(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.
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.
Stent thrombosis is a rare but devastating complication occurring in less than 1% of patients within 30 days of stenting and 0.2-6% annually afterwards. It is associated with higher thrombus burden and less procedural success, resulting in higher rates of death, recurrent heart attack, and recurrent stent thrombosis. Risk factors include stent-related issues like early versus late thrombosis, procedure-related issues like incomplete apposition or expansion, vessel-related issues like long lesions or small vessel size, and patient-related issues like diabetes, impaired heart function, renal disease, or non-compliance with dual anti-platelet therapy. Management depends on thrombus burden grade, with direct angioplasty and stenting for small burdens and
The document summarizes key aspects of cardiac catheterization and hemodynamic data collection. It describes the normal cardiac cycle, pressure measurement systems, normal pressure waveforms, methods to measure cardiac output like thermodilution and Fick, how to evaluate valvular stenosis and regurgitation, determine vascular resistance and shunts. Specific details are provided on assessing aortic stenosis, mitral stenosis, right-sided valves and quantifying regurgitant fractions. Oxygen saturation analysis and Fick principles are outlined for shunt determinations.
Today, in addition to measurement of left ventricular ejection fraction, the simple 12-lead surface ECG remains the only evidence-based means of identifying patients who may obtain the substantial benefits of CRT
This document provides an overview of pacemakers, including their indications, components, and modes of operation. It discusses the types of heart block that qualify as indications for pacemaker implantation. The components of a pacemaker system include the pulse generator which contains the battery and circuitry, and leads which deliver electrical impulses from the generator to the heart and sense cardiac activity. Pacemakers operate in different modes defined by which chambers they pace and sense from. Choosing the optimal pacing mode aims to increase heart rate, maximize stroke volume, use atrial-based pacing, and maintain normal ventricular activation sequence.
Ventricular tachycardia is a fast heart rhythm originating from the ventricles with a rate over 100 bpm. It is classified based on duration (sustained vs non-sustained), morphology (monomorphic, polymorphic, sinusoidal), and symptoms. Causes include structural heart disease, electrolyte abnormalities, drugs, and prolonged QT interval. Diagnosis involves ECG criteria showing ventricular origin. Treatment depends on hemodynamic stability and may include antiarrhythmic drugs, implantable cardioverter-defibrillator, catheter ablation, or surgery. Recurrent ventricular tachycardia is managed long term with devices, drugs, and treatment of underlying causes.
Left ventricular diastolic dysfunction in echocardiographyYukta Wankhede
Left ventricular diastolic dysfunction refers to the heart's inability to properly relax and fill during diastole. It can be caused by primary myocardial diseases like cardiomyopathy, hypertension, or secondary issues like aortic stenosis. Diagnosis involves evaluating left ventricular mass, dimensions, and function using 2D echocardiography, Doppler ultrasound to assess mitral inflow and pulmonary vein patterns, and tissue Doppler imaging of mitral annular motion. Diastolic dysfunction is graded from mild to severe based on these evaluation findings.
This document summarizes dobutamine stress echocardiography (DSE). Key points include:
- DSE uses the drug dobutamine to simulate exercise and increase heart rate, contractility, and myocardial oxygen demand to detect ischemia.
- It is useful for evaluating ischemia, viability, and valvular dysfunction in patients unable to exercise.
- The document reviews the DSE protocol, interpretation of wall motion abnormalities, indications, side effects, and applications for assessing ischemic heart disease, viability, valvular stenosis like mitral and aortic stenosis, 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.
Stent thrombosis is a rare but devastating complication occurring in less than 1% of patients within 30 days of stenting and 0.2-6% annually afterwards. It is associated with higher thrombus burden and less procedural success, resulting in higher rates of death, recurrent heart attack, and recurrent stent thrombosis. Risk factors include stent-related issues like early versus late thrombosis, procedure-related issues like incomplete apposition or expansion, vessel-related issues like long lesions or small vessel size, and patient-related issues like diabetes, impaired heart function, renal disease, or non-compliance with dual anti-platelet therapy. Management depends on thrombus burden grade, with direct angioplasty and stenting for small burdens and
The document summarizes key aspects of cardiac catheterization and hemodynamic data collection. It describes the normal cardiac cycle, pressure measurement systems, normal pressure waveforms, methods to measure cardiac output like thermodilution and Fick, how to evaluate valvular stenosis and regurgitation, determine vascular resistance and shunts. Specific details are provided on assessing aortic stenosis, mitral stenosis, right-sided valves and quantifying regurgitant fractions. Oxygen saturation analysis and Fick principles are outlined for shunt determinations.
Today, in addition to measurement of left ventricular ejection fraction, the simple 12-lead surface ECG remains the only evidence-based means of identifying patients who may obtain the substantial benefits of CRT
This document provides an overview of pacemakers, including their indications, components, and modes of operation. It discusses the types of heart block that qualify as indications for pacemaker implantation. The components of a pacemaker system include the pulse generator which contains the battery and circuitry, and leads which deliver electrical impulses from the generator to the heart and sense cardiac activity. Pacemakers operate in different modes defined by which chambers they pace and sense from. Choosing the optimal pacing mode aims to increase heart rate, maximize stroke volume, use atrial-based pacing, and maintain normal ventricular activation sequence.
