Dr. Smith's ECG Blog

APRIL 2, 2024

Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines. In other words, the RV contracts before the LV and this results in diminished LV EF. So a dual chamber pacer is placed with one lead through the coronary sinus to the LV. Here is the initial ED ECG. What do you think?

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Emergency Medicine Ireland

MAY 13, 2024

Their echo shows a poorly functioning LV and severe MR. The PH here is going to be group 2, PH secondary to left heart disease. Their echo shows a poorly functioning LV and severe MR. The PH here is going to be group 2, PH secondary to left heart disease. To give an example you are handed over someone who has known PH.

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Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Troponins: 3,830 ng/L 4,098 ng/L 1,343 ng/L Echo: LV: normal cavity size and thickness. This is because the anterior anatomic position of the RV ( R ight V entricle ), and its immediate proximity to the sternum — makes the RV much more susceptible to blunt trauma injury than the LV. EF 45%, with mild global hypokinesis.

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RebelEM

APRIL 5, 2023

The right ventricle is instead depolarized by spread of impulse from the left bundle, through the left ventricle (LV) and then to the RV This pattern of electrical spread creates an aberrant QRS morphology Depolarization vector produces delayed R waves in leads V1-3 and delayed S waves in the lateral leads.

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Ken Grauer, MD

JULY 15, 2023

Figure-5: Selected CT scan slice ( IVS = InterVentricular Septum; LV Wall; slit-like LV cavity ). Figure-4: Comparison between the post-conversion 12-lead ECG — and the ECG repeated the next day. Figure-6: Selected Cardiac MRI view. D ISCUSSION : There are many important aspects of this case.

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Intensive Blog

FEBRUARY 7, 2023

Despite thromboaspiration, she had recurrent VF arrests with worsening cardiogenic shock (CS), so an Impella CP (Abiomed, Danvers, MA) was inserted through the right femoral artery for left ventricular (LV) support. 2 L/min of flow to unload the LV (usually P2-P4 level). What is LV distension syndrome? For example, an Impella 2.5

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Emergency Medicine Cases

SEPTEMBER 12, 2023

The post ECG Cases 45 ECG in Weakness and Neurological Symptoms appeared first on Emergency Medicine Cases.

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Dr. Smith's ECG Blog

OCTOBER 28, 2023

LVH can have very thick-walled ventricles and a correspondingly small LV cavity. We did a bedside echo (original quality was not so good, and this is moreover an iPhone video of the screen -- but it is good enough): Notice how small the LV cavity is. This is because of the large LV myocardial mass due to HOCM. Here is his ECG.

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Dr. Smith's ECG Blog

APRIL 22, 2024

Formal Echo: Normal left ventricular cavity size, and normal LV systolic function. Increase in LV wall thickness, asymmetric (see below). That said — LV "strain" should never look like the steep T wave descent that we see in lead V3 of Figure-1 , in which there is no indication of LV "strain" in the lateral chest leads.

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Mind The Bleep

NOVEMBER 12, 2023

This system has its own flaws as there can often be significant overlap between these categories e.g. familial hypertrophic cardiomyopathy will show a hypertrophied LV (HCM) on imaging but as the disease progresses may also show restrictive (RCM) features. It’s a transient disease and LV function normalises in days-weeks. 2006 Apr 11.

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Dr. Smith's ECG Blog

APRIL 18, 2024

The overly tall R wave ( far exceeding 12 mm ) qualifies as LVH ( supported by an ST-T wave appearance in lead aVL completely typical for LV "strain" ). second ( due to slight delay in depolarization of a thicker LV and/or an LV in which the left anterior hemidivision of the conduction system is not functioning ).

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Ken Grauer, MD

MAY 20, 2023

The ST-T wave segment in lead V1 of example D — closely resembles the "shape" of LV strain in an anterior lead from a patient with LVH. In Figure-4 — I've reproduced from the above cited June 20, 2020 post my schematic illustration of the ST-T wave appearance that may be seen in one or more lateral leads for demonstrating LV "strain".

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Taming the SRU

APRIL 11, 2024

Chronic Increased RV free wall thickness Left ventricle evaluation and LV failure EPSS (E-Point Septal Separation) Normal < 7 mm Ensure that M-Mode is as perpendicular as possible to the mitral valve Limitations include: Aortic regurgitation Mitral stenosis Atrial fibrillation Septal hypertrophy Wall motion abnormalities Fractional shortening Measurement (..)

