- Left ventricular (LV) mass decreases significantly after aortic valve replacement (AVR) for both aortic stenosis and aortic regurgitation. However, the degree and pattern of regression differs between the two conditions.
- In aortic stenosis, AVR leads to reductions in both LV mass and the ratio of LV mass to LV volume, reflecting decreased concentric hypertrophy. This is accompanied by improved diastolic filling.
- In aortic regurgitation, LV mass decreases less after AVR while LV volume decreases more, increasing the LV mass to volume ratio and causing more eccentric remodeling. This is associated with worsening diastolic filling early after surgery.
- Long-term studies by
Cabg is superior to pci in heart failure patients with multivessel disease co...drucsamal
PCI is a good alternative to CABG for revascularization in patients with heart failure and viable myocardium. Revascularization of viable myocardium may improve left ventricular function and remodeling, as well as quality of life and survival. While CABG is technically straightforward and evidence-based, PCI has less risk for patients with heart failure despite being technically challenging. More research is still needed comparing PCI to CABG and medical therapy alone for chronic heart failure. Treatment must be individualized based on patient characteristics and local clinical expertise.
This document discusses fractional flow reserve (FFR), which is a technique used to functionally assess the significance of coronary artery stenosis. FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow if there was no stenosis. It is calculated as the ratio of mean distal coronary pressure (Pd) to mean aortic pressure (Pa) during maximal hyperemia induced by pharmacological agents. An FFR value below 0.75 is associated with inducible ischemia, while a value above 0.80 indicates an insignificant stenosis in most cases. FFR has advantages over angiography alone in evaluating stenosis as it accounts for vessel characteristics like length and takes collateral flow into consideration.
The document discusses the physiology of coronary blood flow and the microcirculation. Some key points include:
- Coronary blood flow is determined not only by proximal pressures but also by active compression and decompression of the microcirculation.
- Distal coronary pressure is influenced by both pressure transmitted from the aorta and pressure arising from the microcirculation.
- Fractional flow reserve (FFR) provides a measure of maximum achievable blood flow through a stenosis compared to a normal artery, indicating the functional significance of the stenosis.
- An FFR below 0.80 accurately identifies lesions causing ischemia, while a value above 0.80 reliably excludes ischemia.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
Left bundle branch block (LBBB) is a conduction abnormality with a prevalence of 0.2-2% that is commonly caused by myocardial infarction, coronary artery disease, hypertension, and cardiomyopathies. LBBB can occur transiently due to tachycardia, exercise, or other acute conditions. It involves delayed conduction in the left ventricle that can persist until heart rate slows. Patients with LBBB require cardiac evaluation and have a poorer prognosis, especially those with underlying heart failure or myocardial infarction who are at higher risk for underdiagnosis and lack of reperfusion therapy.
In the first part of this study, we identified the existence of a diastolic interval in which intracoronary resistance at rest is equivalent to time-averaged resistance during FFR measurements. We hypothesize that pressure measurements obtained selectively at this specific interval of the cardiac cycle would allow a new pressure-derived index of stenosis severity that does not require pharmacologic vasodilation; we term this the instantaneous wave-free ratio (iFR). In the second part of the study, this hypothesis was tested in a larger population by comparing iFR and FFR measurements.
This document discusses the diagnosis of myocardial infarction (MI) in the presence of bundle branch blocks. It notes that bundle branch blocks can make ECG diagnosis of MI more difficult by altering depolarization patterns. For right bundle branch block, the criteria for diagnosing a Q-wave MI are the same as normal conduction. For left bundle branch block, the Sgarbossa criteria (ST elevation concordant with QRS, ST depression in V1-V3, discordant ST elevation ≥5mm) have high specificity but low sensitivity for acute MI diagnosis. Certain ECG patterns like abnormal Q waves may suggest prior infarction despite left bundle branch block.
Bundle branch blocks occur when the left or right bundle branch is blocked, preventing normal conduction of electrical impulses through the ventricles. Right bundle branch block is usually benign but can worsen prognosis in acute myocardial infarction by indicating occlusion of the proximal left anterior descending artery. Left bundle branch block is more serious as it can mask signs of myocardial infarction and worsen prognosis in acute infarction. The Sgarbossa criteria can help diagnose myocardial infarction in the presence of left bundle branch block. Left anterior and posterior hemiblocks involve conduction abnormalities localized to one side of the ventricles.
Cabg is superior to pci in heart failure patients with multivessel disease co...drucsamal
PCI is a good alternative to CABG for revascularization in patients with heart failure and viable myocardium. Revascularization of viable myocardium may improve left ventricular function and remodeling, as well as quality of life and survival. While CABG is technically straightforward and evidence-based, PCI has less risk for patients with heart failure despite being technically challenging. More research is still needed comparing PCI to CABG and medical therapy alone for chronic heart failure. Treatment must be individualized based on patient characteristics and local clinical expertise.
This document discusses fractional flow reserve (FFR), which is a technique used to functionally assess the significance of coronary artery stenosis. FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow if there was no stenosis. It is calculated as the ratio of mean distal coronary pressure (Pd) to mean aortic pressure (Pa) during maximal hyperemia induced by pharmacological agents. An FFR value below 0.75 is associated with inducible ischemia, while a value above 0.80 indicates an insignificant stenosis in most cases. FFR has advantages over angiography alone in evaluating stenosis as it accounts for vessel characteristics like length and takes collateral flow into consideration.
The document discusses the physiology of coronary blood flow and the microcirculation. Some key points include:
- Coronary blood flow is determined not only by proximal pressures but also by active compression and decompression of the microcirculation.
- Distal coronary pressure is influenced by both pressure transmitted from the aorta and pressure arising from the microcirculation.
- Fractional flow reserve (FFR) provides a measure of maximum achievable blood flow through a stenosis compared to a normal artery, indicating the functional significance of the stenosis.
- An FFR below 0.80 accurately identifies lesions causing ischemia, while a value above 0.80 reliably excludes ischemia.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
Left bundle branch block (LBBB) is a conduction abnormality with a prevalence of 0.2-2% that is commonly caused by myocardial infarction, coronary artery disease, hypertension, and cardiomyopathies. LBBB can occur transiently due to tachycardia, exercise, or other acute conditions. It involves delayed conduction in the left ventricle that can persist until heart rate slows. Patients with LBBB require cardiac evaluation and have a poorer prognosis, especially those with underlying heart failure or myocardial infarction who are at higher risk for underdiagnosis and lack of reperfusion therapy.
