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Hello, Card, and welcome. Welcome. Welcome. We are

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in Rochester visiting University of Rochester Medical Center

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and super stoked to be talking to Doctor

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La, Doctor Sin O, Doctor Neil Gupta, and

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we're gonna be talking about such an important

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topic in cardiology. But before we start, team,

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why don't we introduce ourselves. Go ahead. Hi

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everyone. I'm La. I'm a Pg 4 first

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year general cardiology fellow here at the University

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of Rochester.

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I grew up in the a great state

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of New Jersey in stayed there at Rutgers,

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Robert Wood Johnson for Medical School. I then

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completed my controlled Medicine residency at Dartmouth Hitchcock

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Medical Center. Now I'm super excited to be

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here at the University of Rochester completing my

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general cardiology fellowship. I'm interested in general and

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interventional cardiology, and in my spare time I

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enjoy running and cycling and I recently picked

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up my guitar again after in long hiatus.

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My name is Dion. And I'm the Chief

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cardiology fellow here at the University of Rochester.

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I actually grew up open Rochester and didn't

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go too far for medical school at the

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Jacobs School of Medicine at the University of

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Buffalo. I did my residency in internal medicine

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here at the university a Rochester, and I

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stayed for fellowship. I'm interested in general cardiology

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and echo. I'm happy to say that I'm

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staying here as faculty for the next academic

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year. In my time I enjoy exercising, cooking,

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and hanging out with my family and friends.

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Hi, everyone. My name Sin, I a third

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year General cardiology fellow here at the University

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overseer of Rochester.

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I grew up in Toronto and went to

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Med school at van University,

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added my residency and internal medicine at Up

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pm Pittsburgh. I will be sticking around with

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the U of r for cardiology fellows hit

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later this year, and this is also where

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I was supposed to give a shout out

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until the Cath out versus here below this

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podcast, Dana and name.

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In my spare time, I elected Cook and

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listened to podcast, hope opioid more of the

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true prime flavor than the medical kind.

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Guys, That's awesome. Thank you and congratulations to

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all the transitions that you guys are gonna

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be having in your career right now. Super

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exciting times and love the shout out. So

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now let's get dirty and talk about some

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cardiology, But before we do that, can you

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take us to 1 of your favorite places

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in the city? So we can settle down

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and get ready to learn.

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Well, absolutely. Well, seeing that it's almost the

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summer, I think we should spend a nice

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day out in the sun's sailing and pedal

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boarding on Lake Ontario, followed by grabbing some

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drinks and dinner by the waterfront.

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Alright. Terrific. I've got my sunscreen ladder up.

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And ready to go. So why don't we

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dive into your case?

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So we have a 63 year old man

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with a past medical history of tension hyper,

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and active tobacco use who presented overnight to

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our emergency department, but a chic complaint of

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sun onset schultz breath. The patient say that

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he was in his usual state of health

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when he suddenly felt short of breath earlier

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this afternoon. He denied any chest pain or

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pressure in hours to days prior to of

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shortness of breath. But did notice some mild

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chest pain described as mitt stern, non radiating

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and non exert

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that get shortly upped he'd be down feeling

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disconnect. This history, Dad is always nov for

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or would you take... I'm unloaded paint 5

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milligrams

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and hydro like 25 milligrams, hyper

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for which she takes a to 20 milligrams

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and ge for which she takes Ol

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20 milligrams. He has never had any surgeries

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as no allergies and no family history, of

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coronary artery disease or sun cardiac.

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Harmful charlie late, she does still smoked tobacco

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but denies any other recreational substance abuse. What

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would be your differential for some shortness of.

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The differential for shortness of breath is quite

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broad as you can imagine. I like to

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distinguish however between a acute versus chronic causes

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of shortness of breath. Fortunately, the differential for

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acute shortness of breath is a bit more

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narrow, and I like to break these down

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into 2 buckets. Cardiac and pulmonary.

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The big cardiac causes of sudden onset shortness

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of breath include acute, coronary syndrome, heart failure,

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and peri t.

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Meanwhile, pulmonary causes of acute onset shortness of

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breath include. Of course, pulmonary embolism as well

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as pneumothorax,

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Bro bass such as from Copd or asthma

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and pneumonia.

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Now, based on the patient's initial presentation, What

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do you think the likelihood of a q

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coronary syndrome miss? That's a great question, Neil.

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I actually think a pulmonary embolism would be

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higher on my differential just based on the

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very limited information we have so far. A

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acute coronary syndrome is certainly possible, but the

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presentation of sudden onset shortness of breath. Followed

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by somewhat mild chest pressures would be more

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atypical of Ac acs. But now that we've

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gone over his initial presentation, Let's refine our

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differential diagnosis a little more. Sin, can you

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tell us about the patient's vitals, physical exam,

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and labs?

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Sure. The patient has tachycardia at 01:30 beats

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per minute with a blood pressure of 01:26

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over 76.

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He is a feb 95.9

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fahrenheit.

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His respiratory rate is 20, but he's already

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a non breather mask with a flow rate

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of 15 liter per minute and a hundred

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percent oxygen. Sat 98 percent on this. He

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later had to be placed on bi.

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His exam shows a patient moderate distress without

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nr rem mask on. And diffuse crackle.

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His cardiac exam is limited by significant tachycardia

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with no obvious memory appreciated. He has no

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fetal edema and is warm.

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Gi exams in soft non tender non abdomen,

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and he has no focal findings on neurologic

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examination. His D is fairly un remarkable aside

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Cr Hong 0.1, which is at his baseline,

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and his Cv is most notable for a

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White Count of 13. His proponents are elevated

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on dynamic at 5 70 to 08:01

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nano per liter.

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At our, 14 or stop thinking the bad.

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An Nt prob B p is 09:48 kilograms

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per ml, which is mildly elevated for our

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assay

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with 900 being the upper limit normal here.

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D dime is Elevated 2.2.

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Ab g on Nr shows ph 7.33,

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Pc o 2 of 38,

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Po 2 of 82,

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of 19,

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and an arterial lac of 2.2.

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Upper normal b 0.8 mel per liter here.

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La fawn, can you describe the patient's initial

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chest x ray and Ekg?

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Sure, Sin. So this chest x expert is

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a frontal projection, and immediately we can see

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diffuse bilateral

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interstitial and aerospace capacities.

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While there's also

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civilization of the pulmonary veins, we do not

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see enlargement of the cardiac silhouette.

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Overall, this chest x clearly points to sense

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of pulmonary edema. Now to go over the

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patient's Ekg.

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We can see the patient is in sinus

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tachycardia at about a rate of 130 beats

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per minute. There are T wave inversion in

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lead 3 and Av f, as well as

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about 0.5

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to 1 millimeter S elevations in leaf 3.

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And about 0.5 millimeter s elevation in the

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lead Ad.

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We can also see a deep qa win

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lead 3, but it should be noted that

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this can be a normal variant.

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So certainly, we're worried about ischemia given this

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dj, though it does not quite meet the

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stem criteria.

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Now, Sin enough, how do these initial labs

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and diagnostics change your differential diagnosis and what

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would be immediate next steps.

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The chest x ran B along with his

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d

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or suggestive of congestive heart failure ideology of

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his shortness breath. Although it's interesting that he

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has no edema on exam,

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which starts making us think about maybe an

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acute el dysfunction process or left sided val

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issue us the ideology.

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The highly elevated dynamic conan raise a question

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of an Mi as 1 possible cause. All

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of the Ecg not fully consist with stem

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as La pointed it out. Flash pulmonary edema

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from hypertensive crisis can present similarly.

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Although he's not hypertensive at this time. Pulmonary

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embolism can't be begin considered as well given

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the elevate d dime, but the level of

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triple troponin elevation is a bit atypical for

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those, and the level of

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can be explained by the pulmonary edema

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without invoking Pe.

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The elevated latitude suggest hypo perfusion, which any

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of these can lead to. In a case

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like this where we up to separate information

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and a presentation that is outside typical norms

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or 1 pathology, a point of care ultrasound

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can be helpful.

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My threshold threshold for obtaining a Ct protocol

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is also low these situations, which is what

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the val team ended up doing.

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Neil, can tell us will be saw in

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Ct.

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Our Ct,

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chest did not show any evidence of pulmonary

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embolism or aortic dissection. Is there anything else

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you can do at bedside to help hone

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your differential file? I think at this point,

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we should get a point of care ultrasound

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or focus on this patient as we worried

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about d heart failure. This was done which

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showed quite dramatically a hyper

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L.

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That's a great idea with the focus of

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fan Good job. Obviously, as this modality becomes

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more available and with handheld machines becoming more

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advanced, We should really be incorporating this into

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our daily practice. Do these findings help narrow

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your differential fund?

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Oh, absolutely, and that's a great point you

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make meal As bedside Focus is incorporated more

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and more and medical training, we all should

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try to do at least a quick focus

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on most of the patients with see in

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cardiology.

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When we see a piper dynamic L in

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combination with evidence of ischemia on Ecg,

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an el opponents

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Our concern now is an acute myocardial infarction

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resulting in possible mechanical

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complication.

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This is an amazing conversation, and I definitely

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wanna just jump in and add to this

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idea of Poke is that Poke is such

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a valuable tool in this particular scenario where

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you really wanna find out what's going on

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under the hood And I think when you're

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using point of care ultrasound or any echo

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in general, you wanna have 2 kind of

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philosophies. 1 is to be systematic and approach

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a cardiac exam in a way that's thorough

266
00:10:30,500 --> 00:10:32,813
and the same every time, and that will

267
00:10:32,813 --> 00:10:34,807
allow you to capture all of the images

268
00:10:34,807 --> 00:10:36,322
that you think are going to be helpful

269
00:10:36,322 --> 00:10:39,615
for most patients. And not miss something by

270
00:10:39,615 --> 00:10:41,934
jumping around in the exam and anchoring on

271
00:10:41,934 --> 00:10:44,014
a particular diagnosis. But at the same time,

272
00:10:44,575 --> 00:10:46,587
before you approach the patient focus, you should

273
00:10:46,587 --> 00:10:48,263
ask yourself, well, what do I expect to

274
00:10:48,263 --> 00:10:51,055
see from this patient's clinical presentation? Like, what

275
00:10:51,055 --> 00:10:52,571
am I gonna be saying? So I have

276
00:10:52,571 --> 00:10:54,900
a patient here who is not doing well,

277
00:10:55,060 --> 00:10:57,134
they're in frank pulmonary edema, I may expect

278
00:10:57,134 --> 00:10:59,608
to see really reduce left ventricular function. And

279
00:10:59,608 --> 00:11:01,218
when you put that echo probe on them,

280
00:11:01,378 --> 00:11:03,292
and you see this hyper dynamic function as

281
00:11:03,292 --> 00:11:05,685
you guys described. Right? That is telling you

282
00:11:05,685 --> 00:11:07,838
a very important piece of information. You're saying

283
00:11:07,838 --> 00:11:10,764
this hyper contract left ventricle does not match

284
00:11:11,044 --> 00:11:14,154
this patient's overall clinical presentation, something something is

285
00:11:14,154 --> 00:11:15,908
going on here. And I may not have

286
00:11:15,908 --> 00:11:17,743
captured all of the heart yet on the

287
00:11:17,743 --> 00:11:21,184
echo imaging, but I'm now suspicious that while

288
00:11:21,184 --> 00:11:23,433
the left ventricle is showing us an elevated

289
00:11:23,649 --> 00:11:25,954
ejection fraction, much of that blood may be

290
00:11:25,954 --> 00:11:27,545
going backwards. In fact, we know where it's

291
00:11:27,545 --> 00:11:29,532
going. It's going back to the lungs resulting

292
00:11:29,532 --> 00:11:32,908
in this crazy presentation of pulmonary edema, and

293
00:11:32,964 --> 00:11:35,825
contributing to the patient's, primary symptoms, which is

294
00:11:35,825 --> 00:11:36,325
respiratory

295
00:11:36,699 --> 00:11:38,547
complaint and everything is starting to make sense.

