This document summarizes a presentation on cardiac resynchronization therapy (CRT). It discusses how CRT works to restore synchronized heart contraction in patients with heart failure and ventricular dyssynchrony. It reviews several important clinical trials that demonstrated the benefits of CRT in reducing mortality and hospitalization. The document also discusses current guidelines for CRT, factors that can reduce the effectiveness of CRT, and ongoing areas of research around using CRT in populations with narrow QRS or mild heart failure symptoms.
This document provides an overview of cardiac resynchronization therapy (CRT). It discusses how conduction delays can lead to electromechanical dyssynchrony and impair the heart's function. CRT aims to improve this synchrony and thereby improve systolic and diastolic function. The document outlines different types of dyssynchrony and methods to assess it, including echocardiography. Current guidelines recommend CRT for symptomatic heart failure patients with low ejection fraction and wide QRS duration. The implantation procedure involves placing right atrial/ventricular leads and a left ventricular lead via the coronary sinus.
Device therapy for heart failure monitoring and managementDIPAK PATADE
The document discusses device therapy for heart failure management and monitoring. It notes that heart failure results in high mortality and morbidity and places a significant financial burden on healthcare systems. Implantable devices like implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) play an important role in managing advanced heart failure by treating arrhythmias, improving morbidity and mortality, and increasing quality of life. Several landmark randomized controlled trials provided evidence of the benefits of CRT in reducing mortality and improving outcomes for heart failure patients.
Device therapy for heart failure monitoring and managementDIPAK PATADE
1) Device therapy such as ICDs and CRT play an important role in managing advanced heart failure by treating life-threatening arrhythmias and improving morbidity and survival.
2) Clinical trials such as MUSTIC, MIRACLE, and CARE-HF demonstrated that CRT improves symptoms, exercise capacity, quality of life and reduces mortality in patients with heart failure and ventricular dyssynchrony.
3) The COMPANION trial showed that CRT with or without an ICD provided greater benefits than medical therapy alone in reducing the risk of all-cause mortality and hospitalizations.
This document provides an overview of cardiac transplant evaluation, management, surgery, and follow up. It discusses the history and indications for transplant, evaluation of potential recipients and donors, organ preservation techniques, transplant surgery including donor cardiectomy and implantation, and post-operative management including immunosuppression and complications. The goal of cardiac transplant is to provide an effective therapy for patients with end-stage heart failure.
1. Stroke is the third leading cause of death globally and its incidence is increasing in India due to risk factors like aging, smoking, and dietary habits.
2. The majority of strokes are ischemic (87%) with atrial fibrillation being the leading cause, and the rest are hemorrhagic.
3. Timely management following the stroke chain of survival - detection, dispatch, delivery, door, data, decision, drug, and disposition - can help improve outcomes. This includes administration of intravenous thrombolysis within 4.5 hours.
The document summarizes several studies on cardiac resynchronization therapy (CRT) for heart failure. The Block HF trial found that CRT was superior to right ventricular pacing alone in reducing death and heart failure-related events in patients with heart failure, left ventricular dysfunction, and AV block. Subsequent trials like COMPANION, CARE-HF, REVERSE, and MADIT-CRT also demonstrated benefits of CRT over medical therapy alone in improving outcomes like mortality, hospitalizations, quality of life and left ventricular function. Updated guidelines have expanded the use of CRT to patients in NYHA class I/II with left bundle branch block and QRS duration over 150ms.
Cardiac surgery is more difficult than other types of surgery due to the moving heart organ containing blood which is vital with no room for mistakes. Historical milestones like the heart-lung machine in 1937 and first coronary artery bypass graft in 1958 allowed cardiac surgery to become viable. Indications for cardiac surgery include CABG, valve repair/replacement, arrhythmia management, and congenital heart defects. Preop preparation assesses patient risk factors. During surgery, a heart-lung machine is used to bypass the heart and oxygenate blood while the surgeon operates. Common procedures like CABG graft arteries to improve blood flow. Postop care focuses on complications like hypothermia, bleeding, and low blood pressure.
- STEMI is a major cause of morbidity and mortality globally and in Saudi Arabia due to increasing risk factors. Only 42% of STEMI patients undergo primary PCI (PPCI) in Saudi Arabia, with only 62% achieving door-to-balloon times under 90 minutes. Mortality is influenced by factors like age, time to treatment, and presence of STEMI networks. PPCI is the preferred reperfusion strategy over fibrinolytics when possible. Guidelines recommend antiplatelet and anticoagulation medications during PPCI and secondary prevention medications like statins long-term.
This document provides an overview of cardiac resynchronization therapy (CRT). It discusses how conduction delays can lead to electromechanical dyssynchrony and impair the heart's function. CRT aims to improve this synchrony and thereby improve systolic and diastolic function. The document outlines different types of dyssynchrony and methods to assess it, including echocardiography. Current guidelines recommend CRT for symptomatic heart failure patients with low ejection fraction and wide QRS duration. The implantation procedure involves placing right atrial/ventricular leads and a left ventricular lead via the coronary sinus.
Device therapy for heart failure monitoring and managementDIPAK PATADE
The document discusses device therapy for heart failure management and monitoring. It notes that heart failure results in high mortality and morbidity and places a significant financial burden on healthcare systems. Implantable devices like implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) play an important role in managing advanced heart failure by treating arrhythmias, improving morbidity and mortality, and increasing quality of life. Several landmark randomized controlled trials provided evidence of the benefits of CRT in reducing mortality and improving outcomes for heart failure patients.
Device therapy for heart failure monitoring and managementDIPAK PATADE
1) Device therapy such as ICDs and CRT play an important role in managing advanced heart failure by treating life-threatening arrhythmias and improving morbidity and survival.
2) Clinical trials such as MUSTIC, MIRACLE, and CARE-HF demonstrated that CRT improves symptoms, exercise capacity, quality of life and reduces mortality in patients with heart failure and ventricular dyssynchrony.
