc Surg | year= 2007 | volume= 133 | issue= 2 | pages= 572-3 | pmid=17258606 | doi=10.1016/j.jtcvs.2006.10.025 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17258606  }} </ref><ref name="pmid685838">{{cite journal| author=Driscoll DJ, Gutgesell HP, McNamara DG| title=Echocardiographic features of congenital mitral stenosis. | journal=Am J Cardiol | year= 1978 | volume= 42 | issue= 2 | pages= 259-66 | pmid=685838 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=685838  }} </ref><ref name="pmid24062899">{{cite journal| author=Bonou M, Lampropoulos K, Barbetseas J| title=Prosthetic heart valve obstruction: thrombolysis or surgical treatment? | journal=Eur Heart J Acute Cardiovasc Care | year= 2012 | volume= 1 | issue= 2 | pages= 122-7 | pmid=24062899 | doi=10.1177/2048872612451169 | pmc=3760527 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24062899  }} </ref><ref name="pmid20435842">{{cite journal| author=Maganti K, Rigolin VH, Sarano ME, Bonow RO| title=Valvular heart disease: diagnosis and management. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 5 | pages= 483-500 | pmid=20435842 | doi=10.4065/mcp.2009.0706 | pmc=2861980 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20435842  }} </ref><ref name="pmid13315850">{{cite journal| author=DEXTER L| title=Atrial septal defect. | journal=Br Heart J | year= 1956 | volume= 18 | issue= 2 | pages= 209-25 | pmid=13315850 | doi= | pmc=479579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13315850  }} </ref><ref name="pmid17030704">{{cite journal| author=Webb G, Gatzoulis MA| title=Atrial septal defects in the adult: recent progress and overview. | journal=Circulation | year= 2006 | volume= 114 | issue= 15 | pages= 1645-53 | pmid=17030704 | doi=10.1161/CIRCULATIONAHA.105.592055 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17030704  }} </ref><ref name="pmid24725467">{{cite journal| author=Geva T, Martins JD, Wald RM| title=Atrial septal defects. | journal=Lancet | year= 2014 | volume= 383 | issue= 9932 | pages= 1921-32 | pmid=24725467 | doi=10.1016/S0140-6736(13)62145-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24725467  }} </ref><ref name="pmid16392241">{{cite journal| author=Demir M, Akpinar O, Acarturk E| title=Atrial myxoma: an unusual cause of myocardial infarction. | journal=Tex Heart Inst J | year= 2005 | volume= 32 | issue= 3 | pages= 445-7 | pmid=16392241 | doi= | pmc=1336732 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16392241  }} </ref><ref name="pmid8407260">{{cite journal| author=MacGowan SW, Sidhu P, Aherne T, Luke D, Wood AE, Neligan MC et al.| title=Atrial myxoma: national incidence, diagnosis and surgical management. | journal=Ir J Med Sci | year= 1993 | volume= 162 | issue= 6 | pages= 223-6 | pmid=8407260 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8407260  }} </ref><ref name="Obstruction">Circulation http://circ.ahajournals.org/content/119/7/1034 (2016) Accessed on December 7, 2016</ref><ref name="pmid16242436">{{cite journal| author=Alphonso N, Nørgaard MA, Newcomb A, d'Udekem Y, Brizard CP, Cochrane A| title=Cor triatriatum: presentation, diagnosis and long-term surgical results. | journal=Ann Thorac Surg | year= 2005 | volume= 80 | issue= 5 | pages= 1666-71 | pmid=16242436 | doi=10.1016/j.athoracsur.2005.04.055 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16242436  }} </ref><ref name="cortriatriatum">circulation http://circ.ahajournals.org/content/36/1/101 (1967) Accessed on 7 December, 2016</ref><ref name="pmid8181134">{{cite journal| author=Moore P, Adatia I, Spevak PJ, Keane JF, Perry SB, Castaneda AR et al.| title=Severe congenital mitral stenosis in infants. | journal=Circulation | year= 1994 | volume= 89 | issue= 5 | pages= 2099-106 | pmid=8181134 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8181134  }} </ref><ref name="pmid7815793">{{cite journal| author=Uva MS, Galletti L, Gayet FL, Piot D, Serraf A, Bruniaux J et al.| title=Surgery for congenital mitral valve disease in the first year of life. | journal=J Thorac Cardiovasc Surg | year= 1995 | volume= 109 | issue= 1 | pages= 164-74; discussion 174-6 | pmid=7815793 | doi=10.1016/S0022-5223(95)70432-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7815793  }} </ref><ref name="pmid7503011">{{cite journal| author=Banerjee A, Kohl T, Silverman NH| title=Echocardiographic evaluation of congenital mitral valve anomalies in children. | journal=Am J Cardiol | year= 1995 | volume= 76 | issue= 17 | pages= 1284-91 | pmid=7503011 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7503011  }} </ref><ref name="pmid3711511">{{cite journal| author=Sullivan ID, Robinson PJ, de Leval M, Graham TP| title=Membranous supravalvular mitral stenosis: a treatable form of congenital heart disease. | journal=J Am Coll Cardiol | year= 1986 | volume= 8 | issue= 1 | pages= 159-64 | pmid=3711511 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3711511  }} </ref><ref name="pmid22030961">{{cite journal| author=Subramaniam V, Herle A, Mohammed N, Thahir M| title=Ortner's syndrome: case series and literature review. | journal=Braz J Otorhinolaryngol | year= 2011 | volume= 77 | issue= 5 | pages= 559-62 | pmid=22030961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22030961  }} </ref>
{| class="wikitable"
! rowspan="2" |Diseases
! rowspan="2" |History
! rowspan="2" |Symptoms
! rowspan="2" |Physical Examination
! rowspan="2" |Murmur
! colspan="4" |Diagnosis
! rowspan="2" |Other Findings
|- style="background: #DCDCDC; padding: 5px; text-align: center;"
!ECG
!CXR
!Echocardiogram
!Cardiac Catheterization
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Mitral Stenosis]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Age ( Mitral annular calcification in older patients)
 
