Thursday, December 4, 2014

Do Vertebral Fractures Predict Cardiovascular Events?

QUESTION: can the presence of vertebral fractures on chest CT help predict cardiovascular events?

METHODS: case-cohort design looking at 5,679 patients undergoing chest CT. Follow-up was for a median duration of 4.4 years. Cases were defined as patients who subsequently developed a cardiovascular event (n = 493).

RESULTS: Cases were more likely to be older males. Prevalent vertebral fractures increased the risk of a cardiovascular event by about 30%.

CONCLUSION: Prevalent vertebral fractures on routine clinical chest CT are related to future cardiovascular events but do not have additional prognostic value to models that already include age, gender and cardiovascular calcifications.

COMMENT: routine chest CT scans do not provide a coronary artery calcium score. This study may help risk stratify patients when the CAC isn't available.

Int J Cardiovasc Imaging. 2014 Dec 2;

Screening for AAA During TTE

Effectiveness of screening for abdominal aortic aneurysm during echocardiography.
This study found that screening for abdominal aortic aneurysm (AP diameter > 30 mm) during transthoracic echocardiography took very little time, but that it should be limited to men ≥65 years and women≥75 years.



Am J Cardiol. 2014 Oct 1;114(7):1100-4

Reliability of Carotid MRI

QUESTION: are carotid MRI's reproducible from imaging center to imaging center?

METHODS: A standardized protocol was implemented at 16 imaging sites and multiple quantitative measurements obtained.

RESULTS: Good to excellent reproducibility was observed.

IMPLICATION:  serial MRIs performed at different imaging centers appear to be reliable in monitoring the progression of carotid atherosclerotic plaques.

Int J Cardiovasc Imaging. 2014 Sep 13;

Monday, November 10, 2014

Can cardiac MRI accurately evaluate mitral valve stenoses?


The evaluation of mitral valve stenosis: comparison of transthoracic echocardiography and cardiac magnetic resonance.
BACKGROUND: transthoracic echocardiography (TTE) is commonly utilized to asses patients with mitral valve stenosis. Can MRI perform as well?

METHODS: Thirty-one patients with isolated mitral stenosis were included. All patients were in sinus rhythm. Planimetric mitral valve area and diastolic velocities were measured with TTE and cardiac magnetic resonance (CMR) imaging.

RESULTS: TTE and CMR results were strongly correlated.

CONCLUSION: CMR is as reliable as TTE in selected patients with mitral stenosis.

COMMENT: there were several criteria for exclusion from this study, including atrial fibrillation. These results clearly remain exploratory and not proven.

Eur Heart J Cardiovasc Imaging. 2014 Feb;15(2):164-9

Wednesday, October 22, 2014

Can CT angiography accurately quantify coronary artery calcification?


Quantifying coronary artery calcification from a contrast-enhanced cardiac computed tomography angiography study.
BACKGROUND: Cardiac computed tomography angiography (CCTA) is used for the assessment of coronary artery stenoses, whereas non-contrast ECG-gated computed tomography is commonly performed to quantify coronary artery calcium (CAC).

METHODS: a review was done of patients who underwent both non-contrast CT and CCTA.

RESULTS: 92 patients were identified. Correlation between non-contrast CT and CCTA was excellent (r = 0.96) for CAC scoring.

CONCLUSIONS: Quantification of CAC from a single contrast-enhanced CCTA scan is feasible and correlates well with non-contrast ECG-gated CT.

