Phuuwadith “Porsche” Wattanachayakul MD

Cardiology Fellow @emory_heart | IM @JeffHealthEH @JeffersonUniv | MD @SirirajMedicine | From 🇹🇭 Interested in ⚡️⚡️

[Ritika Tuli @RitikaTuliMD]

CardioNugget™ 💡

Why can't you calculate RVSP from a torrential TR jet?

In torrential TR, the tricuspid valve behaves more like a wide-open conduit than a restrictive orifice.

➡️ Massive regurgitant flow causes rapid RV-RA pressure equalization early in systole.
➡️ The CW Doppler envelope becomes early-peaking and triangular with a low peak velocity.

Therefore:
❌ 4V² no longer reliably reflects the true RV-RA pressure gradient
❌ RAP is underestimated because IVC-based estimates do not capture the giant systolic c-v waves seen in severe TR

The result is a falsely low calculated RVSP/PASP.

Parabolic TR jet = pressure lesion → Bernoulli works
Triangular TR jet = flow lesion → Bernoulli fails

https://t.co/dYRan7MEHA

#EchoBoards #CardioNugget #CardioTwitter #ASEcho #CardiologyFellowship

[Ronald Witteles @Ron_Witteles]

Is there a ‘better’ TTR stabilizer? How should we even measure stabilization? Complex issues - check out the manuscript by Judge et al & my accompanying editorial in this month’s @JACCJournals JACC:CardioOncology! https://t.co/k9ajoBbh1J https://t.co/TNRWFWZGWn

[Ritika Tuli @RitikaTuliMD]

🫀 #CardioNugget™

Expiratory diastolic flow reversal in the hepatic veins = think constrictive pericarditis.

🔑 During expiration, LV filling increases while RV filling decreases due to enhanced ventricular interdependence. This causes a rise in RA pressure and prominent hepatic vein diastolic flow reversal.

#EchoBoards #CardioNuggets #ASEcho #PericardialDisease #FOAMEd

[Jan Verwerft @VerwerftJan]

Really enjoyed the north american #HFpEF summit online!
#NAHFpEF2026
https://t.co/NbxX666ve0

[Hide Yaku, MD, PhD, FHFSA @JP_HFpEF]

🫀【拡張機能評価、もう迷わない】 2025年ASEガイドを臨床目線で整理した総説(EHJCI 2026)📄 "指標が多すぎて結局どう読む？"を解決する段階的アプローチを解説🧵

🔑大原則 ：拡張機能障害＝左室が"充満圧を上げずに"血液を受け入れられない状態。 弛緩障害・スティフネス↑・充満圧↑が3本柱💡 単一指標では捉えきれない「潜在的状態」が今の主流。
🎯起点はe'(僧帽弁輪部速度) 2025年版は心筋障害を重視。 弛緩マーカーe'を最初に評価→もう1指標を足して診断✨ e'が不確実なら他2指標で代替できる柔軟設計。
📶充満圧推定は3段階で：①e'・E/e'・TR速度(orPASP) ②LARS(18%)・肺静脈血流・LAVI・IVRT ③Valsalva等の補助指標 原則"2つ以上の一致"で判断⚠️
🆚2016年版からの進化 4変数分類→e'起点の段階評価へ。 「判定不能」が激減し病態生理と合致✅ AF・肺高血圧・MAC・心移植には専用アルゴリズムも追加🔧
🤖未来はAIへ EMPEROR-Preserved等の大規模試験でも拡張障害は患者選択・予後の鍵。 AIが多次元データから"潜在フェノタイプ"を抽出し早期発見を後押し📈 臨床と画像が食い違えば右心カテも🫀
🔗https://t.co/Lr1stSUC9K

[Gonzalo Perez @gonzaeperez]

CARDIOPATÍA ARRITMOGÉNICA DEL VENTRÍCULO DERECHO
Revisión @ESC_Journals 👌
🔴Miocardiopatía hereditaria
🔴Escara ventricular y reemplazo graso
🔴Enfermedad multifascética
🔴Transición del enfoque centrado en el fenotipo ⏩genotipo
https://t.co/76MFyCjj2X

[Sara Moscatelli @saramoscatelli7]

🏃‍♂️⚡ Can exercise stress testing (EST) improve the diagnosis and risk stratification of #BrugadaSyndrome?

