💌 #ECG of the week 110 :

👈#پاسخ (2-2):
🔸#Answer :

✅Description and interpretation of #ECG 2

-Rate:
• 84 bpm
-Rhythm:
•Regular
•Sinus rhythm
-Axis:
•Normal
-Intervals:
•PR – Normal (160ms)
•QRS – Normal (100ms)
•QT – 360ms (QTc Bazett 430 ms)
-Segments:
•ST Elevation leads I (<1mm); aVL (1 mm); V1 (1mm); V2 (6mm); V3 (7mm); V4 (7mm); V5 (4mm); V6 (1-2mm)
•ST Depression leads III, aVF
-Additional:
•Note resolution of deep T wave inversion with hyperacute T waves on ST segments in leads V2-3
•Voltage changes as above
-Interpretation:
•Antero-lateral STEMI
• Occlusion of critical lesion suspected from first ECG

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💌 #ECG of the week 111 :

🔸#Answer :

✅Description and interpretation of ECG

Interpretation:
•ST and T wave changes
o Likely ACS given history
o Needs serial ECGs and comparison with prior ECGs
• QRS Fragmentation
o Caused by abnormal ventricular repolarisation
o Due to myocardial scarring, fibrosis or ischaemia

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👈#پاسخ :
🔸#Answer :

✅ c. Supraventricular tachycardia


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👈#پاسخ :
🔸#Answer :

✅ b. Refer for electrophysiology study


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‍ 👈 #پاسخ :
🔸#Answer :

✅ Correct answer is Aneurysm.

👉CT shows a tortuous large aneurysmal left circumflex draining into a large coronary sinus.
Coronary angiography (CAG) and right heart catheterization demonstrated a step up of oxygen saturation with 53% in the superior vena cave and 78% in the right atrium.
His pulmonary artery pressure was 36 mm Hg while pulmonary wedge pressure was 21 mm Hg yielding a transpulmonary gradient of 15 mm Hg. The large, tortuous co-dominant left circumflex artery was seen draining into the coronary sinus and subsequently the right atrium. The patient underwent cardiopulmonary bypass with successful ligation of the aneurysmal left circumflex fistula and coronary sinus in addition to the placement of a left atrial appendage surgical clip.
He had an uneventful recovery. Post procedural TTE done at 6 weeks showed an improved left ventricular ejection fraction (from 25% pre-operatively to 55% post operatively), a reduction of the right ventricular size to normal limits with residual reduced systolic function. No residual flow was noted in the coronary sinus on color Doppler (Figure 5). Patient reported improved functional status with ability to walk 2-3 miles without symptoms.

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🚩#Questions and #answers on the 2019 ESC Guidelines

👈 #پاسخ :
🔸#Answer :

✅ Correct answer is A .

👉 #Answer : According to the 2019 #ESC_Guidelines on Acute Pulmonary Embolism, the correct answer is A : in high pre-test probability of PE and abnormal chest x-ray, CTPA technique with low fetal radiation exposure should be performed. In high-risk PE, haemodynamic instability, thrombolysis or surgical embolectomy should be considered.


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🚩#Questions and #answers on the 2019 ESC Guidelines

👈 #پاسخ :

✅ Correct #Answer : According to the 2019 ESC #Guidelines on dyslipidaemias, the correct answer is B.


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

✅ Correct answer is A.
CMR was performed (see below). ECG-gated CT showed normal coronary arteries and no signs of chest sarcoidosis with normal lung parenchyma and absence of mediastinal adenomegaly. A positron emission tomography PET-CT was performed and no abnormality were found.
At one month, a control CMRI was performed and demonstrated persisting but much less intense late gadolinium enhancement in the AV node. Native T1 and T2 signal were decreased. The ECG at the same time found AV conduction recovery with sinus rhythm at 80/min with a PR interval at 200ms stable during exercise. Diagnosis of atrioventricular node myocarditis of the interatrial septum was made.

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🚩#Questions and #answers on the 2019 ESC Guidelines

👈 #پاسخ :

✅ Correct #answer is D: none of these.
Cather ablation should be considered in experienced centers (IIa C), if ablation is not possible beta-blockers should be considered (IIa, C), amiodarone may be considered (IIb C)

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

✅ Correct answer is C.
Bedside ultrasound revealed oligohydramnios and a single living foetus in a breech presentation. Foetal tracing showed reassuring pattern. Corticosteroid was given to promote foetal lung maturation, and elective Caesarian section was scheduled. Sildenafil was started on the night when she arrived, with careful monitoring of vital signs and clinical symptoms.
Right heart catheterisation was performed a day later, demonstrating severe pre-capillary pulmonary hypertension (mPAP 88 mmHg, PAWP 10 mmHg, PVR 17 WU) without oxygen step-up pattern.
CT scan revealed PDA (see below) Sildenafil was titrated up to 40 mg orally three times per day, without adverse event. Patient discharged after 10 days of admission, without hemoptysis or dyspnea.

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

✅ Correct answer is D.

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

✅ Correct answer is D.

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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
👈 #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
👈 #پاسخ :
🔸#Answer :

✅ Correct answer is VT

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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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