Hemodynamics Exam Oriented Discussion Dr Nishanth Sagar MCH TVM

Good evening. Good evening.

Hello.

One minute.

Participants chat screen.

Can you see all the presentation? Yes,

yes, yes, yes, yes. Right now

It is okay, sir. Yeah, see.

Everyone joined or can we start

actually? Yes, yes. You can start.

We can start, right? Yes, yes. It's

already there.

Okay, so uh

Yeah, so uh thing is cardiac

hemodynamics is a

very important part of your exam

presentations.

Uh so actually you will have a lot of

weightage for your spotters, especially

this year. Uh we might not have uh we're

because of the COVID pandemic, we are

not exactly very sure how the exam

pattern is.

Like in DNB you have virtual cases and

ASCII which play a very important role

right now. This was actually a small

substation for us, but this might be a

very important uh mark scoring part

uh station in your exams. So

actually there are I'm not in going into

I'm just mainly concentrating on the

oximetry run part of it because pressure

tracings

about 10 days back by Dr. Thomas. So

we're mainly dealing with oximetry run.

So what is important is actually

sequential systematic reading.

So that is and I have around 18 cases,

so we'll try to analyze each case and

see uh

uh how to read properly.

Okay. So I would actually require uh

I need uh one of you to volunteer for

analyzing uh the cases.

Okay, so uh

You could please turn on your cameras.

I think we should get to get to know

each other.

Cuz I know some of you people, but I

don't know some of other people

actually.

You could just turn on your cameras now.

Uh the presentation

is mainly

focused on your exams, on your DM exams.

Okay, so what matters is not your

diagnosis. That is a very important

part. The diagnosis does not matter at

all.

In fact, you might be you will be

usually be you won't get something like

straight away straight away case like

ASD or you won't get something like VSD.

Okay, they'll ask you some very

complicated case, but it is essentially

how you analyze each and every part of

this actually matters. It is not that

you

when

you don't suddenly jump into a

diagnosis. You don't just just suddenly

say it is like

RSOV to RV with You don't say a

diagnosis like that. You have to analyze

each and every step. That carries more

weightage rather than jumping and saying

a diagnosis RSOV type. Your diagnosis

may be wrong. For example, in my

what I could not find the diagnosis, but

the analytical steps should be there.

That is what they appreciate. So, it is

your approach that count and never jump

and say the diagnosis. Evaluate each and

every step.

So, that is what is actually important.

Just hold on 1 minute.

So,

that is what is actually important. So,

keeping that in mind, uh

we'll

Okay, keeping that in mind, we should go

for the first case. Okay, is this

appropriate for everyone?

Okay, so I need one person to actually

volunteer to read the case

so that we can go forward with this.

There's no point in me just reading the

case. Okay, so please

So,

this is how it is pressure data.

Yes, or either you can start

Yes.

Who is that?

You can either start with pressures or

either you can start with the oximetry.

So, among

Can I start? The one minute case where

to go.

So, pressures you first read normal or

abnormal. So, you see the pressure

normal or abnormal. Link the pressure to

next in line. See the gradients. Compare

if it's an ASD, compare RA versus LA,

compare RV versus LV.

RA is A6 before -6.

So, RV is 20 by 6.

So, then we compare the pressures. You

have tricuspid valve.

So, you look for a diastolic gradient

across the tricuspid valve. So, 6 by 6

there's no diastolic gradient.

Again, RV to PA. 20 by 6 and 20 by 10.

You look for a systolic gradient across

pulmonary across the pulmonary valve.

Then you look at your pulmonary artery

wedge.

That's a diastolic gradient. Look for

the diastolic gradient as the arrow

shows.

Okay, then you look for the LV. Again,

look for the systolic gradient across

the mitral valve and then a diastolic

gradient across the mitral valve and

systolic gradient across the

aortic valve. So, to be you as you

analyze more cases, you'll be more

confident.

So,

I hope this proves to be useful. So,

we'll go for the first case. I think a

Dr. Ashwin has volunteered. So, Ashwin,

can you just read this?

And what is the impression based on

this?

So, I'll first read the

oximetry.

It's your choice. Yeah, it's your

choice. I'll I'll first read the

oximetry. You can read the pressure.

That's your choice.

Okay.

The SVC saturation is uh 68. Okay.

So, it is fairly normal. Mildly reduced.

Okay, 60 to 80 is reasonably okay. Yeah.

Okay.

Then RA saturation is 70.

Okay. So, what is your comment on

That is normal expected.

It

ideally Yeah. should be similar to SVC

or slightly higher than the SVC. Okay.

Yeah. Because IVC saturation is higher.

Then

RV it is 84.4. So, there is a step up of

14, which is a significant step up from

RV to RA level RA to RV level. RV level.

Then the same saturation is reflected in

the pulmonary artery. Okay. And on the

left side, it is

normal saturations. Expected normal

saturation.

RA pressures? So,

now coming to pressures, RA pressure is

A wave is 7, V wave is 5, and mean is 6.

It's within normal limits. RV pressure

systolic pressure is elevated. It is 110

mm mercury, and the diastolic pressure

is 7. There is no diastolic gradient

across the tricuspid valve. Okay, so

there's no diastolic gradient. Okay. RV

to pulmonary artery, there is a

mild gradient of 10, which is not very

significant RVOT obstruction. Okay. Then

coming to left sided pressures,

LA pressure

AV and mean are

mean pressure is

elevated. Elevated, 14.

Elevated.

Mean pressure mean LA pressure is

elevated.

And LV

pressure is

almost similar to RV pressure. Lower

than RV pressure. Okay.

And the aortic pressure

is

130 bar.

70. 70. So, is there a systolic

gradient?

Is there a systolic gradient across the

aortic valve?

No

no systolic gradient. Aortic pressure is

higher than the aortic Okay, what what

are your comments and what is your

diagnosis? What is your comments and

what is your diagnosis?

Mhm.

So, you have identified a step up at the

level of RV, right? RV

Okay, you have identified a step up at

the level of the RV. So, what could be

its common cause?

Common cause is a VSD. VSD So, if

there's a step up at the

part is If there's a step up

Aortic

Aortic pressure is higher than both

ventricles.

Okay, that is okay. We are dealing with

a top physiology now for that all

pressures to be equal. It may or may not

be a top physiology.

So, you have anyway dealt with a step up

at the level of the RV. Common cause is

a VSD, right?

So, is it left to right or right to left

shunting?

It is a right to left right shunting

only. It's a left right shunting, okay?

And is there PH or not?

There's no desaturation. Is there PH or

not?

Uh there is a PH. Is it severe PH or

mild PH?

Uh pulmonary systolic pressure is 100

Uh

100 So, severe PH. Severe PH So, it's a

VSD with a left to right shunt with

severe PH. Severe PH Okay, so is it

operable or not?

Uh

It's not

Severe PH not operable. You have

actually you have to

calculate the PVR calculate okay, but

just roughly you can If you say is it

operable or not?

It is a pre-Eisenmenger state nearly not

operable. See, it's still shunting it's

a huge shunt from left to right now

because there's a massive systemic

increase in uh in saturation from 70 to

84.

Even if you look at the LA pressure the

LA pressures are also high. So, if you

have a severe PH you're bound to have

low LA pressures.

Okay, so actually this is still

operable.

Okay, okay.

You get my point because there's a huge

Since we have good LA pressure, okay.

There's a huge step up with a large LA

pressures.

So, it's actually VSD with severe PH

but with still shunting left to right

and operable.

So, that is your impression from this

case. So, even if you do an echo you

might see significant

I can I

ask how is the aortic pressure 130 by

70? Maybe the patient has hypertension.

We are not very sure.

But still it cannot be more than any of

the ventricle, no?

Yeah, that is actually okay.

It's logical only. That is the confusing

part of this.

That is logical. Again,

there are a lot of fallacies of taking

in cath data, you can see.

There is a given pressure tracing from

the given pressure tracing.

You read this. Yeah. There are some some

points you missed.

So when you start reading the SVC

saturation is 68. It means that the

comment is the patient is actually very

stable. Okay, if you have a low SVC

saturation of 35 or 40 or 50, it means

the Either a reduced cardiac output or

systemic desaturation.

Yeah, systemic desaturation or reduced

cardiac output. Then what you do is you

compare between the SVC and the aortic

side.

If the aorta is also desaturated, it

means there is systemic desaturation.

However, if the aorta is something in 97

and the SVC has a saturation of 35, it

means that you have a very sick patient

on table.

Okay. That is usually the first question

they ask.

Okay, you What is your comment on the

SVC especially if you have a low SVC

saturation? The first comment they ask

is what is the comment on that?

So you have reasonably good SV

saturation. See, reasonably normal.

Okay. RA pressures are good. There is a

step up at the level of the RV.

Okay. And the pulmonary artery pressures

and pulmonary arteries, there is no step

up. LA is normal. LV is normal. Aorta is

normal.

And when you comment, RA A7 V5 M6

pressures are reasonably okay and the

patient is in sinus rhythm because you

can have an AF.

All right. So you missed that point.

Then when you read about the RV

pressure, RV systolic blood pressure is

high. Diastolic blood pressure is low

and there is no diastolic gradient

across the tricuspid valve.

So M6 and RV is 7, right?

Then

Uh then you then the then you must try

to see in RV and PA there is a there is

there any systolic gradient? There is

not much systolic gradient across the

um

pulmonary valve.

So now we go for LA. A and V are

elevated. M is 14. V is greater than A

as expected. So you have high So the LA

pressures are high in a patient of

uh who's having a left to right shunt

that actually indicates that the patient

is operable.

