Episodes Archives - Cardionerds

Cardiogenic shock (CS) remains a complex, multifactorial syndrome associated with significant morbidity and mortality. The CardioNerds Critical Care Cardiology Series tackles this important syndrome in a series of several episodes including: LV-predominant Shock, RV-predominant Shock, and Bi-ventricular Shock.

In this episode, we review the definitions, pathophysiology, evaluation, and contemporary management, including use of inotropes and mechanical circulatory support, of left ventricular (LV) predominant CS. Series co-chairs Dr. Eunice Dugan and Dr. Karan Desai along with CardioNerds Co-founders Dr. Amit Goyal and Dr. Daniel Ambinder were joined by FIT lead, Dr. Vanessa Blumer, the recipient of the AHA 2021 Laennec Fellow in Training Clinician Award and currently pursuing Advanced Heart Failure and Transplant fellowship at the Cleveland Clinic. Our episode expert is Dr. Shashank Sinha, an Advanced Heart Failure, Mechanical Circulatory Support, and Cardiac Transplant cardiologist, Medical Director of the Cardiac Intensive Care Unit, and Director of the Cardiovascular Critical Care Research Program at INOVA Fairfax Hospital. His illustrious career accomplishments include being a Steering Committee member and site Principal Investigator for the multicenter Cardiogenic Shock Working Group and Critical Care Cardiology Trials Network. Audio editing by CardioNerds academy intern, Anusha Gandhi.

The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

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• LV-CS is complex! It is important to recognize that the pathophysiology of heart failure-related cardiogenic shock (HF-CS) is distinct from that of acute myocardial infarction (AMI-CS), and also crucial to differentiate between LV-dominant, right ventricular (RV)-dominant and biventricular (BiV)-shock.
• The SCAI SHOCK Stage Classification provides a unified and standardized vocabulary when assessing severity of CS, and facilitates communication about the diagnosis, presentation, and evolving nature of CS.
• Norepinephrine is considered the initial vasopressor of choice in most CS patients; the initial inotrope choice is a bit more nuanced!
• When considering mechanical circulatory support (MCS) for LV shock, high-quality data to guide therapy is lacking but one must always consider “the right patient, for the right device, at the right time” and remember that “pumps pump blood, decisions save lives”.
• Multidisciplinary, team-based care is paramount to improving survival of the critically ill patient with CS.

Notes drafted by Dr. Vanessa Blumer.

1. What tools do you use to define LV CS?

• CS is a hemodynamically complex and multifactorial syndrome, one of the most common indications for admission to a cardiac intensive care unit, with short-term mortality ranging from 35-50%.
• It is defined by systemic hypoperfusion and tissue hypoxia due to a primary cardiac insult or dysfunction.
• Clinical criteria used to define CS typically include evidence of hypotension (classically defined as SBP < 90 mmHg for 30 minutes and/or use of vasopressors, inotropes, or MCS to maintain systolic blood pressure > 90 mmHg) AND evidence of end-organ hypoperfusion (for example, serum lactic acid > 2 mmol/L, acute kidney injury, acute liver injury, altered mental status) in the setting of acute coronary syndrome or acute decompensated heart failure.
• Laboratory markers, including serum lactic acid, liver function tests, kidney function, and biomarkers including troponin and natriuretic peptides may be helpful. An echocardiogram is an excellent point of care tool to help demonstrate and confirm evidence of LV systolic dysfunction and/or valvular abnormalities.  Finally, a right heart catheterization (demonstrating an abnormally low cardiac output and index with elevated filling pressures) may be useful in facilitating the diagnosis and subsequent management.

2. How do HF-CS and AMI-CS lead to different phenotypes?

• It is important to recognize that HF-CS is now the predominant cause of CS, accounting for more than half of all CS.
• AMI-CS is characterized by an abrupt presentation due to a primary myocardial ischemic insult leading to necrosis (occurring in 5-10% of AMI patients) and can occur after STEMI or NSTEMI. The canonical clinical course is hypotension due to primary myocardial dysfunction leading to hypoperfusion with congestion as a later clinical or hemodynamic finding.
• Conversely, a patient with heart failure related shock commonly presents with acutely decompensated heart failure and congestion, leading to hypoperfusion, and culminating in hypotension.

3. How do you distinguish LV-dominant, RV-dominant and BiV shock?

• LV predominant CS is characterized by high pulmonary capillary wedge pressure (PCWP) and normal or reduced central venous pressure (CVP) in the setting of reduced cardiac output (CO).
• RV dominant CS is characterized by elevated CVP, normal to low PCWP, and normal to reduced CO.
• BiV shock is characterized by hypotension, elevated CVP, normal or elevated PCWP, and reduced CO.

4. What is the current role for inotropes, vasodilators, and vasopressors in the management of LV CS?

• The Acute Cardiovascular Care Association of the European Society of Cardiology published a position statement for the diagnosis and treatment of patients with AMI complicated by CS in 2020. According to this, vasopressors (norepinephrine preferable over dopamine) in the presence of persistent hypotension received a Level of IIb/B recommendation. Intravenous inotropes to increase cardiac output received a IIb/C recommendation.
• Based on the available evidence and its accompanying limitations, norepinephrine is considered the initial vasopressor of choice in most CS patients.

5. When should we consider management with temporary mechanical circulatory support (t-MCS) devices and how should one strategize device selection?

• Initiation or escalation of t-MCS largely depends on matching the right device to the right patient at the right time. Because the risk and number of complications increases with duration and type of MCS, these decisions are complex, nuanced, and must consider operator and institutional expertise.
• When considering type of device (IABP, Impella, ECMO), SCAI Staging and phenotyping (AMI vs HF CS) are absolutely critical.

6. What are treatment goals when following patients with LV CS?

• Optimize preload, afterload, and contractility
• Perform serial reassessment (≤ q 6hr) of hemodynamics & end-organ perfusion
• Aim for timely and tailored treatment escalation/de-escalation   
• Assess for LV and RV recovery (wean t-MCS, vasopressors and inotropes as able
• Early identification of worsening shock:
  •  Rising Lactate
  •  Increasing pressor requirement
  •  Worsening end-organ function
  •  CPO < 0.6 and/or PAPi < 1
  •  RA > 15 and/or PCWP > 15

Abraham J, Blumer V, Burkhoff D, Pahuja M, Sinha SS, Rosner C, Vorovich E, Grafton G, Bagnola A, Hernandez-Montfort JA, Kapur NK. Heart Failure-Related Cardiogenic Shock: Pathophysiology, Evaluation and Management Considerations: Review of Heart Failure-Related Cardiogenic Shock. J Card Fail. 2021 Oct;27(10):1126-1140. doi: 10.1016/j.cardfail.2021.08.010. PMID: 34625131.

Kapur NK, Kanwar M, Sinha SS, Thayer KL, Garan AR, Hernandez-Montfort J, Zhang Y, Li B, Baca P, Dieng F, Harwani NM, Abraham J, Hickey G, Nathan S, Wencker D, Hall S, Schwartzman A, Khalife W, Li S, Mahr C, Kim JH, Vorovich E, Whitehead EH, Blumer V, Burkhoff D. Criteria for Defining Stages of Cardiogenic Shock Severity. J Am Coll Cardiol. 2022 Jul 19;80(3):185-198. doi: 10.1016/j.jacc.2022.04.049. PMID: 35835491.