3) The COMPANION trial showed that CRT with or without an ICD provided greater benefits than medical therapy alone in reducing the risk of all-cause mortality and hospitalizations.
This document provides an overview of cardiac transplant evaluation, management, surgery, and follow up. It discusses the history and indications for transplant, evaluation of potential recipients and donors, organ preservation techniques, transplant surgery including donor cardiectomy and implantation, and post-operative management including immunosuppression and complications. The goal of cardiac transplant is to provide an effective therapy for patients with end-stage heart failure.
1. Stroke is the third leading cause of death globally and its incidence is increasing in India due to risk factors like aging, smoking, and dietary habits.
2. The majority of strokes are ischemic (87%) with atrial fibrillation being the leading cause, and the rest are hemorrhagic.
3. Timely management following the stroke chain of survival - detection, dispatch, delivery, door, data, decision, drug, and disposition - can help improve outcomes. This includes administration of intravenous thrombolysis within 4.5 hours.
The document summarizes several studies on cardiac resynchronization therapy (CRT) for heart failure. The Block HF trial found that CRT was superior to right ventricular pacing alone in reducing death and heart failure-related events in patients with heart failure, left ventricular dysfunction, and AV block. Subsequent trials like COMPANION, CARE-HF, REVERSE, and MADIT-CRT also demonstrated benefits of CRT over medical therapy alone in improving outcomes like mortality, hospitalizations, quality of life and left ventricular function. Updated guidelines have expanded the use of CRT to patients in NYHA class I/II with left bundle branch block and QRS duration over 150ms.
Cardiac surgery is more difficult than other types of surgery due to the moving heart organ containing blood which is vital with no room for mistakes. Historical milestones like the heart-lung machine in 1937 and first coronary artery bypass graft in 1958 allowed cardiac surgery to become viable. Indications for cardiac surgery include CABG, valve repair/replacement, arrhythmia management, and congenital heart defects. Preop preparation assesses patient risk factors. During surgery, a heart-lung machine is used to bypass the heart and oxygenate blood while the surgeon operates. Common procedures like CABG graft arteries to improve blood flow. Postop care focuses on complications like hypothermia, bleeding, and low blood pressure.
- STEMI is a major cause of morbidity and mortality globally and in Saudi Arabia due to increasing risk factors. Only 42% of STEMI patients undergo primary PCI (PPCI) in Saudi Arabia, with only 62% achieving door-to-balloon times under 90 minutes. Mortality is influenced by factors like age, time to treatment, and presence of STEMI networks. PPCI is the preferred reperfusion strategy over fibrinolytics when possible. Guidelines recommend antiplatelet and anticoagulation medications during PPCI and secondary prevention medications like statins long-term.
1) Coronary artery bypass grafting (CABG) is performed to improve quality of life and reduce mortality for patients with coronary artery disease.
2) Anesthesia for CABG involves monitoring the patient throughout various stages including pre-bypass, maintenance on bypass, and weaning from bypass.
3) Key aspects include induction, myocardial protection through hypothermia and cardioplegia, and monitoring the patient closely during and after coming off bypass.
an updated account on management of TIA, Ischemic and hemorrhagic stroke in Sri Lanka. This is based on American Stroke Association and NICE guidelines.
1) The document discusses the recent management of acute ischemic stroke, outlining evaluation, diagnosis using imaging like CT and MRI, and treatment options including intravenous thrombolysis, intra-arterial thrombolysis, and mechanical thrombectomy.
2) Revascularization through restoration of blood flow is the main target in acute ischemic stroke management in order to minimize brain injury within the time window.
3) Prevention of future ischemic strokes involves optimal medical management as well as interventional procedures like carotid angioplasty and stenting for selected patients with carotid artery stenosis.
This document outlines a stroke management protocol to standardize and expedite treatment for acute ischemic stroke patients. It discusses the importance of minimizing delays from symptom onset to treatment administration given the time-sensitive nature of stroke. The protocol details steps in the pre-hospital, emergency department, and in-hospital phases including rapid neurological assessment, imaging, criteria evaluation, and intravenous thrombolysis administration if eligible, with a goal of completing the entire process within 60 minutes or less. Adhering closely to established guidelines and protocols is emphasized to optimize outcomes for stroke patients.
This document summarizes information on device therapy for congestive heart failure, including cardiac resynchronization therapy (CRT). It discusses:
1) The prevalence and mortality rates of heart failure in the US. Up to 30% of CHF patients have intraventricular conduction delays which increase mortality.
2) NYHA heart failure classifications and guidelines for CRT approval for classes III and IV.
3) Clinical trials that demonstrated the benefits of CRT including increased exercise capacity, quality of life, and decreased hospitalizations and mortality.
4) Anatomical challenges of CRT implantation via the coronary sinus and risks of the procedure. Proper lead placement is important to reduce asynchrony.
This document provides information on approaching a patient presenting with acute coronary syndrome (ACS). It defines ACS and its subtypes, including unstable angina, NSTEMI, and STEMI. It discusses the epidemiology, risk factors, pathophysiology, clinical features, investigations including ECG and cardiac markers, acute management including reperfusion therapies like PCI and thrombolytics, complications, and rehabilitation. The differential diagnosis for a 45-year-old male presenting with 5 hours of chest pain and tightness includes ACS, and the document provides details on evaluating and treating this common cardiovascular condition.
Introduction to afib, Epidemiology of afib, etiology of afib, Clinical presentation of people with afib, Investigation and management
AF related outcomes and complications and differential Diagnosis
Preoperative evaluation and management of vascular surgery patients is important to minimize complications. It includes assessing cardiac, pulmonary, renal, and diabetic status through history, exams, labs, and testing. Patients found to be high-risk may require optimization like smoking cessation or glucose control prior to elective surgery. During surgery, prophylaxis against DVT is recommended according to patient risk factors. Postoperative care focuses on glycemic control and resuming medications appropriately.
