EINSTEIN-Jr clinical trials of Rivaroxaban in children
Rivaroxaban is useful for treatment of venous thromboembolism in adults and is associated with lower risk of bleeding compared to standard anticoagulants. EINSTEIN-Jr phase 2 used bodyweight adjusted rivaroxaban for children with venous thromboembolism [1]. It was a single arm multicenter study three age groups – children younger than 6 months, those in age group 6 months to 5 years and in children and adolescents between 6-17 years. Studies were done at 54 sites across Australia, Europe, Israel, Japan and North America. The study was in children with confirmed venous thromboembolism who have been treated for at lea...
Source: Cardiophile MD - November 25, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: General Cardiology Source Type: blogs

INTERMACS classification for advanced heart failure
INTERMACS classification for advanced heart failure was developed as a sub classification for advanced heart failure, typically for those in advanced NYHA (New York Heart Association) Functional Class III and IV. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) developed this classification with seven clinical profiles and an arrhythmia modifier [1].  This was to allow optimal selection of patients for medical and pacing therapies, cardiac transplantation and mechanical circulatory support. They found that 80% of current devices are being used in 2 profiles with the highest level of clin...
Source: Cardiophile MD - November 24, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: General Cardiology Source Type: blogs

Important aspects in the management of neurocardiogenic syncope
Neurocardiogenic syncope is the most common cause of syncope. Initial measures in management include lifestyle modifications, increasing the fluid and salt intake and education about physical counterpressure methods. Pharmacological measures may be tried next. Pacemaker implantation has been tried in those with predominantly cardioinhibitory syncope [1]. Physical counterpressure measures are movements like leg crossing and hand gripping which may prevent loss of consciousness in those who feel the presyncopal symptoms. These measures increase the systemic vascular resistance and blood pressure to counter the vasodepressiv...
Source: Cardiophile MD - November 20, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: General Cardiology Source Type: blogs

Drug coated balloons in coronary artery disease
Drug coated balloons are a novel therapeutic option in certain situations of coronary artery disease. An established use of drug coated balloon is for in-stent restenosis of both bare metal and drug eluting stents [1]. Drug coated balloon transfers antiproliferative drugs into the vessel wall during single balloon inflation. This is done by means of a lipophilic matrix. The advantage over drug eluting stent is that there is no permanent implant. Drug eluting stents have the disadvantages of neo-atherosclerosis and stent thrombosis. Even temporary implants like bioresorbable scaffolds have elevated thrombotic risk. Drug co...
Source: Cardiophile MD - November 18, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Coronary Interventions Source Type: blogs

Is too much of exercise bad for you?
It is well known that regular exercise is good for the heart. Almost all guidelines recommend 150 minutes a week of moderate intensity physical activity. But like the old saying that too much of good things can be harmful, is too much exercise bad for you? The Copenhagen City Heart Study assessed the dose of jogging and long term mortality [1]. In the introduction of their article, they mentioned the historical anecdote of sudden death of Pheidippides, a professional running courier in 490 BC. It is believed that he ran from Marathon to Athens, Greece, approximately 25 miles to give the news of victory of Athens overs Per...
Source: Cardiophile MD - November 17, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: General Cardiology Source Type: blogs

Mitral valve area by pressure half time
Measurement of mitral valve area by pressure half time is an often applied method using Doppler echocardiography. Mitral valve area by pressure half time Mitral valve area can be calculated from the pressure half time (PHT) of the initial downward slope of the mitral A wave, which fuses with the E wave in mitral stenosis. Lower the slope, lower the mitral valve area and higher the severity of mitral stenosis. Pressure half time is the time taken for the gradient to reduce to half of its peak value. PHT 220 ms corresponds to a mitral valve area of 1 square centimeter. Here the PHT is 163 ms, hence mitral valve area will be...
Source: Cardiophile MD - November 13, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Echocardiography Source Type: blogs

