**CASE OF THE MONTH**

Female, mid 20s
Fit & healthy
No CVS risk factors
Only 💊 is COC pill

Experiences central chest pain during sport (exertion), not happened before

Recently has been well, no coryzal or other symptoms

Here is admission ECG First troponin I is 358ng/L (normal <18)
Second troponin I is 409ng/L

Here is chest x-ray, initially thought of as (and subsequently reported as) normal

Another nice example recently of the importance of a systematic approach to assessment of mitral regurgitation during TOE

Indication was known MR, assess suitability for TEER

Mid oesophageal 4Ch & 5Ch views...wondering if we have the right patient! No real MR to see...
The segmentation approach in the bicommisural view is a very reliable and easy-to-do method

Start at the lateral side of the valve with X-plane (Philips) / MultiD (GE) and you have A1-P1 coaptation on the right side...do this with 2D only & then with colour Doppler too

Deep dive on #EARLYTAVR from ##TCT2024

Lots already said & discussed

It takes time to read the paper, read the supplementary appendix, analyse the results, think about them etc!

Some thoughts...🧵 On Sunday I wrote a thread about asymptomatic severe AS and what we knew already from RECOVERY & AVATAR RCTs and what the guidelines currently advocate

Here's the 🧵 in case you missed it

https://x.com/dr_benoy_n_shah/status/1850645694698135554?t=TAVDsW79WuDguZBGOutVBg&s=19

Tomorrow - Oct 28th - we learn the results of 3 landmark randomised studies in patients with aortic stenosis (AS)

Results of EARLY-TAVR, EVOLVED & TAVR UNLOAD will be unveiled at #TCT2024 in a Joint LBCT Session with #NEJM

These could well be practice-changing studies...

A 🧵


#TCT2024
The first 2 RCTS - EARLY TAVR & EVOLVED - concern the management of asymptomatic severe aortic stenosis (ASAS for this 🧵)

Currently, ASAS (with normal LV function) is not a Class I indication for valve intervention in either 🇪🇺 or 🇺🇲 VHD guidelines

*Mitral valve assessment by TTE*

Transthoracic echocardiography (TTE), when performed with care and diligence, can reveal a lot about the valve. TOE isn't necessary in all cases to determine leaflet pathology.

A worked example below: In the PLAX view, you can assess the scallops of the leaflets

In a true PLAX view with aortic valve clearly visible, you mostly see the A2-P2 interface. Here, you can see a clear & large prolapse of the posterior leaflet

Good teaching case for Fellows from a recent emergency scan

Happy heart or unhappy heart?

What can you deduce from these spectral Doppler traces of mitral (left) and tricuspid regurgitation (right)?

#echofirst #cardiotwitter #ACCFIT

Lots of excellent replies. A lot of information to glean from 'just' the CW Doppler traces

The ECG is broad and with a pacing spike just before the QRS complex...so a pacemaker is in situ

MR trace: faint, not severe MR by jet density

But look at the MR Vmax, not even 4m/s!

1/

As we approach the end of 2023, what was the most important paper you read this year?

Mine wasn't in cardiology

I think this went under the radar a little, but it shouldn't have...the impact of private equity (PE) takeovers in healthcare

An end-of-year 🧵

Before going further, we should clarify what PE actually is. Now, I am NOT a financial expert at all, but here goes...!

PE is essentially the investment of capital (equity) into a private (non-public listed) company or business. Read this for more 👇🏽

hbr.org/2007/09/the-st…

Sixty years ago this month - October 1963 - US cardiologist Dr Robert Bruce published a paper detailing his efforts to devise a multi-stage treadmill test

Little did he know this would go on to become the Bruce protocol the most widely used for exercise testing

A thread...

Prior to this, 'stress testing' to evaluate cardiac function was performed using the Masters 2-step technique, first described in 1935. This crude but simple test involved repeated steps up & down over 90 seconds

sciencedirect.com/science/articl…

Thank you Denisa for sharing our Discussion Forum piece recently published in EHJ CVS Img

It's something that I've thought about a lot in recent years, so finally decided to put thoughts down on paper!

A brief 🧵...

https://twitter.com/denisamuraru/status/1701098650946912320

We know now that it is perfectly possible for symptomatic individuals to have abnormal stress tests, with inducible ischaemia, but not have significant epicardial CAD on angiography

So we should stop using epicardial CAD as the arbiter of whether the test is 'right' or 'wrong'

Today – July 5th 2023 – marks exactly 75 years since the National Health Service (NHS) was established in 🇬🇧

Long admired around the 🌍for its free-at-the-point-of-care principle, today the NHS is itself on life support

Let us remind ourselves how the NHS came to be

#NHS

1/ The establishment of the NHS was the culmination of attempts to provide healthcare services to Britain’s citizens for at least a century

The designers of the NHS did not start with a clean slate - the service was a rationalisation of services that already existed

#NHS75

2/

The #NHSWorkforcePlan is a 151 page PDF

I have been through it. Here's what you need to know - a summary & some thoughts

Long 🧵incoming...