Acute coronary syndrome (ACS) results from an imbalance between myocardial oxygen supply and demand due to diminished blood flow from an occlusive coronary artery thrombus. ACS is classified as ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS), which includes non-STEMI and unstable angina. Treatment involves antiplatelet and anticoagulant medications, revascularization procedures like percutaneous coronary intervention (PCI), and lifestyle modifications to prevent recurrent events.
Patients admitted to the intensive care unit (ICU) are at increased risk for cardiac arrhythmias. They may be the reason for admission or resulting from the underlying condition. Treating exacerbating and contributing factors is the first step in management, however in certain cases may not be sufficient. Further the diagnosis of the arrhythmia may difficult from the ECG. An invasive cardiac electrophysiology study (EPS) can be helpful in establishing the diagnosis and can be combined with catheter ablation to eliminate the substrate. The field of cardiac electrophysiology is rapidly developing with technological advances providing insights into the mechanism of certain arrhythmias and expanding the therapeutic potential. This presentation will provide an overview of recent developments and insights into the management of common arrhythmias on the ICU.
This document provides an overview of atrial fibrillation including its definition, pathophysiology, diagnosis, treatment options and the Cox-Maze procedure. Atrial fibrillation is characterized by rapid, irregular contractions that result in ineffective pumping. It is caused by either focal triggers or reentrant wavelets circulating in the atria. Treatment involves rate control, anticoagulation and procedures to restore normal sinus rhythm such as the Cox-Maze procedure which uses incisions and ablation to disrupt the pathways that support reentrant wavelets.
The document summarizes updates from the 2015 CPR and ECC guidelines developed by the International Liaison Committee on Resuscitation (ILCOR). Key changes included emphasizing high-quality chest compressions, use of automated external defibrillators, and early defibrillation for cardiac arrest. The guidelines were informed by reviews of over 250 studies and recommendations were made using the GRADE methodology. Updates were provided for defibrillation, airway management, drug administration including epinephrine timing, and post-cardiac arrest care such as targeted temperature management.
Arrhythmia-induced cardiomyopathy (AIC) refers to left ventricular dysfunction caused by tachyarrhythmias or frequent ectopy. There are two types - type 1 is solely due to the arrhythmia, while type 2 involves an arrhythmia exacerbating an underlying cardiomyopathy. Successful treatment of the arrhythmia via catheter ablation or cardioversion can reverse the left ventricular dysfunction in type 1 AIC. Aggressive treatment with catheter ablation is recommended to eliminate the arrhythmia whenever possible in order to prevent or treat AIC.
This document provides an overview of mechanical circulatory support devices. It discusses the evolution of such devices and their terminology. Temporary devices discussed include intra-aortic balloon pumps and Impella pumps. Long-term devices discussed include pulsatile flow devices like HeartMate I as well as continuous flow devices like HeartMate II, HeartWare HVAD, and HeartMate 3. Clinical trials are summarized that evaluated these devices as bridges to transplant or destination therapy. Biventricular support devices like the total artificial heart are also covered. The document concludes with recommendations from organizations on the use of these devices.
EXERCISE TOLERANCE TESTING A BREIF NOTE.pptxAjilAntony10
This document provides information on exercise stress testing, including:
1. It describes exercise stress testing as a diagnostic and prognostic tool for assessing patients with suspected or known ischemic heart disease by evaluating their heart's response to increased metabolic demands during exercise.
2. It outlines the clinical relevance of exercise stress testing for evaluating patients with chest pain or known heart disease and notes sensitivity of 78% and specificity of 70% for detecting coronary artery disease.
3. It discusses protocols, safety considerations, electrocardiographic changes monitored, and contraindications for exercise stress testing.
Shortness of breath in a 51 year old womanescardio
This document describes the case of a 51-year-old woman presenting with progressive shortness of breath on exertion for 2 years. Echocardiography revealed features consistent with rheumatic mitral stenosis, including restricted leaflet motion and a mitral valve area of 1.1 cm2 by planimetry and 0.64 cm2 by pressure half-time. Due to favorable clinical factors but unfavorable anatomy, the patient underwent percutaneous mitral commissurotomy (PMC), which was successful in increasing her mitral valve area to 1.6 cm2 with only mild residual mitral regurgitation. She was discharged the next day on anticoagulation and maintained improved exercise capacity at 1
This document summarizes stroke treatment procedures at Beaumont Hospital from 2010-2013. It finds that 107 patients underwent mechanical thrombectomy for ischemic stroke, with 12 receiving general anesthesia. Risk factors for the GA patients included hypertension, smoking, and atrial fibrillation. Most strokes involved the middle cerebral or internal carotid arteries. Complications from the procedure included hemorrhage and low MRS scores at 3 months for GA patients. The need for GA may increase over time, requiring improved protocols to ensure safer anesthesia for high-risk stroke patients undergoing emergent clot retrieval.
An analysis of outcomes of emergency physicianDrArpan Chouhan
This study analyzed outcomes of emergency department-based thrombolysis for stroke performed at Scarborough Acute Trust in the UK between 2004-2009. 110 patients received thrombolysis for acute ischemic stroke. 79 patients treated through the emergency department had an average treatment time of 2.7 hours and 6-month mortality of 15%. 19 patients treated from hospital wards had a treatment time of 3.4 hours and 12% mortality. Outcomes were similar to other European cohorts. The study concluded that thrombolysis for acute ischemic stroke is achievable and safe in district general hospital settings.
This document discusses cardiovascular emergencies that commonly occur in dialysis patients, including pericarditis, ischemic heart disease, arrhythmias, hypotension, and air embolism. It provides details on the pathophysiology, risk factors, clinical presentation, diagnosis, and management of these conditions. Prevention strategies are also covered, such as monitoring electrolytes and dry weight to avoid hypotension, and using beta-blockers and ACE inhibitors to reduce mortality from heart failure.