Right? So LV is good and aorta is good.

So based upon this you try to comment on

this. So VSD, severe PH with left to

right shunt and the patient is operable.

Right?

So any doubts on this from any of the

audience?

Check the gradient is

uh expected out. Given the LA and LV

mean LA pressure and the LV end

diastolic.

Mean LA pressure and the mean LA

pressure, okay. LV 14 LV

9 Yeah, there is a 5 mm gradient

actually. Yeah, that is okay.

But actually even if you take mitral

stenosis you need to have a higher

gradient, right?

Using the Fick's formula, it's not that

much of a gradient.

Okay, okay. It should be a significant

gradient.

Right? So we are clear on this?

So as you cases go by you'll have more

complicated cases.

So anyway, the method of how you read

this is like this.

So it's VSD, severe PH, left to right

shunt, operable, right?

So this is a usual question. The next

question they'll ask is what are the

cause of step up in the ventricular

level?

So one is a VSD which shunts left to

right.

One is an ARSOV to RV. One is coronary

AV fistula to RV. And one is PDA with

PR. Again, you get how PDA with PR gives

you, right?

PR goes into the ventricle.

So VSD, ARSOV to RV, coronary AV fistula

to RV, and PDA with PR. You also have a

lot of rare causes.

You know, usually these you should at

least these four causes, okay?

We clear on this?

So next case.

So again, 9-month old child or baby who

underwent a palliative procedure on day

40 of life.

Okay. Would anyone care to read this?

Say that. Can I try? Yeah, you can try

to try, no problem.

Uh SVC

saturation is 54, that is low. Yeah,

low. So, again, you should be then when

you once you look at the SVC saturation,

you straight away look at the It can be

either due to low cardiac output state

or due to systemic desaturation.

Okay.

So, you look at the aortic pressure.

Aortic pressure is also low, right?

Yeah, yeah. Okay, so again

RA is almost same as SVC.

Uh RA is okay, fine. 255, there is no

uh step. Step up, yeah.

Uh then from RA to RV then from RV RV to

PA, there is a step up. Of 20.

diastolic gradient across the tricuspid

valve. Don't miss that step. Is there a

diastolic gradient across the tricuspid

valve? No, there's no diastolic

gradient. Don't miss the gradient. Must

always see gradients across valves.

Right, next.

From RV to PA, there is a

gradient.

Systolic gradient.

Systolic gradient.

Systolic gradient. From 100 to 20. 80.

Okay.

80 mm gradient.

Then, diastolic pressure is normal.

Okay.

Then,

LA pressure mean is eight normal. Okay.

Then,

LV systolic pressure is normal 100.

There is no gradient across the mitral

valve. Okay. Diastolic

Diastolic gradient.

There's no diastolic gradient, yeah.

Then, aortic pressure is 100 by

30. That diastolic pressure is very low

with a wide pulse pressure. Okay. And is

there a systolic gradient across the

aortic valve?

There is no systolic gradient. Okay. So,

what are your impressions and what is

your diagnosis?

So, patient underwent a palliative

procedure on day 40. Yeah.

So, there is a step up from RV to PA,

significant step up.

Okay.

So, that could be due to a shunting at

the great vessel level. Okay.

Uh

it could be either a PDA. Okay. Or an AP

window. Okay.

And

there's a step down from LA to LV.

Okay.

There could be I think Ashwin will tell

me. What about the pressures? There's

something unique about the pressures in

the chambers.

With that itself, you can get a

diagnosis.

Can I try? Equalization Equalization of

systolic Yeah, exactly. See, when you

note the RV systolic BP is equal to the

LV systolic BP, which is equal to the

aortic BP. So, what does that signify?

It's a hallmark of a certain condition.

What is it?

Tetralogy of Fallot. Exactly. So,

tetralogy of Fallot, the abnormality in

that case is the RV systolic BP P is

equal to LV systolic BP is equal to

aortic systolic BP. That's correctly

exactly 100.

So, when you see it, the first thing

which you should strike is it is a

tetralogy of Fallot. So, if you look at

this Exactly. There should be a should

be a large unrestricted VSD.

Right?

Okay. Okay. And is there a Keeping that

in mind, is there a severe PS?

Severe. Yeah, severe PS. So, you have a

severe PS with shunting of blood towards

the mixing of blood. So, right That's

why you have this desaturation in the

level of aorta.

Right?

So, your basic diagnosis is stuff. This

tetralogy of Fallot. You have a severe

PS with an unrestricted VSD. Are you

clear on that?

Okay. So, what is the palliative

procedure on day 40 of life?

Maybe BT shunt. Exactly. So, So, why do

So, what is indicative of a BT shunt

here?

The pulse pressure wide pulse pressure

on the aorta. What about the level of

pulmonary artery?

The aorta. My diagnosis is stuff.

Physiology, VSD under large unrestricted

VSD with severe PS

with

BT shunt. Okay.

And it's responsible for the large pulse

pressure. Again, see, your diagnosis is

not important. It's just how you

analyze. Even if you can If you are not

able to reach the diagnosis, it does not

actually matter.

As long as you are even able to stay say

all these steps. Does anyone have a

doubt on this case?

No doubts.

Okay, fine.

So, we'll go for the next case.

Okay. So, diagnosis.

So, aortic saturation is decreased,

but aorta is still more than the PA.

Step up at the level of PA level.

LV systolic BP is equal to RV systolic

BP is equal to aortic systolic BP. Large

unrestricted VSD, severe PS. So, stuff

with a BT shunt.

All right?

So, one of the general dictates is that

as soon as you get your hemodynamic

study, oximetry study, straight away you

look at the aorta and pulmonary artery.

The first thing you look at is the aorta

and pulmonary artery saturation, okay?

Pulmonary artery is more than normal.

Okay, suppose the pulmonary artery

saturation is something like 75.

Or suppose pulmonary artery is 85, then

you can straight away say there's a left

to right shunt. If the aorta is less

than normal, then you think of a right

to left shunt.

If the pulmonary artery is much more

than the aorta, you start thinking of a

TGA.

If the pulmonary artery is equal to

aorta, you think of an admixture

physiology.

So, this is a very important step. First

thing you get in such a thing is before

reading anything, straight away in your

mind, you look at the pulmonary artery

and the aortic aorta.

Pulmonary artery is more than normal,

left to right shunt. Aorta is less than

normal, right to left shunt.

Pulmonary artery is more than the aorta,

TGA.

Pulmonary artery is equal to aorta,

admixture physiology.

All right?

So, once you diagnose a TGA, I'll give

you an example. Suppose you diagnose TGA

based on this step. PA is more than PA

saturation is more than the aortic

saturation, you diagnose a TGA.

You know TGA is incompatible with life,

so there should be a shunt at some

level. So, you look for the presence of

ASD, VSD or PDA.

Right? And then you look for the

presence of a PS. That's how you

diagnose it.

The first thing if you diagnose TGA, the

next step is you look for a balanced

shunt.

Only then the patient will be alive.

Then is there a PS or not? Right?

So, this is a very important thing,

okay?

You clear on this? We'll go for the next

thing.

So, again, 23 32-year-old male, sudden

onset chest pain with heart failure

symptoms.

So, who's reading the Smitty there?

Smitty? Not there.

Okay. Anyone else? So, then Yes, sir. I

shall read. Shall I read? Dhanush.

Dhanush, you are there? Yes, sir. I'm

there.

Uh

Uh I would like to start with the

saturation. Okay. SVC saturation is 70.

Okay. Then you comment on this.

Simultaneously you must comment on this.

Yeah,

it's 70, which is uh quite higher than

normal. Okay, normally what we look at

we look at the mixed venous oxygen

saturation. Again, people are lazy. They

only look at the SVC saturation. Again,

SVC saturation is pretty decent. Even

that alone is pretty good enough. Okay,

so SVC saturation is good. So, patient

is stable. Okay.

At the RA level, we are having a step up

of 16 from 70 to 86.

So, significant

that uh it's a significant step up. Then

at the RV level, we are having a step

down of 6 mm mercury. Okay.

Then at the PA level, we are having a

pressure of 80.

Okay. So,

um

I mean a saturation. Saturation of of 80

is there.

Then uh coming to the uh

in the left side, LA, LV, and aortic

pressures are

expected. Okay. Uh maybe a bit

desaturation is there in the LV and the

aorta level, 95.

Okay, fine. It is lying significant

desaturation. So, you know what I mean?

Right now

Yeah, cath readings if you have done

cath readings, you know, the oximetry

run can be marked marked can be markedly

different. Sometimes you'll have to be

keep the patient there and then again do

a repeat cath study if it doesn't

qualify. So, okay. So, LA LV

So, right now we are having a we are

having a step up at the at the RA level

and a step down at the RV level. Okay,

step down at the RV level you can keep

it plus minus. Okay, let's keep that.

Okay, fine.

Then at the pressures level

Uh

okay. Um so, we are not having any A or

or V waves. So, I'm not able to say

whether patient is in sinus rhythm or

not. Okay. But uh mean RA pressure is

elevated uh 12. Definitely elevated,

yeah. And um

at the RV pressure may uh this I think

it's a RV systolic pressure. Uh okay, RV

RV mean pressure is uh 36.

That is also quite elevated. And the

pulmonary artery pressures is 36 bar 18.

Is there a systolic

No, there is a mild

No, there is no systolic gradient

between RV to PA. So then Then

What about the diastolic pressures?

The diastolic pressure in the pulmonary

artery is also elevated.