In the first part of this study, we identified the existence of a diastolic interval in which intracoronary resistance at rest is equivalent to time-averaged resistance during FFR measurements. We hypothesize that pressure measurements obtained selectively at this specific interval of the cardiac cycle would allow a new pressure-derived index of stenosis severity that does not require pharmacologic vasodilation; we term this the instantaneous wave-free ratio (iFR). In the second part of the study, this hypothesis was tested in a larger population by comparing iFR and FFR measurements.
This document discusses the diagnosis of myocardial infarction (MI) in the presence of bundle branch blocks. It notes that bundle branch blocks can make ECG diagnosis of MI more difficult by altering depolarization patterns. For right bundle branch block, the criteria for diagnosing a Q-wave MI are the same as normal conduction. For left bundle branch block, the Sgarbossa criteria (ST elevation concordant with QRS, ST depression in V1-V3, discordant ST elevation ≥5mm) have high specificity but low sensitivity for acute MI diagnosis. Certain ECG patterns like abnormal Q waves may suggest prior infarction despite left bundle branch block.
Bundle branch blocks occur when the left or right bundle branch is blocked, preventing normal conduction of electrical impulses through the ventricles. Right bundle branch block is usually benign but can worsen prognosis in acute myocardial infarction by indicating occlusion of the proximal left anterior descending artery. Left bundle branch block is more serious as it can mask signs of myocardial infarction and worsen prognosis in acute infarction. The Sgarbossa criteria can help diagnose myocardial infarction in the presence of left bundle branch block. Left anterior and posterior hemiblocks involve conduction abnormalities localized to one side of the ventricles.
Assessment of Intermediate Coronary Artery Lesion with Fractional Flow Reserv...Premier Publishers
Fraction flow reserve (FFR) is considered the gold standard for assessing intermediate coronary lesions. Retrospective data analyses showed variable relationship between intravascular ultrasound (IVUS) parameters and FFR results. This study aimed to determine the optimal minimum lumen area (MLA) by IVUS that correlates with FFR and to assess the correlation between two modalities in assessing intermediate coronary lesions. Methods: Fifty eight intermediate coronary lesions mainly located in proximal and mid segments of large main coronary vessels with RVD (3-4mm) were analyzed using both IVUS and FFR to assess the significance of coronary stenting and to determine the optimal IVUS-MLA that correlates with FFR value < 0.8. Results: IVUS-MLA ranged from 2.5 to 4.2 mm2 had a highly significant positive correlation with FFR value < 0.8 (p < 0.0001). Using the ROC curve analysis, IVUS-MLA < 3.9 mm2 (84.2% sensitivity, 80% specificity, area under curve (AUC) = 0.68) was the best threshold value for identifying FFR <0.8>< 0.8 in coronary vessels with RVD (3-4mm). Different MLA cutoffs should be used for different vessel diameters.
1. Left bundle branch block (LBBB) is a conduction abnormality caused by impaired conduction in the left bundle branch or its fascicles.
2. LBBB can be chronic or intermittent and is often caused by coronary artery disease or hypertension.
3. On ECG, LBBB is characterized by a QRS duration ≥120ms and other abnormalities including broad R waves and abnormal ST-T wave patterns.
4. LBBB can make ECG diagnosis of myocardial infarction difficult and criteria like Sgarbossa scores are used to help identify MI in the setting of LBBB.
This document discusses fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), which are used to assess the severity of a stenosis. It notes that calculating FFR requires making assumptions and simplifications from a fluid mechanics perspective. Specifically, it assumes hydraulic models, neglects venous pressure, assumes equal myocardial resistances, and faces challenges in measuring distal pressure due to dynamic pressure effects, which are more problematic at higher flow rates. The document suggests iFR measurement of distal pressure could be even more inaccurate due to typically higher velocities during the wave-free period.
The document summarizes research on aortic dilatation in patients with bicuspid aortic valves. Key points include:
- Bicuspid aortic valves affect 1.3% of the population and are responsible for more deaths than other congenital heart defects. Approximately 50% of patients with a bicuspid valve also have dilatation of the aorta.
- There are three main patterns of aortic dilatation associated with bicuspid valves - types 1, 2, and 3 - which involve different segments of the aorta.
- The prevalence of aortic dilatation increases with age and ranges from 20-84% depending on the study. Dilatation begins in childhood and progresses
1. The seminar discussed coronary blood flow and myocardial oxygen consumption. Key determinants include heart rate, systolic pressure, and left ventricular contractility.
2. Myocardial oxygen extraction is near maximal at rest, so increases in demand are met by proportional increases in coronary flow and oxygen delivery.
3. Fractional flow reserve measures the ratio of distal coronary pressure to aortic pressure during maximal hyperemia. An FFR below 0.75 is associated with ischemia while above 0.80 is usually not.
The document discusses the history and details of the arterial switch operation (ASO) for transposition of the great arteries (TGA). It provides a timeline of pioneers of techniques from 1959 to 1989. It then discusses specifics of the neonatal repair procedure, important technical aspects like coronary transfer techniques, and factors that influence long term outcomes like coronary patterns, ventricular function, and rhythm disturbances. It concludes with take home messages that earlier ASO leads to better results and the procedure now has a mortality rate of less than 5%, making it safe.
Spinal cord protection in aortic surgeriesthanigai arasu
Spinal cord protection is important during aortic surgeries to prevent neurological deficits. The risk is highest with open thoracoabdominal aortic aneurysm (TAAA) repair. Techniques to protect the spinal cord include minimizing ischemia time, increasing cord tolerance through hypothermia, augmenting perfusion, and monitoring for ischemia. Early detection of ischemia allows interventions like reattachment of segmental arteries or modifying perfusion to salvage the cord. While endovascular repair reduces risk compared to open surgery, open repair requires strategies like distal aortic perfusion, cerebrospinal fluid drainage and evoked potential monitoring to optimize spinal cord protection.
This document discusses the physiological basis of coronary revascularization. It covers topics such as coronary physiology, myocardial viability assessment, and coronary revascularization. Some key points include:
- Coronary blood flow is proportional to perfusion pressure over resistance and is regulated by various metabolic and endothelial factors.
- Myocardial ischemia occurs when oxygen demand exceeds supply. Coronary autoregulation and flow reserve help maintain adequate flow.
- Myocardial viability refers to dysfunctional tissue with limited scarring that has potential for functional recovery after revascularization through mechanisms like stunned myocardium and hibernation.
- Various techniques can assess viability including cardiac imaging and evaluating improvement in function after revascularization. Viability assessment aids decisions about revascularization
This article reviews the role of invasive hemodynamics in the care of patients across the
entire spectrum of human heart failure.
