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Cardionerds: A Cardiology Podcast

Cardionerds: A Cardiology Podcast

Written by: CardioNerds
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Welcome to CardioNerds, where we bring you in-depth discussions with leading experts, case reports, and updates on the latest advancements in the world of cardiology. Tune in to expand your knowledge, sharpen your skills, and become a true CardioNerd! Hygiene & Healthy Living Physical Illness & Disease Psychology Psychology & Mental Health
Episodes
  • 454. ACHD Surgery 101: Thinking Like a Surgeon with Elizabeth Stephens

    454. ACHD Surgery 101: Thinking Like a Surgeon with Elizabeth Stephens
    Jun 10 2026
    CardioNerds (Drs. Rawan Amir, Tripti Gupta, and Alysha Joseph) discuss the fundamentals of adult congenital heart disease (ACHD) surgery with Dr. Elizabeth Stephens. Audio editing by CardioNerds academy intern, Grace Qiu. Using a case of a young adult undergoing a Ross procedure, the episode walks through what happens in the operating room—from induction and intraoperative transesophageal echocardiography (TEE) to cardiopulmonary bypass (CPB), myocardial protection, and surgical repair. The discussion highlights key concepts including cardioplegia, cross-clamp and bypass times, hypothermic circulatory arrest, and the complexity of redo sternotomy. This episode provides learners with a practical framework to interpret operative reports, anticipate postoperative physiology, and better collaborate with surgical teams. This episode was produced by the CardioNerds ACHD Council and planned by Dr. Rawan Amir. CardioNerds Adult Congenital Heart Disease PageCardioNerds Episode Page Pearls “LV distension kills patients.”Preventing left ventricular distension with appropriate venting and awareness of aortic insufficiency is critical to intraoperative safety. TEE can change the surgical plan in real time.Findings such as underestimated aortic regurgitation, mitral pathology, or a PFO may directly alter cannulation and cardioplegia strategy. Cross-clamp time = myocardial ischemic time; bypass time = systemic stress.Both are key predictors of postoperative complications including renal injury, bleeding, and ventricular dysfunction. Redo sternotomy risk is driven by anatomy, not just number.Aorta adherent to the sternum, conduit position, and chamber pressurization define risk more than the number of prior surgeries. Think longitudinally—ACHD surgery is lifetime planning.Surgical materials and strategies must account for future interventions, especially in younger patients. Notes: Notes drafted by Dr. Alysha Joseph, aided by generative artificial intelligence. What are the key steps in congenital cardiac surgery from incision to closure? Preoperative planning is multidisciplinary, involving surgeon, anesthesia, cardiology, and ICU teams; high-risk inductions (e.g., critical AS, Williams syndrome) are identified earlyTEE is performed immediately after induction to reassess anatomy and may reveal new findings (e.g., underestimated AI, mitral disease, PFO)Median sternotomy is performed, followed by creation of a pericardial well to optimize exposureHeparin is administered prior to cannulation; arterial and venous cannulas are placed for initiation of CPBCross-clamp is applied and cardioplegia delivered to arrest the heart, allowing a still and protected operative fieldSurgical repair (e.g., Ross procedure) is performed, followed by de-airing, cross-clamp removal, and reperfusionPatient is weaned from bypass with TEE reassessment, hemostasis achieved, and chest closed What is cardioplegia and how is it delivered? Cardioplegia is a potassium-rich solution that arrests myocardial activity and reduces metabolic demandMost commonly used solution in the U.S. is Del Nido cardioplegia, originally developed for pediatric myocardiumDelivery strategies include: Antegrade (via aortic root) – standard approach Ostial (direct coronary delivery) – used when aortic root cannot be relied upon Retrograde (via coronary sinus) – useful in severe AI or coronary disease NOTE: Severe aortic regurgitation can impair antegrade delivery and requires alternative strategies and LV venting What do cross-clamp time and bypass time represent clinically? Cross-clamp time = duration of myocardial ischemia while the heart is arrestedBypass time = total duration on CPB, reflecting systemic exposure to non-physiologic circulationProlonged cross-clamp time (>2–3 hours) increases risk of myocardial dysfunction, especially with poor baseline functionLonger bypass time is associated with increased risk of renal injury, coagulopathy, and bleedingThese metrics often reflect both case complexity and intraoperative challenges What is hypothermic circulatory arrest (HCA) and when is it used? HCA involves complete cessation of blood flow to allow a bloodless surgical fieldTypically used in complex aortic arch repairsPatients are cooled to ~18°C to reduce metabolic demand and protect organsDuration is ideally limited to <30 minutes to minimize neurologic injuryAdjuncts include: Antegrade cerebral perfusion (ACP) – provides targeted brain perfusion Retrograde cerebral perfusion (RCP) – less effective for oxygen delivery What makes redo congenital cardiac surgery high risk? Re-entry risk depends on anatomical relationships: Aorta adherent to sternum (especially midline) poses high risk of catastrophic bleeding RVOT conduits or pressurized chambers near sternum increase injury risk Loss of peripheral vascular access from prior procedures limits bailout optionsAccumulated comorbidities (renal, hepatic dysfunction) increase ...
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    43 mins
  • 453. ACS Guidelines Question #1 with Dr. Sunil Rao

