1. Heart Embryology
   1. starts 3rd week
      1. develops from splanchnic mesoderm
      2. neural crest cells
   2. formation of a single tube
   3. cardiac looping
      1. cardiac looping
      2. by week 4
      3. defect can lead to dextrocardia
   4. primitive circulation begins by week 4
   5. adult derivatives of embryonic structure
   6. Septation of the chambers
      1. Atria
         1. septum primum grows toward endocardila cushion
            1. Subtopic 1
         2. secundum forms in septum primum
         3. septum secundum develops as foramen secundum maintains right-to-left shunt
         4. septum secundum expands and covers most of the foramen secundum. The residual is the foramen ovale
         5. Remaining portion of the septum primum forms valve of the foramen valve
         6. septum secundum and septum primum fuse to form the atrial septum
         7. Foramen ovale usually closes soon after birth because of the increase LA pressure
         8. Patent Foramen Ovale caused by failure of septum primum and septum secundum to fuse after birth
            1. Can lead to paradoxical emboli
         9. ASD( L TO R)
            1. Ostium Primum
            2. Down syndrome
            3. Ostium Secundum
            4. Most common
      2. Ventricles
         1. Muscular IV forms
            1. Subtopic 1
         2. aorticopulmonary septum forms and fuses with muscular IV to from membranous IV
         3. growth of endocardial cushions separates atria from ventricles
         4. VSD(L TO R)
            1. Membranous
            2. Muscular
2. Anatomy
3. Fetal circulation
   1. Subtopic 1
   2. Subtopic 2
   3. Subtopic 3
4. adult derivatives of fetal structures
5. Characteristic of the valves
6. Layers of the heart
   1. pericaridum
      1. Fibrous pericardium(tough)
      2. Visceral pericardium(surrounding heart)
      3. Pericarditits
      4. contains pericardial fluid
         1. pericardial effusion
            1. cardiac tamponade
            2. Becks Triad
            3. Hypotension
            4. Distended neck veins
            5. Muffled voices
   2. endocardium
   3. epicardium(visceral pericardium)
7. Coronary arteries
   1. SA node supplied by RCA
   2. AV node supplied by PDA
   3. Right dominant circulation
      1. PDA from RCA
   4. Left dominant circulation
      1. PDA from LCX
   5. Codominant circulation
      1. PDA from RCA and LCX
   6. Cornonary artery occlusion common in LAD
   7. Coronary blood flow peaks in early diastole
8. Floating Topic
9. Sites of auscultation with murmurs
10. Physiology
    1. Cardiac muscle contraction
       1. calcium induced calcium release via ryanodine receptor
    2. Cardiac output
       1. C0=SVxHR
          1. determinants of cardiac output
       2. stroke volume
          1. preload
             1. approximated by EDV
          2. afterload
             1. approximated by MAP
          3. contractility
             1. sympathetic stimulation via B1
             2. increase intracellular calcium
             3. digitalis
             4. cardiac glycoside
             5. digoxin
             6. blocks NA+/K+ pump
             7. increases intracellular CA2+
       3. heart rate
    3. Frank-starling's law
       1. increase in volume(EDV)
          1. increase in force of contraction(increase in stretch of myofibers )
             1. increase in SV
    4. Blood pressure
       1. MAP=COxTPR
       2. Systolic or diastolic
       3. Pulse difference
          1. Systolic-diastolic
          2. atherosclerosis/aging
          3. aortic regurgitation
          4. PDA
          5. Aortic stenosis
    5. resistance
       1. Diameter
          1. mainly determined by arterioles
       2. viscosity
       3. length
    6. blood vessels
       1. arterioles(35mmHg)
          1. regulars of MAP
       2. capillaries
          1. slowest velocity
          2. largest cross sectional areas
          3. Gas exchange
       3. veins/venules(16mmHg)
          1. capacitance vessels
             1. reservoirs for blood volume
          2. more compliant
       4. Vena cava 0 mmHg
       5. Aorta 120 mmHg
    7. cardiac and vascular function curves
    8. pressure volume loop
       1. isovolumetric contraction
       2. systolic ejection
       3. isovolumetric relaxation
       4. rapid filling
       5. reduced filling
    9. Cardiac cycle
    10. heart sounds
11. Cardiac and Vascular function curves
12. Floating Topic
13. Electrophysiology and arrhythmias
14. Myocardial Action Potential
    1. Phase 0
       1. rapid upstroke and deoplarisation
          1. fast voltage gated Na+ channels open
    2. initial reoplarisation
       1. fast Na+ close
          1. fast voltage gated K+ open
    3. Phase 2
       1. Plateau
          1. Ca2+ influx balances K+ efflux
             1. Ca2+ triggers Ca2+ release from SR and myocyte contraction
    4. Phase 3
       1. Rapid repolarisation
          1. K+ efflux through slow K+ channels and closure of Ca2+ channels
    5. Phase 4
       1. Resting Potential
          1. High K+ permeability through K+ channels
15. Pacemaker Action Potential
    1. Phase 0
       1. upstroke
          1. Opening of Ca2+...Fast Na+ permanently inactivated
    2. Phase 3
       1. reoplarisation
          1. inactivation of C2+ channels
             1. opening of K +
             2. K+ efflux
    3. Phase 4
       1. slow spontaneous diastolic depolarization due to If channels(slow Na+ channels open