It’s another session of CardioNerds Rounds! In these rounds, Dr. Natalie Stokes (Formerly FIT at University of Pittsburgh and now General Cardiology Faculty at University of Pittsburgh) and Dr. Karan Desai (formerly FIT at University of Maryland and now General Cardiology faculty at Johns Hopkins) join Dr. Rick Nishimura (Professor of Medicine at Mayo Clinic) to discuss the nuances of managing mitral regurgitation through real cases. Dr. Nishimura has been an author or Chair of the ACC/AHA valve guidelines going back 20 years and has been recognized internationally as one of the world’s best educators, so you don’t want to miss the #NishFactor on these #CardsRounds! Audio editing by CardioNerds academy intern, Pace Wetstein.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes. 

Speaker disclosures: None

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Case #1 Synopsis:

A man in his 70s with a history of non-ischemic cardiomyopathy (last known LVEF 15-20%) and atrial fibrillation, presented with decompensated heart failure in the setting of moderate to severe mitral regurgitation. He was diuresed, transitioned to GDMT, and referred to cardiac rehabilitation. Over the next 6 months, he continued to have debilitating dyspnea (NHYA Class IIIa) and his outpatient physicians were limited on titrating GDMT further due to hypotension. A TEE was done which demonstrated EF 15%, severe MR by color and quantitation (EROA of 0.5 cm2; Regurgitant Volume of 65 mL), systolic flow reversal in the pulmonary vein and severe tricuspid regurgitation. We were asked how we would approach this case

Case #1Takeaways

1. In attempting to keep the evaluation of chronic mitral regurgitation relatively simple, we should ask ourselves three primary questions: (1) What is causing the MR; (2) How much MR is there; and (3) What is the hemodynamic consequence of the MR.
2. To the first question of what is the etiology of the MR – a simple framework is to think of the etiology as an issue of the valve (primary) or an issue of the ventricle/atria (secondary). There is further classification that can be made based on the Carpentier Classification which speaks to the valve leaflet movement and position (normal leaflet motion, excessive leaflet motion [e.g., prolapse], or restricted in systole and/or diastole [e.g., rheumatic heart disease]).
3. During rounds, Dr. Nishimura provided some historical context in that the original valve guidelines had recommendations for intervention on primary mitral regurgitation and not secondary – given that it is considered a disease of the ventricle. Trials like the COAPT trial have greatly shifted our practice in treating secondary mitral regurgitation. Though, we have to be familiar with which patients with secondary MR would truly derive benefit from mitral valve intervention
4. In regards to the COAPT trial, patients with moderate to severe (3+) or severe (4+) mitral regurgitation who remained symptomatic despite maximally tolerated guideline-directed medical therapy (GDMT) were included. Dr. Nishimura makes the point that about one-third of patients intended to be enrolled in the trial were not included because they improved so much on GDMT. And thus, when evaluating patients for consideration of mitral valve intervention in secondary MR – and specifically transcatheter edge to edge repair (TEER) – every effort to optimize GDMT should be made first before intervening. Other important inclusion and exclusion criteria included that patients had LVEF between 20-50%, LV end-systolic diameter less than or equal to 70 mm, and absence of severe pulmonary hypertension (defined as pulmonary artery systolic pressure > 70 mmHg despite vasodilator therapy) or moderate to severe right ventricular failure.
5. Dr. Nishimura asks our audience if the patient is truly on optimal GDMT and/or optimized? There are basic tools that clue us into optimization including chest x-ray (e.g., is there still pulmonary vascular congestion) and physical examination (e.g., what is the venous pressure).
6. Dr. Nishimura makes an interesting point in correlating our examination with the echocardiographic findings. In patients with largely secondary MR, where the leaflets have poor coaptation and we have a weak ventricle we may not expect to hear a very loud murmur on examination (e.g., there isn’t enough pump to generate the murmur). However, if we hear a significant murmur (e.g., like our patient described in the case with a loud, 3/6, blowing murmur) with presumed secondary MR, our antennae should be up for a possible primary component.

Case #2 Synopsis:

A man in his early 60s with a history of prior LAD PCI in the setting of an NSTEMI and diabetes presented to your hospital in SCAI Stage C to D Cardiogenic Shock with the background of worsening orthopnea and edema several weeks prior. You are told the patient had a recent echo with LVEF 15%, mild LV dilation, reduced RV function and moderate to severe functional MR. When you meet the patient, he is confused, nauseous and with poor perfusion (e.g., cool extremities and Lactate of 7 mmol/L). The patient is taken for left and right heart catheterization with RHC showing significant elevated filling pressures, large V-waves, and low cardiac index. An IABP is placed and LHC is performed where an acute appearing lesion in the proximal LAD and Mid-RCA are treated with PCI. Over the next week the IABP is weaned and removed and low doses of GDMT started. But once the IABP is removed, nausea returns and lactate starts rising again. Hemodynamics and TEE images are obtained with the IABP at 1:1 and on standby and show significant worsening of the hemodynamics and MR with IABP on standby, with the MR in the severe category, and we are asked to comment on what to do next.

Case #2 Takeaways

1. Dr. Nishimura suggests we approach this complex case with a simple question: how much of his shock/congestion is a result of his pump (the LV) versus how much is a result of his valve? Dr. Nishimura notes there is a subset of patients who have dynamic mitral regurgitation, which is primarily related to changes in the structure of the annulus/apparatus that happen with changes in preload/afterload/contractility. These patients can go from mild to severe depending on the loading conditions, as they are exquisitely sensitive to these conditions
2. Dr. Nishimura notes the continuous wave doppler of the mitral regurgitation can give us a rich amount of detail. The MR continuous wave doppler signal reflects the instantaneous doppler between the left ventricle and left atrium. If we pay attention to the signal during isovolumic contraction – if there is a rapid rise in the signal, that suggests that we are generating LV systolic pressure rather quickly and contractility may be preserved (e.g., this refers to dP/dT which has several caveats but qualitatively can be informative us).
3. These patients with dynamic MR who we cannot control the loading conditions, it may be better to treat the MR itself.

References

1. Stone GW, Lindenfeld J, Abraham WT, Kar S, Lim DS, Mishell JM, Whisenant B, Grayburn PA, Rinaldi M, Kapadia SR, Rajagopal V, Sarembock IJ, Brieke A, Marx SO, Cohen DJ, Weissman NJ, Mack MJ; COAPT Investigators. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. N Engl J Med. 2018 Dec 13;379(24):2307-2318.
2. Writing Committee Members, Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Feb 2;77(4):e25-e197.

In this episode, Dr. Carly Fabrizio (Advanced Heart Failure and Transplant Cardiology Physician at Christiana Care Hospital), CardioNerds Critical Care Series Co-Chair Dr. Mark Belkin (Advanced Heart Failure and Transplant Fellow at University of Chicago) and CardioNerds Co-Founder Dr. Amit Goyal (Cleveland Clinic) join Dr. Gavin Hickey (Director of the AHFTC Fellowship and medical director of the left ventricular assist device program at UPMC) and Dr. David Kaczorowski (Surgical Director for the Advanced Heart Failure center, Department of Cardiothoracic Surgery at UPMC) for a discussion on post-cardiotomy shock. Audio editing by CardioNerds Academy Intern, student doctor, Shivani Reddy.

Post-cardiotomy shock is characterized by heart failure that results in the inability to wean from cardiopulmonary bypass or develops post cardiac surgery. Patients who develop post-cardiotomy shock typically require inotropic support and may ultimately require temporary mechanical circulatory support. Post-cardiotomy shock carries a high mortality rate. However, early recognition and prevention strategies can help mitigate the risk for developing post-cardiotomy shock.

