ECMO – Extracorporeal membrane oxygenation
ECMO – extracorporeal membrane oxygenation ECMO – Extracorporeal membrane oxygenation – has been in use for the past four decades to support persons who are unlikely to survive with mechanical ventilation. ECMO is used in both adult and pediatric practice, though in the initial years, use of ECMO was restricted to pediatric intensive care. The enthusiasm for use of ECMO in adults have been triggered by the beneficial effect noted during the last H1N1 influenza pandemic [1]. In contrast from cardiopulmonary bypass which is used for a short period during cardiac surgery, ECMO is used to support for a ...
Source: Cardiophile MD - December 26, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiac Surgery Source Type: blogs

Modified Blalock – Taussig shunt
Modified Blalock – Taussig shunt The original Blalock – Taussig (BT) shunt was designed by Helen B Taussig (physician) and Alfred Blalock (surgeon) at the John Hopkins Hospital. This was based on the observation by Helen B Taussig that infants with severe pulmonary stenosis or pulmonary atresia had worsening of cyanosis after spontaneous closure of ductus arteriosus. The BT shunt was an anastomosis between subclavian artery and pulmonary artery, to enhance pulmonary blood flow those infants with severe cyanotic congenital heart disease with low pulmonary blood flow. Different techniques have been used to modify...
Source: Cardiophile MD - December 23, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiac Surgery Blalock – Taussig shunt BT shunt classic Blalock – Taussig shunt Modified Blalock – Taussig shunt modified BT shunt Source Type: blogs

Mogul signs on chest X-ray
This article has been cited in Chest [2]. A mogul can form due to left ventricular pseudoaneurysm after mitral valve replacement [3]. Early recognition of this is important as pseudoaneurysms are prone for rupture with catastrophic results. Mogul signs on chest X-ray In addition to the mogul signs, the chest X-ray shows prominent upper lobe vessels (antler sign) and double atrial shadow or shadow within shadow of left atrial enlargement. The left atrial shadow is seen as a double density within the right atrial shadow as part of the enlarged left atrium extends posterior to the right atrium. All these features are suggesti...
Source: Cardiophile MD - December 20, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology X-ray Source Type: blogs

FFR with CT angiography
Fractional flow reserve (FFR) is usually estimated invasively using a Doppler flow wire introduced into the coronary artery and measuring the pressure drop across the coronary stenosis during maximal hyperemia induced by adenosine. FFR has been shown to be of great significance while assessing the severity of borderline coronary stenosis in deciding the need for coronary angioplasty. Fractional flow reserve estimated by computed tomographic angiography (FFRCT) is a novel technique of getting similar information non invasively. FFR with CT angiography has been shown to be superior to conventional CT coronary angiography a...
Source: Cardiophile MD - December 18, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiac CT scan FFR FFRCT Noninvasive Fractional Flow Reserve Source Type: blogs

Electrical storm – Management
Electrical storm – Management Electrical storm: Recurrent unstable ventricular tachycardia (VT)/ventricular fibrillation (VF) requiring more than three direct current (DC) shocks per day. Beta blocker is the single most effective therapy for recurrent VT unless the person is in shock. A combination of intravenous amiodarone with oral propranolol has been found to be superior to intravenous amiodarone with oral metoprolol [1]. Stellate ganglion block / ablation is being increasingly used as a modality for treatment of drug refractory ventricular tachycardia. Temporary blockage of stellate ganglion can be obtained by...
Source: Cardiophile MD - December 18, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Ablation of stellate ganglion Stellate ganglion block Temporary blockage of stellate ganglion Source Type: blogs