296
00:11:38,706 --> 00:11:40,063
And so I love that you now pivot

297
00:11:40,063 --> 00:11:42,878
it to say, well, is there a mechanical

298
00:11:43,176 --> 00:11:45,092
complication going on here, such that we are

299
00:11:45,092 --> 00:11:45,650
not having

300
00:11:46,224 --> 00:11:48,937
adequate forward flow out of the L t

301
00:11:48,937 --> 00:11:50,454
out of the aortic valve into the order

302
00:11:50,454 --> 00:11:53,667
per perfusion the body, but rather going backwards

303
00:11:53,805 --> 00:11:55,970
perhaps and this may lead us to the

304
00:11:55,970 --> 00:11:57,880
diagnosis for this particular patient. So I just

305
00:11:57,880 --> 00:12:00,028
love how you were able to recognize what

306
00:12:00,028 --> 00:12:02,097
you were seeing on focus and pivot to

307
00:12:02,097 --> 00:12:04,100
further the care of this patient 1 last

308
00:12:04,100 --> 00:12:06,403
point about focuses is sometimes in the moment,

309
00:12:06,562 --> 00:12:08,310
we are not able to capture everything because

310
00:12:08,310 --> 00:12:09,739
we have to tend to the patient's clinical

311
00:12:09,739 --> 00:12:12,614
needs. They're hem compromised But sometimes when the

312
00:12:12,614 --> 00:12:14,363
dust settles, we can get in a formal

313
00:12:14,363 --> 00:12:16,032
echo, and that kinda will fill in the

314
00:12:16,032 --> 00:12:18,337
pieces and the gaps and help us recognize

315
00:12:18,337 --> 00:12:19,847
what is going on with the patient and

316
00:12:19,847 --> 00:12:21,535
the guy next step. So Did you end

317
00:12:21,535 --> 00:12:23,375
up getting a formal echo after this point

318
00:12:23,375 --> 00:12:24,894
of care ultrasound? Yeah.

319
00:12:25,535 --> 00:12:27,855
Absolutely. Thank you for asking. And what I

320
00:12:27,855 --> 00:12:29,948
would say is what we first notice there's

321
00:12:29,948 --> 00:12:30,607
a hyper

322
00:12:31,698 --> 00:12:34,347
of 80 percent, kinda like what La

323
00:12:34,802 --> 00:12:36,019
notice on his focus

324
00:12:36,394 --> 00:12:38,861
with a Pd distribution wall motion have morality.

325
00:12:39,433 --> 00:12:41,899
There was normal Rv, size and function with

326
00:12:41,899 --> 00:12:44,843
an estimated mildly elevated Rbc systolic pressure of

327
00:12:44,843 --> 00:12:46,116
40 millimeters of mercury.

328
00:12:46,609 --> 00:12:49,346
There was noticeable pap muscle rupture

329
00:12:49,725 --> 00:12:52,622
with a fl anterior much leaflet with posterior

330
00:12:52,841 --> 00:12:55,893
directed much of regurgitation. The reg tent volume

331
00:12:55,893 --> 00:12:57,411
was 77.5

332
00:12:57,411 --> 00:12:57,911
milliliters,

333
00:12:58,530 --> 00:13:01,007
with a reg fraction of 64

334
00:13:01,007 --> 00:13:02,705
percent. Based off of an L

335
00:13:03,098 --> 00:13:04,847
and diastolic solid volume of a hundred and

336
00:13:04,847 --> 00:13:05,585
60 milliliters

337
00:13:06,039 --> 00:13:08,740
and an L and systolic volume of 39

338
00:13:08,740 --> 00:13:09,217
millimeters.

339
00:13:09,694 --> 00:13:11,601
Wow, a fl wet valve leaflet.

340
00:13:12,094 --> 00:13:13,368
What a dramatic presentation?

341
00:13:14,084 --> 00:13:16,155
It's important to remember that due to the

342
00:13:16,155 --> 00:13:16,655
rapid

343
00:13:17,190 --> 00:13:18,168
equalization of pressures

344
00:13:18,544 --> 00:13:20,216
between the L and L.

345
00:13:20,869 --> 00:13:23,423
Approximately 50 percent of patients with moderate to

346
00:13:23,423 --> 00:13:24,322
severe acute

347
00:13:25,099 --> 00:13:28,553
regurgitation have no audible murmur. Also, while mechanical

348
00:13:28,771 --> 00:13:31,733
complications such as pap muscle rupture typically occur

349
00:13:31,733 --> 00:13:32,291
in stem.

350
00:13:32,848 --> 00:13:35,873
These complications can also occur, albeit much less

351
00:13:35,873 --> 00:13:37,306
commonly in end semi.

352
00:13:37,958 --> 00:13:40,262
Now, Sin, our patients of blood pressure starting

353
00:13:40,262 --> 00:13:42,249
to fall too. What do you think should

354
00:13:42,249 --> 00:13:43,759
be the immediate next step here.

355
00:13:44,554 --> 00:13:47,112
The drop in mean arterial pressure reflects poor

356
00:13:47,112 --> 00:13:48,727
forward flow given a severe

357
00:13:49,262 --> 00:13:49,501
regurgitation.

358
00:13:50,774 --> 00:13:52,946
Reduction is your friend here, but the hypo

359
00:13:53,004 --> 00:13:54,516
is going to limit medical therapy.

360
00:13:55,169 --> 00:13:57,427
As such, this patient needs mechanical circulatory

361
00:13:57,806 --> 00:14:00,442
support with balloon of being to her modality

362
00:14:00,442 --> 00:14:02,380
for many patients given the simultaneous

363
00:14:03,572 --> 00:14:06,204
reduction and improved cardiac perfusion that this device

364
00:14:06,204 --> 00:14:08,038
provides. Given that this is likely caused by

365
00:14:08,038 --> 00:14:10,351
an Mi the patients should also have coronary

366
00:14:10,351 --> 00:14:12,998
and geography have right for catheter characterization. To

367
00:14:12,998 --> 00:14:15,789
guide next steps. The cardiac surgery team should

368
00:14:15,789 --> 00:14:17,942
also be contacted sooner rather than later so

369
00:14:17,942 --> 00:14:20,255
the patient can be evaluated for valve for

370
00:14:20,255 --> 00:14:21,610
hair slash replacement.

371
00:14:22,024 --> 00:14:24,893
And that's exactly what happened next. S, can

372
00:14:24,893 --> 00:14:26,805
you describe for us what was seen on

373
00:14:26,805 --> 00:14:29,138
cardiac catheter authorization, definitely.

374
00:14:29,689 --> 00:14:33,119
So for initial stabilization, the Icu, the patient

375
00:14:33,119 --> 00:14:34,953
had a balloon called place at that bedside

376
00:14:34,953 --> 00:14:37,266
via the right frontal artery. He was then

377
00:14:37,266 --> 00:14:39,913
sent down emergency to the cath lab. White

378
00:14:39,913 --> 00:14:43,022
court capitalization there showed Cd of 9,

379
00:14:43,660 --> 00:14:45,754
K pressure of 55 over 19

380
00:14:46,211 --> 00:14:47,805
and wedge pressure of 17.

381
00:14:48,218 --> 00:14:50,443
With the cardiac index of 1.4.

382
00:14:51,158 --> 00:14:53,462
This was worth 1 1 balloon web support.

383
00:14:53,859 --> 00:14:56,028
When the balloon pump was turned off temporarily

384
00:14:56,322 --> 00:14:59,205
the white tracing showed large b waves to

385
00:14:59,205 --> 00:15:00,024
40 millimeter

386
00:15:00,560 --> 00:15:01,277
of mercury,

387
00:15:01,835 --> 00:15:05,196
which again confer severe mitral regurgitation. Given that

388
00:15:05,196 --> 00:15:08,140
the low Cardiac index, despite Iv p support

389
00:15:08,140 --> 00:15:11,164
suggested that the Iv support was insufficient, the

390
00:15:11,164 --> 00:15:13,631
patient was upgraded to imp Cp.

391
00:15:14,284 --> 00:15:17,081
With subsequent juvenile cardiac index to 2.2.

392
00:15:17,800 --> 00:15:19,478
Now that the patient was more stable,

393
00:15:20,037 --> 00:15:22,375
we proceeded with coronary and geography.

394
00:15:22,849 --> 00:15:24,681
We start out with views of the right

395
00:15:24,681 --> 00:15:25,478
coronary artery.

396
00:15:26,036 --> 00:15:28,347
There's an all plaque in the mid Rca,

397
00:15:28,666 --> 00:15:29,941
which is not flow limiting.

398
00:15:30,673 --> 00:15:34,342
It's about 60 percent stenosis severity. The patient

399
00:15:34,342 --> 00:15:36,974
has a right dominant system. The left main

400
00:15:36,974 --> 00:15:39,925
and left ci look pigment without obvious disease.

401
00:15:40,498 --> 00:15:41,933
The mid Led, however,

402
00:15:42,491 --> 00:15:44,802
has a very tight tubular lesion right after

403
00:15:44,802 --> 00:15:47,114
to take off the first eye will Timmy

404
00:15:47,114 --> 00:15:49,840
1 flow beyond it. Best shield in the

405
00:15:49,919 --> 00:15:53,189
A cra view. We also see faint left

406
00:15:53,189 --> 00:15:54,066
to red lateral.

407
00:15:54,704 --> 00:15:57,118
So there might be a distal or obstruction

408
00:15:57,336 --> 00:15:57,789
that will not

409
00:15:58,549 --> 00:16:00,949
appreciate an year. The patient with then taken

410
00:16:00,949 --> 00:16:01,929
for a t

411
00:16:02,389 --> 00:16:04,070
meal. Can you describe what we saw?

412
00:16:04,789 --> 00:16:05,269
Of course,

413
00:16:05,843 --> 00:16:08,067
Rt T was performed at bedside in the

414
00:16:08,147 --> 00:16:08,647
Cbs.

415
00:16:09,418 --> 00:16:11,722
The L function was normal with basal to

416
00:16:11,722 --> 00:16:13,469
mid infer wall motion at in.

417
00:16:14,279 --> 00:16:17,377
The posterior media pap muscle was rupture served

418
00:16:17,377 --> 00:16:19,522
with small segments of the 8 pure muscle

419
00:16:19,522 --> 00:16:21,849
leaflet float of the 828

420
00:16:21,905 --> 00:16:22,405
sc

421
00:16:22,953 --> 00:16:24,648
leading to mitral valve non.