Ventricular tachycardia is a fast heart rhythm originating from the ventricles with a rate over 100 bpm. It is classified based on duration (sustained vs non-sustained), morphology (monomorphic, polymorphic, sinusoidal), and symptoms. Causes include structural heart disease, electrolyte abnormalities, drugs, and prolonged QT interval. Diagnosis involves ECG criteria showing ventricular origin. Treatment depends on hemodynamic stability and may include antiarrhythmic drugs, implantable cardioverter-defibrillator, catheter ablation, or surgery. Recurrent ventricular tachycardia is managed long term with devices, drugs, and treatment of underlying causes.
Left ventricular diastolic dysfunction in echocardiographyYukta Wankhede
Left ventricular diastolic dysfunction refers to the heart's inability to properly relax and fill during diastole. It can be caused by primary myocardial diseases like cardiomyopathy, hypertension, or secondary issues like aortic stenosis. Diagnosis involves evaluating left ventricular mass, dimensions, and function using 2D echocardiography, Doppler ultrasound to assess mitral inflow and pulmonary vein patterns, and tissue Doppler imaging of mitral annular motion. Diastolic dysfunction is graded from mild to severe based on these evaluation findings.
This document summarizes dobutamine stress echocardiography (DSE). Key points include:
- DSE uses the drug dobutamine to simulate exercise and increase heart rate, contractility, and myocardial oxygen demand to detect ischemia.
- It is useful for evaluating ischemia, viability, and valvular dysfunction in patients unable to exercise.
- The document reviews the DSE protocol, interpretation of wall motion abnormalities, indications, side effects, and applications for assessing ischemic heart disease, viability, valvular stenosis like mitral and aortic stenosis, and pulmonary hypertension.
The document discusses guidelines for assessing diastolic dysfunction according to the ASE/EACVI 2016 guidelines. It defines diastolic dysfunction and describes the stages from grade I to grade IV. For each grade, it discusses the pathophysiology and key echocardiographic findings including mitral inflow patterns, tissue Doppler measurements, pulmonary vein flow, and left atrial size. The guidelines simplify the assessment of diastolic function into four grades based on parameters of left ventricular relaxation, left atrial pressure, mitral E/A ratio, E/e' ratio, pulmonary vein flow, and left atrial size.
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.
Cardiac resynchronization therapy (CRT) uses electrical pacing of both ventricles to coordinate their contractions and improve heart function in patients with heart failure. It is recommended for patients with left ventricular ejection fraction below 35%, prolonged QRS duration over 150ms, and evidence of electrical or mechanical dyssynchrony. CRT works by pacing both ventricles simultaneously to resynchronize their contractions, improving heart pumping ability and reducing symptoms. About 30% of patients do not respond adequately, often due to factors like lack of sufficient dyssynchrony, lead placement issues, or scar tissue in the ventricles.
Based on the size of the defect, perimembranous VSDs between 4-18 mm in diameter would be suitable for closure with the Amplatzer VSD occluder. The device size would need to be selected based on the actual defect size as assessed by echocardiography. Adequate rims around the defect are required but specifics on rim measurements are not provided in this document. Other factors such as indications for closure and no contraindications to the percutaneous approach would also need to be evaluated for a particular patient.
1. Chronic coronary syndromes (CCS) refer to conditions involving atherosclerotic plaque buildup in the coronary arteries that can cause various clinical presentations depending on the dynamic nature of the disease process.
2. The most common clinical scenarios in patients with suspected or established CCS involve those with stable angina symptoms, new onset of heart failure, recent acute coronary syndrome, or asymptomatic patients more than 1 year after initial diagnosis or revascularization.
3. Evaluation and management of patients with suspected CCS involves assessing symptoms, risk factors and comorbidities, performing basic testing, estimating pre-test probability of CAD, selecting appropriate non-invasive testing to confirm diagnosis when needed, calculating risk, and determining long-
This document provides an overview of atrial fibrillation (AF), including its pathogenesis, types, diagnosis, and management. Some key points:
- AF is the most common cardiac arrhythmia, affecting around 6% of those over 65. It increases the risk of stroke.
- It occurs when the normal sinus rhythm is overridden by disorganized electrical impulses, usually originating in the lungs.
- Types include paroxysmal, persistent, and permanent. Symptoms range from none to palpitations, dyspnea, chest pain, and neurological issues.
- Diagnosis is made via ECG showing irregular rhythm without P waves. Workup evaluates for underlying causes and stroke risk factors.
The document summarizes information about the intra-aortic balloon pump (IABP), which is a circulatory assist device used to support the left ventricle through counterpulsation. It describes how the IABP works by inflating and deflating a balloon catheter timed to the cardiac cycle to displace aortic blood. It provides details on patient criteria, device set-up, monitoring, complications, and weaning from the IABP.
This document discusses complications that can occur during percutaneous coronary intervention (PCI), specifically contrast-induced nephropathy and coronary perforation. It defines contrast-induced nephropathy as acute kidney injury occurring after administration of radiocontrast media. Coronary perforation is defined as extravasation of contrast or blood from the coronary artery during or after PCI. The document discusses risk factors, prevention, diagnosis and management of these complications.
