1) The document discusses various cases involving cardiac resynchronization therapy (CRT) implantation and troubleshooting.
2) Techniques described include accessing the coronary sinus using guidewires when dissection occurs and using a steerable catheter to engage alternative cardiac veins.
3) Optimizing outcomes involves addressing issues like phrenic nerve stimulation, adjusting atrioventricular delays, and replacing unstable leads over time.
This document provides guidelines for access to care for adults with congenital heart disease (ACHD). It recommends that ACHD patients receive care at regional ACHD centers of excellence that are equipped and staffed to meet their complex needs. These centers should coordinate care and be a resource for the medical community and patients. It also provides recommendations for the frequency of cardiac follow-up based on the complexity of a patient's congenital heart condition.
TAVR SAVR evolution of a groundbreaking therapyLuisArturo RV
TAVR has evolved from its first human implantation in 2002 to becoming a standard treatment for aortic stenosis. Pivotal clinical trials showed TAVR was superior to medical management for inoperable patients and non-inferior to SAVR for high-risk patients. Later trials found TAVR non-inferior to SAVR for intermediate-risk patients. The latest PARTNER 3 and Evolut trials found TAVR non-inferior and even superior to SAVR for low-risk patients, with lower rates of rehospitalization, stroke, and better functional improvement. Ongoing developments aim to reduce vascular complications, permanent pacemaker rates, and expand TAVR to younger patients. T
This document discusses catecholaminergic polymorphic ventricular tachycardia (CPVT), a condition characterized by adrenergically mediated polymorphic ventricular arrhythmias without structural heart disease. It has a prevalence of 1 in 10,000 and mortality of up to 50% before age 20 if untreated. The gold standard for diagnosis is exercise stress testing showing exercise-induced bidirectional or polymorphic ventricular tachycardia. Treatment involves lifestyle changes, beta-blockers, flecainide, and an ICD for those with cardiac arrest or recurrent arrhythmias despite medical therapy. Genetic testing identifies mutations in RYR2 or CASQ2 genes in the majority of cases.
This document discusses cardiac resynchronization therapy (CRT) for heart failure patients. Some key points:
- CRT improves symptoms, exercise tolerance, quality of life and reduces mortality for selected heart failure patients.
- Non-response to CRT remains a problem, occurring in 30-45% of patients.
- Patient selection factors like QRS duration, bundle branch block pattern and degree of ventricular dyssynchrony impact response.
- Optimal lead placement and device programming are important for response. Follow-up optimization of atrioventricular and interventricular delays can improve outcomes.
1) The document discusses various cases involving cardiac resynchronization therapy (CRT) implantation and troubleshooting.
2) Techniques described include accessing the coronary sinus using guidewires when dissection occurs and using a steerable catheter to engage alternative cardiac veins.
3) Optimizing outcomes involves addressing issues like phrenic nerve stimulation, adjusting atrioventricular delays, and replacing unstable leads over time.
This document provides guidelines for access to care for adults with congenital heart disease (ACHD). It recommends that ACHD patients receive care at regional ACHD centers of excellence that are equipped and staffed to meet their complex needs. These centers should coordinate care and be a resource for the medical community and patients. It also provides recommendations for the frequency of cardiac follow-up based on the complexity of a patient's congenital heart condition.
TAVR SAVR evolution of a groundbreaking therapyLuisArturo RV
TAVR has evolved from its first human implantation in 2002 to becoming a standard treatment for aortic stenosis. Pivotal clinical trials showed TAVR was superior to medical management for inoperable patients and non-inferior to SAVR for high-risk patients. Later trials found TAVR non-inferior to SAVR for intermediate-risk patients. The latest PARTNER 3 and Evolut trials found TAVR non-inferior and even superior to SAVR for low-risk patients, with lower rates of rehospitalization, stroke, and better functional improvement. Ongoing developments aim to reduce vascular complications, permanent pacemaker rates, and expand TAVR to younger patients. T
This document discusses catecholaminergic polymorphic ventricular tachycardia (CPVT), a condition characterized by adrenergically mediated polymorphic ventricular arrhythmias without structural heart disease. It has a prevalence of 1 in 10,000 and mortality of up to 50% before age 20 if untreated. The gold standard for diagnosis is exercise stress testing showing exercise-induced bidirectional or polymorphic ventricular tachycardia. Treatment involves lifestyle changes, beta-blockers, flecainide, and an ICD for those with cardiac arrest or recurrent arrhythmias despite medical therapy. Genetic testing identifies mutations in RYR2 or CASQ2 genes in the majority of cases.