Yes, so you must keep You must tell them

So both

So both the pulmonary artery systolic

and diastolic pressures are elevated.

The LA mean pressure is also elevated

16. Okay.

And

coming to the LV, we are having a

The LV systolic pressure is elevated at

158 bar 9. And also in the aorta we are

having But there is no There is no

systolic gradient between the LV and the

aorta. And we are having a wide pulse

pressure situation with a 160 bar 30. So

your comments, your final comments and

your diagnosis.

So

there is a step up in the RA level with

with a high pulse pressure. So there may

be

a left-to-right shunting at the at the

atrial level with

and and adding it with the with the high

volume pulse, it may be an

an RSOV to the right atrium. Okay. Is

that the That's the answer. You And you

can also you

With also there is pulmonary artery have

mild pulmonary artery hypertension.

And that could be some hyperkinetic PH

due to flow.

Yes.

Okay.

Uh so

I Why this is You straightaway forget

about this clinical presentation. In the

clinical presentation is suggestive of

an RSOV.

Okay. Uh

Did Did Did everyone get why this is an

RSOV to RA?

Is there any doubts on this?

Why this is an RSOV to RA? Why Why is

this not an ASD? I straightaway say this

is an ASD. Why is this not an ASD? You

forget about the clinical picture.

You Suppose you forget about the

clinical picture. Why this is not an

ASD?

The pressures are not equal between the

left atrium and the right atrium.

Ah exactly. That is the point. See, when

you have a large unrestricted ASD, okay,

if you pull the catheter from the LA to

how do you distinguish a restricted ASD

and an under-restricted ASD in cath lab?

One of course an under-restricted

restricted ASD will not have significant

step

uh

left right shunt and hence you won't

have a saturation difference there.

When you pull the catheter from the LA

to RA, if the mean pressure difference

is less than 2 3, it indicates an

under-restricted ASD.

Right? And then A will be equal to B and

X will be equal to Y.

Right? But you look at this, the RA mean

is 12 and the LA mean is 16. Right?

There is still if if this is an ASD, it

is a restrictive ASD.

Because the gradient is more than two.

But a restrictive ASD will never have

such a large step up of 16.

That is not possible.

Okay.

So it is not an it is ultimately it is

not an ASD. And if you look at the large

pulse pressure,

the other diagnosis is an RSOV2

RA.

Keeping the pulse pressure and the

clinical symptoms in mind. So this is a

very important point. You have to look

once you diagnose a step up at one

level, you look at the LA and RA or

similarly LV and RV.

The mean gradients are four, the

difference of four. So you cannot So it

has If it's an ASD, it has to be a

restrictive ASD. A restrictive ASD will

never cause such a large step up.

So it is definitely not an ASD. You have

to think of something else. The clinical

picture and the wide pulse pressure

would probably indicate an RSOV2 RA.

Okay.

So step up at the atrial level, wide

presentation and the clinical

presentation indicates an RSOV2 RA.

So what are the causes of step up at the

atrial level? Again, frequently asked.

ASD, RSOV2 RA, VSD with PR. Again, you

can understand VSD with PR how it

becomes.

Gerbode defect,

coronary AV fistula to RA and PAPVC.

Right?

So I have a question.

You said there's a step down between RA

to RA. Why has that occurred?

Very simple question. There's no

particular answer for this.

Just screening.

Uh exactly, you might have taken the uh,

sample at the

jet which originates from the LA to RA.

If you suppose you take it a bit higher

or a bit lower, you might get a

different saturation. This might have

been taking you you might get actually

more of a saturated blood. That's why

this might not have much significance.

You must keep that also in mind.

Right? And I missed one point. The step

up at the level of PA is also important.

The last case,

PDA, AP window,

RSOV to RVOT,

coronary origin of pulmonary artery,

ALCAPA and BT shunt.

Right?

So, this is a very important table.

What is the significance step up is

again in some uh, guy called Antman.

Atria 7%, ventricle is 5%, great vessel

is 5%, any level is 7%. Okay.

So, atria 7%, ventricle 5%, great vessel

5%, any level. Suppose you take an SVC

saturation and PA saturation the

difference is more than seven, there's

some shunt going on somewhere.

Right?

And PV to LA of more than 2%

significant.

Okay, which is Why does the LA have a

lower saturation than the PV?

You take your

saturation be 100 and the LA saturation

It's the bronchial veins. The bronchial

veins draining. Okay, some people say

there are unidentified veins draining.

Not really sure on that.

Okay, so 18-year-old asymptomatic

acyanotic child,

S2 wide split, 3x6 ESM at the base.

So, who's going to read this?

Mitty, you there?

Uh, yeah.

Uh, Mitty, try and read this.

Uh, saturation

SVC saturation is 72.

That means child is

boy is stable. RA saturation SVC to RA,

there is a step up of 13%. Significant

step-up. on

There is a significant step-up, okay.

Significant step-up. Yeah.

Okay.

Uh

from

The RA saturation

is 95, slightly on higher side. Okay.

Uh

then pulmonary

LA saturation

is 97, uh which is normal.

Not able to hear you.

saturation is 97, which is normal. Okay.

Pressures? Then

Uh then the pressures, the right atrial

pressure mean RA pressure is normal and

the

uh

and the patient is in sinus rhythm.

Okay.

Uh there is a

Um RV systolic pressure is elevated.

There is no diastolic gradient across

the tricuspid valve. Uh RV systolic

pressure is elevated. Then there is a uh

step-down of

Um

No, there is a a gradient across the

pulmonary valve. Okay.

Uh the Systolic gradient.

Then You mean systolic gradient, right?

Systolic gradient across Yeah, okay.

Yes.

Uh systolic gradient across pulmonary

valve.

Then

Pulmonary wedge pressure

is a normal pressure is 10.

Uh

And V is more than A as expected. We'll

take it.

And V is more than

And LV pressures are normal. There is no

diastolic

gradient across the

mitral valve.

And aortic pressures are

normal. Pulse pressure This

Okay. So there is a step the level of uh

EC to RA.

So, it could be an

a

a effect to the effect.

And but again the same point applies as

in

PAPVC PAPVC PAPVC Why it's a PA Why it's

not an ASD is the same point as

discussed last time. You look at the

mean gradient between

uh say RA and pulmonary artery wedge

pressure is five.

So, if it has to be an ASD, it has to be

a restrictive ASD.

And restrictive ASD will not cause such

a large step up.

Right? So, it's an unrestricted So, it

is it cannot be an ASD. Or if it is an

ASD, it could be only a restrictive ASD.

And

uh so, the large step up here would be

mostly a PAPVC.

Right? Which is draining probably

somewhere into the SVC or somewhere. Not

very sure, but all over SVC. So, it's

probably a PAPVC.

So, and then in an ASD A and uh A and B

will be equal and X and Y will be equal.

So, it's an unrestricted So, it's

probably a

So, this is what is an unrestricted ASD

catheter pullback from the LA to RA and

mean gradient difference will be less

than two. A will be equal to V, X will

be equal to Y. For a PAPVC, it may or

may not have a restrictive ASD. So, it's

not a clear-cut ASD. That's another

important point.

So, whenever you diagnose ASD, always

look for the Is there a pressure

difference?

Right? So, we clear on this?

We go for the next one.

Uh 1 minute. Yeah. So, 12-year-old boy

uh 12-year-old white fixed S2 diagnosed

clinically as ASD who was non-cyanotic.

So, Sobit is there?

Uh yes, sir. I'm there. Uh

I said I'll start with the saturation.

Uh SVC saturation is 88. Okay. It's a

bit on higher side, sir.

It's on higher It's 70 uh higher. Okay.

And uh

uh SVC to RA there is uh

normal

there is no

function saturation RA to RE

there is no

significant step up RV to PA also it is

normal only

and

there is

left side

uh

LA there is a

hello

oh yes

Okay LA LV and femoral artery all are

having desaturated

and desaturated

yes It's still desaturated right? yes

yes Okay so comment on your pressures

pressure on the right side

uh pressures are elevated mean pressure

is Yeah you must say our patient is in

sinus rhythm patient is in sinus rhythm

mean mean RA pressure is

slightly elevated okay uh

there is no gradient across the

tricuspid valve okay

and this is RV systolic pressure is

elevated

elevated okay

RV to PA there is a mild

systolic gradient is there Again it's

not very significant 15 only na?

okay then

then on the left side there is mean

pressure is patient mean pressure

on the PA diastolic pressure?

Slightly on the higher side usually it's

around 10 na? uh yeah slightly on the

higher side LA pressures?

LA pressures normal only

mean pressure is six Again what is

something is there something unique on

the LA pressure what is it?

A is equal to V Okay that is one thing

keep in mind. Okay. Uh

Uh

And there is both RA and LA mean are

equal. So, the there are some

unrestricted ASD

ASD, right? Okay, so then next?

And uh

Uh LV pressure is normal only. Uh

femoral artery pressure also normal with

uh

Uh normal only. Uh saturation

uh all the chambers are equal. So, ASD

plus uh TAPVC uh uh TAPVC might be the

Okay, so you are diagnosing

TAPVC with ASD. So, that is actually the

correct answer. So, uh see the first

thing I told you, whenever you take a

tracing, always look at the PA tracing

and the

aorta first. PA and aorta. Here the PA

and aorta are almost the same, 88,

right? Yeah, the femoral artery is

actually for aorta actually. Here is the

femoral artery. So, both are 88. So,

both if they are both same, it indicates

an admixed physiology. Okay? Okay. Okay.

Now, if you see uh beyond RA, all

pressures are roughly the same

pressures.

