1. InfectIve endocardItIs
MohaMed salIh azIz

2. defInItIon
 Life-thre te
a ninginfe tio invo
c n lvingthee o a ium
nd c rd
a thec rd cva s
nd a ia lve .
 Ma a oinvo s p l d fe ts
y ls lve e ta e c .
 Infe tivep fe dtob c ria
c re rre a te l.

4. epIdeMIology
 10 0 0 c s sp r ye r in theUS
-2 ,0 0 a e e a
 Ma :Fe a ra 1.7:1
le m le tio
 Ne tre s
w nd
 Me n a ew s3 in 19 6 no > 5 % o p tie a
a g a 0 2 , w 0 f a nts re
o r6
ve 0
 De linein inc e eo rhe a fe r
c id nc f um tic ve
 Mo p s ticva s
re ro the lve
 Mo no o o ia c s s inje te d
re s c m l a e , c d ruguse
 Mo s p
re ta hylo o c l infe tio
cca c n

5. epIdeMIology
 Mitra va a ne2 -4 %
l lve lo 8 5
 Ao va a ne5 6 (b us idva in 2 % o
rtic lve lo -3 % ic p lve 0 f
a na va IE)
ll tive lve
 Bo m l a a rticva s0 6
th itra nd o lve -3 %
 Tric p va 0 %
us id lve -6
 P o va <1%
ulm nic lve
 Rig a le s e 0 %
ht nd ft id d -4

6. Classification
 Old :
 Sub c Ba te l End c rd
a ute c ria o a itis
 De th in 3 m nths
a -6 o
 Ac Ba te l End c rd
ute c ria o a itis
 De th in < 6w e
a e ks
 Ne :
w
 NativeVa End c rd
lve o a itis
 P s ticVa End c rd
ro the lve o a itis

7. pathogenesIs
 Alte tio o theva
ra n f lvula e o lia s c
r nd the l urfa e
le d tod p s n o p te tsa fib
a ing e o itio f la le nd rin
 Ba te m w s e ingo no a te l
c re ia ith e d f n-b c ria
thro b ticve e tio (NBTE)
mo g ta n
 Ad re ea g w furthe p te t a fib
he nc nd ro th, r la le nd rin
dps n
e o itio
 Exte io toa ja e s ture
ns n d c nt truc s
 P p ry m c , a rticva ringa s e s c nd tio
a illa us le o lve b c s , o uc n
s te
ys m

8. pathogenesIs
 Lo p s ure(d w tre m s eo s tura le io
w re s o ns a ) id f truc l s n
 Atria s eo m l va (MR)
l id f itra lve
 Ve ntric r s eo a rticva (AR, AS w R)
ula id f o lve ith
 C ng nita a no a (MV p la s , b us idAV)
o e l b rm lity ro p e ic p
 Sc rringfro rhe a he rt d e s o s le s a a
a m um tic a is a e r c ro is s
c ns q nc o a ing
o e ue e f g
 P s ticva s
ro the lve
 Othe turb nc , hig
r ule e h-ve c je
lo ity ts
 Ve ntric r s p l d fe t
ula e ta e c
 Ste ticva
no lve
 Dire t m c nic l d m g fro c the rs p c m ke le d
c e ha a a a e m a te , a e a r a s

9. pathogenesIs
 Tra ie b c re ia
ns nt a te m
 Tra a tio o m o a s
um tiza n f uc s l urfa ec lo dw
c o nize ith
b c ria(o l, GI)
a te ra
 Lo g d , c a d in 15 0m
w ra e le re -3 inute s
 Sus e tib
c p ility toc m le e
o p m nt-m d te b c ria killing
e ia d a te l
 Le d to c nc p o p p
a s o e t f ro hyla xis

11. MIcrobIology
 Staphylococcus aureus (3 -4 %)
0 0
 Virid nsg ups p c c i (18
a ro tre to o c %)
 Ente c c i (11%)
ro o c
 C a ula e g tives p
o g s -ne a ta hylo o c (11%)
c ci
 Streptococcus bovis (7%)
 Othe s p c c i (5
r tre to o c %)
 No n-HAC Gra ne a s(2
EK m g tive %)
 HAC Org nis s(2
EK a m %)
 Fung (2
i %)
 “ ulturene a ” -2 %)
C g tive (2 0

