Cardiac features of carcinoid syndrome are tricuspid regurgitation, pulmonary stenosis and right ventricular endocardial plaques
These result in heart failure

Pattern of cardiac involvement in carcinoid syndrome

Serotonin which is secreted in excess amounts in carcinoid syndrome is the cause of the cardiac manifestations
It is metabolised in the lungs and liver
So in most cases of carcinoid syndrome, there is no involvement of the heart
But in cases of metastatic carcinoid syndrome involving liver and the lungs, the heart is directly exposed to huge quantities of serotonin
Right heart lesions are seen in liver metastasis and …

Barium swallow – Right anterior oblique view chest x-ray – showing normal indentations of oesophagus
Click on image for an enlarged view

The normal indentations of the esophagus seen in a right anterior oblique view during barium swallow are made by (from above downwards):

Aortic arch – 22.5 cm from incisor teeth
Left bronchus – 27.5 cm from incisor teeth
Left atrium

Clinical importance:

In olden days, when echocardiography was not available, this was used to detect left atrial enlargement in cases of mitral stenosis
When left atrium is enlarged, it may compress on the esophagus and cause dysphagia – …

Kussmaul’s sign refers to the inspiratory increase in jugular venous pressure (or central venous pressure)
Some sources consider Kussmaul’s sign as the absence of inspiratory fall in jugular venous pressure

Causes:

Constrictive pericarditis
Restrictive cardiomyopathy

Mechanism:

Normally there is inspiratory decrease in JVP (Read Mechanism of inspiratory decrease in JVP)
In the conditions mentioned above, the pericardium / myocardium is stiff
The negative intrathoracic pressure is not transmitted to the heart
The heart cannot accommodate the increased blood flow that occurs during inspiration
Hence the jugular venous pressure will be elevated

The jugular venous pressure falls during inspiration
The mechanism is as follows
During inspiration, there is increase in negative intrathoracic pressure
This negative pressure is also transmitted into the heart and hence there is increased blood flow into the heart
As a result, the jugular venous pressure falls during inspiration

The ECG changes found in hyperkalemia are:

Tall tented T waves
Widening of PR interval and QRS complex
Absence of P wave in extreme cases

Ross procedure, also known as aortopulmonary translocation is a procedure used for the treatment of aortic stenosis
In this, the patient’s stenotic aortic valve is removed and his pulmonary valve is transplanted to take its place
A homograft is used in the place of the pulmonary valve

Advantages:

The pulmonary valve that is transplanted can continue to grow
Better longevity for the homograft valve as it is placed in the low pressure pulmonary circulation

Ketamine causes stimulation of the cardiovascular system
It increases myocardial oxygen demand
The hemodynamic changes include increase in

Heart rate
Cardiac Index
Systemic Vascular Resistance
Systemic and pulmonary artery pressure

Since ketamine produces hypertension, it is rarely used in hypertensive patients

Reference:
Hypertension: a companion to Brenner and Rector’s the kidney By Suzanne Oparil, Michael A. Weber

Distal runoff is the blood flow in the post stenotic region of a blood vessel
Adequate distal runoff is an important factor in the success of vascular grafts
Poor distal runoff promotes thrombosis formation within the graft – the risk is even more in prosthetic grafts

How to assess distal runoff?

Angiography can be used to assess distal runoff – TIMI (Thrombolysis In Myocardial Infarction) flow grading
Based on the amount of contrast material that reaches the distal segment and the rate of clearance of contrast in distal segment, there are 4 TIMI flow grades

Grade 3 – …

Aortic stenosis – rheumatic
Click on image for an enlarged view
In the following conditions, aortic stenosis can coexist with aortic regurgitation (aortic incompetence).

Rheumatic
Congenital bicuspid aortic valve
Calcific degeneration of aortic valve
Atherosclerotic degeneration of aortic valve
Infective endocarditis in a case of aortic stenosis

H0w aortic stenosis and regurgitation can coexist?

It can be explained by the following analogy
Consider a normal aortic valve to be a door
It closes and opens completely during each cardiac cycle
Now consider the door to be stuck in the mid position
It neither closes completely nor opens completely
Similarly, when the aortic valve is …

It refers to the decrease in the systolic blood pressure by more than 10mm Hg during inspiration
Seen in

cardiac tamponade
constrictive pericarditis
obstructive pulmonary disease

The reason for the decrease in systolic blood pressure during inspiration is explained in this article : Inspiratory decrease in systolic blood pressure and pulse volume – Mechanism
Mechanism of pulsus paradoxus:

In cardiac tamponade

Tense fluid in the pericardial sac impairs ventricular filling
Also, the negative intrathoracic pressure is not well transmitted to the pericardial sac
Fall in pulmonary venous pressure is more than the fall in left atrial pressure
Hence filling of the …