So, either it is a tricuspid atresia or

TAPVC.

Are you clear on that point? Yes. So,

what what admixed physiology mimics an

ASD?

It is TAPVC.

Okay. Okay, so in this uh catch points,

uh

one is you have a step up at the level

of the SVC, Okay. and beyond the RA, and

beyond it, all pressures have almost the

same all chambers have almost the same

saturation.

Yes. Right? The first thing you compare

femoral artery and uh aorta and

pulmonary artery, both are equal

saturations. That indicates an admixed

physiology. Beyond RA, all chambers have

the same saturation. So, probably it is

either TAPVC or or tricuspid atresia.

What mimics an ASD is TAPVC. Okay. Yes.

So,

again I have actually uh

So, where is it draining? So, you have

so we all diagnose it TAPVC. Yes. So, is

it a supracardiac TAPVC or infracardiac

TAPVC? Supracardiac.

Okay, is it obstructed or not

obstructed? That is also important.

Non-obstructive. Why? LA mean is

There's no pH.

Obstructive has pH, no?

Obstructive usually

one uh obstructive has pH.

Right?

Yes, yes.

See, one again, see a 12-year-old boy if

it's an infracardiac obstructive PV.

He's unlikely to live for so long. It

has to be a supracardiac

non-obstructive.

Okay, next question. Why is the patient

non-cyanotic?

Dreaming. Good pulmonary flow.

No, it's not The reason is not that.

See, you clinically identify the sinus

cyanotic, no? 85.

Clinically for you to detect cyanosis,

your saturation should be less than 85.

Okay. Probably if you make this patient

exercise, you might find a cyanosis.

Right? Okay. Okay. So, you can't say you

don't say a saturation of 90 and then go

back saying the patient is cyanotic,

okay? Okay. Okay. This is a very

important point. So, clinically if you

want to detect, it should be 85.

So, uh okay.

SVC saturation is increased because

there is a some There's all the

pulmonary veins are connected to the

SVC.

All chambers distal to RA are same

saturation. PA pressure is mild

elevation. TAPVC supracardiac

non-obstructive type. Clear on that?

Yes, yes. So, first thing, look at the

PA, look at the

aorta. Both are same and mixed

physiology.

Okay.

So, you start off with that.

So, 36-year-old

Somebody has raised a

question in the chat. I think they're

going to ask Yeah, we can ask now. What

is the problem?

I don't know. Somebody posted a

question.

What is the significance of

elevated diastolic pressure? What is

What was it? Uh one thing is an elevated

diastolic pressure is indicative of RV

diastolic dysfunction because of patient

or the chamber could be failing.

That is one important thing. So, if you

find an elevated RV diastolic pressure,

it indicates that the patient probably

the chamber is usually might be failing.

So, that is that's one thing to look

for. It's not a very hardcore sign. It's

a soft sign, actually.

I'm not able to access that uh access

that chat, actually.

Okay. So, a 36-year-old old echo pre-

shows a VSD with severe MR, okay. So, a

CTVS guy comes and requests a pre-op of

CAG, okay. You are near planning for a

surgical closure plus minus mitral valve

replacement. And the CTVS guy requests a

I requested a pre-op CAG. So, you

decide, "Okay, we'll do a cath, also."

Anyway, we are taking up the patient for

in the cath lab, we'll do a cath, also,

then we'll do a CAG. So, who's going to

read this Is there anyone apart from

Tremendous Medical is there?

I don't know most of the people. Hafiz

under

Hafiz

Hafiz is not there.

Okay.

So, we'll

I don't know most of you guys. So,

let's say who has not read so far.

Sham Sham Shamjad and

Uh Sham, read.

Sham, read.

Sham

Okay. Uh yes, yes, reading. I can hear.

I can hear. I can hear. Yes, crystal

clear.

Okay.

The uh the 36-year-old uh person with

echo VSD with severe MR

Uh the SVC saturation uh

is actually 40 on. Okay. Um

the aortic saturation is normal, so it

is a low cardiac output Okay, low

cardiac output state, okay. So, once you

So, once you diagnose that, you should

be very careful in doing the procedure,

right?

Yes. Okay.

The low cardiac output state there

uh you can see that in the RA pressures

are actually 87.

That means there is a significant uh a

step up at the level of the RA level.

Okay.

And RV pressures are 90.

Okay. All RV saturation is 90. It's

almost uh there's no significant PA

pressures are also okay. Okay. Pulmonary

pressure is not available. LV pressures

uh

LA is not available. LV LV saturation is

around 98. That is normal. Then femoral

artery

femoral artery saturation is also

normal.

Okay.

Almost normal.

So, I'm going coming to the pressure you

can see that there is a significant

increase in the RA pressure.

And the RV pressures were actually

uh

RV systolic and diastolic pressures were

elevated. You have missed one point.

That's why there's systematic step by

step. See, there's only V24. Where is

the A?

V24.

Exactly.

In the AF fibrillation. So, that's you

must never miss a point. That's why. The

patient is in atrial fibrillation. Okay.

Patient is in atrial fibrillation. And

atrial pressures

RA pressures were elevated also. Okay.

Around 14.

Then RV pressures were 80 by 10. That is

a

There is a

uh Severe PH. Uh severe PH is a systolic

pressure elevated, but there is no

significant diastolic gradient. Okay.

Pulmonary pressures were also elevated

with 80 by 27.

And there is no significant uh

significant systolic gradient between

both.

Okay. And pulmonary artery

uh pressures were actually elevated

again elevated

uh with a

uh mean pressure of a 23.

Okay. And

LV pressures were

LV pressures were 90 by 11 and there is

a actually a significant diastolic

gradient.

Again, see that that gradient you don't

you don't have the available A now, so

the mean might not be correct. Okay. So,

keep that in mind because patient is in

AF now.

Okay, next.

Then femoral femoral artery.

Then femoral artery is

femoral artery pressure is 90 by 54

and there is no significant systolic

gradient.

So I think that at the level of

the level of RA there was actually a

significant

significant gradient significant step

So there was actually a

left to right shunt

at the level of RA.

Okay.

And

the level of RA and there there is also

significant

and there is a

systolic pressures were at the lower

lower side because of the associated

less of cardiac outflow into the left

side of the heart so that

that and there is a

That means probably there is a

when

ventricular septal defect that

has been draining

into the RA.

Ventricular septal defect draining into

you mean a chamber?

Okay, possible but chamber is rare.

No, I'll tell you I'll tell you what

actually I've missed certain points as

So you first thing is when you consider

a step up at the level of the RA you

must consider whether there's an ASD. Is

there an ASD in this patient?

No. No because the mean LA pressures and

the RA pressures are completely

different, right?

Uh That is done. Okay. So your diagnosis

is VSD. Patient has severe PH, right?

Uh

So VSD severe PH. Now what can cause a

step up

at the level of the RA

if a patient has severe PH?

TR. TR.

The patient has VSD with TR. The TR

that's why you must always What are the

other causes of step up? This is very

important. So, you have seen one as an

ASD, two TAPVC or PAPVC, three have seen

an ARSOV. Two is the fourth case. VSD

with TR. So, you must be very clear.

It's a pre-op echo has been done. No one

is going to miss such a large ASD,

right?

No one can miss it, especially when you

have a severe MR with an ASD with a

torrential flow across the valve. Uh

okay. So, you're not going to miss it.

So, there's obviously no ASD. No one is

going to miss such a large ASD, right?

So, so you have a VSD

with severe TR. The TR is causing the

step up in the RA. Okay. Okay. Okay, VSD

and the patient is in atrial

fibrillation with congestive cardiac

failure that is causing the low cardiac

output state.

Okay. Okay, so my question is if it's

such a large VSD, why is the pressures

You know the VSD the systolic pressures

between both chambers will be equal,

right? If it's a large ASD VSD.

The RV systolic and the RV systolic

pressures both will be equal. Why it's

not equal? One is 19 and one is 80. So,

what is the cause for it?

So, again the VSD might be closed by a

tricuspid leaflet or by an aneurysm.

It's about to be closing or something

like that.

Okay, so this is actually a difficult

case.

Okay.

Okay. Okay, that's

Uh that's why you won't get that

equalization. It's partially being

closed. Okay. Okay, maybe the tricuspid

leaflet is coming and impinging

something like that.

Okay. So, the patient is having AF.

There are prominent V waves indicative

of an MR. You got that clear?

Uh okay. Huge step up in the RA level.

The step up the reason is a VSD with TR.

It's not an ASD because the there is a

significant mean pressure difference

between the LA and RA. It's a low

cardiac output state, right? Mm okay.

Severe PH. Okay. Okay, RV systolic blood

pressure is not equal to systolic

pressure because I told you the reason

why. Okay. The first question is

will you do a pre-op CAG for this

patient?

You have to do.

Again, see the

low SVC saturation

and collapse. When you inject the dye

itself, the patient might collapse.

Okay. Okay, so preferably don't do it at

this big point. Okay. Okay, you have

such a low systemic saturation, such a

low arterial blood pressure. Again, it's

not advisable to do.

Or if you do it, you do it with minimal

amounts of dye just for just to see. But

be careful in doing it. Okay, if the

patient has an infection, you treat the

infection, do something Just it's not

Again, it's not a run-of-the-mill CAG as

previously before. So, always keep your

eyes open in the cath lab. Right?

Uh especially if you have a point of

care device where you can see the AB You

can see the saturation immediately.

Okay, so I had one more question from

this actually. So,

SVC, RA, RV, pulmonary artery.