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Dr. Smith's ECG Blog

OCTOBER 6, 2023

This ECG is diagnostic of anterior LV aneurysm in the presence of RBBB. See more such cases of RBBB with LV aneurysm here. It is a particularly difficult LV aneurysm to diagnose on the ECG because the RBBB creates an R-wave that otherwise would not be there. He was hospitalized for 16 days. There will be very little recovery.

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Ultrasound Gel

MAY 9, 2022

They discuss Felipe's take on our coverage of the Quantitative LV Function in PEA article (ep 119) as well as thoughts on ultrasound and cardiac arrest research in general. link] In the first of our new series of author interviews, hosts Zach Risler and Mike Prats interview the illustrious Felipe Teran.

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Emergency Medicine Cases

SEPTEMBER 13, 2022

Takotsubo Syndrome is a retrospective diagnosis of exclusion—with an angiogram ruling out occlusion, a ventriculogram showing apical ballooning, and a follow up echo showing recovery of LV function. Complications of Takotsubo Syndrome include LV failure, apical thrombus, and polymorphic VT from long QT.

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Ken Grauer, MD

DECEMBER 23, 2023

As a result — the IVS ( I nter V entricular S eptum ) and the LV ( L eft V entricle ) depolarize normally with RBBB conduction — and it is only after the LV has depolarized that the RV ( R ight V entricle ) now depolarizes via slow conduction through ventricular myocardium ( because of the "block" in the right bundle branch ).

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Dr. Smith's ECG Blog

JULY 26, 2023

But the well-formed Q-wave and the presence of a normal T-wave in inferior leads led me to believe this was Old Inferior MI with persistent ST Elevation, otherwise known as inferior LV aneurysm. Anterior LV aneurysm is much easier to recognize because the Q-wave is usually a QS-wave (no R-wave at all), in at least one lead.

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Sensible Medicine

JANUARY 22, 2024

The STICH trial, published in 2011, randomized about 1200 patients with impaired LV systolic function and severe coronary artery disease amenable to surgery to CABG or medicine alone. If I had severe angina, heart failure, left main or multi-vessel proximal disease with LV dysfunction, I would strongly consider bypass surgery.

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Dr. Smith's ECG Blog

NOVEMBER 10, 2008

Very often, such large anterior MI result in persistent ST elevation and they may or may not have a demonstrable "LV aneurysm" by echo. in acute MI, and almost always lower in LV aneurysm. More accurately, there was a substantial mass of myocardium that died (infarcted, meaning irreversibly).

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Taming the SRU

AUGUST 6, 2023

Mainstay of treatment for LV thrombus is anticoagulation, with mean time to resolution of 103 days. About 14% of patients will have recurrence of LV thrombus. Diagnostic test of choice is TTE with cardiac MRI as gold standard if TTE negative with high clinical suspicion.

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Sensible Medicine

APRIL 15, 2024

It’s an ingenious device that goes across the aortic valve into the LV. It spins and spins and pumps blood from the failing LV into the aorta. It makes a lot of noise but trials showed it ineffective. Then came something called the microaxial flow pump, called Impella. It can deliver many liters of cardiac output.

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Dr. Smith's ECG Blog

APRIL 14, 2023

Smith's ECG Blog ) — ST-T wave changes of LV “strain” most often manifest in one or more of the lateral leads. But instead of seeing ST-T wave changes of LV “strain” in lateral leads — some patients manifest a “mirror-image” of strain in anterior leads. Figure-1: The initial ECG in today's case ( See text ). What About Lead V4?

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Emergency Medicine Cases

OCTOBER 13, 2020

How can one distinguish MI vs LV aneurysm on ECG? 9 patients presented with potentially ischemic symptoms and Q-waves. Which had Occlusion MI? What is the differential diagnosis of Q-waves? The post ECG Cases 14: Q-wave and Occlusion MI appeared first on Emergency Medicine Cases.

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Dr. Smith's ECG Blog

JULY 27, 2023

The lateral chest lead ST depression ( with terminal T wave inversion in leads V4,V5 ) supports my impression of marked LVH by the typical ST-T wave appearance of LV “strain”. PEARL #1: The frontal plane axis in this initial ECG is vertical ( small amplitude, nearly isoelectric QRS in lead I — in the face of huge inferior lead R waves ).