Eur Heart J Cardiovasc Imaging. 2014 Feb;15(2):210-5

Friday, October 17, 2014

Point of Care Ultrasonography vs Formal Echocardiography

BACKGROUND: Frequently, hospitalized patients are referred for transthoracic echocardiograms. The availability of a pocket mobile echocardiography device that can be incorporated on bedside rounds may be a useful and frugal alternative.
METHODS: This was a cross-sectional study designed to compare the accuracy of pocket mobile echocardiography images with those acquired by transthoracic echocardiography in a sample of hospitalized patients. Each patient referred for echocardiography underwent pocket mobile echocardiography acquisition and interpretation by a senior cardiology fellow with level II training in echocardiography. Subsequently, transthoracic echocardiography was performed by skilled ultrasonographers and interpreted by experienced echocardiographers. Both groups were blinded to the results of the alternative imaging modality. Visualizability and accuracy for all key echocardiographic parameters (ejection fraction, wall motion abnormalities, left ventricular end-diastolic dimension, inferior vena cava size, aortic and mitral valve pathology, and pericardial effusion) were determined and compared between imaging modalities.
RESULTS: A total of 240 hospitalized patients underwent echocardiography with pocket mobile echocardiography and transthoracic echocardiography. The mean age was 71 ± 17 years. Pocket mobile echocardiography imaging time was 6.3 ± 1.5 minutes. Sensitivity of pocket mobile echocardiography varied by parameter and was highest for aortic stenosis (97%) and lowest for aortic insufficiency (76%). Specificity also varied by parameter and was highest for mitral regurgitation (100%) and lowest for left ventricular ejection fraction (92%). Equivalence testing revealed the pocket mobile echocardiography outcomes to be significantly equivalent to the transthoracic echocardiography outcomes with no discernible differences in image quality between pocket mobile echocardiography and transthoracic echocardiography (P = 7.22 × 10(-7)). All outcomes remain significant after correcting for multiple testing using the false discovery rate.
CONCLUSIONS: The results from rapid bedside pocket mobile echocardiography examinations performed by experienced cardiology fellows compared favorably with those from formal transthoracic echocardiography studies. For hospitalized patients, this finding could shift the burden of performing and interpreting the echocardiogram to the examining physician and reduce the number and cost associated with formal echocardiography studies.


Am J Med. 2014 Jul;127(7):669.e1-7

Wednesday, April 30, 2014

Association of conventional risk factors for cardiovascular disease with IMT in middle-aged and elderly Chinese.


Association of conventional risk factors for cardiovascular disease with IMT in middle-aged and elderly Chinese.
Int J Cardiovasc Imaging. 2014 Mar 14;
Authors: Wang HM, Chen TC, Jiang SQ, Liu YJ, Tian JW

To study the association between known risk factors for cardiovascular disease and intima-media thickness (IMT) in the carotid and popliteal arteries in middle-aged and elderly Chinese adults. 686 middle aged and elderly Chinese adults from the China Da Qing Diabetes Prevention Study who had full clinical, laboratory, ultrasound examination results were enrolled in the study. Common carotid artery (CCA) and popliteal artery (PA) IMT were obtained using high resolution ultrasound machine. Pearson's or Spearman's correlation analysis and logistic regression analysis were used to determine association between risk factors [age, gender, tobacco smoking, body mass index (BMI), diabetes mellitus (DM), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, total triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, glycosylated hemoglobin (HbA1c)] and CCA- or PA-IMT. The age range of the study population was 45-87 years, 384 of them (56 %) were women. The prevalence of high blood pressure and DM was 60.6 and 68.8 %, respectively. Participants in DM group tended to be older, had greater value for SBP, HbA1c and PA-IMT, but smaller value for DBP than those in control group. Smoke status, BMI, blood lipids and CCA-IMT were not statistically different between groups. Pearson's or Spearman's rank correlation analysis showed that CCA-IMT had a positive correlation with age, gender, DM, SBP, BMI and HbA1c, negative correlation with HDL-C. PA-IMT showed a positive correlation with age, gender and SBP. Univariate logistic regression analysis showed that elevation of age, SBP, BMI, HbA1c and having DM were significant predictors of CCA-IMT thickening, so was reduction of HDL-C. Risk factors that predicted significant thickening of PA-IMT were age, gender, tobacco smoking. After adjusted for age and gender, except HDL-C, the other four risk factors (SBP, BMI, HbA1c and having DM) that predicted CCA-IMT thickening remained significant; however! none of the risk factors predicted PA-IMT thickening after adjusted for age and gender. The current results provide evidence that CCA-IMT is a superior marker for atherosclerosis compared with PA-IMT. Aggressive control of SBP, HbA1c and proper control of weight may postpone thickening of CCA-IMT.

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Friday, March 28, 2014

4D-Cine CT imaging of a bicuspid pulmonary valve.

A 71-year-old woman underwent diagnostic workup for progressive shortness of breath. Transthoracic echocardiography showed a dilated main pulmonary artery (MPA) and an anomalous configuration of the pulmonary valve. CT revealed a bicuspid pulmonary valve (BPV) and confirmed MPA dilation. Further congenital abnormalities were excluded. An isolated finding of BPV is rather rare. To our knowledge we present the first 4-dimensional CT images of a BPV. As in this case, 4-dimensional cine cardiac CT may be helpful to reveal the underlying cause of MPA dilation.