Okay, fine. This is a

Okay, so neonate, day three of life.

Okay, so who is Anyone apart from

Trivandrum Medical College willing to

read this?

See, a lot of people, but no one is

willing to read this.

Uh hello, sir.

You are?

Uh sir, Saurabh Kapadia from Mumbai.

Mumbai? Okay, I have people from Mumbai.

Which college?

Uh Jaslok Hospital. Jaslok, you're doing

DNB there? Yes. Yeah, okay. So, your

exam is right now OSCE based, right?

Yes. OSCE and 100 marks, uh virtual case

presentation. Right? We

We have to suggest to that kind of exam

here also.

Saurabh, that is actually more

different. You just imagine our

professors with a virtual case.

The others, you'll have standard

questions like dyspnea, grades of

dyspnea, what are the limitations of

NYHA. Here, you won't have anything.

Uh that is there, but still

imagine our professors with this. Okay,

forget about it.

You can read about it. Uh you You

Saurabh, you it. You read it. The unit

day three of life, right? Yes, sir.

Uh

So, on this uh

aorta uh saturation is 62. Yeah.

And uh pulmonary artery saturation is

98%.

The diagnosis from that is

Uh could be a case of TGA.

Yeah, TGA. First So, once you see a TGA,

you must see where is the level of

shunt. So, the reason the patient will

survive. So, is that shunt at the atrial

level, ventricular level, or uh

uh ductus level?

Okay. And is there PS or not? Okay.

So, you can read, okay.

Uh so, there is uh step up at the level

of RA. Okay.

Uh then

step up at the level of pulmonary

artery.

see the first thing I'm missing the SVC

saturation is very low, right?

Yes, sir. Yeah, you

then the pulmonary artery saturation is

high. The pulmonary artery is the aorta

in this case. Yes, sir. So, there's a

significant pressure saturation

difference. It means that there is slow

flow of blood through the tissues, and

there's more time for extraction. So,

the patient is in shock.

Yes, sir. Okay. So, in this case the

patient is in shock. So, you must the

cath study must go on very carefully

after this. If possible, call a senior

colleague. Okay. So, all those things

are there.

So, the SVC saturation is low

when compared to the uh pulmonary

artery. In this case, the aorta. Okay.

So, next is the step up at the level.

Okay, fine.

Can I ask one doubt? Yeah.

Uh when the aortic saturation is already

60, it is expected to be 36, now. With

that alone, can we say he's in shock?

He's in shock. So, he's in shock. It's a

TGA, right? Pulmonary artery I'm asking.

Your SVC is expected to be 3

Oh, it's a Okay. Okay. I I understand.

Okay. In this case, the PA is equal to

the aorta, and aorta is equal to the PA.

Oh, okay. Okay. Okay, next.

Uh yes, sir.

Uh so, are we uh two aortas connected?

So, 62% 52 8 to 62. Then There's no

gradient. Is gradient, no gradient.

No gradient. I mean, you're doing

saturation. I'm sorry, saturation.

Yeah, saturation.

Uh then, left-sided saturations, uh 99%,

99%, and then pulmonary arteries

connected, 98%. No step up or step down.

Uh then, pressures, uh

RA pressure is around four. RA to RV, uh

there is significant gradient.

Uh RA to RV, there's no gradient. You

look for the diastolic gradient, right?

Yes, sir. Okay.

Yeah, diastolic gradient, I don't think

that much, because again, it's a mean

pressure.

Yes, sir.

So, it's around two only. Okay, sir. I

know it. Uh

then, uh

LA pressure is around eight, and RA

pressure is around mean pressure is

around four.

So,

not a non-restrictive non-

non-restrictive ASD is not present here.

And you mean there's a restrictive ASD

or non-restrictive ASD?

The ASD, sir. The ASD is not

Yeah, what is it, restrictive or

non-restrictive?

Might be a restrictive ASD. It's a

restrictive ASD, right? Okay, fine.

Yeah.

And uh

then,

uh

uh

RV to

uh

aorta pressure

uh is around 77 by 48. So, low output

situation with mean of 58. Then,

LA pressure is around eight, and LV

pressure is around 23 by six. So,

uh

LV and RV pressures are also different.

So, it is basically a restrictive ASD,

no VSD.

Okay, so why is the patient in shock?

Maybe the ASD

is easy.

You probably have a restrictive ASD.

Yes, sir.

is the patient in shock?

Maybe

is day three of Second is day three of

right? So, what happens on day Uh so,

the PDA is closing. So, PDA closes,

right?

Yes, sir. So, it's a TGA with closure of

the

with closure of the

PDA probably and that is also the reason

of shock. So, what do you do now?

Uh sir,

two options. Either you do balloon

atrial septostomy or you start PG

infusion and post the patient for

intracardiac repair. So, PG infusion,

you can start the patient PG infusion

and you can plan for immediate

septostomy followed by corrective

surgery, right? Yes, sir. It's a fairly

usually asked exam question, right? Yes,

sir. It's usually asked. So,

first you look at the pressures, aortic

pressure and the pulmonary pressure and

the

Is there a pressure Is both are Aorta is

much more than the TGA.

Then you look for where is the shunt

level, atrial, ventricular, or great

arterial. And then you look for is there

a PS or not, right? Yes, sir. And in

this case, the patient is in shock

because the PDA is closing.

Yes, sir. And so, you do a PG infusion

or immediate septostomy, right? Yes. So,

this is a fairly Next question is a

12-year-old boy with an Is it easy one?

12-year-old boy with an incidentally

detected continuous murmur.

Okay, who wants this?

Uh

Should I continue, sir?

Uh if anyone is willing, let them try it

because there are a lot of people Okay,

sir.

Anyone is there? Anyone wants?

Okay, I don't think anyone is willing.

So, you can start You can try.

Okay, sir. Thank you.

Uh so, here uh

aortic saturation is uh 86, uh around

86. So, patient is cyanotic.

And pulmonary artery saturation is

around 70. Okay, so the aorta is more

than pulmonary artery. Yeah. Okay. No,

but you can read You always read that in

your mind. So, when you are given a

table, you keep that in your mind and

then but you start telling from the SVC,

right? Because the examiner don't want

you to jump from aorta to pulmonary

artery and all those things. So, you

start from below, but in your mind you

can treat like that.

Yes, sir. Okay.

And so, SVC uh

to RA no significant step up. SVC

saturation is good. Patient is stable.

Oh, yeah. Yes, sir. SVC saturation is

good. RA saturation no step up. No step

up at the level of RV also or pulmonary

artery also.

Okay.

And uh

LA to LV to aorta uh saturation stroke

uh little

uh less, but there's no significant step

up or step down.

It's desaturated, right? Yes, sir.

Desaturated. Anything less than 93 is

desaturation. So, again, pressures?

Uh pressures uh

So, pressures at the level of uh right

atrium is uh A 7 and V is 5, mean of 6,

and RV is 28 by 7.

the first thing is patient is in sinus

rhythm with reasonably This may be

slightly elevated RA pressures because

the mean is around 6.

The patient is in sinus rhythm, right?

And A is more

Yes, sir. Okay, next is?

Uh then, pulmonary artery pressure is 25

by 12. So, no PH here. So, already okay.

LA? Uh LA pressure is around A A wave is

10, V wave is 11, mean of 10.

you're okay. So, LA pressure more than

RA pressure. Okay. Then, LV is around

110 by 9, and aorta is 110 by 70.

So, what are your comments?

Uh What is your diagnosis?

Uh this patient has a incidentally

detected continuous murmur, and patient

is uh cyanotic. There's no uh

significant

VSD here, and uh no significant step up

at the level of any chamber. So, could

be because of uh

uh extracardiac condition like pulmonary

AV fistula. Yeah, that's the answer,

actually. So, yeah. The only abnormality

you find in this uniform desaturation

across all left chambers

So, it's usually a pulmonary

incidentally found continuous moment

usually a pulmonary AV fistula.

Okay, low pulmonary arteries low

pulmonary venous saturation you think of

one is could be could be a lung disease.

You can have severe pneumonia, okay. You

can have pulmonary edema, alveolar

hypoventilation or due to a pulmonary AV

fistula.

In this case

the clinical condition is contiguous is

is is a

is

measured with a pulmonary AV fistula.

Right?

So, the Yes, sir.

So, the next one 16-year-old boy who

came for cataract surgery, right? So,

who's willing for this? I think I've

shown you the answer. So, let's see.

So, who wants to read this?

Nobody is there we lost random video

college guys to read it.

Okay, so I

Elias is there?

Elias?

Elias is my junior actually. So, that's

why I I don't I know I I know few people

on the list.

Elias there?

No, sir.

He's not there.

But he's silent.

So,

who else is there who I don't I don't

know many people do I know.

So, I think we can

Okay, from anyone from

Anyone No one is willing to read it.

Sir, I will read. You will read Who is

this?

Hello.

Yeah?

Hello.

Yeah, what's your name?

Sir, Surya, sir.

You're from?

Uh sir, Madras Medical College. Okay,

from MMC, right? That's the college

where I did my MD. Elias only sent me

the link.

Yeah, yeah, Elias. Okay, fine. You can

start reading. Okay.

Um sir, SVC saturation and IVC

saturation are fairly okay. The patient

is not in uh

at present desaturation. Okay, so

reasonably stable patient, okay. Stable

patient. Um

RA sat There there step up gradient at

the level of uh RA atrial level or

ventricular level. Okay.

Um

the

There is a significant difference

between more than seven. I mean the

level of great arteries there is a

shunt.