This document discusses cardiac resynchronization therapy (CRT) for heart failure patients. Some key points:
- CRT improves symptoms, exercise tolerance, quality of life and reduces mortality for selected heart failure patients.
- Non-response to CRT remains a problem, occurring in 30-45% of patients.
- Patient selection factors like QRS duration, bundle branch block pattern and degree of ventricular dyssynchrony impact response.
- Optimal lead placement and device programming are important for response. Follow-up optimization of atrioventricular and interventricular delays can improve outcomes.
This document discusses low flow, low gradient aortic stenosis. It begins by introducing aortic stenosis and its prevalence. It then outlines the different types of low flow, low gradient aortic stenosis, including those with low ejection fraction and those with normal ejection fraction. For those with low EF, the document discusses the pathophysiology, importance of distinguishing true from pseudo-severe stenosis, and role of dobutamine stress echocardiography in making this distinction. It provides details on dobutamine stress echo protocol and parameters used to identify true severe stenosis versus pseudosevere stenosis.
High density lipoprotein cholesterol (HDL-c), often termed “good cholesterol”, is one of the major targets of cardiovascular risk reduction. Constant attempts have been made over the past 3 decades to increase their level in the blood in an attempt to reduce cardiovascular risk. In spite of these efforts, raising HDL-c still remains an enigma.
While several methods are known to raise HDL-c, they are not as dramatic as reduction of low density lipoprotein cholesterol (LDL-c). Statins, fibrates, niacin and cholesteryl-ester transfer protein (CETP) inhibitors are useful in increasing HDL-c. However, it was recently demonstrated that raising HDL-c using these pharmacological means did not have any significant effect on reducing clinical cardiovascular events. The 2013 ACC/AHA guidelines on managing blood cholesterol did not give much importance to HDL-c management too.
An important question is the method with which HDL-c is tested. Is HDL-cholesterol more important or HDL lipoprotein particle number? Are HDL-based therapies dead? Are there newer ongoing techniques that raise HDL cholesterol as well as reduce cardiovascular risk?
Shashikiran Umakanth presented this at the Egyptian Association of Endocrinology, Diabetes & Atherosclerosis (EAEDA) 2014 conference at Alexandria, Egypt. This conference was help in association with Endocrine Society, USA and the European Association for the Study of Diabetes (EASD).
The document discusses newer advancements in heart failure device therapy. It summarizes that device therapies have greatly improved outcomes for heart failure patients. Some key devices discussed include implantable cardioverter defibrillators (ICDs) which reduce sudden cardiac death, cardiac resynchronization therapy which improves heart function, and left ventricular assist devices (LVADs) which are increasingly being used as long term support devices or as a destination therapy for end stage heart failure patients. The document provides details on the development, indications, benefits and risks of these various heart failure devices.
This document summarizes recent clinical trials evaluating new treatments for heart failure with reduced ejection fraction (HFrEF). It finds that sodium-glucose cotransporter-2 inhibitors (SGLT2i) like dapagliflozin and empagliflozin are now foundational therapies for HFrEF as they reduce mortality, hospitalizations, and improve outcomes. Two novel agents, vericiguat and omecamtiv mecarbil, are described as well-tolerated therapies that may provide additional benefit by reducing residual risk in select HFrEF patients. Vericiguat is now FDA-approved and recommended by guidelines for recent worsening HF, while omecamtiv me
1) The study compared outcomes of STEMI patients undergoing primary PCI with thrombectomy (Group T) versus without thrombectomy (Group S).
2) MRI results at 3 months showed significantly smaller infarct size and less transmurality in Group T compared to Group S.
3) Procedural results favored Group T with higher rates of TIMI 3 flow and complete ST resolution. One-year outcomes also favored Group T with lower rates of MACE.
This document provides guidance on pre-procedural preparation and tips for CRT implantation. It discusses evaluating patients before implantation through imaging, labs, and clinical assessments. Key steps in implantation include accessing veins, placing the RV lead first usually in the septum, cannulating the coronary sinus, performing venograms to select target veins, and placing the LV lead aiming for the lateral or posterior wall. Positioning the leads to maximize electrical delay and hemodynamics is important.