LinkedIn for Your Job Search June 17, 2024Bruce Bennett
This webinar helps you understand and navigate your way through LinkedIn. Topics covered include learning the many elements of your profile, populating your work experience history, and understanding why a profile is more than just a resume. You will be able to identify the different features available on LinkedIn and where to focus your attention. We will teach how to create a job search agent on LinkedIn and explore job applications on LinkedIn.
1) Coronary artery bypass grafting (CABG) is performed to improve quality of life and reduce mortality for patients with coronary artery disease.
2) Anesthesia for CABG involves monitoring the patient throughout various stages including pre-bypass, maintenance on bypass, and weaning from bypass.
3) Key aspects include induction, myocardial protection through hypothermia and cardioplegia, and monitoring the patient closely during and after coming off bypass.
an updated account on management of TIA, Ischemic and hemorrhagic stroke in Sri Lanka. This is based on American Stroke Association and NICE guidelines.
1) The document discusses the recent management of acute ischemic stroke, outlining evaluation, diagnosis using imaging like CT and MRI, and treatment options including intravenous thrombolysis, intra-arterial thrombolysis, and mechanical thrombectomy.
2) Revascularization through restoration of blood flow is the main target in acute ischemic stroke management in order to minimize brain injury within the time window.
3) Prevention of future ischemic strokes involves optimal medical management as well as interventional procedures like carotid angioplasty and stenting for selected patients with carotid artery stenosis.
This document outlines a stroke management protocol to standardize and expedite treatment for acute ischemic stroke patients. It discusses the importance of minimizing delays from symptom onset to treatment administration given the time-sensitive nature of stroke. The protocol details steps in the pre-hospital, emergency department, and in-hospital phases including rapid neurological assessment, imaging, criteria evaluation, and intravenous thrombolysis administration if eligible, with a goal of completing the entire process within 60 minutes or less. Adhering closely to established guidelines and protocols is emphasized to optimize outcomes for stroke patients.
This document summarizes information on device therapy for congestive heart failure, including cardiac resynchronization therapy (CRT). It discusses:
1) The prevalence and mortality rates of heart failure in the US. Up to 30% of CHF patients have intraventricular conduction delays which increase mortality.
2) NYHA heart failure classifications and guidelines for CRT approval for classes III and IV.
3) Clinical trials that demonstrated the benefits of CRT including increased exercise capacity, quality of life, and decreased hospitalizations and mortality.
4) Anatomical challenges of CRT implantation via the coronary sinus and risks of the procedure. Proper lead placement is important to reduce asynchrony.
This document provides information on approaching a patient presenting with acute coronary syndrome (ACS). It defines ACS and its subtypes, including unstable angina, NSTEMI, and STEMI. It discusses the epidemiology, risk factors, pathophysiology, clinical features, investigations including ECG and cardiac markers, acute management including reperfusion therapies like PCI and thrombolytics, complications, and rehabilitation. The differential diagnosis for a 45-year-old male presenting with 5 hours of chest pain and tightness includes ACS, and the document provides details on evaluating and treating this common cardiovascular condition.
Introduction to afib, Epidemiology of afib, etiology of afib, Clinical presentation of people with afib, Investigation and management
AF related outcomes and complications and differential Diagnosis
Preoperative evaluation and management of vascular surgery patients is important to minimize complications. It includes assessing cardiac, pulmonary, renal, and diabetic status through history, exams, labs, and testing. Patients found to be high-risk may require optimization like smoking cessation or glucose control prior to elective surgery. During surgery, prophylaxis against DVT is recommended according to patient risk factors. Postoperative care focuses on glycemic control and resuming medications appropriately.
Acute coronary syndrome (ACS) results from an imbalance between myocardial oxygen supply and demand due to diminished blood flow from an occlusive coronary artery thrombus. ACS is classified as ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS), which includes non-STEMI and unstable angina. Treatment involves antiplatelet and anticoagulant medications, revascularization procedures like percutaneous coronary intervention (PCI), and lifestyle modifications to prevent recurrent events.
Patients admitted to the intensive care unit (ICU) are at increased risk for cardiac arrhythmias. They may be the reason for admission or resulting from the underlying condition. Treating exacerbating and contributing factors is the first step in management, however in certain cases may not be sufficient. Further the diagnosis of the arrhythmia may difficult from the ECG. An invasive cardiac electrophysiology study (EPS) can be helpful in establishing the diagnosis and can be combined with catheter ablation to eliminate the substrate. The field of cardiac electrophysiology is rapidly developing with technological advances providing insights into the mechanism of certain arrhythmias and expanding the therapeutic potential. This presentation will provide an overview of recent developments and insights into the management of common arrhythmias on the ICU.
This document provides an overview of atrial fibrillation including its definition, pathophysiology, diagnosis, treatment options and the Cox-Maze procedure. Atrial fibrillation is characterized by rapid, irregular contractions that result in ineffective pumping. It is caused by either focal triggers or reentrant wavelets circulating in the atria. Treatment involves rate control, anticoagulation and procedures to restore normal sinus rhythm such as the Cox-Maze procedure which uses incisions and ablation to disrupt the pathways that support reentrant wavelets.
The document summarizes updates from the 2015 CPR and ECC guidelines developed by the International Liaison Committee on Resuscitation (ILCOR). Key changes included emphasizing high-quality chest compressions, use of automated external defibrillators, and early defibrillation for cardiac arrest. The guidelines were informed by reviews of over 250 studies and recommendations were made using the GRADE methodology. Updates were provided for defibrillation, airway management, drug administration including epinephrine timing, and post-cardiac arrest care such as targeted temperature management.
