🧵What does the left atrial appendage do? Is it just a nidus for thrombus?

A brief review of proposed & proven functions of the LAA👇

#CardioTwitter #EPeeps #MedEd
@drpaulfriedman @ChetRihal #1 LAA plays a very important capacitance role.

Animal studies in 1990s showed:

- LAA is more compliant than LA
- LAA acts like a decompression chamber during systole
- The capacitance/reservoir role is key when LAP is elevated
- Eliminating LAA acutely ⬆️ LA pressure in dogs

Residents/fellows often ask if ✍️ a review paper is worthwhile.

👇a short🧵with pros/cons/tips on writing review articles.

#MedTwitter #AcademicChatter #MedStudentTwitter #MedEd Is ✍️ a review a good idea?

Short answer: yes

Pros:
1. No resources/funding required
2. Gain in-depth knowledge in a specific area
3. SOA reviews are highly cited
4. Excellent venue to hone✍️skills

Cons:
1. Time consuming
2. Not a substitute 4 original🔬
3. Unpredictable fate

🧵Many IMGs seek temporary research🔬opportunities in the US every year. The process can be long, frustrating & unpredictable.

🙋🏻‍♂️I have experienced it both ways.
👇 a few tips that might be helpful: 1. Have a clear objective.

What do wish to get out of such an opportunity?

A LOR? couple📝 to help u match? Advanced🔬skills to establish an academic career?

Objectives evolve over time..

However! people who reflected at the outset & came w clear goals are more successful.

All you need to know about residual peri-device leaks (PDLs) after LAA occlusion in this 🧵

💢How frequent?
💢Do they matter?
💢What’s their mechanism?
💢Best way to manage?

#CardioTwitter #MedEd #EPeeps How frequent? It depends on how you define PDL!

📌 In PROTECT AF, any PDL at 45d was 41% but ⬇️ to 32% at 1yr (2/3 of leaks ≥3mm)

📌 In Amulet IDE, any PDL at 45d was 51% w Watchman & 36% w Amulet

📌 In PINNACLE FLX, any PDL w Watchman FLX was 17% at 45d & ⬇️ to 10.5% at 1yr

🧵Step-by-Step ICE-guided MitraClip

1/8 Transseptal puncture

📌3D ICE allows biplane imaging - ⬆️ TSP precision

📌ICE>TEE in presence of septal occluders (visualize infer-pos FO)

📌 Measuring TSP-MV height is feasible w a modest learning curve

#CardioTwitter #MedEd 2/8 Baseline Assessment of MR

📌 After dilating the septum, cross with ICE to LAA —> insert the CDS

📌 Biplane imaging here displays two views identical to the LVOT/commissural views on TEE

AV Rails are useful in complex paravalvular leak closure, but not commonly discussed in the literature

This short🧵sheds some light on AV rails & their attributes.

#CardioTwitter #MedEd 💢When should I I use a rail?

📌 Simple leaks don’t require a rail

📌 Rail upfront in serpiginous/Ca++ leaks. I use it in 1/3 of cases. When in doubt, use a rail!

📌 Rails are also great opportunity to ‘electively’ master snaring 😉

But sometimes rails can be challenging👇

🧵TV surgery

1/5 What to do with ‘moderate’ TR during mitral surgery?

🤔Rational to fix: Already there & TR may not get better

🧐Rational not to fix: TR may get better, ⬆️ CPB time, ⬆️ pacer risk, may end up w valve replacement

A new RCT tried to help us. What did it show?👇 2/5

Previously, no RCT data existed ➡️ variable TV repair rate (5-75%)

💢401 DMR pts ➡️ MV surgery (>85% repair) vs MV surgery+TV ring

💢To qualify, pts needed moderate TR or TV annulus >4cm

💢1 endpoint: reoperation for TR, TR progression by 2 grades or to severe, or death

A med student asked: why do we need epicardial coronary arteries? Can’t the ❤️ utilize the abundant oxygenated blood within it? We then talked about transmyocardial revasc (TMR), which apparently has resurfaced some recently. Thought I’ll summarize my read on it in this thread 👇 1. TMR theory is based on reptilian circulation. Reptiles are devoid of epicardial arteries & hence rely on intramyocardial sinusoids for tissue oxygenation.
2. 1st TMR attempt (sort of) was by Claude Beck in 1935. Beck noted that external myocardial injury > new vessel formation