* [[Rheumatic fever]]
 
* [[Endocarditis]]
 
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* [[Dyspnea on exertion]]
 
* [[Paroxysmal nocturnal dyspnea]]
 
* [[Orthopnea]]
 
* New onset [[atrial fibrillation]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Mitral facies
 
* Heart murmur
 
* [[JVD|Jugular vein distension]]
 
* Apical impulse displaced laterally or not palpable 
 
* Diastolic thrill  at the apex
 
* Signs of heart failure in severe cases
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Diastolic murmur
 
* Low pitched
 
* Opening snap  followed by decrescendo-crescendo rumbling murmur
 
* Best heard with the bell of the stethoscope at apex at end-expiration in left lateral decubitus position 
 
* Intensity increases after a [[valsalva maneuver]], after exercise and after increased after load (eg., squatting, isometric hand grip) 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* [[P mitrale]]
* [[Atrial  fibrillation]]: No P waves and irregularly irregular rhythm
 
* [[Right axis deviation]]
 
* Right ventricular hypertropy: Dominant R wave in V1 and V2
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Straightening of the left border of the heart suggestive of enlargement of the [[left atrium]]
 
* Double right heart border (Enlarged left atrium and normal right atrium)
 
* Prominent left atrial appendage
 
* Splaying of [[carina|subcarinal angle]] (>120 degrees)
 
* Calcification of [[mitral valve]]
 
* [[Kerley B lines]] 
 
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Reduced valve leaflet mobility
 
* Valve calcification
 
* Doming of mitral valve
 
* Valve thickening 
* Enlargement of left atrium 
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Right heart catheterization:'''
* [[Pulmonary capillary wedge pressure]] (left atrial pressure)
'''Left heart catheterization:'''
* Pressures in left ventricle
 
* Determines the gradient between the left and right atrium during ventricular diastole (marker of the severity of mitral stenosis)
 
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* [[Hemoptysis]] ([[heart failure]])
 
* [[Ortner's syndrome]]
|-
| colspan="10" |
|-
|style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Mitral Regurgitation]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* [[CAD]]
 
* [[MI]]
 
* [[Rheumatic fever]]
 
* [[Endocarditis]]
 
* [[Mitral valve prolapse]]
 
* [[Cardiomyopathy]]
 
* [[Radiation therapy]]
 
* Trauma
 
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* [[Palpitations]]
 
