ECG/X-ray Quiz
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Transcript of ECG/X-ray Quiz
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SPOTTERS
Moderator
Dr Raja Selvarj
Presenter
Dr Praveen Gupta
Date-16.03.2017
JIPMER,
PONDICHERRY(INDIA)
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Spotter 1Identify the abnormality in the ecg
© 12/02/ 2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Answer
Sinus rhythm at 84 beats per minute,
PR interval 360 msec, Normal axis, Narrow QRS complex, No ST-T wave changes QT interval 360 msec, QTc-430 msec so the
Ecg suggestive of first degree AV block
© 12/02/ 2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Spotter-2, What is the ECG abnormality (Tachycardia ECG)…
© 11/03/2017, Department of Cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Spotter-2(Tachycardia ECG, Rhythm strip)…
© 11/03/2017, Department of Cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Spotter-2Tachycardia ECG, Post adenosine injection…
© 11/03/2017, Department of Cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Spotter-2Sinus ECG
© 11/03/2017, Department of Cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Answer
Narrow complex, regular tachycardia
Rate around 200 beats per minute
P wave were not seen
No significant ST-T wave changes seen
There is no evidence of pre-excitation in the baseline ecg
Diagnosis is Short RP tachycardia
DD AVNRT.
Final diangosis- Patient underwent EPS/ablation at JIPMER, Cardiology department.
EPS was suggestive of Atrial tachycardia with origin from left atrium, posterior in
origin. Patient underwent successful ablation.
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Spotter 3Identify the abnormality in the ecg
Tachycardia ECG
© 30/12/ 2016, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Spotter 3, Conti…Sinus ECG
© 30/12/2016, Department of Cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Description of the ECG
Tachycardia ECG- Regular narrow complex
tachycardia rate 200/minutes, LBBB morphology LAD QRS duration nearly 120 msec No AV dissociation, No P wave, No capture beat No fusion beat
Sinus ECG
Sinus rhythm at around 75 per
minute,
LAD,
No ST-T wave changes,
No evidence of pre-excitaion
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Answer
Patient underwent Electrophysiological study at Department of
Cardiology, JIPMER, Pondicherry, India, by Dr Raja Selvaraj and his
team.
It was suggestive of Antidromic reentrant tachycardia
with mahaim accessory pathway. Patient underwent
successful radiofrequency ablation Final diagnosis is Mahim fiber tachycardia
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Electrocardiographic Features of Mahaim fiber
The resting electrocardiogram (ECG) is usually normal
No delta wave with Mahaim fiber conduction
ECG features that suggest Mahaim fibers as the cause of a tachycardia with a left
bundle branch block pattern These include:
QRS axis between 0 and minus 75º
QRS duration of 0.15 seconds or less
R-wave in lead 1
rS complex in lead V1
Precordial transition in lead V4 or later
Cycle length between 220 and 450 milliseconds (heart rates of 130 to 270)http://www.uptodate.com/index
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Spotter 4Identify the abnormality in the ecg
© 17/01/ 2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Diagnosis of the ECG
Narrow complex tachycardia irregularly irregular No visible P wave seen Heart rate around 140 beats per minute ST segment depression with T wave inversion in lead II,III,avF, V4-V6
ECG is suggestive of atrial fibrillation with fast
ventricular effect with digoxin effect
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Spotter 550 yr/male with chest pain
Identify the abnormality in the ecg, localize the coronary artery involved
© 23/01/2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Answer
ECG-Sinus rhythm at 100/minute Inferior axis nearly 90 degree in view of equiphasic QRS in lead I Diffuse ST segment depression with T wave inversion in lead
I,II,III,avF,avL, V2-V6 ST segment elevation in lead avR, V1 PR interval 120 msec QT interval 360 msec QTc interval 464 msec The ECG suggestive of ACS/USA/ Most likely artery involved is
LMCA
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CAG of the patient
© 27/01/2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
CAG, 27/01/2017(Pro no- 18538/ CD No-13338)-Right dominance, LMCA=Ostial 90-95% stenosis, LAD=Ostial 70-80%,LCX= Ostial 70-80%, RCA=Moderte diffuse diseases, max 60-70%. Diagnosis- CAD/TVD/LMCA Diseases.