Non infarction Q waves
Precise guide for Allied Health Science Students especially cardiac specialty students, DGNM, B.Sc Nursing & M.Sc Nursing Students regarding Non Infarction Q waves
This document provides an overview of mechanical circulatory support devices. It discusses the evolution of such devices and their terminology. Temporary devices discussed include intra-aortic balloon pumps and Impella pumps. Long-term devices discussed include pulsatile flow devices like HeartMate I as well as continuous flow devices like HeartMate II, HeartWare HVAD, and HeartMate 3. Clinical trials are summarized that evaluated these devices as bridges to transplant or destination therapy. Biventricular support devices like the total artificial heart are also covered. The document concludes with recommendations from organizations on the use of these devices.
Echocardiographic Evaluation of LV Diastolic FunctionJunhao Koh
The document discusses methods for evaluating left ventricular diastolic function using echocardiography. It describes the four phases of diastole, parameters used to assess diastolic function including mitral inflow patterns, mitral annular tissue Doppler, pulmonary vein flow, left atrial size and the Tei index. Grades of diastolic dysfunction and approaches from ASE/EAE and Mayo Clinic are summarized. Continuous wave Doppler of aortic regurgitation is also presented as a noninvasive method to evaluate left ventricular relaxation.
1. The document discusses the management of single ventricle physiology, which involves connecting the systemic and pulmonary circulations in parallel rather than series due to the inability to establish two independent functioning ventricles.
2. The management involves initial palliation through procedures such as the bidirectional Glenn shunt or pulmonary artery banding, followed by definitive palliation with a Fontan operation around 3 years of age to connect the systemic venous return directly to the pulmonary arteries without an interposing ventricle.
3. The Fontan operation has evolved over time from atrio-pulmonary connections to total cavopulmonary connections using intra-atrial tunnels or extracardiac conduits to more efficiently direct superior vena c
This document summarizes the evaluation of aortic valve stenosis using echocardiography. It describes the normal aortic valve anatomy and various types of aortic valve stenosis including calcific, bicuspid, rheumatic, and supravalvular or subvalvular stenosis. Doppler echocardiography is used to evaluate aortic valve stenosis severity based on valve area, mean gradient, and peak jet velocity. Stress echocardiography with dobutamine can help distinguish true severe from pseudo-severe low-flow, low-gradient aortic stenosis.
Stent thrombosis is a rare but serious complication of percutaneous coronary intervention (PCI) with mortality rates between 25-40%. It is classified based on timing (acute, subacute, late, very late) and etiology (primary, secondary). Risk factors include premature discontinuation of dual antiplatelet therapy, smoking, diabetes, chronic kidney disease, acute coronary syndrome, and high platelet reactivity. Strategies to minimize stent thrombosis involve careful patient selection, optimal stent deployment, adherence to potent dual antiplatelet regimens, and treatment involving emergent thrombectomy with escalated antiplatelet therapy.
This document discusses coronary guidewires used in percutaneous coronary intervention (PCI). It begins by outlining the history of angioplasty and guidewire development. It then covers the purpose, components, classifications, and appropriate uses of guidewires. The main components include the core, tip, coils, covers, and coatings. Guidewires are classified based on flexibility, device support, and clinical usage. Complications like vessel perforation, pseudolesions, and entrapment are also discussed. Proper guidewire manipulation and strategies for difficult lesions are outlined to maximize safety and efficacy.
This document discusses various echocardiographic scoring systems used to assess mitral valve anatomy and predict outcomes of percutaneous balloon mitral valvuloplasty (PBMV). The Wilkins score and Commissural Calcification score are described in detail. The Wilkins score grades leaflet thickening, mobility, calcification and subvalvular involvement on a scale of 4-16. A score ≤8 indicates favorable anatomy for PBMV. The Commissural Calcification score quantifies calcification at each commissure. Other discussed scores include the Cormier score, RT-3DE score, Chen score, Reid score and Nobuyoshi score. Limitations of the scoring systems and ideas for an ideal future scoring
This document provides a history and overview of prosthetic heart valves. It discusses the timeline of key prosthetic valve designs from 1954 to present day. The main types of prosthetic valves covered are mechanical valves (ball & cage, tilting disc, bileaflet) and bioprosthetic/tissue valves (homograft, heterograft such as porcine). Newer technologies like stentless, percutaneous, and sutureless valves are also summarized. Valve characteristics like durability, thrombogenicity, and hemodynamics are compared for different valve types.
Ventricular arrhythmias originate in the ventricles and include premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation. Ventricular tachycardia is defined as three or more consecutive ventricular beats at a rate over 100 beats per minute and can be caused by mechanisms like reentry, automaticity, and triggered activity. Polymorphic ventricular tachycardia includes conditions like torsades de pointes and Brugada syndrome. Acute management of sustained ventricular tachycardia includes termination attempts using antiarrhythmic drugs or cardioversion, while long term prevention focuses on drugs, ablation, or implantable cardioverter defibrillators depending on symptoms and left ventricular function.
PREMATURE VENTRICULAR COMPLEX: DIAGNOSIS AND MANAGEMENTajay pratap singh
This document discusses premature ventricular complexes (PVCs) and catheter ablation for treating PVCs. It defines PVCs as early ventricular depolarizations that do not necessarily lead to contractions. Common causes of PVCs include electrolyte abnormalities, ischemia, and cardiomyopathies. The prevalence of PVCs increases with age and longer monitoring. Frequent PVCs can impair left ventricular function and cause a PVC-induced cardiomyopathy. Catheter ablation is an effective treatment for eliminating PVCs when medications are ineffective or not tolerated.
