How did the pericardial fluid became radio opaque ?
Archive for January, 2013
This X-Ray surprised me . . . may be . . . Mr Roentgen as well !
Posted in cardiac radiology, Cardiology - Clinical, tagged pericardial effusion by xray chest, radi-opaque pericardial effusion on January 31, 2013| 1 Comment »
The ultimate journal on cardio- vascular physiology
Posted in cardiology journals, tagged American journal of physiology, physiology of heart on January 31, 2013| Leave a Comment »
http://ajpheart.physiology.org/
Many of the wonderful breakthrough articles are totally free . Enjoy and enrich .
When mitral valve gets fatigued . . . AML moves differently !
Posted in cardaic physiology, Cardiology -unresolved questions, Echo library and gallery, echocardiography, tagged AML movement M shaped, echocardiography, M MODE CHO AML, rare mode echo, trifid m mode echo of aml, trifid mitral inflow doppler on January 31, 2013| Leave a Comment »
Anterior mitral leaflet (AML) is an unique structure in the heart .It is the fastest moving structure inside the heart . It is the first structure visualised by echocardiogram by Elder and Hertz in early 1950s .
While AML is known for vigorous motion , the PML motion is subdued . By tradition AML shows a motion which resembles alphabet M .
But AML is not be taken lightly . It can change it’s motion not only in pathological states but also in health . One such pattern is trifid motion of AML . Following is a Echo Image in a perfectly normal Individual .
Possible mechanisms underlying Trifid motion of AML
- The plane of M-mode cut will change the mitral valve motion .(May be this is most common ).M-mode at tip of mitral valve may be trifid ,however a little beyond may record a bifid-M pattern .
- Redundant mitral valve
- Mid diastolic AML drag
- Signs of elevated LVEDP
- Finally , it could be a sign of mitral valve fatigue after excrcise . Some of these persons revert back to M pattern after a brief period of Trifid motion following exercise .
Does trifid AML motion result in Tri-phasic doppler flow as well ?
Mitral valve filling is classical E and A .
This usually correspond to M pattern of anatomical AML motion .
Do the anatomy goes hand in hand with physiology ? Will the mid diastolic AML drag result in augmented flow ?
We are looking at this phenomenon .
Surprising facts about PFOs from the land mark study by Hagen
Posted in cardiology -congenital heart disease, tagged autopsy study on pft, hagen 1984 mayo clinic proceedings, patent foramaen ovale, pfo, stretched pfo on January 31, 2013| Leave a Comment »
It was in 1984 this paper came from mayo clinic proceedings .
Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59:17-20.
When interventional cardiology was not even in infancy . Now it remains the only data base of nearly 100o hearts studied after autopsy .
After reading the article I got few surprises
- The mean incidence is 27.3 % of general population ( That is 27 crore people with PFO in India )
- In first three decades it goes up to 40 % .
- PFOs size increase with age due to stretch of inter atrial septum
- It measures 3.4mm in the first decade and it can grow up to 5.8 mm in later decades .
http://download.journals.elsevierhealth.com/pdfs/journals/0025-6196/PIIS0025619611632606.pdf
Mayo clinic continues to be pioneers in providing vital research about PFO
Following is another excellent review article on PFO and stroke
My presentations at World congress cardiology : Dubai 2012
Posted in Cardiology research topics, My presentations, tagged dr s venkatesan, dr venkatesan, IVC diameer in RV infarction, madras medical college, My presentations and publications, venkatesan, world congress Dubai cardiology 2012, World congress of cardiology on January 31, 2013| Leave a Comment »
Abstracts published in Circulation 2012
Paper 1
Echocardiographic IVC diameter: a simple, bedside guide to monitor fluid therapy in right ventricular infarction
Sangareddi Venkatesan1,*, G Gnanavelu1, M.S Ravi1, V.E Dhandapani1, G Karthikeyan1,D Muthukumar1
, Madras medical college, Chennai, India
Introduction:
Right ventricular infarction (RVMI) is one of the unique subsets of acute coronary syndrome. In RVMI augmentation of RV preload with fluids is considered vital. The seemingly paradox of raising the already raised RVEDP and RAP is often a risky hemodynamic adventure .There is no simple guide to monitor fluid therapy in RVMI.