    453. ACS Guidelines Question #1 with Dr. Sunil Rao
    Jun 4 2026

    The following question refers to Section 7.1 of the 2025 ACS Guidelines.

    The question is asked by Thomas Jefferson medical student and CardioNerds Academy Intern Dr. Grace Qiu, answered first by University of Michigan fellow and CardioNerds FIT Ambassador Dr. Kayla Secrest, and then by expert faculty Dr. Sunil Rao.

    Dr. Rao is an interventional cardiologist, Professor of Medicine at NYU Grossman School of Medicine, Deputy Director of the Leon H. Charney Division of Cardiology, and the Director of Interventional Cardiology for the NYU Langone Health System. He is the Editor-in-Chief for Circulation Cardiovascular Interventions and was the Chair of the Writing Committee for the 2025 ACS Guidelines.

    This episode is part of our comprehensive Decipher the Guidelines Series covering the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes.



    Question #1

    A 68-year-old man with a history of hypertension, hyperlipidemia, stage III chronic kidney disease, and prior tobacco use presents to a local emergency department with reports of chest pain while raking leaves at home. Upon arrival, he is hemodynamically stable with a heart rate of 86 beats per minute and a blood pressure of 133/85 mmHg. His EKG reveals ST elevations in the septal and anterior leads (V1-V4). He is given 324mg of aspirin and is promptly evaluated by the interventional cardiology team, who elects to take him emergently to the catheterization lab. Upon arrival to the catheterization lab, the nurse asks the interventional fellow which access sites they should prep for this case? How should the interventional fellow respond?

    A

    Right radial artery only

    B

    Radial + bilateral femoral

    C

    Bilateral femoral only



    Answer #1

    Explanation

    The correct answer is B. Radial and bilateral femoral

    Radial artery access is the preferred vascular access site for coronary angiography and PCI in patients with ACS. Transradial access has been shown to reduce mortality, bleeding, and vascular complications compared with transfemoral access (Class I, LOE A). Radial access also allows earlier ambulation and is associated with greater patient comfort.

    Although the right radial artery is the most widely studied upper-extremity access site, alternative sites such as the ulnar and distal radial arteries have demonstrated similar outcomes.

    However, the radial artery may be required as a bypass conduit for CABG. In institutions where the radial artery is routinely used for surgical grafting, this potential future use should be considered when selecting vascular access.

    In addition, transfemoral access—preferably performed with ultrasound guidance—should be considered in patients in whom temporary mechanical circulatory support (MCS) is anticipated or in those for whom radial access is not feasible due to anatomical or technical constraints. Prepping bilateral groins in addition to the radial artery provides a backup strategy for urgent MCS placement or for transition to femoral access should radial access fail.

    For these reasons, prepping both the radial artery and bilateral groins is the most appropriate response.

    Radial-only preparation is incorrect because, although radial access is preferred, patients with STEMI may still require emergent MCS or alternative access if the radial artery is unsuitable. Preparing only the wrist without backup femoral access may delay care should hemodynamic instability occur.

    Femoral-only preparation is incorrect because transradial access provides superior outcomes in ACS, including significant reductions in all-cause mortality, major bleeding, and vascular complications. RCTs and meta-analyses, including MATRIX (which showed lower MACE and net adverse clinical events with radial access) and SAFARI-STEMI (which showed no difference in mortality but was underpowered)—support radial as first-line access when feasible.

    Main Takeaway

    For patients with ACS undergoing PCI, radial access is strongly preferred to reduce mortality, bleeding, and vascular complications.

    Guideline Loc.

