Hu Said: Cardiology Board Review Series

In this episode, we explore the timing and indications for aortic valve replacement (AVR) in aortic stenosis (AS). Is it possible to qualify for AVR if AS is not severe, or if AS is asymptomatic? What are the key considerations when choosing between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), and when might palliation be more appropriate? What are th...

In this episode, we explore various types of aortic valve stenosis (AS) other than conventional AS, including low-gradient AS, bicuspid and unicuspid valves, subvalvular and supravalvular AS. What is the difference between classical low flow low gradient AS, paradoxical low flow low gradient AS, and normal flow low gradient AS? What parameters on dobutamine stress echo allow you to and valvular co...

In this episode, we explore the epidemiology of valvular disease, and then jump in to aortic stenosis, focusing on the presentation, grading of severity, measurement of gradients on invasive and non-invasive modalities, and calculation of valve area. What is Heyde's syndrome? What is the Gallavardin phenomenon? What is pulsus parvus et tardus? What are the cutoffs for mild, moderate, and severe AS...

In this episode, we review post-heart transplant issues, including immunosuppression, rejection, complications, and long-term monitoring. What are the three phases of immunosuppression? How do calcineurin inhibitors, antimetabolites, and corticosteroids prevent rejection? What are the key differences between hyperacute rejection, acute cellular rejection, antibody-mediated rejection, and chronic r...

In this episode, we review pre-heart transplantation issues, including indications for heart transplant, exclusion criteria for heart transplant, levels of listing for heart transplant, and serial testing while on the wait list. What is the definition of advanced heart failure? What are the indications for evaluation for heart transplant? What are major exclusion criteria for heart transplant? Wha...

In this episode, we review cardiopulmonary exercise testing (CPET) and its role in heart failure management and transplant evaluation. What term describes the value at which oxygen uptake plateaus despite a continued increase in the intensity of exercise? What term describes the threshold during exercise at which lactic acid begins to accumulate in the blood and carbon dioxide production starts to...

In this episode, we review patient selection for left ventricular assist devices (LVADs), LVAD types, components, physiology, and troubleshooting. LVAD evaluation may be reasonable in patients in which INTERMACS profiles? What is the function of the driveline, system controller, pump cable, and rotor of the LVAD? What is a typical fixed speed, and how close should the actual speed be to the fixed...

In this episode, we review the use of imaging in assessing patients before and after LVAD implantation. What are concerning findings on pre-LVAD echocardiogram, other than an overly small left ventricular (LV) cavity? On post-LVAD echocardiogram, what emergency would be suggested by the combined findings of an increased left ventricular internal diameter at end diastole (LVIDd), worsened mitral re...

In this episode, we go over the practical use and management of intra-aortic balloon pumps (IABP) in the cardiac intensive care unit. How does the IABP assist during systole and diastole, and what are the hemodynamic benefits of its inflation and deflation? What physiologic effects does the balloon pump have on cardiac output, coronary perfusion, left ventricular wall stress, pulmonary capillary w...

In this episode, we review the use of inotropes in acute decompensated heart failure and cardiogenic shock? What are the effects of activating alpha-1 receptors, beta-1 receptors, and beta-2 receptors? What are the effects of inhibiting phosphodiesterase-5? What is the vasoconstriction-vs-inotropy-plot and where does each inotrope and vasopressor sit on the plot with respect to the intropy=0 verti...

In this episode, we review central venous pressure (CVP) waveform interpretation. What is signified by the a, c, and v waves, and the x and y descents? What do giant a peaks signify? What do cannon a waves signify? What does absent a peak signify? What does a prominent v peak or merged CV peak signify? What does a diminished v peak signify? What does a merged ACV peak signify? What does a rapid y...

In this episode, we review pulmonary artery (Swan-Ganz) catheterization. What are indications and contraindications to pulmonary artery catheter placement? What variables make up the oxygen content equation and oxygen delivery equation? What is the difference between mixed venous oxygen saturation (SvO2) and central venous oxygen saturation (ScvO2)? What conditions cause elevated or depressed SvO2...

In this episode, we review the assessment of right ventricular (RV) size and function. What is the normal range of RV basal diameter, mid diameter, and longitudinal diameter? What are the relative advantages and drawbacks of tricuspid annular plane systolic excursion (TAPSE), tissue Doppler peak systolic velocity S’ at the tricuspid annulus, RV fractional area change (RV FAC), and RV index of myoc...