12. Streptococcus Viridans
 Ora o in
l rig
 9 % c ra
0 ure te
 3 % c m lic tio
0 o p a ns

13. Strep. Gallolyticus (Bovis)
 GI le io
s ns
 C c lo
A o n
 c lo s o y o b riume m s uldb p rfo e
o no c p r a ne a ho e e rm d

14. Strept. Pneumoniae
 Rare
 Typ a ha fulm nt c urs
ic lly s ina o e
 As o ia d ep riva
s c te e lvula a s e s
r bcs
 As o ia d ep ric rd
s c te e a itis
 Ao va typ a invo d
rtic lve ic lly lve
 H/O a o l a us
lc ho b e
 C nc nt m ning in ~ 70
o urre e itis %

15. Group B strep ( agalactiae)
 Ris fa to ( DM, live fa
k c rs r ilure e c
, le tivea o n,
b rtio
c rc m , a o lis a d a us )
a ino a lc ho m nd rug b e
 As o ia d w villo a e m o thec lo
s c te ith us d no a f o n
 Mo lity is5 %
rta 0

16. Enterococcus
 Affe tso e m n a r GU m nip tio
c ld r e fte a ula ns
 Affe ts yo e w m n a r o s Ma ula ns
c ung r o e fte b t. nip tio
 4 % no o vio und rlyinghe rt d e s .
0 b us e a is a e
 9 % d ve p ahe rt m ur.
5 e lo a urm
 P rip ra s m taa unc m o
e he l tig a re o m n.

17. Staph aureus
 Fulm nt c urs .
ina o e
 W es re d m ta ta infe tio e m c rd l
id p a e s tic c ns .g yo a ia
a s es s p
b c s e , urule p ric rd , va ringa s e s s a
nt e a itis lve b c s e , nd
p rip ra a s e s sin b in, kid ys s le n.
e he l b c s e ra ne , p e
 4 % c nc o d a
0 ha e f e th.
 1/3ne lo ic l m nife ta nse he ip g .
uro g a a s tio .g m le ia
 Them s c m o c us tiveo a min d a d ts
ot o mn a a rg nis rug d ic .
 Le ss ve in a d tstha no d ic .
s e re d ic n n-a d ts
 C a ula e– s p C m o in p s ticva
o g s ve ta h. o m n ro the lve
e o a itis
nd c rd .

18. Gram –ve endocarditis
 E.gg m– b c ( HAC
ra ve a illi EK, e ro a te a ).
nte b c ric e
 Inc a e ris in d a d ts e e p s ticva s
re s d k rug d ic , ld rly, ro the lve
a c
nd irrho .
tic
 C isc m o
HF o m n
 P g s isp o
ro no is o r
 Mo lity ~ 8 %
rta 0

19. Salmonella species
 Va lvula p rfo tio
r e ra ns
 Atria thro b
l mi
 Myo a itis
c rd
 p ric rd
e a itis

20. Serrata marcescenses
 No d m inly in d a us rs
te a rug b e
 Typ a invo m l a a rticva
ic lly lve itra nd o lve
 La e ve e tio a ne r to l o c io o theva
rg g ta n nd a ta c lus n f lvular
o e
rific
 Ab e eo s nific nt und rlyingva
s nc f ig a e lvula d s tio
r e truc n

21. Pseudomonas
 Druga d ts
d ic
 Affe tsno a va s
c rm l lve
 Ma r e b licp no e
jo m o he m na
 Ina ility tos rilizeva s
b te lve
 Ne lo icc m lic tio
uro g o p a ns
 Ringa and nnula a s e s s
r b c se
 Sp nica s e s s
le b c se
 P g s iveC
ro re s HF
 As o ia d w theus o P nta c a
s c te ith e f e zo ine nd
Trip le m
le nna ine

22. Fungal endocarditis
 Inc a e ris in d a d ts im uno o ro is d b a
re s d k rug d ic , m c m m e , ro d
s e truma io s C c the rs
pc ntib tic , V a te .
 C nd ap rp ilo isa c nd atro ic lisp d m tein
a id a s s nd a id p a re o ina
inje tingd a us rs
c rug b e .
 C nd aa ic nsa a p rg
a id lb a nd s e illusno ruga d ts
n-d d ic
 P o p g s d to
o r ro no is ue
 La e b
rg , ulky ve e tio , inva io o m c rd
g ta ns s n f yo a ium
 W es re d s p e b li
id p a e tic m o
 P o p ne tio o a
o r e tra n f ntifung l a e into ve e tio
a g nts g ta ns
 -veb o c
lo d ulures
 Mo lity >8 % fo m ld a > 4 % fo ye s
rta 0 r o s nd 0 r a ts