422
00:16:25,264 --> 00:16:28,154
There was severe, posterior directed mitral

423
00:16:28,530 --> 00:16:31,478
regurgitation with systolic flu reversal seen in the

424
00:16:31,478 --> 00:16:34,527
pulmonary vein. The V contracted looked on the

425
00:16:34,527 --> 00:16:37,185
color doppler measured at about 1.1 centimeters.

426
00:16:37,644 --> 00:16:41,000
The imp was positioned approximately 3.2 centimeters from

427
00:16:41,000 --> 00:16:42,773
the aortic valve and as well.

428
00:16:43,572 --> 00:16:46,209
Neil, now that we have visualize our flow

429
00:16:46,209 --> 00:16:48,067
mitral on both tint

430
00:16:48,526 --> 00:16:49,346
and tu.

431
00:16:49,979 --> 00:16:51,574
Can you describe for us what are the

432
00:16:51,574 --> 00:16:52,074
echo

433
00:16:52,771 --> 00:16:55,961
parameters of acute bi of regurgitation? Great question,

434
00:16:56,838 --> 00:16:58,832
there's actually a lockdown down pack air, so

435
00:16:58,832 --> 00:16:59,630
please bear with me.

436
00:17:00,360 --> 00:17:02,685
Typically, patients with acute severe mitral

437
00:17:03,058 --> 00:17:06,232
regurgitation are really really sick. So proper recognition

438
00:17:06,232 --> 00:17:08,002
and diagnosis is absolutely.

439
00:17:08,629 --> 00:17:10,942
Echo parameters used to diagnose a Qm mr,

440
00:17:11,261 --> 00:17:13,494
opposed chronic Mr are actually pretty similar.

441
00:17:14,053 --> 00:17:16,525
However, there are some ways to help differentiate

442
00:17:16,525 --> 00:17:17,323
the premise of the.

443
00:17:18,280 --> 00:17:21,567
For first, the clinical presentation is so so

444
00:17:21,567 --> 00:17:23,802
controlled in these patients. As they usually have

445
00:17:23,802 --> 00:17:26,595
some analysis h from pulmonary edema.

446
00:17:27,247 --> 00:17:29,316
And they usually our hypo times, which is

447
00:17:29,316 --> 00:17:32,362
a marker of cardio cell. Patients with chronic

448
00:17:32,419 --> 00:17:35,364
mr typically have an insidious onset of symptoms

449
00:17:35,364 --> 00:17:38,488
over time. Chronic Mr is also associated the

450
00:17:38,488 --> 00:17:39,307
left ventricular

451
00:17:39,685 --> 00:17:42,078
and left updates they'll dilation with a acute

452
00:17:42,078 --> 00:17:45,048
mitral regurgitation The heart doesn't have time to

453
00:17:45,048 --> 00:17:47,445
remodel, and these chamber sizes are usually more,

454
00:17:47,845 --> 00:17:50,801
fairly often, patients with a Qm mr have

455
00:17:50,801 --> 00:17:52,260
a hyper contract l.

456
00:17:53,053 --> 00:17:54,801
As blood can now travel to a low

457
00:17:54,801 --> 00:17:58,377
pressure left atrium opposed to the au. Also

458
00:17:58,377 --> 00:18:01,159
a fill mental valve leaflet or pap muscle

459
00:18:01,159 --> 00:18:01,659
rupture

460
00:18:02,049 --> 00:18:04,309
is usually specific for acute much.

461
00:18:05,009 --> 00:18:06,390
There are several quantitative

462
00:18:06,690 --> 00:18:08,930
factors something we at with which to include

463
00:18:08,930 --> 00:18:10,049
mitral pathology,

464
00:18:10,450 --> 00:18:11,089
color doppler,

465
00:18:12,219 --> 00:18:14,923
regurgitation flow as well as continuous wave out.

466
00:18:15,241 --> 00:18:17,252
Echo parameters of severe mushroom

467
00:18:17,626 --> 00:18:18,126
regurgitation

468
00:18:18,501 --> 00:18:19,478
include a large

469
00:18:19,932 --> 00:18:21,779
volume that greater than 6 see mode.

470
00:18:22,579 --> 00:18:23,240
And a

471
00:18:23,539 --> 00:18:26,019
regurgitation fraction of greater than or equal to

472
00:18:26,019 --> 00:18:28,740
50 percent. The reg volume is the amount

473
00:18:28,740 --> 00:18:30,759
of blood enters a left atrium

474
00:18:31,231 --> 00:18:33,375
systole from the left function function. This is

475
00:18:33,375 --> 00:18:35,860
obviously add. This is because

476
00:18:36,234 --> 00:18:38,537
flow will follow the path to least system.

477
00:18:39,190 --> 00:18:41,829
So prefer to enter a low catcher left

478
00:18:41,829 --> 00:18:42,069
atrium,

479
00:18:42,710 --> 00:18:45,669
poster a high pressure aorta. So considering a

480
00:18:45,669 --> 00:18:48,250
normal stroke volumes 50 to a hundred milliliters

481
00:18:48,884 --> 00:18:51,281
I reg volume of 60 milliliters is quite

482
00:18:51,281 --> 00:18:51,520
a.

483
00:18:52,160 --> 00:18:54,237
Reg it in fraction is simply the ratio

484
00:18:54,237 --> 00:18:55,890
above that enters a left h atrium

485
00:18:56,327 --> 00:18:58,395
divided by the total amount of log that

486
00:18:58,395 --> 00:19:00,941
the L pumps out. So are there to

487
00:19:00,941 --> 00:19:04,217
be severe much of regurgitation At least 50

488
00:19:04,217 --> 00:19:05,648
percent of the blob that is pumped from

489
00:19:05,648 --> 00:19:06,546
the left ventricle

490
00:19:06,921 --> 00:19:09,069
is actually going backwards into your off trip.

491
00:19:09,387 --> 00:19:11,509
This may be useful in their acute mi

492
00:19:11,709 --> 00:19:14,367
and the L of not dilate, and volumes

493
00:19:14,426 --> 00:19:17,463
actually are increased. Color doppler is another extremely

494
00:19:17,463 --> 00:19:20,181
useful tool as it helps so the direction

495
00:19:20,181 --> 00:19:22,609
motif the regurgitation. Whether it being posterior,

496
00:19:23,460 --> 00:19:26,243
anterior or central. If there is a pathology

497
00:19:26,243 --> 00:19:28,549
involving 1 of the leaflets, the color flow

498
00:19:28,549 --> 00:19:30,457
is usually directed in the opposite traps.

499
00:19:31,429 --> 00:19:33,107
Looks like our patient care who in a

500
00:19:33,107 --> 00:19:37,283
fall anterior pulp. His jet direct posterior. Typically

501
00:19:37,582 --> 00:19:39,920
severe Mr has a large colored boxer

502
00:19:40,314 --> 00:19:42,628
which usually league encompasses at least 50 percent

503
00:19:42,628 --> 00:19:44,942
of the lost train. Well this may not

504
00:19:44,942 --> 00:19:47,175
be the case in patients with very eccentric

505
00:19:47,175 --> 00:19:50,490
judge. Additionally, all doppler usually allows for

506
00:19:50,869 --> 00:19:51,850
identification of slow,

507
00:19:52,470 --> 00:19:55,509
which is typically referred to as proxima iso

508
00:19:55,509 --> 00:19:58,481
velocity surface area. Or more simply put peace.

509
00:19:58,800 --> 00:20:00,976
This can lead to the calculation of the

510
00:20:01,034 --> 00:20:03,189
and vulnerable and measurement of law effective,

511
00:20:03,908 --> 00:20:04,945
tent or area,

512
00:20:05,518 --> 00:20:08,621
or the r pit. This is essentially a

513
00:20:08,621 --> 00:20:11,405
measurement of the area that the soul travels

514
00:20:11,405 --> 00:20:13,792
it. So the bigger the hole, the bigger

515
00:20:13,792 --> 00:20:15,720
the leap. And ERA

516
00:20:15,720 --> 00:20:18,134
greater than or equal to pump 4 centimeters

517
00:20:18,273 --> 00:20:20,984
square is associated with severe much. Furthermore,

518
00:20:21,543 --> 00:20:23,616
appease all of greater than Or to 1

519
00:20:23,616 --> 00:20:24,116
centimeters

520
00:20:24,429 --> 00:20:26,267
that Nike was limit of 30 to 40

521
00:20:26,267 --> 00:20:29,143
centimeters meters a second. Is associated with severe

522
00:20:29,143 --> 00:20:29,703
always well.

523
00:20:30,342 --> 00:20:30,821
Lastly,

524
00:20:31,300 --> 00:20:33,864
Avi contract a measurement of the smallest portion

525
00:20:33,864 --> 00:20:35,772
of the mr set. And the value of

526
00:20:35,772 --> 00:20:38,317
greater than 0.7 is a marker of severe

527
00:20:38,317 --> 00:20:41,123
mr. Continuous way doppler also helps the diagnose

528
00:20:41,338 --> 00:20:42,029
severity electric

529
00:20:42,547 --> 00:20:44,774
vegetation. The C w can be traced and

530
00:20:44,774 --> 00:20:47,104
use of to reg tint volume

531
00:20:47,558 --> 00:20:49,626
cross the module valve will the quotation of

532
00:20:49,626 --> 00:20:50,286
the continuity.

533
00:20:51,313 --> 00:20:53,702
Assessment of the pulmonary veins is also so

534
00:20:53,702 --> 00:20:56,989
shit. The Atrium are diastole during ventricular.

535
00:20:57,604 --> 00:21:00,247
So blood flows in the pulmonary veins enters

536
00:21:00,247 --> 00:21:01,677
a left atrium bearing system.

537
00:21:02,313 --> 00:21:03,052
Severe mitral

538
00:21:03,426 --> 00:21:05,572
regurgitation causes his blood to reverse and now

539
00:21:05,572 --> 00:21:07,480
what leaves the left atrium and enters the

540
00:21:07,480 --> 00:21:08,592
pulmonary vein dry.

541
00:21:09,244 --> 00:21:11,805
This typically referred to as pulmonary veins the

542
00:21:11,805 --> 00:21:14,305
solid soul aerosol and is usually path

543
00:21:14,605 --> 00:21:16,045
for severe much phase.

544
00:21:16,858 --> 00:21:17,992
Thanks for that incredible

545
00:21:18,364 --> 00:21:20,107
explanation Neil. I know I definitely will have

546
00:21:20,107 --> 00:21:22,168
to go back to listen to that segment

547
00:21:22,168 --> 00:21:23,832
again, just to make sure I got everything.

548
00:21:24,324 --> 00:21:26,820
Sin, can you tell us about lip path

549
00:21:27,118 --> 00:21:29,353
of pap muscle rupture and how can this

550
00:21:29,353 --> 00:21:32,067
be explained by the patients left heart catheter

551
00:21:32,067 --> 00:21:32,625
characterization findings?