* Symptoms of heart failure in severe cases
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Palpation'''
* Brisk carotid upstroke and hyperdymanic carotid impulse on palpation
 
* Apical impulse is displaced to left
 
* S3 and a palpable thrill
'''Auscultation'''
* Murmur
 
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* [[Holosystolic murmur]]
 
* High pitched, blowing
 
* Radiates to axilla
 
* Best heard with the diaphragm of the stethoscope at apex in left lateral [[decubitus]] position
 
* Intensity increases with hand grip or squatting
 
* Decrease in intensity on standing or [[valsalva maneuver]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* [[P mitrale]] in lead II
* Increased QRS voltage
* [[Right axis deviation]]
* [[Atrial fibrillation]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Acute MR'''
* [[Kerley B lines]]
* No enlargement of cardiac silhouette
'''Chronic MR'''
* Enlarged cardiac silhouette
* Straightening of left heart border
* Splaying of subcarinal angle
* Calcification of mitral annulus
* Double right heart border
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Enlargement of left atrium and ventricle
* Identify valve abnormality
* Valve calcification
* Severity of regurgitation
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Grading of MR is done with left ventriculography
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Decompensated and acute MR may lead to [[heart failure]]
|-
| colspan="10" |
|-
|style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Atrial septal defect]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Frequent respiratory or lung infections
* [[Dyspnea]]
* Tiring when feeding (Infants)
* Shortness of breath on exertion
* [[Palpitations]]
* Swelling of feet
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* [[Shortness of breath]]
* [[Fatigue]]
* [[Failure to thrive]]
* Swelling of feet and abdomen ([[Right heart failure]])
* [[Palpitations]]
* Respiratory infections
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Inspection'''
* Precordial bulge
* Precordial lift
'''Palpation'''
* Right ventricular impulse
* Pulmonary artery pulsations
* Thrill
'''Auscultation'''
* Murmur
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Midsystolic (ejection systolic) murmur
 
* Widely split, fixed S2
 
* Upper left sternal border
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Normal
* Prolonged PR interval
* [[Right bundle branch block]]
* ECG findings varies according to the underlying type of ASD
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
*Increased pulmonary markings
*[[Cardiomegaly]]
*Triangular appearance of heart
*Schimitar sign
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Gold standard test for diagnosis of atrial septal defect  (for more information click [[Atrial septal defect echocardiography]])
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Defect size
* Pulmonary venous return
* [[Pulmonary vascular resistance]]
* [[Pulmonary artery hypertension]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Asymptomatic until later part of their life
* May be associated with [[migraine with aura]]
|-
| colspan="10" |
|-
|style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Atrial myxoma|Left Atrial Myxoma]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* [[Dyspnea]]
* [[Orthopnea]]
* [[Pulmonary edema]]
* Hyperpigmentation of skin and endocrine activity
* Cerebral [[embolism]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Symptoms may mimic mitral stenosis
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Skin'''
* Signs of an embolic phenomenon
* [[Raynaud's phenomenon]]
* Swelling
* Clubbing
'''Auscultation:'''
* Lung: Fine crepitations
 
* Heart: Characteristic "tumor plop"
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Early diastolic sound as "tumor plop"
 
* Low frequency diastolic murmur may be heard if the tumor obstructing mitral valve 
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Often normal
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Often normal
'''Rare findings:'''
* [[cardiomegaly]]
* Left atrial enlargement
* tumor calcification etc.,
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Initial and most useful diagnostic study
* For more information click [[Myxoma echocardiography or ultrasound]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Useful to detect vascular supply of the tumor by the coronary arteries
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Associated with Carney complex (genetic predisposition)
|-
| colspan="10" |
|-
|style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Prosthetic Valve Obstruction
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* History of valve replacement
* Systemic embolism
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Shortness of breath
* Fatigue
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Ausculation'''
 
Muffling of murmur
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Muffling or disappearance of prosthetic sounds
 
* Appearance of new regurgitant or obstructive murmur
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Degree of stenosis
* Assess thrombus size and location
* Differentiate between thrombus, [[pannus]] and vegetations
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Causes:
* Thrombus
* Pannus formation
|-
| colspan="10" |
|-
|style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Cor Triatriatum]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Dyspnea on exertion
* Recent onset of [[congestive heart failure]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Dsypnea on exertion
* Orthopnea
* Tachypnea
* Palpitations
* Growth failure
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Auscultation'''
* Murmur
'''Other findings'''
* Signs of heart failure
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Diastolic murmur with loud P2
 