Dangerous Signs on Holter Monitoring
Holter monitoring is ambulatory monitoring using a digital recorder attached to a belt. Two or three channels are usually recorded with an appropriate number of patch electrodes attached to the chest. Twelve channel Holter monitoring can also be done using standard lead placement [1]. Holter monitoring is usually done when an arrhythmia is suspected, though ischemic ST segment deviation can also be picked up by Holter. Dangerous signs to look for on a Holter tracing are life threatening bradyarrhythmias and tachyarrhythmias. Dangerous bradyarrhythmias are long pauses or episodes of complete heart block with low ventricul...
Source: Cardiophile MD - December 17, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Wrong statement about Mahaim fiber tachycardia – Cardiology MCQ – Answer
Wrong statement about Mahaim fiber tachycardia – Cardiology MCQ – Answer Correct answer: 3. Mahaim fiber tachycardia is always orthodromic Mahaim fibers do not conduct retrogradely. So Mahaim fiber tachycardia is always with wide QRS complexes, antidromic with LBBB pattern. It may be noted that in WPW syndrome both narrow QRS (orthodromic) and wide QRS (antidromic) tachycardia are possible as the pathway can conduct both anterogradely and retrogradely. Kent bundle responsible for WPW syndrome does not have decremental conduction, which is a usual property of the atrioventricular (AV) node. Read more on Mahaim f...
Source: Cardiophile MD - December 13, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Wrong statement about Mahaim fiber tachycardia – Cardiology MCQ
Wrong statement about Mahaim fiber tachycardia – Cardiology MCQ Decremental conduction No delta wave Mahaim fiber tachycardia is always orthodromic Mahaim fibers do not conduct retrogradely Post your answer as a comment below. Correct answer will be posted after 2 days. The post Wrong statement about Mahaim fiber tachycardia – Cardiology MCQ appeared first on All About Cardiovascular System and Disorders. (Source: Cardiophile MD)
Source: Cardiophile MD - December 11, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Rautaharju and Dmitrienko formulae for QT interval correction
Various logarithmic and linear formulae for correction of QT interval has been discussed before. These include Bazett’s formula, Fridericia’s formula and Baseline correction for logarithmic correction and Framingham formula and Hodges formula for linear correction. Of these, Bazett’s and Fridericia’s were introduced in 1920 (exactly one century back!). Rautaharju’s formula and Dmitrienko’s formula are two relatively recent formulae for correction of QT interval. The older formulae have problems during calculation of QTc during exercise. QTc using Bazett’s formula increased with ex...
Source: Cardiophile MD - November 26, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Dmitrienko QTc formula Karjalainen QTc nomogram QT correction nomogram Rautaharju QTc formula Source Type: blogs

Rheumatic heart disease
This lecture will discuss about rheumatic fever, latest diagnostic criteria (Revised by American Heart Association in 2015), and an overview of rheumatic heart disease. Echocardiogram pictures and brief discussion of catheter based, and surgical management are added. The post Rheumatic heart disease appeared first on All About Cardiovascular System and Disorders. (Source: Cardiophile MD)
Source: Cardiophile MD - November 24, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Aortic regurgitation Aortic stenosis Austin Flint murmur Graham Steell murmur mitral regurgitation mitral stenosis Pulmonary regurgitation Tricuspid regurgitation Tricuspid stenosis Source Type: blogs

Coronary artery disease
This lecture will give an overview of coronary artery disease including the universal definition of myocardial infarction. The new term chronic coronary syndrome will be introduced. Coronary artery disease or CAD is known by various names like ischemic heart disease, atherosclerotic coronary heart disease and coronary heart disease. The post Coronary artery disease appeared first on All About Cardiovascular System and Disorders. (Source: Cardiophile MD)
Source: Cardiophile MD - November 23, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Acute coronary syndrome Chronic coronary syndrome myocardial infarction Perioperative myocardial infarction periprocedural myocardial infarction troponin elevation Universal definition of myocardial infarction unstable angina unstabl Source Type: blogs

RWMA – Echo
RWMA – Echo The term regional wall motion abnormality or RWMA can be used in any imaging which shows movements of the myocardial segments like echocardiography, cine cardiac magnetic resonance imaging, cine computed tomography and nuclear cardiology imaging. The left ventricular myocardium has been divided into 17 segments by the American Society of Echocardiography [1]. The true apex is a separate segment in this 17-segment nomenclature. In the previous 16 segment nomenclature, there is no separate true apical segment. True apical segment is beyond the left ventricular cavity towards the apex. More details at: Desc...
Source: Cardiophile MD - November 20, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Echocardiogram Library Echocardiography 17 myocardial segments echocardiographic myocardial segments Regional wall motion abnormality RWMA Source Type: blogs

Atrial septal defect
This video covers certain features of atrial septal defect including X-ray chest, ECG, echocardiogram and finally device closure of ASD. Both secundum and primum ASDs are demonstrated. Transesophageal echo images of ASD are also shown. Fluoroscopic view of ASD device with delivery cable and venous sheath is seen at the end. Another video without narration, showing TEE in dual ASD is shown below: (Source: Cardiophile MD)
Source: Cardiophile MD - November 20, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Echocardiogram Library Echocardiography ASD ASD device closure dual ASD ostium primum ASD ostium secundum ASD TEE in ASD Source Type: blogs