552
00:21:33,519 --> 00:21:35,839
At the risk of overs simplifying things and

553
00:21:35,839 --> 00:21:39,119
ob upsetting na compressors throughout a country, normal

554
00:21:39,119 --> 00:21:42,192
left ventricle has 2 pap muscles. All the

555
00:21:42,327 --> 00:21:44,017
lateral and the poster media

556
00:21:44,390 --> 00:21:47,486
muscles given their locations. Each pap muscle has

557
00:21:47,486 --> 00:21:49,788
chord connecting to both leaflets of the mitral

558
00:21:49,788 --> 00:21:52,779
valve. On average around 62 of such chord

559
00:21:53,079 --> 00:21:56,839
for pap muscle. The pap muscles actively contract

560
00:21:56,839 --> 00:21:58,575
just before the rest of the ventricle eventual

561
00:21:58,694 --> 00:22:01,008
and by cooling on the 4 day, prevent

562
00:22:01,008 --> 00:22:03,882
the mitral valve of leaflets faint laps when

563
00:22:03,882 --> 00:22:06,515
the left ventricle contracts. If the woods applied

564
00:22:06,515 --> 00:22:09,089
to pap muscle is abruptly cut off, and

565
00:22:09,089 --> 00:22:11,809
there is little no lateral lotus p as

566
00:22:11,809 --> 00:22:13,990
is often in the case in a stem

567
00:22:14,223 --> 00:22:15,969
The cells in the pap are muscle become

568
00:22:15,969 --> 00:22:18,690
nec and in 2 7 days to structural

569
00:22:18,746 --> 00:22:20,888
integrity of the pap muscle is reduced. If

570
00:22:20,888 --> 00:22:23,625
the L function is preserved or even hyper,

571
00:22:24,395 --> 00:22:25,689
the movement of the my

572
00:22:26,459 --> 00:22:28,602
compounded with tension from the 4 day exert

573
00:22:28,602 --> 00:22:31,871
eye shea stress onto dysfunction pap muscle. Leading

574
00:22:31,871 --> 00:22:33,164
to a complete or

575
00:22:33,536 --> 00:22:36,946
tear depending on situation. In fact, most cases

576
00:22:36,946 --> 00:22:39,380
of pap muscle rupture or associated with a

577
00:22:39,658 --> 00:22:41,911
small amount of ischemia and the left ventricle

578
00:22:42,127 --> 00:22:43,504
overall. The post

579
00:22:43,880 --> 00:22:46,429
pap muscle receives all of its blood supply

580
00:22:46,429 --> 00:22:48,261
from the Pd in most people.

581
00:22:48,753 --> 00:22:51,613
While the lateral pap muscle receives it from

582
00:22:51,613 --> 00:22:54,314
the La, usually the first dia and the

583
00:22:54,314 --> 00:22:56,697
left ci flex, usually the o 1. As

584
00:22:56,697 --> 00:22:59,648
such, hosts media pap muscle tears are sister

585
00:22:59,648 --> 00:23:02,901
12 times as common as unilateral. But again,

586
00:23:03,139 --> 00:23:05,122
given how the chord connect to the leaflets,

587
00:23:05,693 --> 00:23:07,920
This can sole affect both leaflets of the

588
00:23:07,920 --> 00:23:10,466
mitral valve. Without the pap and muscle t

589
00:23:10,466 --> 00:23:13,090
into leaflets, the lift of can pro during

590
00:23:13,090 --> 00:23:13,886
ventricular systole.

591
00:23:14,378 --> 00:23:15,753
Causing severe mitral

592
00:23:16,207 --> 00:23:18,992
regurgitation. Additionally, given that many of these patients

593
00:23:18,992 --> 00:23:22,433
also have Rb infarction from an Rca obstruction

594
00:23:22,433 --> 00:23:25,150
that the R can become older overwhelmed by

595
00:23:25,150 --> 00:23:27,467
the reg slow, leading to a death spiral.

596
00:23:28,026 --> 00:23:30,594
In this particular patient, While we do not

597
00:23:30,594 --> 00:23:33,699
see obvious or say obstruction, the presence are

598
00:23:33,699 --> 00:23:36,007
left to right collateral as well as basal

599
00:23:36,007 --> 00:23:36,666
to emit

600
00:23:37,360 --> 00:23:40,557
and inferior walls hypo on goal suggests that

601
00:23:40,557 --> 00:23:42,782
either a small vessel from the Rca was

602
00:23:42,782 --> 00:23:44,768
obstructed at the time of the Mi and

603
00:23:44,768 --> 00:23:46,517
no longer visible on geography.

604
00:23:47,009 --> 00:23:49,323
Or goes a transient occlusion of the mid

605
00:23:49,962 --> 00:23:51,579
Lesion that has sims spontaneously

606
00:23:51,957 --> 00:23:52,457
rec.

607
00:23:53,234 --> 00:23:54,910
Is important to keep in mind that up

608
00:23:54,910 --> 00:23:57,893
to 30 percent of stem have spontaneous re

609
00:23:58,189 --> 00:24:00,599
rationalization. And the all appearance of the Rca

610
00:24:00,657 --> 00:24:02,886
plaque could suggest that this was a culprit.

611
00:24:03,378 --> 00:24:04,890
I think it is less likely that the

612
00:24:04,890 --> 00:24:07,674
tight La lesion is solely responsible for what's

613
00:24:07,674 --> 00:24:10,060
going on here, although given that the La

614
00:24:10,060 --> 00:24:12,696
is speeding the collateral. Is certainly possible that

615
00:24:12,696 --> 00:24:15,157
there was a multi fit event here. I

616
00:24:15,157 --> 00:24:18,016
should add that other possible ideologies of pap

617
00:24:18,016 --> 00:24:20,971
muscle rupture include 1 chest formal, although that's

618
00:24:20,971 --> 00:24:24,733
classically near for the tri valves muscles, endo,

619
00:24:25,585 --> 00:24:26,858
cocaine abuse, and of course,

620
00:24:27,893 --> 00:24:29,816
ideologies. But it doesn't seem like any of

621
00:24:29,816 --> 00:24:30,691
these were the case here.

622
00:24:31,566 --> 00:24:34,373
That's a very interesting proposition for the mechanism

623
00:24:34,509 --> 00:24:37,387
bleed to this patient's pap muscle rupture. Now

624
00:24:37,387 --> 00:24:39,056
that we know what is going on with

625
00:24:39,056 --> 00:24:40,884
our patient and also have an idea how

626
00:24:40,884 --> 00:24:42,872
it happened. She, can you take us through

627
00:24:42,872 --> 00:24:44,859
the management for a acute mr due to

628
00:24:44,859 --> 00:24:45,892
pap muscle rupture?

629
00:24:46,783 --> 00:24:49,814
Ultimately, this is a mechanical problem and requires

630
00:24:49,814 --> 00:24:52,924
a mechanical solution. Pac muscle rupture is 1

631
00:24:52,924 --> 00:24:55,317
of the indications for cardiac surgery in the

632
00:24:55,317 --> 00:24:57,799
setting of stem. Given that has an 80

633
00:24:57,799 --> 00:25:00,048
percent mortality in the first week if Treated

634
00:25:00,104 --> 00:25:02,909
and performing con complement cabbage as a classroom

635
00:25:03,284 --> 00:25:05,112
recommendation from the Acc and Aha.

636
00:25:05,683 --> 00:25:07,665
However, the patient does need to be brought

637
00:25:07,665 --> 00:25:09,806
out the shock state as much as possible,

638
00:25:10,203 --> 00:25:12,661
and this is where mechanical circulatory support as

639
00:25:12,661 --> 00:25:14,923
a role. This is a class 2a way

640
00:25:15,059 --> 00:25:16,274
recommendation by the Acc.

641
00:25:17,046 --> 00:25:19,589
While being optimized for surgery, the patients should

642
00:25:19,589 --> 00:25:21,736
be on aspirin and an Iv anti clyde

643
00:25:21,736 --> 00:25:22,371
such as heparin.

644
00:25:23,103 --> 00:25:26,533
Invasive hem with swarm gan catheter, and arterial

645
00:25:26,533 --> 00:25:29,005
line can also help with titration thrusters,

646
00:25:29,563 --> 00:25:31,898
probes and diuretics, and until attempts.

647
00:25:32,769 --> 00:25:34,690
And when it comes to surgery Scene, is

648
00:25:34,690 --> 00:25:36,930
there a difference between repair or replacement of

649
00:25:36,930 --> 00:25:37,650
the mitral valve?

650
00:25:38,289 --> 00:25:39,330
It's an excellent question.

651
00:25:39,825 --> 00:25:42,644
While in most primary, much regurgitation disorders

652
00:25:43,025 --> 00:25:45,825
repair as preferable to replacement, calculated and muscle

653
00:25:45,825 --> 00:25:47,744
rupture is rare enough that we have no

654
00:25:47,744 --> 00:25:49,997
strong evidence based to guide us. The major

655
00:25:49,997 --> 00:25:53,846
arguments against repair or that edema, tissue necrosis

656
00:25:53,904 --> 00:25:55,739
and lack of tens cell strength in the

657
00:25:55,739 --> 00:25:58,211
recently ischemic my and pap muscle,

658
00:25:58,864 --> 00:26:00,862
mean that the repair might not hold, and

659
00:26:00,862 --> 00:26:03,279
a patient will have recurrent severe much

660
00:26:03,658 --> 00:26:06,829
regurgitation, requiring repeat surgery. As such, a coral

661
00:26:06,949 --> 00:26:09,902
bearing Mitral Valve basement strategy might be superior.

662
00:26:10,381 --> 00:26:12,477
According to 1 analysis of the Sc sds

663
00:26:12,615 --> 00:26:16,377
database and 20 11 to 20 18, 79.8

664
00:26:16,377 --> 00:26:19,399
percent of patients receiving mental valve surgery or

665
00:26:19,399 --> 00:26:22,279
pap muscle rupture have mental valve replacement. And

666
00:26:22,279 --> 00:26:24,357
the rest have repair. So in day day

667
00:26:24,357 --> 00:26:26,594
practice, it does seem that replacement as preferred.

668
00:26:26,914 --> 00:26:28,672
I should note that the database does not

669
00:26:28,672 --> 00:26:31,799
have enough granularity to make conclusions on the

670
00:26:31,799 --> 00:26:33,014
type of pap muscle

671
00:26:33,468 --> 00:26:35,376
I. E. Was it partial or complete and

672
00:26:35,376 --> 00:26:37,840
a type of surgery, but it does show

673
00:26:37,840 --> 00:26:39,929
that the patients who received replacement

674
00:26:40,478 --> 00:26:42,944
tended to be more in a cardio shock

675
00:26:42,944 --> 00:26:44,557
state, higher of f

676
00:26:45,012 --> 00:26:46,682
essentially be more sick overall.

677
00:26:47,493 --> 00:26:49,877
Would suggest that these were likely the complete

678
00:26:49,877 --> 00:26:51,705
terror patients were received replacement.

679
00:26:52,261 --> 00:26:54,169
And how about Trans catheter interventions?