The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

This episode is supported by the 5th Annual Going Back to the Heart of Cardiology (A MedscapeLIVE Conference). Join co-chairs Dr. Robert Harrington and Dr. Fatima Rodriguez January 24-26, 2025 at the Fontainebleau Hotel in Miami Beach, Florida.

The agenda will explore the latest advancements in cardiology including cardiovascular prevention, atherosclerosis and thrombosis, cardiovascular dysfunction, arrhythmias, and valvular heart disease. Network, attend engaging presentations by renowned cardiologists, visit the exhibit and poster hall, participate in an exclusive immersive experience, and earn up to 13 CME/CE credits.

Register today with code CARDIONERDS for 30% OFF your registration. Click here for more information.

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• Weaning from cardiopulmonary bypass is an intricate process that includes: rewarming the patient, de-airing the cardiac chambers, ensuring a perfusing heart rhythm, confirming adequate ventilation and oxygenation, removing the intracardiac catheters and cannulas and slowly reducing the blood diverted to the cardiopulmonary circuit and returning it small aliquots to the patient. Much to monitor during the process!

• Assessing the risk for post-cardiotomy shock prior to going to the OR is important. Consider left ventricular, right ventricular, and valvular function, and don’t forget about the value of hemodynamic assessments (pulmonary artery catheter evaluations) to ensure patients are adequately compensated.

• Close peri-operative monitoring of hemodynamics, hemo-metabolic derangements, and acid/base status can help identify patients who are failing therapy and may require upgrade to temporary MCS.

• RV assessment is challenging. Utilizing both imaging and hemodynamic evaluations can help understand which RV’s will require more support.

• Multi-disciplinary discussions with a heart team approach prior to cardiac surgery are valuable in identifying high risk patients for post cardiotomy shock and discussing contingency plans if issues arise.

(drafted by Dr. Carly Fabrizio)

1. How can we diagnose post cardiotomy shock?
   • We can diagnose post cardiotomy shock as patients who are undergoing cardiac surgery that develop hypotension and or tachycardia with hypoperfusion and end organ dysfunction.

• How can assess the risk of developing postcardiotomy shock prior to going to the OR?
  • LV systolic function is not the only evaluation of cardiac function
  • Don’t ignore the RV!
  • Valvular function must be evaluated in conjunction with LV/RV function
  • Hemodynamics can be helpful prior to going to the OR
    • Filling pressures and CO/CI evaluation –> the more normal range – the less risk of post cardiotomy shock
    • If going in more deranged –> more complications are likely to occur
  • Think about what options are available post operatively if issues arise
    • Include a multi-disciplinary discussions and planning prior to going to the OR

• Are there any specific pre-operative or intra-operative risk factors that may predispose someone to developing post cardiotomy shock?
  • Many factors can lead to postcardiotomy shock. Some pre-op factors include:
    • Poor pre-operative cardiac function (RV and /or LV function)
    • Entering the OR in cardiogenic shock (inotropes, temporary MCS)
    • Well compensated patients with chronic ventricular dysfunction
  • Intra-operative factors:
    • Prolonged cross-clamp time
    • Prolonged cardiopulmonary bypass (CPB) times (often seen in complex operations)
    • Inadequate myocardial protection
    • Ventricular distention
    • Technical factors

• What is actually occurring in the OR when weaning from CPB?
  • After the aorta cross clamp is removed- the heart is allowed to re-perfuse
    • Remember that the heart has been ischemic for a considerable amount of time
  • Lungs are re-inflated
  • Temporary atrial and ventricular pacing wires are placed
  • Stable rhythm is achieved and the heart is paced if necessary
  • Acid / base status and electrolytes (potassium) are optimized
  • Once the heart is de-aired, CPB is gradually weaned
    • The flow of the CPB circuit is gradually reduced and more of the patient’s blood volume is gradually allowed to pass through the heart and lungs
  • TEE is performed while weaning bypass
  • Once bypass is completely weaned, the cannulas used to establish CPB are removed
  • Anticoagulation is reversed
  • Assess for hemostasis
  • Chest tubes are placed, and closure occurs

• What are the clinical and laboratory parameters which help determine whether vasoactive support alone will be enough vs. when temporary MCS may be needed?
  • Assess perfusion first
    • BP
    • Urine output
    • Lactic acid
  • PA catheter data /  hemodynamic data
    • Cardiac output/index (CO/CI)
    • Pulmonary artery pressures (PAP)
    • Central venous pressures (CVP)
    • Mixed venous oxygen saturation
    • Cardiac power output (CPO) and cardiac power index (CPI)
      • CPO < 0.6 or CPI < 0.32 are considered low
  • Serial blood gas
    • Focus on pH and bicarbonate (acid/base status)
  • Optimize inotropic support accordingly
    • Favor epinephrine in safe dosing limits and minimizing drugs that increase afterload whenever possible
    • Consider Milrinone if the blood pressure is adequate
  • If pulmonary hypertension
    • Inhaled nitric oxide or inhaled prostacyclin
  • If worsening despite these measures –> consider escalation to temporary MCS

• Left ventricular assist devices (LVAD) do not support the right ventricle. How can we identify RV failure in these patients and when should you upgrade to RV mechanical circulatory support?
  • Most patient that require left-sided support by nature often have underlying right-sided dysfunction as well
  • Pre-operative – assessment of the RV is important:
    • CVP
    • PAPi (PA systolic pressure- PA diastolic pressure / CVP)
    • CVP: PCWP ratio
  • RV failure can occur in any patient
    • No great, reliable, and reproducible data on when or how to support the RV following LVAD implantation, or cardiogenic shock in general. More studies are needed.

• What’s different about how you assess the RV dysfunction in the OR compared to someone who is in the ICU? When do you consider using RV mechanical support upfront in the OR?
  • Intra-operative TEE and direct visualization are both used in the OR to assess RV function
  • Try to avoid upfront RV mechanical support in the OR
    • Optimize with invasive hemodynamic monitoring prior to OR
      • Temporary MCS can be used to optimize patient and help with diuresis pre-operatively
  • Continue to optimize the RV while in the OR
    • Remove volume through hemoconcentration while on CPB circuit to optimize volume status
  • Consider temporary MCS for the RV when medical therapy is maximized, and the patient still remains marginal as measured by:
    • LVAD flows, cardiac output/index, mixed venous gases and metabolic parameters

• Are there any surgical consideration to influence the type of temporary MCS for postcardiotomy shock?
  • Strategize first by asking:
    • What is failing? LV, RV, lungs, or a combination
    • What access is available?
  • Ex: Bi-ventricular failure with hypoxemia and peripheral arterial disease: consider central VA ECMO
  • Ex: Pure LV failure but RV and lungs OK –> temporary LV assist device

• How can we prevent, or decrease the risk, of post-cardiotomy shock ?
  • Optimized hemodynamics going into the OR using a PA catheter
  • Multi-disciplinary discussion with cardiac anesthesia, critical care team, etc. for high-risk cases
  • Ensure adequate end-organ perfusion
  • Avoid pre-operative medications that worsen peri-operative vasoplegia
    • ACE-i/ARB/ARNI, milrinone etc.