Conceptual principles of ventricular function, ventricular-arterial interaction, load
response, and ventricular interaction in the right and left heart are reviewed.
Principles and practice of invasive exercise testing are provided, along with detailed
discussions on the role of invasive hemodynamics in the evaluation and management of
advanced heart failure, shock, mechanical circulatory support, and pulmonary
hypertension.
Isolated monomorphic premature ventricular complexes (PVCs) without
structural heart disease are generally benign.
► Frequent PVCs can cause reversible cardiomyopathy or aggravate an existing
cardiomyopathy.
► Short coupled PVCs can trigger sustained ventricular fibrillation. These are
often from the Purkinje tissue or rarely the outflow tract.
► Beta blockers are considered first-line therapy but have low efficacy.
Catheter ablation and AADs are reasonable to suppress PVCs in appropriate
patients.
► Ablation is often curative and success depends on location and accessibility
of PVCs.
► Implantable defibrillators are reasonable in patients at higher risk of sudden
cardiac death.
ECG Interpretation
The ECG is used to diagnose heart conditions by representing the electrical activity of the heart over time. It can detect abnormalities in heart rhythm, rate, and structure. A standard ECG has 12 leads that examine the heart from different angles. Common things to analyze include rhythm, rate, axis, waves, intervals, and complexes. Various arrhythmias and conduction abnormalities can be identified based on their characteristic ECG patterns.
(1) Premature ventricular contractions (PVCs) were traditionally thought to be benign, but can sometimes lead to left ventricular dysfunction or cardiomyopathy, known as PVC-induced cardiomyopathy (PVCI-CMP).
(2) High PVC burden (over 20% of heartbeats), long duration of symptoms, and PVCs originating from the epicardium or left ventricle are risk factors for developing PVCI-CMP.
(3) Treatment options for symptomatic PVCI-CMP include medications, which have adverse effects, or catheter ablation, which has high success rates of over 80% in reducing PVC burden and improving left ventricular function.
1. The document discusses electrocardiogram (ECG) findings in a patient presenting with left bundle branch block (LBBB) and possible myocardial infarction (MI).
2. It outlines criteria like the Sgarbossa criteria that can help identify ST segment changes indicating MI in the setting of LBBB, though these have limited sensitivity.
3. Serial ECGs and cardiac enzyme levels are also useful to help diagnose MI in patients with LBBB due to the challenges of ECG interpretation.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
Echocardiography plays an important role in diagnosing ischemic heart disease through evaluating wall motion abnormalities, localizing infarcts, assessing infarct size, and detecting complications. It can detect abnormalities such as ventricular rupture, pseudoaneurysms, ventricular septal defects, and clots. Stress echocardiography enhances interpretation of stress tests and evaluates functional importance of coronary artery disease. Echocardiography is accurate for evaluating patients with known or suspected coronary artery disease.
This document discusses coronary blood flow physiology, including the determinants of coronary resistance, autoregulation, microcirculation, and how blood flow is affected by exercise and the presence of coronary stenosis. It covers topics like the three resistance beds, flow-mediated dilation, metabolic mediators, neural and paracrine control, and the pushing and suction wave mechanism of diastolic flow. Measurement techniques and abnormalities in blood flow with normal coronary arteries are also briefly mentioned.
This case report describes an 82-year-old male who developed intracardiac shunts following a redo aortic valve replacement surgery. Doppler echocardiography detected shunts from the left ventricle outflow tract across the membranous septum into the right atrium, right ventricle, and left atrium. The anatomical basis for this complication is the proximity and relationship of the thin membranous septum to the aortic root, tricuspid valve, and ventricular chambers. Aggressive debridement during valve surgery can cause injury and necrosis of the membranous septum, leading to fistula formation over time. While the shunts were initially small and asymptomatic, they could enlarge
The document summarizes key aspects of coronary blood flow regulation and determinants of myocardial oxygen consumption. It discusses how:
1) Myocardial contraction and oxygen delivery are closely linked, and the balance between oxygen supply and demand is critical for normal heart function.
2) The major determinants of myocardial oxygen consumption are heart rate, systolic pressure, and left ventricular contractility. Increases in these factors require proportional increases in coronary flow and oxygen delivery.
3) Coronary vascular resistance has three main components - epicardial conduit resistance, microcirculatory resistance, and extravascular compressive resistance which varies through the cardiac cycle. Maintaining the balance of these factors is important for adequate oxygen supply
This document discusses strategies to minimize right ventricular pacing, which can have deleterious effects. It summarizes several clinical trials that evaluated ventricular versus atrial or dual-chamber pacing. The trials generally found that atrial or dual-chamber pacing reduced atrial fibrillation compared to ventricular pacing, though effects on other outcomes like mortality were less clear. The document recommends that right ventricular pacing be avoided or minimized when possible, through use of AAI pacing, DDD pacing with long fixed AV delays, search AV hysteresis algorithms, or mode-switching algorithms that favor intrinsic conduction.
This document summarizes research on outcomes of bypass surgery and endovascular therapy for peripheral artery disease. It reviews studies showing higher patency rates and limb salvage with autogenous vein grafts compared to prosthetic grafts. More recent studies demonstrate the benefits of targeting the angiosome of the bypass and evaluating outcomes based on patient comorbidities. While bypass surgery remains the standard for complex anatomical lesions when veins are suitable, endovascular therapy is becoming more common first-line based on guidelines, though randomized controlled trials are still needed to directly compare approaches. The optimal indications for bypass surgery in 2014 likely include anatomical lesions not amenable to angioplasty, availability of autogenous veins, life expectancy over 2 years, and treatment
This document summarizes the examination of patients for arterial and venous disease. It describes risk factors for arterial disease and how to examine the arteries, including inspection, palpation of pulses, and Buerger's test. Signs and symptoms of conditions like intermittent claudication, acute ischemia, and critical limb ischemia are provided. Conservative and surgical treatment options for arterial disease are outlined. The document also covers examination of veins, including inspection for signs of venous disease and palpation of varicosities. Tests for venous incompetencies like the tap test are described. Treatment options for venous disease including compression, dressings, medications, and surgical ablation procedures are summarized.
