Musa A. Sharkawi
@MusaSharkawiMD
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Interventional & Structural Cardiologist | @Brighamwomens trained | @RCSI_Irl Alumnus | Opinions are my own 🍉
Georgia, USA
Joined June 2016
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New account! Unfortunately, my old account
@MusaSharkawi
was hacked last year the day my son was born and I lost access to it (probably a good thing!). Here's a pic of Baby Shark Yousef to kick off this new account.
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Anything to say
#MedTwitter
? This isn’t worthy of outrage or even just empathy?
Dr Hamam Allouh, a specialist in Nephrology, was killed along with his family by an Israeli airstrike on their home. When last asked why he doesn’t evacuate he replied: "Who will treat the patients? I didn't study medicine for years to think about my life and leave the patients."
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Challenging case:
Young patient with recent viral prodrome. Came in extremely sick, EF 5%, BP 80’s/60’s. Somnolent, cold extremities. PH 7.01, Lactic acid 16, Trop 0.6.
Recurrent cardiac/PEA arrest, intubated. Unable to transport to Cath Lab.
#ACCFIT
@MCGCardFellows
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Tough case: AMI cardiogenic shock. Poor LV function, severe AS.
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Step-by-step tweetorial on percutaneous post-infarct VSD closure. Late presenting inferior MI.
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Here are some important interventional cardiology algorithms I've compiled over the past couple of years. The good IC/CTO operator always knows what the next step is. Major credit to
@esbrilakis
for many of these algorithms. Must think systematically about every PCI. 1/
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After 5 years away from family due to the travel ban and the COVID-19 pandemic, flight home to Jordan is booked!
#ImmigrantDocs
#Vaccination
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Gratifying when patients feel so much better. High risk submassive PE. Tachypnic and breathless at rest. PAs 59->38 mmHg. Off O2, tachycardia gone.
#PERT
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Walking to a cath lab room to do a mitral ViV replacement and casually see this cine in the room next door.
@BrianBergmark
@kevinjamescroce
@PinakShahMD
@benpeterson71
@BrighamFellows
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Snare-assisted Evolut crossing. Aneurusmal root, horizental aorta.
Pre-snared prior to crossing.
#ACCFIT
@MCGCardFellows
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Another trick to help cross a bioprosthesis during TAVR: Use a deflection balloon/buddy wire and bump into the Evolut FX system. A 10mm Mustang can be placed through the standard 6Fr sheath.
@MCGCardFellows
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1/ Watching daily atrocities on kids, I’m remembering my childhood best friend and cancer ward roommate, Sasha.
He was a Jewish kid, I was Palestinian. Our moms became really close - Sasha’s mom ran to mine for consolation when he died. I still remember that hug and their tears.
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Airport Tweet: It’s been a wonderful two years
@BrighamWomens
. I am very proud to have made great friends here along the way. Will miss you all.
@PinakShahMD
@TsuyoshiKaneko1
@MorganHarloff
@DLBHATTMD
@kevinjamescroce
@RonnieRamadan
@benpeterson71
@Ajar_Kochar
@BrighamFellows
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New titles. Very grateful for my family’s encouragement and the support of current and prior partners and mentors. Thank you all.
@MCGCardFellows
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Tough case: young pt, some weeks post-op ortho sx p/w severe dyspnea, tachypnea, tachycardia, hypoxia SBP 90s. Large burden clot/PE on CT. Asked to consider CDT then we put a probe on their chest: thoughts?
#ACCFIT
#MedEd
#FOAMed
#CardioTwitter
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MRSA Endocarditis - Vegetation on Micra device extending into the RVOT. Management shown below.
#ACCFIT
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Etiology of stent thrombosis? Before and after treatment.
We must image 100% of the time.
#ACCFIT
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Severe ISR of a single underexpanded LCx stent. In-stent NIH and peri-stent calcium. Management?
#ACCFIT
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Today, my mother’s cousin along with 8 of her other cousin’s grandchildren were killed in an Israeli air strike where they were sheltering in Southern Gaza (Rafah).
Their whole neighborhood in Rimal, northern Gaza was razed to the ground.
War crimes must stop. Ceasefire now.
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First BASILICA in Augusta, GA. Big thanks to colleagues who were happy to chat and share their experiences:
@RonnieRamadan
@raleonardi1
@PinakShahMD
@AdamGreenbaumMD
This is how to democratize the field.
@MCGCardFellows
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Middle-aged pt p/w stable exertions angina on med therapy. Strong fam hx of CAD. Positive ETT. Referred for angiography. What’s the next step? Poll below.
#ACCFIT
#Cardiotwitter
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Young patient p/w salvos torsades de pointe QTc 580. TTE once stablized showed the remarkable findings below. No prior malignancy.
#ACCFIT
#echofirst
@onco_cardiology
@FilipeAMoura
@mirvatalasnag
@heartdoc45
@DavidWienerMD
@purviparwani
@SaurabhSDani
@DrNasrien
@DocStrom
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Pt with critical PVD transferred for high risk PCI. Calcified LM, LCx ACS, RCA CTO, low EF, MR, now stable on heparin.