1. What is role of advanced therapy evaluations when assessing high risk patients going to the OR?
   • Important to think about options pre-operatively
     • Selection committee discussions to weigh-in on candidacy for LVAD or cardiac transplant and if that may be more beneficial than other cardiac surgical interventions

1. How does team-based care help with decision making?
   • Optimize patients pre procedure and support them peri-procedure
   • Involving palliative care team and establishing patient goals prior to surgery

1. Lorusso, Raffa, Alenizy, et al. “Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1—Adult patients.” JHLT. 38(11): 1125-1143. 2019.https://www.sciencedirect.com/science/article/pii/S1053249819316328
   
2. Fukuhara, Takea, Garan, et al. “Contemporary mechanical circulatory support therapy for postcardiotomy shock.” Curr Topics Review Article. 64:183-191. 2016. https://link.springer.com/content/pdf/10.1007/s11748-016-0625-4.pdf

In this episode, Daniel Ambinder and Amit Goyal (CardioNerds co-founders), Dr. Gurleen Kaur (medicine resident at Brigham and Women’s Hospital and Director of CardioNerds Internship), student doctor Adriana Mares (medical student at the University of Texas El Paso/Texas Tech University Health Sciences Center El Paso, CardioNerds Academy Intern), and Dr. Teodora Donisan (general cardiology fellow at the Mayo Clinic and CardioNerds Academy Chief) discuss with Dr. Mayra Guerrero (Interventional Cardiologist and Professor of Medicine at the Mayo Clinic) about challenges with diagnosing and treating valve disease in women, as well as ideas on how to increase recruitment for women in cardiology including interventional and structural cardiology. Dr. Guerrero shares her inspiring personal journey and advice for how to navigate becoming a structural cardiologist as an international medical graduate, woman, and mother. Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.

Video Version • Notes • Production Team

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• “Work hard, give it your best, and your work will speak for itself. Don’t be afraid to work hard and you’ll be able to achieve anything you want.”
• “I’m very fortunate to have had the opportunities that I’ve had, but now it’s my responsibility and the responsibility of many to make sure that we create those opportunities and that we provide mentorship for others who may want to follow the same steps into this field.”
• “I get angry, it’s normal to have emotions, but what I’ve learned is to transform my anger into something good – think of a project, find a paper, do something good for your career…channel that energy to do something good.”
• “It’s important that even at young ages you start thinking about how to pay it forward.”
• “Don’t wait too long to have kids. There’s never a perfect time to be a parent. Once you decide to have a family don’t put a pause on your personal life for your career.”

Notes (by Dr. Teodora Donisan)

• Structural valve disease in women and valve care in the global setting
  • Heart disease is the leading cause of death for women. However, the awareness regarding this major public health concern has been declining over the past decade. Valve disease awareness is one of the lowest, at less than 3%.
  • Women have higher mortality than men when they undergo surgical aortic or mitral interventions, mainly because of a higher risk profile. For example, women with severe aortic stenosis usually present at older ages and have many associated comorbidities, however the outcomes are good when they are treated with transcatheter aortic valve replacement (TAVR). Despite this, women are less likely to be referred for aortic valve replacement (AVR) than men. Once women are referred for therapy, they are more likely to be treated with TAVR than surgical aortic valve replacement (SAVR).
  • There is a deficiency in trial enrollment for women which we need to address in order to generate the knowledge we require with regards to treatment. We also need to identify whether there are referral biases when it comes to AVR.
  • Another hypothesis for the disparities in valve disease treatment for women when compared with men might be the decreased number of women in cardiology, especially in interventional cardiology (<10% of interventional cardiologists are women). Of note, <3% of TAVR operators are women (1.5% are surgeons and 1.5% are interventional cardiologists).

• Diversity and inclusion in interventional cardiology
  • About 8% of interventional cardiologists are women and only 4.2% of cardiologists are Latinx.
  • In order to increase recruitment for WIC, the problem needs to be addressed on multiple levels.
    • Mentorship should be provided to cardiology fellows, and they should be supported in their choice for interventional cardiology. This should be equally offered and tailored to women and underrepresented minorities. Support should be given even earlier in their careers and lives, at school and even with the education they receive at home. Career goals can be achieved with hard work and determination, and this should be an integral part of the education and upbringing from an early age.
  • There is an institutional responsibility to help address this problem. It can start with training to decrease unconscious bias, improvements in workplace conditions (e.g., schedule flexibility, provide maternity/paternity leave, lactation rooms), opening leadership opportunities for women and URiMs, establishing diversity and inclusion committees.
  • The FDA, industry, and societies should have DE&I committees to ensure inclusive representation in clinical trial leadership and to ensure recruitment of women and minorities.
• Work life harmony as an interventional cardiologist
  • You must choose your life partner well, caring for your family is teamwork.
  • You might miss moments, but if you work together with your partner and children, it works out.
  • It’s important to provide a strong role model for your family.

Vogel B, Acevedo M, Appelman Y, et al. The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030. Lancet. 2021;397(10292):2385-2438.

CardioNerds (Amit Goyal and Dan Ambinder), Series Co-Chair Dr. Dinu Balanescu (Academy House Faculty and Chief Resident at Beaumont Hospital), and Episode Lead Dr. Manu Mysore (Former CardioNerds Ambassador and Cardiologist at the University of Maryland) discuss The Need for Cardio-Oncology with Expert Faculty Dr. Bonnie Ky, Director of Penn Cardio-Oncology Translation Center of Excellence and Editor-in-Chief of JACC CardioOncology. Audio editing by CardioNerds Academy Intern, student doctor Yousif Arif. This episode is supported by a grant from Pfizer Inc.

Cardio-Oncology is a burgeoning field. There is a need for cardiologists and oncologists to work together in a multidisciplinary fashion using multi-modality imaging and personalized medicine. Cardiologists in particular need to understand basic oncology, anti-cancer therapies, and address risk factors which play an important role in oncologic progression and/or adverse cardiovascular events. The field can only be furthered by research with a focus on specificity of endpoints and multidisciplinary collaboration. The future of the field is in the hands of investigators and clinicians alike.

This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan. 

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

This episode is supported by the 5th Annual Going Back to the Heart of Cardiology (A MedscapeLIVE Conference). Join co-chairs Dr. Robert Harrington and Dr. Fatima Rodriguez January 24-26, 2025 at the Fontainebleau Hotel in Miami Beach, Florida.

The agenda will explore the latest advancements in cardiology including cardiovascular prevention, atherosclerosis and thrombosis, cardiovascular dysfunction, arrhythmias, and valvular heart disease. Network, attend engaging presentations by renowned cardiologists, visit the exhibit and poster hall, participate in an exclusive immersive experience, and earn up to 13 CME/CE credits.

Register today with code CARDIONERDS for 30% OFF your registration. Click here for more information.

Pearls • Notes • References • Production Team

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Cancer Statistics (National Institute of Cancer website). https://www.cancer.gov/about-cancer/understanding/statistics. Published 2018. Accessed August 4, 2022.

Cardinale D, Biasillo G, Cipolla CM. Curing Cancer, Saving the Heart: A Challenge That Cardioncology Should Not Miss. Curr Cardiol Rep. 2016;18(6):51.

Okwuosa TM, Prabhu N, Patel H, et al. The Cardiologist and the Cancer Patient: Challenges to Cardio-Oncology (or Onco-Cardiology) and Call to Action. J Am Coll Cardiol. 2018;72(2):228-232.

Sun L, Parikh RB, Hubbard RA, et al. Assessment and Management of Cardiovascular Risk Factors Among US Veterans With Prostate Cancer. JAMA Netw Open. 2021;4(2):e210070.