Case presentation ,double chambered right ventricleAliaa Shaban
This document presents a case study of a 19-year-old male with a history of surgical closure of a ventricular septal defect and resection of a subaortic membrane as a child. He later developed shortness of breath. Transthoracic echocardiography revealed a double-chambered right ventricle, which is a rare congenital anomaly where an anomalous muscle band divides the right ventricle into two chambers. Though considered acquired, it is commonly associated with other congenital anomalies like ventricular septal defects. Surgical intervention is indicated for symptomatic patients or those with a peak gradient over 40 mm Hg.
Evaluation and management of Pacemaker malfunctionPRAVEEN GUPTA
The document discusses the evaluation and management of pacemaker malfunctions. It describes how to differentiate between various types of single chamber pacemaker malfunctions including pacing stimuli present with failure to capture, pacing stimuli present with failure to sense, and pacing stimuli absent. Common causes of these malfunctions are then outlined such as lead dislodgment, insulation defects, threshold increases, and undersensing. The document stresses the importance of obtaining baseline pacemaker data during initial programming and follow-up to properly diagnose malfunctions.
Esc guideline for atrial fibrillation 2020 [dr pranab]PranabanandaPal1
This document discusses atrial fibrillation (AF) and its management. It defines AF and describes its prevalence, complications, and patterns. It outlines how to confirm, characterize, and screen for AF. Investigations for AF are discussed. The integrated ABC pathway for managing AF is described, including assessing stroke risk and bleeding risk, and options for anticoagulation. Methods for rate control and rhythm control of AF are provided.
The document discusses surgical management of pulmonary stenosis, a congenital heart defect where the pulmonary valve is narrowed. It describes the embryology, causes, symptoms, diagnostic tests including echocardiogram and catheterization, and treatments including balloon valvuloplasty to widen the valve. Balloon valvuloplasty is the recommended treatment for symptomatic patients and helps avoid the need for open heart surgery.
Conduction system pacing as resynchronizationSergio Pinski
This document discusses various cardiac resynchronization therapies including biventricular pacing, His bundle pacing, and left bundle branch pacing. It notes that while biventricular pacing achieves imperfect resynchronization in about 20-30% of patients, His bundle pacing has been shown to fully correct left bundle branch block in some cases. Left bundle branch pacing is also discussed as an emerging therapy. The document reviews several studies comparing different resynchronization approaches and outlines criteria for assessing left bundle branch capture during pacing. It concludes by proposing a framework for selecting among resynchronization therapies based on the underlying conduction abnormality.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Cardiac resynchronization therapy (CRT) involves implanting electrodes in the left and right ventricles of the heart to coordinate their contractions and improve heart function in patients with heart failure. CRT works by delivering electrical pulses that resynchronize the timing of the ventricles' contractions. Studies show CRT can improve symptoms, exercise capacity, quality of life and reduce mortality and hospitalizations in heart failure patients. CRT devices include a pacemaker or defibrillator and leads placed in the heart to deliver electrical pulses. Doctors program the devices to optimize timing between the ventricles. CRT is effective for treating ventricular dyssynchrony seen in conditions like left bundle branch block.
Transcatheter Aortic Valve Replacement (TAVR): Established and Emerging Indic...Allina Health
By Paul Sorajja, MD. The efficacy and safety of transcatheter valve replacement in high-risk, non-operable patients is leading to new valve therapy options for a broader pateint population. "The options we have today to fix problems without opening the chest would have been unimaginable 10 years ago."
This document discusses routine follow-up procedures for patients with cardiac resynchronization therapy (CRT) devices. It recommends using the PBL-STOP method to review the patient's presenting rhythm, battery status, lead status, sensing, thresholds, and observations from the device. The device can provide 14 months of trended data on arrhythmias, activity levels, and fluid status that should be compared to the patient's reported symptoms. The trends can help assess issues like atrial fibrillation, heart rate variability, day and night heart rates, activity levels, fluid buildup, and how much pacing is received. The trend information should be evaluated to see if it matches any signs of worsening heart failure.