Cardiology X-ray chest PA view
In this lecture, we will have an overview of Cardiology X-ray Chest PA view. This will cover pulmonary veins, pulmonary arteries, various cardiac chamber enlargements, prosthetic heart valves, cardiac implantable electronic devices like pacemakers, cardiac resynchronization therapy and implantable cardioverter defibrillator appearances on chest X-ray. (Source: Cardiophile MD)
Source: Cardiophile MD - November 12, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology cardiac chamber enlargementg cardiac implantable electronic devices like pacemakers implantable cardioverter defibrillator prosthetic heart valves pulmonary arteries pulmonary artery Source Type: blogs

Clinical Examination of Cardiovascular System
This lecture gives a comprehensive coverage of clinical examination of the cardiovascular system including inspection, palpation, percussion and auscultation. A previous lecture on important symptoms of heart disease is a companion to this lecture: https://www.youtube.com/watch?v=3eO-yOQsx4U (Source: Cardiophile MD)
Source: Cardiophile MD - November 12, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology auscultation cardiac murmurs Cardiovascular system examination Clinical examination clubbing of digits differential clubbing differential cyanosis Erb’s area facial dysmorphism general examination Gibson’s area Gibso Source Type: blogs

ECG basics
Electrocardiogram is the recording of the electrical signals of the heart. Electrocardiogram (ECG) recorded from the body surface is known as surface ECG while that recorded with intracardiac electrodes are called electrograms. Standard surface ECG uses four electrodes on the limbs of which one is an indifferent electrode and 6 electrodes on the chest. Various combinations of limb electrodes record 6 ECG leads while chest electrodes record 6 chest leads to make a total of 12 leads in the standard 12 lead ECG. The leads can be recorded in sequence, groups of 3 each or simultaneous 12 leads. Multiple simultaneous leads are...
Source: Cardiophile MD - November 11, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology ECG standardization left ventricular hypertrophy left ventricular volume overload P congenitale P mitrale P pulmonale P tricuspidale Pardee's sign Pardee's sign on ECG right ventricular volume overload Source Type: blogs

Clinical examination – CVS Part III
Clinical examination – CVS Part III Part III of clinical examination of the cardiovascular system covers auscultation of the cardiovascular system. Starting with auscultatory areas, the lecture takes you through heart sounds, clicks, opening snap, pericardial knock, pericardial rub and cardiac murmurs. The section on cardiac murmur starts with classification and gives the Levine’s grading of cardiac murmurs. Various types of systolic, diastolic and continuous murmurs are detailed. (Source: Cardiophile MD)
Source: Cardiophile MD - November 10, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Clinical examination – CVS Part II
Clinical examination – CVS Part II Part II of this series covers inspection, palpation and percussion of the precordium. Sternal deformities, surgical scars, dilated veins and arteries and the apex beat are important findings to look for during inspection. Apex beat (rarely double and triple apical impulse), left parasternal heave and pulsations, right parasternal pulsations, Suzman’s sign and thrills are the important findings on palpation. Percussion has limited role currently. Dullness beyond the apex beat, right heart border within the right sternal edge and dullness of second left intercostal space are so...
Source: Cardiophile MD - November 9, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Echocardiograms in a few congenital heart diseases
In this series, we have echocardiograms of a few congenital heart diseases. The first one shows left ventricle to right atrium shunt associated with a perimembranous ventricular septal defect. Various possibilities are discussed. The second one shows an ostium primum atrial septal defect with tricuspid regurgitation. Associated tricuspid regurgitation is also seen. Third one shows a few views of tetralogy of Fallot (TOF). There is a patent ductus arteriosus associated with TOF in this case. The intact patch at the site of intracardiac repair of the subaortic ventricular septal defect in TOF is seen in the last few frames...
Source: Cardiophile MD - November 8, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Echocardiogram Library Echocardiography ASD LV-RA shunt ostium primum ASD perimembranous VSD TOF Source Type: blogs