Yu C, Pathan F, Tan TC, Negishi K. The Utility of Advanced Cardiovascular Imaging in Cancer Patients-When, Why, How, and the Latest Developments. Front Cardiovasc Med. 2021;8:728215.

Bellissimo MP, Canada JM, Jordan JH, et al. Changes in Physical Activity, Functional Capacity, and Cardiac Function during Breast Cancer Therapy. Cancer Epidemiol Biomarkers Prev. 2022;31(7):1509.

Lyon AR, López-Fernández T, Couch LS, et al. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J. 2022.

International Cardio-Oncology Society ( IC-OS). IC-OS exits to advance cardiovascular care of cancer patients and survivors by promoting collaboration among researchers, educators and clinicians around the world. Learn more at https://ic-os.org/.

CardioNerds (Daniel Ambinder and Amit Goyal) join Dr. Arielle Schwartz (Emory University cardiology fellow), Dr. Joshua Zuniga (former Emory vascular medicine fellow and now USC cardiology fellow), and Dr. Patrick Zakka (UCLA cardiology fellow) from the Emory University School of Medicine. They discuss a case of a young woman with new onset hypertension refractory to 3 antihypertensive agents who is ultimately diagnosed renovascular hypertension due to fibromuscular dysplasia complicated by saccular aneurysm. Dr. Bryan Wells (Director of Vascular Medicine at Emory University) provides the ECPR for this episode. Audio editing by CardioNerds Academy intern, Dr. Christian Faaborg-Andersen.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

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Gornik HL, Persu A, Adlam D, Aparicio LS, Azizi M, Boulanger M, Bruno RM, de Leeuw P, Fendrikova-Mahlay N, Froehlich J, Ganesh SK, Gray BH, Jamison C, Januszewicz A, Jeunemaitre X, Kadian-Dodov D, Kim ES, Kovacic JC, Mace P, Morganti A, Sharma A, Southerland AM, Touzé E, van der Niepen P, Wang J, Weinberg I, Wilson S, Olin JW, Plouin PF. First International Consensus on the diagnosis and management of fibromuscular dysplasia. Vasc Med. 2019 Apr;24(2):164-189. doi: 10.1177/1358863X18821816. Epub 2019 Jan 16. Erratum in: Vasc Med. 2019 Oct;24(5):475. Erratum in: Vasc Med. 2021 Aug;26(4):NP1. PMID: 30648921.

Olin, Circulation. 2014;129:1048-1078. Fibromuscular Dysplasia: State of the Science and Critical Unanswered Questions A Scientific Statement From the American Heart Association

S.H.KimMD, MPH†Jeffrey W.OlinDO‡James B.FroehlichMD, MPH§XiaokuiGuMA§J. MichaelBacharachMD‖Bruce H.GrayDO¶Michael R.JaffDO#Barry T.KatzenMD∗∗EvaKline-RogersMS, RN, NP§Pamela D.MaceRN††Alan H.MatsumotoMD‡‡Robert D.McBaneMD§§Christopher J.WhiteMD‖‖Heather L.GornikMD, MHS†. Clinical Manifestations of Fibromuscular Dysplasia Vary by Patient Sex: A Report of the United States Registry for Fibromuscular Dysplasia. JACC. Volume 62, Issue 21, 19–26 November 2013, Pages 2026-2028

CardioNerds Dr. Josh Saef, Dan Ambinder, join Dr. Jim Kimber and interview experts Dr. Adrienne Kovacs, and Dr. Lauren Lastinger and discuss behavioral health needs and psychosocial wellbeing in the congenital heart disease population. In this episode, our experts tackle issues surrounding mental and behavioral health including anxiety/depression, ADHD, neurodevelopmental disabilities, psychosocial challenges, stressors unique to patients with ACHD and their families, and how the healthcare system can better optimize mental health care for the CHD patient population. Audio editing by CardioNerds Academy Intern, Pace Wetstein.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.

The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more

Disclosures: None

This episode is supported by the 5th Annual Going Back to the Heart of Cardiology (A MedscapeLIVE Conference). Join co-chairs Dr. Robert Harrington and Dr. Fatima Rodriguez January 24-26, 2025 at the Fontainebleau Hotel in Miami Beach, Florida.

The agenda will explore the latest advancements in cardiology including cardiovascular prevention, atherosclerosis and thrombosis, cardiovascular dysfunction, arrhythmias, and valvular heart disease. Network, attend engaging presentations by renowned cardiologists, visit the exhibit and poster hall, participate in an exclusive immersive experience, and earn up to 13 CME/CE credits.

Register today with code CARDIONERDS for 30% OFF your registration. Click here for more information.

Pearls • Notes • References • Guest Profiles • Production Team

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1. Among patients with congenital heart disease, symptoms of anxiety are more common than symptoms of depression. “Heart-focused anxiety” relates to symptoms attributable to a heart condition including fear of appointments, surgery, or health-uncertainty. It is important to differentiate this from generalized anxiety.
2. Predictors of depression and anxiety include patient-reported physical health status. Defect severity (mild, moderate, great complexity) and physician-diagnosed NYHA class were NOT associated with rates of depression/anxiety [2].
3. Despite CHD, patient self-reported Quality of Life (QoL) is relatively high. Predictors of decreased QoL include older age, lack of employment, never having married, and worse self-reported NYHA functional class
4. Important treatment strategies include: education for patients and caregivers, early identification and referral to mental health providers, incorporation of providers into CHD teams, and encouraging physical activity and peer-interaction.

Notes (developed by Dr. Jim Kimber)

Mental Health Terminology:

Adults with CHD face the same mental health challenges as people who don’t have a heart condition. Symptoms of depression and anxiety are the most common: Approximately 1/4 – 1/3 of CHD patients will struggle with clinically significant depression or anxiety at any one point. Up to ½ will meet lifetime diagnostic criteria for these conditions

• Mood and anxiety disorders differ in that they have separate diagnostic criteria. Importantly, research often uses self-reported symptoms, rather than patients who have formally met diagnostic criteria.

• Historically, the focus has been on depression.  However, elevated symptoms of anxiety are much more common than elevated symptoms of depression.

• It is important to make the distinction between “Generalized Anxiety,” and “Heart-Focused Anxiety.”
  • Heart-Focused Anxiety: symptoms of anxiety directly related to having a heart condition, such as fear of appointments / worry about a decline in health status, getting an ICD, preparing for surgery, transplants, or having a shortened life expectancy, etc. This may also include a significant component of health uncertainty – the idea that patients are aware of need for a likely intervention but without ability to prognosticate timelines (e.g. need for valve replacement). This component differentiates CHD patients from those with acquired heart disease who have not been surrounded by such uncertainty for significant components of their life.
  • Generalized Anxiety: excessive worry about a lot of factors beyond their control and accompanied by other symptoms like: muscle tension, sleep disturbance.

• Manifestations of mood and behavioral health problems include: impaired peer relationships, impaired romantic relationships, poor school or work performance, difficulty getting or keeping a job.  Persons may struggle with inconsistent medical follow-up, inconsistent compliance, and substance abuse.

Predictors & Prevalence of Depression / Anxiety:

• Defect Severity (mild, moderate, great complexity) was not associated with depression or anxiety. Similarly, physician diagnosed NYHA Class was not associated with depression/anxiety [2].
• Known predictors: patient-reported physical health status impacts symptoms of depression/anxiety [2].There is also a link between social wellbeing and psychological well-being. Other studies have highlighted that perceived health status is an important predictor.

