I had PICC line Vancomycin Toxicity which scarred my septum (acute multi organ failure given a rapid bolus with AKI AIN/ATN 0 GFR, fluid overload bright red, 105° and went into flash pulmonary edema and acute congestive heart failure Myocarditis CM and SJS/TENS shed >70% skin).
Wound up with rate dependant LBBB, 2nd°- 3rd° block, and have suffered several Takotsubo (inverse) as well with peak Trop l @4.4.
I have similar symptoms as to your running, could the inverse Takotsubo be related?
(44 @ vanc tox, cardiac issues ever since 2009....GI/GO)
I often ask radiologists for addendums to routine imaging reports that are too boilerplate, or unfocused on the “reasons for examination.”
It really does help to have your own expertise, motivation, and persistence to track down outside the box diagnoses. Unfortunately other times this can lead us physicians down interminable rabbit holes of self-over-diagnosis... which would make for an interesting follow up post! “All the possible thing I almost diagnosed myself with.”
My list would be long these 20 years in practice😟 but when you find one, especially one that is actionable, well done
I am not optimistic ML or AI will advance the field of echo interpretation. Attempts to automate the process of measuring the key parameter of ejection fraction using computer assistance have been going on for decades... and all have failed. Currently, there is a lot of buzz around measurement of strain as a better parameter for pump function of the heart. Clinical applicability is limited due to failure to visualize endocardium of the LV, something that is patient , machine and technician dependent and many other factors. A company Ultromics has developed a cloud-based AI platform which alleges superior interpretation . The studies are weak, biased and unlikely to be reproduced.
Garbage in creates garbage out and echo is just too operator dependent to be useful IMHO.
Cardiologists utilize beta-blockers somewhat interchangeably for the indications I mentioned. We seek the most effective and well-tolerated type and dosage.
One area where they are not interchangeable is heart failure/cardiomyopathy/post MI where I utilize carvedilol or metoprolol succinate almost exclusively.
There are slight variations in beta-selectivity and alpha-selectivity among the various beta-blockers which play a roll in efficacy and tolerability.
Using the anatomic landmarks of the aortic root, aortic valve and mitral valve from the parasternal long-axis view it is possible to know with absolute certainty that the echo image is not off-axis and the basal basal bulge is real. In addition, this was confirmed in apical 4C and apical LAX views. The CTA showed the same area of hypertrophy therefore for anatomy MRI not warranted. I utilize MRI in cases of uncertain anatomy and to better define risk of SCD utilizing LGE.
I am surprised no MRI--upper septal "pseudo-bulge" is often the result of off-axis echo imaging. MRI less operator dependent. Of course could not do the dynamic imaging of the stress echo.
Fascinating first person case report. Thanks for generously sharing. Glad you are doing so well. You appear to be one of those rare doctors doing self care who actually doesn't have a fool for a patient.
I had a workup for palpitations (that's another topic: gastric-lapband-associated ventricular ectopy), and got a copy of the echo data. I subsequently got a copy of the cardiologist's readout. I was seriously wondering if he'd seen my echo, or was looking at something else. I got a better interpretation from the tech, reading the screen and applying her 20 years of doing the exams, than from what he said.
Given the progress in machine learning and it’s application to radiology, I wonder what is the author’s opinion of ML to echo interpretation in light of his experience. Seems to me that given the variability in human skill, the partnership between machine and well trained humans could decrease the miss rate.
Plethora of information if you drop it into the search box at "scholar.google.com". Or ask your doc if they're familiar with it by either the generic (nebivolol) or trade (Bistolic) names. They should already be well familiar with the use of beta blockers for management of the aforementioned arrhythmias but there's a chance they feel it's inappropriate in a given case. And, I'd not go med shopping from an online article. One of the parts of the "art" of medicine is the requirement that the doc manages using the tools they're familiar with. Throwing a new drug into a mix where a patient already requiring several other therapeutic agents is potentially tricky. When you add to the mix that a given patient's response to one drug or another is not always uniform, sorting potential drug interactions is an area of concern.
Depending on who's reading, they could well be from a service that's literally paying the docs by the number of studies read and reported out. A friend who did this for several years as a radiologist had to read 20 or more studies per hour or she got dinged. It's a corporate medicine thing. I'll never understand why corporate well-being is better than adequate patient care.
I had PICC line Vancomycin Toxicity which scarred my septum (acute multi organ failure given a rapid bolus with AKI AIN/ATN 0 GFR, fluid overload bright red, 105° and went into flash pulmonary edema and acute congestive heart failure Myocarditis CM and SJS/TENS shed >70% skin).
