This document provides a summary of a cardiology division morning report discussing a 56-year-old woman who presented with chest pressure and shortness of breath. She had a history of obesity, diabetes, hypertension, and low ejection fraction. Tests showed significant coronary artery disease involving the left anterior descending, left circumflex, and right coronary arteries, as well as reduced right ventricular function. She developed complete heart block and required inotropic support. Her condition initially stabilized but she remained in heart block. Plans were made for pacemaker placement, but her rhythm improved with theophylline. The discussion focused on management strategies for right ventricular ischemia including restoration of rhythm, optimization of preload and oxygen delivery, inotropes, re
The two major causes of acute right ventricular (RV) failure in ICU patients are acute cor pulmonale (ACP) during acute respiratory distress syndrome (ARDS) and ACP during acute massive pulmonary embolism (PE).
The increase in pulmonary vascular resistance (PVR) in ARDS can be secondary either to « structural » mechanisms related to lung injury per se and to « functional » mechanisms related to the effects of mechanical ventilation with positive end expiratory pressure (PEEP). The latter mechanism is enhanced when PEEP overdistends more than it recruits lung volume and when tidal volume (VT) is high. The recommended protective ventilation with low VT and PEEP adjusted to driving pressure can also reduce the RV afterload. A reduced central blood volume can also play a role in the increase in PVR (extension of the West’s zone 2). In this case, volume administration can reduce the PVR and improve the RV function. Finally, prone positioning also exerts a beneficial effect on RV afterload through a decrease in PVR (lung recruitment, decrease in hypoxic vasoconstriction, increase in central blood volume with decrease in the extent of zone 2).
In acute PE, RV dysfunction is associated with poor outcome. Thrombolytic treatment, which is indicated in cases of severe PE with shock, prevents hemodynamic decompensation in patients with intermediate risk PE, but also results in increased risk of severe hemorrhage and stroke. In the case of PE with low cardiac output and no RV dilatation, fluid administration can be indicated to improve cardiac output. In cases of systemic arterial hypotension, vasopressors such as norepinephrine can be indicated to restore adequate RV perfusion pressure. Indication of inotropic agents such as dobutamine, which improves the RV-pressure artery coupling should be evaluated individually. Surgical pulmonary embolectomy can be indicated when the thrombolytic therapy is contra-indicated in acute PE with shock.
ICN Victoria presents Dr Aiden Burrell talking on the diagnosis, clinical features and treatment of right ventricular failure for the Intensive Care Specialist
The right ventricle (RV) is not important, until it is. Under normal conditions RV function merely keeps central venous pressure low and delivers all the venous return per beat into the pulmonary circulation under low pressure. If pulmonary artery pressures increase due to pulmonary vascular disease (embolism, ARDS, COPD), over-distention (COPD, asthma) or ischemia (embolism, pulmonary hypertension), the RV rapidly dilates decreasing left ventricular (LV) diastolic compliance via ventricular interdependence. Most clinicians presume that the RV is merely a weaker version of the LV, but follows that same rules. But this in not true. Normally, RV filling occurs without any measurable change in RV distending pressure owing to conformational changes in its shape rather than distention of its wall fibers. This effect allows central venous pressure to remain low despite major dynamic change sin venous return associated with breathing. RV ejection is exquisitely dependent of RV ejection pressure. Thus, if disease processes increase pulmonary artery impedance then RV dilation and failure will eventually occur. Furthermore, most of RV coronary blood flow occurs during systole, unlike LV coronary blood flow, which primarily occurs in diastole. Thus, systemic hypotension or relative hypotension where in pulmonary artery pressures equal or exceed aortic pressure must cause RV ischemia. Clinically these findings carry a common end result. For cardiac output to increase RV volumes must increase. If increasing RV volumes also result in increasing filling pressures then RV over distention may be occurring causing RV free wall ischemia. If relative systemic hypotension exists then selective increases in arterial pressure will improve RV systolic function. Accordingly, fluid resuscitation, if associated with rapid increases in central venous pressure should be stopped until evidence of acute cor pulmonale is excluded. Acute cor pulmonale can be treated by improving LV systolic function, coronary perfusion pressure or reducing pulmonary artery outflow impedance. The normal response of the RV to slowly increasing pulmonary artery pressures is to increase its intrinsic contractility (Anrep effect), but if the pressure load exceeds such adaptation, RV hypertrophy develops in an asymmetric fashion initially in the infundibulum before progressing to the RV free wall and septum. In chronic RV failure, dilation and RV wall thinning occurs as the heart reverts to preload to sustain stroke volume (Starling effect). Importantly, all these effects and their response to therapies can be assessed at the bedside using echocardiography and pulmonary arterial catheterization.
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
central venous pressure and intra-arterial blood pressure monitoring. invasiv...prateek gupta
central venous pressure and intra-arterial blood pressure monitoring. various sites for cvp and Ibp insertion. working principle for cvp and ibp. indication and complication. various waveform of cvp and ibp
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
The two major causes of acute right ventricular (RV) failure in ICU patients are acute cor pulmonale (ACP) during acute respiratory distress syndrome (ARDS) and ACP during acute massive pulmonary embolism (PE).
The increase in pulmonary vascular resistance (PVR) in ARDS can be secondary either to « structural » mechanisms related to lung injury per se and to « functional » mechanisms related to the effects of mechanical ventilation with positive end expiratory pressure (PEEP). The latter mechanism is enhanced when PEEP overdistends more than it recruits lung volume and when tidal volume (VT) is high. The recommended protective ventilation with low VT and PEEP adjusted to driving pressure can also reduce the RV afterload. A reduced central blood volume can also play a role in the increase in PVR (extension of the West’s zone 2). In this case, volume administration can reduce the PVR and improve the RV function. Finally, prone positioning also exerts a beneficial effect on RV afterload through a decrease in PVR (lung recruitment, decrease in hypoxic vasoconstriction, increase in central blood volume with decrease in the extent of zone 2).
In acute PE, RV dysfunction is associated with poor outcome. Thrombolytic treatment, which is indicated in cases of severe PE with shock, prevents hemodynamic decompensation in patients with intermediate risk PE, but also results in increased risk of severe hemorrhage and stroke. In the case of PE with low cardiac output and no RV dilatation, fluid administration can be indicated to improve cardiac output. In cases of systemic arterial hypotension, vasopressors such as norepinephrine can be indicated to restore adequate RV perfusion pressure. Indication of inotropic agents such as dobutamine, which improves the RV-pressure artery coupling should be evaluated individually. Surgical pulmonary embolectomy can be indicated when the thrombolytic therapy is contra-indicated in acute PE with shock.
ICN Victoria presents Dr Aiden Burrell talking on the diagnosis, clinical features and treatment of right ventricular failure for the Intensive Care Specialist
The right ventricle (RV) is not important, until it is. Under normal conditions RV function merely keeps central venous pressure low and delivers all the venous return per beat into the pulmonary circulation under low pressure. If pulmonary artery pressures increase due to pulmonary vascular disease (embolism, ARDS, COPD), over-distention (COPD, asthma) or ischemia (embolism, pulmonary hypertension), the RV rapidly dilates decreasing left ventricular (LV) diastolic compliance via ventricular interdependence. Most clinicians presume that the RV is merely a weaker version of the LV, but follows that same rules. But this in not true. Normally, RV filling occurs without any measurable change in RV distending pressure owing to conformational changes in its shape rather than distention of its wall fibers. This effect allows central venous pressure to remain low despite major dynamic change sin venous return associated with breathing. RV ejection is exquisitely dependent of RV ejection pressure. Thus, if disease processes increase pulmonary artery impedance then RV dilation and failure will eventually occur. Furthermore, most of RV coronary blood flow occurs during systole, unlike LV coronary blood flow, which primarily occurs in diastole. Thus, systemic hypotension or relative hypotension where in pulmonary artery pressures equal or exceed aortic pressure must cause RV ischemia. Clinically these findings carry a common end result. For cardiac output to increase RV volumes must increase. If increasing RV volumes also result in increasing filling pressures then RV over distention may be occurring causing RV free wall ischemia. If relative systemic hypotension exists then selective increases in arterial pressure will improve RV systolic function. Accordingly, fluid resuscitation, if associated with rapid increases in central venous pressure should be stopped until evidence of acute cor pulmonale is excluded. Acute cor pulmonale can be treated by improving LV systolic function, coronary perfusion pressure or reducing pulmonary artery outflow impedance. The normal response of the RV to slowly increasing pulmonary artery pressures is to increase its intrinsic contractility (Anrep effect), but if the pressure load exceeds such adaptation, RV hypertrophy develops in an asymmetric fashion initially in the infundibulum before progressing to the RV free wall and septum. In chronic RV failure, dilation and RV wall thinning occurs as the heart reverts to preload to sustain stroke volume (Starling effect). Importantly, all these effects and their response to therapies can be assessed at the bedside using echocardiography and pulmonary arterial catheterization.
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
central venous pressure and intra-arterial blood pressure monitoring. invasiv...prateek gupta
central venous pressure and intra-arterial blood pressure monitoring. various sites for cvp and Ibp insertion. working principle for cvp and ibp. indication and complication. various waveform of cvp and ibp
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Acute myocardial infarction associated with right bundle branch block and cha...YasserMohammedHassan1
Acute myocardial infarction may be associated right bundle branch block.
Accompanied trifascicular heart block had pre-streptokinase left anterior fascicular block
with left axis deviation and post-streptokinase left posterior fascicular block with right axis
deviation.
Case-1:
A 23 years old medical student presented with occasional palpitation, shortness of breath and chest discomfort. He had the following ECG.
A 53 years old gentleman presented with palpitations for last 5 hours. He is smoker, diabetic, dyslipidemic and hypertensive. He had exertional chest discomfort for last 5 years and did coronary angiogram 3 years back and CAG revealed TVD and advised for revascularization. But he refused and was irregular in medication and reluctant for life style modification. He came to emergency department with this ECG.
Brief Overview – ACLS Algorithm
Rhythm Based Management of Cardiac Arrest.
Monitoring during CPR.
Access for Parenteral Medications during Cardiac Arrest.
Advanced Airway.
Medications for Arrest Rythms.
Interventions Not Recommended for Routine Use During Cardiac Arrest.
Broken Heart Syndrome: A Stress Responseasclepiuspdfs
Takotsubo cardiomyopathy, also known as broken heart syndrome, stress cardiomyopathy, or apical ballooning syndrome, is described as a type of emotional or physical stress response that may mimic acute coronary syndrome (ACS) or myocarditis. It is a form of reversible left ventricular dysfunction with characteristic apical ballooning, contributing to its’ name, along with diagnostic proof on coronary catheterization or angiography of the absence of significant coronary artery stenosis classically expected in ACS. The damage seen is typically transient, appearing to completely resolve within months with very low percentage of long-term sequelae or recurrence.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Right Ventricular Infarction - Morning report 040411
1. Cardiology Division MorningCardiology Division Morning
ReportReport
Michael G. Katz, MD
Fellow in Cardiovascular Disease
University of Rochester
April 4, 2011
2. HPI
56 year old morbidly obese, diabetic WF with
cardiac RF of HTN, and HL.
Nurse by training, but on medical disability due to
chronic low back pain. Non-smoker. Lives with
husband, son, and daughter.
In her usual state of sedentary health until day of
presentation.
2
3. Other cardiac history
April 2010, symptoms of SOB
EKG: LBBB
TTE:
• LVEF 40-45%
• Septal, anterior, and inferior mild HK
Regadenoson nuclear SPECT:
• LVEF 44%
• Mild global hypokinesis
• Normal rest/rest perfusion
3
4. Presentation
January 2011
Awoke from sleep at 12am with L-sided, moderate intensity, chest
pressure. Radiation to L shoulder and neck. Associated with SOB.
Spontaneously remitted, but recurred at 3am. Took NTG x2, but when
discomfort unrelieved, called EMS.
Brought to Mary Imogene Bassett Hospital, Cooperstown, NY.
4
11. Transferred to SMH for further management (eg. Medicine of the Highest
Order).
Arrived intubated, sedated, on IABP, with temporary RV pacing wire, on
norepinephrine 2.5 mcg/min.
HR 84 BP 115/46
Repeat Swan:
• RA 18
• PA 43/24
• CO/CI 2.6/1.35
11
15. Dobutamine added
Paceport PA Catheter placed for sequential AV pacing
WBC in mid-20s (work-up over first 24 hours without evidence of
systemic infection)
15
18. “Thus the right ventricle may be said to be made for the sake of
transmitting blood through the lungs, not for nourishing them.”
- William Harvey, 1616
19. • Most anteriorly situated chamber
• Behind sternum
• Shape of RV is complex:
• RV appears triangular when
viewed from
• the side and crescent shaped when
viewed in cross section
• influenced by the position of the
interventricular septum
• Under normal loading and
electrical conditions, the septum is
concave toward the LV in both
systole and diastole
20. RV delimited by the annulus of the
tricuspid valve and by the pulmonary
valve.
RV
Can be described in terms of 3
components:
1. the inlet, which consists of the
tricuspid valve, chordae tendineae,
and papillary muscles;
2. the trabeculated apical myocardium;
3. the infundibulum, or conus, which
corresponds to the smooth myocardial
outflow region
21. RV contrtraction is sequential:
• contraction of the inlet and trabeculated myocardium and
ending with the contraction of the infundibulum
(approximately 25 to 50 ms apart)
• Contraction of the infundibulum is of longer duration than
contraction of the inflow region
22. The RV contracts by 3 separate mechanisms:
1. Inward movement of the free wall, which produces a bellows
effect
2. Contraction of the longitudinal fibers, which shortens the long
axis and draws the tricuspid annulus toward the apex; and
3. Traction on the free wall at the points of attachment
secondary to LV contraction.
Shortening of the RV is greater longitudinally than radially.
23. • RV afterload represents the load
that the RV has to overcome
during ejection
• Heightened sensitivity to
afterload change in comparison
to LV
• In clinical practice, pulmonary
vascular resistance (PVR) is the
most commonly used index of
afterload
24. • Blood supply of RV varies by dominance
• pRCA flow occurs in both diastole and
systole
• 80% of pop R dominant, RCA supplies RV
• Lateral wall of the RV is supplied by the
marginal branches of the RV
• posterior wall and the inferoseptal region
are supplied by the PDA
• Anterior wall of the RV and the
anteroseptal region are supplied by
branches of the LAD
• The infundibulum derives its supply from
the conal artery,
• separate ostial origin in 30% of cases.
• separate ostium explains the
preservation of infundibular contraction
in the presence of pRCA occlusion
Coronary Perfusion of RV
25. RV seems particularly resistant to ischemia
More favorable oxygen supply-demand ratio
• Lower O2 requirement due to smaller muscle mass in comparison to LV
• Improved O2 delivery due to biphasic nature of coronary blood flow
Left to right collateral blood flow
? – Direction perfusion of myocardium from RV via thesbian veins
25
31. 48 hours after admission to CCU
Remains in 3rd
degree AVB
RHC similar to admission
High FiO2 and PEEP requirements
Pressors weaned to dobutamine alone
Ihaled epoprostenol added
31
32. Thereafter…
FiO2 and PEEP requirements improved.
Hemodynamics stabilized and IABP was weaned off. Pressors were quickly
weaned.
Although there was now intermittant sinus rhythm, patient remained in
3rd
degree AVB for the majoriy of time. It was thought that atrial rhythm
would be slow to return.
Plans for PPM pacer were made, but before this a trial of theophyline was
attemped.
32
33. Treatment
1) restoration of physiologic rhythm
2) optimization of ventricular preload
3) optimization of oxygen supply and demand
4) parenteral inotropic support for persistent hemodynamic compromise;
5) reperfusion, and
6) mechanical support with intra-aortic balloon counterpulsation and RV
assist devices.
33
36. Many patients show spontaneous improvement in hemodynamic status in
3 to 10 days regardless of revascularization.1,2
RV performance may normalize in over 3 to 12 months.3,4,5
36
1. J Am Coll Cardiol 1984;4:931–9
2. Circulation 1987;75:996–1003
3. Br Heart J 1977;39:1319–23
4. Circulation 1987;75:996–1003
5. Am Heart J 1990;119:816–22
Pre-”modern”
era of PCI
the next day VF arrest, 2 rounds of CPR with with amiodarone drip started; bedside echo performed immediately after the code was reported to have inferior WMA with LVEF of 20%
SMH presentation
Underlying rhythm
LV concentric LVH LVEF 45% LA 3.5 Trace TR PAS 36 mmHg TA 15 mmHg TR gradient 21 mmHg
In contrast to the LV, twisting and rotational movements do not contribute significantly to RV contraction. Moreover, because of the higher surface-tovolume ratio of the RV, a smaller inward motion is required to eject the same stroke volume.
Acute proximal RCA occlusion results in RV dysfunction in nearly 50% of cases with transmural infero-posterior infarction. Although the proximity of the culprit lesion and its relationship to RVFW perfusion correlates with the presence or absence of RVI in most patients, there are exceptions in which proximal occlusions do not result in RV ischemic dysfunction, attributable in most cases to restora- tion of RVFW perfusion through prominent collaterals or spontaneous antegrade reperfusion. In the rare cases in which RV ischemic dysfunction occurs in association with culprit lesions distal to the major RV branches, RV branch flow is impaired by adjacent thrombus or RV branch stenosis.
In the past, however, the importance of RV function has been underesti- mated. This perception originated from studies on open- pericardium dog models and from the observation that pa- tients may survive without a functional subpulmonary RV (Fontan procedure). In the 1940s, studies using open- pericardium dog models showed that cauterization of the RV lateral wall did not result in a decrease in cardiac output or an increase in systemic venous pressure. 1–3 As was later dem- onstrated, the open-pericardium model did not take into account the complex nature of ventricular interaction. In 1982, Goldstein and colleagues2 showed that RV myocardial infarction (RVMI) in a closed-chest dog model led to signif- icant hemodynamic compromise. These findings were further supported by clinical studies demonstrating an increased risk of death, arrhythmia, and shock in patients with RVMI.
When a closed pericardial model was developed RCA infarction in canines, it was shown that there was acute RV dilatation and consequent intrapericardial pressure elevation due to the pericardial constraint. There is also a reduction in RV systolic pressure, LV end diastolic size, CO, and aortic pressure. All of these findings normalized when the pericardium was incised. As filling progresses, the noncompliant right ventricle ascends a steep pressure-volume curve, lead- ing to a pattern of rapid diastolic pressure elevation. Right ventricular diastolic dysfunction adversely affects LV diastolic properties through diastolic interactions mediated by the reversed curved septum and exacerbated by elevated intrapericardial pressure (9,39–45). Acute RV dilation and elevated RV diastolic pressure shift the interventricular septum toward the volume-deprived left ventricle, thereby impairing LV compliance and further limiting LV filling. More than this, under normal conditions, it has been shown that early systolic bulging of the septum into RV, contributing to early generation of RV pressure and effective pulmonary blood flow. This observation may explain why decomposition more frequent with anterior or septal concomitant involvement. Hemodynamics in progressive pulmonary vascular disease. A decrease in pulmonary arterial pressure (PAP) in patients with PH may be a sign of low cardiac output (CO) and severe RV failure. PVR indicates pulmonary vascular resistance; PCWP, pulmonary artery capillary wedge pressure; and MPAP, mean PAP.
With RVI: peak RV systolic pressure is depressed and RV relaxation is delayed. “a” wave is augmented as mean atrial pressure is increased. There is now a prominent x descent a relatively blunted y descent. The y descent is blunted because the RV is relatively dilated and stiffened by this point and this imparts resistance to early filling. Note that diastolic RV and LV pressures are elevated and equalized. With RAI: The mean RA pressure is elevated with now severe depression of the “a” wave and blunting of the x descent.
High-grade atrioventricular (AV) block and bradycardia- hypotension without AV block commonly complicate infe- rior myocardial infarction (56–58) and have been attributed predominantly to the effects of AV nodal ischemia and cardioinhibitory (Bezold-Jarisch) reflexes arising from stim- ulation of vagal afferents in the ischemic LV inferoposterior wall (59–61). We and others have documented that in patients with acute RVI there is an increased incidence of high-grade AV block compared to those without right heart involvement (12,15,62–64). Recent observations from our laboratory now also document that bradycardia-hypotension without AV block is also more common in patients with RVI (65,66)