@MCGCardFellows
#ACCFIT
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Challenging pci. Subtotally occluded RCA with bridging collaterals - extreme calcification. The beauty of algorithmic approach to complex PCI.
@MCGCardFellows
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Improvement until ECMO decannulation, impella removal and discharge home.
Take home:
1- TEE invaluable in guiding ECPR
2- Severe pulmonary circulation stasis of flow can occur with VA ECMO/severe Bi-vent failure and can be alleviated by CPR and eventual LV unloading.
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Moderate to severe AS, came in with dyspnea and CHF. LVEF 45%. Left dominant system. Ostium of the LCx spared (also seen on recent TAVR CT).
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Pt with dyspnea and hemolysis. Prior MVR (29mm Mosiac), no IE.
Some small technical variations in mitral PVL closure we’ve incorporated below.
@MCGCardFellows
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For all us immigrants, the news of the FDA issuing emergency use authorization for Pfizer/BioNTech Covid-19 vaccine is a step closer for us finally visiting our families back home.
Caption: Spring time hike in Jordan and wild pomegranate tree blossoms (2014).
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Difficulty delivering Evolut - Getting caught on bioprosthesis frame.
Tried Lunde, buddy wire, wire manipulation/delivery system torque. Finally snared Lunde from LV using contralateral femoral access and used it to deliver the valve.
#cathlabhacks
#ACCFIT
#SCAIFIT
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Recurrent multilayer stent ISR. I use these challenging cases as an excuse to catch up with
@kevinjamescroce
@MCGCardFellows
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Sick patient- New EF 25%, severe pulmonary edema, calcific left main/LAD disease.
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Middle aged male p/w mild chest pain and back pain. Chest pain resolves with a nitro. Persistent back pain. Xray/HR/bilateral BP normal.
@smithECGBlog
@Dr_OkeefeECG
@ShariqShamimMD
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Acute limb ischemia- Antegrade access, single run of CAT 6 embolectomy with residual atherosclerotic stenosis s/p POBA only result. Good flow.
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Final result. Instantaneously off pressors, improvement in hemodynamics, resolution of symptoms and home soon after. Are others also seeing a big wave of PE patients?
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When you are waiting for a CCU bed to open up for your cath lab patient at night.
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Cardiogenic shock due to wide open mitral PVL ~1/3 valve circumference. Stabilized with IABP and brought for PVL closure.
@MCGCardFellows
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#TipsForNewDocs
Patient comes to the ED with dizziness and dyspnea. Sometimes you must treat before waiting for “documented” labs. K 8.8, new acute kidney injury.
#ACCFIT
#FOAMed
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CTO more calcified than expected. Prior failed attempt. AWE.
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There’s nothing like seeing cardiogenic shock, cardiac arrest and sick STEMI patients in clinic follow-up.
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Another war crime committed by Israel on my Family in Gaza.
Today, my second cousin, Ahmed, was killed along with his very young daughter and his mother in law. They were bombed in their refugee camp.
These daily war crimes should come to an end..
#SilenceIsComplicity
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#TAVR
peeps: Elderly patient, absolutely not surgical, with the anatomy below. How would you approach? Annular area: 450 mm2.
@djc795
@ekgpdx
@adnanalkhouli
@HarshGMD
@mhammadah
@AlkashkariWail
@BGalperMD
@MSampleMD
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Older stable patient. Is it acceptable to do isolated ostial LM PCI ad hoc?
Nitro and IVUS. It’s real.
@MCGCardFellows
@mmamas1973
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Late-presenting degenerative severe AI, patient comes in with ambulatory cardiogenic shock (CI 1.4). No surgical option. Bailout TAVR.
@MCGCardFellows
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3D TEE can also help you know which leak was entered.
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STEMI activation. Pleuritic chest pain with pericarditis like ECG.
Diagnosis: pneumopericardium from a malignant esophago-pericardial fistula.
@MCGCardFellows
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Patient w/borderline shock, critical AS MG 58, EF 10% and the annulus below. No surgical option, so proceeded with TAVR BEV.
@MCGCardFellows
@Deya_AlkhatibMD
@aroravis
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Unexpected challenge.. pt with severe AS, ACS, severe cardiomyopathy and hypotension.
Rota LAD, IVUS, PCI. Didn’t wire the large diag.. thread.
#ACCFIT
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Older gentleman, Critical AS MG 50 mmHg, EF 30%, NSTEMI, HF. A common scenario in our region.
@MCGCardFellows
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Cause of stent thrombosis?
When will IC imaging in PCI be class I indication in our guidelines?
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Almost classic platypnea-orthodeoxia in a young patient. Low level unexplained hypoxia and significant right to left shunting.
#ACCFIT
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Elderly pt p/w progressive dyspnea over many months found to have severe AS. Afebrile. What’s that structure in the LVOT? High surgical risk- how would you treat?
#ACCFIT
#CardioTwitter
#EchoFirst
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How would you evaluate/treat this RCA lesion? Older patient w/ anterior STEMI, LAD culprit + critical LCx nonculprit PCI during index procedure.
