Dr. Usman's Cardiology Notes

VT vs SVT with Aberrancy – ECG Criteria for Accurate Diagnosis Wide complex tachycardia (WCT) is VT unless proven otherwise. Correct differentiation between ventricular tachycardia (VT) and supraventricular tachycardia (SVT) with aberrancy is critical because management differs significantly and misdiagnosis can be dangerous. --- 1. Basic Definitions Ventricular Tachycardia (VT) A tachycardia originating below the His bundle (ventricular myocardium or Purkinje system), usually with wide QRS ≥ 120 ms. SVT with Aberrancy A supraventricular rhythm conducted through abnormal ventricular conduction (e.g., bundle branch block or accessory pathway), producing a wide QRS. --- 2. Why It Matters Treating VT as SVT (e.g., giving AV nodal blockers in unstable VT) can cause hemodynamic collapse. Treating SVT as VT is generally safer (e.g., amiodarone). In structural heart disease, ischemic heart disease, or prior MI → assume VT. --- Stepwise ECG Approach to Wide Complex Tachycardia --- Step 1: Clin...

  Classification of Left Atrial (LA) Thrombus Left atrial thrombus is a clinically significant finding, most commonly associated with atrial fibrillation, rheumatic mitral valve disease, and severe left ventricular dysfunction. Proper classification helps guide anticoagulation, cardioversion planning, and interventional strategy. --- 1. Classification Based on Location A. Left Atrial Appendage (LAA) Thrombus Most common site (>90% in non-valvular AF) Best visualized on TEE Often associated with: Atrial fibrillation Low LAA emptying velocity (<20 cm/s) Spontaneous echo contrast (“smoke”) Clinical significance: Contraindication to cardioversion and catheter ablation until resolved. --- B. Left Atrial Body Thrombus Seen in: Rheumatic mitral stenosis Severely dilated LA May be mural or mobile Higher embolic risk if pedunculated or mobile More common in valvular AF compared to non-valvular AF. --- 2. Classification Based on Mobility 1. Mural (Non-mobile) Thrombus Attached along LA...

  Watch the above video for ECG example explained. Premature Ventricular Complexes (PVCs) Arising from the Inferoapical Left Ventricle Premature ventricular complexes (PVCs) originating from the inferoapical left ventricle (LV) represent a less common subset of idiopathic ventricular ectopy. Unlike the more frequent right ventricular outflow tract (RVOT) PVCs, inferoapical LV PVCs arise from the distal inferior wall or apical segments of the LV and have distinct electrocardiographic and mapping characteristics. Recognition of their ECG pattern is essential for: Accurate localization Differentiation from fascicular or papillary muscle PVCs Planning catheter ablation --- Anatomical Substrate The inferoapical LV corresponds to: Distal inferior wall True apex (inferior portion) Region supplied mainly by the posterior descending artery (RCA or LCx depending on dominance) Potential arrhythmogenic substrates: Idiopathic focal automaticity Triggered activity Small areas of fibrosis (post-m...

M-Mode Echocardiography: Normal Values and Key Diagnostic Findings What is M-Mode in Echocardiography? M-Mode (Motion mode) is a one-dimensional echocardiographic technique that records the motion of cardiac structures along a single ultrasound line over time. It provides: Excellent temporal resolution Precise linear measurements Accurate assessment of valve motion LV dimension and wall thickness quantification Although 2D and Doppler imaging are routine, M-mode remains essential for standard chamber measurements and subtle motion abnormalities. --- Standard M-Mode Views 1. Parasternal Long Axis (PLAX) – LV Measurements Cursor placed perpendicular to LV long axis at the level of mitral leaflet tips. Measurements Taken: IVSd (Interventricular septal thickness in diastole) LVIDd (LV internal diameter in diastole) LVIDs (LV internal diameter in systole) LVPWd (Posterior wall thickness in diastole) --- Normal Adult LV M-Mode Values (ASE-Based) LV Dimensions LVIDd Men: 4.2 – 5.8 cm Women: 3...

Rheumatic Heart Disease (RHD) on Echocardiography (Guideline-oriented, practical approach) 1. Mitral Valve – Most Commonly Involved Morphologic Features (Highly Suggestive of Rheumatic Etiology) • Leaflet thickening (≥3 mm at leaflet tip in diastole) • Anterior leaflet doming (“hockey-stick” appearance) • Commissural fusion • Subvalvular thickening and chordal shortening • Restricted posterior leaflet motion Mitral Stenosis (Rheumatic Pattern) • Planimetry: Reduced MVA • Mean gradient elevated • Pressure half time prolonged • Funnel-shaped valve in diastole Rheumatic Mitral Regurgitation • Eccentric MR jet • Leaflet restriction rather than prolapse • Thickened tips with preserved base (early disease) --- 2. Aortic Valve Involvement Typical Features • Cusp thickening • Commissural fusion • Restricted cusp motion • Central AR jet (coaptation defect) Rheumatic AR often coexists with rheumatic MS. --- 3. Multivalvular Disease Pattern (Clue to RHD) • Mitral + Aortic involvement common • Tri...

Rheumatic Mitral Stenosis – Key Echocardiographic Assessment Points 1) Morphologic Features (2D Echo – Parasternal & Apical Views) • Thickened mitral leaflets (especially leaflet tips) • Diastolic doming of anterior leaflet (“hockey stick” appearance) • Commissural fusion (best seen in parasternal short axis) • Reduced leaflet mobility • Subvalvular involvement: chordal thickening, fusion, shortening • Calcification (late disease) Rheumatic MS typically shows leaflet tip restriction with relatively preserved basal leaflet mobility (early disease). --- 2) Mitral Valve Area (MVA) – Severity Assessment • Planimetry (PSAX at leaflet tips in mid-diastole) – Gold standard if image quality good • Pressure Half-Time (PHT method): MVA = 220 / PHT • Continuity equation (if significant MR absent) Severity grading: • Mild: MVA > 1.5 cm² • Moderate: 1.0–1.5 cm² • Severe: < 1.0 cm² • Very severe: ≤ 0.8 cm² Always prefer planimetry when feasible. --- 3) Transmitral Doppler Assessment • Mean...

Mitral Inflow E/A Ratio by Pulsed Wave Doppler A Practical, Guideline-Based Approach --- 1. Introduction Mitral inflow assessment using pulsed wave (PW) Doppler is a fundamental component of diastolic function evaluation. The E/A ratio reflects the relationship between early passive LV filling (E wave) and late filling due to atrial contraction (A wave). It is simple to measure but frequently misinterpreted if age, heart rate, and complementary parameters are not considered. Guidelines reference: ASE/EACVI Recommendations for the Evaluation of LV Diastolic Function (2016 update). --- 2. Physiology Behind E and A Waves During diastole: • Early rapid filling → E wave • Diastasis → minimal flow • Atrial contraction → A wave Normal physiology: Young adults: E > A (E/A > 1) With aging: relaxation slows → E decreases, A increases --- 3. Correct Method of Measuring E/A Ratio A. Image Acquisition View: Apical 4-chamber Doppler type: Pulsed Wave (PW) Sample volume size: 1–3 mm B. Correct ...