FFR, Sgarbosa, Brugada, Stress testing, Tumors, TAVR, EKG Flashcards
1
Q
What is the relationship between Angiographic stenosis and Physiologic stenosis?
A
poor correlation between physiologically significant stenosis and angiographic percent diameter stenosis
2
Q
Define coronary flow reserve (CFR)?
A
Ratio measured with a Doppler wire between:
- resting coronary flow velocity and
- hyperemic flow velocity after administration of a vasodilator such as adenosine
*Limited by the fact that it interrogates the entire coronary circulation, both epicardial vessels and microvasculature
3
Q
In what situation may CFR be abnormal despite a physiologically normal epicardial vessel?
A
microvascular dysfunction
4
Q
What variables can affect calculation/reproducibility of resting coronary flow and thus CFR?
A
- Heart rate
- Blood pressure
5
Q
Define Fractional Flow Reserve (FFR)?
A
- maximum myocardial blood flow in the presence of an epicardial stenosis compared with the maximum flow in the hypothetical absence of the stenosis
- FFR = [(Pd-Pv) / Resistance] / [(Pa-Pv) / Resistance] *at Maximal hyperemia
- FFR = Pd/Pa (Pd = distal coronary pressure, Pa = proximal aortic pressure)
6
Q
What medications are used to induce maximal hyperemia in FFR measurements? Why are these medications used?
A
- Nitroglycerin –> epicardial artery resistance is minimized and reduces epicardial spasm
- Adenosine –> microvascular resistance is minimized
7
Q
What characteristic allows for pressure measurements to identify significant lesions in FFR?
A
Normal epicardial vessels have very little pressure loss along there course (proximal = distal pressure)
8
Q
What factor allows for elimination of variables (HR, BP, LV contractility) in the calculation of FFR, which normally affect resting hemodynamics?
A
FFR is measured at maximal hyperemia *eliminates the effects of resting hemodynamics
9
Q
What is a normal FFR value? What is the ischemic FFR threshold?
A
Normal = 1.00
Ischemic = < 0.75
Gray zone = 0.75-0.80
10
Q
What are the unique features of FFR?
A
- Normal value of 1.0 in every patient and vessel
- Well defined ischemic threshold of < 0.8
- Specific for the epicardial vessel
- Independent of the microvasculature
- Accounts for collateral blood flow
- Independent of hemodynamic changes
- Excellent reproducibility
- Validated against a true noninvasive reference standard
- Extensively validated against clinical outcomes in a variety of patient populations and lesion subsets
11
Q
Describe the Sgarbossa Criteria
A
- Concordant ST elevation > 1mm in leads with positive QRS complex –> score 5
- Concordant ST depression > 1mm in any lead from V1-V3 –> score 3
- Excessively discordant ST elevation > 5mm in leads with a negative QRS complex –> score 2
**A minimal score of 3 was required for a specificity of 90 percent.
**the third finding requires further validation, since a high take-off of the ST segment in leads V1 to V3 has been described with uncomplicated LBBB, particularly if there is underlying left ventricular hypertrophy. In a substudy from the ASSENT 2 and 3 trials, the third criteria added little diagnostic or prognostic value
12
Q
What trial gave rise to the Sgarbossa Criteria?
A
GUSTO-1 trial -thrombolytic therapy for acute MI
13
Q
Define the modified Sgarbossa criteria?
A
≥ 1 lead with ≥ 1mm of concordant ST elevation
≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
≥ 1 lead anywhere with ≥ 1mm STE and proportionally excessive discordant STE, as defined by ≥ 25% of the depth of the preceding S-wave
14
Q
In what other clinical situation is Sgarbossa criteria utilized for the diagnosis of MI?
A
RV pacing (also demonstrates LBBB on EKG)
15
Q
What is the Brugada criteria used for?
A
stepwise approach for differentiating VT vs. SVT with aberrancy If any of the four criteria is positive –> VT if non of the criteria are positive –> SVT with abberancy
16
Q
Define the Brugada Criteria?
