SPOTTERS(ECG,CXR,ECHO, FLURO IMAGE)

DR MAHENDRA Cardiology, JIPMER

Probable Diagnosis ?

AV Block: 2nd degree, Mobitz I (Wenckebach Phenomenon)

• Progressive prolongation of the PR interval culminating in a non-conducted P wave.

• The PR interval is longest immediately before the dropped beat.

• The PR interval is shortest immediately after the dropped beat.

• The P-P interval remains relatively constant.• The greatest increase in PR interval duration is

typically between the first and second beats of the cycle.• The RR interval progressively shortens with each beat of the

cycle.• The Wenckebach pattern tends to repeat in P:QRS groups with

ratios of 3:2, 4:3 or 5:4.

• 40 year old male presented with complain of• Palpitation• Dyspnoea –III• b/l pedal edema• Family history- elder brother died at age of 30

year due to sudden cardiac arrest.

? Probable diagnosis

ARVD• Major echo criterion • Regional RV akinesia, dyskinesia, or aneurysm• and 1 of the following (end diastole)— PLAX RVOT ≥32 mm PSAX RVOT ≥36 mm fractional area change ≥33%

• Minor echo criterion • Regional RV akinesia or dyskinesia• and 1 of the following (end diastole)— PLAX RVOT ≥29 to <32 mm PSAX RVOT ≥32 to <36 mm fractional area change ≥33% to <40%

? Probable Diagnosis

Brugada type 1

• Diagnostic Criteria• Type 1 (Coved ST segment elevation >2mm in >1 of V1-V3

followed by a negative T wave) is the only ECG abnormality that is potentially diagnostic. This has been referred to as Brugada sign.

• ECG abnormality must be associated with one of the following clinical criteria to make the diagnosis:

• Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT).

• Family history of sudden cardiac death at <45 years old .

• Coved-type ECGs in family members.• Inducibility of VT with programmed electrical

stimulation .• Syncope.

? Probable Diagnosis

Ashman phenomenon

• wide complex QRS complexes that follow a short R-R interval preceded by a long R-R interval.

• Duration of the refractory period of the myocardium is proportional to the R-R interval of the preceding cycle.

• A short R-R interval is associated with a shorter duration of action potential and vice versa.

• A long R-R cycle will prolong the ensuing refractory period, and if a shorter cycle follows, the beat terminating the cycle is likely to be conducted aberrantly.

• Because the refractory period of the right bundle branch is longer than the left, the right bundle will still be in the refractory period when the supraventricular impulse reaches the His-Purkinje system, resulting in a complex with right bundle branch morphology.

Chest X-ray findings suggestive of CAP include

Levoposition of the heart without tracheal deviation, which may be mistaken for cardiomegaly.

The right border is not seen because it is superimposed on the spine on frontal projection.

The left border is elongated and flattened, with prominence of the main pulmonary artery, which is separated from the aortic knob by a radiolucent zone (Snoopy's sign)

The 2-D echocardiogram findings include

Right ventricular enlargement, abnormal septal motion, cardiac hypermobility with swinging motion of the heart, and teardrop appearance with bulbous ventricle and elongated atria.

Another striking echocardiographic findings include, failure to obtain standard views via the usual acoustic windows.

Congenital Absence of Pericardium

Problable echo image diagnosis?

• Tricuspid annular plane systolic excursion (TAPSE)-

• distance of systolic excursion of the RV annular plane towards the apex.

• obtained by M-mode cursor passed through the tricuspid lateral annulus in a four-chamber view and measuring the amount of longitudinal displacement of the annulus at peak-systole.

• Normal value for TAPSE: above 16 mm.

Culprit artery localization ?

Probable diagnosis?

Constrictive pericarditis

• M-mode in parasternal short axis view at papillary muscles level in constrictive pericarditis- septal bounce with abnormal septum movement in early diastole (arrow).

• Other feature-

increased echogenicity in the region of the pericardium

apical four-chamber view, pulse wave Doppler recording of mitral inflow: inspiratory decrease in E-wave velocity

pulse wave Doppler recording of tricuspid inflow: inspiratory increase in E-wave velocity by

35% (arrow)

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