Risk Stratification

All patients with congenital heart disease are at risk for mental health disorders and need to be screened. Those at heightened risk include patients with genetic syndromes (in particular, those with 22q11 deletion, associated with more severe psychiatric disorders), prematurity, longer hospital stays, and those with lower family socioeconomic status.

Patients who have undergone cardiopulmonary bypass have higher likelihood of neurologic insults (CVA), but also cognitive dysfunction following surgery. In research, Apolipoprotein E has been predictive of neurodevelopmental dysfunction following cardiac surgery. 

Other factors, including the number of surgeries, and how often they were separated from peers growing up might also impact mental health well-being in adults.

Quality of Life (QoL) and Assessment

Approach-IS Study

• International Study looking at patient-reported outcomes in adults with CHD.
• Over 4,000 patients from 15 countries were enrolled.
• Self-Reported Questionnaires administered to gain information on perceived health

status, psychological functioning, health behaviors, quality of life (Scale 0-100) [9]

•  Patients have lived with CHD their entire life, and report relatively high QoL
  • Older age, lack of employment, never having married, and worse NYHA functional class (self- reported) are associated with lower QoL

Alternative Assessment for Nonverbal Patients:

• Concerns may come from caregivers or parents
• May demonstrate behavioral changes: outbursts, changes in feeding/eating habits or weight loss/gain, changes in sleeping patterns, fatigue, low mood, anhedonia
• Screening should begin early in childhood (early assessment and diagnosis allows for enrollment in beneficial social / developmental programs)
• Cardiac Neurodevelopmental Outcome Collaborative (CNOC): recommend screenings for various ages and provide suggested screening algorithms.

Transition to Adult Teams: process that occurs during early adolescence

Goals: stay in uninterrupted health care throughout their lives, avoid lapses in care, have an established process, allow patients to develop knowledge and skills to assume maximal responsibility for their healthcare management, and adapt information delivery as necessary

• The I <3 Change Website provides information for people transitioning from pediatric to adult cardiology teams
• Beginning in adolescence, pediatric provider is recommended to speak independently with their cardiologist at every visit.
• Transition is a family process: parents are involved in care and successful transition to help bridge the gap towards independence for the patient

Strategies to Ensure Treatment Success

Education is Key:

• Parents and caregivers need an understanding of what CHD concerns are, expected follow up needs, etc.
• Engage all stakeholders in Medical Home: home health aide, caregiver, primary care physician, etc.

Utilize Screening Tools and Implement Routine Screening

Refer to Mental Health Provider when Appropriate

Embed mental health professional into the Team: identify providers who have an interest in mental health (psychologist / psychiatrist) who are qualified to treat patients with congenital heart disease

• Improves access and reduces stigma
• Allows for ease of access / rapid consultation

Encourage appropriate physical activity: exercise and physical activity has physiologic and mental health benefit, improves mood, stress, anxiety, etc. Mental health benefit is present regardless of type / intensity / duration of activity

• Ask patients if they avoid particular activities and provide reassurance

Offer opportunities for peer interaction: patient education sessions, etc.

Provide Positive Reinforcement: comment on patients’ resilience and effective coping.

Destigmatize It!

Practice of carefully worded Key Sentences help to destigmatize mental health disorders:

• “Does thinking about your health every make you worried or depressed?”
• “How are you doing from a psychological perspective?”
• “I know that patients sometimes struggle with low mood or anxiety. If that ever happens to you, let me know, and we can discuss it.”

Gonzalez, V.J., et al., Mental Health Disorders in Children With Congenital Heart Disease. Pediatrics, 2021. 147(2).

PubMed CrossRef

Kovacs, A.H., et al., Depression and anxiety in adult congenital heart disease: predictors and prevalence. Int J Cardiol, 2009. 137(2): p. 158-64.

PubMed  CrossRef

Gaynor, J.W., et al., Validation of association of the apolipoprotein E ε2 allele with neurodevelopmental dysfunction after cardiac surgery in neonates and infants. J Thorac Cardiovasc Surg, 2014. 148(6): p. 2560-6.

PubMed CrossRef

Schmithorst, V.J., et al., Organizational topology of brain and its relationship to ADHD in adolescents with d-transposition of the great arteries. Brain Behav, 2016. 6(8): p. e00504.

PubMed CrossRef

Cassidy, A.R., et al., Executive Function in Children and Adolescents with Critical Cyanotic Congenital Heart Disease. J Int Neuropsychol Soc, 2015. 21(1): p. 34-49.

PubMed CrossRef

Kolaitis, G.A., M.G. Meentken, and E. Utens, Mental Health Problems in Parents of Children with Congenital Heart Disease. Front Pediatr, 2017. 5: p. 102.

PubMed CrossRef

Boukovala, M., et al., Effects of Congenital Heart Disease Treatmenton Quality of Life. Am J Cardiol, 2019. 123(7): p. 1163-1168.

PubMed CrossRef

Müller, J., J. Hess, and A. Hager, Sense of coherence, rather than exercise capacity, is the stronger predictor to obtain health-related quality of life in adults with congenital heart disease. Eur J Prev Cardiol, 2014. 21(8): p. 949-55.

PubMed CrossRef

Apers, S., et al., Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease – International Study (APPROACH-IS): rationale, design, and methods. Int J Cardiol, 2015. 179: p. 334-42.

PubMed CrossRef

Adult Congenital Heart Association
Founded in 1998, the Adult Congenital Heart Association is an organization begun by and dedicated to supporting individuals and families living with congenital heart disease and advancing the care and treatment available to our community. Our mission is to empower the congenital heart disease community by advancing access to resources and specialized care that improve patient-centered outcomes. Visit their website (https://www.achaheart.org/) for information on their patient advocacy efforts, educational material, and membership for patients and providers

CHiP Network

The CHiP network is a non-profit organization aiming to connect congenital heart professionals around the world. Visit their website (thechipnetwork.org) and become a member to access free high-quality educational material, upcoming news and events, and the fantastic monthly Journal Watch, keeping you up to date with congenital scientific releases. Visit their website (https://thechipnetwork.org/) for more information.

Heart University
Heart University aims to be “the go-to online resource” for e-learning in CHD and paediatric-acquired heart disease. It is a carefully curated open access library of educational material for all providers of care to children and adults with CHD or children with acquired heart disease, whether a trainee or a practicing provider. The site provides free content to a global audience in two broad domains: 1. A comprehensive curriculum of training modules and associated testing for trainees. 2. A curated library of conference and grand rounds recordings for continuing medical education. Learn more at www.heartuniversity.org/

CardioNerds (Amit Goyal and Dan Ambinder) join Dr. Radi Zinoviev, Dr. Josh Cohen, and Dr. Tiffany Dong (CardioNerds Ambassador) from the Cleveland Clinic for a day on Edgewater beach. They discuss the following case of the evaluation and management of prosthetic tricuspid valve stenosis in a patient with a history of Ebstein Anomaly. The expert commentary and review (ECPR) is provided by Dr. Jay Ramchand, staff cardiologist with expertise in multimodality cardiovascular imaging at the Cleveland Clinic.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

This episode is supported by the 5th Annual Going Back to the Heart of Cardiology (A MedscapeLIVE Conference). Join co-chairs Dr. Robert Harrington and Dr. Fatima Rodriguez January 24-26, 2025 at the Fontainebleau Hotel in Miami Beach, Florida.