A
- Absence of RS complex in all precordial leads
- R to S interval > 100ms in one precordial lead
- AV dissociation
- Morphology criteria for RBBB or LBBB present in precordial leads
*dominant R wave in V1 –> criteria for RBBB
*dominant S wave in V1 –> criteria for LBBB
*if any are positive –> VT
*all negative –> SVT
17
Q
Common EKG features of VT:
A
- Absence of typical RBBB or LBBB morphology
- Extreme axis deviation (“northwest axis”)
- QRS is positive in aVR and negative in I + aVF.
- Very broad complexes (>160ms)
- AV dissociation (P and QRS complexes at different rates)
- Capture beats (occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.)
- Fusion beats (occur when a sinus and ventricular beat coincides to produce a hybrid complex.)
- Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.
- Brugada’s sign (The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms)
- Josephson’s sign (Notching near the nadir of the S-wave -RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller.)
18
Q
What is the expected battery longevity for current ICD generators?
A
6-10 years, depending on:
- burden of pacing
- pacing threshold and impedance
- need for high-voltage therapies
- vendor or model
19
Q
Define primary and secondary cardiac tumors? Which are more common?
A
Primary arise from the heart (0.001-0.03%) in autopsy series.
Secondary tumors have metastasized to the heart *Secondary cardiac tumors are more common
20
Q
What percentage of primary cardiac tumors are benign?
A
75% - adults
90% - children
21
Q
What are the most common primary cardiac tumors in adults and children?
A
Adults –> myxoma (50% of all primary tumors) Children –> rhabdomyomas and fibromas
22
Q
What are common symptoms associated with left-sided and right-sided cardiac masses?
A
Left sided –> stroke, visceral infarction, MI, Peripheral emboli, dyspnea, orthopnea, PND
Right sided –> PE, pleuritic chest pain, dyspnea, peripheral edema, ascites, hepatomegaly
23
Q
What is the most common valvular tumor?
A
papillary fibroelastoma
24
Q
What are features suggestive of malignant cardiac tumors?
A
Large Broad-based tumors
May completely occupy the cardiac chamber
Pericardial or Hilar involvement.
25
What are the preferred methods for imaging/diagnosing cardiac tumors (in order)?
TTE
TEE
Cardiac MR
-provides optimal assessment of the location, functional characteristics, soft tissue features of cardiac tumors
T1 and T2 weights sequences can offer further information regarding soft tissue characterization and demonstration of fluid components.
Cardiac CT
Endomyocardial biopsy
Pericardial biopsy or Pericardial fluid analysis
26
When is enodmyocardial biopsy for cardiac tumor considered:
- diagnosis cannot be established by noninvasive means
- tissue diagnosis can influence course of therapy
- chance of successful biopsy are reasonably high
- procedure performed by experienced operator
27
What percentage of patients with chest pain and new LBBB have acute coronary occlusion?
2-4%
\*no difference in patients who present with old LBBB
28
What is the sensitivity of ST elevation on EKG (with normal conduction) for cornoary occlusion?
And with LBBB?
- 70%
- 70% (modified Sgarbossa crieteria)
29
What is the "Rule of Appropriate Discordance?"
When is it used?
- means that in normal LBBB (without MI), ST segment (and usually T-wave) are in the opposite direction (discordant to) the majority of the QRS
- Concordance (ST segment in the same direction as the QRS) is abnormal --\> STEMI
- Sgarbossa Criteria
30
- no evidence of coronary occlusion,
- all ST-T complexes are discordant and appropriately proportional.
- There is no concordant STE.
- 5 mm of discordant STE in lead V2, but the S-wave is 40 mm, for a ratio of 5/40, or 0.125, which is a normal ratio.
\*\*Thus, by the unweighted Sgarbossa criteria, it is anterior STEMI, but by the ratio rule, it is non-ischemic. This turned out to not be MI or acute coronary syndrome, as predicted by the rule.
31
- subtle concordant STE in lead aVF, almost 1 mm.
- 2 mm of discordant STE in lead III. Since the S-wave is only 3 mm, this is proportionally excessively discordant ST elevation.
\*\*You should be very worried about STEMI here and, if you are reluctant to activate the cath lab, you should at the very least contact your cardiologist for an emergent formal ECHO, and obtain serial ECGs at least every 10-15 minutes to look for evolution.
32
- tachycardia, which can exaggerate discordant STE, but should never cause concordant STE, which is now clearly seen in leads III and aVF, with reciprocal proportionally excessive ST depression in aVL and aVR.