Arrhythmia-induced cardiomyopathy (AIC) refers to left ventricular dysfunction caused by tachyarrhythmias or frequent ectopy. There are two types - type 1 is solely due to the arrhythmia, while type 2 involves an arrhythmia exacerbating an underlying cardiomyopathy. Successful treatment of the arrhythmia via catheter ablation or cardioversion can reverse the left ventricular dysfunction in type 1 AIC. Aggressive treatment with catheter ablation is recommended to eliminate the arrhythmia whenever possible in order to prevent or treat AIC.
This document provides an overview of mechanical circulatory support devices. It discusses the evolution of such devices and their terminology. Temporary devices discussed include intra-aortic balloon pumps and Impella pumps. Long-term devices discussed include pulsatile flow devices like HeartMate I as well as continuous flow devices like HeartMate II, HeartWare HVAD, and HeartMate 3. Clinical trials are summarized that evaluated these devices as bridges to transplant or destination therapy. Biventricular support devices like the total artificial heart are also covered. The document concludes with recommendations from organizations on the use of these devices.
EXERCISE TOLERANCE TESTING A BREIF NOTE.pptxAjilAntony10
This document provides information on exercise stress testing, including:
1. It describes exercise stress testing as a diagnostic and prognostic tool for assessing patients with suspected or known ischemic heart disease by evaluating their heart's response to increased metabolic demands during exercise.
2. It outlines the clinical relevance of exercise stress testing for evaluating patients with chest pain or known heart disease and notes sensitivity of 78% and specificity of 70% for detecting coronary artery disease.
3. It discusses protocols, safety considerations, electrocardiographic changes monitored, and contraindications for exercise stress testing.
Shortness of breath in a 51 year old womanescardio
This document describes the case of a 51-year-old woman presenting with progressive shortness of breath on exertion for 2 years. Echocardiography revealed features consistent with rheumatic mitral stenosis, including restricted leaflet motion and a mitral valve area of 1.1 cm2 by planimetry and 0.64 cm2 by pressure half-time. Due to favorable clinical factors but unfavorable anatomy, the patient underwent percutaneous mitral commissurotomy (PMC), which was successful in increasing her mitral valve area to 1.6 cm2 with only mild residual mitral regurgitation. She was discharged the next day on anticoagulation and maintained improved exercise capacity at 1
This document summarizes stroke treatment procedures at Beaumont Hospital from 2010-2013. It finds that 107 patients underwent mechanical thrombectomy for ischemic stroke, with 12 receiving general anesthesia. Risk factors for the GA patients included hypertension, smoking, and atrial fibrillation. Most strokes involved the middle cerebral or internal carotid arteries. Complications from the procedure included hemorrhage and low MRS scores at 3 months for GA patients. The need for GA may increase over time, requiring improved protocols to ensure safer anesthesia for high-risk stroke patients undergoing emergent clot retrieval.
An analysis of outcomes of emergency physicianDrArpan Chouhan
This study analyzed outcomes of emergency department-based thrombolysis for stroke performed at Scarborough Acute Trust in the UK between 2004-2009. 110 patients received thrombolysis for acute ischemic stroke. 79 patients treated through the emergency department had an average treatment time of 2.7 hours and 6-month mortality of 15%. 19 patients treated from hospital wards had a treatment time of 3.4 hours and 12% mortality. Outcomes were similar to other European cohorts. The study concluded that thrombolysis for acute ischemic stroke is achievable and safe in district general hospital settings.
This document discusses cardiovascular emergencies that commonly occur in dialysis patients, including pericarditis, ischemic heart disease, arrhythmias, hypotension, and air embolism. It provides details on the pathophysiology, risk factors, clinical presentation, diagnosis, and management of these conditions. Prevention strategies are also covered, such as monitoring electrolytes and dry weight to avoid hypotension, and using beta-blockers and ACE inhibitors to reduce mortality from heart failure.
Similar to Cardiac Resynchronisation therapy.pptx (20)
LinkedIn for Your Job Search June 17, 2024Bruce Bennett
This webinar helps you understand and navigate your way through LinkedIn. Topics covered include learning the many elements of your profile, populating your work experience history, and understanding why a profile is more than just a resume. You will be able to identify the different features available on LinkedIn and where to focus your attention. We will teach how to create a job search agent on LinkedIn and explore job applications on LinkedIn.
Learnings from Successful Jobs SearchersBruce Bennett
Are you interested to know what actions help in a job search? This webinar is the summary of several individuals who discussed their job search journey for others to follow. You will learn there are common actions that helped them succeed in their quest for gainful employment.
Parabolic antenna alignment system with Real-Time Angle Position FeedbackStevenPatrick17
Introduction
Parabolic antennas are a crucial component in many communication systems, including satellite communications, radio telescopes, and television broadcasting. Ensuring these antennas are properly aligned is vital for optimal performance and signal strength. A parabolic antenna alignment system, equipped with real-time angle position feedback and fault tracking, is designed to address this need. This document delves into the components, design, and implementation of such a system, highlighting its significance and applications.
Importance of Parabolic Antenna Alignment
The alignment of a parabolic antenna directly affects its performance. Even minor misalignments can lead to significant signal loss, which can degrade the quality of the received signal or cause communication failures. Proper alignment ensures that the antenna's focal point is accurately directed toward the signal source, maximizing the antenna's gain and efficiency. This precision is especially crucial in applications like satellite communications, where the antenna must track geostationary satellites with high accuracy.
Components of a Parabolic Antenna Alignment System
A parabolic antenna alignment system typically includes the following components:
Parabolic Dish: The primary reflector that collects and focuses incoming signals.
Feedhorn and Low Noise Block (LNB): Positioned at the dish's focal point to receive signals.
Stepper or Servo Motors: Adjust the azimuth (horizontal) and elevation (vertical) angles of the antenna.
Microcontroller (e.g., Arduino, Raspberry Pi): Processes sensor data and controls the motors.
Potentiometers: Provide feedback on the antenna's current angle positions.
Fault Detection Sensors: Monitor for potential faults such as cable discontinuities or LNB failures.
Control Software: Runs on the microcontroller, handling real-time processing and decision-making.
