Echo: Abnormal Ventricular Diastolic Function

Extract from Snider's Echo book (Restrictive Cardiomyopathy):

Restrictive cardiomyopathy is characterized by
1) abrupt cessation of diastolic filling in the first 1/3rd of diastole
2) Associated with large atria, normal-sized ventricles and variable systolic function.

Normal LV dimensions, normal or low fractional shortening %.
Abrupt increase in LV dimension in early diastole (Abrupt posterior motion of LVPW and anterior motion of IVS) followed by no further increase in dimensions (i.e. flat LVPW & IVS throughout the rest of diastole)

Abrupt cessation of filling creates a jerky, spasmodic wall motion.

Doppler fl0w pattern:
MV Doppler:
Peak E and % of E area - Normal
Peak A & % of A area - Decreased
Therefore, E/A ratio is increased.

Mitral Deceleration Time:
Decreased less than 150 ms
LV. IVRT (Isovolumic relaxation time) - shorter

Mechnism of short deceleration time (MV): Rapid equalization of LVEDP and Atrial pressure(corresponds to "Rapid filling wave" in LV trace in cath lab).
Further shortening of TV deceleration occurs with inspiration (Increased filling -> septum bows to left -> Decreases LV diastolic function.
Mid-diastolic MR or TR (correspond to peak of rapid filling wave)

Systemic venous flow pattern:
1) Decreased forward flow during systole
2) Increased or prolong flow reversal during atrial contraction (worse during inspiration)...Reflects decreased RV compliance.

Diastolic forward flow in MPA (during inspiration)


Cath: Angiographic Projections

According to site of injection:


Anatomy of interest
Pulmonary Valve
Sitting up view
TOF, Pulm. Atresia
Peripheral PAs
Sitting up view
RAO30° / LAO60°
Central PAs
Long Axial Oblique
RAO30°/ LAO60°
AVC, Tri. Atresia
Asc. Ao.
(Ao. Root)
Long axial Oblique
RAO30° / LAO60°
30-40°¯ ± 10-15°LAO (Laid-back or Down-the-barrel view)
Coronaries in TGA
Desc. Ao.
RAO ± ­angulation helps in some PDAs.
(For Sec. ASD)
Hepatoclavicular view
Named projections:

Sitting up view: 30-40°­ / Lateral

Central PAs in TOF, Pulm. Atresia
Pulmonary sling
Vascular ring (Double aortic arch)
Hepatoclavicular view (4 Chamber view)*
Lat camera only (LAO 40°/­40°)
PA camera is not part of this view. Can be used as determined by the operator.
Complete and Partial AVC
Tricuspid atresia
Straddling TV or MV
Single ventricle
Inlet VSD
Secundum ASD (Injection in RUPV)

Long axial oblique view (L.Ax.Obl.)*

(RAO 20°,¯10° / LAO 70°,­ 20°)
Ventricular septal defects:
Malalignment (TOF)
Sub pulmonary
Apical (L.Ax.Obl.)
Anterior (RAO)
Mid-Posterior (L.Ax.Obl.)
Subaortic stenosis
Subpulmonary stenosis in TGA
Secundum ASD (injection in RUPV) - Hepatoclavicular view is more preferred.
(*Hepatoclavicular view and L.Ax.Obl view are called axial views, since they ‘line up’ in the long axis of the heart.)

Laid-back view: (35 degree caudal in PA view)
For demonstration of coronary arteries in d-TGA
See posting in "Anatomy: Coronary anatomy in TOF, d-TGA, ..."

Sleeping bat view: (35 degree caudal in PA or RAO or LAO view)
For demonstration of distal Sano shunt junction with branch PAs.
See posting "sleeping bat view" in this blog.
LPA origin: (LAO 15 degree, cranial 20 degree on PA camera & Straight lateral)
Dr. Rao uses this. He says, Bergeron described it.

Cath: Screening before PFO closure

Name, Age, Gender
PMH: CAD, DM, HT, Hyperchol, Afib, Carotid Dz, PE, DVT, First trimester miscarriage (How many), Migraine (with or without aura)
Family Hx: PE, DVT, Miscarriage
Smoker: Current, Former
ETOH: (amt, current, Former)
Meds at the time of episode: (Antiplatelet, Warfarin, Statin, OCP, Other)
Initial complaint: (Description, Date & Time)
Nature of episode: TIA, Stroke, Peripheral embolism, Other, Retinal ischemia
Valsalva in history: (lifting, coughing, straining, laughing, sex within 30 min of onset). If yes, explain
Prolonged immobility: (hospitalization, travel, etc. within 1 week of episode)
Concurrent illness:
Previous spell suggestive of TIA/Stroke/Peripheral emb - Dates if yes)
Evidence of multiple lesions on exam
Cardiac murmur
Crochetage in EKG

Protein C & S
Factor V Leiden (APC res.)
Lupus anticoagulant
Anticardiolipin AB
Antiphosphotidylserine Ab
Prothrombin gene mutation
Cholestrol panel (TC, HDL, LDL, TG)
TOAST criteria:
Large vessel (Probable, Possible)
Cardioembolic (Probable - Lesion _____, Possible)

Some references:
JACC 2005;46:1768-76. State of the art paper. Patent Foramen Ovale: Current pathology, pathophysiology, and clinical status.