A fascinating new state-of-the-art review highlights that exercise testing is much more than a tool for assessing exercise capacity. In Brugada syndrome, the *recovery phase* may be the key moment to uncover concealed disease and identify patients at higher arrhythmic risk.

🔍 Key takeaways:
✅ Type 1 Brugada ECG pattern is rarely unmasked during peak exercise (~1%) but becomes evident in up to 25% of patients during early recovery.
✅ The transition from sympathetic activation to parasympathetic rebound appears to play a crucial role in ECG changes and arrhythmogenesis.
✅ Premature ventricular contractions (PVCs) occurring during early recovery may represent an important marker of future ventricular fibrillation risk.
✅ Exercise-induced malignant arrhythmias are rare, suggesting that EST is generally safe when performed with appropriate monitoring.
✅ Careful ECG monitoring during the first minutes of recovery may provide valuable diagnostic and prognostic information.

💡 The review supports the concept that both *peak exercise* and *early recovery* offer complementary insights into the electrophysiological substrate of Brugada syndrome and may help refine individualized risk assessment.

An important reminder that sometimes the most informative part of a stress test is not the exercise itself—but what happens immediately afterwards.

#BrugadaSyndrome #Electrophysiology #Cardiology #InheritedCardiacConditions #SuddenCardiacDeath #Arrhythmias #SportsCardiology #ExerciseTesting #ECG #RiskStratification #PrecisionMedicine #JACCAsia

[Ashkan Ehdaie MD @EhdaieMd]

The following tracing was obtained during threshold testing for LBBAP lead (unipolar). #Epeeps

Change in QRS shown below- Whats happening? Poll below 👇👇

[Hide Yaku, MD, PhD, FHFSA @JP_HFpEF]

HFpEFはなぜ従来の血管作動薬が効きにくいのか?
私も一緒に論文を書かせて頂いたことのある血行動態分野でご高名なDavid Kaye先生らのReviewのご紹介。

ポイント👇
・静脈は全血液の約7割を貯める"容量血管"
・HFpEFでは静脈の"ゆとり"が失われ、血液の逃がし場所が縮んでうっ血に
・静脈は動脈と"別物":拡張薬で緩みにくく、収縮刺激で締まりやすい
・従来の"血管に効く薬"の多くは動脈中心で奏効せず
・次の治療標的は「静脈」なのかも
🔗https://t.co/odBfKzxzNT

[Sandeep Gautam @gautamsand]

🎯 Efficacy findings: Acute success is no longer the differentiator
➡️Across all currently available single-shot PFA platforms—acute PVI approached 100%.
➡️First-pass isolation was generally mid-90s to 100%, with only a few outlier studies reporting lower rates.
➡️Long-term arrhythmia approximately 55–88% at 12 months (6 months for the balloon-in-basket system). ✴️However, direct comparisons between catheters are difficult because studies differed substantially in AF type (paroxysmal vs persistent), monitoring intensity, adjunctive lesion sets, and f/U protocols.
🧑‍🎓The most important observation is that evidence supporting dose escalation remains surprisingly limited
⭐️Only two studies specifically evaluated whether delivering additional applications improved outcomes. ⭐️Neither a simplified dosing protocol nor the addition of extra “olive” applications resulted in a significant improvement in freedom from arrhythmia.

