Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For CLL patients with high-risk cytogenetics on ibrutinib who develop a cardiac event such as an MI, would you continue ibrutinib?
It depends on the cardiac event (and the CLL status). After any serious event, if the CLL is under good control (clinical CR), I think it is very acceptable to stop the ibrutinib and wait until clinical progression occurs - which can be a while for some patients (median 2 years from the E1912 study)...
Do you routinely order a pre-operative TTE in patients with apparently compensated CHF, but who have not had an echocardiogram in some time?
In a patient with compensated CHF (with stable symptoms), I do not routinely order pre-operative echocardiograms for evaluation of ejection fraction. There are some situations in which it may be helpful for perioperative risk assessment, counseling, and management.The 2024 ACC/AHA (American College ...
How do you approach the decision of when to perform left heart catheterization in a patient with an NSTEMI who recently had an acute ischemic stroke?
This is a complicated question. Most acute CVA patients have non-MI troponin elevations, and I generally treat them medically. If there is a true NSTEMI associated with CVA, it requires a thoughtful approach. I generally divide my NSTEMI patients into high-risk and non-high-risk. I will perform a di...
How do you decide between opting for semi-elective outpatient versus inpatient TAVR for patients with severe critical AS?
Most patients undergo semi-elective procedures, which are more favorable for hospital reimbursement and reduce the risk of acute kidney injury. However, in a small subset of patients (<20%) with critical aortic stenosis (AS) and severe symptoms, particularly syncope, inpatient management is required...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
What factors should be prioritized when deciding the timing of CIED extraction in patients with high surgical risk or multiple comorbidities?
I'll do my best to respond, though the question isn’t entirely clear to me. If the intent is to determine which patients should be prioritized for CIED extraction, the key consideration is whether the benefits outweigh the risks. The most straightforward case is persistent bacteremia, especially in ...
If a pregnant patient with a mechanical heart valve takes warfarin throughout her pregnancy, what are the chances that the fetus will be harmed?
Warfarin is effective for thromboembolic prevention in pregnant patients with mechanical valves. There is however an overwhelming evidence that warfarin taken during pregnancy is deleterious to the fetus. Its use during the first 6–12 weeks of gestation can be associated with important fetal complic...
What is your approach to medical management and echocardiographic surveillance for pregnant patients with severe aortic stenosis during the first, second, and third trimesters?
There is no need for routine echocardiographic surveillance during pregnancy if the patient is asymptomatic and there is no change in the level of BNP. The echo can be helpful for the assessment of pulmonary pressure in patient who develops symptoms .Change in the BNPlevel and echocardiographic PA p...
If a patient has potential arrhythmic-sounding syncope and a noninducible type 2 or 3 Brugada ECG pattern, have we excluded Brugada syndrome as the etiology for their syncope?
This is a complex question with a few nuanced components. The first component is qualifying an arrhythmic versus non arrhythmic cause of syncope. I would stress that this is based on generalization as there are no features that will provide absolute certainty for the nature of a single syncopal even...
Is there any data to support the use of bivalirudin over heparin in patients on VA-ECMO without ongoing concerns for HIT?
Multiple recent meta-analyses and retrospective studies suggest that bivalirudin may reduce the risk of circuit thrombosis, major bleeding, and in-hospital mortality compared to heparin in VA-ECMO patients, even in the absence of HIT.[1][2][3][4][5][6][7][8] Some studies also report improved time in...