Stroke 2004;35:803-4. Patent foramen ovale and recurrent stroke: Closure is the best option: Yes.
Stroke 2004;35:804-5. Patent foramen ovale and recurrent stroke: Closure is the best option: No.
Stroke 2004;35:806. Patent foramen ovale and stroke Closure by further randomized trial is required.


Surgery: Hegar Sizing of RVOT

From Cardiac Surgery. Safeguards and Pitfalls in Operative Technique - Siavosh Khonsari (2nd ed. 1996)
Hegar sizes are similar to French sizing. The size number is the circumference of the dilator in mm. So, the diameter is the size/π. (π = 3.14).

Above table is based on 'The quantitative anatomy of the normal child's heart. Rowlatt, UF., Rimoldi, HJA., Lev, M. Pediatr Clin North Am 1963;10:499'.

Cath: Coronary Fistula

Case #1
Asymptomatic murmur in a 2 year old. H/O Asthma since 6 months of age
(The following images are from Balaguru et al. Catheter Cardiovasc Interv 2006;67:942-6)

Additional reference:
Valente, AM, et al. Circulation Cardiovascular Interventions 2010;3:134-9. Predictors of long-term adverse outcome in patients with congenital coronary fistula (Some what adult oriented study from Boston Children's Hospital. The following image is from this article, showing mural thrombus in mid-circumflex branch - 2 yrs after transcatheter closure).

Anatomy: Shone's Complex

Shone's Complex:
1) Supravalvar Mitral Ring
2) Parachute Mitral Valve
3) Subaortic Stenosis
4) Coarctation of Aorta

Images below are from: Shone, JD., Sellers, RD., Anderson, RC., Adams, P., Lillehei, CW., Edwards, J. The developmental complex of "parachute mitral valve", supravalvar mitral ring of left atrium, subaortic stenosis and coarctation of aorta. Am J Cardiol 1963;11:714. Extensive report of 8 cases with clinical, pathologic and EKG information.

Supravalvar Mitral Ring

Parachute Mitral Valve (Partial type)

Parachute Mitral Valve

Subaortic Stenosis

Coarctation of aorta


ICU / EKG: Postop ST segment elevation

8 yr old girl, s/p PAPVR repair
(LUPV to LSVC to CS was repaired)
Baseline EKG (EKG #1) is unremarkable for immediate postop.

EKG #1
Approx. 10 hrs later, ST segment elevation was noted in monitor. Therefore, EKG was repeated. No complaints from patient.

EKG #2
Next morning: EKG was improving

EKG #3


Is this pericarditis, developing in ~10 hrs after conclusion of surgery?

Why don't we see it in more postop. patients?

Also, see posting titled "ICU - Postop. chest pain"


Statistics: Picking a test

Flow charts below depict tests suitable for different circumstances:
(Source: Medical Statistics at a glance. Aviva Petrie & Caroline Sabin. 2nd ed.2005)

ICU: EKG strip for interpretation

First postop. day after repair of AV septal defect. 3 month old Down's syndrome baby.
Earlier, there was transient complete heart block in the OR.


ICU: Swan Ganz Catheter Data

ICU: Vasopressin

Review article: Physiology of Vasopressin relevant to management of septic shock Holmes, CL. et al. Chest 2001;120:989-1002.

Quite an useful article to get to understand the available information, both in children and adults.

ICU: Swan data display

After the earlier readings above, patient was suctioned and given neb. albuterol...the following readings were observed.
Question: Why is the Cardiac Output higher with lower PA saturations?!

This telemetry trace shows drop in systemic oxygen saturation at the same time as well. Therfore, the A-V difference of saturations (between pulse ox & PA sat from Swan-Ganz) actually narrowed during this time. Therefore, the CO increased.
Patient also became tachycardiac following this which also contributes to increase in CO.
You may be able to read the numbers if you click on the image (larger image will display)


Board Exam Questions from 2000, 2002, 2008

Click on title above to download Board Exam Questions document.
Once get to the document, you can save it from "File"..."Download As"...a file format of your choice.


Anatomy: Aberrant RSCA, Pulmonary Sling, Barium Swallow

Aberrant Subclavian Artery Origin

(RSCA crosses midline, posterior to esophagus)

Netter diagram

Pulmonary Sling: Origin of LPA from RPA

(LPA crosses midline anterior to esophagus, inbetween esophagus & trachea)

(Diagrams below are from Esophagography in Anomalies of Aortic Arch System. A.C. Klinkhamer. The Williams & Wilkins Company, Baltimore MD. 1996)

How to use the Table:

1. First, review plain CXR (PA view; High dose film) - Ascertain aortic arch sidedness & position of descending aorta in thorax.

2. Second, study Barium Swallow Study - Usually Frontal and Oblique views (Note: Lateral view is ideal for Pulmonary sling and Double aortic arch, but not useful in other anomalies)

Image source: Esophagography in anomalies of the aortic arch system. A.C. Klinkhamer. The Williams & Wilkins Company, Baltimore, MD. 1969. Copyright - Excerpta Medica Foundation.

Related link: Barium Swallow