This document discusses coronary artery perforation during percutaneous coronary intervention (PCI). Some key points:
- Coronary perforation can occur during or after PCI and is defined as extravasation of contrast or blood from the coronary artery. Proximal or mid vessel perforations are more severe while distal perforations often have a benign course.
- Perforations are classified based on their severity. Treatment depends on the severity and location of the perforation. Conservative measures often suffice for minor perforations while techniques like prolonged balloon inflation or stenting may be needed for more severe perforations to stop bleeding.
- Factors like the use of atherectomy or laser devices, complex lesions, small vessels, and guide
The document discusses guidelines for assessing diastolic dysfunction according to the ASE/EACVI 2016 guidelines. It defines diastolic dysfunction and describes the stages from grade I to grade IV. For each grade, it discusses the pathophysiology and key echocardiographic findings including mitral inflow patterns, tissue Doppler measurements, pulmonary vein flow, and left atrial size. The guidelines simplify the assessment of diastolic function into four grades based on parameters of left ventricular relaxation, left atrial pressure, mitral E/A ratio, E/e' ratio, pulmonary vein flow, and left atrial size.
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.
Cardiac resynchronization therapy (CRT) uses electrical pacing of both ventricles to coordinate their contractions and improve heart function in patients with heart failure. It is recommended for patients with left ventricular ejection fraction below 35%, prolonged QRS duration over 150ms, and evidence of electrical or mechanical dyssynchrony. CRT works by pacing both ventricles simultaneously to resynchronize their contractions, improving heart pumping ability and reducing symptoms. About 30% of patients do not respond adequately, often due to factors like lack of sufficient dyssynchrony, lead placement issues, or scar tissue in the ventricles.
Based on the size of the defect, perimembranous VSDs between 4-18 mm in diameter would be suitable for closure with the Amplatzer VSD occluder. The device size would need to be selected based on the actual defect size as assessed by echocardiography. Adequate rims around the defect are required but specifics on rim measurements are not provided in this document. Other factors such as indications for closure and no contraindications to the percutaneous approach would also need to be evaluated for a particular patient.
1. Chronic coronary syndromes (CCS) refer to conditions involving atherosclerotic plaque buildup in the coronary arteries that can cause various clinical presentations depending on the dynamic nature of the disease process.
2. The most common clinical scenarios in patients with suspected or established CCS involve those with stable angina symptoms, new onset of heart failure, recent acute coronary syndrome, or asymptomatic patients more than 1 year after initial diagnosis or revascularization.
3. Evaluation and management of patients with suspected CCS involves assessing symptoms, risk factors and comorbidities, performing basic testing, estimating pre-test probability of CAD, selecting appropriate non-invasive testing to confirm diagnosis when needed, calculating risk, and determining long-
This document provides an overview of atrial fibrillation (AF), including its pathogenesis, types, diagnosis, and management. Some key points:
- AF is the most common cardiac arrhythmia, affecting around 6% of those over 65. It increases the risk of stroke.
- It occurs when the normal sinus rhythm is overridden by disorganized electrical impulses, usually originating in the lungs.
- Types include paroxysmal, persistent, and permanent. Symptoms range from none to palpitations, dyspnea, chest pain, and neurological issues.
- Diagnosis is made via ECG showing irregular rhythm without P waves. Workup evaluates for underlying causes and stroke risk factors.
The document summarizes information about the intra-aortic balloon pump (IABP), which is a circulatory assist device used to support the left ventricle through counterpulsation. It describes how the IABP works by inflating and deflating a balloon catheter timed to the cardiac cycle to displace aortic blood. It provides details on patient criteria, device set-up, monitoring, complications, and weaning from the IABP.
This document discusses complications that can occur during percutaneous coronary intervention (PCI), specifically contrast-induced nephropathy and coronary perforation. It defines contrast-induced nephropathy as acute kidney injury occurring after administration of radiocontrast media. Coronary perforation is defined as extravasation of contrast or blood from the coronary artery during or after PCI. The document discusses risk factors, prevention, diagnosis and management of these complications.
Non infarction Q waves
Precise guide for Allied Health Science Students especially cardiac specialty students, DGNM, B.Sc Nursing & M.Sc Nursing Students regarding Non Infarction Q waves
This document provides an overview of mechanical circulatory support devices. It discusses the evolution of such devices and their terminology. Temporary devices discussed include intra-aortic balloon pumps and Impella pumps. Long-term devices discussed include pulsatile flow devices like HeartMate I as well as continuous flow devices like HeartMate II, HeartWare HVAD, and HeartMate 3. Clinical trials are summarized that evaluated these devices as bridges to transplant or destination therapy. Biventricular support devices like the total artificial heart are also covered. The document concludes with recommendations from organizations on the use of these devices.
Echocardiographic Evaluation of LV Diastolic FunctionJunhao Koh
The document discusses methods for evaluating left ventricular diastolic function using echocardiography. It describes the four phases of diastole, parameters used to assess diastolic function including mitral inflow patterns, mitral annular tissue Doppler, pulmonary vein flow, left atrial size and the Tei index. Grades of diastolic dysfunction and approaches from ASE/EAE and Mayo Clinic are summarized. Continuous wave Doppler of aortic regurgitation is also presented as a noninvasive method to evaluate left ventricular relaxation.
