Dr. Usman's Cardiology Notes

  Chronic Thromboembolic Pulmonary Hypertension (CTEPH) – Key Points Definition Chronic obstruction of pulmonary arteries by organized thromboembolic material leading to persistent pulmonary hypertension and progressive right heart failure. Diagnostic Criteria After ≥3 months of effective anticoagulation: Mean pulmonary artery pressure (mPAP) >20 mmHg Pulmonary vascular resistance (PVR) >2 Wood units Pulmonary artery wedge pressure ≤15 mmHg Imaging evidence of chronic thromboembolic disease Pathophysiology Incomplete resolution of pulmonary emboli Fibrosis and organization of thrombus Small vessel arteriopathy develops over time Increased RV afterload → RV dysfunction/failure Risk Factors Previous pulmonary embolism/DVT Recurrent venous thromboembolism Splenectomy Ventriculoatrial shunts Chronic inflammatory disorders Antiphospholipid syndrome Infected pacemaker leads Malignancy Symptoms Progressive exertional dyspnea Fatigue Exercise intolerance Syncope/presyncope Chest disc...

 A ventricular ectopic beat spreads away from its site of origin through the myocardium. The ECG polarity depends on the direction of depolarization relative to a lead. If the electrical wavefront moves toward a lead → the QRS is positive. If it moves away from a lead → the QRS is negative. In PVCs or VT, the earliest activation begins at the ectopic focus. Therefore, leads “looking at” the site of origin see activation moving away from them, producing a predominantly negative QRS complex (QS or rS pattern). Example: A PVC arising from the right ventricle spreads mainly toward the left ventricle. Right precordial leads like V1 are near the origin and see activation moving away → negative QRS in V1. Left-sided leads may see activation moving toward them → positive QRS. This principle is used for VT localization: Negative inferior leads → inferiorly directed activation → superior origin. LBBB morphology VT usually originates in the right ventricle. RBBB morphology VT usually originat...

  Evaluation of mitral prosthetic valve stenosis. Evaluation of Mitral Prosthetic Valve Stenosis on Echocardiography Introduction Mitral valve replacement significantly improves symptoms and survival in patients with severe mitral valve disease. However, prosthetic mitral valves may eventually develop obstruction due to thrombosis, pannus formation, structural degeneration, calcification, or infective vegetations. Echocardiography remains the cornerstone for assessing prosthetic mitral valve function and detecting stenosis. Evaluating prosthetic mitral valve stenosis can be challenging because prosthetic valves normally produce higher gradients than native valves. A comprehensive approach using two-dimensional imaging, Doppler assessment, and comparison with baseline studies is essential. --- Causes of Prosthetic Mitral Valve Stenosis Common causes include: Prosthetic valve thrombosis Pannus ingrowth Structural valve degeneration Calcification of bioprosthetic leaflets Vegetations ...

Evaluation of aortic prosthetic valve stenosis When the Valve Becomes the Problem: Echocardiographic Evaluation of Aortic Prosthetic Valve Stenosis Aortic valve replacement can dramatically improve symptoms and survival in patients with severe aortic valve disease. However, even after successful valve implantation, prosthetic valves are not immune to complications. One of the most important and challenging problems is prosthetic valve stenosis. For echocardiographers and clinicians, evaluating a stenotic prosthetic aortic valve requires more than simply measuring gradients. Prosthetic valves naturally produce higher velocities than native valves, and distinguishing normal prosthetic hemodynamics from true obstruction can sometimes feel like solving a puzzle. This article reviews the practical echocardiographic approach to evaluating aortic prosthetic valve stenosis in a clear and clinically useful way. --- Understanding Prosthetic Valve Stenosis Prosthetic valve stenosis refers to obst...

The imbalance between tethering and closing forces results in secondary mitral regurgitation. Tug of War Inside the Heart: Understanding Secondary Mitral Regurgitation Secondary mitral regurgitation (SMR), also called functional mitral regurgitation, is not primarily a disease of the mitral valve leaflets themselves. Instead, it occurs due to distortion of left ventricular geometry, leading to an imbalance between tethering and closing forces of the mitral valve. --- What is Secondary Mitral Regurgitation? In secondary MR, the mitral valve leaflets are structurally normal, but the surrounding ventricular apparatus becomes abnormal. The left ventricle dilates or remodels, preventing proper leaflet coaptation during systole, resulting in backward leakage of blood from the left ventricle into the left atrium. Common causes include: Ischemic cardiomyopathy Dilated cardiomyopathy Chronic heart failure Left ventricular remodeling after myocardial infarction --- The Concept of Tethering vs Cl...

  LAP Pressure estimation in Atrial Fibrillation  Left Atrial Pressure (LAP) Estimation in Atrial Fibrillation Introduction Estimating Left Atrial Pressure (LAP) in patients with atrial fibrillation (AF) is challenging because of: Beat-to-beat variability Absence of organized atrial contraction Variable RR intervals Fusion of Doppler signals Despite these limitations, echocardiography remains useful for noninvasive LAP estimation. --- Challenges in AF 1. No A wave on transmitral Doppler 2. Marked respiratory and cycle length variation 3. Variable preload 4. Difficulty averaging measurements 5. Tissue Doppler variability --- General Principles Use averages of 5–10 consecutive beats Prefer beats with similar RR intervals Avoid post-ectopic beats Combine multiple parameters rather than relying on one index --- Echocardiographic Parameters for LAP Estimation 1. Mitral Inflow Doppler E Wave Velocity High E velocity suggests elevated LAP. E >1.0–1.2 m/s may indicate increased fil...

  Spontaneous Coronary Artery Dissection (SCAD) Introduction Spontaneous Coronary Artery Dissection is a non-atherosclerotic, non-traumatic separation of the coronary arterial wall leading to formation of a false lumen or intramural hematoma, resulting in impaired coronary blood flow and acute coronary syndrome (ACS). It is an important cause of myocardial infarction in young and middle-aged women without traditional cardiovascular risk factors.  --- Epidemiology Predominantly affects women (≈85–90%) Common in age 44–53 years Important cause of MI in women <50 years Pregnancy-associated SCAD is well recognized May account for up to 4% of all ACS cases overall and a much higher proportion in younger women  --- Pathophysiology Two proposed mechanisms: 1. Inside-out mechanism An intimal tear allows blood to enter the arterial wall creating a false lumen. 2. Outside-in mechanism Bleeding from vasa vasorum causes intramural hematoma without an intimal tear. The expanding he...