Alcohol Ablation of Vein of Marshall for Persistent Atrial Fibrillation
Highly diagrammatic representation of coronary veins Vein of Marshall (VOM) is a tributary of the coronary sinus with abundant sympathetic and parasympathetic innervation. It has been implicated in the genesis and maintenance of atrial fibrillation (AF).  Three reasons described are the myocardial extensions into the structure, node like remnants within the vein and the rich autonomic innervation surrounding it [1] It is anatomically related to the mitral isthmus. Mitral isthmus is the region between the left inferior pulmonary vein ostium and the mitral annulus. Oblique vein of Marshall is the residua of the embryon...
Source: Cardiophile MD - November 6, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Mural endocarditis
Vegetations in infective endocarditis are usually situated on the valves. If they are located on the walls of the cardiac chambers, it is known as mural endocarditis [1]. When mural endocarditis occurs without any cardiac structural abnormalities like ventricular septal defects, it is called primary mural endocarditis [2]. Primary mural endocarditis is extremely rare. Left atrial mural endocarditis usually occurs due to the jet lesion of mitral regurgitation [1,3]. Left atrial mural endocarditis is usually picked up by trans esophageal echocardiography. Vegetations are mostly located just distal to the mitral orifice betw...
Source: Cardiophile MD - October 31, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: General Cardiology Source Type: blogs

Extremely high HDL – beneficial or harmful?
This study showed extremely high HDL was associated with lower risks for all-cause mortality and cardiovascular events compared to low HDL. But they had higher risks compared to very high HDL. Paradoxically high all-cause mortality in those with extremely high HDL has also been reported in another study of 52 268 men and 64 240 women [5]. Though most of these studies showed a negative role for extremely high HDL, there is recent study from Korea which showed that extremely high HDL was not associated with increased risk of mortality, myocardial infarction and stroke [6]. That study with 343,687 subjects also defined extrem...
Source: Cardiophile MD - October 20, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Systemic right ventricle – Cardiology MCQ – Answer
Systemic right ventricle – Cardiology MCQ – Answer Systemic right ventricle can be seen in all of the following except: Correct answer: 2. Following arterial switch operation for complete transposition of great arteries In arterial switch operation (Jatene procedure), normal anatomical relationship is restored by switching the aorta and pulmonary artery so that aorta arises from the left ventricle and pulmonary artery arises from the right ventricle. Hence it is a systemic left ventricle and pulmonary right ventricle. Systemic right ventricle is seen after atrial switch repair for complete transposition of...
Source: Cardiophile MD - October 11, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Potassium channel suppressed in hypokalemia – Cardiology MCQ – Answer
Potassium channel suppressed in hypokalemia – Cardiology MCQ – Answer Potassium channel suppressed in hypokalemia – Correct answer: 1. Ikr Prolongation of action potential duration in hypokalemia is due to inhibition of the outward potassium current. IKr, the rapid component of the delayed rectifier potassium current, is markedly suppressed in hypokalemia. There is rapid inactivation of IKr during repolarization. Downregulation of IKr occurs in chronic hypokalemia. In addition chronic hypokalemia causes internalization of IKr channels, reducing their surface density on the plasma membrane. ...
Source: Cardiophile MD - October 9, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Bromocriptine has been shown to be useful in all except – Cardiology MCQ – Answer
Bromocriptine has been shown to be useful in all except:  Correct answer: 3. Peripheral arterial disease Bromocriptine is used for suppression of lactation and in the treatment of Parkinsonism. It has been shown to be useful in type 2 diabetes mellitus as well. Recent studies have shown its benefit in peripartum cardiomyopathy [1]. Being an ergot derivative, one of the adverse effect noted in the study was peripheral arterial occlusion. 16kDa prolactin subunit has been shown to produce endothelial dysfunction cardiac muscle cell dysfunction in experimental studies. Prolactin can promote inflammation in peripartum...
Source: Cardiophile MD - October 6, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: General Cardiology 16kDa prolactin subunit peripartum cardiomyopathy Prolactin and peripartum cardiomyopathy. Prolactin can promote inflammation in peripartum cardiomyopathy Source Type: blogs

