Benigno Valderrábano Salas

It’s well known that there is a certain delay between electrical activity and a mechanical phenomenon at the myocardial level. However, the temporal relationship between myocardial electrical activity and venous return flow has never been studied, so we will probably see these discrepancies between the Doppler spectrum of venous flow and the ECG. But it is only a theory; there is no evidence.

I know the S wave seems to start before the QRS complex. But it's not the first time I've observed that. I don't have an explanation for this discrepancy between the Doppler spectrum and the electrical activity recorded on the ECG. They're probably temporally related phenomena, but not occurring simultaneously. 🤷🏻‍♂️

It may also be difficult with EKG.

Fellows, what does this layer of jets in the 4C view tell you? @ASE360 @escardio #echofirst @ACCinTouch #ACCEarlyCareer

Continuous-wave Doppler interrogation in valvular heart disease: pearls and pitfalls | European Heart Journal - Imaging Methods and Practice | Oxford Academic academic.oup.com/ehjimp/advance…

What is best formula to estimate mPAP on #echofirst? 📝 finds minimal end-diastolic PR pressure best correlation (R = 0.92) & diagnostic accuracy AUC 0.96 bit.ly/4nQrzvm in almost 600 pts referred for RHC for PH dx, integrates both PR & TR signals At 24.5 mm Hg cutoff, mPAPDPmin 89% sensitivity, 94% specificity At 20 mm Hg, mPAPDPmin sensitivity⬆️99% w/ net reclassification driven by more accurate downgrading of pts w/o PH

ASE and the @accpchest recently partnered on a project to develop two educational webinars to improve the understanding of cardiovascular ultrasound's application in pulmonary hypertension. You can find them on our #new Right Heart Resources web page! bit.ly/4nQ5E7p

Very interesting image of IVC! Any guesses on what the red flow is? (clue: congenital anomaly) - See thread for source/full case. #POCUS #echofirst #FOAMed

@ISICEM Critical Care Input Early vasopressin administration in septic shock: A systematic review, meta-analysis, and multicenter retrospective observational study sciencedirect.com/science/articl… #ISICEMelearning #Meded @Sciencedirect

#JADEL I hope you enjoy reading my CASE editorial: Blow Hard! cvcasejournal.com/article/S2468-… I discuss Antonio Maria Valsalva, the complex physiology of the Valsalva maneuver, & include a link to learn about goal-directed methods: youtu.be/MAbId_9dUgU?li… @CASEfromASE @ASE360

🫀In cardiogenic shock, we still focus heavily on MACROcirculation: 📉 blood pressure 📉 cardiac output 📉 LVEF 📉 vasopressor dose But what if the real battle is happening deeper? 🩸 At the microcirculatory level. This excellent ATS viewpoint highlights one of the most important evolving concepts in shock physiology: ⚠️ normalization of macrocirculation does not necessarily mean restoration of tissue perfusion. Despite advances in cardiogenic shock management, mortality remains >40%. Even more striking, up to 45% of deaths occur in patients with normalized cardiac index. That disconnect may be explained by persistent: 🩸 microvascular dysfunction 🩸 impaired capillary perfusion 🩸 endothelial dysfunction 🩸 tissue hypoxia despite “acceptable” hemodynamics The review reinforces that: Microcirculation is not a passive bystander. It may be a central driver of: • organ dysfunction • lactate persistence • shock progression • mortality Particularly interesting is the emphasis on simple bedside tools. We often think microcirculation requires advanced devices, yet: 📌 capillary refill time (CRT) 📌 mottling 📌 ΔPCO₂ 📌 lactate trends still carry strong prognostic value. A CRT >3 seconds at ICU admission was associated with worse outcomes, and combining CRT with the CardShock score achieved an impressive AUC of 0.93 for outcome prediction. The article also reviews modern technologies: 🔬 handheld vital microscopy 🔬 sublingual microcirculation imaging 🔬 NIRS 🔬 laser Doppler assessment bringing “real time” bedside microcirculatory monitoring closer to clinical practice. One of the strongest physiological messages: ⚠️ Shock is not only about flow. It is about effective tissue level oxygen delivery. The review beautifully summarizes the four major mechanisms of microvascular dysfunction: • heterogeneity • hemodilution • congestion • edema Particularly relevant for intensivists: 📌 venous congestion itself may worsen microvascular flow 📌 elevated filling pressures impair driving pressure 📌 edema increases oxygen diffusion distance This is highly relevant in: • advanced heart failure • VA ECMO • mixed shock states • fluid overloaded patients Another important takeaway: Persistent microcirculatory dysfunction after VA ECMO initiation was associated with increased mortality, even when macrocirculation improved. Perhaps the key message of this paper is: 🩸 Microcirculation should no longer be considered a secondary endpoint in cardiogenic shock. It may become one of the most important physiological targets of the next decade. 📖 Merdji H, American Journal of Respiratory and Critical Care Medicine. 2026, 212(3), 410–413 doi.org/10.1093/ajrccm….