          1. Accounts for automaticity of SA and AV nodes.
             1. slope of phase 4 determines HR
16. Floating Topic
    1. Subtopic 1
17. Subtopic 1
18. Electrocardiogram
    1. P wave
       1. atrial depolarisation
    2. PR interval
       1. AV nodal delay
       2. 0.12-0.2 s
    3. QRS complex
       1. -
          1. Q wave
             1. Septal deoplarisation
          2. R Wave
             1. Ventricles deoplarisation
          3. S wave
             1. Basal deoplarisation
          4. <0.12 s
    4. QT interval
       1. Ventricular depolarization and Ventricular repolarization
       2. <0.43
    5. T wave
       1. Ventricular repolarisation
    6. J point
       1. junction between end of QRS complex and start of ST segment
    7. ST segment
       1. Isoelectric,ventricles deoplarised
    8. U wave
       1. prominent in hypokalemia , bradycardia
19. Cardiac arrhythmias
20. Mechanism
    1. Increased automaticity
    2. triggered activity
    3. Reentry
21. Cardiac Axis
22. Tachycardia > 100 bpm
    1. supraventricular (narrow QRS complex)
       1. SA node:Sinus tachycardia
       2. AV node/atria
          1. Paroxysmal supraventricular tachycardia (PSVT)
       3. Atrial flutter
          1. Saw toothed shape
             1. Subtopic 1
       4. Atrial fibrillation (Afib)
          1. irregularly irregular heart beat
             1. Subtopic 1
    2. ventricular (wide QRS complex)
       1. premature ventricular contraction
       2. ventricular tachycardia (VT)
          1. monomorphic VT
          2. polymorphic VT
             1. Torsades de pointes :type of polymorphic VT
             2. treatement
             3. magnesium sulfate
             4. caused by
             5. drugs:
             6. antibiotics: macrolides- ezythromyocin
             7. hypokalemia and hypomagnesia
             8. Subtopic 1
             9. Long QT interval
       3. Ventricular fibrillation (VF)
          1. completely irregular rhythm with no identifiable waves
             1. fatal
          2. needs CPR and defibrillation
23. Bradycardia <60 bpm
    1. SA node:Sinus bradycardia
       1. Sick sinus Syndrome
          1. syncope
          2. dizziness
    2. AV node: AV blocks
       1. first degree
          1. Subtopic 1
       2. second degree
          1. Mobitz type 1 (Wenckeback)
             1. asymptomatic
          2. Mobitz type 2
             1. symptomatic
       3. third degree
    3. Bundle branch blocks
       1. RBBB
       2. LBBB
24. Can be classified into
25. Floating Topic
26. Starlings curve
27. Floating Topic
28. Floating Topic
29. Floating Topic
30. Floating Topic
31. Congenital Long QT syndrome
    1. inherited disorder of myocardial repolarisation
    2. due to ion channel defects
    3. increased risk of sudden cardiac death
32. Pathology
33. Congenital Heart disease
34. Floating Topic
35. Floating Topic
36. Floating Topic
37. Floating Topic
38. RVH to compensate
    1. shunt becomes right to left
       1. causes late cyanosis
       2. clubbing
       3. polycythemia
39. Other anomalies
    1. coarctation of the aorta
40. Acyanotic
    1. Ventricular septal defect
       1. most common
       2. most resolve
       3. larger lesions may lead to LV overload and HF
       4. TYPES
          1. muscular
          2. membranous
    2. Atrial septal defect
       1. defect in the interatrial septum
       2. wide fixed split S2
       3. ostium secundum more common
       4. may lead to paradoxical emboli
    3. Patent ductus arteriosus
       1. continuous machinery murmur
       2. patency maintained by PGE synthesis and low oxygen tension
       3. treatment
          1. Endomethicin
             1. decreases PGE
    4. uncorrected left to right shunt leads to
       1. Eisenmenger syndrome
          1. increased pulmonary blood flow
             1. pathologic remodeling of vasculature
             2. pulmonary hypertension
41. Early cyanosis (5Ts)
    1. Persistent Truncus arteriosus
       1. truncus arteriosus fails to divide
          1. lack of aorticopulmonary septum
          2. most Patients have VSD
    2. Transposition of great vessels
       1. aorticopulmomary septum fails to divide
          1. Aorta leaves RV
          2. Pulmonary trunk leaves LV
       2. Not compatible with life
          1. patients present with
             1. VSD
             2. PDA
             3. Patent foramen ovale
    3. Tricuspid atresia
       1. absence of tricuspid valve and hypoplastic RV
       2. requires both ASD and VSD for survival
    4. Tetralogy of Fallot
       1. Pulmonary infundibular stenosis
          1. pulmonary stenosis
             1. forces RIGHT TO LEFT across VSD and causes RVH
       2. Right ventricular hypertrophy
          1. boot-shaped heart
       3. Overriding aorta
       4. VSD
       5. children often squatt
    5. Total anomalous of Pulmonary return
       1. Pulmonary veins drains into right heart circulation ( SVC, coronary sinus)
       2. associated with ASD, PDA
    6. Ebstein anomaly
       1. displacement of tricuspid valve leaflets into RV
          1. associated with tricuspid regurgitation