680
00:26:55,058 --> 00:26:56,729
Given that most of these patients are very

681
00:26:56,729 --> 00:26:59,513
sick, often requiring a academy support on pressures,

682
00:26:59,990 --> 00:27:01,263
it would be great if there was a

683
00:27:01,263 --> 00:27:01,763
trans

684
00:27:02,138 --> 00:27:04,723
solution to offer this population. Either as a

685
00:27:04,861 --> 00:27:07,253
destination therapy or as a bridge surgery when

686
00:27:07,253 --> 00:27:10,123
the patient is more optimized, I e, no

687
00:27:10,123 --> 00:27:11,877
longer in an acute shock or an acute

688
00:27:12,037 --> 00:27:14,836
Mi state. Currently, around half of all patients

689
00:27:14,836 --> 00:27:17,459
presenting with pap muscle rupture are not offered

690
00:27:17,459 --> 00:27:19,764
surgery due the prohibitive of surgical risk. As

691
00:27:19,764 --> 00:27:21,671
a result, there are several case reports of

692
00:27:21,671 --> 00:27:24,146
6 success whole trans for edge to edge

693
00:27:24,146 --> 00:27:26,368
repair for these patients. Well the largest price

694
00:27:26,368 --> 00:27:28,511
series out of scripts showed that while the

695
00:27:28,511 --> 00:27:31,227
procedural success is there with significant reduction of

696
00:27:31,227 --> 00:27:33,452
severity of mitral regurgitation, 4 of the 5

697
00:27:33,452 --> 00:27:35,757
patients who receive the therapy still died during

698
00:27:35,757 --> 00:27:38,882
that hospitalization. This probably reflects the fact that

699
00:27:38,882 --> 00:27:41,278
these are very sick patients and did not

700
00:27:41,278 --> 00:27:43,595
have many other options. Of course, even if

701
00:27:43,595 --> 00:27:46,163
the ball standard treatment of surgical repair slash

702
00:27:46,163 --> 00:27:49,056
basement of the valve con incompetent bypass drafting

703
00:27:49,353 --> 00:27:51,347
around 10 to 40 percent of patients with

704
00:27:51,347 --> 00:27:53,954
pap muscle rupture do not survive during hospitalization,

705
00:27:54,471 --> 00:27:56,138
which is a sobering reminder of just how

706
00:27:56,138 --> 00:27:57,250
much work has to be done here.

707
00:27:57,964 --> 00:28:00,664
La fawn, metal, we've talked extensively about the

708
00:28:00,664 --> 00:28:03,229
acute much regurgitation for pap muscle rupture

709
00:28:03,617 --> 00:28:05,445
Kain take us through a brief overview of

710
00:28:05,445 --> 00:28:08,225
the other mechanical complications of acute core air

711
00:28:08,225 --> 00:28:08,623
syndrome.

712
00:28:09,258 --> 00:28:09,814
Of course,

713
00:28:10,624 --> 00:28:13,734
So the 4 major mechanical complications of an

714
00:28:13,734 --> 00:28:16,684
acute myocardial infarction are acute modular regarded regurgitation

715
00:28:16,684 --> 00:28:20,286
from pap muscle rupture, ventricular sep defect ventricular

716
00:28:20,286 --> 00:28:22,356
free wall rupture and pseudo aneurysms.

717
00:28:22,834 --> 00:28:25,063
I think it's important to emphasize that all

718
00:28:25,063 --> 00:28:27,850
of the combinations have relatively high mortality rates.

719
00:28:28,183 --> 00:28:30,910
Babylon muscle rupture we have already talked extensively

720
00:28:30,966 --> 00:28:33,908
about. The ventricular sep defects occur 3 to

721
00:28:33,908 --> 00:28:35,896
5 days after a trans mural in fact.

722
00:28:36,309 --> 00:28:38,710
The clinical presentation can vary from just an

723
00:28:38,710 --> 00:28:42,089
isolated murmur typically described as a heart, loud

724
00:28:42,390 --> 00:28:44,924
hollow systolic murder heard best at the left

725
00:28:45,044 --> 00:28:47,294
lower stern border all the way to cardio

726
00:28:47,430 --> 00:28:49,737
shock. Echo will show a left to right

727
00:28:49,737 --> 00:28:51,940
shu across the septum, right heart

728
00:28:52,617 --> 00:28:55,007
authorization will show a step up in oxygenation

729
00:28:55,007 --> 00:28:57,078
between the Ra and a Pa, as well

730
00:28:57,078 --> 00:28:58,534
as an elevated Q.

731
00:28:59,482 --> 00:29:02,740
Anterior and api Vs are typically caused by

732
00:29:02,819 --> 00:29:06,339
Led and forks, while posterior Vs are associated

733
00:29:06,395 --> 00:29:09,758
with inferior in Spark. Ps are generally managed

734
00:29:09,758 --> 00:29:12,395
by initiating after load reductions such as with

735
00:29:12,395 --> 00:29:14,952
an intra aortic balloon pump followed by urgent

736
00:29:14,952 --> 00:29:18,003
surgical or per subcutaneous repair. Next, we have

737
00:29:18,003 --> 00:29:20,960
ventricular free wall rupture, which presents with elevated

738
00:29:21,119 --> 00:29:24,655
Jb d, muffled heart sounds, and Pulse paradox.

739
00:29:25,209 --> 00:29:27,835
As blood comes in contact with and irritates

740
00:29:27,835 --> 00:29:31,098
to peri, the patient's Ekg can show nude

741
00:29:32,371 --> 00:29:34,453
Elevations. As you can imagine, these cases of

742
00:29:34,453 --> 00:29:37,156
very high mortality rates, and the management is

743
00:29:37,156 --> 00:29:40,390
emergent surgery. Lastly, we have pseudo aneurysms, which

744
00:29:40,748 --> 00:29:43,457
Unlike the others typically present weeks to years

745
00:29:43,457 --> 00:29:46,484
after in fact. Pseudo aneurysms occur when a

746
00:29:46,484 --> 00:29:49,932
cardiac rupture is contained by the peri adhesion

747
00:29:50,164 --> 00:29:52,399
And a most commonly involves the inferior or

748
00:29:52,399 --> 00:29:55,272
lateral walls, as anterior wall rupture are more

749
00:29:55,272 --> 00:29:58,065
likely to cause massive hem peri and immediate

750
00:29:58,065 --> 00:30:00,879
death. Patients usually present with shortness of breath

751
00:30:00,879 --> 00:30:04,019
or chest pain, but can be asymptomatic. Diagnosis

752
00:30:04,159 --> 00:30:06,559
involves the use of multiple imaging modalities such

753
00:30:06,559 --> 00:30:07,299
as echo,

754
00:30:08,094 --> 00:30:10,716
which can demonstrate pseudo aneurysms with a narrow

755
00:30:10,716 --> 00:30:14,236
neck. Once diagnosed, pseudo aneurysms should be urgently

756
00:30:14,372 --> 00:30:16,279
repaired due to a high risk for rupture.

757
00:30:17,169 --> 00:30:19,798
So La, tell us, what about happening of

758
00:30:19,798 --> 00:30:20,356
our patients?

759
00:30:21,073 --> 00:30:24,101
I'd be happy to. It certainly scary managing

760
00:30:24,101 --> 00:30:25,955
such a sick patient who was deteriorating

761
00:30:26,491 --> 00:30:29,619
overnight. Ce presented with such significant pulmonary edema,

762
00:30:29,778 --> 00:30:32,013
he was immediately started on wide pop with

763
00:30:32,013 --> 00:30:34,648
positive pressure ventilation, hoping to reduce his L,

764
00:30:34,807 --> 00:30:37,460
preload and after load. As if blood pressures

765
00:30:37,460 --> 00:30:40,259
began to drop norepinephrine was started. Cardiac Surgery

766
00:30:40,259 --> 00:30:42,740
was console consultant and an intra aortic balloon

767
00:30:42,740 --> 00:30:45,710
was placed at bedside. A cardiac customization was

768
00:30:45,710 --> 00:30:48,102
performed during which the intra aortic balloon pump

769
00:30:48,102 --> 00:30:50,575
are removed and replaced by an imp. The

770
00:30:50,575 --> 00:30:53,526
patient ultimately underwent a successful tissue mitral valve

771
00:30:53,526 --> 00:30:56,243
replacement and cabbage with Lima to the Led

772
00:30:56,243 --> 00:30:56,981
and diagonal.

773
00:30:57,434 --> 00:30:59,181
He could occasionally to do well several months

774
00:30:59,181 --> 00:31:01,564
out from surgery with no much regurgitation on

775
00:31:01,564 --> 00:31:01,802
echo.

776
00:31:02,612 --> 00:31:04,202
Man, I'm so glad this patient had a

777
00:31:04,202 --> 00:31:06,509
good outcome, especially after Sin gave us all

778
00:31:06,509 --> 00:31:08,816
the mortality with this complication of Mind.

779
00:31:09,468 --> 00:31:11,218
Thanks for joining us through the case. Fun.

780
00:31:11,775 --> 00:31:12,571
Thanks everybody.

781
00:31:13,367 --> 00:31:15,913
La. Sin, and Neil, what a crazy case

782
00:31:15,913 --> 00:31:18,221
and an amazing salvage, and I'm so glad

783
00:31:18,221 --> 00:31:19,984
that you're patient is doing well. You took

784
00:31:19,984 --> 00:31:22,367
us from a chief complain of D and

785
00:31:22,367 --> 00:31:25,385
uncovered real bad within this heart, acute pap

786
00:31:25,385 --> 00:31:27,945
rupture, which as you pointed out just generally

787
00:31:27,945 --> 00:31:30,175
has an ab invisible prognosis, but it sounds

788
00:31:30,175 --> 00:31:32,406
like with a rapid escalation of care. In

789
00:31:32,406 --> 00:31:34,954
this case, mechanical circulatory support when a medical

790
00:31:34,954 --> 00:31:37,919
therapy was failing, quick recognition of the pathology

791
00:31:37,919 --> 00:31:40,232
and then a great treatment plan with multi

792
00:31:40,232 --> 00:31:43,104
disciplinary team. Your patient actually had the outcome

793
00:31:43,104 --> 00:31:45,018
we pray for when we have patients like

794
00:31:45,018 --> 00:31:46,789
this. So thank you so much for walking

795
00:31:46,789 --> 00:31:48,387
us through the case giving us an overview

796
00:31:48,387 --> 00:31:51,503
of mechanical complications in Mi, and it's specifically

797
00:31:51,503 --> 00:31:53,741
a deep dive in pap rupture with acute

798
00:31:53,741 --> 00:31:56,869
mitral regurgitation. And I definitely appreciate that deep

799
00:31:56,869 --> 00:31:58,784
dive into the echo findings these because that

800
00:31:58,784 --> 00:32:00,619
can be very helpful. In this case, and

801
00:32:00,619 --> 00:32:02,890
as well as in all cases of mitral

802
00:32:03,109 --> 00:32:05,269
regurgitation. So thank you, team. You did a

803
00:32:05,269 --> 00:32:08,309
stellar job, what a master class presentation. Thank

804
00:32:08,309 --> 00:32:09,430
you so much for having us.

805
00:32:11,440 --> 00:32:14,014
And now for the that's for cardio perspectives

806
00:32:14,153 --> 00:32:16,706
and review segment for this episode, we're excited

807
00:32:16,706 --> 00:32:19,612
to introduce doctor Jeff B. He is a

808
00:32:19,829 --> 00:32:21,742
interventional cardiologist here at the U r that

809
00:32:21,742 --> 00:32:24,690
we all love working with. He's also associate

810
00:32:24,690 --> 00:32:26,921
program director of our interventional fellowship as well.

811
00:32:27,572 --> 00:32:29,402
And we're excited to say that he won

812
00:32:29,402 --> 00:32:30,993
the teacher of the year award this year,

813
00:32:31,231 --> 00:32:32,822
so really excited to have him on our

814
00:32:32,822 --> 00:32:33,618
podcast today.