Assessment of Intermediate Coronary Artery Lesion with Fractional Flow Reserv...Premier Publishers
Fraction flow reserve (FFR) is considered the gold standard for assessing intermediate coronary lesions. Retrospective data analyses showed variable relationship between intravascular ultrasound (IVUS) parameters and FFR results. This study aimed to determine the optimal minimum lumen area (MLA) by IVUS that correlates with FFR and to assess the correlation between two modalities in assessing intermediate coronary lesions. Methods: Fifty eight intermediate coronary lesions mainly located in proximal and mid segments of large main coronary vessels with RVD (3-4mm) were analyzed using both IVUS and FFR to assess the significance of coronary stenting and to determine the optimal IVUS-MLA that correlates with FFR value < 0.8. Results: IVUS-MLA ranged from 2.5 to 4.2 mm2 had a highly significant positive correlation with FFR value < 0.8 (p < 0.0001). Using the ROC curve analysis, IVUS-MLA < 3.9 mm2 (84.2% sensitivity, 80% specificity, area under curve (AUC) = 0.68) was the best threshold value for identifying FFR <0.8>< 0.8 in coronary vessels with RVD (3-4mm). Different MLA cutoffs should be used for different vessel diameters.
1. Left bundle branch block (LBBB) is a conduction abnormality caused by impaired conduction in the left bundle branch or its fascicles.
2. LBBB can be chronic or intermittent and is often caused by coronary artery disease or hypertension.
3. On ECG, LBBB is characterized by a QRS duration ≥120ms and other abnormalities including broad R waves and abnormal ST-T wave patterns.
4. LBBB can make ECG diagnosis of myocardial infarction difficult and criteria like Sgarbossa scores are used to help identify MI in the setting of LBBB.
This document discusses fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), which are used to assess the severity of a stenosis. It notes that calculating FFR requires making assumptions and simplifications from a fluid mechanics perspective. Specifically, it assumes hydraulic models, neglects venous pressure, assumes equal myocardial resistances, and faces challenges in measuring distal pressure due to dynamic pressure effects, which are more problematic at higher flow rates. The document suggests iFR measurement of distal pressure could be even more inaccurate due to typically higher velocities during the wave-free period.
The document summarizes research on aortic dilatation in patients with bicuspid aortic valves. Key points include:
- Bicuspid aortic valves affect 1.3% of the population and are responsible for more deaths than other congenital heart defects. Approximately 50% of patients with a bicuspid valve also have dilatation of the aorta.
- There are three main patterns of aortic dilatation associated with bicuspid valves - types 1, 2, and 3 - which involve different segments of the aorta.
- The prevalence of aortic dilatation increases with age and ranges from 20-84% depending on the study. Dilatation begins in childhood and progresses
1. The seminar discussed coronary blood flow and myocardial oxygen consumption. Key determinants include heart rate, systolic pressure, and left ventricular contractility.
2. Myocardial oxygen extraction is near maximal at rest, so increases in demand are met by proportional increases in coronary flow and oxygen delivery.
3. Fractional flow reserve measures the ratio of distal coronary pressure to aortic pressure during maximal hyperemia. An FFR below 0.75 is associated with ischemia while above 0.80 is usually not.
The document discusses the history and details of the arterial switch operation (ASO) for transposition of the great arteries (TGA). It provides a timeline of pioneers of techniques from 1959 to 1989. It then discusses specifics of the neonatal repair procedure, important technical aspects like coronary transfer techniques, and factors that influence long term outcomes like coronary patterns, ventricular function, and rhythm disturbances. It concludes with take home messages that earlier ASO leads to better results and the procedure now has a mortality rate of less than 5%, making it safe.
Spinal cord protection in aortic surgeriesthanigai arasu
Spinal cord protection is important during aortic surgeries to prevent neurological deficits. The risk is highest with open thoracoabdominal aortic aneurysm (TAAA) repair. Techniques to protect the spinal cord include minimizing ischemia time, increasing cord tolerance through hypothermia, augmenting perfusion, and monitoring for ischemia. Early detection of ischemia allows interventions like reattachment of segmental arteries or modifying perfusion to salvage the cord. While endovascular repair reduces risk compared to open surgery, open repair requires strategies like distal aortic perfusion, cerebrospinal fluid drainage and evoked potential monitoring to optimize spinal cord protection.
This document discusses the physiological basis of coronary revascularization. It covers topics such as coronary physiology, myocardial viability assessment, and coronary revascularization. Some key points include:
- Coronary blood flow is proportional to perfusion pressure over resistance and is regulated by various metabolic and endothelial factors.
- Myocardial ischemia occurs when oxygen demand exceeds supply. Coronary autoregulation and flow reserve help maintain adequate flow.
- Myocardial viability refers to dysfunctional tissue with limited scarring that has potential for functional recovery after revascularization through mechanisms like stunned myocardium and hibernation.
- Various techniques can assess viability including cardiac imaging and evaluating improvement in function after revascularization. Viability assessment aids decisions about revascularization
This article reviews the role of invasive hemodynamics in the care of patients across the
entire spectrum of human heart failure.
Conceptual principles of ventricular function, ventricular-arterial interaction, load
response, and ventricular interaction in the right and left heart are reviewed.
Principles and practice of invasive exercise testing are provided, along with detailed
discussions on the role of invasive hemodynamics in the evaluation and management of
advanced heart failure, shock, mechanical circulatory support, and pulmonary
hypertension.
Isolated monomorphic premature ventricular complexes (PVCs) without
structural heart disease are generally benign.
► Frequent PVCs can cause reversible cardiomyopathy or aggravate an existing
cardiomyopathy.
► Short coupled PVCs can trigger sustained ventricular fibrillation. These are
often from the Purkinje tissue or rarely the outflow tract.
► Beta blockers are considered first-line therapy but have low efficacy.
Catheter ablation and AADs are reasonable to suppress PVCs in appropriate
patients.
► Ablation is often curative and success depends on location and accessibility
of PVCs.
► Implantable defibrillators are reasonable in patients at higher risk of sudden
cardiac death.
ECG Interpretation
The ECG is used to diagnose heart conditions by representing the electrical activity of the heart over time. It can detect abnormalities in heart rhythm, rate, and structure. A standard ECG has 12 leads that examine the heart from different angles. Common things to analyze include rhythm, rate, axis, waves, intervals, and complexes. Various arrhythmias and conduction abnormalities can be identified based on their characteristic ECG patterns.
(1) Premature ventricular contractions (PVCs) were traditionally thought to be benign, but can sometimes lead to left ventricular dysfunction or cardiomyopathy, known as PVC-induced cardiomyopathy (PVCI-CMP).
(2) High PVC burden (over 20% of heartbeats), long duration of symptoms, and PVCs originating from the epicardium or left ventricle are risk factors for developing PVCI-CMP.