1. The document discusses the management of single ventricle physiology, which involves connecting the systemic and pulmonary circulations in parallel rather than series due to the inability to establish two independent functioning ventricles.
2. The management involves initial palliation through procedures such as the bidirectional Glenn shunt or pulmonary artery banding, followed by definitive palliation with a Fontan operation around 3 years of age to connect the systemic venous return directly to the pulmonary arteries without an interposing ventricle.
3. The Fontan operation has evolved over time from atrio-pulmonary connections to total cavopulmonary connections using intra-atrial tunnels or extracardiac conduits to more efficiently direct superior vena c
This document summarizes the evaluation of aortic valve stenosis using echocardiography. It describes the normal aortic valve anatomy and various types of aortic valve stenosis including calcific, bicuspid, rheumatic, and supravalvular or subvalvular stenosis. Doppler echocardiography is used to evaluate aortic valve stenosis severity based on valve area, mean gradient, and peak jet velocity. Stress echocardiography with dobutamine can help distinguish true severe from pseudo-severe low-flow, low-gradient aortic stenosis.
Stent thrombosis is a rare but serious complication of percutaneous coronary intervention (PCI) with mortality rates between 25-40%. It is classified based on timing (acute, subacute, late, very late) and etiology (primary, secondary). Risk factors include premature discontinuation of dual antiplatelet therapy, smoking, diabetes, chronic kidney disease, acute coronary syndrome, and high platelet reactivity. Strategies to minimize stent thrombosis involve careful patient selection, optimal stent deployment, adherence to potent dual antiplatelet regimens, and treatment involving emergent thrombectomy with escalated antiplatelet therapy.
This document discusses coronary guidewires used in percutaneous coronary intervention (PCI). It begins by outlining the history of angioplasty and guidewire development. It then covers the purpose, components, classifications, and appropriate uses of guidewires. The main components include the core, tip, coils, covers, and coatings. Guidewires are classified based on flexibility, device support, and clinical usage. Complications like vessel perforation, pseudolesions, and entrapment are also discussed. Proper guidewire manipulation and strategies for difficult lesions are outlined to maximize safety and efficacy.
This document discusses various echocardiographic scoring systems used to assess mitral valve anatomy and predict outcomes of percutaneous balloon mitral valvuloplasty (PBMV). The Wilkins score and Commissural Calcification score are described in detail. The Wilkins score grades leaflet thickening, mobility, calcification and subvalvular involvement on a scale of 4-16. A score ≤8 indicates favorable anatomy for PBMV. The Commissural Calcification score quantifies calcification at each commissure. Other discussed scores include the Cormier score, RT-3DE score, Chen score, Reid score and Nobuyoshi score. Limitations of the scoring systems and ideas for an ideal future scoring
This document provides a history and overview of prosthetic heart valves. It discusses the timeline of key prosthetic valve designs from 1954 to present day. The main types of prosthetic valves covered are mechanical valves (ball & cage, tilting disc, bileaflet) and bioprosthetic/tissue valves (homograft, heterograft such as porcine). Newer technologies like stentless, percutaneous, and sutureless valves are also summarized. Valve characteristics like durability, thrombogenicity, and hemodynamics are compared for different valve types.
Ventricular arrhythmias originate in the ventricles and include premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation. Ventricular tachycardia is defined as three or more consecutive ventricular beats at a rate over 100 beats per minute and can be caused by mechanisms like reentry, automaticity, and triggered activity. Polymorphic ventricular tachycardia includes conditions like torsades de pointes and Brugada syndrome. Acute management of sustained ventricular tachycardia includes termination attempts using antiarrhythmic drugs or cardioversion, while long term prevention focuses on drugs, ablation, or implantable cardioverter defibrillators depending on symptoms and left ventricular function.
PREMATURE VENTRICULAR COMPLEX: DIAGNOSIS AND MANAGEMENTajay pratap singh
This document discusses premature ventricular complexes (PVCs) and catheter ablation for treating PVCs. It defines PVCs as early ventricular depolarizations that do not necessarily lead to contractions. Common causes of PVCs include electrolyte abnormalities, ischemia, and cardiomyopathies. The prevalence of PVCs increases with age and longer monitoring. Frequent PVCs can impair left ventricular function and cause a PVC-induced cardiomyopathy. Catheter ablation is an effective treatment for eliminating PVCs when medications are ineffective or not tolerated.
This document discusses coronary artery perforation during percutaneous coronary intervention (PCI). Some key points:
- Coronary perforation can occur during or after PCI and is defined as extravasation of contrast or blood from the coronary artery. Proximal or mid vessel perforations are more severe while distal perforations often have a benign course.
- Perforations are classified based on their severity. Treatment depends on the severity and location of the perforation. Conservative measures often suffice for minor perforations while techniques like prolonged balloon inflation or stenting may be needed for more severe perforations to stop bleeding.
- Factors like the use of atherectomy or laser devices, complex lesions, small vessels, and guide
This document summarizes an upcoming webinar on anticoagulation therapy for left ventricular thrombus. The webinar will feature expert panelists discussing left ventricular thrombus treatment guidelines, off-label use of direct oral anticoagulants, and results from the RED VELVT observational study comparing warfarin and DOAC therapy. The panelists will also take questions from attendees.
