Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you approach treatment planning for lung SBRT in a patient with a lesion within 1 cm of a defibrillator?
V-fib requiring defibrillation poses an immediate life-threatening situation. Even if the patient doesn't regularly need their pacemaker, one would need to know that their defibrillator is functioning. In this case, I don't think there's any choice except to move the pacemaker/defibrillator to the o...
What is a reasonable MCS option for patients in cardiogenic shock and the presence of a VSD as a bridge to cardiac surgery?
Impella 3.5 or 5
In light of the NOAH-AFNET6 and ARTESiA trials, how would you approach the decision regarding anticoagulation for patients with incidentally-detected AF <24 hrs on pacemakers/defibrillators?
Finding the right answer for subclinical atrial fibrillation is sometimes hard to tease out the subtleties. The 2023 ACC/AHA/HRS atrial fibrillation guidelines were published in Jan 2024 (Joglar et al., PMID 38033089) and a section (6.4.1) is dedicated to patients with CIED without prior atrial fibr...
What is/are your preferred technique(s) for obtaining LV-Ao pressure gradients in the cath lab?
Two other ways to do this I learned while the Langston Cather was on back order to use a 6F 75 or 85 cm R2P sheath parked in the ascending aorta and a 4F pigtail in the LV. With two transducers (on off the side of R2P and one on pigtail) and a 2F difference in size of catheters, you get nice fidelit...
How would you balance the risk of intracranial hemorrhage with thrombosis of mechanical valves in patients with infective endocarditis?
I'm not sure that there is a good answer to this question. If you look at it segmentally, clearly, patients with mechanical valves require anticoagulation, especially in the mitral position. In patients with endocarditis and native valves, whether or not to anticoagulate the patient after or before ...
Should we routinely include geriatric functional assessments to determine candidacy for TAVR?
Studies have shown that 40-50% of older patients with severe AS and high (≥8%) or prohibitive (≥15%) risk for perioperative mortality with surgical aortic valve replacement (based on the STS score) fail to survive with improved quality of life 1 year after undergoing TAVR. This suggests that TAVR ma...
In patients presenting to the hospital with atrial fibrillation of >/= 48 hours and are started on anticoagulation, provided they spontaneously convert with AV nodal blocking agents but then revert back into AF, would you need LAA imaging before a rhythm control strategy with AADs or cardioversion?
I would approach this the same way as if the patient had never spontaneously converted. There is a risk of stroke with chemical as well as electrical cardioversion, so should factor in CHA2DS2-VASc when making that decision. If CHA2DS2-VASc is 0 and no other high-risk features (rheumatic disease, HC...
How do you approach the use of anticholinergic medications that are prescribed for patients for non-cardiac issues, given evidence that increased anticholinergic burden may elevate the risk of out-of-hospital cardiac arrest?
Diminishing vagal tone should always be approached with caution because of the potential for adverse cardiovascular outcomes. These include sudden death as well as the potential for ischemic events caused by increasing oxygen demand. However, we need to be careful not to extrapolate these concerns t...
What is a reasonable stepwise approach to diagnostic imaging when there is ongoing concern for cardiac amyloidosis?
Abnormalities on CMR are not diagnostic of cardiac Amyloidosis. Although LGE, abnormal ECV, and abnormal T1 are findings commonly seen in Cardiac amyloidosis, the absence of one or more does not rule out amyloid. In the setting of increased LV thickness and clinical suspicion of amyloid, I would hav...
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...