Unexplained dyspnea? Here’s the new ESC framework for diagnosing HFpEF — and it goes way beyond a basic echo 🧵 From Landsteiner et al., Eur Heart J 2026, a stepwise domain-based approach

Pulmonary embolism management just changed dramatically. The new 2026 AHA/ACC Multisociety PE Guideline introduces: • A completely new PE classification system • Stronger role for PERT teams • More clarity on thrombectomy/thrombolysis • Early discharge for selected patients • Long term follow up recommendations This is probably the biggest PE guideline shift in years.

Coronary slow flow is not diagnostic of microvascular dysfunction in patients with angina and unobstructed coronary arteries. Coronary physiology interrogation has debunked one of the fallacies of the last decades.

#JADEL New in @CASEfromASE Some CASE reports are able to change clinical practice through their educational message: doi.org/10.1016/j.case… Check out this 52yo woman with embolic stroke from unknown source. Remember, not all shunts are PFOs. 😜🤪😃 #NowInScopus @ASE360

📌Ventricular free-wall rupture, ventricular pseudoaneurysm & papillary muscle rupture complicating acute myocardial infarction A clinical consensus statement of the @escardio & @EACTS #PositionPaper #MechanicalComplications #MI

An intriguing spectral Doppler pattern. A patient with normal biventricular size and function. CW Doppler interrogation across the tricuspid valve in 4 chamber view is shown, consistently yields systolic diastolic flow. Whats are possible explanation?

📄 Hypertension-related LVH: not all phenotypes carry the same risk 🔗 DOI: doi.org/10.1093/ehjimp… 🫀 Hypertension is the most common cause of LV hypertrophy—but its cardiac expression is far from uniform. This large UK Biobank CMR study (n >24,000) provides a comprehensive look at LVH phenotypes and their prognostic impact. ✨ Four CMR-defined phenotypes: 👉 Normal LV 👉 LV remodelling 👉 Eccentric LVH 👉 Concentric LVH 📊 As shown in the graphical abstract (page 2): ➡️ each phenotype has distinct structural and functional signatures ✨ Key findings: 🔹 Eccentric LVH = worst phenotype ➡️ Most impaired LV function (EF + strain) ➡️ Largest chambers ➡️ Highest risk: MACE → HR 2.5 Heart failure → HR 9.0 🔹 Concentric LVH: ➡️ Highest wall thickness and native T1 (fibrosis) ➡️ ↑ Heart failure risk (HR 4.1) ➡️ No significant MACE association 🔹 LV remodelling: ➡️ Intermediate phenotype ➡️ Smaller chambers, milder changes 📊 Key pathophysiological insight: 👉 LVH is not a binary condition—but a spectrum of myocardial adaptation ➡️ From remodelling → concentric or eccentric hypertrophy ➡️ Driven by pressure load, volume load, and myocardial response 💡 Clinical take-home message: 👉 Not all LVH is equal ✔ Eccentric LVH → high-risk phenotype ✔ Concentric LVH → fibrotic, HF-prone phenotype 👉 CMR enables: precise phenotyping improved risk stratification potential tailored treatment strategies 🚨 Bottom line: In hypertension, LV geometry matters—because different phenotypes carry very different prognoses. #Cardiology #CMR #Hypertension #LVH #CardiacImaging #HeartFailure #RiskStratification #PrecisionMedicine #UKBiobank 🫀📊

Surgical anatomy of the #Ao_root doi.org/10.1016/j.jtcv… Surgical math of #Ao _root doi.org/10.1016/j.jtcv…