The agenda will explore the latest advancements in cardiology including cardiovascular prevention, atherosclerosis and thrombosis, cardiovascular dysfunction, arrhythmias, and valvular heart disease. Network, attend engaging presentations by renowned cardiologists, visit the exhibit and poster hall, participate in an exclusive immersive experience, and earn up to 13 CME/CE credits.

Register today with code CARDIONERDS for 30% OFF your registration. Click here for more information.

Jump to: Case media – Case teaching – References

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1. Tricuspid stenosis is uncommon (<1% of the US population) and thus we have a lack of evidence as well as guideline recommendations.
2. While there are no official diagnostic criteria for severe tricuspid stenosis, some echocardiographic features include flow acceleration across the valve, a mean pressure gradient of ≥ 5mmHg and an inflow VTI of > 60cm.
3. Structural findings that support the presence of severe tricuspid stenosis include a moderately dilated RA and a dilated IVC, though these are not specific.
4. Right heart catheterization hemodynamics that support tricuspid stenosis include a high right atrial pressure and gradual “y” descent.
5. Bioprosthetic tricuspid valves are generally favored over mechanical valves due to risk of thrombosis and longevity of these valves in the tricuspid position.

• What are causes of tricuspid stenosis?

Causes of tricuspid stenosis can be divided into congenital and acquired causes. Congenital causes include tricuspid atresia or stenosis. Acquired causes include rheumatic heart disease, carcinoid syndrome, endocarditis, prior radiation, or fibrosis from endomyocardial procedures or placement of electrical leads. Rheumatic heart disease is the most common cause of tricuspid stenosis and is usually associated with mitral valvulopathy.

• What are the symptoms and physical exam findings of tricuspid stenosis?

Findings revolve around right sided congestion or heart failure symptoms such as peripheral edema, abdominal distension with ascites, hepatomegaly, and jugular venous distension. When examining the jugular vein, you may see prominent a-waves and an almost absent or slow y descent reflective of delayed emptying of the right atrium (in the absence of tricuspid regurgitation). The murmur of tricuspid stenosis includes an opening snap and low diastolic murmur at the left lower sternal border with inspiratory accentuation. Patients may also report fatigue due to decreased cardiac output from obstruction.

• On echocardiography, what are the features supportive of severe tricuspid stenosis?

Qualitatively, the leaflets may be thickened with reduced mobility and there may be diastolic dooming of the valve. Doppler may show high gradients of ≥ 5 mmHg, which may be elevated if there is coexisting tricuspid regurgitation and lower with decreased cardiac output. Associated structural changes include dilated right atrium and inferior vena cava.

• What is expected on right heart catheterization for tricuspid stenosis?

Assuming the patient remains in sinus rhythm, patients with tricuspid stenosis would display high right atrial pressures and a gradual “y” descent. A diastolic gradient may be measured with dual catheters in the right atrium and the right ventricle.

• What are the treatment options for tricuspid stenosis?

Medical management of tricuspid stenosis includes diuretics and addressing the underlying cause. Intervention is indicated for symptomatic severe tricuspid stenosis although the current 2020 ACC/AHA Valve Guidelines do not address tricuspid stenosis. The 2014 ACC/AHA guidelines give a class I indication for tricuspid stenosis surgery during left sided surgery while there is a class I indication for isolated tricuspid stenosis if symptomatic. Percutaneous options include balloon valvotomy while those who are surgical candidates are eligible for valve repair or replacement. Surgical options include repair or replacement with bioprosthetic favored over mechanical given the latter’s susceptibility to thrombosis.

1. Nishimura, R. A., et al. (2014). “2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.” Circulation 129(23): 2440-2492.
2. Otto, C. M., et al. (2021). “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.” Circulation 143(5): e35-e71.

It’s another session of CardioNerds Rounds! In these rounds, Dr. Stephanie Fuentes (EP FIT at Houston Methodist) joins Dr. Hugh Calkins (Professor of Medicine and Director of the Electrophysiology Laboratory and Arrhythmia Service at Johns Hopkins Hospital) to discuss the nuances of atrial fibrillation (AF) management through challenging cases. As an author of several guideline and expert consensus statements in the management of AF and renowned clinician, educator, and researcher, Dr. Calkins gives us many pearls on the management of AF, so don’t miss these #CardsRounds! 

This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes. 

Speaker disclosures: None

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Case #1 Synopsis:

A woman in her mid-60s presents with symptomatic paroxysmal atrial fibrillation (AF). An echocardiogram has demonstrated that she has a structurally normal heart. Her primary care doctor had started Metoprolol 50 mg twice a day but she has remained symptomatic. In office, an EKG confirms AF, but she converts to sinus while there. She is seeking advice to prevent further episodes and in general wants to avoid additional medications

Case #2 Takeaways

1. We discussed several potential options for treatment. Amongst the first things we discussed was amiodarone. In a patient of this nature without structural heart disease and under the age of 70, Dr. Calkins discussed that he would probably consider amiodarone as a 2nd line option. While amiodarone may be effective in maintaining sinus rhythm in comparison to other antiarrhythmic medications like sotalol, flecainide, and propafenone, it does have significant toxicity.
2. If antiarrhythmic drugs (AAD) were to be considered, we also discussed the options of dofetilide versus sotalol. Dofetilide typically requires inpatient initiation due to the risk of QT
    prolongation and Torsades. Since women tend to have longer corrected QT (QTc) intervals, high dose dofetilide may be more proarrhythmogenic in women. Though, Dr. Calkins noted that many patients don’t tolerate sotalol due to fatigue and generally dofetilide is well tolerated.
3. When it comes to the “pill in the pocket” approach, Dr. Calkins noted that its utility is more so in patients with persistent AF that is known to not stop on its own. For instance, an individual who has AF a few times a year that is persistent may benefit from flecainide or propafenone (“in the pocket”) instead of being brought in for an electrical cardioversion. In this scenario, the first time one of these agents is used, the patient ought to be closely monitored. For our patient, her episodes were too frequent and self-terminating for a “pill in the pocket” approach to be effective.
4. Current guideline recommendations for catheter ablation include a Class IA recommendation for patients with paroxysmal AF refractory to AADs, and a Class IIA recommendation as first-line therapy for patients with paroxysmal AF.
5. In the 2020 ESC Atrial Fibrillation Guidelines, catheter ablation is given a Class IA recommendation to improve symptoms of AF recurrences in patients who have failed or are intolerant of one Class I or III AADs. For patients who have failed or have been intolerant of beta blocker alone for rhythm control, catheter ablation is given a Class IIA recommendation. As first-line therapy in paroxysmal AF, catheter ablation is given a Class IIA recommendation as well.
6. Of note, three recent trials have demonstrated catheter ablation as first line therapy is reasonable and newer guidelines will reflect this. Specifically, EARLY-AF compared ablation (cryoablation) vs AAD (mainly with flecainide/propafenone) as a first line therapy. The cryoablation arm showed significantly less recurrence of AF at one year
   • The guidelines clearly state that aligning the treatment plan with the patient’s goals and risk tolerance are paramount. Catheter ablation does have potential complications such as pericardial effusion or access-related issues, though these are rare. Furthermore, as time has passed, catheter ablation success rates have improved.
   • Up and coming techniques such as electroporation may be game-changing with regards to success rate and safety. Waiting times for a procedure may be an issue, so one could consider an AAD, such as flecainide, as a standing dose awaiting the procedure.
7. Regarding predictors of success for catheter ablation, Dr. Calkins noted that the key factor was type of AF. With paroxysmal AF there is roughly 70-80% success rate with the 1st procedure, 50-70% with persistent AF, and 30-50% with longstanding persistent AF. Other predictors of success include BMI (higher BMI associated with a lower success rate and a higher rate of complications), left atrial size (with a linear dimension of ≥ 5.5 cm indicating less likelihood of success), age, and obstructive sleep apnea.
8. One of the questions that was raised was screening for structural heart disease before starting flecainide/propafenone. Typically, an EKG and TTE are done, and if they are not suggestive of structural heart disease, Dr. Calkins noted it would be reasonable to use these agents. With increasing age, there’s increased risk of subclinical CAD, though it is not in the guidelines to perform functional testing or anatomic imaging prior to starting these agents.
9. Finally, Dr. Calkins noted as an aside that in patients with sick sinus syndrome, management in the past has involved placing a permanent pacemaker (PPM) followed by AAD agents. However, catheter ablation may be a better option because it treats AF and improves the sinus rate because of its effect on the autonomic system, eliminating pauses that would have otherwise warranted a pacemaker. After ablation, the resting HR can improve 10-30 bpm and this can be a marker of successful catheter ablation.

