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

Role of adenosine in atrial fibrillation
First and foremost, it must be remembered that adenosine is not to be given in atrial fibrillation if there is an atrioventricular bypass tract (ventricular pre-excitation) like Wolff-Parkinson-White syndrome. This is because it slows conduction through the atrioventricular (AV) node, but does not affect the accessory pathway. Secondly, adenosine can rarely induce atrial fibrillation and very rarely ventricular fibrillation. Adenosine guided pulmonary vein ablation has been studied as adenosine might identify pulmonary veins at risk of reconnection by unmasking dormant conduction. Identifying dormant conduction will guide...
Source: Cardiophile MD - June 19, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Idarucizumab for reversal of direct thrombin inhibitor dabigatran
Idarucizumab is a monoclonal antibody fragment used to reverse the anticoagulant effect of direct thrombin inhibitor dabigatran. RE-VERSE AD (Reversal of Dabigatran Anticoagulant Effect With Idarucizumab) clinical trial evaluated the safety and efficacy of 5 g idarucizumab given intravenously [1]. An article on interim analysis of 90 patients was published first. In that report, 51 patients in group A of the study had serious bleeding while 39 patients in group B required an urgent procedure. Primary end point of the study was the maximum percentage reversal of the anticoagulant effect of dabigatran within four hours of a...
Source: Cardiophile MD - June 18, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Clinical importance of LBBB
Left bundle branch block (LBBB) is usually associated with structural heart disease, unlike right bundle branch block which may be seen without associated heart disease. LBBB is one cause for paradoxical splitting of second heart sound. Normal split closes in expiration. In paradoxical splitting, split is audible in expiration and closes in inspiration. In normal conduction sequence, left bundle branch is activated first. Hence a left bundle branch block can affect the initial vector in the ECG. This leads to errors in interpretation of Q waves in myocardial infarction. Secondary ST segment and T wave abnormalities common...
Source: Cardiophile MD - June 17, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

HOST-EXAM trial
This study is definitely hypothesis generating and calls for a multi national, double blind comparison on a larger scale to get a better conclusion on long term antiplatelet monotherapy after PCI with DES.  AUGUSTUS trial A somewhat similar disadvantage for aspirin was suggested in the AUGUSTUS trial among patients with atrial fibrillation and recent ACS or PCI [2]. Adding apixaban to P2Y12 inhibitor resulted in lower bleeding compared with vitamin K antagonist and a lower rate of death or rehospitalization. Addition of aspirin resulted in greater bleeding without any difference in efficacy. 92.6% of the patients...
Source: Cardiophile MD - June 15, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Identification of culprit vessel from ECG
Identification of culprit vessel or infarct artery localization from ECG is useful during primary angioplasty. The initial diagnostic angiogram shot is taken in the artery which is not the culprit vessel, with a diagnostic catheter. Guide catheter is used for diagnostic shot in the suspected culprit vessel after that. This saves time during primary angioplasty. Have a look at the ECG below: Inferior wall infarction It shows show ST segment elevation in leads II, III and aVF of about 3mm. ST segment depression is seen in leads I, aVL and V1 to V5. Overall features are suggestive of hyperacute phase of inferior wall myocard...
Source: Cardiophile MD - June 14, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Angiography and Interventions Cardiology ECG / Electrophysiology ECG Library Source Type: blogs

Athlete ’ s heart
Athlete’s heart Athlete’s heart denotes structural, functional and electrical remodeling seen in trained athletes. It is a physiological adaptation helping athletes perform physical tasks better than non-athletes [1]. Though most of the findings in athlete’s heart are related to the left ventricle, changes do occur in the right ventricle as well. Effect of exercise on the left ventricle During aerobic exercise which is isotonic, the heart rate and stroke volume increases. Systemic vascular resistance falls, but slight to moderate increase in blood pressure can occur due to the increased cardiac output. As...
Source: Cardiophile MD - June 12, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Left ventricular reverse remodeling
In this study, change in LVESV was the single most important predictor of all cause and cardiovascular mortality. Clinical parameters could not predict outcome events in this study. Similar beneficial effect on left ventricular remodeling was demonstrated long back in the trials with angiotensin converting enzyme inhibitors. SOLVD (Studies of Left Ventricular Dysfunction) study showed that in patients with heart failure and reduced left ventricular ejection fraction, chronic treatment with angiotensin converting enzyme inhibitor enalapril prevented progressive left ventricular dilatation, systolic dysfunction and increase ...
Source: Cardiophile MD - June 11, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Renal denervation for hypertension
Renal denervation for hypertension, initially thought to be a promising procedure, went into disrepute after the publication of the SYMPLICITY HTN-3 trial [1]. But the procedure has staged a potential comeback after the publication of SPYRAL HTN-OFF MED trial [2]. SYMPLICITY HTN-3 was a prospective, single blind, randomized, sham controlled trial of patients with severe resistant hypertension. Patients were receiving a stable antihypertensive regimen of maximally tolerated doses of at least three anti hypertensive medications including a diuretic. Primary efficacy endpoint was change in office blood pressure at 6 months. ...
Source: Cardiophile MD - June 10, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