- Lead V3 has an inexplicable QRS with profound concordant STE.
- So this is clearly diagnostic of STEMI (There is also ST depression out of proportion: \> 30% of the R-wave in leads V5 and V6)
- Dx: 100% acute RCA occlusion
33
What is peak/max VO2?
maximum rate of oxygen consumption as measured during incremental exercise
34
What is the peak VO2 when patients are generally considered candidates for heart transplantation?
\< 14 ml/kg/min
or
\< 12 ml/kg/min on beta-blockers
35
What is normal Cardiac Index (CI)?
Cardiac Output (CO)?
CI = 2.5-4 L/min/m2
CO = 4-8 L/min
36
EKG findings of LVH:
- increased amplitude (voltage) of QRS
- supported (and strengthened) by presence of secondary ST-T wave changes
- Other: left atrial abnormality, LAD, and/or prolonged intrinsicoid deflection, prominent U waves may be present
37
EKG Criteria for LVH (Sokolow and Lyone):
Precordial leads
- Sv1 and R v5 or v6 \> 35 mm
- R v5 or v6 \> 25 mm
Limb leads
-R aVL \> 11 mm
38
EKG Criteria for LVH (Romhilt and Estes Point system)
\*\*5 or more = LVH, 4 or more = probably LVH\*\*
Amplitude (any of the following) = 3 points
- Any limb lead R or S \> 20 mm
- Sv1 or Sv2 \> 30 mm
- Rv5 or Rv6 \> 30 mm
ST-T change = 3 points (1 with digitalis)
Left atrial abnormality = 3 points
Left axis deviation (-30 or more) = 2 points
Intrinsicoid deflection = 1 point
39
EKG Criteria for LVH (Cornell)
Men: Ravl + Sv3 \> 28 mm
Women: Ravl + Sv3 \> 20 mm
40
EKG Criteria for left atrial abnormality
- Prominent notching of P-wave (especially L2) with P-wave duration \> 0.12s
- Leftward shift of P-wave axis
- Increased duration and depth of terminal negative portion of P in V1 ( \> 0.04 mm-sec)
41
Key characteristics of RVH
- R/S ratio in V1 \> 1 and R wave \> 5mm
- QR in V1
- RAD
- Right atrial enlargement
-S1Q3T3 pattern and S1S2S3 pattern
\*S1S2S3 pattern due to RVH = (SII \> SIII)
42
EKG criteria for Right atrial enlargement
- peaked P (amplitude \> 2.5 mm) in leads II, III, and aVF
- Rightward shift in P-wave axis ( \> +75)
- Increased area ( \>0.06 mm/sec or amplitude \> 1.5 mm) of initial positive portion of P wave in V1
43
Differential diagnosis of RAD
- RVH
- Lateral wall MI
- Left posterior hemiblock
- COPD
- Normal Young Adult
44
Differential diagnosis: Prominent R wave or R/S ratio in V1
- RVH
- Ventricular Pre-excitation (WPW)
- Posterior wall MI
- Hypertrophic Cardiomyopathy
- If qR pattern, incomplete RBBB with septal MI
- Normal Variant
45
EKG findings: Acute PE
- Rightward shift of the QRS axis ( \> 90 or indeterminate)
- S1Q3T3 pattern
- Incomplete or complete RBBB (often transient)
- ST-segment deviation (depression or elevation) in V1-V2
- Sinus tachycardia, atrial flutter, atrial fibrillation
46
RBBB diagnostic criteria
- Broad QRS \> 120 ms
- RSR' pattern in V1-V3 (M-shaped QRS complex)
- Wide, slurred S wave in the lateral leads (I, aVL, V5-V6)
47
Causes of RBBB
- RVT / cor pulmonale
- PE
- Ischemic heart disease
- Rheumatic heart disease
- Myocarditis or cardiomyopathy
- Degnerative disease of the conduction system
- Congenital heart disease (e.g. ASD)
48
Incomplete RBBB criteria
-RSR' patterin in V1-V3 with QRS duration \< 120 ms
\*Normal variant often seen in children (of no clinical significance)
49
RBBB pathophysiology
- activation of the RV is delayed as depolarization has to spread across the septum from the LV
- LV is activated normally, meaning that the early part of the QRS is unchanged
- Delayed RV activation produces a secondary R wave (R') in the right precordial leads (V1-V3) and a wide, slurred S wave in the lateral leads
- Delayed activation of the RV also gives rise to secondary repolarization
50
EKG findings: Ostium Primum ASD
-rSR's' in lead V1
+
-Left axis deviation
\*Normal axis = Ostium secundum
\*Low atrial rhythm = sinus venosus ASD
51
What is Ashman phenomenon (Ashman beat)?