(3) Treatment options for symptomatic PVCI-CMP include medications, which have adverse effects, or catheter ablation, which has high success rates of over 80% in reducing PVC burden and improving left ventricular function.
1. The document discusses electrocardiogram (ECG) findings in a patient presenting with left bundle branch block (LBBB) and possible myocardial infarction (MI).
2. It outlines criteria like the Sgarbossa criteria that can help identify ST segment changes indicating MI in the setting of LBBB, though these have limited sensitivity.
3. Serial ECGs and cardiac enzyme levels are also useful to help diagnose MI in patients with LBBB due to the challenges of ECG interpretation.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
Echocardiography plays an important role in diagnosing ischemic heart disease through evaluating wall motion abnormalities, localizing infarcts, assessing infarct size, and detecting complications. It can detect abnormalities such as ventricular rupture, pseudoaneurysms, ventricular septal defects, and clots. Stress echocardiography enhances interpretation of stress tests and evaluates functional importance of coronary artery disease. Echocardiography is accurate for evaluating patients with known or suspected coronary artery disease.
This document discusses coronary blood flow physiology, including the determinants of coronary resistance, autoregulation, microcirculation, and how blood flow is affected by exercise and the presence of coronary stenosis. It covers topics like the three resistance beds, flow-mediated dilation, metabolic mediators, neural and paracrine control, and the pushing and suction wave mechanism of diastolic flow. Measurement techniques and abnormalities in blood flow with normal coronary arteries are also briefly mentioned.
This case report describes an 82-year-old male who developed intracardiac shunts following a redo aortic valve replacement surgery. Doppler echocardiography detected shunts from the left ventricle outflow tract across the membranous septum into the right atrium, right ventricle, and left atrium. The anatomical basis for this complication is the proximity and relationship of the thin membranous septum to the aortic root, tricuspid valve, and ventricular chambers. Aggressive debridement during valve surgery can cause injury and necrosis of the membranous septum, leading to fistula formation over time. While the shunts were initially small and asymptomatic, they could enlarge
The document summarizes key aspects of coronary blood flow regulation and determinants of myocardial oxygen consumption. It discusses how:
1) Myocardial contraction and oxygen delivery are closely linked, and the balance between oxygen supply and demand is critical for normal heart function.
2) The major determinants of myocardial oxygen consumption are heart rate, systolic pressure, and left ventricular contractility. Increases in these factors require proportional increases in coronary flow and oxygen delivery.
3) Coronary vascular resistance has three main components - epicardial conduit resistance, microcirculatory resistance, and extravascular compressive resistance which varies through the cardiac cycle. Maintaining the balance of these factors is important for adequate oxygen supply
This document discusses strategies to minimize right ventricular pacing, which can have deleterious effects. It summarizes several clinical trials that evaluated ventricular versus atrial or dual-chamber pacing. The trials generally found that atrial or dual-chamber pacing reduced atrial fibrillation compared to ventricular pacing, though effects on other outcomes like mortality were less clear. The document recommends that right ventricular pacing be avoided or minimized when possible, through use of AAI pacing, DDD pacing with long fixed AV delays, search AV hysteresis algorithms, or mode-switching algorithms that favor intrinsic conduction.
This document summarizes research on outcomes of bypass surgery and endovascular therapy for peripheral artery disease. It reviews studies showing higher patency rates and limb salvage with autogenous vein grafts compared to prosthetic grafts. More recent studies demonstrate the benefits of targeting the angiosome of the bypass and evaluating outcomes based on patient comorbidities. While bypass surgery remains the standard for complex anatomical lesions when veins are suitable, endovascular therapy is becoming more common first-line based on guidelines, though randomized controlled trials are still needed to directly compare approaches. The optimal indications for bypass surgery in 2014 likely include anatomical lesions not amenable to angioplasty, availability of autogenous veins, life expectancy over 2 years, and treatment
This document summarizes the examination of patients for arterial and venous disease. It describes risk factors for arterial disease and how to examine the arteries, including inspection, palpation of pulses, and Buerger's test. Signs and symptoms of conditions like intermittent claudication, acute ischemia, and critical limb ischemia are provided. Conservative and surgical treatment options for arterial disease are outlined. The document also covers examination of veins, including inspection for signs of venous disease and palpation of varicosities. Tests for venous incompetencies like the tap test are described. Treatment options for venous disease including compression, dressings, medications, and surgical ablation procedures are summarized.
Sympathectomy for pheripheral arterial disease present roleAravind Endamu
1) Lumbar sympathectomy was historically used to treat occlusive arterial disease by increasing blood flow through vasodilation. However, it provided only short-term and palliative benefits.
2) While lumbar sympathectomy increases skin blood flow, it does not significantly increase true nutritional blood flow in skeletal muscle. There is no physiological basis for its use in intermittent claudication.
3) Today, lumbar sympathectomy still has limited indications for selected patients with rest pain or ischemic ulcers when arterial reconstruction is not possible. It provides only short term pain relief and ulcer healing.
Peripheral vascular diseases can be acute or chronic and complete or incomplete based on time course and severity. Acute arterial occlusion causes pain, pallor, pulselessness, coldness, and paralysis in the affected limb. Emboli originate elsewhere while thrombi form within the obstructed vessel. Chronic vascular insufficiency may cause claudication, rest pain, ulceration, or gangrene. Investigations include doppler, angiography, and ABI to assess severity and guide management including risk factor modification, exercise, medications, and surgeries. Buerger's disease specifically involves small vessels, smoking, and distal ischemia.
The document provides an overview of transcatheter aortic valve implantation (TAVI), including a brief history of its development, descriptions of the Edwards Sapien valve and delivery systems, approaches for TAVI, and complications. It also discusses patient screening and risk stratification, as well as newer valve devices that are being developed.
1) PAD is associated with increased risk of myocardial infarction and ischemic stroke due to shared risk factors of atherosclerosis.
2) Clinical features of PAD range from asymptomatic to intermittent claudication to critical limb ischemia manifested by rest pain, ulcers or gangrene.
3) Diagnosis involves assessment of symptoms and risk factors as well as tests such as ankle-brachial index, duplex ultrasound and angiography. Treatment depends on severity and may include lifestyle modification, medication, angioplasty or bypass surgery.
