‍ 🚩#Quiz Of The Week
‍ 👈 #پاسخ :
🔸#Answer :

✅Correct answer is Right Heart catheterization

Results from right and left heart catheterisation showed pulmonary hypertension with elevated ‘wedge’ and ‘LV end diastolic’ pressures, dramatically elevated cardiac output, and low systemic vascular resistance with only mildly elevated pulmonary vascular resistance. Overall, these findings are in keeping with a diagnosis of ‘high-output cardiac failure’.

Notably, significant difference was noted in oxygen saturations between the superior and inferior vena cava (SVC 34.0% vs IVC 91.8%), suggesting a left-to-right shunt in the abdominal/pelvic area.
CT abdomen-pelvis & invasive angiogram confirmed the presence of a very large arteriovenous malformation (AVM) in the pelvis, with a major feeding artery ~1.5 cm in diameter and a 3-4 cm vein returning blood to the IVC. The final diagnosis was eventually achieved: high-output heart failure due to a large pelvic AVM.
A subcutaneous ICD was implanted successfully, and percutaneous transarterial embolisation of the left internal artery feeders AVM was performed. Although only a partial occlusion was achieved, the patient's symptoms dramatically improved (to NYHA class II) with a significant reduction of about 20 mmHg in sPAP as assessed by echocardiography at 6-9 months after the procedure.

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🚩#Questions and #answers on the 2019 ESC #Guidelines

👉Know your #ESCGuidelines?

🔸A 41-year-old lady continues to show tachycardiomyopathy despite beta blockers and an attempt of ablation. According to the 2019 ESC Guidelines on Supraventricular Tachycardia.
What is the correct management of this patient?

A. Ablate and pacing
B. Add amiodarone
C. Continue monitoring
D. All of these

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🚩#Quiz Of The Week
‍ 👈 #پاسخ :
🔸#Answer :

✅ Correct Answer is A.
AV nodal ablation with subsequent pacing (“ablate and pace”) either biventricular or his-bundle pacing, is recommended.

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🚩#Questions and #answers on the 2019 ESC #Guidelines

👉Know your #ESCGuidelines?

🔸A 41-year-old lady continues to show tachycardiomyopathy despite beta blockers and an attempt of ablation. According to the 2019 ESC Guidelines on Supraventricular Tachycardia.
What is the correct management of this patient?

A. Ablate and pacing
B. Add amiodarone
C. Continue monitoring
D. All of these

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🚩#Quiz Of The Week
‍ 👈 #پاسخ :
🔸#Answer :

✅ Correct Answer is A.
AV nodal ablation with subsequent pacing (“ablate and pace”) either biventricular or his-bundle pacing, is recommended.

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🚩#Questions and #answers on the 2019 ESC #Guidelines

👉Know your #ESCGuidelines?

🔸According to the 2019 ESC/EAS Dyslipidaemia Guidelines, the addition of a PCSK9 inhibitor is recommended for patients already taking a maximally tolerated statin dose and ezetimibe if the LDL-C goal is not achieved:

A. After 4-6 weeks
B. In very-high-risk FH patients
C. For secondary prevention ,in patients at very-high-risk
D. All these patients

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🚩#Quiz Of The Week
‍ 👈 #پاسخ :
🔸#Answer :

✅ Correct answer is D.

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🚩#Quiz Of The Week

🔸Clinical case challenge by Andreas Bugge Tinggaard et al, Aarhus University Hospital, Aarhus, Denmark.

🔹A 57-year-old male was hospitalised with an ischemic stroke verified on MRI. ECG showed AF. Echocardiography revealed a structurally normal heart. The patient was discharged with dabigatran. Another MRI-verified stroke led to re-hospitalisation 19 days later. Transesophageal echocardiography excluded intracardiac thrombi. Dabigatran was substituted with warfarin and the patient was referred for transcatheter left atrial appendage occlusion.
What does the CT show?

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🚩#Quiz Of The Week
‍ 👈 #پاسخ :
🔸#Answer :

✅ Answer is: Absence of the LAA caused by chronic thrombotic occlusion and epithelialization of the orifice.
The CT shows no contrast filling of the LAA. Multiplanar CT images revealed contours of a LAA and 3D-TEE confirmed LAA absence with a smooth-walled surface covering the orifice.


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🚩#Questions and #answers on the 2019 ESC #Guidelines

👉Know your #ESCGuidelines?

🔸According to the 2019 ESC/EAS Dyslipidaemia Guidelines, the addition of a PCSK9 inhibitor is recommended for patients already taking a maximally tolerated statin dose and ezetimibe if the LDL-C goal is not achieved:

A. After 4-6 weeks
B. In very-high-risk FH patients
C. For secondary prevention ,in patients at very-high-risk
D. All these patients

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🚩#Quiz Of The Week
‍ 👈 #پاسخ :
🔸#Answer :

✅ Correct answer is D.

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🚩#Quiz Of The Week

* #ESCardioEd challenge by Dr Umberto Barbero and team, Santissima Annunziata Hospital of Savigliano, ASLCN1, Savigliano, Italy.

✳️ After two days from an episode of acute pain in the left shoulder, which radiated posteriorly and lasted one hour then slowly vanished, a 74 years-old lady reported the episode to her General Practioner who asked for an ECG (figure below). She was referred to the emergency department where echocardiography showed severe impairment of left ventricular function with mid-apical akinesia and hyperkinetic basal segments, with a giant thrombus in the apex (video in the comments section). She was taken in our Intensive Cardiac Unit and she was treated with diuretics, heparin, aspirin, beta-blockers and ticagrelor and prepared for coronary angiography.

