Posted in echocardiography, tagged best web site for echocardiography, canadian society of echocardiography, cardiomath, echocardiography, mitral valve orifice, myocardial performance index, pisa mitral, stress tests on January 27, 2011| Leave a Comment »
Few web sites provide free cardiology service. This one from cardiomath beats all ! It makes the job easier for all those cardiologists who spend lots of time in echo lab . It provides simple online tool for all common calculations in clinical echocardiography
Here is the link to the website of cardiomath
With due Courtesy to
Author: Dr. Chi-Ming Chow Developer: Edward Brawer Illustrator: Ellen Ho
Sponsored by Canadian society of echocardiography
Posted in cardiac surgery, Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, Echo library and gallery, echocardiography, myocardial disease, tagged acquired vsd, cabg, cardiogenic shock, catheter closure of vsr, dobutamine for vsr, free wall rupture, lad bypass in vsr, lvedp in vsr, mechanical complications of stemi, post infarct vsd, stable vsr, surgery for vsr, sutures give way in vsr, tissue friability in vsr, unstable vsr, ventricular septal rupture, vsr closure without cabg, vsr closure without coronary angiogram, vsr vs mr on January 14, 2011| 2 Comments »
We know, electrical deaths constitute the bulk of sudden cardiac deaths in MI. Mechanical deaths due to pump failure, muscle rupture , valve leak , also cause significant deaths .(Surprisingly many of the mechanical deaths may also fulfill the sudden death criteria !)
Free wall rupture is invariably a fatal event. Papillary muscle trunk rupture leads to severe LVF and unless intervened sure to result in fatality.
The ones who tear their interventricular septum are some what blessed ! Here , the rupture does not result in instant death as there is no loss of blood , instead , there is an volume over load of right ventricle followed by the left ventricle after a few beats. Hypotension is the rule. Even though this is a major complication there is something about VSR which makes it unique.
Sudden giving way of IVS has a decompressing effect on the ailing left ventricle.This many times bring a temporary relief to LV and if the patient survives the first few hour he is likely to stabilise further . In fact , sudden deaths within 24hours after the onset of VSR is an exception.This defect always gives the cardiologists and surgeon some time to plan the management. We need to use this time judiciously.
The natural history is delicate . Five themes are possible
* Pleasant themes occasionally witnessed !)
Here is 55 year old women came with extensive anterior MI with lower septal rupture.(She belonged to type 3 of the above scheme)
Note the septal rupture is visible even in 2D Echo
Color flow showing significant shunting from LV to RV.This shunt depends upon the LV contractile function, LVEDP and ofcourse the RV pressure
If there is severe RV dysfunction or bi ventricular dysfunction flow across the defect is inconspicuous.Brisk left to right shunting may be an indirect marker for good LV systolic function and absence of significant pulmonary hypertension.Both imply a better outcome.
The main determinant of survival is the underlying LV dysfunction and associated co morbidity(Renal function ) and complications .
Infero -posterior ruptures tend to be complex and may have multiple irregular tracks that makes it difficult to repair.
Investigations
Echo cardiogram is the mainstay .Serial echos should be done to assess the mechanical function and the progress of VSR.Hemodynamic monitoring may be done without injuring the patient .
Medical management
Surgeons role
Timing of surgery
Continues to be a controversy . Surgeons love to operate in a stable patient. But they need to realise , surgery is often needed to stabilise many patients. . The issue of tissue friability is blown out of proportion in the literature .When a life is is at danger we can not worry about friable tissues !
The rule of thumb could be
Surgical options
In our experience each of the above , has a role in a given patient depending upon the logistic , financial , social and even the available expertise. (A good surgeon in bad Institution !)
Is coronary angiogram mandatory before attempting to close VSR ?
Logically yes. If it is not available just do not bother . But, many times , when issue is saving lives , we can not afford to be too scientific , many lives have been saved by not following such strict protocols .A simple emergency thoracotomy and closure of rupture site (Without even touching the LAD ) can be a distinct and viable option in a selected few .
Role of cardiologists
Contrary to the popular belief the role of cardiologists is minimal , except to prepare the patient and hand over to the surgeon.
Interventional approach to close a VSR is currently be termed as an adventurous option ! The VSRs can assume unpredictable shapes and the tears can be multiple in different planes. The devices , catheters and other hard ware are not specifically made to tackle these issues .An acquired VSR should never be compared with congenital VSD.
Posted in cardiology -Therapeutics, echocardiography, tagged ball valve thrombus, free floating la clot, LA clot, mitral stenosis, rheumatic heart disease on January 6, 2011| 1 Comment »
Rheumatic heart disease is rampant in India. Advanced forms of mitral stenosis are still common.
Critical mitral stenosis with LA clot formation is often seen.
But here is a women in late twenties presenting for the first time with syncope .
And what you see inside is not a fiction . . .
Left atrial clot occupying the whole cavity ! Where is the blood bound for left ventricle ?
4 chamber view
Luckily the clot is so big and MVO is less than 1 sq cm. It is highly unlikely the LA clot can negotiate the orifice.
Small fragments can dislodge .This patient developed syncope whenever she bends and lie down at a particular position.
What needs to be done in this patient ?
Can it be lysed ? No ,Emergency surgery is required with concomitant mitral valvotomy or mitral valve replacement.
Is there a temporary aortic filter available to prevent systemic emboli from heart ?
Distal protection devices are available only temporarily in the coronaries and carotids during interventional procedures.There is no aortic protection devices for LA,LV clots in high risk patients . When IVC filters are used block a potential pulmonary clot why not aortic filters for preventing systemic emboli ?
Why we have not thought about this . . . is surprising . May be intensive anti coagulation is as effective .
Posted in Cardiology - Clinical, cardiology -Therapeutics, Cardiology -unresolved questions, echocardiography, tagged abbas et all, echo pvr, mayo clinic arizona, pulmonary vascualr resistance by echocardiography, pvr, rvot vti, scottsdale, tr jet rvot vti on December 27, 2010| Leave a Comment »
Calculating the pulmonary vascular resistance (PVR) has been a big head ache for all those involved in pediatric and (for many )in adult cardiology as well . The complex formulas , the delicate oximeter samples, the catheters, a sick child , an arrhythmia prone right ventricle , restless staff nurses , and finally the mathematics ! all make it a dreaded exercise .
Echo is a great physiological tool . . . It is now been used over 50 years . It is our earnest belief , Doppler can measure the flow and pressure any where within the heart however dynamic the chambers may be !
Then ,why can’t we have a simple formula by this non invasive method to calculate PVR ?
Yes , Dr Abbas et all from the desert hospital of Arizona raised this question and reported a new equation to calculate PVR.
Their hypothesis is as simple as this . . .
Substitute PA pressure with TR jet
Substitute PA flow by RVOT VTI ( Velocity time integral )
And we get
This is the simplest way to arrive at PVR at the bedside .
An example
Is it validated ?
Yes .
Then,why it is not being followed widely ?
It is a too simple method to use ! That is the biggest excuse ! We are tuned to think , a complex parameter can not be measured in a simple manner . Any thing simple must be wrong !
But the reality is . . .
Cath calculations are much more complex with so many variables which can get terribly wrong .
The irony about this hypothetical science of PVR is , we do not know which is gold the standard ? In fact , none can be a standard . So , to label PVR derived by echo , as an inferior modality can not be accepted .It is all the more funny , as we are trying to define a new formula with the help of flawed and battered parameter namely the cath derived PVR .
Final message
Abbas’s formula is indeed a realistic way of arriving at PVR by echocardiogram. If only we measure it routinely /serially in as many patients as we can , a new data base will be created .Which can later be proven as a fact.It is suggested every cath lab should try to validate this formula.
Link to full text article : Courtesy of JACC
Posted in cardiology congenital heart disese, echocardiography, Uncategorized, tagged cardiological society of india csi kolkatta 62nd annula scientific, dynamic echocardiography, echo during squatting, squatting and tof, tetrology of fallot, TOF, venous return during squatting on December 8, 2010| Leave a Comment »
Squatting is an excellent hemodynamic adaptation in patients with TOF. Children with TOF assume this posture in a natural and effortless manner . For years cardiologists are fascinated by this maneuver and the mechanism by which it gives relief to those patients with TOF.
Now , we have realised this posture has a new diagnostic role in echocardiography ! This paper was presented in the recently concluded Annual scientific sessions of cardiological society of India held in Kolkatta December 2010
Download the full presentation in PDF format ( Squat Echo)
Posted in Echo library and gallery, echocardiography, Uncategorized, tagged dr s venkatesan, drsvenkatesan, echo clippings, echo clips, echo for diagnosis, echo quiz, echo spot diagnosis, echocardiography videos, interesting echo images, non compacted rv, pulmonary balloon valvotomy, ra rv dilatation, rare echo cases, rv dp/dt, rv dysfunction, sever vps, stunning echocardiography, valvular pulmonary stenosis, venkatesan s on November 5, 2010| 3 Comments »
A female child aged 14 was referred for progressive breathlessness and abdominal distension
Abnormally dilated right atrium with significant pericardial effusion .www.drsvenkatesan.com
Can you guess the diagnosis ?
Apart form RA ,RV dilatation , the RV apex is seen filled with coarse treabeculations.This is believed to be a type of non compaction http://www.drsvenkatesan.com
Still difficult to conclude ? Look at the following Image.
Tricuspid regurgitation is significant . http://www.drsvenkatesan.com
If you have thought . . .
All are acceptable differential diagnosis
But the real diagnosis is none of the above .
Need more time . . . the following Doppler tracing will settle the issue !
Doppler velocity in RVOT at 88mmhg. http://www.drsvenkatean.com
The final diagnosis was . . .
Here , RV functional assessment becomes vital , but it is difficult many times. A simple clue is , as the RV is able to generate 88mmhg pressure it implies , the contractility should be near normal .
RV EF %, RV Dp/Dt , Tricuspid annular motion by tissue Doppler are additional measures. Cine MRI can be a useful investigation prior to intervention.
Final message
Posted in Echo library and gallery, echocardiography, tagged giant left atrium, left atrial aneurysm, mitral regurgitation, rheumatic heart disease on November 5, 2010| 1 Comment »
A young women with Rheumatic heart disease .
Giant left atrium in rheumatic MS . http://www.drsvenkatesan.com
Mitral regurgitation is significant .www.drsvenkatesan.com
When do you call a left atrium as giant ? When it is referred to as Aneurysmal dilatation ?
It is all semantics. Whenever LA becomes more than 6 cm , at least in two diameters many prefer to call it giant .
In India , 6 cm LA is such a common finding , we have kept a cut off at an arbitrary 9 cm .
What factors determine a LA to dilate like a balloon ?
The exact mechanism is not known.It could be the intrinsic weakness of LA wall , as very few with RHD develop this. Many LAs resists dilatation even in the midst of extreme LA pressure. But , it is a well-known fact , mitral regurgitation provokes greater LA dilatation than MS alone .This implies volumetrics play a major role than pressure dynamics in determining LA size. Acuteness of hemodynamic insult is inversely proportional to LA size.
By the way, what is the purpose of recognizing the LA as Aneurysmal ?
Electro-physiological Issues
Implication in cath lab
During PTMC LA size can be an issue as the plane of IAS is distorted and make things difficult for septal puncture . Further the balloon , guidewire may often slip back into RA .
Implication for the surgeon.
For the surgeon the implication could be more. As a cardiologist I can’t comment about that .One thing we have observed is when LA becomes huge , the size of mitral annulus is too fictitious and funnily enough we have recorded up to 6 cm of mitral annulus . No valve is available for this size . We learnt from the surgeons , large LA rarely pose a problem as they suture the much smaller valve in a larger annulus .(Which makes the task that easier )
Does the LA size regress after surgery ?
In many it does regress , in as many it doesn’t. We have seen giant LAs continuing to trouble the patient even after a successful mitral valve replacement.
Posted in echocardiography, tagged acute pulmonary embolism, bernhiem effect, d shaepd septum, echocardiography of pulmoanry embolism, lpa thrombus, mappet 2, massive pulmonary embolism, mpa bifurcation thrombus, mpa thrombus, paradoxical ivs motion, piped, rpa throbus, rv dysfunction in pulmonary embolism, thrombolysis for acute pulmonary embolism, wall motion defect in pulmonary embolism on October 10, 2010| Leave a Comment »
There were days when acute pulmonary embolism(APE) was almost always diagnosed post-mortem. We are in the era , where we can recognise most of the pulmonary embolism without any difficulty.
Experience has taught us , when to suspect this dreaded syndrome . Any unexplained, dyspnea, hypoxia, tachycardia , syncope* with vague chest discomfort and a predisposing condition (DVT , post operative state ,etc) will make acute PE highly likely .
*Postural dyspnea and syncope is a classical finding in many.
Pulmonary Echogram
We have advanced multi detector CT scans and MR angiogram , V/P scans and pulmonary angiograms to diagnose and confirm Acute PE .What we fail to realise is we also have a simple bed side tool called echocardiography to rapidly detect, assess the pulmonary anatomy and its hemodynamic status. In fact , we can visualize the entire MPA, and its bifurcation and to certain extent RPA,LPA. It is strange physicians always ask for pulmonary angiogram to diagnose APE , when we have a totally non invasive pulmonary echogram available at the bedside .It can rule out almost all cases of massive pulmonary embolism with a good festivity and specificity .
How often Echo miss a Acute PE ?
Echo may fail to image a thrombus if it is distal but it is very rare to miss a thrombus in MPA, and its bifurcation. Most of the patients with massive pulmonary embolism , are likely have a thrombus in the bifurcation.
Even if echo fails to image a thrombus , the effects of acute pulmonary arterial hypertension on the tender walled right ventricle is conspicuous. In fact, the effect of Acute PE on the RV morphology and function is the single most important feature to suspect APE . This is also considered as an indication for thrombolysis.
The following Echo features suggest Acute Massive Pulmonary embolism.Imaging these patients may be difficult especially if they are acutely dyspneic .Luckily , pulmonary artery short axis view can be obtained even in supine position in most of the patients.
Less common features
Diagnosing RV hypertension
TR jet
MPA acceleration time (Not useful in an emergency situation )
Other thinks to look in Echo
Unanswered questions
At what pressure RV begins to dilate ?
This is not clear.The response of RV , to pressure overload is not constant. In acute raise of RV pressure ,RV tend to dilate , while in chronic PAH RV hypertrophies and dilates .It is believed , the first signs of dilation begin , even with a 30mmhg of PA pressure . So , even minor dilatation could become important in acute PE.
Can RV dilatation alone , be taken as evidence for hemodynamic instability ?
Yes , but realise , clinical , hemodynamic instability is much more important than degree of RV dilatation (Hypotension /hypoxia )
The curious behavior of RV and TR jet in APE ?
Normal peak RV pressure is 25-30mmhg .In acute pulmonary hypertension RV pressure is supposed to raise . But it does not always happen.It all depends upon how the RV respond to the sudden raise in its afterload.
Some RVs fight vigorously and take on the challenge imposed by pulmonary embolus.These are the patients who show strong TR jets which may reach 60 mmhg. More often , the RV is stunned and overwhelmed by the unexpected sequence of events and lose the battle from the beginning .They become flabby and dilated.These patients do not show any significant TR jet , in spite of raising PA pressure. This implies, a good TR jet > 3.5 could virtually rule out severe RV dysfunction.
(One popular thought gaining ground is , the primary determinant of pulmonary artery systolic pressure in Acute PE is the RV contractile force , rather than pulmonary impedance .)
Hypotension is common in APE .What is the relationship between PAH and systemic blood pressure ?
Final message
RV faces the brunt of the hemodynamic attack of acute PE. .Differentiating simple RV involvement from RV dysfunction is a difficult and subjective exercise. But , it need to be done accurately as RV dysfunction becomes an indication for thrombolysis . RV dilatation , wall motion defect, mild PAH, all indicate RV dysfunction . Diagnosing RV dysfunction is better done by the treating physician who has the overall clinical data.
Posted in echocardiography, Infrequently asked questions in cardiology (iFAQs), Uncategorized, tagged commissural calcium, echocardiography of mitral stenosis, mitral stenosis, mitral valve area, mitral valve area by planimetery, mvo by pressure half time, planimetery, post ptmc mitral valve area, rheumatic heart disease, sub valvular fusion on October 6, 2010| Leave a Comment »
Planimetery is the age old method to measure the mitral valve area( MVA) by echocardiography.
Advantage
Disadvantage
How to improve the accuracy of planimetery ?
Color Doppler aided 2D planimetery . This can improve some of the limitations , as it provides a hemodynamic MVO(Some what physiological ) Of course , pressure halftime derived MVO is purely a physiological orifice .
Other options to measure MVO
Advantages and disadvantages of Pressure half time derived MVO will be posted soon.
Posted in cardiac surgery, Cardiology - Clinical, echocardiography, tagged echocardiogram, mitral, mitral valv e, mitral valve repair, tee, transesophageal echo on September 7, 2010| Leave a Comment »
Mitral valve can be termed as the most important valve of heart . The reason for this : It is the only valve that is dependent on the Left ventricular function (The parameter which determines the ultimate outcome in any form CAD ! )
So , indirectly mitral valve function will invariably be affected by some degree at least in most patients with LV dysfunction. (After all LV free wall , is a component of mitral valve apparatus.)
While , we have numerous modalities to assess mitral valve function , the one that has fascinated the surgeons during mitral valve surgery is the intra operative TEE.
Many believe TEE provides live images of mitral valve which are not possible even under direct vision ! The eye of the TEE sees the mitral valve from a posterior location , (of -course It can see at any angle !) while surgeon can see in one angle . The types of repair , the adequacy of repair, the annulus status, even a trial mitral run , can be done with the help of TEE.
The TEE probe silently does this job sitting inside the esophagus , without obstructing the surgeon’s operative field .
The success of TEE as an investigative tool did not come easy.Decades of observation , innovation and learning( Especially from department of cardiac science Mayo clinic USA , where they standardized the views. ) are involved .
Now we have omni plane, real time 3D TEE probes .
The books which are considered the best for TEE aspects of mitral valve and it’s repair are
Dr.S.Venkatesan MD 