Arrhythmia-induced cardiomyopathy (AIC) refers to left ventricular dysfunction caused by tachyarrhythmias or frequent ectopy. There are two types - type 1 is solely due to the arrhythmia, while type 2 involves an arrhythmia exacerbating an underlying cardiomyopathy. Successful treatment of the arrhythmia via catheter ablation or cardioversion can reverse the left ventricular dysfunction in type 1 AIC. Aggressive treatment with catheter ablation is recommended to eliminate the arrhythmia whenever possible in order to prevent or treat AIC.
Management of pv cs and ventricular tachycardia in advanced heart failuredrucsamal
1. This document discusses therapeutic options and novel approaches for managing premature ventricular contractions (PVCs) and ventricular tachycardia (VT) in patients with advanced heart failure.
2. Frequent PVCs can themselves cause cardiomyopathy, but ablation of PVCs has been shown to improve left ventricular ejection fraction and size in some cases. PVC ablation is generally safe and well-tolerated.
3. For managing VT in advanced heart failure, a multidisciplinary team approach is important. Options discussed include various antiarrhythmic drugs, early VT ablation, and hemodynamic support such as percutaneous left ventricular assist devices during ablation procedures.
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 discusses post-myocardial infarction ventricular septal rupture (VSR). It notes that VSR incidence has decreased with improved reperfusion therapies. Surgical repair is the definitive treatment but is high risk, while percutaneous closure and mechanical support have improved outcomes. The timing and presentation of VSR depends on its pathophysiology, which can include acute or delayed rupture. Diagnosis is via echocardiography. Management involves surgical closure if stable, while unstable patients may be supported with devices or surgery delayed. Percutaneous closure is an option for inoperable cases.
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.
Rrt in icu dr said khamis zagazig april 2018 latestFarragBahbah
The document provides an overview of renal replacement therapy (RRT) modalities for critically ill patients with acute kidney injury (AKI). It discusses the history and evolution of RRT, including intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). The pros and cons of IHD and CRRT are presented. Key considerations for RRT include which modality to use, anticoagulation options, dialysate buffers, and membranes. Guidelines for determining therapy dose and duration and criteria for discontinuing RRT are summarized. Outcomes with IHD versus CRRT remain unclear due to limitations of existing studies. Overall, the document reviews best practices for delivering RRT to critically ill AK
1) Congenitally corrected transposition of the great arteries (ccTGA) is a rare cardiac anomaly where the connections of the great arteries and ventricles are discordant. The right ventricle functions as the systemic ventricle and the tricuspid valve is the systemic atrioventricular valve.
2) The right ventricle is not well-suited to function as the systemic ventricle long-term, often leading to ventricular dysfunction, tricuspid regurgitation, and heart failure. Management options include physiologic repair, anatomic repair such as the double switch operation, or a Fontan pathway.
3) The ideal surgical approach remains debated and depends on the individual
Ventricular septal rupture (VSR) is a rare but lethal complication of myocardial infarction (MI).
Bimodal peak
Range: few hours 2 weeks
Average time to rupture
2-8 days
Time course may be accelerated by thrombolysis, possible related to intramyocardial hemorrhage
The document provides information on percutaneous balloon mitral valvuloplasty (PBMV) for the treatment of mitral stenosis. It discusses the epidemiology and natural history of rheumatic heart disease and mitral stenosis. PBMV is recommended for symptomatic patients with moderate to severe mitral stenosis who have favorable valve morphology and no significant mitral regurgitation or left atrial thrombus. Echocardiography is important for assessing valve anatomy and ruling out contraindications prior to the procedure. The goal of PBMV is to safely and effectively dilate the mitral valve and relieve obstruction while avoiding complications such as mitral regurgitation or cardiac tamponade. Younger patients with pliable
Mechanical circulatory support devices such as left ventricular assist devices (LVADs) are increasingly being used as an alternative to cardiac transplantation for patients with advanced heart failure. LVADs are mechanical pumps that are implanted to support the left ventricle and improve cardiac output. They can be used as a bridge to transplantation, destination therapy for those ineligible for transplant, or potentially as a bridge to recovery in some cases. Common LVAD devices are continuous flow pumps that are more pulsatile than earlier generation pulsatile pumps. LVADs have been shown to improve symptoms, quality of life and survival for advanced heart failure patients.
Hypertrophic cardiomyopathy (HCM) is defined by a thickened left ventricular wall without an identifiable cause. It can range from asymptomatic to causing heart failure, arrhythmias, or sudden cardiac death. Treatment depends on whether the left ventricular outflow tract (LVOT) is obstructed. For symptomatic patients with LVOT obstruction despite maximum medical therapy, septal reduction procedures like alcohol septal ablation or surgical myectomy are recommended. Alcohol septal ablation involves injecting alcohol into a septal perforator artery to ablate tissue and reduce the gradient. Surgical myectomy directly resects septal muscle. Both procedures significantly reduce gradients and improve symptoms but surgical myectomy provides better gradient and symptom reduction with a lower risk of
[Paper Report] Coronary Artery Bypass Graft versus Percutaneous Coronary In...Hao-Chen Ke
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This study evaluated outcomes of patients undergoing double valve replacement (DVR) with or without aortic root enlargement (ARE) for rheumatic heart disease. 100 patients underwent DVR, with ARE performed in 50 patients using autologous or bovine pericardium patches. There were no significant differences in preoperative risk factors or operative times between groups. Postoperatively, the ARE group had lower mean pressure gradients and higher ejection fractions, indicating reduced prosthesis-patient mismatch. There were no significant differences in complications, mortality, or lengths of stay between groups. The study concludes that ARE can be safely performed with DVR to allow implantation of larger prostheses without increasing morbidity or mortality.