Real-Time Angle Position Feedback
Real-time feedback on the antenna's angle position is essential for maintaining precise alignment. This feedback is typically provided by potentiometers or rotary encoders, which continuously monitor the azimuth and elevation angles. The microcontroller reads this data and adjusts the motors accordingly to keep the antenna aligned with the signal source.
Fault Tracking in Antenna Alignment Systems
Fault tracking is vital for the reliability and performance of the antenna system. Common faults include cable discontinuities, LNB malfunctions, and motor failures. Sensors integrated into the system can detect these faults and either notify the user or initiate corrective actions automatically.
Design and Implementation
1. Parabolic Dish and Feedhorn
The parabolic dish is designed to reflect incoming signals to a focal point where the feedhorn and LNB are located. The dish's size and shape depend on the specific application and frequency range.
2. Motors and Position Control
Stepper motors or servo motors are used to control the azimuth and elevation of
I am an accomplished and driven administrative management professional with a proven track record of supporting senior executives and managing administrative teams. I am skilled in strategic planning, project management, and organizational development, and have extensive experience in improving processes, enhancing productivity, and implementing solutions to support business objectives and growth.
Joyce M Sullivan, Founder & CEO of SocMediaFin, Inc. shares her "Five Questions - The Story of You", "Reflections - What Matters to You?" and "The Three Circle Exercise" to guide those evaluating what their next move may be in their careers.
Khushi Saini, An Intern from The Sparks Foundationkhushisaini0924
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4. INTRODUCTION
IMPORTANT CLINICAL
STUDIES OF
PATIENTS WITH HF
AND WIDE
QRS COMPLEX
MECHANICAL
BENEFITS OF CRT
REDUCING THE
RATE OF
CRT NONRESPONSE
DETAILS OF
PROCEDURE
MARKERS OF
DYSSYNCHRONY
CRT
CURRENT
CONTROVERSY
AND FUTURE
DIRECTIONS
CURRENT
ACC/AHA/HRS
GUIDELINES
5. INTRODUCTION
• Systolic heart failure is a major problem globally & While pharmacologic therapy has drastically
improved outcomes in patients with systolic heart failure, hospitalizations from systolic heart
failure continue to increase and remain a major cost burden.
• Ventricular dyssynchrony arises because of delayed ventricular activation and contraction of the
ventricle, thereby disturbing the normally coordinated heartbeat
• In a dyssynchronously beating ventricle, one or more ventricular segments contract out of time
with the rest of the ventricle, which reduces the heart’s pumping efficiency by wasting energy and
worsening valvular regurgitation
• Approximately one third of patients with systolic heart failure (HF) and New York Heart Association
(NYHA) functional class III or IV symptoms suffer from dyssynchronous ventricular contraction4
• The aim of CRT is to restore mechanical synchrony by electrically activating the heart in a
synchronized manner
• There is strong evidence from randomized controlled trials showing that CRT combined with optimal
medical therapy improves HF symptoms, left ventricular ejection fraction (LVEF), and quality of life
(QOL),
while decreasing heart failure hospitalizations and reducing mortality
6. MARKERS OF DYSSYNCHRONY
• The American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm
Society (HRS) and Heart Failure Society of America (HFSA) guidelines for the use of cardiac
resynchronization therapy use a QRS duration of more than 120 ms on the 12-lead
electrocardiogram as a marker of ventricular dyssynchrony
• As the QRS complex represents ventricular depolarization, it follows that a wide QRS denotes
prolonged ventricular conduction time and nonsimultaneous activation of the ventricular walls.
7. • Cardiac resynchronization therapy is typically accomplished by adding a left ventricular pacing lead
to a standard pacemaker or defibrillator system, which typically includes right atrial and right
ventricular leads
• After cannulation of the coronary sinus, retrograde venography is performed to identify
coronary sinus anatomy. The pacing lead is then advanced into the target vein, ideally in the area of
the left ventricle with the greatest delay in contraction
• Optimal lead placement is dependent on the presence of an acceptable target vein, adequate
pacing capture threshold, lack of stimulation of the phrenic nerve and/or diaphragm, and lead
stability
8.
9. MECHANICAL BENEFITS OF CRT
1. cardiac resynchronization therapy has been shown to decrease all 3 types of dyssynchrony
2. Intraventricular dyssynchrony within the left ventricle, which is often most prominent between the
early-activated interventricular septum and late activated posterolateral wall
3. Interventricular (V-V) dyssynchrony between the left and right ventricles, which is most often the
result of delayed activation of the left ventricle due to left bundle branch block
4. Atrioventricular (A-V) dyssynchrony secondary to prolonged AV nodal conduction coupled with His-
Purkinje system dysfunction.
5. Another benefit of pacing from the left ventricular lateral wall is early activation of the anterolateral
papillary muscle, which can decrease the severity of mitral regurgitation.