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Happy Father’s Day to this selfless kind man from Jaffa who literally fought to save my life and has always been an amazing role model. I can’t say enough to thank you for everything.
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Pt w/ ischemic CM, stable for years, now NSTEMI and quite ill. Ostial LAD thrombotic lesion & distal LM stenosis. Co-dominant.
#ACCFIT
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Hazy distal left main lesion in a patient with NSTEMI. Remarkable IVUS images below. How would you manage?
#ACCFIT
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RCA STEMI pt went to CCU then did this as we were walking out of the hospital (not sure why/how ECG was obtained...).
TVP @ bedside. Rhythm back the next morning, eventually home without a PPM.
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Major clinical improvement. MG 4 mmHg. EF normalized.
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Challenging mitral case. Elderly patient with prior MVr w/ 30mm Geoform ring now dehiscence and severe MR. Thread below on how we tackled this case.
@MCGCardFellows
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Challenging pericardiocentesis. No subxiphoid or Apical windows. Went parasternal. Ultrasound skills valuable to develop.
#ACCFIT
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Can you help with the last case? It’s “just” a diagnostic right and left.
Chronic “hypotension” and cardiomyopathy.
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Extremely proud of the cardiac team
@AUG_University
@AUG_Health
for taking care of this wonderful young man and his family.
@MCGCardFellows
@EvanHinerMD
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Flail bioprosthetic mitral leaflet w/ torrential MR treated with MVIV. Patients feel LA pressure.
Successful hemodynamic result = key in structural heart procedures.
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How much PCI is too much in one sitting? Sick patient, low EF, surgical turndown. IABP and 85 cc contrast. More below.
@MCGCardFellows
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Inferior STEMI, CHB/asystole, cardiac arrest(s), cardiogenic shock. Swift work by all involved -> pt walking the halls a few days later.
#ACCFIT
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NSTEMI. SVG to RCA culprit, stented elsewhere a few months ago. Native angio below.
@MCGCardFellows
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Tunneled HD line with persistent staph bacteremia. SVC almost occluded - Vegetation/thrombus. Learning these can be managed with minimalist approach.
@MCGCardFellows
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What’s going on here? (Going from LAO to RAO).
Congenital absence of pericardium and excessive cardiac levoposition (significant lateral/posterior rotation).
It can be associated with bicuspid AV as in this case. Also had a dilated aorta - used a MP to engage.
@MCGCardFellows
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A couple of years post mitral ViV & ASD closure.
This was seen incidentally on a “routine” TTE. Likely thrombus. No IE. How to manage? Poll below.
@MCGCardFellows
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2/ For the sake of Sasha’s memory and the 9000+ children killed in Gaza in recent weeks… for the sake of humanity, Ceasefire Now.
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Should take all large bore access out in the lab for the reason below.
Pre-closed impella in setting of shock. Dissection/closure despite breaking perclose suture. MP sheath picture after rewiring perclose.
#ACCFIT
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We now have an IC fellowship position opening
@MCG_AUG
@MCGCardFellows
for July 1, 2023. Any interested fellows should submit enquiries to our program coordinator saritchie
@augusta
.edu.
@aroravis
@KimAtianzar
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Final note: For rare and complex structural/interventional procedures, it is always good to keep step-by-step notes for future reference.
#ACCFIT
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TAVR in an older patient with bifasicular block and a shelf of calcium down the LVOT.
Risk of PVL and pacemaker.
Aimed for zero height but must deploy very slowly a la pure AI.
@MCGCardFellows
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@mandeep_mayo
Have had good success with using a polymer jacketed wire with a double “JL”-like bend for such cases. Figure D below.
Good suggestions by others on this thread.
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An MCS option in treating patients with biventricular failure: Tandem LVAD + Protek Duo.
Pros: Excellent support (~4-4.5L/min), unloads LV, perhaps less hemolysis.
Cons: Large fem catheters (needs antegrade perfusion), position sensitive, takes a bit longer to place.
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NSTEMI/ISR and what appeared to be significant difficulty with prior pci in a tortuous LCx.
8 Fr 45 cm sheath, 8 Fr EBU 4.0, 8 Fr guideliner from the beginning made relatively easy work of this for our fellow.
#ACCFIT
@MCGCardFellows
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Severe dog boning of a 3.5 NC balloon at 24 atm at this lesion after rota with a 1.75 burr. Next step?
#ACCFIT
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A friendly reminder:
Don't try patent hemostasis with ulnar access closure. It is a deeper artery than
#radialfirst
and more likely to bleed subQ. I put in at least 15cc in the TR band as
@ImmadSadiq
taught me.
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Challenging AS case: Relatively young pt, "extreme" obesity, subacute dyspnea over 1 year + NYHA IV, TTE EF 15%, MG 35, DI 0.11, AVA 0.4, LV thrombus. Clean cors, PCWP 37, CI 1.3, borderline HD requiring dobutamine. CTA bicuspid calcium score 2900, annular Ca. High risk for Sx.
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Stumbled upon old notes from the days of studying for echo boards. That exam was quite the challenge.
@MCGCardFellows
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