🖥️🩺 Dive into the world of digital health w/ the newest CardioNerds episode!

➡️ Ep. 366: Integrating Digital Health into Practice

🌟-ing Drs. Alexis Beatty & Seth Martin along w/ Drs. Nino Isakadze, Karan Desai MD FACC, & Daniel Ambinder, MD!

🔗 Listen now: cardionerds.com/366-digital-he…!

📣📣📣 Finally, this interesting episode on “ Cardio -toxicity of novel immunotherapies”💉 with our expert Tomas G. Neilan, MD, MPH
and our amazing people from CardioNerds is out! Giselle A. Suero Abreu, MD PhD Evelyn J. Song Daniel Ambinder, MD Teodora Donisan, MD Dinu V. Balanescu, M.D. Amit Goyal MD MAS

cardionerds.com/365-cardioonco…

Join us on the 4th annual Cardiometabolic Risk in Inflammatory Condition on April 26th

Learn more at nyulmc.org/cvinflammation…

After 12 pm on Tues 4/23, only onsite registration is available

CardioNerds NYU CVD Prevention Brittany Weber Dr. Michael Garshick Brigham and Women's Hospital Amit Goyal MD MAS Daniel Ambinder, MD

An terrific review of MVP accompanied by extraordinary original illustration by CardioNerds Academy Fellow Ramy Doss. SO TALENTED!!!

19/19 Congratulations on finishing this CardioNerds tweetorial!

Big shoutout to Richard Ferraro for the detailed review. Also, heartfelt gratitude for the supportive CardioNerds family
Amit Goyal MD MAS Daniel Ambinder, MD Tommy Das, MD Jessie Holtzman Rawan Amir

18/19 Now, let's bring it all together!
Take a look at the algorithm below!

17/19 When to place ICD?

🔶2ry prevention after VF/sustained VT
🔶1ry prevention: Unclear, need shared decision making
- Multiple non-invasive risk factors + complex VA + scarring on CMR
- Unexplained syncope + High risk VA
- Inducible monomorphic VT on EP study

16/19 In the absence of severe MR, is there a benefit for mitral valve repair/replacement?

🔶 Limited evidence, small studies
🔶 Benefit younger > older
🔶 Possible indications:
- Frequent ICD ⚡/malignant VA
- Symptomatic 'mechanical' PVCs due to leaflet-LV contact

15/19 Mapping and ablation of papillary muscle arrhythmias can be challenging. Here are some expert tips:

🔶 Use intracardiac echocardiography
🔶 Use contact force sensing catheters or cryoablation to improve contact
🔶 Perform before MV surgery to avoid neochordal damage

14/19 What about the role of catheter ablation?

When?
🔶 Symptomatic VA/ PVC cardiomyopathy with failed/undesired AAD
🔶 Recurrent VF

What to ablate?
🎯 Substrate: channels in scar
🎯 Triggers: PVC origin, Purkinje triggers

Is it effective?
🔶60-90% acute success

13/19 What's the role of medical treatment with antiarrhythmic drugs?

✔️Symptomatic relief and suspected PVC cardiomyopathy
❓ No clear evidence for SCD prevention
🔶Betablockers 1st line, Class Ic, Class III AAD may be used.
🔶Possible role of Quinidine in PVC-induced VF

12/19 What about the role of EP study in risk assessment?

❓Not well established

✔️''Positive'' study if induction of sustained monomorphic VT (only in 5%) or Induction of PVT/VF with ≤2 ventricular extra-stimuli (VES)

❌Induction of PVT/VF by ≥3 VES is non specific.

11/19 What is the role of CMR in risk stratification?

In addition to similar findings to those seen on TTE , additional risk markers include:

🔶LGE: Focal fibrosis within papillary muscles and inferior/inferolateral wall

🔶T1 mapping: Diffuse myocardial fibrosis

10/19 What is Pickelhaube sign?

🔶high-velocity systolic signal in the tissue doppler of MV annulus resembling the 'Pickelhaube helmet' spike
🔶> 16 cm/s = higher risk
🔶Best assessed in posterolateral annulus
🔶Mechanism: Sharp pull of the postero-basal LV wall

9/19 What is mitral annular disjunction (MAD)?

🔶 Abnormal atrial displacement of the hinge point of the mitral valve

🔶Associated with MVP (78%) or isolated finding (22%)

🔶 Features associated with arrhythmogenesis: depth > 5mm, inferolateral location, systolic curling!

7/19 What are the high-risk ECG features?

🔶 Inferior T wave inversions/ biphasic: in 65% of patients with malignant ventricular arrhythmias(VA), but present in 40% of all patients with MVP!

🔶Complex VA: short coupled PVC, fast, frequent, multiform, PM/peri-mitral origin

5/19 What's the mechanism of arrhythmias in MVP?

🔶Substrate: ++ traction> fibrosis especially affecting papillary muscles & inferobasal left ventricle
🔶Trigger: PVCs due to myocardial stretching or mechanical friction, Purkinje fiber ectopy
🔶Modulator: ++sympathetic tone

4/19 There are predominantly 2 pathological forms of MVP:

🔶 Barlow’s disease: develops in younger age, diffuse bi-leaflet disease with elongated chordae

🔶Fibroelastic deficiency: develops in older age, usually affecting a single cusp with chordal rupture

3/19 What is the risk of SCD in mitral valve prolapse?

🔶 In average 0.2-0.4% (3 times the risk of general population)

🔶 Since MVP is very common, the number of individuals at risk is similar to the number at risk in the HCM population

2/19 What is MVP and why is it important?

🔶 Definition: Superior displacement of mitral leaflet(s) by > 2 mm beyond annulus during systole
🔶 Affects 1-3% of the population
🔶 Overall benign, but can be associated with significant MR , IE, HF, and sudden death