Most important cardiotoxicity of immune checkpoint inhibitors – Cardiology MCQ – Answer
Most important cardiotoxicity of immune checkpoint inhibitors – Answer Cardiotoxicity of immune checkpoint inhibitors – Correct answer: 1. Fulminant myocarditisImmunotherapy with immune checkpoint inhibitors is becoming standard of care for multiple types of malignancies. Important immune checkpoint inhibitors are ipilimumab which acts against cytotoxic T lymphocyte-associated antigen 4 (CTLA-4); nivolumab and pembrolizumab which act against programmed cell death 1 (PD-1) and atezolizumab which targets PD-1 ligand (PD-L1). Autoimmune fulminant myocarditis has been described in persons treate...
Source: Cardiophile MD - October 4, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Right Heart Catheters
Right heart catheterization was the initial type of cardiac catheterization introduced by Werner Forssmann in 1929, who did self-catheterization [1]. But later, with development of coronary interventions, it became less commonly done. Now there is a renewed interest as it is useful in the evaluation of pulmonary hypertension [2] and heart failure as well as in congenital heart diseases. Though the catheter used by Forssmann was a ureteral catheter, dedicated right heart catheters came into use later.  Cournand catheter is a right heart diagnostic catheter named after the Nobel laureate André Cournand, who shar...
Source: Cardiophile MD - September 16, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Intravascular Lithotripsy for Severely Calcified Coronary Arteries
Intravascular lithotripsy uses acoustic pressure waves to modify calcium inside the blood vessels, increasing the compliance of the vessel and facilitates stent deployment [1]. The device takes care of one of the important night mares of an interventionalist, the calcified coronaries! Disrupt CAD III was a prospective multicenter study for the regulatory approval of intravascular coronary lithotripsy [1]. Optical coherence tomography (OCT) was used to assess the mechanism of modification of calcium in a substudy. Primary safety endpoint of Disrupt CAD III was freedom from major adverse cardiovascular events (MACE) of card...
Source: Cardiophile MD - September 15, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Laser atherectomy
Laser atherectomy is a novel technique useful in in-stent restenosis, stent under expansion, balloon uncrossable lesions and chronic total occlusions [1]. An important advantage of excimer laser atherectomy over other atherectomy devices is delivery on a standard 0.014-inch guidewire [2]. The technique can be mastered after a short period of training. Major limitation is the presence of heavy calcification, which requires rotational atherectomy for clearance. But when there is inability to pass a rota wire, laser may be useful in creating an upstream channel to permit rota wire passage. Laser device works by producing mon...
Source: Cardiophile MD - September 11, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Dark Chocolates and the Heart
Are dark chocolates good for the heart? A study published in Circulation suggests that eating dark chocolate can improve coronary vasomotion and reduce platelet reactivity [1]. Dark chocolates which contain 70% cocoa have lots of flavonoids – potent antioxidants which helps to overcome the oxidative stress. They also decrease the activation of blood platelets responsible for thrombosis. High oxidative stress and limited availability of antioxidants can cause endothelial damage in the arteries, leading to increased chances for a thrombosis. Flavonoid rich dark chocolate has the potential for a beneficial effect on gr...
Source: Cardiophile MD - September 7, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