* No opening snap or a loud S1
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Non specific but may have
* [[Right axis deviation]]
* Right atrial enlargement
* [[Right ventricular hypertrophy]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Normal cardiac silhouette
* Hemodynamic changes similar to mitral stenosis (non specific findings)
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Direct visualization of membrane through the atrium
* +/- visualization of accessory chamber
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Normal left ventricular hemodynamic profile with a trans atrial gradient
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Types
* Cor triatriatum sinistrum
* Cor triatriatum dextrum
|-
| colspan="10" |
|-
|style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Congenital Mitral Stenosis
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Respiratory distress shortly after birth
* Recurrent severe pulmonary infections
* Other associated congenital cardiovascular anamolies
* [[Atrial fibrillation]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
'''Infants:'''
* Exhaustion and sweating on feeding
* Rapid breathing
* [[Failure to thrive]]
* Pulmonary infections
* Chronic cough
'''Older patients:'''
* Dyspnea
* Orthopnea
* Paroxysmal nocturnal dyspnea
* Peripheral edema
* Fatigue
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Auscultation'''
* Murmur
'''Other findings'''
* Signs of heart failure
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Mild-Moderate'''
* Loud S1
 
* Loud P2
 
* Low frequency diastolic murmur best heard at the apex
'''Severe'''
* Soft S1
 
* Loud pulmonic component of S2 with minimal respiratory splitting of S2
 
* Holodiastolic murmur with presystolic accentuation best heard at the apex
 
* Early diastolic murmur of pulmonic valve regurgitation
 
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
*Sharp P waves in leads I and II
*Inversion of P wave in lead III
*Marked Q waves in leads II and III
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Left atrial dilation
* Moderate enlargement of right heart
* Pulmonary venous congestion
* Esophageal compression
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Reduced valve leaflet mobility
* Left atrial size
* Severity of mitral stenosis
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Very rare condition
|-
| colspan="10" |
|-
|style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Supravalvular Ring Mitral Stenosis
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Other associated congenital heart defects
* Fatigue
* Frequent respiratory infections
* Failure to thrive
* Poor feeding
* Precocious congestive heart failure
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Shortness of breath
 
* Tachypnea
* Dyspnea
* Nocturnal cough
* Heamoptysis
* [[Syncope]]
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Auscultation:'''
 
Lungs: Fine, crepitant rales and rhonchi or wheezes may be present
 
Heart: Murmur
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* An apical mid diastolic murmur with presystolic accentuation
 
* No opening snap
 
* The murmur is more prominent if associated with [[VSD]] or [[PDA]]
 
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Left atrial and ventricular enlargement
* Alveolar edema
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Supramitral ring''':
* Associated with normal mitral valve apparatus
'''Intramitral ring:'''
* Hypomobility of the posterior leaflet
* Reduced interpapillary muscle distance
* Reduced chordal length
* Dominant papillary muscle
* Hypoplastic mitral annulus
(Difficult to visualize membrane <1mm in size)
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
* Persistently elevated pulmonary venous pressures
* Increased pulmonary artery pressure
|style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Types'''
* Supramitral
* Intramitral
It is attached between the opening of the atrial appendage and the mitral annulus which helps in differentiating with Cor triatriatum sinister.
* Intramitral type is associated with shone complex
|}


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}
[[CME Category::Cardiology]]


[[Category:Needs overview]]
[[Category:Disease]]
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[[Category:Cardiology]]
[[Category:Valvular heart disease]]
[[Category:Congenital heart disease]]
[[Category:Congenital heart disease]]
[[Category:Pediatrics]]
[[Category:Surgery]]
 
[[Category:Cardiac surgery]]
{{WH}}
[[Category:Emergency medicine]]
 
[[Category:Intensive care medicine]]
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[[Category:Up-To-Date cardiology]]
[[Category:Up-To-Date]]

Latest revision as of 16:16, 18 February 2020

Right ventricular outflow tract obstruction Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Keri Shafer, M.D. [3]

Overview

Right ventricular outflow tract obstruction must be distinguished from an ASD, a small VSD, aortic stenosis, and acyanotic or pink tetralogy of Fallot.