This document discusses percutaneous mitral valve interventions for mitral regurgitation. It begins by describing the anatomy of the mitral valve and causes of mitral regurgitation. It then discusses the natural history of mitral regurgitation and indications for surgery. Current percutaneous options are described including the MitraClip device, which is the only FDA approved one. The MitraClip procedure involves grasping the leaflets edges to reduce regurgitation. Early results show high rates of procedural success for MitraClip in patients at high risk for surgery. Complications are usually low at 15-19% and include bleeding, partial clip detachment, and stroke.
The document summarizes optimization of cardiac resynchronization therapy (CRT) post-implantation. It discusses:
1) Several methods for optimizing atrioventricular (AV) delay using echocardiography to maximize left ventricular filling, including Ritter's method, iterative method, and methods using left ventricular outflow tract velocity time integral or mitral inflow velocity time integral.
2) Methods for optimizing the ventricular-ventricular (VV) interval using electrocardiogram patterns.
3) Other optimization techniques including impedance cardiography, finger plethysmography, and algorithms using peak endocardial acceleration. Regular optimization is important to maximize benefits of CRT for selected patients.
This document discusses low flow, low gradient aortic stenosis. It begins by introducing aortic stenosis and its prevalence. It then outlines the different types of low flow, low gradient aortic stenosis, including those with low ejection fraction and those with normal ejection fraction. For those with low EF, the document discusses the pathophysiology, importance of distinguishing true from pseudo-severe stenosis, and role of dobutamine stress echocardiography in making this distinction. It provides details on dobutamine stress echo protocol and parameters used to identify true severe stenosis versus pseudosevere stenosis.
High density lipoprotein cholesterol (HDL-c), often termed “good cholesterol”, is one of the major targets of cardiovascular risk reduction. Constant attempts have been made over the past 3 decades to increase their level in the blood in an attempt to reduce cardiovascular risk. In spite of these efforts, raising HDL-c still remains an enigma.
While several methods are known to raise HDL-c, they are not as dramatic as reduction of low density lipoprotein cholesterol (LDL-c). Statins, fibrates, niacin and cholesteryl-ester transfer protein (CETP) inhibitors are useful in increasing HDL-c. However, it was recently demonstrated that raising HDL-c using these pharmacological means did not have any significant effect on reducing clinical cardiovascular events. The 2013 ACC/AHA guidelines on managing blood cholesterol did not give much importance to HDL-c management too.
An important question is the method with which HDL-c is tested. Is HDL-cholesterol more important or HDL lipoprotein particle number? Are HDL-based therapies dead? Are there newer ongoing techniques that raise HDL cholesterol as well as reduce cardiovascular risk?
Shashikiran Umakanth presented this at the Egyptian Association of Endocrinology, Diabetes & Atherosclerosis (EAEDA) 2014 conference at Alexandria, Egypt. This conference was help in association with Endocrine Society, USA and the European Association for the Study of Diabetes (EASD).
The document discusses newer advancements in heart failure device therapy. It summarizes that device therapies have greatly improved outcomes for heart failure patients. Some key devices discussed include implantable cardioverter defibrillators (ICDs) which reduce sudden cardiac death, cardiac resynchronization therapy which improves heart function, and left ventricular assist devices (LVADs) which are increasingly being used as long term support devices or as a destination therapy for end stage heart failure patients. The document provides details on the development, indications, benefits and risks of these various heart failure devices.
This document summarizes recent clinical trials evaluating new treatments for heart failure with reduced ejection fraction (HFrEF). It finds that sodium-glucose cotransporter-2 inhibitors (SGLT2i) like dapagliflozin and empagliflozin are now foundational therapies for HFrEF as they reduce mortality, hospitalizations, and improve outcomes. Two novel agents, vericiguat and omecamtiv mecarbil, are described as well-tolerated therapies that may provide additional benefit by reducing residual risk in select HFrEF patients. Vericiguat is now FDA-approved and recommended by guidelines for recent worsening HF, while omecamtiv me
1) The study compared outcomes of STEMI patients undergoing primary PCI with thrombectomy (Group T) versus without thrombectomy (Group S).
2) MRI results at 3 months showed significantly smaller infarct size and less transmurality in Group T compared to Group S.
3) Procedural results favored Group T with higher rates of TIMI 3 flow and complete ST resolution. One-year outcomes also favored Group T with lower rates of MACE.