Revascularization in heart faliure seminarAnkit Jain
This document discusses revascularization in patients with heart failure due to coronary artery disease and residual left ventricular dysfunction. It provides details on myocardial hibernation and stunning - two states of sustained contractile dysfunction despite viable myocardium. Revascularization can lead to improved survival and reverse remodeling in such patients if a sufficient amount of viable myocardium is present. Techniques to assess myocardial viability include stress echocardiography, nuclear imaging with SPECT or PET, and cardiac magnetic resonance. Revascularization is recommended for patients who have viability in at least 25% of the left ventricular segments.
This document discusses diagnostic and surgical treatment options for mitral valve stenosis. It presents the case of a 46-year-old female patient with severe mitral stenosis who has not responded well to pharmacological treatment. Two main surgical interventions are considered: balloon mitral valvuloplasty and mitral valve annuloplasty. Studies are presented showing that valvuloplasty can improve left ventricular function and strain, while annuloplasty may be associated with higher gradients and worse quality of life. Based on the patient's history and characteristics, the document recommends valvuloplasty as it allows for variable improvement in health compared to mitral surgery, which carries a higher risk of compromising health. Close monitoring is still advised
Tetralogy of fallot-Pumlmonary valve preservationIndia CTVS
This document summarizes a study on preserving the pulmonary valve during tetralogy of Fallot (TOF) repair. The study found that:
1) A pulmonary valve-sparing approach was successfully used in 82 of 102 patients (80%).
2) Significant markers for a successful valve-sparing operation included having a trileaflet pulmonary valve, a pulmonary annulus Z-score greater than -4, and a postoperative right ventricle to left ventricle pressure ratio less than 0.7.
3) 70 of 82 patients (85%) who had a valve-sparing operation developed less than moderate pulmonary insufficiency.
This document discusses the management of valvular regurgitation in patients with cardiomyopathy. It notes that secondary mitral regurgitation is common in end-stage cardiomyopathy and can affect up to 60% of heart failure patients. While medical management focuses on treating the underlying heart failure, the document finds that mitral valve repair with an undersized annuloplasty ring can significantly improve symptoms and survival rates, comparable to heart transplantation. Several studies showed mitral valve repair improved ejection fraction and functional status while carrying an acceptable mortality risk in this high-risk group. The conclusion is that mitral valve surgery should be considered for symptomatic patients with severe secondary mitral regurgitation who remain symptomatic despite medical optimization.
This document discusses various imaging modalities for assessing the right heart, including echocardiography and cardiac magnetic resonance imaging (CMR). It provides details on:
1) The challenges of using echocardiography to evaluate right ventricular (RV) structure and function due to its complex geometry, though it is commonly used. Quantitative measures like fractional area change and tricuspid annular plane systolic excursion are recommended.
2) CMR is considered the clinical reference technique due to unlimited imaging planes, superior resolution, and ability to perform 3D volumetric rendering, making it ideal for serial exams.
3) Other modalities like multidetector computed tomography and radionuclide techniques play roles
Whom to refer for mitral valve repair and whom notdrucsamal
This document discusses the treatment of mitral regurgitation in patients with heart failure. It describes the mechanisms of functional and ischemic mitral regurgitation. While medical therapy can improve symptoms and survival, cardiac resynchronization therapy may also help reduce mitral regurgitation severity and improve outcomes. Surgery to repair the mitral valve is an option but the risk of recurrence of mitral regurgitation is high, especially with more advanced left ventricular remodeling. Randomized trials are still needed to determine whether surgical correction provides clear benefits over medical therapy alone in high-risk patients. Percutaneous mitral valve repair may be a lower risk option for inoperable patients to reduce symptoms.
Fluid responsiveness in Paediatric Critical Carepune2013
The document discusses methods for predicting fluid responsiveness in critically ill patients. It describes how static parameters like central venous pressure and pulmonary artery occlusion pressure are poor predictors on their own. Dynamic parameters that measure stroke volume variation with respiration are better predictors if the patient is mechanically ventilated. The ability to predict fluid responsiveness is important to optimize fluid administration and prevent under- or over-hydration in critically ill patients.
The document discusses methods for predicting fluid responsiveness in critically ill patients. It describes how static parameters like central venous pressure and pulmonary artery occlusion pressure are poor predictors on their own. Dynamic parameters that measure stroke volume variation with respiration are better predictors if the patient is mechanically ventilated. The ability to predict fluid responsiveness is important to optimize fluid administration and prevent under- or over-hydration in critically ill patients.
The document discusses arterial stiffness in predicting preeclampsia. There is evidence that preeclampsia is associated with increased arterial stiffness, an important predictor of outcomes. A meta-analysis showed arterial stiffness indices are significantly higher in preeclamptic women compared to normotensive pregnant women. Arterial stiffness varies throughout normal pregnancy, reaching its lowest point in the second trimester and rising in the third trimester, while in preeclamptic women it continues to increase throughout pregnancy. Measuring arterial stiffness in early pregnancy may help identify women at risk of developing preeclampsia.
Mitral regurgitation (MR) occurs when there is abnormal backflow of blood from the left ventricle into the left atrium during systole. It can be caused by problems with the mitral valve apparatus including the annulus, leaflets, chordae tendineae and papillary muscles. MR is classified as acute, chronic compensated, or chronic decompensated. Chronic MR puts a volume overload on the left atrium and ventricle, leading to dilation and hypertrophy as compensatory mechanisms. However, this can eventually cause reduced cardiac output, pulmonary congestion, and heart failure.
The document discusses the management of a failing right ventricle in pulmonary arterial hypertension (PAH). It begins by describing the natural history of idiopathic PAH and the predictors of survival. It then discusses the physiology of the right ventricle, how it is linked to the left ventricle, and the determinants of right ventricular function. The document concludes by outlining the goals and general management strategies for chronic and acute right ventricular failure in PAH.
This document discusses goal directed fluid therapy and fluid management in the perioperative period. It begins by introducing the importance of intravenous fluid therapy and issues related to both excess and restrictive fluid administration. It then discusses various fluid monitoring techniques including static parameters measured by pulmonary artery catheters, minimally invasive monitors like LiDCO and pulse contour analysis devices, dynamic parameters like stroke volume variation, and echocardiography. The document also addresses fluid responsiveness, factors influencing venous return and the Frank-Starling relationship, and the high incidence of non-responders to fluid challenges.
Resistive index and its applications in UrologyPrateek Laddha
This document discusses the resistive index (RI), a measure of pulsatile blood flow used in urology. It provides background on how the RI is calculated and explores its applications in evaluating conditions like renal obstruction and non-obstructive renal disease. While early studies showed promise for the RI, later research found it lacks specificity. The RI is influenced by vascular compliance and resistance. It may help identify transplant complications but not differentiate causes of dysfunction. The document concludes the RI remains a nonspecific marker of transplant dysfunction.