In this episode, we review diastolic function and diastolic dysfunction. What are the four phases of diastole? What are the characteristics of normal diastolic filling patterns, and how do they change in mild, moderate, and severe diastolic dysfunction? How do the E and A waves on Doppler of mitral inflow evolve with increasing stages of diastolic dysfunction? How do E and A waves vary with age, p...

In this episode, we review the very common issue of diuretic resistance and cardiorenal syndromes. What are the key actions of diuretics along different segments of the nephron? How do factors like hypoalbuminemia, renal perfusion pressure, and competing anions reduce loop diuretic efficacy? What role does chronic RAAS activation play in creating sodium avidity in the distal tubules and collecting...

In this episode, we review the role of biomarkers and lab abnormalities in congestive heart failure. What are ANP, BNP, CNP, and DNP? What effect does BNP have on glomerular filtration rate, urinary sodium excretion, adrenal aldosterone secretion, and peripheral vascular tone? What is the relationship between BNP and NTproBNP? What are some factors that increase BNP and NTproBNP? What are some fac...

In this episode, we review the presentation and management of acute heart failure decompensation (ADHF). Why is venous dilation with IV nitroglycerin beneficial in patients with ADHF? What are the four quadrants of the Forrester-Stevenson classification? What is the relative conversion between oral and IV loop diuretics? When is a right heart catheterization indicated? What is the difference betwe...

In this episode, we review chronic heart failure with reduced, mildly reduced, improved, and preserved ejection fraction (HFrEF, HFmrEF, HFimpEF, HFpEF). What are the stages of HF, and what therapies should be given to patients with pre-heart failure? What does adverse myocardial remodeling involve? While core GDMT for HFrEF is well-known, what constitutes core GDMT for HFpEF and HFmrEF? When shou...

In this episode, we go over the diagnosis and management of non-compaction cardiomyopathy (LVNC), stress cardiomyopathy, and myocarditis. What imaging criteria are used to define LV noncompaction, and how does this differ between echocardiography and cardiac MRI? What are the most common microbes causing myocarditis? Can athletes with LVNC or myocarditis participate in competitive sports? Tune in...

In this episode, we explore various forms of dilated cardiomyopathies (DCM) and their distinct features. What are the hallmark characteristics of idiopathic dilated cardiomyopathy on echocardiogram, and how does the sphericity index predict prognosis? How do we differentiate between dilated cardiomyopathies like sarcoidosis, peripartum cardiomyopathy, tachycardia-mediated cardiomyopathy, and hemoc...

In this episode, we review restrictive cardiomyopathies (RCM), including amyloidosis and hypereosinophilic syndrome. What is the ice-cream cone appearance of the atria? What is the cherry-on-top appearance on strain imaging? What is the difference between AL, SSA, ATTR, and AA amyloidosis – which ones never have cardiac involvement and which ones always have cardiac involvement? Which amyloidosis...

In this episode, we explore types of hypertrophic cardiomyopathy (HCM) other than idiopathic HCM and obstructive HCM, including apical HCM, Fabry's disease, and Danon's disease. We also review an HCM-mimic, athlete's heart. What are 10 ways that athlete's heart can be distinguished from HCM on imaging? Which cardiomyopathies will have thinning (echogenecity) of the basal inferolateral wall instead...

In this episode, we explore the medical and surgical management of hypertrophic cardiomyopathy (HCM) and hypertrophic obstructive cardiomyopathy (HOCM). What cautions should you take with inotropes, vasodilators, diuretics, preload, and afterload in patients with HOCM? Do you initiate and uptitrate therapies based on symptoms, heart rate, QTc, or left ventricular outflow tract (LVOT) gradient? How...

In this episode, we review the diagnosis and imaging of hypertrophic cardiomyopathy (HCM) and hypertrophic obstructive cardiomyopathy (HOCM). How does the location of septal hypertrophy differ by age? Why does systolic anterior motion (SAM) of the mitral valve occur? What is the role of crypts in HCM? What is the Brockenbrough-Braunwald-Morrow sign? Tune in for answers to these questions. Difficul...

In this episode, we review pre-operative cardiovascular risk stratification for noncardiac surgery. What is considered a low-risk surgery? What does "risk" refer too–risk of what? How are emergent surgery, urgent surgery, time-sensitive surgery, and elective surgery defined? How does functional capacity factor into decisions about preoperative testing? What are the cardinal steps for determining w...