815
00:32:34,669 --> 00:32:36,190
Everyone. This is Jeff B. I'm 1 of

816
00:32:36,190 --> 00:32:38,109
the interventional cardiologist from strong,

817
00:32:39,390 --> 00:32:41,069
C Hospital, And I wanna say thank you

818
00:32:41,069 --> 00:32:43,630
to our fellows for inviting me to participate

819
00:32:43,630 --> 00:32:46,197
in this discussion of this great case. So

820
00:32:46,197 --> 00:32:47,314
thanks everyone for having me.

821
00:32:48,669 --> 00:32:52,119
So this gentleman had a relatively dramatic initial

822
00:32:52,257 --> 00:32:55,067
presentation and This is a circumstance where he

823
00:32:55,067 --> 00:32:57,224
need to be able to think on your

824
00:32:57,224 --> 00:33:00,041
feet to sort of, quickly narrow down the

825
00:33:00,101 --> 00:33:00,840
differential diagnosis

826
00:33:01,555 --> 00:33:02,994
because some of the issues that could be

827
00:33:02,994 --> 00:33:06,195
going on or potentially immediately life threatening. So

828
00:33:06,195 --> 00:33:08,355
you really wanna focus on things that you

829
00:33:08,355 --> 00:33:10,595
would need to identify an intervene on quickly.

830
00:33:11,009 --> 00:33:12,628
I agree that based on the

831
00:33:13,007 --> 00:33:14,205
description of the patient's symptoms,

832
00:33:14,685 --> 00:33:17,402
pulmonary embolism would be a top of the

833
00:33:17,402 --> 00:33:19,020
list in terms of concern

834
00:33:19,333 --> 00:33:20,845
The 1 thing that you have going against

835
00:33:20,845 --> 00:33:23,392
that is the significant amount of pulmonary edema

836
00:33:23,392 --> 00:33:25,643
that the patient is exhibiting both on physical

837
00:33:25,859 --> 00:33:28,008
exam as well as on his chest x

838
00:33:28,008 --> 00:33:31,776
ray pulmonary edema is a relatively uncommon finding

839
00:33:31,776 --> 00:33:33,794
and pulmonary embolism. And so

840
00:33:34,412 --> 00:33:36,903
that's something that I would really you know,

841
00:33:37,063 --> 00:33:39,054
sort of push me to look for alternate

842
00:33:39,054 --> 00:33:39,554
diagnoses.

843
00:33:40,408 --> 00:33:42,719
On similar lines, I wanted to make a

844
00:33:42,719 --> 00:33:44,471
comment on the use of a d dime

845
00:33:44,471 --> 00:33:45,768
in this clinical circumstance.

846
00:33:46,557 --> 00:33:49,102
Which I think has limited clinical utility. D

847
00:33:49,102 --> 00:33:50,874
dime is really useful in somebody,

848
00:33:51,488 --> 00:33:54,135
who has low risk pulmonary embolism

849
00:33:55,083 --> 00:33:57,018
you're looking to rule out pulmonary embolism,

850
00:33:57,714 --> 00:33:59,866
finding of an elevated d dime in in

851
00:33:59,866 --> 00:34:00,765
someone who

852
00:34:01,221 --> 00:34:04,104
has multiple clinical signs or symptoms consistent or

853
00:34:04,104 --> 00:34:05,852
potentially consistent with a pulmonary embolism.

854
00:34:06,250 --> 00:34:08,713
The finding of a, negative d dime is

855
00:34:08,713 --> 00:34:10,303
not gonna do much to sway you away

856
00:34:10,303 --> 00:34:12,425
and the finding of positive d dime is

857
00:34:12,623 --> 00:34:14,613
not really gonna change your clinical suspicion at

858
00:34:14,613 --> 00:34:15,091
all. So,

859
00:34:15,887 --> 00:34:17,797
you know, electing to obtain a d dime

860
00:34:17,797 --> 00:34:18,615
in the circumstances,

861
00:34:19,469 --> 00:34:21,936
really gonna be not a much clinical utility.

862
00:34:22,750 --> 00:34:24,670
Based on the review of the patient's vital

863
00:34:24,670 --> 00:34:26,750
signs, I think it's readily apparent that this

864
00:34:26,750 --> 00:34:27,730
patient is in

865
00:34:28,030 --> 00:34:29,150
in pretty bad shape,

866
00:34:30,109 --> 00:34:31,329
the 1 thing that's

867
00:34:32,440 --> 00:34:34,509
especially concerning is the patient's heart rate of

868
00:34:34,509 --> 00:34:36,259
a hundred and 30 beats per minute in

869
00:34:36,259 --> 00:34:37,372
sinus tachycardia.

870
00:34:38,979 --> 00:34:41,696
Residents of sinus tachycardia and somebody who you're

871
00:34:41,696 --> 00:34:44,273
evaluating for either pulmonary embolism or

872
00:34:45,132 --> 00:34:46,671
an acute coronary syndrome

873
00:34:47,303 --> 00:34:49,156
really carries with it a lot of pro

874
00:34:49,372 --> 00:34:51,920
weight and can be used to identify patients

875
00:34:51,920 --> 00:34:53,193
that are at higher risk for,

876
00:34:53,829 --> 00:34:55,979
acute d compensation during the course of their

877
00:34:55,979 --> 00:34:56,297
illness.

878
00:34:57,505 --> 00:34:58,800
In this patient's particular

879
00:34:59,255 --> 00:34:59,414
presentation,

880
00:35:00,447 --> 00:35:02,219
the decision to get the Ct,

881
00:35:03,071 --> 00:35:04,525
I'm not certain I would have

882
00:35:05,393 --> 00:35:07,308
perform the diagnostic work up in that order.

883
00:35:08,026 --> 00:35:10,819
As I mentioned before, the finding of pretty

884
00:35:10,819 --> 00:35:13,088
significant pulmonary edema it's

885
00:35:13,698 --> 00:35:15,760
severe enough to impact the patient's ability to

886
00:35:15,760 --> 00:35:17,664
oxygen would really argue view against the thrust

887
00:35:17,664 --> 00:35:18,299
of the Pe.

888
00:35:19,171 --> 00:35:19,806
I think, you know,

889
00:35:20,614 --> 00:35:22,840
a quick, point of care ultrasound as the

890
00:35:22,840 --> 00:35:23,952
team ended up doing,

891
00:35:24,588 --> 00:35:25,780
would be 1 way to really,

892
00:35:26,575 --> 00:35:29,239
really sort of narrow down the diagnostic

893
00:35:29,699 --> 00:35:31,300
picture to either right or a left side

894
00:35:31,300 --> 00:35:33,780
and issues without the need for obtaining a

895
00:35:33,859 --> 00:35:35,539
Ct scan of the chest, which is gonna

896
00:35:35,539 --> 00:35:38,813
carry with it. Pretty significant contrast load that

897
00:35:38,813 --> 00:35:41,746
you may want to utilize doing something else

898
00:35:41,746 --> 00:35:43,967
like potentially looking at his coronary arteries.

899
00:35:44,460 --> 00:35:46,380
Point of care Ultrasound can definitely be a

900
00:35:46,380 --> 00:35:49,900
great bedside diagnostic tool. Point occur Ultrasound machines

901
00:35:49,900 --> 00:35:52,791
on the market are continuing to improve. And

902
00:35:52,791 --> 00:35:54,143
becoming more widely available.

903
00:35:54,779 --> 00:35:57,188
The quality of the machines and some circumstances

904
00:35:57,484 --> 00:36:00,049
can vary pretty widely. So the older machines

905
00:36:00,049 --> 00:36:01,989
did not have the ability to measure doppler

906
00:36:02,130 --> 00:36:03,889
waveforms or get good color doppler.

907
00:36:04,609 --> 00:36:06,769
So in some circumstances that can really limit

908
00:36:06,769 --> 00:36:09,598
your ability to evaluate for some processes.

909
00:36:10,212 --> 00:36:11,963
In this case, for example, would have been

910
00:36:11,963 --> 00:36:14,668
very useful to have, the ability to have

911
00:36:14,668 --> 00:36:16,736
color doppler over the mitral valve that would

912
00:36:16,736 --> 00:36:18,048
have major diagnosis

913
00:36:18,824 --> 00:36:20,920
immediately and showing you this if you're mitral

914
00:36:21,217 --> 00:36:23,690
regurgitation, whereas, you, you know, without collar doppler.

915
00:36:23,849 --> 00:36:25,785
You're really left with trying to make some

916
00:36:25,843 --> 00:36:28,006
determinations based on the hyper day ami y.

917
00:36:28,323 --> 00:36:30,861
Who would definitely agree that using point of

918
00:36:30,861 --> 00:36:34,351
her ultrasound just like any ultrasound, more modality

919
00:36:34,351 --> 00:36:36,828
and formal echo cardio really need to be

920
00:36:36,828 --> 00:36:37,487
very simple

921
00:36:37,860 --> 00:36:40,244
systematic and thorough and do your same exam

922
00:36:40,244 --> 00:36:41,435
the same way every time.

923
00:36:42,150 --> 00:36:43,977
The other thing that's really important to keep

924
00:36:43,977 --> 00:36:45,065
in mind is that

925
00:36:45,422 --> 00:36:47,174
point of care Ultrasound is gonna be very

926
00:36:47,174 --> 00:36:49,563
good at finding findings that are there. I

927
00:36:49,563 --> 00:36:50,779
think it's less useful,

928
00:36:51,314 --> 00:36:53,640
you know, for ruling things out. You know,

929
00:36:53,960 --> 00:36:55,579
I think you need to be careful about

930
00:36:55,640 --> 00:36:56,699
completely excluding

931
00:36:57,000 --> 00:36:59,480
certain diagnoses just on the presence or absence

932
00:36:59,480 --> 00:37:01,400
of the findings based that point of your

933
00:37:01,400 --> 00:37:03,572
ultrasound due to some of the limitations quality

934
00:37:03,572 --> 00:37:05,401
of the device. 1 thing that I would

935
00:37:05,401 --> 00:37:08,106
add about this patient's, treatment course is that

936
00:37:08,664 --> 00:37:10,309
you know, some patients like this

937
00:37:10,669 --> 00:37:12,984
useful to have a low threshold for invasive

938
00:37:12,984 --> 00:37:15,219
assessment of hem thermodynamics, you know, taking the

939
00:37:15,219 --> 00:37:16,735
patient like this to the Cath lab might

940
00:37:16,735 --> 00:37:18,433
allow you to make a more rapid diagnosis

941
00:37:18,492 --> 00:37:19,130
of this problem.