- occurs when a premature supra ventricular beat occurs before the right bundle branch has recovered from its refractory period --\> results in the PVC being displayed as RBBB
- frequently occurs with PAC's, however can also be seen in A-fib, atrial tachycardia as R-R intervals can vary
- No clinical significance, patient's may feel palpitations
52
Explain the PATHWAY-2 trial?
"Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomized, double-blind, crossover trial." *The Lancet - 2015*
Clinical Question --\> In patients with resistant hypertension treated with an ACE/ARB, CCB and a diuretic, is the addition of spironolactone superior to placebo, doxazosin or bisoprolol to control blood pressure?
Sprinolactone group --\>
- higher reduction in hom systolic blood pressure
- higher proportion of patients achieved home SBP goals (\< 135mmHg)
\*\*No difference in diastolic BP between the groups
Criticisms:
- Potential selectie reporting of outocomes
- Potential for attrition bias
- Home SBP target of \< 135mmHg for both diabetics and non-diabetics
- Mean dose of effective or tolerated drug not reported
- Short duration of follow up
- Direct switch from one drug to another
53
Define Bruce Protocol
- Developed in 1963 by Robert A. Bruce
- standardized multistage treadmill test for assessing cardiovascular health
- patient walks on an uphill treadmill in a graded exercise test with electrodes on the chest to monitor the EKG.
- Every 3 minutes, the speed and incline of the treadmill are increased (3 Mets increase)
- 7 stages, only very fit athletes can complete all 7 stages
- Modified Bruce Protocol --\> treadmill initially horizontal, instead of sloped
54
What are two of the most serios contraindications to ETT that can sometimes be overlooked?
- Aortic dissection
- Pulmonary Embolus
55
What are the absolute contraindications to ETT?
* CHF, uncontrolled
* High-risk UA
* Arrhythmia, uncontrolled
* Aortic Dissection
* Acute MI
* Myocarditis / Pericarditis
* Pulmonary Embolus
* Severe symptomatic AS
56
What are the relative contraindications to ETT?
* Stenotic heart disease (moderate)
* Tachy/bradyarrythmia
* Electrolyte abnormalities
* AV block (high-degree)
* LMCA disease
* Hypertension (BP \> 200/110 mmHg)
* HOCM
57
What are indications to stop ETT?
* Patien'ts desire to stop
* CNS symptoms
* Moderate angina
* Arrhythmias (serious)
* ST-elevation \> 1.0mm
* Hypotension (SBP drop \> 10 mmHg below baseline)
58
What is the hallmark of an abnormal ETT?
How is this abnormal response defined?
* ST-segment depression
* ≥ 1.0mm horizaontal or downsloping ST-segment depression measured 0.08 seconds after the J point
59
What are additional features of an ETT that increase the likelihood of a true-positive test result?
- Occurrence at a low exercise workload
- Involvement of several EKG leads
- Greater magnitude of depression
- Longer persistence in the recovery period.
60
What is the significance of ST-depression that occurs only in the recovery period?
same diagnostic accuracy as ST-segment depression during exercise
61
What are the most frequently identified lead abnormalities on ETT?
* Positive responses in V4-V6 ( \> 90%) regardless of site of anatomical CAD
* ST-depression confined to inferior leads --\> usually represents false positive findings
62
When does ST-elevation usually show up on ETT?
What does this mean?
* Can be arrythmogenic if exercise continues.
* Can localize site of myocardial ischemia (unlike ST-depression) and usually indicates high-grade stenosis
63
What EKG findings preclude interpretation of exercise EKG?
* Paced ventricular rhythm
* Pre-excitation (WPW)
* LBBB
* Reduce specicity --\> ST-T abnormalities, Digoxin use, LVH
64
Can ETT/EKG interpretation be performed in the setting of RBBB?
* Yes
* Right precordial leads (V1-V3) must be ignored and interpretation is confined to left precordial leads (V4-V6)
65
What are the three clinical CAD risk categories defined by the ACC/AHA?
* Low ( \< 1% mortality rate)
* Intermediate ( 1-3% mortality rate)
* High ( \> 3% mortality rate)
66
What is the most important/strognest prognostic ETT variable?
* Exercise capacity / duration
* patient's at high risk for left main/three-vessel CAD
* high clinical event rate
67
What are clinical variables in ETT that identify higher-risk patients?
* Poor exercise capacity
* Hypotension, exercise induced
* Chronotropic incompetence
* during exercise or or post-exercise
* Ventricular ectopy
* ST-depression (weaker than other variables)
68
Define Duke Treadmill Score (DTS)
* weighted index combining:
* treadmill exercise time using standard Bruce protocol
* maximum net ST segment deviation (depression or elevation)
* exercise-induced angina.
* Developed to provide accurate diagnostic and prognostic information for the evaluation of patients with suspected coronary heart disease.
* Typical observed range of DTS is from -25 (highest risk) to +15 (lowest risk).
69
What is the equation for the DTS?
70
What are the recommendations for pre-operative stress testing?
* Elevated risk and poor functional capacity --\> pharmacologic stress testing, if it will change management (Class IIa)
* Elevated risk and unknown functional capacity --\> exercise testing to assess functional capacity if it will change management (Class IIb)
* Elevated risk and poor ( \< 4 METS) or unknown functional capacity --\> exercise testing with cardiac imaging to assess for myocardial ischemia if it will change management (Class IIb)
* Testing not recommended for low-risk surgery (Class III)
* Reasonable to forgo exercise testing and proceed to surgery in patients with elevated risk and excellent functional capacity, defined as \> 10 METS (Class IIa)
* Reasonable to forgo exercise testing and proceed to surgery in patients with elevated risk and moderate to good functional capacity, defined as 4-10 METS (Class IIb)
71
In what groups of patients should stress imaging be the initial testing modality?
* inability to exercise with requirement for pharmacologic stress
* significant abnormalities on resting EKG that preclude interpretation of the stress EKG
* high pretest probability of CAD
72
What are the Class I indications for stress testing?
* Standard ETT in patients at intermediate pretest probability of CAD who can exercise and have interpretable EKG
* Exercise imaging in patients at intermediate or high pretest probability of CAD who can exercise and have an uniterpretable EKG
* Pharmacologic imaging in patients with intermediate or high pretest probability of CAD who are unable to exercise.
73
How to obtain the parasternal long axis view?
* Position the TTE transducer:
* 3rd-4th intercostal space
* at left parasternal border
* index marker pointing toward the right shoulder (11 o'clock)
* Adjust sector depth to:
* 10-16 cm to see the descending aorta in SAX
* increase to 20cm to assess for a left pleural effusion
74
What are the assessment goals in parasternal long axis?
* LV size and function
* RV size
* Mitral valve
* Aortic valve
* Left pleural effusion
* Pericardial effusion
* Aortic dissection
75
What structures can be identified in parasternal long axis view?
* Aortic Valve
* Descending aorta (Ao)
* Inter-ventricular septum (IVS)
* Left atrium (LA)
* LV
* Mitral valve
* RVOT
76
What structures can be identified in parasternal short axis view?
* Anterolateral papillary muscle (AL)
* Inter-ventricular septum (IVS)
* LV
* Posteromedial Papillary Muscle (PM)
* RV
77
What should parasternal short axis be used to assess?
* LV size and function
* RV size and function
* Pericardial effusion
78
How to obtain parasternal short axis view?
* Position the TTE transducer
* 3rd-4th intercostal space
* left parasternal border
* index marker poiting towards the left shoulder (2 oclock)
* view can easily be obtained by rotating the probe 90 degrees clockwise from the parasternal LAX view and tilting the probe downards
* Adjust the sector deptht to:
* 10-16 cm to see the entire LV
79
What structures should be identified in the apical four chamber view?
