Thrombus, tumor or vegetation?
This question is often faced by the echocardiographer while evaluating a mass detected on the heart valves or cardiac chambers. Usual method is to take it in the clinical context. There could also be non-infective vegetations of marantic endocarditis which are almost impossible to differentiate from infective vegetations. Marantic vegetations can be suspected in the presence of small and multiple vegetations changing from one examination to another, without associated abscess or valve destruction [1]. It may be noted that echocardiography is neither 100% specific nor 100% sensitive for the diagnosis of infective endocardi...
Source: Cardiophile MD - December 15, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Deep vein thrombosis of upper limbs vs lower limbs
The chance of pulmonary embolism is 6% for upper extremities, while it ranges from 15 – 30% with lower limbs. Recurrence at one year is 2-5% for upper extremities while it is 10% for lower extremities. The incidence of post thrombotic syndrome is much higher for lower extremities than upper extremities. (Source: Cardiophile MD)
Source: Cardiophile MD - December 10, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Types of LAD
Left anterior descending coronary artery, known in short as LAD has been classified into four types depending on the length:
Type 1: Does not supply the left ventricular apex.
Type 2: Supplies part of the apex, the rest being supplied by the right coronary artery.
Type 3: Supplies the entire apex.
Type 4: Supplies the apex and more than 25% of the inferior wall (wrap around LAD).
Reference
Rehman I, Kerndt CC, Rehman A. Anatomy, Thorax, Heart Left Anterior Descending (LAD) Artery. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncb...
Source: Cardiophile MD - December 9, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Pharmacological closure and maintaining patency of ductus arteriosus
Prostaglandin E1 is used for maintaining ductal patency in ductus dependent circulations [1]. Both oral [2] and intravenous paracetamol [3] have been used for pharmacological closure of patent ductus arteriosus in newborns. Indomethacin was the earlier drug being used for pharmacological ductal closure, but seldom used now because of its adverse effects. Then came ibuprofen, which is still being used. Paracetamol is the latest addition, with a better side effect profile than ibuprofen.
Ductus dependent circulations are classified into ductus dependent pulmonary circulations and ductus dependent systemic circulations. Bo...
Source: Cardiophile MD - December 6, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Predisposition to statin adverse effects
Some situations likely to predispose to statin adverse effects are impaired renal or hepatic function, history of previous statin intolerance or muscle disorders and unexplained elevation of SGPT. In addition to these, age above 75 years, Asian ancestry and previous hemorrhagic stroke are potential conditions to considered while considering high intensity statin therapy with regard to predisposition for adverse effects. Concomitant usage of drugs likely to affect statin metabolism should also be considered. (Source: Cardiophile MD)
Source: Cardiophile MD - December 5, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Potential disadvantages of perioperative heparin bridging
Some of the potential disadvantages of perioperative heparin bridging are risk of thromboembolism due to subtherapeutic dose, more prolonged total hospital stay and cost as well as inconvenience of heparin therapy.
In addition to this, there can be excessive bleeding during re-initiation of warfarin with heparin overlap. Hence continuing warfarin through the procedure is becoming standard of care in certain special instances. This is more applicable to procedures with relatively low bleeding risk in those with high risk of thromboembolism. Cataract surgery under topical anesthesia is one such potential situation in which ...
Source: Cardiophile MD - December 4, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Location of atherosclerotic plaques in relation to a myocardial bridge
Atherosclerotic plaques are usually located 20 – 30 mm proximal to the myocardial bridge. Reversal of systolic flow from the bridge segment has been noted on Doppler tracing. In the coronary segment proximal to the bridge, the retrograde flow collides with the antegrade flow, causing high systolic wall shear stress. This is thought to be the reason for the location of coronary plaques about 20 – 30 mm upstream of the myocardial bridge [1].
Reference
1. Tarantini G et al. Left Anterior Descending Artery Myocardial Bridging: A Clinical Approach. J Am Coll Cardiol. 2016 Dec 27;68(25):2887-2899. (Source: Cardiophile MD)
Source: Cardiophile MD - December 4, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
What is the best treatment option for prosthetic valve thrombosis presenting with stroke?
In patients having prosthetic valve thrombosis presenting with stroke, surgery is the first option as thrombolysis is contraindicated. Surgical treatment has a combined risk of death or stroke of 9%.
For prosthetic valve thrombosis without stroke:
If the thrombus in the prosthetic valve is less than 5 mm in size, only intravenous heparin is recommended. For larger thrombi there are two options: thrombolysis versus surgical treatment.