Differentiating Right ventricular outflow tract obstruction from other Diseases

Right ventricular outflow tract obstruction must be distinguished from several other conditions. [1]

1. Atrial septal defect: Also has a systolic ejection murmur, wide fixed split S2, EKG showing RVH. In ASD the split of the S2 is fixed, there is no ejection click. [2]

2. Small Ventricular septal defect: Amyl nitrate increases venous return and increases the murmur of pulmonary stenosis, in VSD the murmur becomes softer.

3. Mild left-sided outflow obstruction: With valsalva maneuver the murmur of aortic stenosis becomes softer after about 5 beats, with pulmonary stenosis it becomes softer within 3 beats.

4. Acyanotic or pink tetralogy of Fallot: with amyl nitrate and increased venous return the murmur of PS increases, and the murmur of tetralogy decreases because of peripheraldilation and an increase in right to left shunting. [3]

The differential diagnosis of aortic regurgitation includes other valvular abnormalities:[4][5][6][7][8][9]

Aortic regurgitation should also be differentiated from other diseases that might cause similar clinical presentation, such as:[10][11][12][13]

Following are the cardiac conditions having similar presentation as Aortic regurgitation:[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36]

Diseases History Symptoms Physical Examination Murmur Diagnosis Other Findings
ECG CXR Echocardiogram Cardiac Catheterization
Mitral Stenosis
  • Age ( Mitral annular calcification in older patients)
  • Mitral facies
  • Heart murmur
  • Apical impulse displaced laterally or not palpable
  • Diastolic thrill at the apex
  • Signs of heart failure in severe cases
  • Diastolic murmur
  • Low pitched
  • Opening snap followed by decrescendo-crescendo rumbling murmur
  • Best heard with the bell of the stethoscope at apex at end-expiration in left lateral decubitus position
  • Intensity increases after a valsalva maneuver, after exercise and after increased after load (eg., squatting, isometric hand grip)
  • Right ventricular hypertropy: Dominant R wave in V1 and V2
  • Straightening of the left border of the heart suggestive of enlargement of the left atrium
  • Double right heart border (Enlarged left atrium and normal right atrium)
  • Prominent left atrial appendage
  • Reduced valve leaflet mobility
  • Valve calcification
  • Doming of mitral valve
  • Valve thickening
  • Enlargement of left atrium
 Right heart catheterization:

Left heart catheterization:

  • Pressures in left ventricle
  • Determines the gradient between the left and right atrium during ventricular diastole (marker of the severity of mitral stenosis)
Mitral Regurgitation
  • Trauma
  • Symptoms of heart failure in severe cases
 Palpation
  • Brisk carotid upstroke and hyperdymanic carotid impulse on palpation
  • Apical impulse is displaced to left
  • S3 and a palpable thrill

Auscultation

  • Murmur
  • High pitched, blowing
  • Radiates to axilla
  • Best heard with the diaphragm of the stethoscope at apex in left lateral decubitus position
  • Intensity increases with hand grip or squatting
 Acute MR

Chronic MR

  • Enlarged cardiac silhouette
  • Straightening of left heart border
  • Splaying of subcarinal angle
  • Calcification of mitral annulus
  • Double right heart border
  • Enlargement of left atrium and ventricle
  • Identify valve abnormality
  • Valve calcification
  • Severity of regurgitation
  • Grading of MR is done with left ventriculography
Atrial septal defect
  • Frequent respiratory or lung infections
  • Dyspnea
  • Tiring when feeding (Infants)
  • Shortness of breath on exertion
  • Palpitations
  • Swelling of feet
 Inspection
  • Precordial bulge
  • Precordial lift

Palpation

  • Right ventricular impulse
  • Pulmonary artery pulsations
  • Thrill

Auscultation

  • Murmur
  • Midsystolic (ejection systolic) murmur
  • Widely split, fixed S2
  • Upper left sternal border
  • Increased pulmonary markings
  • Cardiomegaly
  • Triangular appearance of heart
  • Schimitar sign
Left Atrial Myxoma
  • Symptoms may mimic mitral stenosis
 Skin