What's the diagnosis?

1. Late anterior #STEMI presentation, by then asymptomatic
2. #Brugada Syndrome
3. #Takotsubo syndrome
4. Dilated #Cardiomyopathy with embolizing left ventricular apical thrombus

✅ #مشاهده_تصویر 👇

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🚩#Quiz Of The Week
👈 #پاسخ :
🔸#Answer :

✅ Correct answer is Takotsubo.

The ECG evolved with an ischemic pattern in the next days (figure 1), but the coronary angiography showed normal coronary arteries (video in comments section). As part of a MINOCA work-up the patient received cardiac magnetic resonance: T2-weighted sequences which identified the presence of oedema of the apical and mid-segments, without any sign of late gadolinium enhancement, consistent with the diagnosis of Takotsubo syndrome (figure 2). After 3 months, follow-up echocardiography revealed the complete recovery of ventricular function with the disappearance of the apical thrombus and of pericardial effusion.
While every option mentioned could be advocated as potentially true, CMR was the key diagnostic algorithm with the evidence of a typical Takotsubo pattern. The ECG findings in Takotsubo cardiomyopathy ― also known as stress-induced cardiomyopathy, broken-heart syndrome or apical-ballooning syndrome ― are nonspecific, meaning there is no typical ECG appearance to diagnose this disease state.

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🚩#Quiz Of The Week

* #ESCardioEd challenge by Dr Francesco Petracca and team, Cardiocentro Ticino Institute, Lugano, Switzerland.

✳️ A 44-year-old woman with history of drug addiction and cirrhosis related to chronic hepatitis C infection, presented to the out-patient clinic with severe right-sided heart failure. She underwent partial tricuspid valve resection and De Vega annuloplasty in 2001 for infective endocarditis and in 2009 a tricuspid #valve_replacement with a Carpentier-Edwards Perimount Magna 31 mm valve, for symptomatic severe tricuspid regurgitation recurrence.
Transthoracic #echocardiography on admission showed degeneration of the bioprosthetic valve.
The heart team decided to proceed with a trans-jugular implantation of a new valve in view of the patient’s overall frailty and significant comorbid conditions.
The preoperative computed tomography showed total occlusion of the internal jugular vein up to the subclavian vein confluence (figure 2 below), making this vascular access route unsuitable.

What #vascular access would you choose?

✅ #مشاهده_تصویر 👇

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🚩#Quiz Of The Week
👈 #پاسخ :
🔸#Answer :

✅ Occlusion of the internal jugular vein made it necessary to perform the procedure through a trans-femoral (TF) venous route.
A 29-mm Edwards Sapien 3 transcatheter heart valve (Edwards Lifesciences) was inserted over the wire in the inferior vena cava. Under fluoroscopic and transesophageal echocardiographic guidance, the valve was then advanced into the degenerated tricuspid biological prosthesis (Figure 3 below) and positioned in the usual manner for Sapien 3 valve deployment, with use of the prior stent’s frame as a reference. The valve was deployed with excellent results (Figure 4). Post-deployment echocardiogram confirmed a well-positioned valve, with optimal placement, and a trivial pari-valvular leak.
The patient tolerated the procedure well with no peri-procedural complications, reporting an immediate improvement in her symptoms.
At 12 months follow-up the patient is stable, asymptomatic, with no other hospital admission for acute decompensated right heart failure.
TF transcatheter tricuspid valve-in-valve replacement is a valid therapeutic option in patients with prohibitive surgical risk. This access is safe and feasible and allows good prosthesis positioning. Multimodality imaging and discussion in a heart team helps to make the optimal treatment decisions.

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🚩#Quiz Of The Week

✅ #EHRA2021 #ECG competition session :

67 yo patient with no history of heart disease presents to the ER with dizziness and palpitations.

What’s the most likely diagnosis?

1. Atrial fibrillation with LBBB
2. Atrial flutter with LBBB
3. Ventricular tachycardia
4. AVNRT with aberration
5. Antidromic AVRT

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🚩#Quiz Of The Week
👈 #پاسخ :
🔸#Answer :

✅ Correct answer is VT

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🚩#Quiz Of The Week

✅ warm-up : #EHRA2021

A 19-year old male was admitted after aborted sudden cardiac death, with ongoing mechanical ventilation and stable haemodynamic parameters without the need for inotropic or vasopressor agents. There was no relevant comorbidity in the history, the patient was a heavy smoker (5 pack-year) and used cannabinoids occasionally. Before the event the patient consumed an excessive amount of alcohol, he fainted suddenly while dancing. After 5 minutes of immediately started BLS, ALS was initiated by the Ambulance Service. Ventricular fibrillation was recorded, after repeated defibrillations, ROSC occurred after 20 minutes. During ALS 300 mg amiodarone and 4 mg epinephrine was administered. Resting ECG showed 80 BPM sinus rhythm with suspected pre-excitation.

What's the most likely cause of aborted sudden cardiac arrest in this patient?


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🚩#Quiz Of The Week
👈 #پاسخ :
🔸#Answer :

The patient had a normal coronary angiogram and normal cardiac MRI. During a period of further observation he developed a narrow complex tachycardia at 180 beats per minute. Further ECGs suggested evidence of pre-excitation more clearly and he underwent an EP study and successful ablation of a left posterolateral accessory pathway. An invasive EPS with ablation is recommended in WPW syndrome patients after aborted SCD due to an AF episode and rapid conduction over the AP, causing VF. During the EPS the anterograde and retrograde conduction properties of the AP should be recorded, alongside with the shortest RR interval during induced AF if it occurs during rapid atrial pacing.

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