Clinical examination – CVS Part I
Clinical examination CVS Part I Clinical examination should be focussed to the situation. A quick examination to assess vitals and a general survey is the rule in the emergency room. A more detailed examination is needed in all other situations. Even in the emergency room, after the initial crisis is managed, a more detailed examination is needed. General examinations looks for features related to cardiovascular disease like clubbing, cyanosis and stigmata of infective endocarditis. Facial dysmorphic features are important in the evaluation of congenital heart disease. In this part I, general examination, examination of t...
Source: Cardiophile MD - November 6, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Tetralogy of Fallot – Pre and Post Repair Echocardiogram
Tetralogy of Fallot – Pre and Post Repair Echocardiogram Tetralogy of Fallot is the commonest cyanotic congenital heart disease in the adult. Large subaortic ventricular septal defect with overriding aorta, infundibular pulmonary stenosis and right ventricular hypertrophy are the components of tetralogy of Fallot. A patent ductus arteriosus is seen in this case as a natural protective mechanism to improve the pulmonary blood flow. The echocardiogram after repair shows the intact patch over the erstwhile subaortic ventricular septal defect. There is no residual ventricular septal defect. (Source: Cardiophile MD)
Source: Cardiophile MD - November 6, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Echocardiogram Library Echocardiography aortic override continuous flow across the ductus patch across the ventricular septal defect patent ductus arteriosus right to left shunt Tetralogy of Fallot Source Type: blogs

Cardiac embryology – Audio narration
Cardiac embryology – Audio narration Cardiovascular system is the first system to develop in the embryo. Cardiac progenitor cells develop into cardiac myoblasts. This topic covers the looping of the heart tube and cardiac septation with the formation of interatrial septum, interventricular septum and aorticopulmonary septum. (Source: Cardiophile MD)
Source: Cardiophile MD - November 5, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology aorticopulmonary septum interventricular septum Bulbus cordis Conus cordis endocardial cushions foramen ovale ostium primum ostium secundum septum primum septum secundum spiral septum Truncus arteriosus Source Type: blogs

Z-score
One often reads Z-score of various parameters in pediatric cardiology textbooks. Z-score of pulmonary arteries in tetralogy of Fallot is one example. This will decide whether a repair will be followed by right ventricular afterload mismatch or not. Z score correlates the measurement with the body surface area (BSA). Z score checks how many standard deviations the measured value of the structure deviates from the population mean. Z-score for a given BSA = (Observed measurement − Population mean)/Population standard deviation (Source: Cardiophile MD)
Source: Cardiophile MD - November 4, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Cardiac physiology – Audio narration
Cardiac physiology – Audio narration Includes cardiac cycle, action potential and the conduction system of the heart in a sequence. Cardiac cycle describes all the phases of the cardiac cycle. The diagrammatic representation of action potentials of the myocardial cell and pacemaker cell are given. Phases of the cardiac action potential are explained along with difference in case of pacemaker cells. Electrical systole of the heart is defined. The conduction system of the heart includes the sinoatrial node, internodal pathways, atrioventricular node, bundle of His, bundle branches and the Purkinje fibres. (Source: Cardiophile MD)
Source: Cardiophile MD - November 4, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Atrioventricular node AV node Bachmann’s bundle Bundle of His Diastasis Internodal pathways isovolumetric relaxation phase Isovolumic contraction phase Purkinje fibres rapid ejection phase SA node Sinoatrial node Tho Source Type: blogs

Important symptoms of heart disease
: Slides with audio narration Important symptoms of heart disease are chest pain, breathlessness, fatigue, syncope, near syncope, edema, hemoptysis (spitting of blood) and cyanosis (bluish discoloration of skin, lips and tongue). Please listen to the audio narration for details. You may subscribe to the Youtube channel for future updates. (Source: Cardiophile MD)
Source: Cardiophile MD - November 3, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Antiarrhythmics after ablation of AF (5A Study)
  Antiarrhythmic drugs after ablation of atrial fibrillation (5A Study) was published in Circulation in 2009 [1]. One hundred and ten patients after catheter ablation of atrial fibrillation was randomized to receive antiarrhythmic drugs or no antiarrhythmics for six weeks. The drugs used in the 5A study were the class Ic drugs propafenone and flecainide if there was no left ventricular dysfunction or coronary artery disease. In those with coronary artery disease and normal left ventricular function, sotalol was used. In those with abnormal left ventricular function, sotalol or dofetilide were used. The patients w...
Source: Cardiophile MD - October 20, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