23. Q fever ( Coxiella burnetii)
 Mo t p tie ha und rlyinghe rt d e s .
s a nts ve e a is a e
 C nicp s nta n.
hro re e tio
 Exp s toa a a itsp d ts
o ure nim ls nd ro uc .
 H/O influe -likeillne s6 m nthsp vio ly.
nza s -12 o re us
 m jo o c s so c in p s ticva s
a rity f a e c ur ro the lve
 C m o a c a rticva
o m nly ffe ts o lve
 As o ia d w he a s le m g ly, thro b c p nia
s c te ith p to p no e a m o yto e ,
hyp rg m a lo ule m a im unec m le
e a m g b ne ia nd m o p x
g m rulo p
lo e ne hritis .

24. Culture –ve endocarditis
 <5%
 Re e a m tra n o a io s
c nt d inis tio f ntib tic .
 Slo g w e HAC
w ro th .g EK
 Fung l e o a itis
a nd c rd .
 No ultura leintra e r m ro rg nis s(e
n-c b c llula ic -o a m .g
Ba ne s e ie , c m ia T. w p i).
rto lla p c s hla yd , hip le
 Ma ntice o a itis
ra nd c rd .

25. characterIstIcs of causatIve organIsMs
 Ad re efa to c a fo g w in the
he nc c rs ritic l r ro th
ve e tio
g ta n
 C n a he to d m g d va s(Sta h, Stre a
a d re a a e lve p p nd
Ente c c i ha a he instha m d tea c e
ro o c ve d s t e ia tta hm nt)
 Sta h a he in b sfib
p d s ind rino e a fib ne tin
g n nd ro c
 Ba te trig e tis ue c r p d tio fro lo a
c ria g r s -fa to ro uc n m c l
m no yte a ind ep te t a g g tio s the
o c s nd uc la le g re a n o
o a m b c m e lo e in theve e tio
rg nis s e o e nve p d g ta n
 P te tio fro im unec a nc le d to la e
ro c n m m le ra e a s rg
num e o b c ria(10 -10 p r go tis ue
b rs f a te 9 10
e f s )

26. rIsk factors
 Struc l he rt d e s
tura a is a e
 Rhe a , c ng nita a ing
um tic o e l, g
 P s tiche rt va s
ro the a lve
 Inje te d us
c d rug e
 Inva ivep c d s(?
s ro e ure )
 Ind e
w llingva c r d vic s
s ula e e
 Othe infe tio w b c re ia(e . p um nia
r c n ith a te m .g ne o ,
m ning )
e itis
 His ry o infe tivee o a itis
to f c nd c rd

27. clInIcal ManIfestatIons
 Sym to s
p m
 Fe r, s e ts c
ve w a , hills
 Ano xia m la e w ig lo s
re , a is , e ht s
 Signs
 Ane ia(no o hro ic no o ytic
m rm c m , rm c )
 Sp no e a
le m g ly
 Mic s o iche a
ro c p m turia p te
, ro inuria
 Ne o c ng
w r ha inghe rt m ur, C
a urm HF
 Em o o im uno g d rm to g s ns
b lic r m lo ic e a lo ic ig
 Hyp rg m a lo uline ia e va d ESR, C , RF
e a mg b m , le te RP

29. cardIac pathologIc changes
 Ve e tio o va c s line
g ta ns n lve lo ure s
 De truc n a p rfo tio o va le fle
s tio nd e ra n f lve a t
 Ruptureo c rd ete ina , intra ntric r s p ,
f ho a nd e ve ula e tum
p p ry m c s
a illa us le
 Va ringa s e s
lve bcs
 Myo a ia a s e s
c rd l b c s
 C nd tio a no a s
o uc n b rm litie

30. S. Aureus mitral valve vegetation, anterior
leaflet

33. pathologIc changes
 Kid y
ne
 Im unec m le g m rulo p
m o p x lo e ne hritis
 Em o w infa tio a s e s
b li ith rc n, b c s
 Ao m o a urys s
rtic yc tic ne m
 C re ra e b lis
e b l mo m
 Infa tio a s e s m o a urys s
rc n, b c s , yc tic ne m
P urule m ning isra
nt e itis re