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Mechanical complications such as ventricular septal rupture, left ventricular free wall rupture, and papillary muscle rupture are lethal complications of acute myocardial infarction. While rare, occurring in only a small fraction of AMI cases, they carry extremely high mortality rates even with optimal treatment. Ventricular septal rupture has a mortality rate of 19-54% with surgery and is almost uniformly fatal with medical management alone. Left ventricular free wall rupture presents with sudden cardiac tamponade and is also rapidly fatal without surgery. Surgical repair techniques aim to exclude the injured myocardium with patches, though outcomes remain poor. Early stabilization is crucial to improving survival from these catastrophic AMI complications.
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2. DEFINITION
• Premature ventricular contractions (PVCs) are early
depolarization of the myocardium originating in the
ventricle.
• Traditionally they have been thought to be relatively
benign in the absence of structural heart disease.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)
6. EPIDEMIOLOGY
• PVCs are common with an estimated prevalence of 1% to
4% in the general population.
• In a normal healthy population PVCs have been detected in
1% of subjects on standard 12-lead electrocardiography and
between 40% and 75% of subjects on 24- to 48-hour Holter
monitoring.
• Their prevalence is generally age-dependent ranging from
1% in children 11 years 7 to 69% in subjects 75 years.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)
7. PVC-INDUCED CARDIOMYOPATHY
(PVCI-CMP)
• Commonly thought to be a benign entity the concept of PVC-
induced cardiomyopathy was proposed by Duffee et a in 1998
when pharmacological suppression of PVCs in patients with
presumed idiopathic dilated cardiomyopathy subsequently
improved left ventricular (LV) systolic dysfunction.
• It was only15 years ago that the term of (PVCi-CMP) emerged.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysioloy. 2012;5:229-236.)
Marie Sadron Blaye- Felice,MD et al, (Heart Rhythm2016;13:103–110)
10. CLINICAL EVALUATION
• Because a single 24-hour recording may not reflect the true PVC load due to day-to-day
variability, a strong suspicion that frequent PVCs may be the cause of LV dysfunction
may warrant extended Holter recordings of 48 to 72 hours or several 24-hour Holter
recordings.
• Echocardiographic features in PVC-induced cardiomyopathy include decreased LVEF,
increased LV systolic and diastolic dimensions, wall motion abnormalities, which are
often global as opposed to regional as well as mitral regurgitation (typically due to mitral
annular dilatation)
• Two-dimensional speckle tracking strain imaging detect subtle changes in the ventricles
function whereas the LVEF remains preserved.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)
11. CLINICAL EVALUATION
• Coronary angiography should be performed in every patient with
reduced LV systolic function to exclude significant coronary artery
disease except for those with a low cardiovascular risk.
• Cardiac MRI may be warranted in detecting arrhythmogenic right
ventricular cardiomyopathy with LV involvement and infiltrative
disease when clinically suspected.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)
12. PARAMETERS SIGNIFICANTLY RELATED
TO THE PVCI-CMP
1. PVC burden
2. Symptoms : Presence or absence of palpitation
3. Duration of symptoms
4. Age and gender
5. Morphology and Sit of origin
Marie Sadron Blaye-Felice, MD, (Heart Rhythm2016;13:103–110)
13. PVCS BURDEN
• Majority of patients with frequent PVCs have a benign course
whereas up to one third of them develop PVCi-CMP.
• The prevalence of PVCi-CMP is estimated as only 5% to 7%
among patients with a PVC burden 10%.
• Baman and Fred Morady et al suggested that a PVC burden of
24% had a sensitivity and specificity of approximately 80% in
separating the patient populations with impaired versus preserved
LV function.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)
Timir S. Baman, MD, Fred Morady et al, (Heart Rhythm 2010;7:865–869)
14. PVCS BURDEN
• Takemoto et al analyzed the result of ablation with relation to 3 pre
specified subgroups (<10%,10%–20%, >20%) based on the burden of
PVCs on 24-hour Holter monitoring the subgroup with >20% of PVCs
at baseline had the most benefit from ablation with significant
improvement in LVEF and LV dimensions
• When the PVC burden was expressed in the absolute number of PVCs
before RFA, the subgroup with >20 000 PVCs per day was shown to be
associated with highest risk of LV dysfunction and heart failure.
Clin. Cardiol. 38, 4, 251–258 (2015) A. Saurav et al: PVC-induced cardiomyopathy
15. SYMPTOMS
AGE AND GENDER
• Absence of symptoms are independently associated with PVCi-
CMP because diagnosis of PVCs is delayed in asymptomatic patients
often made fortuitously over the course of the developing CMP
• The duration of palpitations of 30 to 60 months specially more than
60 months
• More common with increasing age and in males
Marie Sadron Blaye- Felice, MD, (Heart Rhythm2016;13:103–110)
Fred Morady , MD, et al ,Heart Rhythm 2012;9:92–95
16. MORPHOLOGY AND SITE OF ORIGIN
• Long PVC-QRS duration
• Epicardial origin of the focus
• Interpolated PVCs
• LV origin of PVCs
• Long PVC coupling interval
• High PVC QRS amplitude
• Presence of polymorphic PVCs
17. MORPHOLOGY AND SITE OF ORIGIN
• Longer PVC-QRS duration, especially in the presence of a LBBB
participate in the alteration of LV function because of the electrical
and therefore likely associated mechanical dyssynchrony.