* Descending Aorta (Ao)
* Inter-atrial septum (IAS)
* LA
* Left lower pulmonary vein (LLPV)
* LV
* MV
* RA
* Right upper pulmonary vein (RUPV)
* RV
* TV
80
How to obtain apical four chamber view?
* Position the TTE transducer
* 4th or 5th intercostal space
* midclavicular line or at the point of apical pulsation
* index marker pointing towards the left (3 oclock)
* Adjust the sector depth to:
* 14-18cm to image the atria
* 6-10 cm to assess the LV apex
81
What should the apical four chamber view be used to assess?
* LV, RV size and function
* RA and LA size and function
* MV and TV's
* Pericardial effusion
82
What should the subcostal four chamber view be used to assess?
* LV, RV size and function
* MV and TV's
* RA, LA size and function
* Pericardial effusion
* Cardiac motion during code blue
83
What structures should be identified on subcostal four chamber view?
* Inter-atrial septum (IAS)
* Inter-ventricular septum (IVS)
* LA
* RA
* MV
* TV
* RV
* LV
* Liver
84
How to obtain subcostal four chamber view?
* Position the TTE transducer:
* subxiphoid region of the abdomen
* flat and push down with a slight tile to the patients right
* index marker pointing towards the left (3 oclock)
* Adjust the sector depth to:
* 16-24cm to image the entire LA and LV
85
How to obtain the subcostal IVC view?
* Position the TTE transducer:
* in the subxiphoid region of the abdomen
* tilt to the patient's left
* index marker pointing towards the head (12 oclock)
* view can easily be obtained by rotating the probe 90 degrees counterclockwise from the subcostal 4C view
* Adjust the sector depth to:
* 16-24cm to image the entire IVC
86
What should the subcostal IVC view be used to assess?
* IVC size (measure in mm or cm)
* change in IVC size with respiration (use m-mode)
87
What structures should be identified on the subcostal IVC view?
* IVC
* Liver
* RA
88
What are the most common indications for TEE?
* left atrial thrombus evaluation
* endocarditis
* prosthetic valve function
* perioperative cardiac surgery complications
* providing guidance in transcatheter procedures
89
What are the major complications associated with TEE?
* Cervical spine immobility
* Recent Upper GI surgeries
* Esophageal strictures
* Prior perforated upper GI structures
* Upper GI bleed (active)
90
TEE terms:
- Advance
- Withdraw
- Turn
- Flexion
- Extension
- Rotation
- Advance: vertical forward motion of probe
- Withdraw: vertical backward motion of probe
- Turn: rotation of entire probe
- Flexion/Extension: motion of tipe of the probe in a plane parallel to the long-axis of the probe, controlled by a large dial at the base of the probe
- Rotation: electronic movement of the image plane in a circular fasion, controlled by a button on the probe and displayed as an angle on the image
91
Describe the difference (incidence, location, degree of injury) in CHB in anterior vs. inferior MI?
Inferior
* 4% of patients, may be transient
* associated with higher location of AV block (typically the AV node)
* lesser degree of myocardial injury
Anterior
* 1% of patients, serious complication of anterior MI, poorer short term outcomes (including survival)
* associated with lower location of block is usually below the AV node --\> higher long-term block
* greater degree of myocardial injury
92
What is the starting view for TEE?
How to obtain this view?
* Mid-esophageal 4-chamber view
* Mid-esophageal positioning, 0 degree rotation, maximum depth to show the entire LV, probe extended to include as much of the apex as possible
93
What are the second and third images obtained on a TEE?
After obtaining ME apical 4-chamber view:
* 2nd --\> ME, apical, 2 chamber view --\> rotating to 60 degrees
* 3rd --\> ME, apical, Long axis (LAX) view --\> rotating to 120 degrees
94
TEE views utilized to assess regional LV function / EF?
* lateral wall and inferior septum --\> ME, A4C
* anterior and inferior walls --\> ME, A2C
* anterior septum and inferior lateral wall --\> ME, ALAX
95
Quantitative EF measurements in TEE can be made utilizing what methods?
* 3D full volume acquisition with automated border detection
* Biplane approach with tracing of endocardial borders at end-diastole and end-systole in A4C ad A2C views
96
What is the best TEE view for evluating the LAA?
- ME, A2C
- imaged in two orthogonal planes (0 and 90 degrees)
97
What TEE view is this?