SCD-HeFT 2005
The Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) trial was published in NEJM in 2005 [1]. SCD-HeFT randomized 2521 patients into three groups. They were in New York Association (NYHA) class II or III congestive heart failure (CHF) and had left ventricular ejection fraction (LVEF) ≤35%. It was a comparison between amiodarone or an implantable cardioverter-defibrillator (ICD) for congestive heart failure, with placebo control. The patients were divided into three groups: Conventional therapy for CHF plus placebo (847 patients) Conventional therapy plus amiodarone (845 patients) Conventional therapy p...
Source: Cardiophile MD - October 20, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Vernakalant – class IIIa
Vernakalant – class IIIa Vernakalant is a class IIIa antiarrhythmic agent as per the Modernized Classification of Cardiac Antiarrhythmic Drugs [1]. The class effect is voltage dependent K+ channel blocker. Specifically, it is a Kv1.5 channel–mediated, ultrarapid K+ current (IKur) blocker, which is atrium specific. Atrium-specific actions of vernakalant are as follows: Increase in action potential recovery time Increase in refractory period Decreased reentrant tendency The drug is used for immediate conversion of atrial fibrillation. It can cause mild QTC prolongation. Hence caution is needed if other QT prolo...
Source: Cardiophile MD - October 16, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology atrial specific potassium channel blocker IKur ultra rapid potassium current Source Type: blogs

Adenosine – Class IIe
Adenosine – Class IIe Adenosine is a class IIe antiarrhythmic agent as per the Modernized Classification of Cardiac Antiarrhythmic Drugs [1]. Autonomic inhibitors and activators constitute new class II. Adenosine is an adenosine A1 receptor activator, activating A1 receptors in supraventricular tissue (sinoatrial node, atrial tissue and atrioventricular node). It activates G protein–coupled inward rectifying K+ channels and IKAdo. Adenosine hyperpolarizes the sinoatrial node and shortens the action potential durations in atrial and AV node tissue. It reduces early afterdepolarization (EAD)/ delayed afterdepolar...
Source: Cardiophile MD - October 16, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology adenosine and asthma cAMP-mediated triggered ventricular tachycardia Source Type: blogs

Ibutilide – class IIIa
Ibutilide – class IIIa Ibutilide is a class IIIa antiarrhythmic agent as per the Modernized Classification of Cardiac Antiarrhythmic Drugs [1]. The class effect is voltage dependent K+ channel blocker. Specifically, it is a HERG channel –mediated rapid K+ current (IKr) blocker. Ibutilide increases the refractoriness of atrial and ventricular myocytes, atrioventricular (AV) node and the His-Purkinje system. The drug has been approved for the conversion  of acute atrial flutter and atrial fibrillation. The infusion is stopped when the arrhythmia resolves or a new ventricular tachycardia develops. If the...
Source: Cardiophile MD - October 15, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Sotalol – class IIIa
Sotalol – class IIIa Sotalol is a class IIIa antiarrhythmic agent as per the Modernized Classification of Cardiac Antiarrhythmic Drugs [1]. The class effect is voltage dependent K+ channel blocker. Specifically, it is a HERG channel –mediated rapid K+ current (IKr) blocker. It has additional action on beta 1 and beta 2 receptors. Sotalol increases refractory period and decreases tendency for reentry. The drug is useful in ventricular tachycardia without structural heart disease and in those with a remote myocardial infarction. It is also useful in atrial fibrillation with conduction through accessory ...
Source: Cardiophile MD - October 15, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Amiodarone – class IIIa
Amiodarone – class IIIa Amiodarone is designated as class IIIa antiarrhythmic agent in the Modernized Classification of Cardiac Antiarrhythmic Drugs [1]. This is the group of voltage dependent K+ channel blockers. It is a nonselective K+ channel blocker. Another drug in class IIIa is dronedarone, which is a related drug free of iodine atoms and hence the thyroid related adverse effects of amiodarone. Amiodarone is useful in wide range of atrial and ventricular arrhythmias and it is a so called broad spectrum antiarrhythmic agent and widely used. Amiodarone prolongs QTc, but torsades des pointes is rare, pos...
Source: Cardiophile MD - October 15, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Polysorbate and hypotension with amiodarone Source Type: blogs

