Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Which clinical and echocardiographic parameters (i.e. LVEF, AVA) do you use when determining patient candidacy for LV device-assisted percutaneous balloon aortic valvuloplasty in patients with cardiogenic shock and severe AS?
This is a tough one and there is no one best answer. The entire clinical picture must be taken into account. Typically, use of an RHC can help guide a patient in cardiogenic shock the best. Historically, patients with mean gradients over 40 mmHg with AVA < 1.0 cm sq by echo or by invasive testing wi...
Is there a preferred heart rate range for patients with moderate to severe paravalvular leak post-TAVR?
There is no optimal heart rate in managing moderate to severe paravalvular regurgitation after TAVR. I generally begin at 70 BPM. Depending on associated conditions such as CAD or mitral stenosis the rate can be increased with echo guidance for optimal rate
What would be a reasonable means of mechanical circulatory support as a bridge to AVR for patients with severe aortic regurgitation complicated by cardiogenic shock?
Options are limited when dealing with severe aortic regurgitation. LAVA-ECMO should be considered to provide needed support. This can reduce the increased left-sided filling pressures and urgent surgery is warranted. Tandem heart can also be considered to help provide needed support without increase...
Among asymptomatic patients with chronic, severe primary MR, can serial global longitudinal strain measurements assist with determining timing for repeat surveillance TEEs and/or facilitate timing for MVR?
The first issue when discussing asymptomatic, severe valve disease is clarifying symptom status. Hemodynamic stress echocardiography or catheterization may unmask symptoms or elevated pulmonary artery pressures at an age-appropriate workload; abnormalities of functional capacity or pulmonary pressur...
What is a reasonable surveillance strategy and length of time to maintain patients with thrombosed bioprosthetic valves on systemic anticoagulation?
When a patient is clinically stable, CT scans and echocardiography can help in differentiating thrombus from pannus formation in bioprosthetic valves (though not perfectly). In the setting of significant symptoms or hemodynamic compromise, surgical valve replacement should be considered (transcathet...
When should we consider using acarbose for postprandial hypotension?
Primarily in neurogenic Orthostatic Hypotension patients, and less frequently in POTS patients, they give a history of dizziness and hypotension with meals. First, we like to confirm the cause and recommend the following, checking before and after BPs at baseline and then with the following: Try sm...
What is your approach to initiating and titrating midodrine for both inpatient and ambulatory settings?
It depends on the indication: Orthostatic Hypotension: 2.5 mg TID CC Inpatient - Check orthostatics SEATED 5', then Standing 1' 3' 5' about one hour after dosing. Increase by 2.5 mg every other dose until patient clinically not orthostatic or 10mg TID CC is achieved or seated hypertension or other s...
Should vasodilatory therapies be considered first-line in the management of hypertension in patients with severe aortic regurgitation?
Yes, ACEi or ARB or dihydropyridine Calcium channel blockers would be the preferred anti-hypertension medication classes in patients with HTN and significant aortic regurgitation. There is no role, however, for using these agents in patients with severe AR without HTN.
Should a toe-brachial index be obtained in lieu of resting ABI as an initial screen for PAD in high-risk patients such as those with longstanding diabetes or advanced age with stiffened vessels?
Yes, a TBI should be used instead of an ABI in patients with diabetes and chronic kidney disease as the ABI is likely to be inaccurate due to non-compressible vessels. An arterial duplex and TBI should be the test of choice in this patient population.
Should all pregnant patients with newly reduced LVEF <45% be referred as soon as possible to advanced heart failure given high risk for maternal morbidity/mortality in setting of suspected peripartum cardiomyopathy?
The ESC EURObservational Research Programme demonstrated that at six months, in women with peripartum cardiomyopathy: Left ventricular function recovery occurred in 46% of women, whereas 23% continued to have persisting and severe left ventricular dysfunction Re-hospitalization rate was one in 10, a...