GALACTIC-HF Trial: Omecamtiv mecarbil
GALACTIC-HF trial evaluated omecamtiv mecarbil, a cardiac myosin activator in heart failure with reduced ejection fraction [1]. The study had 8256 patients which included inpatients and outpatients with symptomatic heart failure with an ejection fraction of 35% or less. It was a placebo controlled trial of omecamtiv mecarbil in addition to standard heart failure therapy. Primary outcome was a composite of first heart failure event or death from cardiovascular causes. Heart failure event was defined as hospitalization or urgent hospital visit for heart failure. Over a median follow up of 21.8 months, primary outcome event ...
Source: Cardiophile MD - June 8, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Echocardiographic assessment of LV diastolic function
Though there are several parameters for evaluation of left ventricular diastolic function by echocardiography, the most commonly used are the pulsed Doppler mitral E/A ratio and tissue Doppler mitral E/e’ ratio. Some of the other useful parameters are mitral E velocity deceleration time, changes in mitral inflow with Valsalva maneuver, mitral L velocity, isovolumic relaxation time, left atrial maximum volume index, pulmonary vein systolic/diastolic velocity ratio, color M-mode Vp and E/Vp ratio. Tricuspid regurgitation jet velocity and pulmonary regurgitation end diastolic velocity indicating pulmonary hypertension ...
Source: Cardiophile MD - June 7, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Non invasive cardiac output monitoring
Conventionally, measurement of cardiac output was done invasively. Initially with dye dilution techniques and later by thermodilution techniques. Both needed pulmonary artery catheterization, which in turn was likely to cause morbidity if used for continuous monitoring. Almost all non-invasive cardiac imaging modalities like echocardiography, computed tomography, magnetic resonance imaging and nuclear imaging can measure cardiac output. But these are not suitable for bedside monitoring, though echocardiography may be used for intermittent bedside assessment. Assessment of cardiac output though desirable, was most often ti...
Source: Cardiophile MD - June 6, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Metabolic modulation in heart failure
Most of the treatment strategies in heart failure like angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), angiotensin receptor-neprilysin inhibitors (ARNI) and beta blockers utilize hemodynamic modulation. Metabolic modulation on the other hand aims at dealing with myocardial energetic deficiency. Important agents in this group are trimetazidine, ranolazine and perhexiline [1]. Trimetazidine is a 3-ketoacyl coenzyme A thiolase inhibitor, while ranolazine inhibits the late sodium current. Perhexiline inhibits carnitine palmitoyl transferase. A meta-analysis on trimetazidine published in ...
Source: Cardiophile MD - May 23, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Chest X-ray in left to right shunts
Chest X-ray is a simple, cheap and easily available investigation for the evaluation of left to right shunts. But it is often avoided in pediatric age group due to concerns of radiation. Cardiac size and lung vascularity can be readily assessed and followed up serially [1]. Lung vascularity pattern is different in pre-tricuspid and post tricuspid shunts. Pattern changes with the development of pulmonary hypertension as the shunt decreases. Cardiac size also decreases when the shunt decreases. Cardiac chamber enlargements are also different according to the level of shunt. Chest X-ray in atrial septal defect Atrial septal ...
Source: Cardiophile MD - May 18, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Coronary angiographic views
Coronary angiography is done in multiple projections or views to get a three dimensional idea of the coronary lesions. Some regions of the coronary arteries may appear foreshortened in certain views so that true length of the lesion may not be appreciated. Actual severity of eccentric stenosis can be ascertained only by multiple orthogonal views. Even though there are several conventional views for coronary angiography, unusual angulations may be needed in an individual case to guide coronary interventions. Often a test shot is given before the actual cine run to see if the branches are overlapping or not. Common projecti...
Source: Cardiophile MD - May 16, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Angiography and Interventions Source Type: blogs

Ebstein ’ s anomaly and pregnancy
Ebstein’s anomaly and pregnancy Ebstein’s anomaly of tricuspid valve was first described by Wilhelm Ebstein in 1866 [1]. It is characterized by distal displacement of the septal and posterior leaflets of tricuspid valve. Anterior leaflet is elongated and sail like. A portion of the right ventricle is ‘atrialized’ due to the distal displacement of the tricuspid valve. Right atrium is often grossly dilated. Right to left shunting occurs across a patent foramen ovale producing cyanosis of variable extent. Ebstein’s anomaly is one of the cyanotic congenital heart diseases in which survival to adul...
Source: Cardiophile MD - May 14, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Management of aortic dissection
Aortic dissection is the most common aortic emergency. It is one of the three acute aortic syndromes, the others being aortic intramural hematoma and penetrating aortic ulcer. It has a grave prognosis with 20% pre hospital and 30% in hospital mortality. Aortic dissection is generally considered as acute when diagnosis is made within 14 days of onset and chronic after that. An intimal and medial tear in the aorta causes blood to seep into the media and the false lumen usually progresses along a variable extend of the aorta. Important risk factors for aortic dissection are hypertension, Marfan syndrome and bicuspid aortic ...
Source: Cardiophile MD - May 4, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Angiography and Interventions Cardiac Surgery Source Type: blogs