EMPEROR-Preserved Clinical Trial Review
EMPEROR-Preserved Clinical Trial is an important study which has shown benefit in patients with heart failure and a preserved ejection fraction (HFpEF) [1]. It was a double blind randomized trial in which 5988 patients with class II-IV heart failure and ejection fraction above 40% were allocated to receive empagliflozin 10 mg daily or placebo, in addition to usual therapy. The median ejection fraction noted in the study patients was 54%, with two thirds of patients having a left ventricular ejection fraction of 50% or more. Primary outcome measure in the study was a composite of cardiovascular death or hospitalization for...
Source: Cardiophile MD - September 2, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Temporary Pacemaker Settings
Related topics: Temporary pacing Temporary pacing ECG Temporary pacing electrode Here we will discuss the basic temporary pacemaker settings. The controls and buttons shown here are symbolic and vary between different models of the pacemakers. Some pacemakers have a display of the modes and parameters in addition. This description is on commonly used single chamber temporary pacemaker. Dual chamber temporary pacemakers will have additional controls and displays. Temporary Pacemaker Settings We will start off by switching on the pacemaker using the on/off button. The display lights up in case of pacemakers with a disp...
Source: Cardiophile MD - August 26, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Triboelectric pacemaker
Usually modern pacemakers are powered by built-in batteries and you need to replace the pulse generator when the battery reaches end of life. What if the device gets charged itself using energy of cardiac contractions? That is exactly what a triboelectric pacemaker powered by cardiac contractions aims to achieve. Triboelectric effect is typically the static electricity which is generated when a plastic comb is used on dry hair. Researchers have tested a symbiotic cardiac pacemaker which uses an implantable triboelectric nanogenerator (iTENG) which harvests energy from cardiac contractions and stores in a capacitor [1...
Source: Cardiophile MD - August 25, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Features of Wenckebach Phenomenon
Progressive prolongation of PR interval followed by missing of a QRS complex is the classical manifestation of Wenckebach Phenomenon or Wenckebach AV block. Features of Wenckebach Phenomenon The increments in PR interval in each successive beat is decremental. This produces progressive shortening of RR intervals. Features of Wenckebach Phenomenon – Shortening of RR Interval The shortest RR interval is in the beat preceding the pause. The longest RR interval is less than twice the shortest RR interval. Features of Wenckebach Phenomenon – Shortest and Longest RR Interval Highest grade of Wenckebach AV block poss...
Source: Cardiophile MD - August 25, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Public access defibrillation
This study showed that trained lay persons can use AEDs safely and effectively. Nationwide dissemination of public access AEDs in Japan was reported in 2010 [1]. 312,319 adults who had out-of-hospital cardiac arrest were included in the study. 12,631 of these patients had ventricular fibrillation and cardiac origin witnessed cardiac arrest. 462 were administered shocks by lay persons with public access AEDs. Though this gave an average percentage of 3.7%, the percentage increased from 1.2% to 6.2% as the number of public access AEDs increased. 14.4% of those with witness cardiac origin cardiac arrest were alive at 1 month ...
Source: Cardiophile MD - August 17, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Reverse Potts Shunt for Pulmonary Arterial Hypertension in Children
Potts shunt was a surgical anastomosis between left pulmonary artery and descending aorta to improve pulmonary blood flow in cyanotic congenital heart disease with decreased pulmonary blood flow. It is a systemic to pulmonary shunt. The report was published one year after the Blalock-Taussig shunt which was also used for a similar purpose [1]. Later Potts shunt like other central aortopulmonary shunts, were discontinued because of higher risk of excessive pulmonary blood flow. A modified Blalock-Taussig shunt is still in use. Reverse Potts shunt is a pulmonary to systemic shunt for relieving pulmonary arterial hypertensio...
Source: Cardiophile MD - August 4, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Classification of TAPVC
Total anomalous pulmonary venous connection (TAPVC) has been classified into four types by Craig JM, Darling RC and Rothney WB in 1957 [1]. It is popularly known as Darling classification. According to this classification, TAPVC is divided into four types based on the anatomic site of the anomalous connection. Type 1 is a supracardiac, type 2 is an intracardiac, type 3 is infracardiac and type 4 a mixed variety. This is the most commonly used classification. In the supracardiac variety, the four pulmonary veins drain into a common venous chamber which drains to the left brachiocephalic vein through a vertical vein. In typ...
Source: Cardiophile MD - July 31, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

