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Combination of diagnostic criteria used to assess the severity of tricuspid regurgitation (TR). This figure lists the 4 proposed combination criteria described by Grant et al.60 In this algorithm, severe TR was present in the presence of a suggestive color Doppler jet and if any ≥1 of the combinations shown were present. ASD indicates atrial septal defect; CW, continuous wave; IVC, inferior vena cava; and RA, right atrial. #Diagnosis #Cardiology #Tricuspid #Regurgitation #Criteria #Severe

RA/CVP Waveform Interpretation Central venous pressure (CVP) or right atrial pressure (RAP) waveform tracings can often times provide useful insight about a patient’s right ventricle (RV), tricuspid valve (TV), and overall cardiopulmonary status. The waveform morphology is easier to identify at slower heart rates and consists of three waves and two descents: - ‘a’ wave (RA contraction at end diastole): lost in atrial fibrillation/flutter due to disorganized atrial activity. ↑ in pathologies that impede forward flow like tricuspid/pulmonic stenosis and pHTN. Classic “cannon waves” caused by RA contraction against a closed TV causing reflection wave back into RA (junctional rhythm, V-tach, third degree block) - ‘c’ wave (TV cusps bulge into RA during early systole): c-v wave fusion and blunting of ‘x’ descent with TR - ‘x’ descent (RA relaxation in mid systole): ↑ in constrictive pericarditis (CP), ↓ with TR (jet ↑ RAP) and RV dysfunction due to ↓ downward movement of RV - ‘v’ wave (rapid filling of RA in late systole). ↑ in TR from regurgitant jet ↑ RAP. Similar tracings obtained for LEFT atrial pressures (↑ ‘v’ wave with mitral regurgitation). Success of mitral valve repair (ie, MitraClip) can be partly gauged by ↓ in ‘v’ wave. - ‘y’ descent (rapid RV filling in early diastole) Steep ↑ with constrictive pericarditis and ↓ with tamponade (↓ RV filling from ↓ caval inflow). Rishi Kumar, MD @rishimd #CVP #Waveform #Interpretation #Diagnosis #Cardiology #Venous

Right Heart Catheterization Cheat Sheet: Interpretation of Pressures and Waveforms Direct measurements ● Central venous pressure (CVP) ● Right-sided intracardiac pressures (RA, RV) ● Pulmonary arterial pressure (PAp) ● Pulmonary capillary wedge pressure (PCWP) ● Cardiac output (CO) ● Mixed venous oxyhemoglobin saturation (SvO2) Indirect measurements ● Systemic vascular resistance (770-1500 d/s/cm5) (SVR = 80 x [mean artery pressure – CVP]/CO) ● Pulmonary vascular resistance (20-120 d/s/cm5) (PVR = 80 x [mean PAp – PCWP]/CO) ● Cardiac index (2.5-4 L/min/m2) (CI = CO/body surface area) ● Stroke volume index (33-47 ml/beats/m2) (SVI = CI/heart rate) ● Left ventricular stroke work index (LVSWI = [MAP – PCWP] x SVI x 0.136) ● Right ventricular stroke work index (RVSWI = [mean PAp – CVP] x SVI x 0.136) ● Oxygen delivery (DO2 = CI x 13.4 x Hb x SaO2) ● Oxygen uptake (VO2 = CI x 13.4 x Hb conc x [SaO2 – SvO2]) RA pressures and waveforms ● a wave:contraction in atrial systole ● x descent: fall in RA pressure (atrial diastole) ● c wave: closure of the tricuspid valve. ● v wave: ventricular systole + passive atrial filling in atrial diastole. ● y descent: fall in RA pressure following opening of the TV + passive filling of RV Usama Nasir MD @usamanasirmd - Visualmed #RHC #Interpretation #Diagnosis #RightHeartCatheterization #CheatSheet #Waveforms #Cardiology

Differentiating PAH from PVH - Echocardiography Pulmonary Artery Hypertension (PAH): • RV size - Enlarged • LA size - Small • RA/LA size ratio - Increased • Interatrial septum - Bows from right to left • RVOT notching - Common • ElA ratio << 1 • Lateral e' Normal • Lateral E/e' <8 • Aortic pressure - Normal/Low • PCWP < 15 mmHg • PADP-PCWP > 7 mmHg Pulmonary Venous Hypertension (PVH): • RV size - May be enlarged • LA size - Large • RA/LA size ratio - Normal (LA > RA size) • Interatrial septum - Bows from left to right • RVOT notching - Rare • ElA ratio > 1 • Lateral e' Decreased • Lateral E/e' > 10 • Aortic pressure - Normal/High • PCWP > 15 mmHg • PADP-PCWP < 5 mmHg Dr. Sanjiv Shah @HFpEF #Differentiating #PAH #PVH #Echocardiogram #comparison #diagnosis #cardiology #pulmonary #arterial #venous #hypertension

$Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management Source:$

Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management Source: https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.1029 Graphic representation of echocardiographic parameters in the assessment of right ventricular dysfunction. Ao, aorta; DTI, Doppler tissue imaging; EF, ejection fraction; ET, ejection time; FAC, fractional area change; IVC, inferior vena cava; IVCT, isovolumic contraction time; IVRT, isovolumic relaxation time; LA, left atrium; LV, left ventricle; LVEDD, left ventricular end‐diastolic diameter; RA, right atrium; RIMP, right ventricular index of myocardial performance; RV, right ventricle; RVEDD, right ventricular end‐diastolic diameter; TAPSE, tricuspid annular plane systolic excursion; TR, tricuspid regurgitation. Reproduced from Harjola et al.99 with permission of the authors. #Diagnosis #Cardiology #Echocardiogram #RightSided #CongestiveHeartFailure #RVFailure #Criteria #Assessment #RVDysfunction #RightVentricular