Basic principles of rotablation
Rotablation or rotational atherectomy uses a diamond coated burr to debulk complex atherosclerotic plaques which are difficult to treat with conventional balloon angioplasty. The physical principle of rotablation is differential cutting. The advancing rotablator burr selectively cuts inelastic material while elastic tissue deflects away from the burr. As 95% of the particles generated by rotablation are less than 5 microns in diameter, they are removed from the body by the reticuloendothelial system [1]. Thus the basic principle of rotablation is quite different from balloon dilatation in which there is displacement of a...
Source: Cardiophile MD - April 28, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Coronary Interventions Source Type: blogs

Neoatherosclerosis
Neointimal proliferation can occur within a coronary stent. Chronic inflammation within the neointima with infiltration of macrophages leads to neoatherosclerosis and result in in-stent restenosis. Disruption of neoatheroma can cause acute thrombotic occlusion [1]. Hence neoatherosclerosis is a complication of percutaneous coronary intervention and can present with recurrence of angina or acute coronary syndrome. Occurrence of neoatherosclerosis is earlier in drug eluting stents than in bare metal stents and has a greater prevalence. Late stent thrombosis due to rupture of the plaques with thin fibrous cap is associated ...
Source: Cardiophile MD - April 26, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

ISCHEMIA Trial – Review
ISCHEMIA Trial – Review International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial was funded by National Heart, Lung, and Blood Institute and others. 5179 patients with moderate or severe ischemia was randomized to an initial invasive strategy or an initial conservative strategy. Initial invasive strategy was angiography and revascularization when feasible. Initial conservative therapy was of medical treatment alone and angiography if medical therapy failed [1]. Primary composite outcome included death from cardiovascular causes, myocardial infarction or hospitaliz...
Source: Cardiophile MD - April 25, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Coronary Interventions Source Type: blogs

Health effects of partial hydrogenation of vegetable oils
Partially hydrogenated vegetable oils contain trans fatty acids which are different from the natural fatty acids in vegetable oils and animal fat [1]. Fatty acids in partially hydrogenated vegetable oils are 14 cis and trans isomers of octadecenoic and octadecadienoic acids that are formed during hydrogenation. Trans fatty acids cause inflammation and calcification of arterial walls. They also inhibit cyclooxygenase needed for conversion of arachidonic acid to prostacyclin, a compound beneficial for the vascular tree. There are reformulations of hydrogenated fat containing the essential fatty acid linoleic acid which get...
Source: Cardiophile MD - April 25, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Fetal and transitional circulation
Fetal circulation is different from adult circulation. The changes occurring soon after birth constitutes transitional circulation. Respiratory gas exchange in the fetus occurs in the placenta rather than the lungs. Fetal cardiovascular system is designed so that the most saturated blood reaches the heart and the brain. Fetal circulation can be called a shunt dependent circulation because there are intracardiac and extracardiac shunts [1]. Cardiac output in the fetus is called combined ventricular output (CVO). Despite the low oxygen partial pressures in fetal blood, presence of fetal hemoglobin and high combined ventric...
Source: Cardiophile MD - April 24, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Major aortopulmonary collateral arteries
Major aortopulmonary collateral arteries (MAPCA) occur in cyanotic congenital heart diseases with decreased pulmonary blood flow (tetralogy of Fallot like physiology). They are a natural protective mechanism to improve pulmonary blood flow. MAPCAs are more likely to occur in pulmonary atresia than in simple tetralogy of Fallot. MAPCAs can also occur in conditions other than the typical pulmonary atresia with ventricular septal defect. In a retrospective review of such cases, 33 had single ventricle anatomy while the rest had two ventricle anatomy. Among those with single ventricle, 15 had unbalanced complete atrioventricu...
Source: Cardiophile MD - April 23, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs

Non-compaction of left ventricle
Non-compaction of left ventricle is often classified as a cardiomyopathy and is characterized by abnormal deep trabeculations, which is more at the apex [1]. Left ventricular non-compaction can be associated with left ventricular dilatation or hypertrophy. Systolic and diastolic dysfunction can occur and other congenital heart diseases can be associated. Ventricular arrhythmias and complete atrioventricular block can occur and present as syncope or sudden cardiac death. Genetic transmission has been noted in 30-50% of patients and several genes have been implicated. NOTCH signaling pathway seems to be the final common pa...
Source: Cardiophile MD - April 23, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs