Posted in Uncategorized, tagged mitral aneurysm, mitral valve, rare echo images, true mitral aneurysm on November 4, 2010| Leave a Comment »
A middle aged female came with palpitation and breathlessness for two months duration to our OPD.
Clinically a non ejection click was present .She was referred with a diagnosis of MVPS to the echo lab
Her echocardiogram created a real buzz in the lab .
What is the diagnosis ?
The diagnosis is hidden somewhere in the frame.
How common is this entity ?
A Color flow imaging is available will be posted if requested .
Posted in cardiology -ECG, Uncategorized, tagged lbbb, lbbb with left axis, lbbb with lvh, left bundel branch block, organic vs benign lbbb, secondary st t changes in lbbb, sgarbosa criteria on October 29, 2010| Leave a Comment »
LBBB is a common ECG abnormality .The ECG is so classical , no one ever misses the diagnosis. But , what we miss often is the significance of it .
What is the cause of LBBB in a given patient is much more important than the LBBB itself !
Though the commonest cause of LBBB is a benign one (Pure electrical defect without any valvular , myocardial or ischemic heart disease ) , it is prudent to rule out organic LBBB . The term organic here refers to structural or ischemic etiology .
LBBB & STEMI
To diagnose STEMI in LBBB we have the much famed Sgarbosa criteria .It is a too popular to forget in spite of it’s limited utility . Applying it in an emergency is not easy exercise . Clinical prediction , cardiac enzymes are safe and could be more accurate. Thanks to ACC guidelines , it has simplified our task .You are encouraged to thrombolyse all cases of new onset LBBB* if clinical picture is strongly suggestive of ACS.(*The term “presumably new” onset LBBB was included , implying it is better to err on the safe side )
LBBB & NSTEMI
No one knows how to recognise NSTEMI in LBBB. Logic would say, primary ST depression might occur. How sensitive it is , and which lead to look for is not known.
LBBB in DCM
Here is an ECG of a patient who came to our OPD absolutely asymptomatic for a routine review . He is been diagnosed as a case of dilated cardiomyopathy with 30% EF and no evidence of ongoing ischemia.If the history is not known he would have been diagnosed as a ACS.
To diagnose cardiomyopathy in LBBB we have no specific criteria. But we have found the following useful
Further inputs are welcome to differentiate organic from benign LBBB
Counter point : When we have facility to do bedside echo , why should we scratch our heads ?
Do not waste time , do a spot echo . . .
Echo can be very useful in ruling out cardiomyopathies and old MI.But remember , echocardiography is unpredictable to detect acute septal MI in the presence of LBBB , as paradoxical motion of IVS tend to mask the ischemic wall motion defect .A simple clue is normal systolic wall thickening will be observed in benign LBBB , in spite of paradoxical motion .This thickening appears as post systolic beaking that face posteriorly . In STEMI and LBBB thinning or absence of thickening is expected.
Posted in Cardiology -Interventional -PCI, Cardiology -unresolved questions, Uncategorized, tagged BARI 2D, bari study, brazil mass 2, cass study, circulation journal mass 2 study brazil, courage, courage study, management of chronic stable angina, mass 1, MASS 2 10 year follow up, MASS 2 5 year follow up, mass 2 5 year folow up, mass 2 circulation, MASS 2 study, mass 2 trial, medical verses surgery verses pci, oat trail, stent or surgery study, what is MASS 2 study ?, zerbini foundation on October 28, 2010| 1 Comment »
MASS 2 study , the 10 year follow-up results are just out in circulation september 2010 .
It is a rare study , where “one to one vs one” was compared ie the effect of medical, CABG , and PCI in chronic CAD .This was done in a single centre in Brazil, between 1995 -2000 . It was followed up till 2010. Interestingly , such a study may not be possible in the future , as many of us have prematurely glorified the PCI and CABG over medical therapy . Recruiting patients for medical therapy alone is becoming a difficult job even in developing countries. Even if we recruit , huge cross over is likely to PCI, CABG for all fancy reasons.
So , in MASS 2 we have a rare treasure on hand . . . Let us give three cheers to those Brazilians who did this study , and shall carefully analyse and interpret the results.
Highlights ( According to my interpretation)
CABG tended to prevent future MI in this study . This could be most significant observation from this study ,( A revelation in fact ! ).It is against the popular belief created by CASS legacy.
What are the observed difference between MASS 2 – 5 year results , which was published in 2004 , and the 10 year follow-up , as on 2010 ?
At the end of 5 years in 2004 , the differences among the three groups were not obvious.The benefits of CABG mainly appeared after the 5th year and at 10 years it was significant.
Shortcoming of MASS 2
Intriguing thoughts
When we say medical therapy is being compared with PCI and surgery , we are actually comparing ,
Medical therapy alone
Medical therapy+ PCI
Medical therapy + CABG .
Every patient in all three groups receive statin , antiplatelet and beta blocking drugs and so on. Even though statistics would vouch for additional benefit , over and above medical therapy , in a given CABG individual , how much of the the accrued benefit is contributed by co- administering medical therapy .It is beyond reasoning even with all gimmicks of statistics.
To exactly quantify the individual benefits and efficiency of PCI , CABG and medical therapy two more study limbs are necessary .
Such a study is possible only in a virtual world ! . Decision making in favor of CABG , especially in chronic stable angina , will continue , to be difficult in the absence of refractory angina .This is due to the modest benefit of CABG , that is expected, at an additional risk , cost and expertise.
Please remember, a person can survive , only with medical therapy for > 10 years but no one can ever live with PCI or CABG for that period of time without adjunct drugs . Guess which modality is going to win the race against CAD in the long run ?
Final message
If any one asks for conclusion of MASS 2 study , don’t ever say “CABG is superior to medical therapy” . Please emphasize , “CABG + medical therapy could be , marginally superior to medical therapy alone in some of the patients with chronic stable angina. (Each word in the above statement is important !) .
So . . . MASS 2 : Is it a shot in the arm or shot in the head for CABG , we do not know !
http://circ.ahajournals.org/cgi/content/abstract/122/10/949
http://circ.ahajournals.org/cgi/content/full/122/10/949 .This study was done by Zerbini foundation Brazil
Posted in Uncategorized, tagged incor, Zerbini brazil, zerbini foundation mass 2 study on October 27, 2010| Leave a Comment »
Brazil is not only known for the glorious sport of football . In the medical field they are among the leaders in cardiac surgery .When cardiac surgery was at it’s infancy even in USA and Europe , one man showed the ultimate determination to take cardiac surgery to the virtually unexplored region of south America in the 1940s and 1950. He is the pioneer of cardiac surgery for the entire continent.
Picture courtesy . Annals of thoracic surgery .
He is the founder of INCOR . Now , Zerbini foundation is carrying the legacy of this man. He has trained so many cardiac surgeons that makes Brazil one of the hot destination for hi tech cardiac surgery .Recently the foundation sponsored the landmark study called MASS 2 which compared medical, survival and interventional forms of treatment.
Posted in Uncategorized, tagged elngated heart, heart in hypoadrenalism, low ct ratio, lower normal for ct ratio, tubular heart copd on October 26, 2010| Leave a Comment »
It is a great journey , the heart begins on the 22nd day of fetal life from a pair of tubes. It joins , folds, bends and grows into a 4 chamber power house and works like a bull for the next 70-80 years , before retiring.
It is an irony in certain population with chronic obstructive pulmonary disease (COPD) heart is stretched , elongated and assumes a tubular shape (Memories of the primitive fetal heart tube !) .The LV cavity becomes small , RV and LV gets aligned one behind the other bringing the CTR further narrow.
Tubular heart
CT ratio will be less than 1/3rd of thorax. (Just more than aorta ! )
Conditions
Here is a patient , 50 year old female with severe emphysema and contracted and elongated heart.
Posted in Uncategorized, tagged central cyanosis, central vs peripheral cyanosis, cyanosis, effect of oxygen on central cyanosis, effect of oxygen on peripheral cyanosis, peripheral cyanosis, peripheral verses central cyanosis on October 22, 2010| 1 Comment »
Answer : Peripheral cyanosis reduces or disappears , while central cyanosis persist.
This is how , 99% of cardiology fellows answered in one of my classes ! And they were quoting few references for it .
Is that correct ? If so , what is the mechanism of oxygen response ?
Comments welcome . Discussion will start soon .
Posted in Uncategorized, tagged central cyanosis, how will you diagnose cyanosis with reduced pulmonary blood flow, hypoxic spells, squatting on October 21, 2010| Leave a Comment »
During clinical examination of cyanotic congenital heart disease(CHD) , the major task is to differentiate conditions with reduced or increased pulmonary blood flow .
When a child with CHD is presented in clinical examinations , students are often asked to arrive at the diagnosis from history , physical examination before going in for ECG, X ray or echocardiography.
History, surprisingly can suggest the correct diagnosis in many (Most ?)
Reduced pulmonary blood flow is often associated with
Relief of dyspnea by assuming squatting position convey important hemodynamic information. It implies there is significant reduction in pulmonary blood flow in standing posture , that gets corrected in the squat position.For squatting to improve pulmonary blood flow there must be a communication between right and left heart .This is most often due to a large VSD, rarely an ASD .
Related article : How squatting relieves hypoxia in TOF ?
*Note : Cyanosis is not specific for reduced pulmonary blood flow. In fact , simple reduction in pulmonary blood flow per se , cannot result in significant cyanosis .There need to be admixture /or right to left to shunt to produce cyanosis .Cyanosis in pure admixutre states like TGV, Single ventricle , Common AV canal , Common atrium TAPVC, are less Dependant on the reduction of pulmonary flow. In these situations RVOT obstruction if present will aggravate the baseline cyanosis.
Examination
Apart from direct evidence for reduced pulmonary blood flow , lack of evidence for increased pulmonary flow could often mean , we are actually dealing with reduced pulmonary blood flow.
The following are the clinical clues to suspect reduced pulmonary blood flow.
* A silent heart is the hall mark of Tetrology of Fallot which constitutes 80% of all CHD with reduced pulmonary blood flow.
Posted in Uncategorized, tagged biventricular enlargement in vsd, chamber enlargement in congenital heart diseases, diastolic verses systolic left to right shunting asd vs vsd, gerbode defect of vsd, right ventricle, ventricular septal defect, vsd shunt to rvot or rv body, which chambers enlarge in vsd ? on October 20, 2010| 2 Comments »
The following questions are asked frequently in clinical cardiology classes on congenital heart disease.
What are the chambers that dilate in ASD ?
Right atrium and right ventricle .
What are the chambers that dilate in VSD ?
LA, LV , ± RV,
* Image courtesy Wikipedia
While there is no controversy about ASD, The chambers that enlarge in VSD , is by and large poorly (or rather wrongly ) understood . Whenever we diagnose VSD , our brain is tuned to think this way : Blood will be shunted form LV to RV. RV would handle more blood and it should enlarge . In reality it does not happen.
The VSD shunts the blood from LV to RV outflow* or even directly into pulmonary artery . Hence , VSD even if it is large , does not dilate the RV until the onset of pulmonary hypertension and RV dysfunction sets in . It is surprising to note , even the RVOT ( The entry point of most VSD jets) does not significantly enlarge
Importance of diastolic shunting in determining RV size in VSD
It is also important to recognise, the VSD shunt predominately occur in systole .(90% ?) In systole , the RV is also contracting along with LV , so it’s size is diminutive and hence RV can not be volume overloaded in most of the VSDs however large it may be. Instead in ASD , there is diastolic overloading involving all regions(Inflow, Body, Outflow) of RV .This enlarges the RV in a classical fashion.
Significance of anatomical location of VSD and RV enlargement
When VSD shunts blo0d into RA as in Gerbode defect it is bound to enlarge RV (like ASD) as there is diastolic volume over load of RV.
In some large muscular VSD , RV body can be volume overloaded. This is because the VSD and RVOT are well separated geographically .The blood that is coming in from LV can enter the pulmonary artery , only in the next cardiac cycle . So , RV needs to accommodate the shunted blood till the next beat. Hence RV enlarges.
What are the situations RV can enlarge significantly in VSD ?
Final message
Right ventricle does not enlarge significantly in uncomplicated VSD .This is in contrary to the traditional teaching and understanding for many years. It enlarges only in specific sub types of VSD or after the onset of PAH and cardiac failure .
Coming soon
Katz-Wachtel phenomenon is not due to bi -ventricular hypertrophy !
Posted in Uncategorized, tagged artificial heart valves, bronchial valves, copd, emphysema, endo bronchial valve, lung valve for copd, lung valves on October 16, 2010| Leave a Comment »
Cardiologists often think heart is the supreme organ. As medical science advances at a rapid pace we fail to notice the development in other specialities .It is getting more and more difficult for a physician in one field , to understand the advances in other . Often it becomes a struggle to decode non cardiac case sheets and prescription filled with latest generation treatemnt modalities .
Here is a stunner at least for me ! to find , artificial valves being used in the human bronchus , to regulate the air flow in patients with emphysema.
So, cardiologists be ready to prescribe ” lung valves ” for managing severe cases of cor pulmonale secondary to emphysema !
Reference
http://www.sciencedaily.com/releases/2007/10/071022120150.htm
Dr.S.Venkatesan MD 