1/ It starts off with a foreward from current NHS CEO Amanda Pritchard

A recognition of the challenges the NHS faces & a summary of what they are proposing to do:

Train
Retain
Reform

More on this later in the details...

2/

On the left is a conventional adult transoesophageal echo probe

On the right is a neonatal TOE (TEE) probe

Occasionally, just occasionally, the latter is your friend (for an adult cardiologist/physiologist)...

A brief 🧵 on safe performance of TOE

#ECHOFIRST #cardiotwitter TOE/TEE is actually one of the safer procedures we do, complications are less likely than with:

- Coronary angiography
- Pacemaker insertion
- Ablations
- PCI
- Valve interventions

And that's natural as it's an investigation, not a treatment/therapeutic procedure

#EACVI2023

How to evaluate thick hearts - tips and tricks

#MedTwitter #cardiotwitter #echofirst #ACCFIT #EACVI #EACVI2023

First talk by @bogdan_popescu1 on echocardiography. Key tips:

♡ Be careful measuring LV wall thickness, use PLAX + PSAX to ensure not including RV
♡ Do GLS in all with increased LV wall thickness
♡ Exercise SE can be v helpful, esp if latent LVOTO revealed

So...after time to read things through, a 🧵 on #IRONMAN

Better late then never! 😆

This was a useful exercise personally as iron deficiency (ID) in HF wasn't an area of great knowledge for me, but I've done my homework now!

Here's what I learnt

#cardiotwitter Iron deficiency (ID) is common in HF. It isn't always associated with anaemia. Its aetiology is considered multifactorial:

⬇️ dietary iron intake
⬇️ dietary iron absorption
⬆️ GI tract iron loss
Impaired iron handling / redistribution

#ESCCongress

Let's get straight to the point about #INVICTUS

The only people not surprised by the results are imagers that do TOEs (TEEs) on these patients! No way VKA was going to lose to NOACs here!😂

A 🧵...

#medtwitter #cardiotwitter #echofirst #epeeps #ESCCongress
Patients with rheumatic MV disease typically have very different atrial appearances on TOE. No matter how well anticoagulated, there is very often spontaneous echo contrast in the LA

These atria are just different...why?

Who is this?

#ESCCongress
A bit of a deep dive on #REVIVED - not ocean floor deep, but just a little more than below the surface!

A lot has already been discussed today, so I'll try not to be too repetitive #ESCCongress
This was NOT a trial of revasc in highly symptomatic patients or ACS patients. It was designed to answer the Q of whether PCI is beneficial in ischaemic myocardial dysfunction / ischaemic cardiomyopathy

*POSTERIORLY DIRECTED MITRAL REGURGITATION*

How many causes of posterior MR do you know?

Let's take a look in this mini 🧵

But...no cheating...vote first!

#echofirst #cardiotwitter #MedTwitter @ASE360 @BSEcho @TheBJCA @BJCA_Women_LTFT @global_wic @WessexSpRs 1. Anterior MV prolapse

Probably the first thing that occurs to most people

AMVL prolapse is less common than PMVL prolapse

Electronic patient records (EPR) - I've seen some negative tweets recently about how cumbersome they can be...but EPR is here to stay so it's important to get them right

I'm fortunate to work somewhere with the most amazing EPR set-up...check it out!

A brief 🧵... Our hospital's IT team have built 1 program from which we get all these options:

E-documents (clinic letters, memos etc)
Blood results
X-rays / scans
Drug chart
Request tests (bloods, imaging, micro, everything)
Link to primary care records
Observations (for in-patients)

**VALVE CASE OF THE MONTH**
@BrHeartValveSoc

Last case of 2021!

If EVER you needed an example of why not to judge a 3-dimensional structure with 2-dimensional imaging...this it it!

I think you'll like this one...😁

#echofirst #cardiotwitter #MedTwitter Male, late 60s, underwent biological MVR (29mm) 11 yrs previously for
Severe MR. Has permanent AF & VVIR pacemaker

Admitted to local hospital with breathlessness

This is admission chest x-ray

The #NHS and GMC expect doctors to speak up whenever they have concerns regarding patient safety...

Yet 'whistleblowers' (WB) continue to be treated abysmally, almost as if they're the problem - see latest example here

A brief 🧵...

bbc.co.uk/news/uk-englan… Probably the most famous WB is Stephen Bolsin, the cardiac anaesthetist that was highly concerned by very high mortality rates in paediatric ❤ surgery in Bristol in late 1980s / early 1990s

He had to leave his job & could not find another job in 🇬🇧

en.wikipedia.org/wiki/Stephen_B…

Well, #EACTS2021 may be over...but I'm not done! 😆

One of the most important sessions was on Women In Cardiothoracic Surgery

I suppose I should clarify - not writing a 🧵on this for likes or 'virtue signalling' - my wife's journey through her training gave me some insights... #EACTS2021
Opening talk on why @EACTS needs a womne's committee from @JolandaKluin - this was a great talk to set the tone for the session