This document discusses methods for quantifying myocardial blood volume (MBV) using magnetic resonance imaging (MRI) contrast agents. It evaluates gadofosveset and ferumoxytol as potential intravascular contrast agents for this purpose. Compartmentalization of water protons and contrast agent between blood vessels and tissue must be accounted for using multi-compartment models. Simulations show gadofosveset's partial binding to albumin causes less than 30% error in measured MBV. Measurements in volunteers and animals found gadofosveset behaves more like an extracellular agent in myocardium, while ferumoxytol agrees with literature as an intravascular agent for MBV quantification when correcting for water exchange.
The document discusses current management and future challenges in treating mitral valve disease, specifically focusing on primary mitral regurgitation, secondary mitral regurgitation, and mitral stenosis due to annular calcification.
For primary mitral regurgitation, surgical repair is the standard of care for symptomatic patients or those with left ventricular dysfunction. New transcatheter mitral valve repair options like the MitraClip are also producing good outcomes in high-risk surgical patients. Clinical trials are underway to evaluate transcatheter options versus surgery for intermediate risk patients.
The management of secondary mitral regurgitation, caused by left ventricular issues, is less clear. Outcomes from ongoing clinical trials of new treatments will help
This document discusses multivalvular heart disease (MVD), which refers to two or more diseased cardiac valves. It defines MVD and provides epidemiological data showing its prevalence. The most common causes of acquired MVD are rheumatic heart disease and degenerative calcific disease. Congenital disorders can also cause MVD. The document examines the pathophysiology and interactions of different valve combinations, such as aortic stenosis with mitral regurgitation. Echocardiography is key for diagnosis but has limitations in MVD, so cardiac catheterization may be needed in some cases.
Similar to Left ventricular mass regression after a v r (20)
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
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ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
2. Myoarchitecture of the ventricle The adult ventricular mass is made up of a three dimensional network of myocardial cells The network is highly structured and arranged in three different layers in which the myocardial cells have a preferred orientation L V has sub epicardial, middle, deep layer The superficial and deep layers are anchored at the ventricular orifices to Fibrous skeleton of the heart
3. CONT.. This suggests that myocardial contraction plays an actual role in cardiac valve function The middle layer is unique to the L V shows a circumferential pattern . No planes of fibrous septation are present between three layer
4. Pathophysiology in A S PRESS OVERLOAD INCREASED SYSTOLIC STRESS WALL THICKENING Concentric LVH
5. A S A S causes gradual obstruction to the LVOT, LV output is maintained by the development of LVH. Myocardial hypertrophy in patient with AS is characterized by increased gene expression of collagen I and collagen II and fibronection that is associated with Rennin angiotension system. In late stage of sever AS the LV decompensate with resulting dilated cardiomyopathy Leads low cardiac output and PHT.
6. Pressure overload increase the systolic wall stress provides the stimulus to increase wall thickness and normalizes peak systolic stress this progress to concentric hypertrophy where the ratio of cavity to wall thickness is markedly less than normal. Myocardial hypertrophy in AS is caused by new myofibrils added in parallel to myocytes, no new myocytes are added but existing myocytes become thicker , not longer with normal myocytes
7. A R VOLUME OVERLOAD INC diastolic stress Inc L V volume Eccentric lv hypertrophy.
8. Volume overload increase in diastolic stress provides a stimulus for elongation of myofibrils to increase LV volume because of increase LV volume by Laplace law systolic stress increase to induce wall thickening , which reduces stress and produces eccentric hypertrophy. The ratio of ventricular radius to wall thickness remains normal.
9. L V mass index of 200g/m”—good systolic function and only hypertrophy of myocardial cells. L V mass of 200—300g/m”—mild degenerative changes were present. L V mass of >300g/m” multiple degenerative changes in ultra structure and LV systolic function was greatly depressed.
10. Degenerative changes. Mitochondrial changes, Disruption of sarcomeric units , Nonoriented growth of fiber components, Disappearance of organelles, Increase in nonmuscular tissue in association with myocardial hypertrophy. Leads to loss of ionotrophic strength and irreversibility.
11. Post A V R L V structure The degree of improvement in L V structure function depends type and extent of secondary cardiomyopathy at operation, coexisting diseases, permananentintraoperative L V damage ,energy loss and regurgitation across the valve replacement devices
12. A S When L V end diastolic pressure is low at operation L V wall thickness and mass regression substantially to 200g/m to 133g/m( kennedy study) The regression continue for more then one year When L V end diastolic pressure has become importantly elevated before AVR either because of afterload mismatch or reduced contractility L V MASS reduced after operation. Krayenbuchl and coll showed that the preoperatively enlarged muscle fiber diameter shortens with in 1-2 yrs after aortic valve replacment as part of process but with some increase in intertial fibrosis , later the fibrosis tented to decrease But the myocardium did not return to normal
13. Aortic allograft and stentless valves replacement leads to greater resolution of L V hypertrophy. Turbulence may be an important factor in reversing ventricular remodeling after implantation of a prosthetic valve as well as relief or reduction of pressure gradient across the LV outflow tract . Mechanical valves oriented to place the major flow orifice to take advantage of eccentric flow pattern in the aorta have optimal performance in that orientation.
14. A R Regression of muscle fiber diameter after AVR also occur after operation for A R. Decrease in interstitial fibrosis content is greater after valve replacement for AR. Abolishing LV volume overload must be performed within 6 months of its inception to permit toward normal in exp studies. L V sys &dia function is mildly or moderately depressed at rest or stress testing usually associated with moderate cardiomegaly L V mass regression occur.
16. LV reverse remodeling imparted by aortic valve replacement for severe aortic stenosis; is it durable? A cardiovascular MRI study sponsored by the American Heart Association Robert WW Biederman1*, James A Magovern3, Saundra B Grant1, Ronald B Williams1, June A Yamrozik1, Diane A Vido1, Vikas K Rathi1, Geetha Rayarao1, Ketheswaram Caruppannan1,2 and Mark Doyle1 * Corresponding author: Robert WW Biederman Author Affiliations 1 Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA 2 Division of Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA 3 Department of Surgery, Division of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA Journal of Cardiothoracic Surgery 2011, 6:53 doi:10.1186/1749-8090-6-53
17. Abstract Background In patients with severe aortic stenosis (AS), long-term data tracking surgically induced effects of afterload reduction on reverse LV remodeling are not available. Echocardiographic data is available short term, but in limited fashion beyond one year. Cardiovascular MRI (CMR) offers the ability to serially track changes in LV metrics with small numbers due to its inherent high spatial resolution and low variability. Hypothesis We hypothesize that changes in LV structure and function following aortic valve replacement (AVR) are detectable by CMR and once triggered by AVR, continue for an extended period. Methods Tweny-four patients of which ten (67 ± 12 years, 6 female) with severe, but compensated AS underwent CMR pre-AVR, 6 months, 1 year and up to 4 years post-AVR. 3D LV mass index, volumetrics, LV geometry, and EF were measured.