This document provides guidance on pre-procedural preparation and tips for CRT implantation. It discusses evaluating patients before implantation through imaging, labs, and clinical assessments. Key steps in implantation include accessing veins, placing the RV lead first usually in the septum, cannulating the coronary sinus, performing venograms to select target veins, and placing the LV lead aiming for the lateral or posterior wall. Positioning the leads to maximize electrical delay and hemodynamics is important.
Case presentation ,double chambered right ventricleAliaa Shaban
This document presents a case study of a 19-year-old male with a history of surgical closure of a ventricular septal defect and resection of a subaortic membrane as a child. He later developed shortness of breath. Transthoracic echocardiography revealed a double-chambered right ventricle, which is a rare congenital anomaly where an anomalous muscle band divides the right ventricle into two chambers. Though considered acquired, it is commonly associated with other congenital anomalies like ventricular septal defects. Surgical intervention is indicated for symptomatic patients or those with a peak gradient over 40 mm Hg.
Evaluation and management of Pacemaker malfunctionPRAVEEN GUPTA
The document discusses the evaluation and management of pacemaker malfunctions. It describes how to differentiate between various types of single chamber pacemaker malfunctions including pacing stimuli present with failure to capture, pacing stimuli present with failure to sense, and pacing stimuli absent. Common causes of these malfunctions are then outlined such as lead dislodgment, insulation defects, threshold increases, and undersensing. The document stresses the importance of obtaining baseline pacemaker data during initial programming and follow-up to properly diagnose malfunctions.
Esc guideline for atrial fibrillation 2020 [dr pranab]PranabanandaPal1
This document discusses atrial fibrillation (AF) and its management. It defines AF and describes its prevalence, complications, and patterns. It outlines how to confirm, characterize, and screen for AF. Investigations for AF are discussed. The integrated ABC pathway for managing AF is described, including assessing stroke risk and bleeding risk, and options for anticoagulation. Methods for rate control and rhythm control of AF are provided.
The document discusses surgical management of pulmonary stenosis, a congenital heart defect where the pulmonary valve is narrowed. It describes the embryology, causes, symptoms, diagnostic tests including echocardiogram and catheterization, and treatments including balloon valvuloplasty to widen the valve. Balloon valvuloplasty is the recommended treatment for symptomatic patients and helps avoid the need for open heart surgery.
Conduction system pacing as resynchronizationSergio Pinski
This document discusses various cardiac resynchronization therapies including biventricular pacing, His bundle pacing, and left bundle branch pacing. It notes that while biventricular pacing achieves imperfect resynchronization in about 20-30% of patients, His bundle pacing has been shown to fully correct left bundle branch block in some cases. Left bundle branch pacing is also discussed as an emerging therapy. The document reviews several studies comparing different resynchronization approaches and outlines criteria for assessing left bundle branch capture during pacing. It concludes by proposing a framework for selecting among resynchronization therapies based on the underlying conduction abnormality.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Cardiac resynchronization therapy (CRT) involves implanting electrodes in the left and right ventricles of the heart to coordinate their contractions and improve heart function in patients with heart failure. CRT works by delivering electrical pulses that resynchronize the timing of the ventricles' contractions. Studies show CRT can improve symptoms, exercise capacity, quality of life and reduce mortality and hospitalizations in heart failure patients. CRT devices include a pacemaker or defibrillator and leads placed in the heart to deliver electrical pulses. Doctors program the devices to optimize timing between the ventricles. CRT is effective for treating ventricular dyssynchrony seen in conditions like left bundle branch block.
Transcatheter Aortic Valve Replacement (TAVR): Established and Emerging Indic...Allina Health
By Paul Sorajja, MD. The efficacy and safety of transcatheter valve replacement in high-risk, non-operable patients is leading to new valve therapy options for a broader pateint population. "The options we have today to fix problems without opening the chest would have been unimaginable 10 years ago."
This document discusses routine follow-up procedures for patients with cardiac resynchronization therapy (CRT) devices. It recommends using the PBL-STOP method to review the patient's presenting rhythm, battery status, lead status, sensing, thresholds, and observations from the device. The device can provide 14 months of trended data on arrhythmias, activity levels, and fluid status that should be compared to the patient's reported symptoms. The trends can help assess issues like atrial fibrillation, heart rate variability, day and night heart rates, activity levels, fluid buildup, and how much pacing is received. The trend information should be evaluated to see if it matches any signs of worsening heart failure.