6. Mitral regurgitation also can be reduced over time because of reverse remodeling
induced by CRT, which reduces left ventricular cavity size, thus reducing mitral annular diameter
and allowing mitral leaflet coaptation
11. MULTISITE STIMULATION IN
CARDIOMYOPATHY TRIAL
(MUSTIC TRIAL)
STUDY POPULATION
• EF less than 35%
• Sinus rhythm
• NYHA III-IV symptoms
• Left ventricular end diastolic
volume more than 60mm
• QRS duration > 150ms
Primary End points
• Exercise tolerance
• Quality of life improvement
• Peak oxygen consumption
( during Active biventricular
pacing for 3 months and backup
RV only pacing for another 3
months)
• REPORTED IN 2001
• ONE OF THE FIRST TRIAL DEMONSTRATING
SIGNIFACANT CLINAICAL IMPROVEMENT
WITH CRT
• SINGLE BLINDED CROSS OVER STUDY
RESULTS
Statistically significant improvement in
• 6 minutes walking distance
• Improved quality of life
• Improved oxygen consumption
12. MULTICENTER INSYNC
RANDOMIZAED CLINICAL
EVALUATION
(MIRACLE TRIAL)
STUDY POPULATION
• EF less than 35%
• Sinus rhythm
• NYHA III-IV symptoms
• Left ventricular end diastolic
volume more than 60 mm
• QRS duration > 130 ms
Primary End points
1. Deaths or hospitalization
secondary to heart failure
2. 6 minutes waking distance
3. Improvement in NYHA
function class
4. Quality of life
• Followed soon after the MUSTIC trial
• Sample size 453
• Randomization into CRT vs Control
groups
• Follow up time 6 months
RESULTS
Statistically significant improvement in
• Deaths or Hospitalization secondary to
heart failure
• Improvement in NYHA FC
• 6 minutes walking distance
• Improved quality of life
• Improved oxygen consumption
14. MULTICENTER INSYNC
RANDOMIZAED CLINICAL
EVALUATION ICD
(MIRACLE ICD TRIAL)
STUDY POPULATION
• EF less than 35%
• Sinus rhythm
• NYHA III-IV symptoms
• Left ventricular end diastolic
volume more than 60 mm
• QRS duration > 130 ms
Primary End points
1. 6 minutes waking distance
2. Improvement in NYHA
function class
3. Quality of life
4. Oxygen consumption
• First Randomized trial that evaluated
the effectiveness of CRT with an ICD
• Sample size 369
• Follow up duration 6 months
• Randomization to CRT-ICD on and
CRT-ICD off groups
RESULTS
Statistically significant improvement in
• Improvement in NYHA FC
• 6 minutes walking distance
• Improved quality of life
• Improved oxygen consumption
The MIRACLE ICD trial also demonstrated that
• CRT does not interfere with the function of ICD
• The time required for the device to detect first VFIB did
not differ between the two groups
• CRT did not have a significant effect on the percentage
of patients who suffered ventricular
tachyarrhythmia's or inappropriate device shocks.
15. COMPANION TRIAL
STUDY POPULATION
• EF less than 35%
• Sinus rhythm
• NYHA III-IV symptoms
• QRS duration > 120 ms
Primary End points
• Composite end point of time to
hospitalization or deaths from
any cause
Secondary end points
• All cause Mortality
• First Randomized trial that was powered
to evaluate the Effect of CRT on Mortality
• Sample size 1520
• Randomization into 3 treatment arms
1. Optimal medical therapy alone (OMT)
2. OMT plus CRT with pacing only (CRT-P)
3. OMT plus CRT with
pacemaker/defibrillator (CRT-D)
• Patient were assigned in a 1:2:2 fashion
• Follow up period 1 year
RESULTS
• The CRT-D group, but not the
CRT-P group, had a significant
reduction in overall mortality as
compared to the group receiving OMT
alone
• The CRT-P group barely missed
statistical significance for overall
mortality (P = 0.059)
16. Results of COMPANION TRIAL
Kaplan-Meier curve showing overall survival in the cardiac resynchronization therapy-pacemaker (CRT-P)
group, CRT-defibrillator (CRT-D) group, and control group in the COMPANION trial. The CRT-D cohort showed
a significant reduction in all-cause mortality, while the CRT-P cohort barely missed statistical significance for
this end point.
17. CARE-HEART FAILURE TRIAL
(CARE-HF TRIAL)
STUDY POPULATION
• EF equal or less than 35%
• Sinus rhythm
• NYHA III-IV symptoms
• QRS duration > 120 ms
Primary End points
• composite of all-cause mortality or
hospitalization for a major
cardiovascular event
Secondary End points
• all-cause mortality.
• Followed COMAPANION trial in 2005
• Sample size 813
• Randomization in OMT group CRT-P
group
• OMT group 404
• CRT-P group 409
• Of note only 8% of people were
having QRS between 120-150, rest
were having QRS> 150
RESULTS
• Compared to OMT alone, CRT-P was
associated with a significant reduction in
all-cause mortality and hospitalization for
major cardiovascular events at 29
months
• CARE-HF was the first trial to show
definitively that CRT-P, even in the
absence of ICD therapy, had a mortality
benefit
18. Combined end point of mortality and/or heart
failure hospitalization
all-cause mortality
Results of CARE-HF trial
19. CURRENT
ACC/AHA/HRS
GUIDELINES
Class I (‘‘Indicated’’)
• Treatment with CRT (with or without
an ICD) is indicated for patients with
sinus rhythm, LVEF of 35% or less,
QRSd of 120 ms or more, and NYHA
class III or ambulatory class IV HF
symptoms despite optimal medical
therapy
Class IIa (‘‘Reasonable’’)
• Treatment with CRT (with or
without an ICD) is considered
reasonable for patients with sinus
rhythm, LVEF of 35% or less, and
NYHA class III or ambulatory class IV
HF symptoms despite optimal
medical therapy, who have frequent
dependence on ventricular pacing
Class IIa (‘‘Reasonable’’)
• Treatment with CRT (with or
without an ICD) is
considered reasonable for patients
in atrial fibrillation (AF), LVEF of
35% or less, QRSd of 120 ms or
more, and NYHA class III or
ambulatory class IV HF symptoms
despite optimal medical therapy
Class IIb (‘‘May Be Considered’’)
• Treatment with CRT may be considered
for patients with sinus rhythm, LVEF of
35% or less, and NYHA class I or class II
HF symptoms, who are undergoing
implantation of a permanent
pacemaker/ICD with anticipated
frequent ventricular pacing
20. Class III (Not Indicated)
• Treatment with CRT is not indicated for
asymptomatic patients with reduced
LVEF in the absence of other
indications for pacing, or for those
whose functional status and life
expectancy are limited predominantly
by chronic noncardiac conditions
21. REDUCINGTHE RATE OF CRT NONRESPONSE
• Despite randomized controlled trials showing significant average improvements in morbidity and mortality
as a result of CRT, the number of patients who do not improve symptomatically remains high at 30%.