Because there is a difference of more

than seven. The left to right shunt. Uh

left to right there is a level of left

to right shunt. Okay.

Um then pulmonary artery I mean left

side saturation are normal.

Okay.

Um

Then coming to the

So coming to the pressure tracings I

mean pressure values

um

RA pressure is slightly high mean of

eight. I mean patient is in sinus

rhythm. Okay. Mean is within the mean as

expected. Uh

Uh mean is

slightly high. Okay. With uh say uh

evidence of

uh

um pulmonary hypertension is there.

Mean BP is slightly systolic diastolic

Systolic systolic is also slightly

say there is a Is there a diastolic

gradient across the tricuspid valve?

Yes, sir. Uh diastolic gradient now?

Yeah, there is a gradient.

Uh

systemic hypertension

There is no diastolic gradient.

Yeah, and is there a systolic gradient

across the pulmonary valve?

Systolic gradient No, sir. Okay, no. So,

you must say that also. Uh okay. So,

Okay, what you mean is more important

than a diagnosis. So, okay, next.

Okay. So, there is some some degree of

PA is that what you're saying? Pulmonary

Yeah, pulmonary artery hypertension is

there. So, moderate at least. Okay.

There is a difference between

uh of pressure between uh

right and left uh

pulmonary artery thing. Okay, so you

compare the main pulmonary artery to the

LPA. Is there a gradient?

Main pulmonary artery to Left and right

pulmonary arteries. Is there a gradient?

Yes, sir. So, that is a significant

gradient now? Yes, the difference

difference is there. I mean difference

is there between main pulmonary artery

and arterial I mean I mean both. So in

in in pulmonary artery a gradient of

more than 20 is significant.

Okay.

more than 20 anyway, definitely there.

So what do you what do you infer from

the gradient there? So what do you what

do you Pulmonary stenosis I mean branch

I mean A branch pulmonary stenosis.

Peripheral PS is there. Okay, the

peripheral PS is causing the increased

RV pressures. RV pressures. Okay, right.

The RV diastolic Okay, fine. Next.

Sir, then there is a

RV uh

Left side is uh okay, sir. I mean A A is

A, B is more than uh A

A is more than A. pressures are normal.

Normal. B both A normal. Aortic pressure

is also

I mean uh slightly low I mean okay, sir.

Uh there is a wide pulse pressure is

there. Okay, wide pulse pressure. Right.

So is there a systolic gradient from LV

to aorta? No, sir. No no systolic

gradient.

gradient across the mitral valve?

Uh

LV and the Mitral valve. So LV

I mean

No. So you have diagnosed a peripheral

PS. Peripheral PS.

Uh

but I mean PDA.

Uh so PDA. PS with PDA. Why is there a

PDA?

Sir, there is a step up at the level of

uh great arteries great arteries. With

wide pulse pressure, right? With wide

pulse pressure. So the diagnosis of

peripheral PS with PDA. Now what what is

the condition of the patient?

Muballa. Yes, comes from Muballa. From

Muballa. Muballa Muballa.

Muballa. Yes, sir.

Surya sir was my senior medicine. Uh

really? Where is he doing now? Where is

he now?

MMC.

Cardiology. I mean you are a So we are

senior.

Yeah, yeah. Did you rag him?

Thank you, sir.

Okay, thank you. So, it's peripheral PS

with PDA and I don't know if congenital

rubella syndrome, okay. So, the step up

in the level of MPA is peripheral PS,

high PA pressures, and high aortic pulse

pressure. Diagnosis peripheral PS with

PDA, congenital rubella syndrome. So,

cause of peripheral PS here congenital

rubella syndrome, Noonan, Alagille,

Williams, cutis laxa, and tough.

Again, tough will have supravalvular

stenosis, valvular stenosis, and then

subvalvular stenosis. One of the

favorite exam questions is where are

what are the levels of obstruction in

tough?

Right? What are the

They will probably can ask you also what

is the name of the what is the name of

the classification of peripheral PS?

GAE's classification.

And if you are they are more bothered,

they'll ask you what is type one, type

two, type three.

Okay.

So, again, 4-year-old cyanotic infant,

okay. So, who is going to read this?

4-year-old cyanotic infant.

Sir, this

Sir, I'm Mom C, sir, from Hyderabad.

Which college?

Hello.

college are you from?

Star Hospital, sir, DNB. Yeah, fine. You

can read it. Excellent.

Yeah.

4-day-old infant cyanotic

4-day-old cyanotic infant,

and the saturation data is showing high

SVC, that is 72%,

and low SVC, 80%, Okay. and IVC, 68%.

So, are they okay? Uh SVC saturations

are higher, Okay. higher than normal.

Maybe some anomalous connection is

there.

And right atrial saturation is 88, and

right ventricular is 89, and MPA is 90.

All are around similar. Okay.

And left atrial saturation and LV

saturations are also similar. Okay. So,

maybe some anomalous connection is

there. And coming to the pressure data,

um

right atrial pressure is A wave is 11, V

wave is 11, and mean is 11. Okay. A is

in sinus rhythm. Yeah. A is equal to V.

Sinus rhythm with

A is equal to V. Maybe ASD is there.

Okay. Right atrial septal defect is

there.

And right ventricular pressure is 60 and

end diastolic is eight.

Okay. There is a 3 mm gradient across

the

right ventricular wall. Maybe high flow

situation.

Okay.

The pulmonary artery pressures are 60

systolic and 33 diastolic. No systolic

gradient.

There is no systolic gradient and higher

mean pressures are there.

42 and left atrial pressure is A is 10

and V is 11 and mean is 10. Okay. Now,

if you compare, is there a gradient

between Diastolic

Uh mean mean right atrial pressure is 11

and the left atrial pressure is 10, sir.

If it's an ASD, it's a non-restrictive

ASD.

Right? Only 1 mm gradient is there. Yes,

sir. Less than 2 mm.

So, if there is an ASD, it's a

non-restrictive ASD.

Yes, sir. Non-restrictive ASD.

Okay. Non-restrictive ASD and LV is LV

systolic is 100 and

diastolic is end diastolic seven.

And diastolic gradient is three, sir,

between LA and LV.

And aorta is

100 systolic and 70 diastolic. There is

no systolic gradient across LV to aorta.

So, diagnosis is? Mhm.

Diagnosis, it is a total anomalous

pulmonary venous connection.

Okay.

Maybe

into the supracardiac supracardiac Yeah,

supracardiac. Okay, but again

Supracardiac total anomalous pulmonary

venous connection. Supracardiac, but

could be obstructive also, no?

Because there's pulmonary artery

You're not very sure of that.

Uh left atrial pressures are not much

elevated.

Okay. We don't know whether pulmonary

capillary wedge pressure

Supra cardiac TAPVC which is

with an ASD, large unrestricted ASD,

right?

Yes, sir.

Okay, so again, one easy method is look

at the PA pressures, look at the MPA

saturation, look at the aortic

saturation. Both are almost same. Okay,

so that indicates an admixed physiology.

All chambers have the same saturation

beyond the RA.

So, it's a TAPVC or tricuspid atresia.

And then you try to find out which one

it is.

All right? And how this capillary wedge

pressure is not there, no, sir? How to

find out whether it is obstructed or

congested?

And again, okay, if you could That's

it's difficult. Now, how do you enter

the pulmonary veins in TAPVC? It's

difficult, now.

Because all you have to put a catheter

into the Through the anomalous pulmonary

vein, through the anomalous

anomalous pulmonary vein. You might not

be able to get it, actually.

So, that is one point. So, again,

so that is one thing, so it's a

So, LSVC step up, RA step up, or beyond

RA, all chambers have almost the same

saturation. LA mean is equal to RA mean,

unrestricted ASD, TAPVC with an

unrestricted ASD.

Right? So, next one. 4-year-old with

poor feeding.

Should I continue, sir? Uh let's see if

somebody else is willing to take up.

No one else is there.

Yes, sir.

Uh 2-year-old with poor feeding, and SVC

saturation is 58, and IVC is 59.

And

right atrium mean saturation What is the

comment on that?

Mhm. SVC IVC saturation?

There is low cardiac output is there,

sir. Yeah, it's slightly lower than

normal. 68 is normal.

No. Okay.

Mhm. Right ventricular is RA is 59.

And right ventricle is 52, and

there is a step up at the level of PA,

sir. Okay.

PA saturation is 78, and left atrial

saturation is 89. Left ventricular is

also 89.

And I don't know whether pulmonary

capillary wedge pressure is not taken or

sample is not taken.

I don't know where the structure

Usually if there is an LA pressure you

can take this reading now. Usually if

you don't get the pulmonary capillary

wedge pressure you take the LA as that.

Okay, sir.

And LV is 89 and aorta is

90. So there is some degree of systemic

desaturation.

There is a step up at the level of PA.

And the LV pressures? And left-sided

saturations are decreasing. Coming to

the pressures, right atrium is

four, mean is four, right ventricle is

67.

And PA pressures are elevated, mean is

40.

Left atrial mean is 13.

And left ventricular pressure is

124 by 12.

And

aortic pressures are 120 by 40. There is

no significant systolic gradient.

Yeah.

There's a wide pulse pressure

difference.

Can see the coming

In aorta there is wide pulse pressure is

there. Yes, so you're impressing

some

PDA with

Okay. Yeah.

When you see PDA there's a PDA accepted

but I can see the there is systemic

desaturation as well as the and the

mixed venous oxygen concentration is

low.

Okay. Patient has poor feeding so what

does this indicate?

Heart failure.

I mean heart

Pulmonary edema.