• Epicardial PVCs have longer PVC-QRS duration than other PVCs
probably because of the paucity of Purkinje fibers in the
epicardium.
Marie Sadron Blaye- Felice, MD, (Heart Rhythm2016;13:103–110)
19. MORPHOLOGY AND SITE OF ORIGIN
• Interpolated PVCs have a longer Ventriculo-atrial block
cycle length compared with PVCs without interpolation.
• The total PVC burden increased with interpolation
Clin. Cardiol. 38, 4, 251–258 (2015) A. Saurav et al: PVC-induced cardiomyopathy
21. MORPHOLOGY AND SITE OF ORIGIN
LV origin of PVCs
Long PVC coupling interval
High PVC QRS amplitude
Presence of polymorphic
PVCs
Marie Sadron Blaye-Felice, MD, (Heart Rhythm2016;13:103–110)
Fred Morady, MD et al, (Heart Rhythm 2011;8:1046 –1049)
23. MEDICAL THERAPY
• Anti-Failure therapies
• Typically, in mildly symptomatic patients with mild LV dysfunction a
trial of β-blockers or a nondihydropyridine calcium channel blocker
should be considered as first-line therapy.
• Class Ic and III antiarrhythmic agents such as flecainide and sotalol
are effective but with significant adverse effect.
• These agents, with the exception of amiodarone, should not be used
in patients with sever LV dysfunction.
Fred Morady, MD et al, (Heart Rhythm 2011;8:1046 –1049)
24. CATHETER ABLATION
• There are growing evidence in favor of catheter ablation for PVCs especially in the
presence of LV dysfunction.
• Multiple studies demonstrating high efficacy of catheter ablation of PVCs with success
rates ranging from 80% to 100%.
• Procedural success may be dependent on the site of origin with lower efficacy for
epicardial foci or multiple PVC morphologies.
• Major complications occur in approximately 3% of cases including death stroke
myocardial infarction cardiac perforation with or without pericardial tamponade pericardial
effusion and blood vessel dissection or stenosis.
A. Saurav et al: PVC-induced cardiomyopathy Clin. Cardiol. 38, 4, 251–258 (2015)
25. CATHETER ABLATION
• In patients with frequent PVCs and PP-ICD indication
ablation improves LVEF and, in most cases, allows removal of
the indication.
• Withholding the ICD and reevaluating within 6 months
of ablation seems to be a safe and appropriate strategy
Ablation of frequent PVCs in patients meeting
criteria for primary prevention ICD implant:
Heart Rhythm. 2015 Dec;12(12):2434-42. doi: 10.1016/j.hrthm.2015.09.011. Epub 2015 Sep 15.
26. • Sarrazin et al considered frequent PVCs to be 5% of the beats observed on a
24-hour monitor.
• Our data suggest that despite the presence of scar tissue in post infarction
patients a component of reversible cardiomyopathy may be present in patients
with frequent PVCs.
• A low ejection fraction with a small amount of scar tissue may suggest a
potentially reversible cardiomyopathy.
Renee M. Sullivan, MD, Brian Olshansky, MD, FHRS doi:10.1016/j.hrthm.2009.08.029
CATHETER ABLATION
How many PVCs are too many in post-MI
patients:
27. PVC MEDIATED CARDIOMYOPATHY
• Ablation of PVC in patient in presence of
structural heart disease
• Reverse or stop of progression of LV dysfunction
28. CATHETER ABLATION
• Frequent PVCs to be 4-5% of the beats observed on a 24-hour monitor
• In patients with frequent PVCs and nonischemic cardiomyopathy EF and
functional class can be improved but not always normalized by
successful PVC ablation
Effect of ablation of in patients with nonischemic
cardiomyopathy:
29. EFFECTIVENESS OF ABLATION
IN PVCI-CMP
• The criterion for an effective ablation procedure was an 80%
reduction in the PVC burden.
• Improved by at least 15% or normalized (ejection fraction 50%)
after an effective ablation procedure.
Timir S. Baman, MD, Fred Morady et al, (Heart Rhythm 2010;7:865–869)
30. CONCLUSIONS
• Frequent PVCs may be the consequence of LV systolic dysfunction
or the cause of LV dysfunction.
• Reduction of frequent PVCs with antiarrhythmic drugs or by
ablation may improve LV function in patients presenting with newly
recognized depressed LV function and frequent PVCs.
• Catheter ablation appears to be more effective than antiarrhythmic
drugs in PVCs frequency reduction and LVEF normalization.
Li Zhong, MD, PhD et al Heart Rhythm2014;11:187–193
31. CASE 1
• 27 years old man with aborted SCD and previous ICD
implantation, LVEF 25%
• Dyspnea
• Palpitation
• Frequent ventricular ectopies, progressive LV dysfunction and
possibility PVC induced cardiomyopathy