This document discusses percutaneous mitral valve interventions for mitral regurgitation. It begins by describing the anatomy of the mitral valve and causes of mitral regurgitation. It then discusses the natural history of mitral regurgitation and indications for surgery. Current percutaneous options are described including the MitraClip device, which is the only FDA approved one. The MitraClip procedure involves grasping the leaflets edges to reduce regurgitation. Early results show high rates of procedural success for MitraClip in patients at high risk for surgery. Complications are usually low at 15-19% and include bleeding, partial clip detachment, and stroke.
The document summarizes optimization of cardiac resynchronization therapy (CRT) post-implantation. It discusses:
1) Several methods for optimizing atrioventricular (AV) delay using echocardiography to maximize left ventricular filling, including Ritter's method, iterative method, and methods using left ventricular outflow tract velocity time integral or mitral inflow velocity time integral.
2) Methods for optimizing the ventricular-ventricular (VV) interval using electrocardiogram patterns.
3) Other optimization techniques including impedance cardiography, finger plethysmography, and algorithms using peak endocardial acceleration. Regular optimization is important to maximize benefits of CRT for selected patients.
The document provides a summary of various news articles from November 23rd, 2015 related to the Indian economy and government/PSUs. Some key points mentioned are:
- Prime Minister Modi said the Indian economy is growing at 7.5% and is expected to grow faster in coming years.
- Rising oil consumption indicates the economy may be picking up momentum as sales of vehicles and fuels have increased.
- RBI Governor Rajan acknowledged that China's economic slowdown has adversely impacted India.
- S&P said India's credit rating could face stress if reforms stray from the government's agenda. Passing the GST bill would be viewed positively.
The document provides a summary of events from Balmer Lawrie in February 2016 related to their 150th Foundation Day celebrations. Key details include:
- Units across India celebrated the 150th Foundation Day on various dates in February with flag hoisting and messages from leadership.
- The Eastern Region celebration in Kolkata was addressed by the Hon'ble Minister of Petroleum and Natural Gas as chief guest.
- Upcoming events in March include National Safety Day and a safety awareness week. Balmer Lawrie will organize related programs.
- The document previews coverage of Foundation Day events in an upcoming special issue and highlights photos from various locations.
The document provides a summary of news related to Balmer Lawrie and other public sector enterprises (PSEs) in India. It includes articles discussing the Indian government maintaining retail inflation below 6%, plans to provide piped natural gas to Kolkata within 3 years, retail inflation rising to a 2-year high of 6.07% in July, exports declining 6.8% in July while gold imports fell over 50%, efforts by the government to finalize GST rules and implement the new tax system by April 2017, and Parliament approving the amended GST bill.
This document discusses several topics related to fetal and placental imaging:
1. T1-3D VIBE MRI sequences show intense and homogeneous enhancement of the normal placenta's intervillous space following contrast administration, while an IUGR placenta shows many patchy unperfused areas.
2. Myocardial tissue Doppler ultrasonography allows measurement of myocardial velocities in systole and diastole without limitations of conventional Doppler, providing a better assessment of fetal cardiac function.
3. A proposed algorithm for the management of intrahepatic cholestasis of pregnancy has some pitfalls, as fetal death can occur abruptly and cannot be reliably predicted from nonstress tests alone.
- BalmerLawrie received media coverage for inaugurating a library and reading room as part of its CSR initiatives.
- The Chairman and Managing Director of BalmerLawrie said the logistics business is the company's bottom line driver and they will invest Rs. 350 crore in growing this business in the next 2-3 years, including setting up temperature controlled warehouses and a multi-modal logistics hub.
- Several articles discussed issues related to public sector undertakings (PSUs) in India, including the government's plans to privatize or close sick PSUs, which labor unions are protesting.
This summary provides the key details from the document in 3 sentences:
The document discusses several news articles related to the Indian economy. It reports that Moody's expects India to grow 7.5% in the upcoming fiscal year, making it the fastest growing economy among G20 nations. It also mentions that the Indian government is taking steps to use surplus land from public sector enterprises for infrastructure projects and is lowering the threshold for e-procurement to Rs. 5 lakh to increase transparency.