Uh

okay, but

more common is probably he's having a

pneumonia or something like that, right?

Left atrial pressures are elevated.

Uh left atrial pressures are not that

high because like it's already there.

Respiratory infection. That's a PDA with

pneumonia as a diagnosis, right?

So you have systemic desaturation. When

you see an

concentrations are low, it's either a

pulmonary A malformation or something

wrong with the lungs.

Okay, in this case

PDA may be associated anomalous SVC.

And also

associated anomalous SVC.

I'm not very sure on that, but it's more

common to have a PDA with pneumonia

presenting in this kind of picture.

Right?

Okay, sir.

PDA more common diagnosis. So, you have

a low MVO2, you have a shunt in the PA

level, high pulse pressure.

So, it's a PDA with pneumonia and PDA

presents with recurrent respiratory

infections.

So, one question they ask is how do you

distinguish between a PDA I said it's an

AP window. How do you distinguish

between a PA and an

between a PDA and AP window on cath

study?

AP window, there will be early

development of PAH will be there, sir.

On cath study, you are doing the cath.

Cath study. Catheter is in your hand.

See, when you in a PDA, what happens is

an AP window, the catheter always goes

into the ascending aorta.

Right? In a PDA, the catheter always

goes into the descending aorta. So, you

distinguish.

Okay? So, RA to RV to PA to PDA through

into the descending aorta is a PDA.

The connection is at the level of

descending aorta.

The connection is at the level of

descending aorta in PDA and

AP window is in the level of Yeah, I'm

talking about another Usually the

AP window is usually

Again, there's a flow direction

different. Medial is plus lateral. I

forgot which one is which.

In a PDA, I think I'm not very sure.

PDA will be lateral jet. Okay, then

maybe maybe

AP window.

Medial.

Okay, this is one you should listen when

they ask.

And the kappa can also be medial. Okay.

So, cause of PV desaturation and lung

pathology and pulmonary hypertension.

So, do a cath study for a sick neonate.

Even if you see the SVC saturation, it

will indicate a sick neonate.

So, anyone?

Okay.

I will try that. Yeah, yeah.

Uh

the SVC saturation is

50 and IVC saturation is also low. The

patient with a normal

aortic saturation is 68.

Okay. Yeah, and pulmonary artery

saturation is 90, so this is a

transposition physiology. Okay.

Okay. Then SVC to RA, there is

no step up. RA saturation is 54 and

right atrium to

right ventricle, there is a

step up of 16.

Okay.

Then

So,

pulmonary artery saturation is 90.

Again, a step up from RV to pulmonary

artery level.

Pulmonary venous and left atrial

saturation You cannot say step up from

the RV to PA, right? Because PA is now

the aorta, it's a TGA.

No, no, aorta.

So, you will lead from the RV into the

aorta.

Uh

Okay.

So, RV and aortic saturation is similar.

Uh pulmonary artery

pulmonary venous saturation is 98, LA

saturation is 98 and pulmonary artery

saturation

uh is

uh LV saturation is

uh 90. So, there is a step desaturation

from LA to LV.

Okay.

And LV saturation and pulmonary artery

saturation are fairly

similar.

Coming to the pressure tracing

uh

RA, the mean pressure is slightly

elevated.

RV pressure is

Patient is in sinus rhythm. Patient is

in sinus rhythm. RV mean pressure is

elevated.

Uh

the RA RA mean pressure is elevated. RV

pressure systemic

pressure is elevated with a normal

diastolic pressure. No gradient between

diastolic gradient between RA and RV.

Then pulmonary artery

pressure is

uh

100 bar 60 with a

mean

pressure of 75.

And aortic

aortic pressure is

30 bar 15 with a mean of 18. So, uh

there is a significant gradient between

RV to aorta uh

Okay.

So, what is the diagnosis?

So, this is a uh

So, when I receive TGA,

tell me where is the shunt? Atrial

shunt, ventricular shunt, or It's a uh

uh

ventricular shunt. Ventricular shunt.

So, is it restrictive or non-restrictive

VSD?

VSD is un- unrestrictive Okay, okay.

Unrestrictive RV systolic pressure on

the RV and this is also nearly also

similar. Nearly similar. So,

unrestrictive. Then the patient will

survive, right?

If you leave him alone. Yes. TGA

unrestrictive VSD. Is there a PS or not?

Is there a PS or not?

What, sir? Is there a PS or not?

Uh

there is a RVOT obstruction is there.

Okay, fine. So, it's a TGA VSD PS.

Okay.

RA mean is more than LA mean. Why is

that?

Normally it's the opposite direction,

right? Why is the RA mean more than LA

mean?

Because of the PS.

Okay.

Pulmonary stenosis.

So, TGA VSD severe PS TCC

aortic stenosis, sir,

pulmonary stenosis. Okay, that is

usually a controversy, right? Is the

pulmonary valve part of the RV or is the

pulmonary part of the pulmonary artery?

So, okay. So, whatever the chamber which

is communicating

say RVOT obstruction, master. Okay,

fine. You can say that.

Hello.

The mic connection got lost. Can we tell

PS it is RVOT obstruction only, no?

Okay, you can say that there is an RVOT

obstruction. That'd be better,

Okay, so that is clear, right?

So again, it's a low cardiac output

state also, right?

So RA mean is more than LA mean, like a

split ratio, pulmonary stenosis, or

TAPVC. Okay?

Usually it's the other way around.

So again, it's a sick patient, so

we have TGA, VSD, okay, RVOT

obstruction, it's in CCF.

Okay, again same question, cath study

for a sick neonate, it's same thing I'm

thinking. This is not This is Okay, cath

study for a sick neonate.

So we need

Uh data.

Uh okay, I'll start with the saturation.

SVC saturation is 68, it is fairly okay.

Uh

and there is no

um

SVC to RA step significant step up or

step down.

RA to RV,

uh it is normal only.

RV to PA, also it is normal.

Left side saturation, pulmonary vein

saturation is 100.

Pulmonary vein to LA, there is a

that is

more

significant, not two.

One or two, okay, fine. Yeah.

There is a step down

at the pulmonary vein to LA.

And

uh

LA to LV, there is a significant step

down. Okay.

Okay, I'm going to my program.

And uh

uh

regarding the pressures,

uh

right side mean pressure is normal.

Slightly elevated, but

sa- sinus rhythm like

A is more than Yeah, A is more than V.

Slightly elevated mean pressure.

RV pressure, RV systolic pressure is

severely elevated. Okay. Uh uh

Okay.

50

20 is significant. Okay. Yes. Sorry.

What does it indicate?

Uh it is significant, no? What does that

indicate?

There is obstruction at two levels.

So? Uh Two levels?

Two levels,

branch and

branch and at the level of the valve.

Okay, so valvular PS and supravalvular

PS. Okay, then. Yes.

Okay.

Okay.

Coarctation of aorta. So, you have

diagnosed branch PS plus valvular PS

plus coarctation of aorta. What else is

there?

There is a step down at Uh hello, there

is a significant step up at

uh

Step up at

step up at

Okay, there's a step down at the level

of ventricle, right? LV Uh yes, yes.

What is the cause of that? That's

See, you look at the main pulmonary RV

systolic pressure as LV systolic

pressure, they're both

same. Uh yeah.

RV systolic and I didn't get you. See,

RV systolic pressure is equal to LV

systolic pressure, right?

Yes. So, there should be an unrestricted

VSD. Uh yes, yes. Okay. Okay.

So, your diagnosis is

there is

supra There is branch PS with

valvular PS.

and

PSV and

the fire fighter right?

Okay.

So again note this RV systolic pressure

is equal to LV systolic pressure equal

to the aortic systolic pressure okay.

This is a hallmark of TOF.

Okay. Make it clear on that. Yes. Yes.

Okay, but is this a TOF?

So again elevated RV pressure indicates

that that is causes to the valvular as

well as the peripheral PS. That is

clear?

Yes. Yes. Okay, step down at the level

of LA to LV with this VSD with right to

left shunt.

Okay, RV SBP is equal to LV SBP is equal

to aortic SBP and we have a coarctation.

So you have severe valvular with branch

pulmonary stenosis with unrestrictive

VSD with right to left shunt, right?

With coarctation. Yes. I hope you have

any questions. Is this a TOF? Because I

told you the hallmark of TOF is that the

systolic blood pressures in the RV, LV

and aorta will be the same. It is same

in this. So is this a TOF?

Yes.

Will anyone say no?

No. TOF is rarely associated with

coarctation. TOF with coarctation will

not occur. That is the point. TOF is

rarely associated with coarctation of

aorta. Okay? Because from the beginning

itself there will be very good blood

flow across the aorta from birth itself.

So rarely in from development itself. So

that's one of the favorite exam

questions. They'll ask you is TOF

associated with coarctation of aorta.

TOF is not associated with coarctation

of aorta. Okay? When you have good blood

flow across an artery that artery is

heavily stenosed. Okay?

So that is the answer. So could this be

TOF? It is not TOF. Okay? Any doubts on

this

this particular case?

Okay. So no doubts. Okay. Fine. Sir,

then what is the diagnosis of previous

case?

There is a severe There is a

supravalvular as well as valvular PS. We

have VSD and a coarctation of aorta.

They are multiple defects.

Any congenital anomaly? I'm not sure

what congenital anomaly which causes all

this.

Okay.

Uh but like I'm not sure if there's any

new syndrome regarding this. I'm not

sure. TOF physiology only, no, sir? This

final No, but it's not TOF like it's TOF

physiology. May not be classical TOF.

It's not classical TOF. Yeah.