IMPROVE VTE risk score and modified IMPROVE VTE risk score
IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) score is a weighted VTE (Venous Thromboembolism) risk score designed for medically ill patients [1], which has been externally validated [2]. While formulating the IMPROVE VTE risk score, data from 15,156 medically ill patients were analyzed to find the cumulative incidence of VTE over a 3 month period after admission [1]. Of the 184 patients who developed symptomatic VTE, 67 had lower extremity DVT (deep vein thrombosis) and 76 had pulmonary embolism. Weightage given was 3 points for previous VTE, 2 points for known thrombophilia, 2 points eac...
Source: Cardiophile MD - July 30, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Cardiac memory
Cardiac memory is the persistence of T wave changes in the ECG after normalization of a wide QRS rhythm [1]. It is a remodeling phenomenon of cardiac repolarization when there is a change in the ventricular depolarization for a period of time. It can occur after ventricular pacing, transient bundle branch block, intermittent pre-excitation, ventricular tachycardia or frequent ventricular premature beats [2]. The term cardiac memory was introduced by Rosenbaum MB et al in 1982 [3]. That seminal work showed that T wave changes may persist for days or weeks after the provoking stimulus which causes the change in activation s...
Source: Cardiophile MD - July 25, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Z- score classification of coronary aneurysms in Kawasaki disease
Z-score is the standard deviation from coronary artery internal lumen diameter normalized for body surface area. AHA classification of coronary artery aneurysms based on Z-score is as follows [1]: 1. No involvement with Z score less than 2 always. 2. Dilatation only with Z scores from 2 to less than 2.5 or a decrease in Z score of 1 or more during follow up if it was less than 2 initially. 3. Small aneurysm with Z score of more than 2.5, but less than 5. 4. Medium aneurysm with Z score 5 or more, but less than 5 and absolute dimension less than 8 mm. 5. Large or giant aneurysm with Z score 10 or more or absolute dimension...
Source: Cardiophile MD - July 24, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Virtual native enhancement instead of late gadolinium enhancement
Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging is considered the gold standard for non-invasive myocardial tissue characterization [1]. Artificial intelligence was used to develop a CMR virtual native enhancement (VNE) imaging which does not need an intravenous contrast as in LGE. VNE uses a deep learning model with multiple streams of convolutional neural networks to enhance existing signals of native T1 maps and cine imaging of cardiac structure and function to produce LGE equivalent images. T1 maps are pixel wise maps of tissue T1 relaxation times. The technology was developed in CMR ...
Source: Cardiophile MD - July 22, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Machine Learning and AI in Cardiology Source Type: blogs

Vaccine associated myocarditis revisited with COVID-19 mRNA vaccines
When I had reviewed the topic of vaccine associated myocarditis for an editorial in the BMH Medical Journal in 2017, most of the cases were associated with small pox vaccination [1]. There were also reports of streptococcal pneumonia vaccine and influenza vaccine associated myocarditis. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) used in the vaccine were also implicated in some cases [2,3]. While the large scale vaccination for small pox in an attempt to prepare for potential bioterrorism was the association in 2003 [4], COVID-19 mRNA vaccines are currently in the limelight for vaccine induced myocarditis...
Source: Cardiophile MD - July 22, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

P2-CHA2DS2-VASc Score
P2-CHA2DS2-VASc score adds additional two points to the CHA2DS2-VASc score for an abnormal P wave axis to predict risk of stroke in atrial fibrillation (AF) [1]. The seminal study was an attempt to identify utility of P wave indices in sinus rhythm to predict the risk of stroke over and above the existing CHA2DS2-VASc score. P wave indices evaluated were prolonged P wave duration, abnormal P wave axis, advanced interatrial block and abnormal P wave terminal force in lead V1. They found that abnormal P wave axis which is an ECG correlate of left atrial abnormality improves the prediction of ischemic stroke. They concluded ...
Source: Cardiophile MD - July 21, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Role of history in the evaluation of syncope
A detailed history is very useful in the evaluation of many cardiac disorders, more so in the assessment of syncope. In some of the causes for syncope, only diagnostic clue will be from the history. Associated symptoms like nausea, sweating, pallor, abdominal discomfort and yawning are usually considered features of neurally mediated syncope [1]. Evaluation of syncope can be difficult as one previous study has shown that the cause remained unknown in 97 of the 204 patients [2]. The situation might be better now because we have better diagnostic modalities including implantable loop recorders which are quite useful in eluc...
Source: Cardiophile MD - July 20, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Segmental approach to congenital heart disease
Segmental approach is used routinely in the echocardiographic evaluation of congenital heart disease. It is also useful in other cardiac imaging modalities used for evaluation of congenital heart disease like computed tomography and magnetic resonance imaging. Chest X-ray is useful in evaluating the cardiac position and visceral situs as it gives an overview of cardiac position in the thorax, position of left and right bronchi, aortic arch, liver and stomach air bubble [1]. Here is a chest X-ray in mesocardia with levo transposition of great arteries: X-ray chest PA showing mesocardia with L-TGA and L-posed aorta seen as ...
Source: Cardiophile MD - July 17, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Echocardiography Source Type: blogs