How to obtain the view?
What is this view used for?
- ME, Bicaval view
- Obtain ME, A4C --\> rotate to 90-100 degrees and turn probe right
- ASD (secundum, sinus venosus), Atrial pathology, Lines/wires, Venous cannula (SVC, IVC)
98
What are the branches of the celiac trunk?
* Splenic artery
* Left gastric
* Common Hepatic
99
What are the branches of the aortic arch?
* Brachiocephalic artery
* Left common carotid
* Subclavian artery
100
What are the criteria for RBBB VT in Brugada criteria?
RBBB (dominant R wave in V1)
* smooth monophasic R wave
* Notched downslop to the R wave - the taller left rabbit ear ( = Marriott's sign)
* qR complex (small Q wave, tall R wave) in V1
* QS complex
* R/S ration \< 1 (small R wave, deep S wave (indicates VT only if LAD is also present)
\*RSR' pattern --\> SVT
101
What are the criteria for LBBB VT in Brugada criteria?
LBBB (dominant S wave in V1)
* Initial R wave \> 30-40ms duration
* Notching or slurring of the S wave (Josephson's sign)
* RS interval (time from R wave onset to S wave nadir) \> 60-70 ms
* QS waves in V6
* qR pattern (small Q wave, large R wave in V6
102
Describe this view?
What structures should be identified?
* Parasternal Short Axis (PSAX)
* Structures:
* Aortic valve and cusps
* Descending Aorta
* LA (possibly LAA)
* Interatrial septum
* RA
* TV (ATVL, STVL)
* RVOT
* Pulmonic Valve
* MPA (possibly L/R pulmonary arteries)
103
WPW
* short PR interval ( \< 120 ms in adults and \< 90 ms in children during NSR)
* slurring of the QRS complex (delta wave), resulting in the QRS complex being \> 120 ms and \> 90 ms in children (widened QRS complex results from fusion of two electrical impulses, one through the normal AV node and the other through the bypass tract)
* Secondary ST-T wave changes (ST-T segment deviation opposite in direction of main QRS deflection)
104
What is the prognosis of severe, untreated AS?
50% at 2 years
105
What are the two FDA approved TAVR valves?
1. Edwards SAPIEN valve (balloon expandable)
2. Medtronic CoreValve (self-expanding)
106
What is the Class I indication for Aortic Valve Replacement?
Severe AS (V max \> 4 m/s, Mean gradient (delta P) \> 40 mm Hg)
+ (any of the following)
1. Symptomatic
2. Asymptomatic
* LVEF \< 50% (stage C2)
* Other Cardiac Surgery
107
What are the class IIa indications for AVR?
Severe AS
+
Asymptomatic
* V max \> 5 m/s, mean gradient \> 60 mmHg, low surgical risk
* Abnormal ETT
108
What are the class IIb indications for AS?
Severe AS
+
Asymptomatic
* Vmax \> 0.3 m/s/y
* Low surgical risk
109
Common EKG features of VT:
* Absence of typical RBBB or LBBB morphology
* Extreme axis deviation (“northwest axis”)
* QRS is positive in aVR and negative in I + aVF.
* Very broad complexes (\>160ms)
* AV dissociation (P and QRS complexes at different rates)
* Capture beats (occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.)
* Fusion beats (occur when a sinus and ventricular beat coincides to produce a hybrid complex.)
* Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.
* Brugada’s sign (The distance from the onset of the QRS complex to the nadir of the S-wave is \> 100ms)
* Josephson’s sign (Notching near the nadir of the S-wave -RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller.)
110
What percentage of patients with chest pain and new LBBB have acute coronary occlusion?
2-4%
\*no difference in patients who present with old LBBB
111
What is the sensitivity of ST elevation on EKG (with normal conduction) for cornoary occlusion?
And with LBBB?
- 70%
- 70% (modified Sgarbossa crieteria)
112
What is the "Rule of Appropriate Discordance?"
When is it used?
- means that in normal LBBB (without MI), ST segment (and usually T-wave) are in the opposite direction (discordant to) the majority of the QRS
- Concordance (ST segment in the same direction as the QRS) is abnormal --\> STEMI
- Sgarbossa Criteria