Wound up with rate dependant LBBB, 2nd°- 3rd° block, and have suffered several Takotsubo (inverse) as well with peak Trop l @4.4.
I have similar symptoms as to your running, could the inverse Takotsubo be related?
(44 @ vanc tox, cardiac issues ever since 2009....GI/GO)
Very interesting case thanks for sharing.
I often ask radiologists for addendums to routine imaging reports that are too boilerplate, or unfocused on the “reasons for examination.”
It really does help to have your own expertise, motivation, and persistence to track down outside the box diagnoses. Unfortunately other times this can lead us physicians down interminable rabbit holes of self-over-diagnosis... which would make for an interesting follow up post! “All the possible thing I almost diagnosed myself with.”
My list would be long these 20 years in practice😟 but when you find one, especially one that is actionable, well done
Titus,
I am not optimistic ML or AI will advance the field of echo interpretation. Attempts to automate the process of measuring the key parameter of ejection fraction using computer assistance have been going on for decades... and all have failed. Currently, there is a lot of buzz around measurement of strain as a better parameter for pump function of the heart. Clinical applicability is limited due to failure to visualize endocardium of the LV, something that is patient , machine and technician dependent and many other factors. A company Ultromics has developed a cloud-based AI platform which alleges superior interpretation . The studies are weak, biased and unlikely to be reproduced.
Garbage in creates garbage out and echo is just too operator dependent to be useful IMHO.
Dr P
JD,
Cardiologists utilize beta-blockers somewhat interchangeably for the indications I mentioned. We seek the most effective and well-tolerated type and dosage.
One area where they are not interchangeable is heart failure/cardiomyopathy/post MI where I utilize carvedilol or metoprolol succinate almost exclusively.
There are slight variations in beta-selectivity and alpha-selectivity among the various beta-blockers which play a roll in efficacy and tolerability.
Dr. P
Rodney,
Using the anatomic landmarks of the aortic root, aortic valve and mitral valve from the parasternal long-axis view it is possible to know with absolute certainty that the echo image is not off-axis and the basal basal bulge is real. In addition, this was confirmed in apical 4C and apical LAX views. The CTA showed the same area of hypertrophy therefore for anatomy MRI not warranted. I utilize MRI in cases of uncertain anatomy and to better define risk of SCD utilizing LGE.
Dr. P
No. Yes. Yes
I am surprised no MRI--upper septal "pseudo-bulge" is often the result of off-axis echo imaging. MRI less operator dependent. Of course could not do the dynamic imaging of the stress echo.
Fascinating first person case report. Thanks for generously sharing. Glad you are doing so well. You appear to be one of those rare doctors doing self care who actually doesn't have a fool for a patient.
Did you get an MRI? Genetic testing? Are you having relatives screened?
I had a workup for palpitations (that's another topic: gastric-lapband-associated ventricular ectopy), and got a copy of the echo data. I subsequently got a copy of the cardiologist's readout. I was seriously wondering if he'd seen my echo, or was looking at something else. I got a better interpretation from the tech, reading the screen and applying her 20 years of doing the exams, than from what he said.
Given the progress in machine learning and it’s application to radiology, I wonder what is the author’s opinion of ML to echo interpretation in light of his experience. Seems to me that given the variability in human skill, the partnership between machine and well trained humans could decrease the miss rate.
The variation in technician approach to the echos is likely to cause supervised learning a bit of heartache. I think it's still gonna take awhile.
I've been unable to find research on pubmed for the use of nebivolol for: "(i.e. PVCs, PACs, VT, afib)"
Could you provide a reference or two to show my electrophysiologist?
Plethora of information if you drop it into the search box at "scholar.google.com". Or ask your doc if they're familiar with it by either the generic (nebivolol) or trade (Bistolic) names. They should already be well familiar with the use of beta blockers for management of the aforementioned arrhythmias but there's a chance they feel it's inappropriate in a given case. And, I'd not go med shopping from an online article. One of the parts of the "art" of medicine is the requirement that the doc manages using the tools they're familiar with. Throwing a new drug into a mix where a patient already requiring several other therapeutic agents is potentially tricky. When you add to the mix that a given patient's response to one drug or another is not always uniform, sorting potential drug interactions is an area of concern.
Depending on who's reading, they could well be from a service that's literally paying the docs by the number of studies read and reported out. A friend who did this for several years as a radiologist had to read 20 or more studies per hour or she got dinged. It's a corporate medicine thing. I'll never understand why corporate well-being is better than adequate patient care.