34. pathologIc changes
 Sp nice rg m nt, infa tio
le nla e e rc n
 Se tico b ndp o ry e b lis
p r la ulm na m o m
 Skin
 P te hia
e c e
 Os r no e : d
le d s iffus infiltra o ne p , a
e te f utro hils nd
m no yte in thed rm l ve s lsw im unec m le
o c s e a s e ith m o p x
d p s n. Te e a e
e o itio nd r nd rythe a us
m to
 J ne a le io : s p e b li w b c ria
a w y s ns e tic m o ith a te ,
ne p a S.C he o g a ne ro is
utro hils nd m rrha e nd c s .
Bla hinga no nd r. P lm a s le
nc nd n-te e a s nd o s

39. case defInItIon
 19 P lle r a P te d rf c ria
77 e tie nd e rs o rite
 19 1 vo Re c ria
8 n yn rite
 19 4Dukec ria
9 rite
 2 0 Mo ifie Dukec ria
00 d d rite

40. ModIfIed duke crIterIa
 Ma r C ria
jo rite
P so itiveb o c
lo d ulture w typ a o a m
s ith ic l rg nis s
 P rs te
e is ntly p so itiveb o c
lo d ultures
 Evid nc o End c rd l invo m nt
e e f o a ia lve e
 P s
o itiveEc c rd g m
ho a io ra
 Os illa
c tingintra a ia m s
c rd c a s
 Ab c s
s es
 De c nc o p s ticva
his e e f ro the lve
 Ne Va
w lvula re urg tio
r g ita n

41. ModIfIed duke crIterIa
 Mino C ria
r rite
 P d p s n (va
re is o itio lvula d e s o IDU)
r is a e r
 Fe r
ve
 Va c r p no e (Arte l e b li, s p p
s ula he m na ria m o e tic ulm na
o ry
infa ts intra ra l he o g , Os r, J ne a
rc , c nia m rrha e le a w y)
 Im uno g p no e (GN, Os r, Ro s o ,
m lo ic he m na le th p ts
Rhe a idFa to
um to c r)

42. ModIfIed duke crIterIa
 De finiteIE
 P tho g c ria
a lo ic rite
C linic l c ria
a rite
 2Ma r C riaOR
jo rite
 1 Ma r a 3m r C riaOR
jo nd ino rite
 5Mino C ria
r rite
 P s ib IE
o s le
 1 Ma r a 1 Mino OR
jo nd r
 3Mino r
 Re c dIE
je te

44. blood cultures
 MULTIP BLOOD C
LE ULTURES BEFORE EMPIRIC
THERAP Y
 If no c a ill
t ritic lly
 3b o c
lo d ulture o r 12 4ho p rio
s ve -2 ur e d
 ?De y the p until d g s c nfirm d
la ra y ia no is o e
 If c a ill
ritic lly
 3b o c
lo d ulture o r o ho
s ve ne ur
 No m retha 2fro s m ve unc
o n m a e nip ture
 Re tive c ns nt b c re ia
la ly o ta a te m

45. “culture negatIve” Ie
 Le sc m o w im ro db o c
s o m n ith p ve lo d ulturem tho s e d
 Sp c l m d re uire
e ia e ia q d
 Bruc lla Myc p s a C m ia His p s a
e , o la m , hla yd , to la m ,
Le io lla Ba ne
g ne , rto lla
 Lo e inc a n m y b re uire
ng r ub tio a e q d
 HAC EK
 Coxiella burnetii (Q Fe r), Trophyrema whipplei w
ve ill
no g win c ll-fre m d
t ro e e e ia

46. hacek
 Haemophilus aphrophilus, H. paraphrophilus,
parainfluenzae
 Actinobacillus actinomycetemcomitans
 Cardiobacterium hominis
 Eikenella corrodens
 Kingella kingae

47. other MIcrobIologIc Methods
P R
C
 Coxiella burnetii
 Tropheryma whipplei
 Bartonella henselae
 Se lo y
ro g
 Coxiella burnetii
 Bartonella
 Brucella
 Legionella
 Chlamydophila psittaci