Auscultation:

  • Lung: Fine crepitations
  • Heart: Characteristic "tumor plop"
  • Early diastolic sound as "tumor plop"
  • Low frequency diastolic murmur may be heard if the tumor obstructing mitral valve
  • Often normal
  • Often normal

Rare findings:

  • cardiomegaly
  • Left atrial enlargement
  • tumor calcification etc.,
  • Useful to detect vascular supply of the tumor by the coronary arteries
  • Associated with Carney complex (genetic predisposition)
Prosthetic Valve Obstruction
  • History of valve replacement
  • Systemic embolism
  • Shortness of breath
  • Fatigue
 Ausculation

Muffling of murmur

  • Muffling or disappearance of prosthetic sounds
  • Appearance of new regurgitant or obstructive murmur
  • Degree of stenosis
  • Assess thrombus size and location
  • Differentiate between thrombus, pannus and vegetations
 Causes:
  • Thrombus
  • Pannus formation
Cor Triatriatum
  • Dsypnea on exertion
  • Orthopnea
  • Tachypnea
  • Palpitations
  • Growth failure
 Auscultation
  • Murmur

Other findings

  • Signs of heart failure
  • Diastolic murmur with loud P2
  • No opening snap or a loud S1
 Non specific but may have
  • Normal cardiac silhouette
  • Hemodynamic changes similar to mitral stenosis (non specific findings)
  • Direct visualization of membrane through the atrium
  • +/- visualization of accessory chamber
  • Normal left ventricular hemodynamic profile with a trans atrial gradient
 Types
  • Cor triatriatum sinistrum
  • Cor triatriatum dextrum
Congenital Mitral Stenosis
  • Respiratory distress shortly after birth
  • Recurrent severe pulmonary infections
  • Other associated congenital cardiovascular anamolies
  • Atrial fibrillation

Infants:

  • Exhaustion and sweating on feeding
  • Rapid breathing
  • Failure to thrive
  • Pulmonary infections
  • Chronic cough

Older patients:

  • Dyspnea
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Peripheral edema
  • Fatigue
 Auscultation
  • Murmur

Other findings

  • Signs of heart failure
 Mild-Moderate
  • Loud S1
  • Loud P2
  • Low frequency diastolic murmur best heard at the apex

Severe

  • Soft S1
  • Loud pulmonic component of S2 with minimal respiratory splitting of S2
  • Holodiastolic murmur with presystolic accentuation best heard at the apex
  • Early diastolic murmur of pulmonic valve regurgitation
  • Sharp P waves in leads I and II
  • Inversion of P wave in lead III
  • Marked Q waves in leads II and III
  • Left atrial dilation
  • Moderate enlargement of right heart
  • Pulmonary venous congestion
  • Esophageal compression
  • Reduced valve leaflet mobility
  • Left atrial size
  • Severity of mitral stenosis
 Very rare condition
Supravalvular Ring Mitral Stenosis
  • Other associated congenital heart defects
  • Fatigue
  • Frequent respiratory infections
  • Failure to thrive
  • Poor feeding
  • Precocious congestive heart failure
  • Shortness of breath
  • Tachypnea
  • Dyspnea
  • Nocturnal cough
  • Heamoptysis
  • Syncope
 Auscultation:

Lungs: Fine, crepitant rales and rhonchi or wheezes may be present

Heart: Murmur

  • An apical mid diastolic murmur with presystolic accentuation
  • No opening snap
  • The murmur is more prominent if associated with VSD or PDA
  • Left atrial and ventricular enlargement
  • Alveolar edema
 Supramitral ring:
  • Associated with normal mitral valve apparatus

Intramitral ring:

  • Hypomobility of the posterior leaflet
  • Reduced interpapillary muscle distance
  • Reduced chordal length
  • Dominant papillary muscle
  • Hypoplastic mitral annulus

(Difficult to visualize membrane <1mm in size)

  • Persistently elevated pulmonary venous pressures
  • Increased pulmonary artery pressure
 Types
  • Supramitral
  • Intramitral

It is attached between the opening of the atrial appendage and the mitral annulus which helps in differentiating with Cor triatriatum sinister.