Thrombolysis has an initial success rate of 70 -80%, but there is a 5 -22% risk of embolism, and 5 -12% risk of disabling stroke. Thrombolysis is the preferred treatment ...
Source: Cardiophile MD - December 4, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
ECG Quiz with discussion – Pacing
ECG Quiz with discussion – Pacing
What are the important findings and diagnosis?
ECG shows a regular wide QRS rhythm at a rate of 60/minute. Each QRS complex is preceded by a narrow spike indicating ventricular paced rhythm. Dissociated P waves are seen suggesting that it is a single chamber ventricular pacing. Left bundle branch block pattern in I and aVL would mean right ventricular pacing. Inferior leads show negative QRS complexes indicating spread of activity from below upwards, suggesting right ventricular apical pacing. Right ventricular pacing causes left ventricular dyssynchrony and can cause left ventricul...
Source: Cardiophile MD - December 3, 2022 Category: Cardiology Authors: Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs
ECG Quiz with Discussion Katz-Wachtel phenomenon
Discussion Katz-Wachtel phenomenon
What does this ECG show?
This ECG shows Katz-Wachtel phenomenon with large biphasic QRS complexes in mid precordial leads. It is typically seen in infants with large ventricular septal defect and biventricular hypertrophy. In addition, there is sinus tachycardia and right axis deviation which are common in an infant. (Source: Cardiophile MD)
Source: Cardiophile MD - December 3, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
ECG Quiz with Discussion
Discussion
What does this ECG show?
This ECG shows Katz-Wachtel phenomenon with large biphasic QRS complexes in mid precordial leads. It is typically seen in infants with large ventricular septal defect and biventricular hypertrophy. In addition, there is sinus tachycardia and right axis deviation which are common in an infant. (Source: Cardiophile MD)
Source: Cardiophile MD - December 3, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
What is secondary AF?
Secondary AF has been defined as self limited atrial fibrillation caused by a reversible etiology. Conditions which cause secondary AF are myocardial infarction, myocarditis, pericarditis, acute pulmonary disease, hyperthyroidism, ethanol intoxication, sepsis and postoperative state. It is well known that postoperative AF can increase the morbidity and ICU/hospital stay after cardiac and non cardiac surgery.
Reference
Quon MJ, Behlouli H, Pilote L. Anticoagulant Use and Risk of Ischemic Stroke and Bleeding in Patients With Secondary Atrial Fibrillation Associated With Acute Coronary Syndromes, Acute Pulmonary Disease, or...
Source: Cardiophile MD - December 1, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Ellis classification of coronary perforation during PCI
Symbolic image of coronary perforation
Ellis classification is based on angiographic appearance of the perforation [1].
Grade I: Extraluminal crater without extravasation
Grade II: Pericardial or myocardial blushing
Grade III: Perforations of one or more millimeter diameter with contrast streaming or spilling
Reference
Ellis SG et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994 Dec;90(6):2725-30. (Source: Cardiophile MD)
Source: Cardiophile MD - December 1, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
In which of the three Eisenmenger syndromes is cardiomegaly unlikely?
In ventricular septal defect with Eisenmenger syndrome, cardiomegaly is unlikely. Though there will be cardiomegaly initially when there is a large left to right shunt, cardiac size regresses when left to right shunt decreases as pulmonary hypertension develops. Pulmonary arteries become prominent. Aorta is not prominent in VSD Eisenmenger. In patent ductus arteriosus with Eisenmenger syndrome, ascending aorta is prominent. Cardiac size comes down in PDA with large left to right shunt when pulmonary hypertension develops.
In atrial septal defect, cardiomegaly is mainly due to the enlarged right atrium. Pulmonary arteries ...
Source: Cardiophile MD - December 1, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Importance of cardiac imaging in patients with ventricular tachycardia
Late gadolinium enhancement on cardiac magnetic resonance imaging identifies scars likely to cause reentrant ventricular tachycardia. Ischemic scars are predominantly subendocardial while post inflammatory scars are predominantly sub epicardial. Scar in dilated cardiomyopathy is located in the mid wall region.
Imaging data is thus useful in deciding on the access (endocardial or epicardial approach) for ablation of ventricular tachycardia. Imaging will also tell us whether there is pericardial calcification which may interfere with catheter navigation in pericardial space in case of epicardial ablation. Similarly presence...
Source: Cardiophile MD - November 27, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