18. Abstract Results All patients survived AVR and underwent CMR 4 serial CMR's. LVMI markedly decreased by 6 months (157 ± 42 to 134 ± 32 g/m2, p < 0.005) and continued trending downwards through 4 years (127 ± 32 g/m2). Similarly, EF increased pre to post-AVR (55 ± 22 to 65 ± 11%,(p < 0.05)) and continued trending upwards, remaining stable through years 1-4 (66 ± 11 vs. 65 ± 9%). LVEDVI, initially high pre-AVR, decreased post-AVR (83 ± 30 to 68 ± 11 ml/m2, p < 0.05) trending even lower by year 4 (66 ± 10 ml/m2). LV stroke volume increased rapidly from pre to post-AVR (40 ± 11 to 44 ± 7 ml, p < 0.05) continuing to increase non-significantly through 4 years (49 ± 14 ml) with these LV metrics paralleling improvements in NYHA. However, LVmass/volume, a 3D measure of LV geometry, remained unchanged over 4 years.
19. Abstract Conclusion After initial beneficial effects imparted by AVR in severe AS patients, there are, as expected, marked improvements in LV reverse remodeling. Via CMR, surgically induced benefits to LV structure and function are durable and, unexpectedly express continued, albeit markedly incomplete improvement through 4 years post-AVR concordant with sustained improved clinical status. This supports down-regulation of both mRNA and MMP activity acutely with robust suppression long term.
20. Left ventricular remodeling early after aortic valve replacement: differential effects on diastolic function in aortic valve stenosis and aortic regurgitation Hildo J. Lamb, PhD*,*,1, Hugo P. Beyerbacht, MD, Albert de Roos, MD*, Arnoud van derLaarse, PhD, Hubert W. Vliegen, MD, FerreLeujes, MD, Jeroen J. Bax, MD and Ernst E. van der Wall, MD * Radiology, Leiden, The NetherlandsCardiology, Leiden University Medical Center, Leiden, The Netherlands Manuscript received March 6, 2002; revised manuscript received August 16, 2002, accepted September 6, 2002.
21. Abstract OBJECTIVES: The aim of this study was to evaluate the effect of aortic valvereplacement (AVR) on left ventricular (LV) function and LV remodeling,comparing patients with aortic valve stenosis to patients withaortic regurgitation. BACKGROUND: Aortic valve disease is associated with eccentric or concentricLV hypertrophy and changes in LV function. The relationshipbetween LV geometry and LV function and the effect of LV remodelingafter AVR on diastolic filling, in patients with aortic valvestenosis compared with aortic regurgitation, are largely unknown. METHODS: Nineteen patients with aortic valve disease (12 aortic valvestenosis, 7 aortic regurgitation) were studied using magneticresonance imaging to assess LV geometry and LV function beforeand 9 ± 3 months after AVR. Ten age-matched healthy malesserved as control subjects.
22. Abstract RESULTS: Before AVR, the ratio between left ventricular mass index (LVMI)and left ventricular end-diastolic volume index (LVEDVI) wasonly increased in patients with aortic valve stenosis (1.37± 0.16 g/ml) compared with control subjects (0.93 ±0.08 g/ml, p < 0.05). After AVR, LVMI/LVEDVI decreased significantlyin aortic valve stenosis (to 1.15 ± 0.14 g/ml, p <0.0001), but increased significantly in aortic regurgitation(1.02 ± 0.20 g/ml to 1.44 ± 0.27 g/ml, p <0.0001). Before AVR, diastolic filling was impaired in bothaortic valve stenosis and aortic regurgitation. Early afterAVR, diastolic filling improved in patients with aortic valvestenosis, whereas patients with aortic regurgitation showeda deterioration in diastolic filling
23. Abstract CONCLUSIONS: Early after AVR, patients with aortic valve stenosis show adecrease in both LVMI and LVMI/LVEDVI and an improvement indiastolic filling, whereas in patients with aortic regurgitation,LVMI decreases less rapidly than LVEDVI, causing concentricremodeling of the LV, most likely explaining the observed deteriorationof diastolic filling in these patients.
24. Left Ventricular Mass Regression One Year After Transcatheter Aortic Valve Implantation ApostolosTzikas, MD, Marcel L. Geleijnse, MD, PhD, Nicolas M. Van Mieghem, MD, Carl J. Schultz, MD, PhD, Rutger-Jan Nuis, MS, Bas M. van Dalen, MD, PhD, Giovanna Sarno, MD, PhD, Ron T. van Domburg, PhD, Patrick W. Serruys, MD, PhD, Peter P.T. de Jaegere, MD, PhD*Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands Accepted for publication September 17, 2010.
25. Abstract Background: Left ventricular (LV) hypertrophy is associated with LV diastolicdysfunction and constitutes a risk factor for cardiac morbidityand mortality. The objective of this study was to investigatethe degree of LV mass regression and the changes of LV diastolicfunction one year after transcatheter aortic valve implantation(TAVI). Methods: Echocardiography was performed at baseline, before discharge,and at one-year follow-up in 63 consecutive patients with severeaortic stenosis who underwent TAVI with the Medtronic CoreValveSystem (Medtronic Inc, Minneapolis, MN). The LV mass was calculatedusing the Devereux formula and indexed to body surface area.
26. Abstract Results: One-year all-cause mortality was 29%. The LV mass index decreasedfrom 126 ± 42 g/m2 at baseline to 110 ± 30 g/m2 at one-year follow-up (p < 0.001). Left ventricular ejectionfraction and LV diastolic function did not change significantly.Mean transaortic gradient decreased from 47 ± 19 mm Hgat baseline to 9 ± 5 mm Hg at discharge and 9 ±4 mm Hg at one year (p < 0.001), and was accompanied by significantclinical improvement. More than mild paravalvular aortic regurgitationwas found in 24% and 15% of patients at discharge and one-yearfollow-up, respectively. Conclusions: A significant regression in LV mass was found one year afterTAVI. However, regression was incomplete and was not accompaniedby an improvement in LV diastolic function