1. ECOCARDIOGRAFIA FETALE DI
II LIVELLO
Prof. ssa Flavia Ventriglia
U.O.C. di Cardiologia Pediatrica
(direttore Prof. B. Marino)
2. ECOCARDIOGRAFIA FETALE II
LIVELLO
COSA E’?
Studio del cuore fetale con ultrasuoni durante la gestazione,
possibile dalla 16a settimana di e.g. fino al termine effettuata da
cardiologi pediatri al fine di effettuare un adeguato counselling ed
organizzare il follow-up e assistenza neonatale
INDICAZIONI
VANTAGGI
RISCHI
IMPLICAZIONI
PROBLEMATICHE MEDICO LEGALI
3. INDICAZIONI
GRAVIDANZE A RISCHIO ACCERTATO PER
CARDIOPATIE CONGENITE
FATTORI DI RISCHIO:
MATERNI, FAMILIARI, FETALI
MATERNI: DISORDINI METABOLICI (diabete)
ESPOSIZIONI A TERATOGENI
(farmaci, virus, radiazioni)
AUTOANTICORPI MATERNI (anti Ro)
5. FETALI:
- ritardo di crescita intrauterina
- poli – oligoidramnios
- gravidanze gemellari
- anomalie extracardiache
- anomalie cromosomiche e
genetiche
- aritmie fetali
- idrope non immune
- arteria ombelicale unica
- traslucenza nucale e/o IT (11-14 sett)
- sospetta cardiopatia all’esame
di I livello
INDICAZIONI
6. VANTAGGI
Possibilità di studiare la storia naturale
delle cardiopatie congenite in utero
Valutare più correttamente il rischio di
ricorrenza delle cardiopatie congenite
Attuare adeguati provvedimenti terapeutici
(diretti e/o indiretti)
7. Storia naturale in utero delle
cardiopatie congenite
Studio della evoluzione
anatomica
Verifica delle ipotesi
patogenetiche
Scompenso e/o morte
intrauterina
9. Verifica delle ipotesi
patogenetiche
Anomalie di migrazione del tessuto
ecto-mesenchimale
Morte cellulare
Anomalie della matrice
extracellulare
Anomalie del flusso intracardiaco
Anomalie del target di crescita
Anomalie del situs e del loop
10. Scopenso e morte
intrauterina
CAUSE
• ARITMIE FETALI
• ANEMIA
• CARDIOPATIE
CONGENITE CON
RIGURGITO
VALVOLARE
• ERNIA
DIAFRAMMATICA,
IGROMA CISTICO
• TRASFUSIONE FETO-
FETALE
• FISTOLE ARTERO-
VENOSE
11. Studio del Rischio di
Ricorrenza
• Lesioni più comuni sono quelle che
ricorrono più frequentemente (DIV)
• Se un figlio è affetto: 2-3%
• Se due o più figli sono affetti: 10%
• Se un genitore è affetto: 5%
• Se genitore è la madre : fino a 10%
• Studi con ecocardiografia fetale hanno
evidenziato maggior ricorrenza delle
ostruzioni dell’efflusso sn e eterotassia
12. Provvedimenti
Terapeutici
DIRETTI
• MEDICI:
terapia
transplacentare
aritmie e scompenso
• INVASIVI:
emodinamica
interventistica,
correzione in utero,
pacing
transaddominale
INDIRETTI
• CONDUZIONE
GRAVIDANZA:
prosecuzione o
interruzione,
anticipazione parto,
attesa, modalità del
parto
• PIANIFICAZIONE
DEL TRATTAMENTO
POST-NATALE
13. RISCHI
• Alterazioni teratogene con una
potenza > 100 mW/cm2
• Color Doppler < 100 mW/cm2
- basse PRF
- minima durata possibile
dell’esame
14. IMPLICAZIONI
• Il riconoscimento precoce in utero di una
malformazione cardiaca pone la madre e
il resto della famiglia di fronte a problemi
psicologici e talora a scelte etiche ed
esistenziali di notevole gravità.