Treatment of infective endocarditis
Discussion of whole list of options of antimicrobials for different varieties of endocarditis is quite a large topic. This discussion is only a broad outline of the antimicrobial treatment of infective endocarditis, meant mainly for exam purpose rather than actual clinical treatment. References to more detailed guidelines have been provided for those who wish to learn more. Inoculum Effect High microbial density as in vegetations cause less antimicrobial activity of some antimicrobial agents. This is known as inoculum effect and has been documented with β-lactams and glycopeptides but not linezolid, in the treatment o...
Source: Cardiophile MD - July 16, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Shanghai score for Brugada syndrome
Shanghai score system for diagnosis of Brugada syndrome was proposed at J Wave Syndromes Consensus Conference held at Shanghai in 2015 [1]. Participants included members of Heart Rhythm Society, the European Heart Rhythm Association and the Asian-Pacific Heart Rhythm Society. It was based on available literature and clinical experience of members of the task force. Scores were based on ECG parameters, clinical history, family history and the results of genetic testing. Highest points in the score was for a spontaneous Type I Brugada ECG which had 3.5 points. A probable pathogenic mutation in Brugada syndrome susceptibilit...
Source: Cardiophile MD - July 9, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Aortic stenosis – TAVR (TAVI) vs SAVR
Aortic stenosis – TAVR (TAVI) vs SAVR As with other cardiac conditions, ACC/AHA guidelines divide aortic stenosis also into stages A to D. In stage A there are conditions which can lead on to aortic stenosis like bicuspid aortic valve or aortic valve sclerosis. Stage B is that of progressive mild – moderate aortic stenosis with leaflet calcification, fibrosis or commissural fusion. Stage C is asymptomatic severe aortic stenosis, which is subdivided into C1 without left ventricular systolic dysfunction and C2 with left ventricular systolic dysfunction with left ventricular ejection fraction (LVEF)
Source: Cardiophile MD - July 5, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Angiography and Interventions Cardiac Surgery Structural Heart Disease Interventions Source Type: blogs