    Section 7.1
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    10 mins
  • 452. Risk stratification in Acute Pulmonary Embolism with Dr. Stavros Konstantinides

    452. Risk stratification in Acute Pulmonary Embolism with Dr. Stavros Konstantinides
    Jun 1 2026
    CardioNerds (Dr. Billy-Joe Mullinax, Dr. Dinu Balanescu, and Dr. Jane Ehret) discuss risk stratification in acute pulmonary embolism with Dr. Stavros Konstantinides, Chair of the 2019 ESC Pulmonary Embolism Guidelines. Using a real-world case, this episode explores how modern PE care has moved beyond “massive” and “submassive” labels toward a dynamic, physiology-based approach. The discussion highlights the limitations of static risk scores, the importance of right ventricular dysfunction and biomarkers, and why normotension does not imply stability. Special emphasis is placed on intermediate-high risk PE, early identification of impending hemodynamic collapse, and the role of lactate, serial reassessment, and PERT teams in guiding escalation of care. Audio editing by CardioNerds intern, Joshua Khorsandi.The 2026 American multi-society PE guidelines were published after this episode was recorded. Dr. Dinu Balanescu and Dr. Billy-Joe Mullinax are Co-chairs for the CardioNerds PE Series, developed in collaboration with the PERT Consortium. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. CardioNerds Pulmonary Embolism PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls Stable blood pressure does not mean low risk in PEHypotension is a late finding. Patients may have severe RV failure, hypoxia, and tissue hypoperfusion while remaining normotensive — a key concept behind “normotensive shock.”Risk stratification in PE must be dynamic, not staticLegacy scores like PESI and Bova provide a snapshot and predict 30-day mortality, but they do not capture short-term trajectory or impending hemodynamic collapse.Intermediate-high risk PE is a dangerous and heterogeneous groupPatients with RV dysfunction, positive biomarkers, tachycardia, hypoxemia, and elevated lactate may have in-hospital mortality approaching 15%, rivaling STEMI.Lactate is a critical but underutilized marker in PEElevated lactate reflects tissue hypoxia and early circulatory failure and may identify patients at risk for collapse before blood pressure declines.PERT enables physiology-driven, patient-centered PE carePERT teams operationalize continuous reassessment, integrate imaging, labs, and clinical trajectory, and allow timely escalation — shifting PE management from rigid categories to real-time decision-making. Notes Drafted by Dr. Jane Ehret. 1. What is the contemporary framework for risk stratification in acute pulmonary embolism? Modern PE risk stratification prioritizes hemodynamics and right ventricular (RV) function rather than clot burden.The 2019 ESC Guidelines classify PE into high risk, intermediate risk (low vs high), and low risk, based on: Hemodynamic status, RV dysfunction on imaging, and Cardiac biomarkers.This framework emphasizes early mortality risk but requires clinical context to guide escalation decisions. 2. Why is normotension insufficient to define “stability” in PE? Blood pressure is a late marker of circulatory failure in PE.Patients can maintain normal BP through Tachycardia, Increased sympathetic tone, and RV compensation.Many patients with preserved BP may already have shock physiology, including hypoxemia, elevated lactate, and RV failure — sometimes referred to as “normotensive shock.” 3. How should intermediate-risk PE be conceptualized clinically? Intermediate-risk PE is heterogeneous, ranging from patients who do well on anticoagulation to those who deteriorate rapidly.Intermediate-high risk PE is defined by RV dysfunction on imaging and positive cardiac biomarkers.Clinical features such as tachycardia, increasing oxygen requirement, and elevated lactate identify patients at highest risk within this group. 4. What are the strengths and limitations of commonly used PE risk scores? Legacy scores are useful for initial risk categorization but are static and limited in predicting short-term deterioration.Most scores were developed to predict mortality or complications at fixed time points rather than dynamic clinical trajectory. 5. What are the commonly used risk scores and clinical tools in PE, and what is each designed to predict? ESC Risk Stratification Algorithm: Identifies high-risk PE by hemodynamics. Uses PESI or sPESI in normotensive patients to distinguish low-risk from non–low-risk PE. Uses RV dysfunction and biomarkers to differentiate intermediate-low from intermediate-high risk. Forms the basis of many institutional PE pathways.PESI and sPESI: Validated to predict 30-day mortality. Widely used to identify low-risk patients appropriate for outpatient management. Heavily influenced by age and comorbidities.Bova Score: Predicts 30-day PE-related complications in normotensive patients.Composite PE Shock Score (CPES): Predicts normotensive shock in ...
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    26 mins
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