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Spotter 6Identify the abnormality in the ecg
© 18/09/2016, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Answer
Description of the ECG
Broad complex regular tachycardia at around 200 beats per minute
Right axis deviation
QRS duration around 280 msec
RBBB morphology
No P wave
No capture wave
No fusion beat
Diagnosis-Broad complex tachycardia, Differential diagnosis- Ventricular tachycardia, Or It could be
Supraventricular tachycardia with aberrancy
Patient underwent EPS study and found to have Bundle branch reentrant tachycarida
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Spotter- 7Identify the abnormality in the ecg
Tachycardia ECG
© 09/03/2017, With permission from RMMCH Hospital, Pondicherry, India: ALL RIGHT RESERVED
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Spotter- 7 Conti………Identify the abnormality in the ecg
Tachycardia ECG
© 09/03/2017, With permission from RMMCH Hospital, Pondicherry, India: ALL RIGHT RESERVED
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Spotter- 7 Conti………Identify the abnormality in the ecg
Sinus ECG
© 09/03/2016, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Answer
Description of the ECG- Broad complex regular tachycardia at heart rate around 190 beats per minute QRS of RBBB morphology QRS duration 240 msec Normal axis No capture beats No fusion beats No AV dissociation seen No visible P wave seen
Negative concordance seen from lead V1-V6, rS seen in lead V6 Final diagnosis- Ventricular tachycardia
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Approach in a patient of Ventricular tachycardia
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Spotter 8Identify ECG abnormality
© 13/01/2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Spotter 6 Conti……….Identify Cardiac MRI abnormality in the above patient
© 14/02/2017, Department of cardiology, JIPMER, Pondicherry, India: ALL RIGHT RESERVED
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Answer
Broad complex regular tachycardia with rate around 200 beats per minute, AV dissociation was present with intermittent visible P wave in lead I,II, V1. No capture beats No fusion beat seen Negative QRS concordance seen in lead V1-V5 QRS complex were of LBBB morphology QRS axis being inferior (QRS complex are positive in lead II,III,avF) Diagnosis of this ECG is Ventricular tachycardia with inferior axis Final diagnosis if RVOT VT Cardiac MRI(14.02.2017)-Severe biventricular dysfunction, RVEF-25%, LVEF-22%,
RV free wall and sub tricuspid dyskinesia suggestive of Arrythmogenic right ventricular
cardiomyopathy
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Spotter 9
Identify the device on the right
side of the chest x-ray Its use? Its present status?
http://www.implantable-device.com/wp-content/
uploads/2011/12
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Answer- Cardiac Contractility Modulation (CCM)
New innovative device therapy for HF Enhance left ventricular systolic function for
symptomatic patients, irrespective of QRS
duration 80% of HF patients have a narrow QRS Implanting the pacing electrodes to superior
and inferior septum of right ventricle Pulse generator deliver large biphasic current
intermittently during the refractory phase of the
cardiac cycle so as to modulate myocardial
intracellular calcium. Intrinsic contractility of the left ventricle will
be enhancedChest X-ray of a patient who is a CRT non-responder and received CCM in 2009 (Optimizer III at that time). He has significant improvement of heart failure symptoms from NYHA class IV to I. There was left ventricular reverse remodeling and increase in ejection fraction. He is free of heart failure rehospitalization in the past 4 years
Liu M, Fang F, Luo XX, Shlomo BH, Burkhoff D, Chan JY, Chan CP,
Cheung L, Rousso B, Gutterman D, Yu CM. Improvement of long-term
survival by cardiac contractility modulation in heart failure patients: A
case–control study. International journal of cardiology. 2016 Mar
1;206:122-6.
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Answer- Cardiac Contractility Modulation (CCM)
Improved HF symptoms and quality of life
Left ventricular reverse remodeling
Reduction of HF hospitalization and mortality
Patients with ejection fraction between 20-40%
seems to benefit more than those with ejection
fraction <20%.
Used in Europe and Hong Kong, China.
FDA approval is underway
Newest generation device (Optimizer IVis a
smaller device)
CCM can be a treatment option for CRT
non-responders ©2017,CCM and Optimizer are trademarks of Impulse Dynamics N.V. A Germany, StuttgartALL RIGHT RESERVED
Kwong JS, Sanderson JE, YU CM. Cardiac Contractility Modulation for Heart Failure: A Meta‐Analysis of Randomized Controlled Trials. Pacing and Clinical Electrophysiology. 2012 Sep 1;35(9):1111-8.
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Spotter 10
Identify the foreign
body shown in x-ray Where it is used Advantage
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Answer Reveal LINQ Insertable Cardiac Monitor (ICM)
Smallest implantable cardiac monitoring device
February 19, 2014 –Medtronic got U.S. Food and Drug
Administration (FDA) clearance
80 percent smaller than other ICMs
Allows continuously and wirelessly monitor patient's heart
for up to three years, with 20 percent more data memory
than its larger predecessor, Reveal® XT
Provides remote monitoring through the Carelink®
Network.
Physicians notifications to alert them if their patients events
Indicated for patients who experience symptoms such as
dizziness, palpitation, syncope (fainting) and chest pain that
may suggest a cardiac arrhythmia, and for patients at
increased risk for cardiac arrhythmias
MR-Conditional, allowing patients to undergo magnetic
resonance imaging (MRI) if neededMedtronic Announces Global Launch of Miniature Cardiac Monitor, Reveal LINQ(TM) ICM
© 2014,MEDTRONIC, ALL RIGHT RESERVED
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THANK YOU