Ranolazine – Class Id
Ranolazine – Class Id Ranolazine, originally introduced as an antianginal agent for the treatment of chronic stable angina, is now being recognized as an antiarrhythmic agent as well. It has been included in the class Id of the Modernized Classification of Cardiac Antiarrhythmic Drugs [1]. Class Id is by virtue of its inhibition of late Na+ current (INaL). It has been included among the drugs for treatment of ventricular arrhythmias in the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death [2]. Ranolazine reduces early after depolarizatio...
Source: Cardiophile MD - October 15, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Propafenone
Propafenone is a Class Ic drug with targets INa, IKr and IKur currents as well as beta receptors and alpha receptors [1,2]. It can cause PR interval prolongation, QRS widening and an increase in the defibrillation threshold (DFT). Propafenone has a half life of 2- 10 hours, suggesting an eight hourly dosage. It is useful in the treatment of ventricular tachycardia (VT) and frequent premature ventricular complexes (PVC), in the absence of structural heart disease. Like flecainide, it can cause drug-induced Brugada syndrome and may worsen heart failure and atrioventricular (AV) block. References Ming Lei, Lin Wu, Dere...
Source: Cardiophile MD - October 15, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Flecainide
Flecainide is a class Ic drug which reduces the peak INa, (dV/dt)max IKr, IKur. It is useful in the treatment of atrial tachycardia, atrial flutter, atrial fibrillation and accessory pathways medicated tachycardias. It reduces excitability, particularly at higher heart rate and slows conduction. This way it can block reentrant pathways. Flecainide can also be used in ventricular tachyarrhythmias resistant to other drug, in the absence of structural heart disease. In the presence of myocardial scar it can cause monomorphic ventricular tachycardia. It can also exacerbate heart failure with reduced ejection fraction (HF...
Source: Cardiophile MD - October 14, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Mexiletine – Class Ib ( & Id?)
Mexiletine – Class Ib (& Id?) Mexiletine is a Class Ib drug. But it has additional effect on late sodium current (INaL), which qualifies for Id inclusion, though it has not been included in that group in the Modernized Classification of Cardiac Antiarrhythmic Drugs [1]. By virtue of that effect, it has been used successfully in the treatment of Long QT syndrome 3 (LQT3) [2]. In addition to shortening QTc, it has been shown to reduce life threatening arrhythmic events in LQT3 patients. It has also been found useful in Timothy syndrome, which is long QT syndrome type 8 (LQT8) [3]. In the case reported, mexiletine s...
Source: Cardiophile MD - October 14, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology late sodium current Long QT syndrome 3 LQT3 LQT8 Timothy syndrome Source Type: blogs

Ivabradine – Class 0 antiarrhythmic agent
Ivabradine – Class 0 antiarrhythmic agent Ivabradine is a Class 0 antiarrhythmic agent as per the Modernized Classification of Cardiac Antiarrhythmic Drugs [1]. It is a Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) channel blocker. Ivabradine inhibits If current (funny current) responsible for diastolic depolarization, which is responsible for the automaticity of the sinus node. Hence it is a pure sinus node inhibitor. Action potential of pacemaker cells As an antiarrhythmic agent, it has been used in the treatment of inappropriate sinus tachycardia [2]. Ivabradine is used more often in heart failure, bas...
Source: Cardiophile MD - October 13, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Antiarrhythmic drug classification
The popular Vaughan Williams classification was published in 1975 [1]. It is still being used by most of us. The Sicilian Gambit published in 1991 [2] has not been so popular because of its complexity. Vaughan Williams classification is approximately as follows:  Class I: Sodium channel blockers ◦a: Moderate Na channel block. e.g. Quinidine, Disopyramide ◦b: Weak Na channel block. e.g. Lignocaine, Mexiletine ◦c: Marked Na channel block. e.g. Flecainide, Propafenone  Class II: Beta blockers  Class III: Potassium channel blockers: Amiodarone, Sotalol, Ibutilide  Class IV: Calcium channel blockers I...
Source: Cardiophile MD - October 13, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Patent ductus arteriosus
Ductus arteriosus normally closes by 72 hours after birth. The structure becomes fibrotic later and remains as the ligamentum arteriosus. Endothelium of mature ductus responds to oxygen which acts as the stimulus of constriction as it receives oxygenated blood from the lungs. Premature ductus does not respond to oxygen that well. Patent ductus arteriosus is much more common in the premature infant than the mature infant. The higher the prematurity, the higher the chance of having a patent ductus arteriosus (PDA). PDA can occur as part of the congenital rubella syndrome. Patent ductus arteriosus – angio Patent ductus...
Source: Cardiophile MD - October 11, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Atypical PDA eddy sounds Gibson’s area Gibson’s murmur inverted Y shaped pattern of calcification train in tunnel murmur Source Type: blogs