• for biventricular pacing to have any effect, pacing must occur. If the patient’s own heart rate
exceeds the device’s programmed lower rate limit, pacing is inhibited and the potential benefits
of resynchronization are missed completely
• Biventricular pacing appears to be of greatest benefit when the ventricle is paced frequently (as
close to 100% as possible)
• The presence of ischemic cardiomyopathy (rather than nonischemic cardiomyopathy) has been
shown to be an independent predictor for CRT nonresponse.
• A large scar burden with nonviable myocardium in the area of pacing, especially with a severely
enlarged and remodeled ventricle, can cause high capture thresholds and can influence mechanical
function.
22. CURRENT
CONTROVERSY
& FUTURE
DIRECTIONS
Patients with AF
Patients with a
relatively narrow QRSd
(120 ms)
Patients with right
bundle branch block
(RBBB)
Patients with NYHA
class I and II HF (ie,
asymptomatic or mildly
symptomatic)
23. Do patients with heart failure who have AF respond as well to CRT
as do patients in sinus rhythm?
• A meta-analysis of prospective cohort studies( totaling 1164 patients) comparing the
impact of CRT on patients in AF versus those in sinus rhythm showed similar
improvement in LVEF between the 2 groups.
• However, the benefit in functional outcome (measured by NYHA functional class, 6-
minute walking distance, for patients with AF was less than that for patients in sinus
rhythm.
• To achieve a high percentage of biventricularly paced beats in patients with AF, often
it is necessary to slow conduction through the AV node ( by the use of Beta blocker/
calcium channel blocker/ digoxin or catheter ablation of AV node).
24. CRT & NARROW QRS (<120MS)
THE
RESYNCHRONIZATION
THERAPY IN NARROW
QRS (RETHINQ TRIAL)
• First Randomized
control trial that
demonstrated the
effect of CRT in
patients with Narrow
QRS.
STUDY POPULATION
• EF 35% or Less
• NYHA class III
• QRS < 120
• Evidence of M
• mechanical dyssynchrony on
ECHO
PRIMARY END POINT
• Peak O2 consumption at 6
months
• Improvement in NYHA class
• Quality of Life
RESULTS
• The study failed to
demonstrate an
improvement in the
primary end points
25. CRT & NARROW QRS (<120MS)
• The RethinQ trial showed that CRT is not beneficial in patients with
systolic heart failure and QRSd of less than 120 ms
• Similar Trial ECHOCRT demonstrated the same Results
So in conclusion CRT is not Indicated In Patient with a Narrow QRS i-e QRS
duration Less than 120
26. CRT and NYHA class I & II
Does CRT cause reverse remodeling in asymptomatic or
mildly symptomatic left ventricular dysfunction, and thereby
slow progression of disease?
Resynchronization
Reverses Remodeling in
Systolic Left Ventricular
Dysfunction
(REVERSE) trial
Multicenter Automatic
Defibrillator Implantation
With Cardiac
Resynchronization Therapy
(MADIT-CRT) trial
27. CRT & NYHA class I & II
Resynchronization
Reverses Remodeling
in Systolic Left
Ventricular
Dysfunction
(REVERSE) Trial
• Design parallel,
blinded, Randomized
• Sample size 610
• NYHA Class I 18%
• NYHA class II 82%
• Randomization in
CRT-ON & CRT-OFF
• Follow up 5 years
STUDY POPULATION
• LV dysfunction (≤40%)
• Prolonged QRS duration
(≥120 ms)
• NYHA class I-II
• Optimal medical therapy
• No indication for
permanent pacing
PRIMARY END POINTS
• composite of all-cause
mortality
• heart failure hospitalization
• progression to a higher HF
class
• worsening global assessment
score.
RESULTS
• The study did show a
statistically significant
reduction in the
composite end point (34%
worsening in CRT-off versus
19% in CRT-on, P50.01)
28. CRT & NYHA class I & II
MADIT-CRT TRIAL
• Design parallel,
blinded, Randomized
• Sample size 1820
• ICM NYHA Class I
14% class II 40%
• NICM NYHA class II
45%
• Randomization into
3:2 into CRT-D or ICD
alone groups
• Follow up 7 years
STUDY POPULATION
• LV dysfunction (≤30%)
• Prolonged QRS duration
(≥120 ms)
• ICM NYHA class I-II
• NICM NYHA class II
• Optimal medical therapy
• Normal sinus rhythm
PRIMARY END POINTS
• composite of all-cause
mortality
• heart failure hospitalization
RESULTS
• there was a 29% reduction
in this combined end point in the
CRT-D group compared to the
group with ICD alone (P= 0.003)
• Reduction in primary end point was
driven primarily by 41% reduction
in Heart failure events alone
• No significant difference in
mortality
29. • Both REVERSE and MADIT-CRT trials
concluded that CRT may indeed be useful in slowing
the progression of mildly symptomatic systolic HF
• Therefore Patient with asymptomatic or Mild heart failure
(NYHA class I & II) with QRS equal or more than 120ms
benefits from Cardiac resynchronization therapy.
30. CRT and RBBB
How the addition of a left ventricular lead could improve synchrony
in patients whose right ventricular activation is delayed?
• RBBB can mask underlying concomitant delay in the left bundle
branch
• The benefit of CRT for patients with RBBB is an area of active investigation, and
further analysis of a larger cohort of patients is needed
• Currently, the ACC/AHA/HRS guidelines do not discriminate with regard to
specific QRS morphology in their CRT recommendations
Editor's Notes
greatest hemodynamic benefit of biventricular pacing occurs when the ventricles are paced as close to 100%of the time as possible
for patients with NYHA class III or IV HF and a wide QRS, CRT also has been shown to cause reverse remodeling, and this isthought to be one reason for the observed decrease in mortality seen in CRT trials.