942
00:37:19,943 --> 00:37:21,479
Especially with the used of ventricular

943
00:37:21,856 --> 00:37:23,849
you could pretty quickly see that there's severe

944
00:37:23,849 --> 00:37:25,524
mitral regurgitation. And,

945
00:37:26,161 --> 00:37:28,210
the ability to obtain a rate heart count

946
00:37:28,567 --> 00:37:30,234
authorization allow you to measure the cardiac output

947
00:37:30,234 --> 00:37:32,855
and another hem parameters would get you a

948
00:37:32,855 --> 00:37:35,157
way to risk strat him and and to

949
00:37:35,157 --> 00:37:36,213
help you decide

950
00:37:36,682 --> 00:37:38,989
which kind of mechanical support strategy would be

951
00:37:38,989 --> 00:37:41,137
best for this patient or if he needs

952
00:37:41,137 --> 00:37:43,260
mechanical support and all. I think this is

953
00:37:43,380 --> 00:37:45,057
time to bring up the idea of a

954
00:37:45,057 --> 00:37:47,854
balloon pump super responder. So a balloon pump

955
00:37:47,854 --> 00:37:50,811
although, in most patients does not provide additional

956
00:37:50,811 --> 00:37:53,688
cardiac output that would be sufficient to resolve

957
00:37:53,688 --> 00:37:54,243
shock states,

958
00:37:54,878 --> 00:37:56,543
in certain subgroups of patients,

959
00:37:57,337 --> 00:38:00,286
there been identified groups of of cases where,

960
00:38:00,842 --> 00:38:03,247
patients may have a an exaggerated hem

961
00:38:03,620 --> 00:38:06,819
response to balloon pump and, keep mitral shoulder

962
00:38:06,954 --> 00:38:08,327
regurgitation is 1 of those circumstances

963
00:38:09,113 --> 00:38:09,352
where,

964
00:38:10,069 --> 00:38:12,777
simply by, you know, improving the patient's after

965
00:38:12,777 --> 00:38:15,485
load, you can result in the and the

966
00:38:15,485 --> 00:38:18,209
substantial improvement in patients for cardiac output. The

967
00:38:18,209 --> 00:38:19,963
other group of patients that tend to be

968
00:38:19,963 --> 00:38:22,436
building from super responders or sort of normal

969
00:38:22,436 --> 00:38:24,372
intensive cardio gen shock patients,

970
00:38:24,749 --> 00:38:25,706
that you see with

971
00:38:26,265 --> 00:38:27,961
advanced cardiomyopathy my is to

972
00:38:28,595 --> 00:38:30,434
wind up having a high map, so those

973
00:38:30,434 --> 00:38:32,355
patients that have not yet gone into a

974
00:38:32,355 --> 00:38:33,555
phase of dial state.

975
00:38:34,195 --> 00:38:36,515
Those patients also tend to respond very well.

976
00:38:37,248 --> 00:38:40,141
To pump counter polarization via the same mechanism

977
00:38:40,199 --> 00:38:42,831
of vaginal load reduction. So you would anticipate

978
00:38:42,831 --> 00:38:44,744
that this patient should have a pretty good

979
00:38:44,744 --> 00:38:46,021
response to balloon therapy.

980
00:38:46,514 --> 00:38:48,194
Although it turns out that he he didn't

981
00:38:48,194 --> 00:38:50,355
actually have a complete response to the belief

982
00:38:50,594 --> 00:38:53,234
And therefore was upgrading to more aggressive mechanical

983
00:38:53,234 --> 00:38:54,034
support strategy.

984
00:38:54,767 --> 00:38:56,063
And really in this circumstance,

985
00:38:56,438 --> 00:38:59,006
pretty much any of the available mechanical circulatory

986
00:38:59,381 --> 00:39:02,423
support. Et ideologies should make us substantial difference

987
00:39:02,423 --> 00:39:05,300
in in terms of, improving an organ function

988
00:39:05,300 --> 00:39:07,936
for this group of patients, either mechanical support

989
00:39:07,936 --> 00:39:10,266
with an imp device as we ended up

990
00:39:10,266 --> 00:39:13,456
doing for this patient versus using Va ecm,

991
00:39:13,775 --> 00:39:16,008
if the patient is in especially bad shape

992
00:39:16,008 --> 00:39:19,770
would would both allow for, adequate improvement patients

993
00:39:19,770 --> 00:39:22,320
cardiac output. And some of that is gonna

994
00:39:22,320 --> 00:39:26,304
vary, from institution to institution on availability of

995
00:39:26,304 --> 00:39:29,188
particular support devices and practice patterns but really

996
00:39:29,188 --> 00:39:32,138
any of the available mechanical support strategies would

997
00:39:32,138 --> 00:39:34,610
would work for him. So the An in

998
00:39:34,610 --> 00:39:36,045
this patient's is very interesting,

999
00:39:36,524 --> 00:39:38,450
and that it does show had of an

1000
00:39:38,450 --> 00:39:40,830
ol plaque in the mid Rc, which looks

1001
00:39:40,830 --> 00:39:43,528
like it definitely could be culprit. Although has

1002
00:39:43,528 --> 00:39:45,036
kind of a torn up appearance with maybe

1003
00:39:45,036 --> 00:39:47,359
s t on top of it. The interesting

1004
00:39:47,359 --> 00:39:49,297
part is that the the vessel has,

1005
00:39:49,676 --> 00:39:52,393
Timmy 3 flow, and there's no abrupt vessel

1006
00:39:52,393 --> 00:39:54,172
cutoff off in any of the runoff territory

1007
00:39:54,231 --> 00:39:56,240
which you would expect for someone a completed

1008
00:39:56,557 --> 00:39:58,697
Mi. But I think the most likely scenario

1009
00:39:58,697 --> 00:40:00,600
is that he rupture to plaque either of

1010
00:40:00,600 --> 00:40:03,429
that that area or a a chunk of

1011
00:40:03,548 --> 00:40:05,690
t down dis into 1 of the board

1012
00:40:05,690 --> 00:40:08,467
distal coronary branches and far that territory, which

1013
00:40:08,467 --> 00:40:10,157
is now subsequently rec

1014
00:40:10,703 --> 00:40:12,688
clearly, based on the clinical scenario, you would

1015
00:40:12,688 --> 00:40:13,744
not attempt to rev

1016
00:40:14,117 --> 00:40:15,943
this already even though it's the pulp vessel,

1017
00:40:16,738 --> 00:40:19,860
because you are planning on likely managing this

1018
00:40:19,860 --> 00:40:22,340
patient surgical as the team will go into

1019
00:40:22,340 --> 00:40:22,980
in a little bit.

1020
00:40:24,179 --> 00:40:26,099
I would also disagree a little bit with

1021
00:40:26,099 --> 00:40:26,394
sin

1022
00:40:27,071 --> 00:40:29,004
characterization of flow in the Led, there's definitely

1023
00:40:29,619 --> 00:40:30,994
80 or 90 percent,

1024
00:40:31,529 --> 00:40:33,678
lesion following the take off a major diagonal

1025
00:40:33,678 --> 00:40:36,564
branch, but I'd characterize the flow as maybe,

1026
00:40:37,282 --> 00:40:38,079
T 2.

1027
00:40:39,276 --> 00:40:40,792
The flow does reach the end of the

1028
00:40:40,792 --> 00:40:41,804
vessel and it's

1029
00:40:42,322 --> 00:40:44,654
slower than normal. Although, not not

1030
00:40:45,189 --> 00:40:47,442
not totally normal. You know. I think it's

1031
00:40:47,738 --> 00:40:50,286
greeting Timmy flow is something that's very subjective

1032
00:40:50,286 --> 00:40:52,525
and you know, matters based on what's your

1033
00:40:52,525 --> 00:40:53,954
contrast flow rate and how long you stand

1034
00:40:53,954 --> 00:40:55,462
in the puddle. You know, in this case,

1035
00:40:55,700 --> 00:40:57,129
I I do think it's probably a little

1036
00:40:57,129 --> 00:40:59,050
better than taking 1. And then, you know,

1037
00:40:59,210 --> 00:41:01,120
again, the decision about whether or not we

1038
00:41:01,120 --> 00:41:03,269
re is that hurry is gonna depend a

1039
00:41:03,269 --> 00:41:03,928
lot on

1040
00:41:04,383 --> 00:41:07,431
what the anticipated surgical management is gonna be

1041
00:41:07,487 --> 00:41:09,256
hun leave alone for now.

1042
00:41:09,974 --> 00:41:11,170
I wanted to take a little bit of

1043
00:41:11,170 --> 00:41:13,323
a deeper dive into the idea of Pis,

1044
00:41:13,483 --> 00:41:14,838
which I find to be 1 of them

1045
00:41:14,838 --> 00:41:16,774
most fascinating concepts and echo

1046
00:41:17,151 --> 00:41:17,605
and

1047
00:41:18,042 --> 00:41:19,953
very creative use of what you normally think

1048
00:41:19,953 --> 00:41:20,828
of as an artifact.

1049
00:41:21,624 --> 00:41:24,671
So Pis is entirely based on color doppler

1050
00:41:24,888 --> 00:41:25,206
assessment.

1051
00:41:25,699 --> 00:41:28,730
Which is a variant of Pulse doppler. And

1052
00:41:28,730 --> 00:41:31,043
1 of the issues with Pulse doppler is

1053
00:41:31,043 --> 00:41:32,500
that there is a maximal

1054
00:41:32,878 --> 00:41:35,111
velocity that pulse wave doppler is able to

1055
00:41:35,111 --> 00:41:37,432
measure. And after that velocity,

1056
00:41:38,068 --> 00:41:41,328
the doppler will start to alias, which means

1057
00:41:41,328 --> 00:41:43,474
that instead of reading out a high velocity

1058
00:41:43,474 --> 00:41:46,038
it'll then become low again. The idea is

1059
00:41:46,038 --> 00:41:48,196
sort of similar to looking at a wagon

1060
00:41:48,196 --> 00:41:50,514
wheel on an old film. So if you're

1061
00:41:50,514 --> 00:41:50,833
watching,

1062
00:41:51,552 --> 00:41:53,390
you know, like, a covered Wagon go across

1063
00:41:53,390 --> 00:41:55,884
the desert covered Wagon wheels might actually look

1064
00:41:55,884 --> 00:41:58,605
like they're going backwards, and that's because of

1065
00:41:58,605 --> 00:42:01,484
the difference between the frame rate of the

1066
00:42:01,484 --> 00:42:03,818
film. And the speed of the wheel. And

1067
00:42:03,818 --> 00:42:05,656
so it's catching at just the right time

1068
00:42:05,656 --> 00:42:07,334
so that it looks like it's going backwards.

1069
00:42:07,734 --> 00:42:09,812
So color doppler because it's based on Pulse

1070
00:42:09,812 --> 00:42:11,990
wave doppler, you actually are able to measure

1071
00:42:12,144 --> 00:42:14,138
the alias thing velocity, and it's given to

1072
00:42:14,138 --> 00:42:16,132
you something called a ny quiz limit, which

1073
00:42:16,132 --> 00:42:18,365
is shown on a scale, usually at the

1074
00:42:18,365 --> 00:42:20,280
upper rates corner and the screen during your

1075
00:42:20,280 --> 00:42:22,923
cup computer color doppler assessment. And you can

1076
00:42:22,923 --> 00:42:24,854
draw out the limit

1077
00:42:25,387 --> 00:42:27,477
of where that velocity line

1078
00:42:27,851 --> 00:42:28,805
flips from

1079
00:42:29,600 --> 00:42:30,952
from 1 direction to the other.

1080
00:42:31,604 --> 00:42:33,599
The advantage of that is essentially you're now

1081
00:42:33,599 --> 00:42:36,314
able to calculate the velocity of blood in

1082
00:42:36,314 --> 00:42:38,948
all areas along the sphere as the flow

1083
00:42:38,948 --> 00:42:41,354
converge to go through the whole. So as

1084
00:42:41,354 --> 00:42:43,894
blood sort of lines up and gets lined

1085
00:42:43,894 --> 00:42:44,927
pass through the opening.