Cardiology MCQs
Which of the following is an innocent murmur? Gibson’s murmur Roger’s murmur Still’s murmur Dock’s murmur Correct answer: 3. Still’s murmur Still’s murmur was described by George Frederic Still in 1909. This is a low pitched murmur heard in the lower left sternal area. It is best heard with the bell of the stethoscope. Still’s murmur is a mid systolic murmur, loudest in supine position and diminishes in intensity on sitting and standing as venous return decreases [Doshi AR. Innocent Heart Murmur. Cureus. 2018 Dec 5;10(12):e3689]. Gibson’s murmur is the train-in-tunnel murm...
Source: Cardiophile MD - July 5, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Cardiology MCQs
Modified Blalock-Taussig shunt is: End to side anastomosis of subclavian artery to a pulmonary artery Side to side anastomosis of main pulmonary artery to aorta Side to side anastomosis of subclavian artery to a pulmonary artery using a conduit Anastomosis of superior vena cava to right pulmonary artery Correct answer: 3. Side to side anastomosis of subclavian artery to a pulmonary artery using a conduit In classic Blalock-Taussig shunt, the subclavian artery is divided and anastomosed to the pulmonary artery as an end to side anastomosis. In modified Blalock – Taussig shunt, a Gore – Tex graft is used to co...
Source: Cardiophile MD - July 4, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Cardiology MCQs
Which of the following is NOT a drug used for metabolic modulation in heart failure? Trimetazidine Ranolazine Perhexiline Sacubitril-valsartan Correct answer: 4. Sacubitril-valsartan Sacubitril-valsartan is an angiotensin receptor-neprilysin inhibitor (ARNI). Trimetazidine is a 3-ketoacyl coenzyme A thiolase inhibitor, while ranolazine inhibits the late sodium current. Perhexiline inhibits carnitine palmitoyl transferase. Latter three are metabolic modulators while sacubitril-valsartan is a hemodynamic modulator in heart failure [Ashrafian H, Neubauer S. Metabolic modulation in heart failure: high time for a definitive ...
Source: Cardiophile MD - July 4, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Cardiology MCQs
Surgical correction for congenitally corrected transposition of great arteries is: Jatene operation Mustard operation Senning operation Double switch operation Correct answer: 4. Double switch operation Definitive surgical correction of c-TGA is known as double switch. Atrial switch is by a modified Senning procedure for rerouting the pulmonary and systemic venous return. Arterial switch is done for correction of ventriculoarterial discordance [Sharma R, Bhan A, Juneja R, Kothari SS, Saxena A, Venugopal P. Double switch for congenitally corrected transposition of the great arteries. Eur J Cardiothorac Surg. 1999 Mar;15(...
Source: Cardiophile MD - July 3, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Cardiology MCQs
Ischemic preconditioning is mediated by: ATP-sensitive potassium channel (KATP) Sodium channel Ikr, the rapid component of delayed rectifier potassium current L-type calcium channel Correct answer: 1. ATP-sensitive potassium channel (KATP) Blockers of ATP-sensitive potassium channel (KATP) like glibenclamide can prevent ischemic reconditioning. KATP channel opener nicorandil can mimic ischemic preconditioning and it is known as pharmacological preconditioning. Stimulation of adenosine receptors is known to simulate ischemic preconditioning. [Tomai F, Crea F, Gaspardone A, Versaci F, De Paulis R, Penta de Peppo A, Chiari...
Source: Cardiophile MD - July 2, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Ischemic preconditioning
The concept of ischemic preconditioning is that multiple short episodes of ischemia can protect the heart from a later sustained ischemia later [1]. In an experimental study, 4 episodes of 5 minutes each, separated by 5 minutes of reperfusion followed by 40 minutes of occlusion showed 75% reduction in infarct size compared to controls. But this benefit was not there when the final occlusion time was 3 hours. Authors suggested that multiple pre-infarction anginal episodes may have a similar effect on limiting infarct size if myocardial infarction occurs subsequently. Others have suggested that similar mechanism might opera...
Source: Cardiophile MD - July 1, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Percutaneous pulmonary valve implantation
Percutaneous pulmonary valve implantation has the elite distinction that it was first percutaneous intervention for a regurgitant lesion in humans [1]. Bonhoeffer P et al described the development of a system for percutaneous stent implantation combined with valve replacement for right ventricle to pulmonary artery prosthetic conduit with valve dysfunction [2]. They used it in a 12 year old boy with stenosis and regurgitation of a prosthetic conduit from right ventricle to pulmonary artery. Percutaneous implantation of bovine jugular valve in the conduit was achieved successfully in 2000. Echo, angio and hemodynamic asses...
Source: Cardiophile MD - June 28, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Angiography and Interventions Structural Heart Disease Interventions Source Type: blogs