Periprosthetic Aortic Valve Regurgitation Grading • Vena Contracta Area • Circumference • Jet Length Mild - Moderate - Severe Mild: 1) 0.1 cm2 VC Area, 8% Circumference Moderate: 2) 0.2 cm2 VC Area, 10% Circumference 3) 0.2 cm2 VC Area, 16% Circumference 4) 0.26 cm2 VC Area, 18% Circumference Severe: 5) 0.7 cm2 VC Area, 30% Circumference #AorticValve #Regurgitation #Periprosthetic #Grading #Classification #Criteria #Diagnosis #cardiology #echocardiography

Complications Following Myocardial Infarction Heart Failure - Ineffcient pumping of the heart. Can be acute or chronic. Dressler Syndrome (rare) - Autoimmune pericarditis. Associated with a high ESR. Develops over weeks to months Papillary Muscle Rupture. Leading to Mitral Regurge Mural Thrombus. Leading to emboli. External (myocardial wall) rupture, Leading to cardiac tamponade. Arrhythmias - Sinus Tachycardia & Bradycardia - Supraventricular (esp AF / Flutter) - Heart Block Ventricular Aneurysm Recurrent MI Pericarditis #Complications #Myocardial #Infarction #Diagnosis #Cardiology

Cardiac Findings in Sarcoidosis Most Commonly Affected Sites: - LV free wall (esp. basal posterior wall) - Interventricular septum. (esp. basal) LV Myocardial Involvement: - LV wall thickening - LV wall thinning - Focal hypokinesis or RWMA - LV Aneurysm - Global systolic dysfunction (+LVEF) - Reduced myocardial strain - Diastolic dysfunction - Papillary muscle involvement Valvular Abnormalities: - Mitral regurgitation due to primary thickening of leaflets - Mitral or tricuspid regurgitation secondary to ventricular dysfunction or pulmonary hypertension Pericardial involvement: - Effusion ECG Abnormalities: - Advanced atrioventricular block - Ventricular arrythmias (V. tachycardia, multifocal) - Right bundle branch block - Axis deviation - Abnormal a-wave #Cardiac #Findings #Sarcoidosis #Cardiology #Involvement #diagnosis

Mechanical Complications in Acute Myocardial Infarction Acute LV/RV Dysfunction: • Regional wall motion, systolic and diastolic function, chamber size and valvular hemodynamics • Many more findings but see separate upcoming infographics! Ventricular Free Wall Rupture: • Large pericardial effusion or expanding pericardial effusion along areas of wall thinning • Features of tamponade • Fibrinous echodensities in pericardial space (blood) • Color Doppler to localize tear • Typically anterior infarct Ventricular Septal Rupture: • Most common locations: basal inferoseptal wall (inferior infarct) and anteroapical (anterior infarct) • Color Doppler with lower Nyquisit limit to localize • Off-axis imaging may be needed • Evaluate for Pulm. HTN and LV/RV dysfunction = poor prognostic signs Papillary Muscle Rupture and Ischemic MR: • Posterior papillary muscle (inferior or lateral MI) most commonly affected • Assess severity of MR and leaflet motion (prolapse or flail?). Highly sensitive to afterload • Severe ischemic MR parameters: EROA ≥ 20 mm2 and Rvol ≥ 30 mL • MR likely to be eccentric and brief in duration (↑ LA pressure). • Typically ↑ mitral E velocity. Ventricular Pseudoaneurysm • Contained rupture along LV free wall; most commonly inferior and inferolateral walls • Small, narrow neck; ratio of neck diameter to max aneurysm size < 0.5 • Bidirectional color and spectral doppler flow through aneurysm neck • Stasis and thrombus in pericardial space Ventricular Aneurysm: • Most frequently with anterior infarct in apical region • Acute aneurysm expands (instead of contracts) during systole • May be associated with thrombus (laminar or pedunculated) • May need contrast echo to identify - Karan Desai MD @karanpdesai via CardioNerds @cardionerds #Complications #Myocardial #Infarction #acuteMI #cardiology #differential #diagnosis #timeline

Graphic representation of transthoracic echocardiographic parameters in the assessment of right ventricular pressure overload. A′ = peak late diastolic (during atrial contraction) velocity of tricuspid annulus by tissue Doppler imaging; AcT = right ventricular outflow Doppler acceleration time; Ao = aorta; E′ = peak early diastolic velocity of tricuspid annulus by tissue Doppler imaging; IVC = inferior vena cava; LA = left atrium; LV = left ventricle; RA = right atrium; RiHTh = right heart thrombus (or thrombi); RV = right ventricle/ventricular; S′ = peak systolic velocity of tricuspid annulus by tissue Doppler imaging; TAPSE = tricuspid annular plane systolic excursion; TRPG = tricuspid valve peak systolic gradient. A. Enlarged right ventricle, parasternal long D(is view B. Dilated RV with basal RV/LV ratio > I .0, and McConnell sign (arrow), four chamber view C. Flattened intraventricle septum (arrows) parasternal short axis view D. Distended inferior vena cava with diminished inspiratory collapsibility, subcostal view E. 60/60 sign: coexistence of acceleration time of pulmonary ejection ms and midsystolic "notch" with mildy elevated (<60 mmHg) peak systolic gradient at the tricuspic valve F. Right heart mobile thrombus detected in right heart cavities (arrow) G. Decreased tricuspid annular plane systolic excursion (TAPSE) measured with M-Mode (<16 mm) H. Decreased peak systolic (S') velocity of tricuspid annulus (<9.5 cmls) #TTE #Echocardiogram #RVStrain #RVOverload #PulmonaryEmbolism #Transthoracic #Diagnosis #RightVentricular #Cardiology