1086
00:42:45,403 --> 00:42:46,617
There's a period of

1087
00:42:46,991 --> 00:42:48,975
lam flow, and then the flow will become

1088
00:42:48,975 --> 00:42:49,372
turbulent.

1089
00:42:49,865 --> 00:42:51,945
And so in that region of lam flow,

1090
00:42:52,105 --> 00:42:54,925
the alias velocity will happen, you can calculate

1091
00:42:55,224 --> 00:42:57,545
the overall flow of blood in the dome

1092
00:42:57,545 --> 00:43:00,036
of blood that's made up by that. By

1093
00:43:00,036 --> 00:43:00,911
that Pis dom.

1094
00:43:01,865 --> 00:43:03,534
1 thing that I think is really important

1095
00:43:03,534 --> 00:43:05,203
to highlight about this case is the,

1096
00:43:05,839 --> 00:43:10,081
overall epidemiology of mechanical complications of Mi, which

1097
00:43:10,081 --> 00:43:10,741
are very

1098
00:43:11,120 --> 00:43:13,358
incredibly widely from institution to institution.

1099
00:43:14,317 --> 00:43:16,589
A lot of it is driven by patient

1100
00:43:16,730 --> 00:43:19,769
populations and abilities to access care, and we

1101
00:43:19,769 --> 00:43:21,769
actually saw an uptick in in the number

1102
00:43:21,769 --> 00:43:24,423
of mechanical complications that we were seeing during

1103
00:43:24,423 --> 00:43:26,494
the course of the Covid pandemic as patients

1104
00:43:26,494 --> 00:43:28,746
waited at home with heart attacks rather than

1105
00:43:28,884 --> 00:43:31,090
seek care immediately like they would have before

1106
00:43:31,209 --> 00:43:33,197
So it can be a marker of places

1107
00:43:33,197 --> 00:43:34,152
where there is,

1108
00:43:34,550 --> 00:43:36,538
more limited to access to care or more

1109
00:43:36,538 --> 00:43:39,003
difficulties than obtaining timely care for Mi.

1110
00:43:40,053 --> 00:43:42,445
We've also seen a number of mechanical complications

1111
00:43:42,445 --> 00:43:43,902
in younger patients who

1112
00:43:44,358 --> 00:43:46,373
ordinarily you wouldn't think of as being as

1113
00:43:46,510 --> 00:43:47,706
especially higher risk for,

1114
00:43:48,359 --> 00:43:50,210
like acute coronary syndromes, but

1115
00:43:50,822 --> 00:43:53,604
because that perceive risk is low, patients, you

1116
00:43:53,604 --> 00:43:54,422
know, don't

1117
00:43:54,796 --> 00:43:56,703
don't think that they're having a heart attack

1118
00:43:56,703 --> 00:43:59,657
and might wait to seek care. So we've

1119
00:43:59,657 --> 00:44:02,597
seen all kinds of mechanical complications and younger

1120
00:44:02,597 --> 00:44:04,106
patients as well, which is, you know, can

1121
00:44:04,106 --> 00:44:06,568
be very unfortunate very difficult for patients to

1122
00:44:06,568 --> 00:44:06,886
deal with.

1123
00:44:07,699 --> 00:44:09,377
The bottom line for dealing with all of

1124
00:44:09,377 --> 00:44:11,615
these mechanical complications is to have a high

1125
00:44:11,615 --> 00:44:13,932
index of suspicion for them as you bring

1126
00:44:13,932 --> 00:44:15,371
patients over to the cath lab. You know.

1127
00:44:15,531 --> 00:44:17,643
This goes back to this overall fundamentals,

1128
00:44:18,021 --> 00:44:21,453
you know, good physical exam, good clinical suspicion

1129
00:44:21,453 --> 00:44:23,309
can help you, more rapidly

1130
00:44:23,688 --> 00:44:26,254
identify these problems and that definitely changes your

1131
00:44:26,254 --> 00:44:27,311
management strategy

1132
00:44:27,688 --> 00:44:30,316
in the Cath lab or, you know, ideally,

1133
00:44:30,635 --> 00:44:32,865
for most circumstances, you'd be focused more on

1134
00:44:32,865 --> 00:44:35,902
rep reproducing the muscle. Whereas for someone who's

1135
00:44:36,379 --> 00:44:39,716
experienced a mechanical complication, the idea shifts more

1136
00:44:39,716 --> 00:44:42,869
towards institution or evaluation from mechanical support and

1137
00:44:43,466 --> 00:44:45,137
keeping them stable until they're able to have

1138
00:44:45,137 --> 00:44:48,421
a definitive repair for surgery. So, for cardiology

1139
00:44:48,478 --> 00:44:49,353
follows that are listening,

1140
00:44:50,164 --> 00:44:52,164
definitely, every single patient that comes to the

1141
00:44:52,164 --> 00:44:53,925
cath lab, you should be listening for murmur

1142
00:44:53,925 --> 00:44:56,324
very carefully. I know that's really difficult. The

1143
00:44:56,324 --> 00:44:57,844
emergency room work can be loud and there's

1144
00:44:57,844 --> 00:45:00,014
a lot of people around, but incredibly important,

1145
00:45:00,570 --> 00:45:03,115
particularly for things like ventricular simple rupture, which

1146
00:45:03,115 --> 00:45:05,025
are gonna be really, really challenging to pick

1147
00:45:05,025 --> 00:45:05,740
up on focus.

1148
00:45:06,632 --> 00:45:08,090
Without a careful color doppler

1149
00:45:08,467 --> 00:45:10,461
examination. Oh, thanks for our fellows for such

1150
00:45:10,461 --> 00:45:12,694
a great presentation, and thanks for inviting me

1151
00:45:12,694 --> 00:45:14,768
to lend my 2 cents to this conversation.

1152
00:45:15,007 --> 00:45:15,940
Thanks everybody. Bye

1153
00:45:17,411 --> 00:45:19,639
And finally, to close out this great episode,

1154
00:45:20,036 --> 00:45:21,730
let us introduce our cardiovascular

1155
00:45:22,105 --> 00:45:24,570
disease fellowship program director of Doctor Be Holmes.

1156
00:45:24,984 --> 00:45:26,905
So he can share his thoughts on our

1157
00:45:26,905 --> 00:45:29,085
program. He is an electro epidemiologist

1158
00:45:29,464 --> 00:45:31,625
and a great metric for every 1 of

1159
00:45:31,625 --> 00:45:34,273
us He's such a strong advocate for our

1160
00:45:34,273 --> 00:45:36,585
daily education, and we just love working with

1161
00:45:36,585 --> 00:45:37,463
them every single day.

1162
00:45:38,340 --> 00:45:40,733
Hi, everyone. I have Be hall, the program

1163
00:45:40,733 --> 00:45:41,871
director for the Cardiovascular

1164
00:45:42,264 --> 00:45:44,342
disease fellowship program here at the University in

1165
00:45:44,422 --> 00:45:44,902
Rochester.

1166
00:45:45,780 --> 00:45:48,178
Thank you, La sin and N for the

1167
00:45:48,178 --> 00:45:50,896
excellent presentation on a patient with acute pap

1168
00:45:50,896 --> 00:45:51,535
muscle rupture.

1169
00:45:52,348 --> 00:45:55,059
This patient was fortunate to receive such outstanding

1170
00:45:55,059 --> 00:45:56,016
care from all of you.

1171
00:45:56,733 --> 00:45:58,806
I learned a lot during this case presentation,

1172
00:45:59,285 --> 00:46:01,294
including the La placed that could tar, which

1173
00:46:01,454 --> 00:46:02,173
I did not know.

1174
00:46:02,892 --> 00:46:05,230
Our fellowship program at the University of Rochester

1175
00:46:05,289 --> 00:46:06,408
is truly Soc.

1176
00:46:06,967 --> 00:46:09,385
We see a wide variety of clinical cases

1177
00:46:09,779 --> 00:46:11,771
serving a catch area that extends down to

1178
00:46:11,771 --> 00:46:12,886
the Pennsylvania border.

1179
00:46:13,683 --> 00:46:16,472
With 6 fellows per class, our graduates pursue

1180
00:46:16,472 --> 00:46:19,101
advanced fellowship as well as academic and private

1181
00:46:19,101 --> 00:46:19,990
practice careers.

1182
00:46:20,784 --> 00:46:23,006
We have a very busy heart transplant center

1183
00:46:23,006 --> 00:46:25,942
and El program, and we offer extensive training

1184
00:46:25,942 --> 00:46:28,655
and critical care, including a 1 year cardiac

1185
00:46:28,655 --> 00:46:29,767
critical care fellowship.

1186
00:46:31,038 --> 00:46:34,293
Additionally, we provide significant research opportunities with 2

1187
00:46:34,293 --> 00:46:35,961
full time research faculty members.

1188
00:46:36,771 --> 00:46:39,000
Our location in Central New York gives fellows

1189
00:46:39,000 --> 00:46:41,148
the opportunity to care for patients in both

1190
00:46:41,148 --> 00:46:42,660
urban and rural communities.

1191
00:46:43,869 --> 00:46:46,284
We are excited about the upcoming fellow applicant

1192
00:46:46,503 --> 00:46:48,897
interview season this fall. And if you decide

1193
00:46:48,897 --> 00:46:50,972
to apply to a program, we really look

1194
00:46:50,972 --> 00:46:51,850
forward to meeting you.

1195
00:46:52,502 --> 00:46:55,125
Thanks again, and great job with the presentation.

1196
00:46:56,794 --> 00:46:58,781
Thank you for 20 n to this card

1197
00:46:58,781 --> 00:47:01,978
unit episode. The audio and editing for this

1198
00:47:01,978 --> 00:47:04,633
episode was performed by me Ot fe h,

1199
00:47:05,012 --> 00:47:07,486
I an in intern card Academy House in

1200
00:47:07,646 --> 00:47:09,880
Poland. And a research follow at the mayo

1201
00:47:10,120 --> 00:47:12,529
Clinic. I invite you to check out our

1202
00:47:12,529 --> 00:47:14,626
website for show notes and references.

1203
00:47:15,083 --> 00:47:18,355
If you find this episode informative, please consider

1204
00:47:18,355 --> 00:47:20,690
sub grabbing to card unit on your favorite

1205
00:47:20,690 --> 00:47:23,329
podcast platform and leaving us a review. It

1206
00:47:23,329 --> 00:47:25,329
really help was a spread word for our

1207
00:47:25,329 --> 00:47:26,309
goal to

1208
00:47:26,849 --> 00:47:27,349
cardiovascular

1209
00:47:28,221 --> 00:47:31,010
education. Finally, this podcast not mean to be

1210
00:47:31,010 --> 00:47:34,118
used for medical advice. The views and expresses

1211
00:47:34,118 --> 00:47:36,601
on our show and site do not reflect

1212
00:47:36,601 --> 00:47:40,104
the opinion or policy of our employers. All

1213
00:47:40,104 --> 00:47:42,945
card unit content is planned, use

1214
00:47:43,465 --> 00:47:44,925
review solely by card.

1215
00:47:45,305 --> 00:47:46,844
Stay to inform more engaging

1216
00:47:47,144 --> 00:47:50,751
conversation and exploration on our upcoming episodes. And

1217
00:47:50,751 --> 00:47:53,467
now it's time to make like s 2

1218
00:47:53,467 --> 00:47:54,186
and a plea.