[Dr. FEVI🫀🩺 @javier20ch]

Vena de Marshall. 🫀⚡️
🔶️La vena de Marshall es un remanente de la vena cardinal izquierda embrionaria que discurre entre la orejuela izquierda y las venas pulmonares izquierdas.
🔶️Lo importante es lo que contiene:
⚡ Fascículo de Marshall (tejido muscular arritmogénico).
⚡ Plexos autonómicos simpáticos y parasimpáticos.
⚡ Conexiones epicárdicas protegidas por grasa.
🔶️Por ello participa en los 3 pilares para generar FA:
🔸️Trigger: genera extrasístoles que inician FA.
🔸️Sustrato: favorece circuitos de reentrada y gaps epicárdicos.
🔸️Modulación autonómica: la estimulación de sus plexos puede inducir FA.
🔶️ La vena de Marshall no es un simple vestigio embrionario; es una estructura neuro-muscular capaz de iniciar, mantener y perpetuar la FA. Por eso se ha convertido en un objetivo terapéutico clave en la ablación moderna de la FA persistente (la infusión con etanol surge como nueva opción). 🫀⚡

📄🆓️⤵️ State-Of-The-Art Review 2026 @JACCJournals 💯👌🏻
https://t.co/wRtVPFbmZ6
https://t.co/qWJKrnsDI0

[RTHahnMD @hahn_rt]

NEW ASE Recommendations for the Intraprocedural Imaging for M-TEER https://t.co/zwUucAIOiP @SLittleMD @ASE360 @JournalASEcho @ACCinTouch @SCAI @purviparwani @iamritu

[Ritika Tuli @RitikaTuliMD]

🫀 #CardioNugget™:

Flow Propagation Velocity (Vp)

Vp = speed of early diastolic blood flow from the mitral valve → LV apex.

How to measure:
▪️ Apical 4-chamber
▪️ Color M-mode through mitral inflow
▪️ Lower Nyquist (~30–40 cm/s)
▪️ Measure slope of first aliasing velocity
📏 Slope = Vp (cm/s)
Interpretation:
✅ >50 cm/s = normal relaxation
⬇️ <45–50 cm/s = impaired relaxation

🔥 E/Vp >2.5 may suggest elevated LV filling pressures.

#EchoBoards #Cardiology #Echocardiography #FOAMed

Image from: https://t.co/4LO5Ost0A0

[Ritika Tuli @RitikaTuliMD]

#CardioNugget™

Cath gradients in AS are not all the same:

Peak-to-peak gradient
Peak LV systolic pressure − peak aortic systolic pressure
The peaks occur at different times → not a true instantaneous gradient
BUT clinically, the peak-to-peak gradient often approximates the mean transaortic gradient.

Peak instantaneous gradient
Closest equivalent to Doppler peak gradient

Mean gradient
The shaded area
Average of all instantaneous LV–Ao gradients during systole

Clinical pearl:
-Echo/cath mean gradients are most clinically useful
-Peak-to-peak gradient should not be used interchangeably with Doppler peak gradient

#CardioNuggets #MedEd #CardioMed #CardioMed #EchoFirst #AorticStenosis #MeanGradient

[Dawit Hailemariam Yesho 🇪🇹 @davehm12]

📊 📝📚 Excited to have attended and presented at #ASCO26. Grateful for the experience. Looking forward to future returns.

Read more on our abstract here: https://t.co/PBW1wylwUM

[Novi Yanti Sari @slumberbell]

Cardiovascular considerations BEFORE cancer therapy🫀

The first of a 3 part #JACCCardioOnc Expert Panel series exploring CV care before, during, & after cancer therapy.

🫀Goals of CV evaluation Prior to cancer therapy:
📍Identify and treat subclinical CVD and cardiovascular risk factors
📍Optimize management of pre-existing CVD and cardiovascular risk factors
📍Perform targeted risk assessment to help inform cancer treatment decisions
📍Establish baseline cardiovascular function
📍Optimize primary prevention therapies
📍Plan cardiovascular surveillance during treatment

🫀Current tools include clinical assessment, biomarkers, 12-lead ECG, #EchoFirst, & risk scores

🫀Important evidence gaps includes cardiotoxicity mechanisms, impact of pre-treatment CV evaluations on clinical outcomes, validation&implementation of risk scores, & the role of AI.