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RebelEM

SEPTEMBER 14, 2023

Device-related complications counterbalance any potential benefit (More bleeding and peripheral ischemic complications warranting intervention occurred more frequently in ECLS group) Duration of mechanical ventilation (Longer in the ECLS group which could alter outcomes) VA ECMO is associated with increased LV afterload (More dobutamine used in ECLS (..)

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Ken Grauer, MD

JANUARY 13, 2024

Pure LV "strain" tends to produce downsloping ST depression with asymmetric T inversion in ≥1 of the lateral leads ( ie, leads I,aVL; V5,V6 ). In addition — the ST elevation in l eads III and aVF , in association with the hypervoluminous T waves in these leads — is not expected with pure LV "strain".

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Dr. Smith's ECG Blog

MAY 14, 2022

After cardioversion, echo showed excellent LV function. Good LV function means that if this is VT it would likely be idiopathic VT 2. At this point — the patient was electrically cardioverted, and a post-cardioversion Echo in sinus rhythm showing normal LV function was obtained. You don’t always see Delta waves."

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Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

The RV > LV. The LV EF was 57% at formal echo. 3) RV Failure leads to hypotension but NOT pulmonary edema (unlike LV failure) 4) Repeat ECGs, right sided ECG and bedside echo may be helpful in making a diagnosis of ACS. Not much difference from 1st ECG. A bedside echo was performed. McConnells sign was present.

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Downeast Emergency Medicine

NOVEMBER 5, 2021

Aorta (A), left ventricle (LV), left atrium (LA). Apical 4-chamber view - Notable findings include dilated right ventricle (RV) with a >1:1 ratio of right ventricle (RV): left ventricle (LV). Parasternal short axis view - notable findings include enlarged right ventricle (RV) with septal flattening (“D-sign”), and pleural effusion.

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Ken Grauer, MD

APRIL 5, 2024

PEARL # 2: Sometimes with LVH — instead of seeing tall R waves with LV "Strain" in the lateral chest leads — we see the " mirror -image" opposite picture in right-sided leads V1,V2 ( ie, LVH may be manifested by deep anterior S waves — with ST elevation in leads V1,V2 and/or V3 ). ie, Panel C in Figure-4 below in today's ADDENDUM ).

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Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. After discussing all of the above with ED staff, we have made a decision to get stat echocardiogram and assess overall LV function and wall motion abnormalities and defer cath lab activation at the time." He awoke with naloxone.

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Dr. Smith's ECG Blog

JANUARY 23, 2023

PMID: 34775811; PMCID: PMC9075358 A bedside ultrasound was performed, shown here: Parasternal short axis view demonstrating inferior LV wall motion akinesis Apical 2 chamber view again demonstrating inferior LV wall akinesis The cath lab was not activated based on the ECG and bedside echo. Epub 2021 Nov 15.

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Dr. Smith's ECG Blog

MARCH 28, 2024

Metoprolol can sometimes convert SVT, and sometimes the rhythm can change to atrial fibrillation. t = 16 minutes Further Care in the ED: Patient hemodynamically stable, discussed options with patient, would prefer medications before attempting cardioversion Patient given metoprolol 5 mg IV with improvement in HR to 110-120s, repeated ~q5 mins x3.

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Dr. Smith's ECG Blog

AUGUST 30, 2020

Follow up: "Some follow-up on my scary EKG from last week - no change on next day EKG, significant LV hypertrophy on echo, equivocal abnormal stress test vs artifact so he got sent to cardiology and had a clean cath. See this case of Type 2 STEMI due to severe hypertension. Here are more Type II STEMI. All for want of a prior EKG.

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Dr. Smith's ECG Blog

APRIL 26, 2017

Notice also the very small LV cavity size at both diastole and systole (poor LV filling with good contractility) and apparent low stroke volume. So there is poor LV filling. This can be due to one or both of very poor compliance (which is no doubt present here, due to LVH) and to low LV filling pressures.

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Dr. Smith's ECG Blog

MAY 30, 2023

Because the RV pressure is normally low (unlike the LV), it is perfused by systolic blood pressure in addition to diastolic, so hypotension is very bad for the RV. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. 1 mg of Atropine was given and the heart rate increased transiently to 60.

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