  • Intramitral type is associated with shone complex

References

  1. ↑ Waller BF, Howard J, Fess S (February 1995). "Pathology of tricuspid valve stenosis and pure tricuspid regurgitation--Part I". Clin Cardiol. 18 (2): 97–102. doi:10.1002/clc.4960180212. PMID 7720297.
  2. ↑ REID JM, STEVENSON JG, BARCLAY RS, WELSH TM (1962). "Combined aortic and mitral stenosis". Br Heart J. 24: 509–15. PMC 1017912. PMID 14491175.
  3. ↑ Shinoda H, Stern PH (1992). "Diurnal rhythms in Ca transfer into bone, Ca release from bone, and bone resorbing activity in serum of rats". Am J Physiol. 262 (2 Pt 2): R235–40. PMID 1539731.
  4. ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 63 (22): e57–185. doi:10.1016/j.jacc.2014.02.536. PMID 24603191.
  5. ↑ Lindman BR, Clavel MA, Mathieu P, Iung B, Lancellotti P, Otto CM; et al. (2016). "Calcific aortic stenosis". Nat Rev Dis Primers. 2: 16006. doi:10.1038/nrdp.2016.6. PMC 5127286. PMID 27188578.
  6. ↑ Chandrashekhar Y, Westaby S, Narula J (2009). "Mitral stenosis". Lancet. 374 (9697): 1271–83. doi:10.1016/S0140-6736(09)60994-6. PMID 19747723.
  7. ↑ Chockalingam A, Gnanavelu G, Elangovan S, Chockalingam V (2003). "Clinical spectrum of chronic rheumatic heart disease in India". J Heart Valve Dis. 12 (5): 577–81. PMID 14565709.
  8. ↑ Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA; et al. (2003). "Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography". J Am Soc Echocardiogr. 16 (7): 777–802. doi:10.1016/S0894-7317(03)00335-3. PMID 12835667.
  9. ↑ Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA (1998). "Long-term follow-up of patients with severe rheumatic tricuspid stenosis". Am Heart J. 136 (1): 103–8. PMID 9665226.
  10. ↑ Choudhry NK, Etchells EE (1999). "The rational clinical examination. Does this patient have aortic regurgitation?". JAMA. 281 (23): 2231–8. PMID 10376577.
  11. ↑ Elkayam U, Goland S, Pieper PG, Silverside CK (2016). "High-Risk Cardiac Disease in Pregnancy: Part I." J Am Coll Cardiol. 68 (4): 396–410. doi:10.1016/j.jacc.2016.05.048. PMID 27443437.
  12. ↑ Lozano HF, Sharma CN (2004). "Reversible pulmonary hypertension, tricuspid regurgitation and right-sided heart failure associated with hyperthyroidism: case report and review of the literature". Cardiol Rev. 12 (6): 299–305. doi:10.1097/01.crd.0000137259.83169.e3. PMID 15476566.
  13. ↑ Anand IS (2016). "High-Output Heart Failure Revisited". J Am Coll Cardiol. 68 (5): 483–6. doi:10.1016/j.jacc.2016.05.036. PMID 27470456.
  14. ↑ Nassar PN, Hamdan RH (2011). "Cor Triatriatum Sinistrum: Classification and Imaging Modalities". Eur J Cardiovasc Med. 1 (3): 84–87. doi:10.5083/ejcm.20424884.21. PMC 3286827. PMID 22379596.
  15. ↑ Roudaut R, Serri K, Lafitte S (2007). "Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations". Heart. 93 (1): 137–42. doi:10.1136/hrt.2005.071183. PMC 1861363. PMID 17170355.
  16. ↑ Apostolakis EE, Baikoussis NG (2009). "Methods of estimation of mitral valve regurgitation for the cardiac surgeon". J Cardiothorac Surg. 4: 34. doi:10.1186/1749-8090-4-34. PMC 2723095. PMID 19604402.
  17. ↑ Alboliras ET, Edwards WD, Driscoll DJ, Seward JB (1987). "Cor triatriatum dexter: two-dimensional echocardiographic diagnosis". J Am Coll Cardiol. 9 (2): 334–7. PMID 3805524.
