WHERE SHOULD YOU PLACE THE LVOT DOPPLER SAMPLE? Calculating aortic valve area using the continuity equation requires an accurate LVOT velocity-time integral (VTI). But a few millimetres can make a difference. 1. Start in the LVOT Use pulsed-wave Doppler and position the sample volume below the aortic valve. 2. Move toward the valve Advance the sample volume gradually toward the aortic valve, observing the spectral waveform. 3. Identify the optimal position As the sample enters the flow acceleration zone, spectral broadening appears. This indicates that the sample is too close to the valve. 4. Move slightly apically Withdraw the sample until spectral broadening disappears and a clear, laminar LVOT signal is obtained. Why does this matter? If the sample is too close to the valve, the measured LVOT VTI may be falsely elevated, causing the calculated aortic valve area to be overestimated. If it is too far into the ventricle, the measurement may not represent the appropriate LVOT flow velocity. Clinical pearl: Correct LVOT sample positioning is essential for reliable grading of aortic stenosis. Reference: ASE recommendations for echocardiographic assessment of aortic stenosis; 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease.

Wide QRS Tachycardia 1️⃣ Ventricular tachycardia (VT) 2️⃣ SVT with aberrancy 3️⃣ SVT with preexcitation (WPW) 4️⃣ SVT with baseline abnormal ECG 5️⃣ SVT with hyperkalemia 6️⃣ Ventricular pacing

ACUTE AORTIC SYNDROMES: 3 CONDITIONS YOU MUST DISTINGUISH Sudden, severe chest or back pain can signal a life-threatening problem in the aortic wall. Three key diagnoses may look similar clinically but differ anatomically. 1. Aortic dissection An intimal tear allows blood to enter the media, creating a false lumen that can extend along the aorta. 2. Intramural hematoma (IMH) Blood collects within the aortic wall without a clearly visible intimal tear or classic dissection flap. It can progress to dissection or rupture. 3. Penetrating atherosclerotic ulcer (PAU) An atherosclerotic plaque ulcerates through the intima into the media, potentially causing IMH, pseudoaneurysm or rupture. Why the distinction matters All three can cause catastrophic complications, but their anatomy, risk of progression and treatment decisions differ.

Primary PCI: Opening the Artery Is Not the Whole Story In STEMI, the angiogram may show a beautiful epicardial result after PCI. But the myocardium can still be injured. (Why) An occluded coronary artery contains more than thrombus. It may contain atherosclerotic debris, thrombotic material and disrupted plaque. During PCI, some of this material can embolize downstream. The result can be: 1️⃣ Distal embolization 2️⃣ Microvascular obstruction/no-reflow 3️⃣ Side-branch occlusion 4️⃣ Reperfusion-related injury So the goal of primary PCI is not simply: (Open the artery) It is: Restore epicardial flow while preserving myocardial perfusion. How PCI evolved Early STEMI intervention relied heavily on balloon angioplasty. The problems were familiar: Residual stenosis ⬇️ recoil ⬇️ reocclusion ⬇️ restenosis Coronary stents changed this by providing a scaffold, reducing residual stenosis and recoil and improving acute vessel patency. Modern primary PCI therefore generally uses stent implantation when appropriate, rather than balloon angioplasty alone. But the 2016 figure needs an important modern update. Some strategies shown in the original diagram are not routine contemporary STEMI practice: Routine thrombus aspiration is not recommended. Large randomized trials failed to show clinical benefit, and routine aspiration may increase stroke risk. Selective/bailout aspiration can still be considered when substantial thrombus persists, particularly after other PCI maneuvers. Likewise, strategies such as routine deferred stenting or distal protection have not become standard approaches for every STEMI patient. Modern PCI has shifted toward: Rapid reperfusion + appropriate stenting + meticulous lesion treatment + prevention/management of no-reflow + selective use of adjunctive technologies. And for complex ACS lesions, contemporary guidelines recommend IVUS or OCT-guided PCI to improve procedural results and reduce ischemic events. Don't stop at: (Did I achieve TIMI 3 flow) Also ask: (Did I restore effective myocardial perfusion) Because an open epicardial artery does not automatically mean that the myocardium is adequately reperfused. Source: Ndrepepa G, Kastrati A. Mechanical strategies to enhance myocardial salvage during primary percutaneous coronary intervention in patients with STEMI. EuroIntervention. 2016;12:319–328. Updated with the 2023 ESC ACS Guidelines and 2025 ACC/AHA ACS Guideline.