Read more in @jaccjournals:
https://t.co/cTCY0Acg99

#CardioOncology

[Carlos El-Tallawi, MD, FACC, FASE @HeartToProve]

@PWesslyMD @LucySafi @PriyaPanday27 @NadeenFaza @ASE360 @JournalASEcho @DavidWienerMD @iamritu @purviparwani @SIwa23288585 @boegel_kelly MAD is a true separation between the LV crest &amp; posterior mitral leaflet/LA junction. Pseudo-MAD mimics this during systole when a voluminous leaflet presses against the LA wall, but it vanishes in diastole. Distinguishing them is key! #ASEchoJC

[Fabricio Vassallo, MD, PhD @fvassallomd]

Left Atrial Volumetric Enlargement in Heart Failure With Reduced Ejection Fraction: Obligatory Consequence or Independent Predictor of Outcome? | JACC: Heart Failure https://t.co/hH5D726cXa

[Ritika Tuli @RitikaTuliMD]

🫀 #CardioNugget™

“Why is the cath gradient HIGHER than the echo gradient in AS?”
Think poor Doppler alignment first.
Doppler only measures velocity parallel to the ultrasound beam.

If the beam is not well aligned with aortic flow:
→ measured velocity is underestimated
→ gradient is underestimated even more

Delta P = 4v^2
Even a small drop in velocity causes a large drop in calculated gradient.
Example:
🔹 True velocity = 5 m/s → gradient = 100 mmHg
🔹 Measured velocity = 4 m/s → gradient = 64 mmHg

Clinical pearl:
➡️ When echo gradients are LOWER than cath, always reassess Doppler windows:

#EchoBoards #ASEcho #Cardiology

[Nadeen N. Faza, M.D. @NadeenFaza]

🧵 10 Key Features of Arrhythmic Mitral Valve Prolapse (AMVP) ⚡🫀(2025 review article in Circ Cardiovascular Imaging)

1️⃣ Ventricular Arrhythmias
Frequent PVCs, NSVT, sustained VT, VF, or sudden cardiac arrest/death can occur even without severe MR.

2️⃣ Bileaflet MVP
A classic high-risk phenotype with multisegment prolapse and marked myxomatous degeneration.

3️⃣ Long, Redundant Leaflets
Thickened, elongated leaflets increase traction on the subvalvular apparatus and myocardium.

4️⃣ Mitral Annular Disjunction (MAD)
Especially inferolateral MAD and disjunction >8.5 mm, reflecting abnormal annular-ventricular coupling.

5️⃣ Mechanical Stretch & Curling
Excessive systolic traction on papillary muscles and inferolateral LV myocardium creates a proarrhythmic substrate.

6️⃣ Pickelhaube Sign
Lateral annular S′ velocity ≥16 cm/s 🚨
A marker of excessive mechanical stress and higher arrhythmic risk.

7️⃣ Abnormal Strain Imaging
Double-peak strain pattern and increased mechanical dispersion suggest electrical and mechanical heterogeneity.

8️⃣ Myocardial Fibrosis
CMR may show focal fibrosis (LGE) in papillary muscles and inferobasal/inferolateral LV segments.

9️⃣ Diffuse Myopathy
Elevated extracellular volume (ECV) indicates diffuse interstitial fibrosis, even when LGE is absent.

🔟 Inflammation + Electrical Instability
PET/CMR studies suggest inflammation may coexist with fibrosis and contribute to malignant ventricular arrhythmias.

💡 The AMVP phenotype:Young patient (often female) + bileaflet MVP + MAD + abnormal strain mechanics + fibrosis/inflammation + complex ventricular ectopy.

⚠️ Remember: The strongest predictor of adverse outcomes remains complex ventricular ectopy on rhythm monitoring.

#ASEchoJC #Epeeps
https://t.co/3zO4XV4Wnl