ECG and CXR in ASD
ECG in atrial septal defect Atrial fibrillation may be seen in adults. Atrial flutter can occur in ASD, even after repair. Inverted P waves seen in inferior leads indicate low atrial rhythm (also known as coronary sinus rhythm) in sinus venosus atrial septal defect. This is due to defective sinus node as the septal defect is in the region of the sinoatrial node. Classical QRS pattern in ASD is the rSR’ in V1 suggestive incomplete right bundle branch block. This pattern in ASD is due to right ventricular volume overload. QRS axis is usually rightward, more so when there is severe pulmonary hypertension. Left axis dev...
Source: Cardiophile MD - October 11, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Coronary sinus rhythm crochetage sign in ASD end on vessels in ASD hilar dance in ASD Low atrial rhythm pulmonary plethora Source Type: blogs

Ostium primum ASD and clinical findings of ASD
Ostium primum ASD Ostium primum atrial septal defect is part of the AV canal defects. In partial AV canal defect, ostium primum ASD is often associated with cleft anterior mitral leaflet producing mitral regurgitation. Tricuspid regurgitation may also be noted. In complete AV canal defect, there is associated canal VSD or inlet VSD and sometimes a single AV valve. Ostium primum ASD being part of the endocardial cushion defects, may be associated with Down syndrome. They are more likely to develop pulmonary hypertension and Eisenmenger syndrome earlier. DiGeorge syndrome and Ellis-Van Creveld syndrome are the other conditi...
Source: Cardiophile MD - October 10, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Wide fixed split of second heart sound Source Type: blogs

ASD overview and secundum ASD
Atrial septal defect (ASD) is the commonest congenital heart disease in the adult, barring of course bicuspid aortic valve. ASD being a post tricuspid shunt, development of pulmonary hypertension and Eisenmenger syndrome is delayed and survival to adult age group is common. Some even argue that pulmonary hypertension in ASD is primary pulmonary hypertension which the individual was otherwise destined to develop. Anyway pulmonary hypertension is likely to develop in ASD with large left to right shunt of long duration, though the severity of pulmonary hypertension is variable. Supra systemic pulmonary arterial pressures are...
Source: Cardiophile MD - October 10, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Bimodal pattern of cyanosis in ASD ostium primum ASD ostium secundum ASD Secundum atrial septal defect sinus venosus ASD Spontaneous closure of ASD Source Type: blogs

ECG and CXR in ventricular septal defect
ECG in ventricular septal defect ECG is normal in a small ventricular septal defect. Large VSD with large left to right shunt will have left ventricular volume overload with small q, tall R and upright T waves in lateral leads. Large VSD progresses to biventricular overload when there is hyperdynamic pulmonary hypertension. The ECG pattern of biventricular hypertrophy is called Katz – Wachtel phenomenon with tall biphasic (R=S) QRS complexes with amplitude over 50 mm in mid precordial leads. This pattern is usually seen in children. Since the QRS amplitude is high it often overshoots the margin of the ECG graph as s...
Source: Cardiophile MD - October 10, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Katz – Wachtel phenomenon peripheral pruning Source Type: blogs

Ventricular septal defect
Ventricular septal defects (VSD) can be divided into perimembranous, muscular, inlet and outlet VSDs, depending on the location. Of these perimembranous VSDs are the commonest. VSDs can decrease in size and undergo spontaneous closure. Spontaneous closure is most likely with small muscular and perimembranous VSD, while inlet and outlet VSDs are least likely to close. Perimembranous ventricular septal defect Perimembranous VSD with perimembranous aneurysm Echocardiogram in ventricular septal defect: Parasternal long axis view shows the subaortic perimembranous ventricular septal aneurysm (marked by arrows). The color mosai...
Source: Cardiophile MD - October 10, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC atrioventricular septal defect doubly committed VSD Eisenmenger complex Eisenmenger reaction Gerbode VSD Inlet ventricular septal defect maladie de Roger Muscular ventricular septal defect Outlet ventricular septal defect perimembr Source Type: blogs