48. echocardIography
 Tra tho c
ns ra ic
 Re tive lo s ns
la ly w e itivity
 Go d s e ific
o p c ity
 Tra e o ha e l
ns s p g a
 De c n o va ringa s e s(8
te tio f lve b c s 7% vs 2 % s ns
. 8 e itivity for
TTE)
 De c n o p s ticva IE
te tio f ro the lve

49. When to go to tee fIrst?
 Lim dtho c w o s= TTE lo s ns
ite ra ic ind w w e itivity
 P s ticva s
ro the lve
 P r va
rio lvula a no a
r b rm lity
 S. aureus b c re iaa s p c dIE
a te m nd us e te
 Ba te m w o a m like toc us IE
c re ia ith rg nis s ly a e
= hig p r p b b
h rio ro a ility o IE
f

50. other tests
 Ele tro a io ra
c c rd g m
 C nd tio d la
o uc n e ys
 Is he iao infa tio
c m r rc n
 C s X-ra
he t y
 Se tice b li in rig id d IE
p mo ht-s e
 Va c lc a n
lve a ific tio
C HF

51. treatMent of Ie
 Na tivevs P s ticVa
. ro the lve
 Ba te id l the p isne e s ry
c ric a ra y c sa
 Era ic tio o b c riain theve e tio
d a n f a te g ta n
 Ma b m ta o a ina tive(s tio ry p s )
y e e b lic lly c ta na ha e
 Ma ne d hig r c nc ntra nso a
y e he o e tio f ntim ro ia a e
ic b l g nts

52. antIMIcrobIal therapy
 Mo t p tie a a b in 3 d ys
s a nts re fe rile -5 a
 Lo d tio o the p (4 w e o m re
ng ura n f ra y -6 e ks r o )
 C m ina n the p m s im o nt fo
o b tio ra y o t p rta r
 Sho r c urs re im ns
rte o e g e
 Ente c c a e o a itis
ro o c l nd c rd
 P s ticva infe tio
ro the lve c ns

53. natIve valve Ie
 Virid nsStre to o c a S. bovis
a p c c i nd
 Aq o P nic
ue us e illin G 12 0m n units a c ntinuo ly
-2 illio /d y o us
o d e q o q fo 4w e
r ivid d 4 r 6 r e ks
 If inte e ia s c p ility to p nic
rm d te us e tib e illin, a ue us
q o
p nic
e illin G 2 m n unitso c ftria ne2gq 4
4 illio r e xo 2
P LUS a ino lyc s efo thefirs 2w e
m g o id r t e ks

54. natIve valve Ie
 Am g o id sfo s rg
ino lyc s e r yne y
 Lo c nc ntra nsa a e ua (1-3m g l)
w o e tio re d q te c /m
 Ge m in 3m /kgd
nta ic g ivid dq o q
e 12 r 8
 Littled tafo q 4d s
a r 2 o ing

55. natIve valve Ie
 Ente c c i, a p illin s ns
ro o c m ic e itive
 Hig ra so fa
h te f ilure
 β-la ta sa b c rio ta , m t c m inew
c m re a te s tic us o b ith
a ino lyc s efo o tim l the p
m g o id r p a ra y
 Hig h-le l g nta ic re is nc o c in 3 %
ve e m in s ta e c urs 5
 Hig o ea p illin fo 8 w e
h-d s m ic r -12 e ks
 Ente c c i, a p illin re is nt
ro o c m ic s ta
 Va o yc p g nta ic
nc m in lus e m in
 Ente c c i, va o yc re is nt
ro o c nc m in s ta
 Line lid o d p m in
zo r a to yc
 P nic
e illin + va o yc + g nta ic ?
nc m in e m in

56. natIve valve Ie
 S. aureus
 P nic
e illina e s ta s m ynthe p nic
s -re is nt e i-s tic e illin
(o c
xa illin o na illin) 1.5 gIV q o c p lo p rin
r fc -2 4 r e ha s o
(c fa lin 1-2gIV q ) fo 4 w e
e zo 8 r -6 e ks
 Am g o id s rg ticb d e no a c s
ino lyc s e yne is ut o s t ffe t urviva l,
no re o m nd d
t cm e e
 Sho c urs in rig id d IE
rt o e ht-s e
 2w e o s m ynthe p nic
e ks f e i-s tic e illin a a ino lyc s e
nd m g o id

57. natIve valve Ie
 Me illin-re is nt S. aureus
thic s ta
 Va o yc isb c rio ta
nc m in a te s tic
 Va o yc p a ino lyc s eo rifa p
nc m in lus m g o id r m in
 Da to yc
p m in
 Line lid
zo

