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🚩#Quiz Of The Week

* ESCardioEd challenge by Pierre Baudinaud et al., Hospital La Pitié Salpétrière, Institute of Cardiology, – Paris.

✳️A 42-year-old Caucasian male presented to the ER with exertional dyspnea and asthenia with 2 weeks duration. ECG showed a complete AVB with a junctional escape rhythm at 29 bpm. The patient lived in Cameroon, Mexico and in Asia. He had returned to France 2 months prior. His past medical history was malaria in 2016, giardiasis in 2016, amoebiasis, a streptococcal skin infection in 2014, conjunctivitis ten years ago and a bacterial meningitis in 1998. He didn’t have any medication at home nor drug consumption. No familial history was found. He received 2mg of atropine without success and was referred to the EP Intensive Care Unit. The standard laboratory tests were unremarkable. Autoimmune profiles, serologies and quantyferon were negative, the Angiotensin-converting enzyme level was low. The biopsy of the accessory salivary gland was normal. The transthoracic echocardiography at admission was normal.
EPS below. Where is the block?
A. AV node block
B. No conduction block
C. Intra Hissian block
D. Infra Hissian block

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🚩#Quiz Of The Week
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👈 #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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🚩#Quiz Of The Week

* #ESCardioEd challenge by Pimpimol Yooprasert and team, Faculty of Medicine Ramathibodi Hospital, Mahidol University - Bangkok

✳️A 22-year-old, 34 weeks pregnant, was referred due to massive hemoptysis.
Personal history: first episode when aged 17 and 7 months pregnant, patient gave birth to a preterm baby who died 2 weeks later of unknown cause, no autopsy.
Five months prior to this admission, she had hemoptysis and acute dyspnea after traveling on a long-distant bus and diagnosed with pneumonia.
Examination: Tachypnea with desaturation, diagnosed with heart failure. Pulse oximetry measured from her left hand showed a saturation of 91 % on room air, and 96 % while on 10 LPM oxygen mask. There was no central or peripheral cyanosis and no clubbing of fingers or toes , but pulse oximetry showed more degree of desaturation of her feet, measured 74 %. On auscultation, there was loud P2 and pansystolic murmur grade III/VI at left lower parasternal border area. Lungs were clear and minimal pedal oedema was noted.
Chest x-ray: cardiomegaly, enlarged pulmonary trunk and right pulmonary artery, increased pulmonary vasculature, and a patchy infiltration at left upper lung zone. ECG: normal sinus rhythm with evidence of right ventricular hypertrophy and right axis deviation.
Blood test: mild normocytic anaemia (Hb 11.4 g/dL, Hct 38.0 %, MCV 81.7 fL), thrombocytopenia with platelet count 88000 /mm3, and normal white blood cell series.
🔸Echocardiogram is below.👇

🔻What would you do next?

A. Emergency baby delivery
B. Right heart catheterization
C. Counseling with multidisciplinary team
D. Bedrest and therapy until delivery


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🔸#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

* #ESCardioEd challenge by Marco Spartera and team, University of Oxford, England.

✳️ A 58-year-old female with worsening effort dyspnoea and fatigue. Clinical examination was notable for jugular venous distension and pitting oedema of the feet and ankles.
Past medical history: Persistent AF 2 years previously and heart failure symptoms, two catheter ablation procedures for AF, including pulmonary vein isolation and roof and mitral isthmus lines. However, symptoms of effort dyspnoea and fatigue had progressed despite maintenance of sinus rhythm.
Family history: dilated cardiomyopathy in the patient’s mother, but further details were not available.
Therapy : Warfarin, Bisoprolol 10 mg od, Ramipril 5 mg od, Spironolactone 37.5 mg od, Furosemide 20 mg od.
ECG: sinus rhythm with no evidence of ischaemia.
TTE: mild left ventricular (LV) dilation, with preserved LV systolic function and normal wall thickness, grade II diastolic dysfunction, mild right ventricle dilatation with preserved systolic function, sPAP 60mmHg. Both atria were moderate-severely dilated.
NT-proBNP: 1967 pg/mL. A 28 gene panel for DCM was negative.
At this stage, despite extensive investigations, no definite aetiology of heart failure was found. CMR is below.👇
The patient’s clinical condition slowly worsened with orthopnoea and NYHA class III heart failure requiring a brief hospital admission for intravenous diuretics. This culminated in a cardiac arrest whilst the patient was driving to attend an outpatient appointment, resulting in a serious motor vehicle accident on the motorway. Brought in hospital by ambulance, patient fully recovered neurologically. Repeat echocardiography revealed a dilated right ventricle with severe pulmonary hypertension. A further cardiac magnetic resonance scan is showed below. No change in the pattern of LGE was observed.

🔻What investigation is most appropriate?

A. Coronary angiography
B. Ventilation-perfusion scintigraphy
C. Right Heart catheterization
D. 7-day Holter ECG
E. Endomyocardial biopsy


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‍ 👈 #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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‍ 👈 #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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‍ 👈 #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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‍ 👈 #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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🔸#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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🔸#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

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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?

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🔸#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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🔸#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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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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