• Fondamentale è la
CORRETTA, APPROFONDITA ED OBIETTIVA
informazione che deve essere data con
umanità alla coppia congiuntamente da
tutti gli specialisti coinvolti che
comprendono l’ostetrico, il neonatologo,
il cardiologo pediatra ed il
cardiochirurgo….COUNSELLING
15. PROBLEMI MEDICO-LEGALI
EMERGENTI - medicina difensiva
• Ritardo nella valutazione della malformazione
cardiaca oltre la 23 sett. (causa: liste di attesa
lunghe)
• Tempi ristretti tra la diagnosi e la decisione sulla
prosecuzione della gravidanza
• Falsi positivi - Falsi negativi
• Impossibilità della precisione diagnostica al 100%
• Possibilità dell’evoluzione della cardiopatia in una
forma più grave
• Il “counselling” quanto deve esporsi sulla prognosi
chirurgica della malformazione quando questa può
cambiare molto per piccole differenze
morfologiche?
16. ECOCARDIOGRAFIA FETALE
II LIVELLO - METODICA
• Definizione anatomica ed emodinamica
normale e patologica del cuore
• Identificazione di difetti settali, rigurgiti
valvolari, lesioni ostruttive
• Valutazione della funzione cardiovascolare
• Diagnosi e monitoraggio dei disturbi del
ritmo cardiaco
19. Per definizione anatomica seguire
approccio sistematico - sequenziale
(situs viscero-atriale, connessioni
veno-atriali, atri e forame ovale,
connessioni atrio-ventricolari,
ventricoli, connessioni ventricolo-
arteriose, arco aortico, dotto
arterioso, cordone ombelicale)
ECOCARDIOGRAFIA
FETALE II LIVELLO
TUTTE LE IMMAGINI ANATOMICHE DERIVANO DA AUTOPSIE SU FETI O NEONATI
CONSERVATI NEL MUSEO DI ANATOMIA PATOLOGICA DIRETTO DAL PROF. P. GALLO
30. ANOMALIE DEL SITUS ATRIALE – ISOMERISMO SINISTRO
ECOCARDIOGRAFIA FETALE
Approccio segmentario-sequenziale
Anomalie del Situs
AU
31. ECOCARDIOGRAFIA FETALE
Approccio segmentario – sequenziale
ISOMERISMO DX
SBOCCO DIRETTO IN ATRIO
DELLE VENE SOVRAEPATICHE
ISOMERISMO SN
AZYGOS CONTINUATION
AZ
AO
AO
AZ
AZ
AO
AZY
35. DOPPIO INGRESSO IN VENTRICOLO UNICO
ECOCARDIOGRAFIA FETALE
Approccio segmentario-sequenziale
Connessione atrio-ventricolare
tipo univentricolare
AD
AS
VU
as
ad
vu
36. ASSENTE CONNESSIONE ATRIO-VENTRICOLARE DX e SN
ATRESIA DELLA TRICUSPIDE – ATRESIA DELLA MITRALE
ECOCARDIOGRAFIA FETALE
Approccio segmentario-sequenziale
Connessione atrio-ventricolare
tipo univentricolare
AD
AS
AS
VD VSvs
vd
ad
as
37. CANALE AV COMPLETO A PREDOMINANZA
ECOCARDIOGRAFIA FETALE
Approccio segmentario-sequenziale
Connessione atrio-ventricolare
modo valvola unica
AD
AS
VD
VS
AU
VD
VS
AD AS
VD
VS
45. ATRESIA AORTICA E MITRALICA – S. CUORE SN IPOPLASICO
ECOCARDIOGRAFIA FETALE
Approccio segmentario-sequenziale
Connessione Ventricolo-Arteriosa
AD
AS
VD
VS
63. NUOVE FRONTIERE RMN
Da gennaio 2008 studiati con
ecografia ostetrica/
ecocardiografia/
RMN fetale oltre
150 feti:
- gruppo A: feti con
dislocazione del cuore per
patologia polmonare
- gruppo B: feti con sindrome
polimalformativa e cardiopatia
congenita
- gruppo C: feti con patologia
cardiaca isolata
POSSIBILE APPROCCIO
MULTIDISCIPLINARE
65. RINGRAZIAMENTI
• Al Prof. Colloridi mio maestro che
mi ha avviato a questa affascinante
branca della cardiologia fetale
• Al Prof. Marino mio attuale
primario che mi consente di
continuarla
• Alle mie strette collaboratrici
Dott.sse Caiaro e Martucci, che
volontariamente si offrono per
questo impegnativo lavoro e lo
rendono possibile con la loro
professionalità ed umanità
• A tutte le famiglie che
dignitosamente affrontano la
diagnosi di una cardiopatia nel loro
bambino