58. natIve valve Ie
 HAC EK
 C ftria ne2gIV q 2 x 4 w e
e xo 4 -6 e ks
 Fung l
a
 Am ho ric
p te in
 Fluc na le
o zo
 Cso
a p fung littled ta
in, a
 Surg ry us lly ne e s ry 1-2w e into tre tm nt
e ua c sa e ks a e

59. natIve valve Ie
 Ind a nsfo s e
ic tio r urg ry
 Re c ry C
fra to HF
 Mo tha o s te ice b lice nt
re n ne ys m m o ve
 Unc ntro d infe tio
o lle c n
 P io g a s nific nt va
hys lo ic lly ig a lvula d func n
r ys tio
 Ine c
ffe tiveantim ro ia the p (e . fung l)
ic b l ra y .g a
 Lo a s p tivec m lic tio
c l up ura o p a ns
 Myc tica urys
o ne m

60. prosthetIc valve Ie
 Sta hylo o c m s c m o
p c ci ot o mn
 C a ula ene a
o g s g tives pta hylo o c
cci
 Ente c c us
ro o c
 Nutrito lly va nt s p c c i
na ria tre to o c
 Fung i

61. prosthetIc valve Ie
 Ris isg a s in thefirs 3m nthsa firs ye r (e rly
k re te t t o nd t a a
P IE)
V
 C a ula e g tives p
o g s -ne a ta hylo o c in e rly e o a itis S.
cci a nd c rd ,
aureus
 La -o e m res ila to na
te ns t o im r tiveva d e s in
lve is a e
m ro io g b m rec a ula e g tives p
ic b lo y ut o o g s -ne a ta hylo o c
c c i.
Va ise o lia d
lve nd the lize

62. prosthetIc valve Ie
 TEE s uldb us d firs
ho e e t
 Sta hylo o c
p cci
 Va o yc o o c
nc m in r xa illin p rifa p in fo a le s s
lus m ic r t a t ix
w e , g nta ic fo thefirs tw w e (3m /kgq 4
e ks e m in r t o e ks g 2)
 Rifa p in s rte a le s 2d ysa r 2o r a e to
m ic ta d t a t a fte the g nts
a idre is nc
vo s ta e

65. prophylaxIs of Ie
 Unc rta
e inty a c ntro rs
nd o ve y
 No ra o ize tria
nd m d ls
 Ind c e e e(unc ntro dc
ire t vid nc o lle linic l s rie , c s -
a e s ae
c ntro s ie )
o l tud s
 De is n a lys
c io na is

70. clInIcal case
 4 yrsm n ESRD, C d ve Re l Tra p nt 2 0
3 a a a ric na ns la 0 4
 Re urre UTIs p c m nt o ne hro to y tub
c nt , la e e f p s m e
 Fe rs c , a re m nta s tus s p iss ro e
ve , hills lte d e l ta , e s ynd m
 Bra yc rd to3 a inc a e P
d a ia 5 nd re s d R

71.  Urinew MRSA, 4 b o c
ith /4 lo d ulture w MRSA
s ith
 Initia TTE: EF 3 -4 %, thic ne AV w m d ra AS,
l 5 5 ke d ith o e te
thic ne o c lc dMV m MR
ke d r a ifie ild
 “ m a d w la t p vio e ho the isno s nific nt c ng .
Co p re ith s re us c , re ig a ha e
In thep s nc o va
re e e f lvula thic ning c nno ruleo e o a itis
r ke , a t ut nd c rd .
 Ne d y TEE
xt a
 thic ne AV, m to m d ra AS, no AR. 2ve e tio ~1 c
ke d ild o e te g ta ns m
o ve
n ntric r s e
ula id
 Ma d thic ne MV, la em b ve e tio >4 mo a l
rke ly ke d rg o ile g ta n c n tria
s ea rio le fle p s ib s c nd ve e tio o p s rio le fle
id nte r a t, o s le e o g ta n n o te r a t,
m MR
ild

72.  Re l a g ft re o dthefo w d y w a s e s
na llo ra m ve llo ing a ith b c s
 Re la e e o AV a MV a re e tio o le
p c m nt f nd nd s c n f ft
ventric r a s e sc vity tw d ysla r
ula b c s a o a te