Congenital heart disease overview
Congenital heart disease can be broadly classified into cyanotic and acyanotic. Acyanotic congenital heart disease can be further subdivided into left to right shunts, obstructive lesions and a miscellaneous group. Cyanotic congenital heart disease can be classified into those with decreased pulmonary blood flow and those with reduced pulmonary blood flow. Left to right shunts include atrial septal defect, ventricular septal defect, patent ductus arteriosus and aortopulmonary window. One person can have more than one of these shunts. Large left right shunts can induce the development of pulmonary hypertension and lead to ...
Source: Cardiophile MD - October 10, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Source Type: blogs

Rheumatic pulmonary valve disease
Organic rheumatic pulmonary valve disease is extremely rare. It has been reported along with disease of the other valves, like a case of quadrivalve disease. Pulmonary valve involvement this case was less severe than that of aortic valve involvement. There was pulmonary stenosis and regurgitation. Some other cases of quadrivalve involvement in clinical and autopsy series are also there. A much more common situation is hypertensive pulmonary regurgitation in mitral valve disease with severe pulmonary hypertension. This is associated with loud pulmonary component of second heart sound (P2) which may also be palpable and a b...
Source: Cardiophile MD - October 9, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Graham steel murmur quadrivalve disease Source Type: blogs

Rheumatic tricuspid stenosis
Rheumatic tricuspid stenosis is often associated with mitral valve disease. As in rheumatic mitral stenosis, there is commissural fusion in rheumatic tricuspid stenosis. Anteroseptal commissure between the anterior and septal leaflets of the tricuspid valve is the one which is most commonly involved. Tricuspid valve being the largest valve in the body, a gradient of 2 mm Hg across it will qualify for tricuspid stenosis. A gradient of 5 mm Hg would mean severe tricuspid stenosis where as the corresponding gradient in severe mitral stenosis is 20 mm Hg. Severe tricuspid stenosis causes right atrial hypertrophy and prominent...
Source: Cardiophile MD - October 9, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Ascites precox giant a waves Slow y descent Source Type: blogs

Rheumatic tricuspid regurgitation
Rheumatic tricuspid regurgitation is almost always associated with mitral valve disease. Organic tricuspid regurgitation is often superimposed on hypertensive tricuspid regurgitation which occurs due to pulmonary arterial hypertension secondary to mitral valve disease. Tricuspid leaflets are thickened and deformed by the rheumatic process which leads to incomplete coaptation and tricuspid regurgitation. Clinically tricuspid regurgitation is manifest as prominent systolic wave in the jugular venous pulse (cv wave) and a pansystolic murmur in the tricuspid area, increasing on inspiration (Carvallo’s sign). Carvallo&rs...
Source: Cardiophile MD - October 9, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC cv waves De Vega procedure Source Type: blogs

Rheumatic heart disease, mitral regurgitation
Though most of the manifestations of acute rheumatic fever does not leave long lasting sequelae, carditis is different. Carditis can resolve without sequelae in a few cases, but most often it leads to valvular lesions which are progressive. The most commonly involved valve is the mitral valve and mitral regurgitation is the commonest lesion in acute rheumatic fever. Stenotic lesions do not occur in the acute phase as they take a long time to develop by progressive fibrosis. According to Paul Wood, the frequency of involvement of the valves in rheumatic fever is according to the hemodynamic load on the valve. In this respe...
Source: Cardiophile MD - October 8, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC MR begets MR Source Type: blogs

Rheumatic fever – diagnostic criteria
Rheumatic fever – diagnostic criteria Acute rheumatic fever is an immunologically mediated disease which occurs about three weeks after a streptococcal sore throat caused by Group A beta hemolytic streptococci. Antibodies to streptococci cross react with various tissues in the body to produce the various manifestations of acute rheumatic fever. The diagnostic criteria initially proposed by Duckett Jones in 1944 has been modified and revised several times. Latest revision was by the American Heart Association. The manifestations of rheumatic fever has been classically divided into major manifestations and minor manife...
Source: Cardiophile MD - October 6, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Carey Coombs murmur erythema marginatum Evidence of preceding streptococcal infection initial episode of acute rheumatic fever Recurrent rheumatic fever Sydenham’s chorea Source Type: blogs