Objectives:
In this context, we reasoned, a simple estimation of IVC diameter and it’s respiratory variation would give an accurate reflection of volume in the right heart chambers Methods: 12 patients with established RVMI by clinical, ECG criteria were the subjects of the study. 6 had associated posterior MI, 3 had lateral ST elevation. Patients were treated as per STEMI protocol .10 were eligible for thrombolysis.The mean blood pressure on admission was 106(70 -120mmhg)
During thrombolyis the blood pressure fell by 5–10mmhg .All patients were administered IV normal saline to augment the blood pressure. 1000ml were given over 1 hour and if the BP was not raising another 1000 ml was infused in the next 1 hours . Results: Bedside echocardiography was done on admission and was repeated during and/or after fluid infusion. The baseline IVC, RA, RV were dilated in 9/12 patients. The mean RV dimension was 2.8cm (2.4 –3.6) RA -3.9 cm(3.6–4.5) The mean IVC diameter was 2.1cm (1.4 –2.6). On completion of 1000ml fluid infusion, the mean IVC diameter was 2.5(2.3–3.0) .In terms of absolute size, IVC increased by 3–5mmin diameter at the end of fluid infusion. It amounted to 20–30% increase of diameter. There was minor increase in RA and RV dimension also. When there
was 30% increase of IVC diameter, JVP became non pulsatile and four patients showed signs of lung congestion. There was a new reversal of E:A ratio in the mitral inflow in 2 patients who had lateral ECG changes .There was no significant increase in RV dp/dt following fluid administration. The TR jet derived peak RV pressure did not show significant difference with reference to fluid therapy. The mean LVEF was 44%(38–62%).
Conclusion:
Simple bedside estimation of IVC dimension by 2D echocardiography, can provide a fairly accurate estimate of volume status of right heart chambers .Careful monitoring of IVC size help us, in the fluid management of RVMI. One rule of thumb is an increase of IVC diameter by 30% from its basal value could be a cut of point for termination of fluid infusion.
Paper 2
Echocardiographic evaluation of papillary muscle function in ischemic mitral regurgitation
Muralidharan Azhakesan1, Venkatesan Sangareddi1, Jai Shankar1, Rudrappa Arunagiri1, Kalyanaraman Kannan1,* and Prof R. Alagesan,Prof P. Arunachalam, Prof V.E. Dhandapani, Prof M.S. Ravi.
1Cardiology, Madras Medical College, Chennai, India
Introduction:
Ischemic MR has been attributed to dysfunction of papillary muscle .The experimental and clinical data emphasize the importance of changes in the geometry of the LV.
Objectives:
To assess the mechanisms of ischemic mitral regurgitation in patients with old myocardial infarction Methods: The study cohort comprises 30 consecutive patients with old myocardial infarction and Mitral regurgitation. Group 1 has old inferior wall myocardial infarction and Group 2 has old anterior wall myocardial infarction. Patients with increased left
ventricular sphericity belong to Group Ia and with normal left ventricular sphericity belongs to Group Ib.Echocardiographic evaluation of all patients was done using Philips iE33 machine.
Results:
The incidence of moderate to severe mitral regurgitation is high in group Ia and II compared to Ib(50%and 40%vs. 20% p0.01). The average left ventricular sphericity is high in group Ia compared to group Ib & groupII (66%VS 49.1%&58.2) .Mitral annular area is increased in patients with moderate to severe mitral regurgitation than patients with mild mitral
regurgitation (46.8mm vs. 41.2mm, p0.01). The incidence of MR in patients with increased LV sphericity to normal LV is 50% vs. 20% p0.01. In all groups of patients, the leaflet tethering distance with moderate to severe MR compared to mild MR is 24.09 mm Vs. 17.84 mm [P0.01]. The papillary muscle systolic peak velocity does not have consistent
correlation with ischemic mitral regurgitation in all groups. In group Ia papillary muscle systolic peak velocity has linear correlation between mild and moderate to severe ischemic mitral regurgitation(5.98m/s vs 7.9 m/s.p0.05)
Conclusion:
1. Mitral leaflet tethering distance is consistently directly proportional to severity of Ischemic mitral regurgitation. 2. Papillary muscle dysfunction is not an independent determinant of ischemic MR in all cases.
References:
Burch GE, De Pasquale NP, Phillips JH. The syndrome of papillary muscle dysfunction. Am Heart J 1968;75:399–415.
Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA. Mechanism of ischemic mitral regurgitation. An experimental evaluation. Circulation 1991;84:2167– 80.
Matsuzaki M, Yonezawa F, Toma Y, et al. Experimental mitral regurgitation in ischemiainduced papillary muscle dysfunction. J Cardiol 1988;18 Suppl:121– 6. Kono T, Sabbah HN, Rosman H, et al. Mechanism of functional mitral regurgitation during acute myocardial ischemia. J Am Coll Cardiol 1992; 19:1101–5.
Cardiac failure following VVI pacemaker, a myth or reality: an echocardiographic study and an indian perspective
Arun Ranganathan1,* Venkatesan Sangareddi, Gnanavelu G, Dhandapani V.E., Ravi M.S. 1Cardiology,
Madras Medical College,Chennai,Tamil Nadu,India, Chennai, India
Introduction:
Permanent pacemakers has revolutionized the management of symptomatic bradyarrhythmias. In India, about 10000 pacemakers are implanted every year. There is a huge cost variation between modern day pacemakers and conventional pacemakers. The apparent advantages of newer generation pacemakers over conventional pacemakers are not clear.There has been some concern about development of cardiac failure with VVI pacemaker1. We have already reported the incidence of cardiac failure with VVI pacemaker from our registry which was surprisingly negligible. In this context, we studied bi-atrial and left ventricular function in patients following VVI pacing.
Objectives:
To Assess Biatrial And Left Ventricular Function In Vvi Pacemaker Implanted Patients. Methods: 31 patients were randomly selected from a group of 526 VVI pacemaker implanted patients of duration more than 6 months with
mean 50 40 months.The shortest duration was 6 months and longest was 185 months. Of the 31 patients,17 were males and 14 were females. The indications for VVI Pacemakers were complete heart block (22 patients) and sick sinus syndrome(9 patients). Patients who sustained MI, valvular heart diseases, cardiomyopathies and who had RWMA were excluded from the study. 31 persons of similar age and sex distribution without pacemaker were included in the
study as controls. All selected patients including controls underwent ECHO, ECG.
Results:
In VVI group there was no significant reduction in EF and LA volume index,but mitral E/E’& RA volume index were reduced significantly. Paradoxical septal motion(PSM) did not influence any parameter.
Conclusion:
Contrary to the popular belief, VVI pacemaker was not associated with worsening LV function and left atrial dimension in our study. But there was a marginal deterioration in LV diastolic functional parameter.There was no significant impact on the quality of life indices, and no adverse outcome observed.We believe VVI pacemaker would continue to be safe and effective for our population.The usage of dual chamber pacemaker may be selectively used and need not be recommended routinely.
Reference:
1. Nathan AW, Davies DW. Is VVI pacing outmoded? Br Heart J 1992; 67: 285–8.
Changing angiographic CAD profile in young STEMI population
Venkatesan S. Sangareddi1, Pattanam S. Chakkaravarthi1, Srikumar Swaminathan1,* 1Department of Cardiology,
Madras Medical College, Chennai, India
Introduction:
Previous data on young patients with acute myocardial infarction have indicated higher rates of normal CAG. Incidence of normal CAG in young STEMI is reported to be between 40–50%. There was a suggestion of decline in normal CAG in young STEMI .In this context, this study was planned.
Objectives:
The present study was conducted at madras medical college, Department of Cardiology, Chennai to assess the incidence of CAD in young diabetic post myocardial infarction patients in the urban and suburban populations of Chennai.
Methods: Angiographic data of 80 consecutive young patients with MI were studied Patients who were nondiabetic,more than 40 years old and not thrombolysed were excluded.
Results:
out of 80 patients 74 were males and 6were females.25% of patients had normal LV function and75% had mild LV dysfunction. All are having DM and 30% are having HT and 40% are smokers In our study 20%of patients with inferior wall MI and 80%had anterior wall MI. CAG was performed on a mean average of 4 weeks after the index myocardial infarction and optimal medical treatment. Of the 80 patients 75%(60) had coronary artery disease and the remaining
25 %( 20) had normal coronaries .Of the 60 patients with CAD, 52(65%) patients had single vessel disease, 4(5%) had double vessel disease and 4(5%) had triple vessel disease.LAD lesion was present in 46patients and RCA lesions found in 16 patients. This made us to think why there is a higher incidence of CAD in these group of patient’s .Physical inactivity has become rampant due to high degree of automation. Diabetes added to this physical inactivity accelerates atherosclerotic process. So these patients might have had CAD already and myocardial infarction might have occurred as an acute insult .More lesions were found in atherosclerotic prone LAD than RCA.
Conclusion:
According to our observation, it seems, CAD in young is taking a different avatar compared to what we have witnessed few decades ago. The incidence of normal coronary arteries following a STEMI is distinctly reduced. While most
have critical SVD, significant subset do have extensive mutivessel disease. We suggest this changing angiographic profile need to recognized and looked for in different geographical locations of our country. It would have major management implication.
Reference:
1. Changes in CAG in young MI patients-Branco LM, Patriciol, Port Cardio 2001 Oct;10(10)
749–55.
Can we diagnose LVH with normal IVS thickness ?
Posted in echocardiography, Uncategorized, tagged definition of LVH, LVH with normal IVs on January 31, 2013| Leave a Comment »
We always look at the thickness of Inter ventricular septum for LVH . The Normal IVS thickness is up to 11 mm in diastole . LVH is definite if IVS measure > 11 mm .It is certain if it is > 12mm . But , we need to realise LVH by definition is not simply wall thickness .
It is increased LV mass .
LV mass can increase without wall thickening . This is referred to eccentric LVH . For example in chronic volume overload states (or even DCMs ) LV mass may increase without septal thickneing .
Final message
LVH is possible without IVS thickening .
One more cause for Q waves without Infarct !
Posted in cardiology -ECG, cardiology -Therapeutics, Cardiology -unresolved questions, Cardiology-Coronary artery disese, tagged inferior mi differential diagnosis, non infarct q waves on January 31, 2013| Leave a Comment »
We know q waves are not synonymous with Infarct . It just represents electrical activity going away from the electrode.This is why it can occur even in physiologically in many leads.
Non infarct Q wave can be recorded with
- LVH
- Fibrosis
- Fluid/Air in beneath the recording lead
- Thick chest wall/pericardium (More often Poor R wave )
When a chamber enlarges (Any chamber ) it is brought near the chest wall the electrode may pick up the intra cavity potential that is recorded as q waves .
(The q wave in V5-V6 in severe volume overload of LV may represent LV cavity potential )
Similarly qR complex in severe RV enlargement in V1 represent RA cavity potential.Right ventricle is anatomically a difficult chamber to understand. It is located anterior below the sternum the inferior and posterior aspect of the RV is facing the diapharagmatic surface
In huge RV enlargement , RV cavity potential or( even RA ) can be picked up by limb leads . While cavity potential is well picked up by unipolar pre-cadial leads , it is uncommon for limb lead record intracavitory potential. However this patient , who was diagnosed as inferior MI by a resident , turned out to be a clear case of severe pulmonary hypertension due to COPD .
Final message
One more differential diagnosis for inferior MI in ECG exists. A grossly dilated RA, RV due to COPD with severe pulmonary hypertension.
Can RV infarction occur with Anterior MI ?
Posted in Cardiology -unresolved questions, cardiology- coronary care, tagged right ventricular myocardial infarction, rvmi v4r, rvmi with st eelvation in v1 to v2 v3 on January 31, 2013| Leave a Comment »
Traditionally RVMI is suspected only with infero -posterio MI .
Can RVMI occur with LAD disease ?
Yes , it is reported up to 13 % of Anterior MI (Cabin AHJ 1987) . Right ventricle has an anterior wall and blood supply to this area is from LAD .
Have a look at this ECG
Reference
2. http://www.nejm.org/doi/full/10.1056/NEJMicm030315
Final message
RVMI is not an exclusive complication of Infero -posterior MI.
Welcome to the “2013” Guidelines for management of STEMI !
Posted in Cardiology -guidelines, cardiology -Therapeutics, STEMI-Primary PCI, Tutorial in clinical cardiology, Uncategorized, tagged 2013 STEMI AHA ACC Guidelines, Current stemi guidelines, New stemi guidelines 2013 on January 28, 2013| Leave a Comment »
Guidelines are meant for simplifying cardiologist’s life as well as ameliorating patient suffering . It should also ensure improving overall outcome with efficient use of human resources and economy .
These guidelines are written from sophisticated centers mainly for consumption in developed countries .Though core concepts will be same , many recommendations are neither possible nor desirable at the exact point of delivery in less developed countries . Please remember these guidelines are not binding on you .Physician discretion is the ultimate principle in medicine.
So , let us read these guidelines apply our mind and try to indigenise . Get maximum out of it for the respective population .
Some of the highlights in this 2013 guidelines
1. Therapeutic hypothermia should be started as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest caused by ventricular fibrillation or pulseless ventricular tachycardia, including patients who undergo primary PCI.31–33
(Level of Evidence: B)
2 . Presumed or New onset LBBB is no longer a Indication for emergency reperfusion
3 . Indication of Primary PCI has the following modification
Reference
http://circ.ahajournals.org/content/early/2012/12/17/CIR.0b013e3182742cf6.full.pdf+html
Coronary artery swing : A new method to rapidly and accurately assess RV function in cath lab !
Posted in Uncategorized, tagged coronary artery swing, digital subtraction angiography for coronary motion movement, lad inter ventricular groove movement, lcx legt av groove motion, longitudinal rv function, lv rv function assessment in cath lab, mapse, reading coronary angiogram, right av groove, rv ejection fraction, rv function assessment simple tool, tapse and coroanry av groove rca motion on January 27, 2013| Leave a Comment »
Right ventricular function assessment has always been difficult in view of it complex shape and limited imaging planes in echocardiography .
Recently , we learnt tricuspid annular motion can give a quick assessment of RV function . This was accomplished by M-mode echo of tricuspid annulus. (TAPSE) tricuspid annular plane systolic excursion . This simple parameter has brought the maligned M mode echocardiography into limelight again.
Currently coronary angiogram is done just like a non invasive echocardiogram across the nooks and corners of any country
Modern day cardiologist is expected to look beyond the coronary artery narrowing when reading coronary angiogram. If only we give little importance to how the coronary artery moves with reference to cardiac cycle we can get excellent information about mechanical properties of heart.
Every cath-lab work station has a DSA mode . With this one can measure the coronary artery swing and document it objectively .Right coronary artery swing faithfully reflect RV longitudinal function . This motion is more accurate than the TAPSE by echo . We have found the normal excursion to be 15-20mm (Slightly lower than TAPSE) . Similarly LCX motion give us an estimate of longitudinal LV function and LAD motion can tell us how IVS moves .
Final message
Coronary artery swing* is a new method ( rapid and accurate) to assess cardiac function in cath lab ! We should utilise this more often .I feel it may throw more valuable than the sophisticated but complex 3D reconstructed and post proceed imaging modalities to assess individual chamber function .
* There is no published reference available for modality .It is so simple concept i think , it does not require any major experiments for a proof !
Reference
RV function assessment ASE guidelines
http://www.echobasics.de/rv-en.html
Normal RV function Indices .
TAPSE (tricuspid annular plane systolic excursion) < 2 cm
TASV (tricuspid annular systolic velocity)< 15 cm/s
Tei-Index (myocardial performance index)> 0,50
TAPSE can be correlated with coronary swing
Further research potential
Now we require comparing the TAPSE with the quantum of RCA swing by angiography. I have asked my fellows to look into this aspect . I guess TAPSE by Echo over-estimates the true motion ( normal 2 cm ) seems on higher side. It includes translational motion of echo which is eliminated in angiographic annular movement .