Case #2 Synopsis:

A man in his mid-60s with a history of surgically placed bioprosthetic AVR, CAD with prior CABG, newly diagnosed ischemic cardiomyopathy with LVEF 20-25% with imaging revealing reversible ischemia in multiple coronary territories, presented to the clinic with dyspnea in the setting of persistent AF now 6 weeks after multi-vessel PCI. Other relevant information is that he appears congested in clinic and his EKG demonstrates a left bundle branck block (LBBB) with QRS at 172 ms. He seeks your opinion for management options.

Case #2 Takeaways

1. Dr. Calkins discussed that the only safe AAD in this circumstance would be Amiodarone, and that the risk of developing complete heart block (CHB) in a patient with LBBB placed on amiodarone is not high enough to preclude its use. One strategy would be to give this patient an amiodarone load followed by direct current cardioversion (DCCV). Following DCCV, if the patient maintains sinus rhythm, one could consider continuing with amiodarone at a lower dose or pursuing catheter ablation as a next strategy.
2. Dr. Calkins emphasized understanding the temporal relationship between AF and HF in patients with reduced ejection fraction. In patients with new-onset AF and reduced EF, aggressive rhythm control with catheter ablation would be warranted because there is a higher likelihood of improving the cardiomyopathy.
3. Another option to consider in patients with HFrEF and permanent atrial fibrillation that remain symptomatic or who have had hospitalizations with HF is AV node ablation with cardiac resynchronization therapy, though for a patient like this other viable treatment options remain to be tested. Regarding an ICD, the patient may recover their EF post-revascularization and implementation of guideline-directed therapy. Thus, with ischemic cardiomyopathy post revascularization, the decision to place an ICD should wait 90 days. Furthermore, the EF may improve with control of the AF.

Case #3 Synopsis:

A woman in her mid-80s with hypertension and recent COVID-19 pneumonia is admitted to the hospital with hypoxia, reduced LVEF and found to have AF with rapid ventricular response. The patient’s underlying conditions were treated and attempts at ventricular rate control were attempted but limited by blood pressure. A DCCV with amiodarone loading was also attempted but failed to maintain sinus rhythm. 

Case #3 Takeaways

1. Some feasible options in this circumstance include further loading with amiodarone and reconsidering another DCCV versus an AV node ablation with permanent pacemaker implantation if medical therapies are limited or failing.
2. Digoxin use for rate control alone in critically ill patients is typically discouraged. This is because we now know that its mechanism of action involves raising vagal tone and acutely ill patients typically have low vagal tone so it may not be helpful. However, in patients with rapid AF and HF, it is reasonable to use it. When used in combination with amiodarone, one may reduce the dose of digoxin in half given its drug-drug interaction

In this episode, Daniel Ambinder (CardioNerds Co-Founder), Dr. Gurleen Kaur (Director of CardioNerds Internship and medicine resident at Brigham and Women’s Hospital), Dr. Eunice Dugan (Cardiology fellow at Cleveland Clinic) and Dr. Zarina Sharalaya (Interventional and Structural Cardiologist at North Texas Heart) learn from the Dr. Sheila Sahni (Interventional Cardiologist and Director of The Women’s Heart Program at The Sahni Heart Center) regarding radiation safety in the cath lab and methods of reducing radiation exposure to the operator. She also discusses radiation safety for the pregnant interventional cardiologist and how to safely manage pregnancy during the gestational period. We hear her inspirational journey as a female interventional cardiologist and her experience in starting the Women’s Heart Program at Sahni Heart Center. Special message by Dr. Jeff Lander, New Jersey ACC Chapter Governor. Audio editing by CardioNerds Academy Intern, Pace Wetstein.

The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.

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1/ Episode 228: @PaChapterACC & @CardioNerds Narratives in Cardiology episode featured a discussion w/ @DrSheilaSahni, @ZSharalayaMD, @EuniceDuganMD, & @Dr_DanMD

Follow this #CardsNarratives🧵on Radiation Safety & Women in Interventional Cardiology pic.twitter.com/YounyfIl8a

“Having anyone who can believe in you when you are really passionate about something is really all you need… the passion is what’s going to carry you through. It’s not about being male or female or pregnant or not pregnant, it’s about what you love to do and how can you master it.”

“Our careers can wait, but family planning cannot. If you are fortunate enough to have the opportunity to start a family even if it’s during your training, you should”.

What are procedural techniques to utilize during a heart catheterization to reduce radiation exposure to the operator?

• Decrease number and length of cine acquisitions and fluoroscopy time
• Decrease the frame rate – halving the frame rate reduces radiation dose by 50%
• Decrease the distance between the image intensifier and the patient
• Limit steep LAO angulations
• Apply collimation as much as possible which reduces overall patient dose and scatter radiation
• Limit digital magnification which can increase skin dose exposure by 50%

What are the important dose limits to consider for a pregnant female and her fetus in the cath lab?

• The US Nuclear Regulatory Commission (NRC) regulatory equivalent dose limit is 5mSv during the entire pregnancy of the declared pregnant woman.
• The annual natural background radiation dose in the US is 3mSv.
• The average under-lead dose to a working pregnant interventionalist over the entire gestation is ~0.3mSv.
• The fetus of a working pregnant interventionalist is estimated to receive ~0.09mSv over an entire gestation.

What are the ways in which pregnant women can protect themselves and the fetus from radiation exposure in the cath lab?

• Disclose (confidentially if desired) pregnancy to the radiation safety office to ensure fetal protection
• Wear an additional dosimeter underneath the lead apron at waist level to track fetal radiation dose
• Decrease occupational exposure via radiation protection measures as summarized below

What are important considerations for lead apron use in the cath lab to maximize radiation protection?

• Make sure your lead fits!
• Do not sit in your lead- sitting in lead can lead to cracks which can decrease protection
• Hang up your lead when not being used
• Consider shoulder pads/arm sleeve addition to lead apron to protect breast tissue
• Ensure that your lead apron is undergoing periodic screening to monitor for defects
• Consider lead thickness – 0.5mm thickness attenuates 98-99.5% of scattered radiation, 0.35mm thickness attenuates 95-96% of scattered radiation

1. Sahni S, Chieffo A, Balter S. Women as one. Radiation Safety in the Practice of Cardiology. https://rad.womenasone.org/. Accessed March 31, 2022.