  18. ↑ Gibson DG, Honey M, Lennox SC (1974). "Cor triatriatum. Diagnosis by echocardiography". Br Heart J. 36 (8): 835–8. PMC 458901. PMID 4412638.
  19. ↑ Cor triatrium https://radiopaedia.org/articles/cor-triatriatum (2016) Accessed on November 29, 2016
  20. ↑ Sosland RP, Vacek JL, Gorton ME (2007). "Congenital mitral stenosis: a rare presentation and novel approach to management". J Thorac Cardiovasc Surg. 133 (2): 572–3. doi:10.1016/j.jtcvs.2006.10.025. PMID 17258606.
  21. ↑ Driscoll DJ, Gutgesell HP, McNamara DG (1978). "Echocardiographic features of congenital mitral stenosis". Am J Cardiol. 42 (2): 259–66. PMID 685838.
  22. ↑ Bonou M, Lampropoulos K, Barbetseas J (2012). "Prosthetic heart valve obstruction: thrombolysis or surgical treatment?". Eur Heart J Acute Cardiovasc Care. 1 (2): 122–7. doi:10.1177/2048872612451169. PMC 3760527. PMID 24062899.
  23. ↑ Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). "Valvular heart disease: diagnosis and management". Mayo Clin Proc. 85 (5): 483–500. doi:10.4065/mcp.2009.0706. PMC 2861980. PMID 20435842.
  24. ↑ DEXTER L (1956). "Atrial septal defect". Br Heart J. 18 (2): 209–25. PMC 479579. PMID 13315850.
  25. ↑ Webb G, Gatzoulis MA (2006). "Atrial septal defects in the adult: recent progress and overview". Circulation. 114 (15): 1645–53. doi:10.1161/CIRCULATIONAHA.105.592055. PMID 17030704.
  26. ↑ Geva T, Martins JD, Wald RM (2014). "Atrial septal defects". Lancet. 383 (9932): 1921–32. doi:10.1016/S0140-6736(13)62145-5. PMID 24725467.
  27. ↑ Demir M, Akpinar O, Acarturk E (2005). "Atrial myxoma: an unusual cause of myocardial infarction". Tex Heart Inst J. 32 (3): 445–7. PMC 1336732. PMID 16392241.
  28. ↑ MacGowan SW, Sidhu P, Aherne T, Luke D, Wood AE, Neligan MC; et al. (1993). "Atrial myxoma: national incidence, diagnosis and surgical management". Ir J Med Sci. 162 (6): 223–6. PMID 8407260.
  29. ↑ Circulation http://circ.ahajournals.org/content/119/7/1034 (2016) Accessed on December 7, 2016
  30. ↑ Alphonso N, Nørgaard MA, Newcomb A, d'Udekem Y, Brizard CP, Cochrane A (2005). "Cor triatriatum: presentation, diagnosis and long-term surgical results". Ann Thorac Surg. 80 (5): 1666–71. doi:10.1016/j.athoracsur.2005.04.055. PMID 16242436.
  31. ↑ circulation http://circ.ahajournals.org/content/36/1/101 (1967) Accessed on 7 December, 2016
  32. ↑ Moore P, Adatia I, Spevak PJ, Keane JF, Perry SB, Castaneda AR; et al. (1994). "Severe congenital mitral stenosis in infants". Circulation. 89 (5): 2099–106. PMID 8181134.
  33. ↑ Uva MS, Galletti L, Gayet FL, Piot D, Serraf A, Bruniaux J; et al. (1995). "Surgery for congenital mitral valve disease in the first year of life". J Thorac Cardiovasc Surg. 109 (1): 164–74, discussion 174-6. doi:10.1016/S0022-5223(95)70432-9. PMID 7815793.
  34. ↑ Banerjee A, Kohl T, Silverman NH (1995). "Echocardiographic evaluation of congenital mitral valve anomalies in children". Am J Cardiol. 76 (17): 1284–91. PMID 7503011.
  35. ↑ Sullivan ID, Robinson PJ, de Leval M, Graham TP (1986). "Membranous supravalvular mitral stenosis: a treatable form of congenital heart disease". J Am Coll Cardiol. 8 (1): 159–64. PMID 3711511.
  36. ↑ Subramaniam V, Herle A, Mohammed N, Thahir M (2011). "Ortner's syndrome: case series and literature review". Braz J Otorhinolaryngol. 77 (5): 559–62. PMID 22030961.

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