Assessment of mitral stenosis by echocardiography
Colour Doppler Echocardiogram in Mitral Stenosis Right panel shows the parasternal long axis view. Doming of the anterior mitral leaflet is seen well and has the appearance of hockey stick. This appearance is classical of rheumatic mitral stenosis. Paradoxical movement of the posterior mitral leaflet is also visible. Normally posterior mitral leaflet moves posteriorly in diastole. Here there is a paradoxical anterior movement due to commissural fusion. Left atrium is dilated. Left panel shows parasternal short axis view. The mitral orifice is seen within the cross section of the left ventricle. The anterior and posterior ...
Source: Cardiophile MD - June 27, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Coronary venous circulation
Importance of knowing the coronary venous circulation has increased in recent years with use of cardiac resynchronization therapy (CRT) for heart failure. Left ventricular epicardial pacing in CRT is achieved by placing a lead in a coronary vein, usually a posterolateral tributary of the coronary sinus. Coronary venous circulation can be visualized by a coronary angiogram levophase. After filling the coronary arteries, the contrast drains into the coronary venous system, finally opacifying the coronary sinus, which drains into the right atrium. Here is a coronary angiogram levophase, with a line diagram beside it: Coronar...
Source: Cardiophile MD - June 26, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Right ventricular infarction
Right ventricular infarction can be associated with inferior wall infarction. It is due to occlusion of the right ventricular branches of the right coronary artery. The actual prevalence of right ventricular infarction may be underestimated because right sided chest leads are not part of routine 12 lead ECG. In a study which included right sided chest leads V3R, V4R, V5R and V6R, ST elevation of 1 mm or more in any of these leads was found to be a reliable sign of right ventricular involvement. It was a study of 67 patients who underwent serial electrocardiograms and 99mtechnetium pyrophosphate scintigraphy and a dynamic ...
Source: Cardiophile MD - June 25, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Congenitally corrected transposition of great arteries
Congenitally corrected transposition of the great arteries (CCTGA or cTGA) is a condition in which there is atrioventricular and ventricular arterial discordance so that the circulation is physiological. Congenitally corrected transposition of great arteries is also known as l-transposition of great arteries (l-TGA) because of the levo transposition of aorta. Levo posed aorta forms a hump along the left upper heart border on chest X-ray. The right atrium connects to the morphological left ventricle, which in turn connects to the pulmonary artery so that systemic venous blood reaches the pulmonary circulation. The left atr...
Source: Cardiophile MD - June 24, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Triangle of Koch
Triangle of Koch is situated on the right atrial aspect of the inter-atrial septum. It is bounded by the septal tricuspid leaflet, tendon of Todaro and the coronary sinus. The atrioventricular node is located at the apex of this triangle [1]. The initial description of the triangle was by Walter Koch in 1909 [2]. Knowledge of the Koch’s triangle is very important to safely perform radiofrequency catheter ablation within the right atrium. Ablation within the triangle of Koch has a risk of injury to the AV node and complete AV block [3]. Tendon of Todaro is a collagenous subendocardial band in the right atrium. It con...
Source: Cardiophile MD - June 23, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Percutaneous left ventricular assist devices
Two well known percutaneous left ventricular assist devices are Impella devices and the TandemHeart. Other mechanical circulatory support (MCS) devices which can be deployed percutaneously are the most familiar intra aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) [1]. Impella (Abiomed, Danvers, MA) is a catheter based microaxial flow pump. It is placed across the aortic valve into the left ventricle and actively pumps blood from the left ventricle into the aorta. This is how Impella unloads the left ventricle in cardiogenic shock. Impella 2.5 delivers an output of 2.5 l/min while Impella CP...
Source: Cardiophile MD - June 22, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Riociguat
Riociguat is a soluble guanylate cyclase stimulator useful in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary arterial hypertension (PAH). CHEST-1 trial was a phase 3, multicenter, randomized, double blind, placebo controlled study [1]. 261 patients with inoperable chronic thromboembolic pulmonary hypertension or persistent or recurrent pulmonary hypertension after pulmonary endarterectomy were randomly assigned to receive either placebo or riociguat. Primary end point of the study was the change in 6 minute walk distance from baseline to the end of 16th week. Secondary end points were...
Source: Cardiophile MD - June 22, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Paradoxical splitting of second heart sound
Normal split of second heart sound is due to the delay in pulmonary valve closure compared to aortic valve. This is mostly contributed to by the pulmonary hang out interval. Hang out interval is the time taken for the actual valve closure after the pulmonary artery and right ventricular pressure tracings crossover. Normal split of second heart sound closes in expiration as the reduced venous return shortens right ventricular ejection. When the split closes in inspiration and becomes audible in expiration, it is called paradoxical splitting of second heart sound. Please note that a wide split of second heart sound as in ri...
Source: Cardiophile MD - June 20, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs