1) Transthoracic and transesophageal echocardiography are important modalities for assessing atrial septal defects (ASDs). TTE can identify RV volume overload and septal flattening, while TEE precisely measures defect size and evaluates rim morphology.
2) The four main types of ASDs - ostium secundum, ostium primum, sinus venosus, and coronary sinus defects - have distinguishing echo features. Doppler can demonstrate shunt direction and magnitude.
3) Echocardiography guides percutaneous ASD closure by assessing defect and rim anatomy, device sizing, and post-procedure result. Understanding echo features is key to ensuring procedure success.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
In this ppt i am going to discuss various spotters, including ECG, X-ray, fluroscopy images and there answers. These spotter now days asked in various DM cardiology exam conducted all over India, so it will help you in your DM Cardiology exam preperationn.
Speckle tracking echocardiography (STE) is an echocardiographic imaging technique that analyzes the motion of tissues in the heart by using the naturally occurring speckle pattern in the myocardium or blood when imaged by ultrasound.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
In this ppt i am going to discuss various spotters, including ECG, X-ray, fluroscopy images and there answers. These spotter now days asked in various DM cardiology exam conducted all over India, so it will help you in your DM Cardiology exam preperationn.
Speckle tracking echocardiography (STE) is an echocardiographic imaging technique that analyzes the motion of tissues in the heart by using the naturally occurring speckle pattern in the myocardium or blood when imaged by ultrasound.
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
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Generally occurs secondary to pulmonary atresia with intact IVS .
Pathophysiology- it develops because of a reduction in the blood flow secondary to inflow impedence from tricuspid atresia or outflow impedence from pulmonary arterial atresia .
Typical findings- a small , hypertrophic RV and a small or absent pulmonary artery
a cardiac surgery presentation about Atrioventricular septal defect,Definition, Prevalence,Anatomy,Classification,presentation ,diagnosis and management
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
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Generally occurs secondary to pulmonary atresia with intact IVS .
Pathophysiology- it develops because of a reduction in the blood flow secondary to inflow impedence from tricuspid atresia or outflow impedence from pulmonary arterial atresia .
Typical findings- a small , hypertrophic RV and a small or absent pulmonary artery
a cardiac surgery presentation about Atrioventricular septal defect,Definition, Prevalence,Anatomy,Classification,presentation ,diagnosis and management
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- 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
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. Introduction
Atrial septal defect (ASD) is the second most
common congenital heart disease in adults.
Approximately 10% of all congenital heart lesions.
Isolated ASD results from abnormal development
of the septa that partition the common atrium of
the developing heart into right and left chambers.
70% of ASDs are of the ostium secundum variety.
The incidence of ASD is approximately 3 per
10,000 live births.
3. Embryology
The interatrial septum forms during the
first and second months of fetal
development.
Stage I is the formation of the septum
primum.
The septum primum walls off a crescent-
shaped portion of the hole between the
right and left atria.
Foramen primum (also called the ostium
primum) stays open
The remaining part of the opening
between the right and left atria is closed
by the septum secundum.
The 2 tissue layers overlap like a flap,
allowing blood flow to continue during
fetal life.
Changes in circulation at birth, closes
the flap permanently.
4.
5. Anatomy and Physiology
Extends from cavo-
atrial junction with
superior and inferior
vena cavae
Ends near the atrio-
ventricular canal
near the tricuspid
valve
6. Ostium Secundum
Most common type of
ASD
Center of the septum
between the right and
left atrium
7. Ostium Primum
Next most common type
Located in the lower
portion of the atrial
septum.
Will often have a mitral
valve defect associated
with it called a mitral valve
cleft.
A mitral valve cleft is a slit-
like or elongated hole
usually involves the
8. Sinus Venosus
Least common type of ASD
Located in the upper portion of
the atrial septum.
Association with an abnormal
pulmonary vein connection
Four pulmonary veins, two from
the right lung and two from the
left lung, normally return red
blood to the left atrium.
Usually with a sinus venosus
ASD, a pulmonary vein from the
right lung will be abnormally
connected to the right atrium
instead of the left atrium.
This is called an anomalous
..asd-veno.jpg
9. Foramen Ovale
Remnant of fetal
circulation
Behaves like flap
valve
Opens during
increased intra-
thoracic pressure
13. WHEN TO SUSPECT IN 2D
ECHO
RIGHT VENTRICULAR DILATION
ABNORMAL MOTION OF IVS- brisk anterior
movement in early systole or flattened
movement throughout diastole
? IAS DROP OUT IN APICAL 4C VIEW
RELATIVE ATRIAL INDEX
14. 2D ECHO
RA RV VOLUME OVERLOAD
SEPTAL FLATTENING IN DIASTOLE
15. RELATIVE ATRIAL INDEX
Standard apical 4C views- right atrial area divided by
left atrial area
Cutoff value of >0.92 predicted patients with ASDs
v/s matched controls with 99.1% sensitivity and 90.5%
specificity.
After closure, significant atrial remodeling occurred
immediately, with a reduction in the mean RAI at day
1 to 0.93 ± 0.16 (P < .0001) and complete
normalization at early follow-up to 0.81 ± 0.12.
16. The Relative Atrial Index (RAI)—A Novel, Simple,
Reliable, and Robust Transthoracic Echocardiographic
Indicator of Atrial Defects
Natalie A Kelly -Journal of the American Society of
Echocardiography
17. The role of echocardiography
Indication – RV – volume load (TTE)
Screening for feasibility of intervention
Native ASD size – septal size on LV aspect
Number of ASD`s
Position of ASD – rims (aorta, AV-valve,
SVC/IVC, right pulmonary veins)
Monitoring of the procedure
Follow-up echocardiography
18. Accurate measurement of the defect size plays a key
role in closing ASD using a percutaneous occluder
device.
It is possible to determine the size of the defect by
transesophageal echocardiography (TEE), which is a
noninvasive technique.
In the literature, it has been emphasized that TEE is a
gold standard in transcatheter closure of ASD and
thus should be used in analyzing septal defect and
rims during the process.
19. Therefore, using echocardiographic parameters
affecting success of closure may prevent possible
complications in percutaneous closure of ASDs.
In terms of success, there is no definite ASD size or
predictor as the size of ASD differs from 1 patient to
another.
Determining other predictors along with the measured
ASD size and evaluating the closure together with
such predictors would increase the chance of
success.
20. Conventionally, the rims of a secundum ASD are
labeled as
aortic (superoanterior),
atrioventricular (AV) valve (mitral or
inferoanterior),
superior venacaval (SVC or superoposterior),
inferior venacaval (IVC or inferoposterior), and
posterior (from the posterior free wall of the atria,
coronary sinus rim).
21. By conventional definition, a margin 5 mm is considered to be adequate.
Podnar et al. defined 10 morphological variations of defects,
the most common type being the defect with deficient aortic rim (42.1%).
The other variants included
central defects (24.2%),
deficient inferoposterior rim (12.1%),
perforated aneurysm of the septum (7.9%),
multiple defects (7.3%),
combined deficiency of mitral and aortic rims (4.1%),
Deficient SVC rim (1%), and
deficient coronary sinus rim (1%).
22. SUB COSTAL 4C VIEW
To go for the subcostal 4C – Keeps the atrial
septum perpendicular to the ultrasound
beam
Distinguishes OS , OP & SV ASDs
Measurements of the septum can be taken
Anomalous drainage of pulmonary veins
Atrial septal aneurysm
23. TTE -views for ASD
PSAX- IAS separates Rt &Lt atrium and runs
posteriorly from NCC of aortic valve.
Not seen in entirety as a result of drop out artefact
APICAL 4C- Posterior aspect of Interatrial septum is
clearly delineated in this view but drop out artefact is
seen in region of fossa ovalis.
Pulmonary venous drainage- 3 veins draining to LA
APICAL 5C VIEW- Anterior aspect of interatrial
septum
24. PSAX VIEW
IAS AGAINST NCC
OF AORTA
APICAL 4C VIEW
SHOWING THE IAS AND 3
VEINS DRAINING TO LA, RT
LOWER PULMONARY VEIN
IS USUALLY NOT SEEN
25. SUB COSTAL 4C VIEW- Useful in patients with COPD and
ventilated patients.
Viewed with breath held in inspiration- index marker in 3o`
clock position.
No IAS drop outs
SUB COSTAL SHORT AXIS- Index marker at 12o`clock
position and sweeping the transducer from midline to Rt side
of patient
26. SUBCOSTAL 4C VIEW
SUB COSTAL SHORT
AXIS VIEW ALSO SHOWS
IVC DRAINING TO RA
AND EUSTACHIAN VALVE
27. Other important views
To visualise SVC- Suprasternal short axis –index
marker in 4 o`clock position
L-SVC is seen from left supraclvicular fossa or
suprasternal short axis
Suprasternal short axis to visualise the the pulmonary
veins draining into left atrium
Cleft mitral valve in AVCD in 12o`clock position in
PSAX
29. En face view in 2D
First the apical 4c view was taken.
The image index marker was at approximately
kept at 1 o'clock.
Keeping the atrial septum and ASD in the region
of interest, the transducer was rotated
counterclockwise approximately 45° to 60°.
Xinseng et al Journal of the American Society of Echocardiography Volume 23, Issue 7 , Pages 714-
721, July 2010
31. Ostium primum ASD
Defect in lower part of IAS
Associated sometimes with inlet VSD
Cleft mitral valve
AV Valve regurgitation
Partial attachment of mitral valve to IVS
32. Primum ASD
LARA
LV
RV
Apical four chamber view demonstrating
a primum atrial septal defect
Colour Doppler flow image from same view
illustrating left-to-right shunt across the primum
atrial septal defect
Fig 5
42. ATRIAL SEPTAL ANEURYSM
CRITERIA
A- PROTRUSION OF
ANEURYSM ATLEAST 15MM
OF PLANE OF IAS
OR
IAS SHOWING 15MM OF
PHASIC EXCURSION
DURING
CARDIORESPIRATORY
CYCLE
B- BASE WIDTH≥ 15MM
43. COLOUR DOPPLER
Shows the direction of the shunt
Caveat- False Positive results due to improper gain and caval
flow streaming near septum can be misdiagnosed as ASD.
PULSED DOPPLER- demonstrates the flow from L to R in
mid systole to mid diastole with second phase in atrial
systole. Some R to L shunting occurs in early systole
QUANTIFICATION OF SHUNT – Qp /Qs
44. OS ASD VIA DOPPLER SINUS VENOSUS ASD VIA DOPPLER
45.
46. CONTRAST
ECHOCARDIOGRAPHY
APICAL 4C VIEW IS USED
AGITATED SALINE USED- 5ml in each 10ml
syringe, 0.5ml of air taken in the syringe and
agitated to create microbubbles.
47. • ARROW SHOWS NEGATIVE
CONTRAST EFFECT
• DIRECT EVIDENCE OF SHUNT-
NON
CONTRAST BLOOD IN RA
•Extent of shunting tend to focus on
numbers of bubbles seen in a single
still frame in the left atrium.
Shunt grading incorporates :
Grade 1: 5 bubbles;
Grade 2: 5 to 25 bubbles;
Grade 3: >25 bubbles;
Grade 4: Opacification of chamber
Echocardiographic Evaluation of Patent Foramen Ovale Prior to Device
Closure
Bushra et al JACC 2010 VOL. 3, NO. 7, 2010
48. RIMS OF ASD
Aortic - Superoanterior
Atrioventricular (AV) valve -mitral or inferoanterior
Superior Vena Caval SVC – Superoposterior
Inferior venacaval (IVC or Inferoposterior) Posterior
(from the posterior free wall of the atria).
53. The transesophageal echocardiography (TEE) probe is at the
mid-lower esophageal level.
The posterior and the mitral rims are best evaluated in
this view.
Rotating the probe to 30° to 40° towards the left will best
profile the aortic (Ao) rim.
The margins are evaluated by carefully moving the probe in
and out and obtaining sections at various levels.
At the level of the
atrioventricular valves (C), the septum forms once again. This
suggests that the ASD is likely to have adequate margins for
catheter closure.
54. In the highest plane (A), the superior venacaval (SVC)-right
atrial junction and the ascending (Asc) aorta are seen; the
atrial septum is visualized as intact.
55. At the mid-level (B), the septum breaks and the
margins(posterior and anterior) of the atrial septal
defects (ASD) (arrows) are clearly seen.
56. At the level of the atrioventricular valves (C), the septum
forms once again.
This suggests that the ASD is likely to have adequate
margins for catheter closure.
57. TEE at 90° to Evaluate the SVC
and IVC Rims
AORTIC RIM IS SEEN
TEE 45 DEGREES
58. This view is best for evaluating the SVC and IVC
rims.
The margins are evaluated by rotating the probe
while keeping it at more or less the same level.
Here the defect is seen with the probe rotated
leftward (B, margins of the ASD shown by the
arrows), while septum is seen to form when the
probe is rotated to the right (A).
The 45°-view is helpful in assessing the posterior
and the aortic rims and often helps to determine
the maximum size of the defect.
72. Conclusion
Echocardiography plays a critical role for patient
selection, guidance, and post-deployment evaluation
for transcatheter closure of ASDs.
Understanding the echoanatomic corelation by
transesophageal echocardiography is perhaps the
most essential requisite to ensure a successful
procedure.
3D echocardiography and ICE (intra-cardiac echo) are
likely to further this understanding in the future
especially in difficult cases like multiple defects and
defects with deficient margins.
80. Natural history of ASD
Natural history of ASD diagnosed in childhood is that the ASD
diameter when untreated increases in 65% of cases, and
30% will have more than a 50% increase in diameter.
Only 4% of ASDs close spontaneously .
A patient with isolated secundum ASD is often asymptomatic
until the third and fourth decade of life.
Typical symptoms that ensue include decreased exercise
capacity, fatigue, syncope and palpitations.
Patients with significant shunting may develop right
ventricular failure, atrial tachycardia, pulmonary hypertension
and embolic events all of which can lead to significant
morbidity and potential mortality.
81. The age at which a patient becomes symptomatic is highly variable
and does not correlate well with shunt size .
The pressure gradient between the two atria and the amount of
shunt flow depend upon both the size of the defect, and the
compliance of the right and left sides of the heart.
Left untreated over time, even small ASDs can develop increased
left-toright shunting due to progressive increase in left ventricular
(LV) diastolic pressure with aging, which causes increased left atrial
pressure.
In patients who develop pulmonary hypertension (PHTN) from their
ASD, approximately 10% will progress to Eisenmenger’s syndrome.
Due to the chronic nature of the disease and patient compensation
over time many patients remain unaware of their decreased
exercise capacity and only realize their symptom improvement post
procedure .
87. Special tee views for
Inferoposterior rims
No Infero posterior rim with probe in normal position
88. Under
TEE Guidance
K.S. Remadevi, MD, FNB, Edwin Francis, DM, and Raman Krishna
Kumar, DM, FACC . Catheterization and Cardiovascular Interventions
(2008)
Retroflexed probe in the stomach and bought towards the esophagus and viewed
In the 70-90o view
Editor's Notes
OSTIUM SECUNDUM- MIDDLE OF ATRIAL SEPTUM
OSTIUM PRIMUM – LOWER PART OF ATRIAL SEPTUM