Again, in this case, you start thinking

if you have a TOF with an associated

coarctation, you think of a DORV, okay?

Sir, how to differentiate between uh

valvular and branch PS, sir?

You do a pullback, now. You get the

different pressure gradients, now. You

take it deep into the pulmonary right

pulmonary artery and you pull back.

You'll get a pressure gradient between

two points, and then you pull back

again, you get another pressure

gradient.

Right? Okay, sir.

So, basically, all these are pullback

studies. If you There's a pressure

tracing starts with that. So, when you

do a pullback, you can see multiple dips

in that if I do a pullback study.

So, when you get a TOF with a

coarctation, you start thinking is it a

DORV, right?

Yes, yes. 30-year-old female is an easy

one. 30-year-old female long-term

asthmatic.

Then we will give to Dhanush.

Dhanush?

Dhanush?

Dhanush is not You want to take a easy

one. Easy

Okay, anyone else who's not from

Trivandrum?

Okay, somebody type any Hello, hello.

Yeah.

Hello. Yeah. That is a

30-year-old female long-term asthmatic

with only pressures.

Okay.

RA pressure So, patient sinus rhythm.

So, RA pressure

A is 11. A A is 11, V is 6, M 9. So, all

RA pressures are elevated. A is more

than B.

A is more than B. A is more than B. A is

more than B.

Then

there is a

there is a diastolic gradient between RA

and RV.

Okay.

of nine

and the RV systolic pressure is

Uh sorry, five five five. And the RV

It is elevated. And RV systolic pressure

is also elevated, 60.

With pulmonary artery is showing a

systolic pressure of 22 and diastolic

pressure of 10 and mean pulmonary artery

pressure is 14, not elevated. So, but

there is a systolic gradient between RV

and pulmonary artery.

So, there is a pulmonary stenosis.

RVOT obstruction is there.

So, then after that coming to the LA

Shall I start? LA pressures are not

elevated.

And LV pressure

Listen carefully. Yes. You might not

have

A is A is more than B. Yeah. A is more

than B, correct. Then LV pressure 110

bar zero and aorta is 110 bar 80, that

is also normal. Okay. So,

coming here there is an there is an RA

RA pressure is elevated with A more than

V with RVOT obstruction. So,

maybe pulmonary stenosis. Pulmonary

stenosis. What about the gradient across

the tricuspid valve?

Gradient across the tricuspid valve,

maybe TS is also there. So, what is the

diagnosis? Yes, with TS.

Carcinoid syndrome. Carcinoid

Carcinoid syndrome.

So, the diastolic gradient across the

tricuspid valve and the systolic

gradient across the pulmonary valve is

combined RV inflow and outflow

obstruction.

So, diagnosis carcinoid. So, first

question, is there a PR in this case?

PR Is there a PR?

Dhanush

Uh PR the

there's no

No PR. Why?

PR and then there will be a large

volume.

What will be The artery will be

Ah, PA

AR AR will have a large aortic pressure

and the lower diastolic pressure.

Similarly, PA also will have a large

systolic pressure and the lower

diastolic

of PA.

Okay. Ah.

Okay.

So, what other condition we have TS and

PS?

Epstein's anomaly is associated with

this. Okay.

You can have it sometimes the large

tricuspid defect going and occluding it.

37-year-old female who's having dyspnea

on exertion, functional class three. I

think we'll give it to some other

people. Saurabh is there?

Yes, sir. So, you can read this.

37-year-old female with dyspnea of

exertion, functional class three. Uh, RA

pressures with A of nine, V of eight,

mean of seven.

Uh,

then RV pressure

uh 72.

a few patients in sinus rhythm with A

more than V. Yes, sir.

And RV pressures are elevated

with N sir ED's end diastolic pressure.

Yeah, end diastolic

End diastolic pressure of 10. And

pulmonary artery pressures are 68

What about the RV pressures?

Uh, it's elevated and there is a

End diastolic pressure?

End diastolic pressure is also elevated.

Yeah, okay.

So, pulmonary artery pressures are 68 by

27 with mean of 34. So,

indicating pulmonary arterial

hypertension.

And is there a systolic gradient across

the pulmonary valve?

Uh,

you turn pressure on.

No, sir. Not uh Okay, so no systolic

then.

Uh, then uh

LA

LA pressures are A wave of 18, V wave of

16, A more than V.

And with mean of 17.

And LA pressures are also elevated.

Okay. And

uh LV pressure is 140 by uh end end

diastolic pressure of five. And aortic

Is there a diastolic gradient across the

mitral valve?

Uh, yes, sir.

Around 17. Now, if you look at Kuys

formula also

If you look at Kuys formula also, now

you have like

uh what is it? Kuys formula only?

LA mean minus LVEDP LVEDP by two. So, LA

mean is 17. LVEDP by two is 2.5.

It's around 14.5. Okay.

Uh, sir, which formula is this? Kuys, C

U I, Kuys formula, C U I. Okay, sir.

is LA pressure

Yes, sir. minus LVEDP by two. It's not

whole by two, just LVEDP by two. It is

17

minus five by two. 2.5 Yeah, it's 14.5.

Yes, sir. Then there is severe

uh Sir, what it represents, sir? That

14.5?

It represents the mean gradient.

Yeah, the capillary wedge. Mean gradient

between LA and LV. Yeah. Ah, there

there.

Okay, so

you have a severe gradient across the

diastolic gradient across the mitral

valve. Okay, then.

Uh, then aortic pressure of 98 by 40 to

severe systolic gradient across from uh

across the

uh

aortic valve. So, what are your

conclusions on this?

Uh

Sir, first of all, there is significant

elevation of RV

and diastolic pressure as well as

systolic pressure. There is pulmonary

arterial hypertension. Okay. There is

elevated LA pressures Okay. and

with

gradient across the mitral wall as well

as aortic wall.

Okay. So, causes?

Could be a

simultaneous

stenotic lesion of both mitral and

aortic walls. You're saying severe AS?

This PH. Severe AS, severe MS, PH. Yes.

Yeah.

Okay. So, rheumatic heart disease. Okay.

So, one thing is that look at the

diastolic pressures in the RV. They are

also elevated, right?

Yes, sir. It indicates that the RV is

going to fail.

Yes, sir. Not yet failed because the RV

pressure is 72. The RV is able to

generate a very good pressure. So, it's

not yet failed, but it may fail because

the end diastolic pressure is slowly

rising.

Yes, sir.

There's one more thing there. Now,

whenever you get such kind of thing,

whenever there is PH, always look if

there is an associated pre-capillary

component to it. This is your routine

post-capillary hypertension, huh?

Yes, sir. So, you might have an

associated pre-capillary component. For

this, you either look at the diastolic

pressure gradient, which is more

accurate, or your transpulmonary

pressure gradient.

So, you look at You can look at the

diastolic pressure gradient. That is LA

mean minus

pulmonary artery end diastolic pressure.

So, how much is it?

72. Uh 27.

Minus 72. So, 10. More than seven is

indicates a pre-capillary component.

Okay. Or you can look at the

transpulmonary gradient, which is both

means. Mean LA minus mean PA minus mean

LA. So, that is 72

17. Yes. And more than 12 is

significant. 12. 12. So, there's an

additional pre-cap amount of 12. So,

there's an additional pre-capillary

component to it. There's an additional

vasoactive component to it. Do you get

my point?

Yes, sir. So, it could It is

both hyperkinetic as well as reactive

pH. It's reactive as well as passive

transmission. Yes, sir. So, you have

passive as well as a vasoactive

component there. In addition, you have

reactive component, obstructive

component, as well as a as well as a

passive passive component.

Passive transmission of pressures. So,

one of the favorite question they ask is

what are the types of

pulmonary artery hypertension you can

give an MS. And

they'll ask you to grade it and up to

what grade can you get an MS.

So, according to so, all those are usual

questions.

Inshallah.

Yeah. Gradient to tell severe AS is it

40 in cap?

It's usually mean gradient, but with

usually we we take the systolic gradient

only in cath study. Is it 40 or 50?

40, isn't it? 40 40.

Okay.

Okay, so it's severe AS, severe MS. AR

is there, sir? Yeah. And mild AR because

you can see a wide pulse pressure also.

Probably some mild AR.

Okay.

So, diagnose severe MS with moderate PH

with elevation of RV filling pressures.

Severe AS, mild AR. Reactive PH is also

present in addition, okay?

You have diastolic pressure gradient of

10 and a transpulmonary pressure

gradient of 17. So, whenever you

diagnose PH, always look is there a

pre-capillary component gradient

addition?

Okay?

So,

let's say this is a this is a

37-year-old female, right?

Let's say this is a 67-year-old female,

in which you expect a pre-capillary

component to be there.

You get my question? Yes. No, sir. See,

you have a 37-year-old female and you

have a 67-year-old female. Okay, both

have the same disease, MS. Yes, sir.

Which patient will have a pre-capillary

component more likely?

The young patient will have. Young and

patient. Young patient. That's why even

in your congenital MS also, you have

stronger, I mean, will have

more PH in them. Because younger vessels

younger vessels will have a more

tendency to contract. Juvenile MS. I

mean, juvenile MS, sorry, juvenile MS.

Okay.

So, severe MS, moderate PH, elevation of

RV filling pressures, severe AS, mild

AR, reactive PH. That is important. So,

we're going step by step. You won't miss

anything.

So, rather than jumping and straightaway

saying the diagnosis is MS,

you don't miss any step because they

rarely give you any simple cases.

Okay. Case study for a pre-op

40-year-old.

Only one more.