J Cardiovasc Comput Tomogr. 2014 Mar-Apr;8(2):170-1

Wednesday, March 19, 2014

Echocardiographic Diagnosis of Constrictive Pericarditis

BACKGROUND: Constrictive pericarditis is a potentially reversible cause of heart failure. The differential diagnosis includes restrictive myocardial disease and severe tricuspid regurgitation.

HYPOTHESIS: Echocardiography is helpful in the diagnosis of constrictive pericarditis

METHODS: Patients with surgically-confirmed constrictive pericarditis were compared to patients with restrictive myocardial disease or severe tricuspid regurgitation.

RESULTS: Three variables were independently associated with constrictive pericarditis: 1) ventricular septal shift, 2) medial mitral e' ; and 3) hepatic vein expiratory diastolic reversal ratio.

CONCLUSIONS: Echocardiography is helpful in the diagnosis of constrictive pericarditis.

Circ Cardiovasc Imaging. 2014 Mar 14

Monday, March 17, 2014

The clinical significance and management of patients with incomplete coronary angiography and the value of additional computed tomography coronary angiography.

HYPOTHESIS: coronary computed tomography angiography (CTA) is useful for patients with incomplete invasive coronary angiography (ICA).

METHODS: consecutive patients referred for coronary CTA after ICA, which did not visualize at least one native coronary artery or by-pass graft.

RESULTS: ICA did not identify by-pass grafts in 2% and did not identify native coronary artery in 0.2 % of cases. The explanations for an incomplete ICA included ostium anomalies, left main spasms, access site problems, ascending aorta aneurysms, and tortuous take-off of a subclavian artery. After coronary CTA, revascularization was found to be indicated in 24 % of ICA patients.

CONCLUSION: Incomplete coronary angiography is a rare, but significant clinical problem. Coronary CTA provides important clinical information in these patients.

Int J Cardiovasc Imaging. 2014 Mar 13

Friday, March 14, 2014

Advanced echocardiography for the critical care physician: part 2.

This article is the second part of a series that describes practical techniques in advanced critical care echocardiography and their use in the management of hemodynamic instability. Measurement of left ventricular function and segmental wall motion abnormalities, evaluation of left ventricular filling pressures, assessment of right-sided heart function, and determination of preload sensitivity, including passive leg raising, are discussed. Video examples help to demonstrate techniques described in the text. Chest. 2014 Jan;145(1):135-42

Tuesday, March 11, 2014

ACC Statement on Pre-authorization

The American College of Cardiology has come out with a position statement warning that scan pre-authorization policies by insurance companies may limit patient access to care. Denials from the insurance companies are frequently at odds with American College of Cardiology established Appropriate Use criteria.

COMMENT: I have yet to see an insurance representative take me up on my offer to have them see the patient, and have them take responsibility for their health. Pre-authorization has not been conclusively shown to reduce costs (the ACC position statement addresses this issue in detail) but it certainly increases clinic overhead costs and reduces patient access to care.

Sunday, March 9, 2014

Usefulness of speckle tracking echocardiography in hypertensive crisis and the effect of medical treatment.

Usefulness of speckle tracking echocardiography in hypertensive crisis and the effect of medical treatment.
Am J Cardiol. 2013 Jul 15;112(2):260-5
Authors: Alam M, Zhang L, Stampehl M, Lakkis N, Dokainish H

The acute impact of hypertensive crisis, and changes after treatment, on left ventricular (LV) systolic and diastolic function using comprehensive echocardiography, including speckle tracking, has not been well characterized. Thirty consecutive patients admitted to the hospital from the emergency room with hypertensive crisis underwent Doppler echocardiography at baseline and after blood pressure optimization. The mean age of the patients was 54 ± 13 years, with 19 men (63%). The most common presenting symptoms included dyspnea (70%), chest pain (43%), and altered mental status (13%). Mean systolic and diastolic blood pressures at presentation were 198 ± 12 and 122 ± 12 mm Hg, decreasing to 143 ± 15 and 77 ± 12 mm Hg (p <0.001 for both) after treatment. There was no significant change in LV ejection fraction between baseline and follow-up (48 ± 18% vs 46 ± 18%, p = 0.50); however, global longitudinal LV systolic strain (-10 ± 4% to -12 ± 4%, p = 0.01) and global systolic strain rate (-1.0 ± 0.4 vs -1.4 ± 0.6 s(-1), p = 0.01) significantly improved. Mean global early diastolic strain (-7.2 ± 4.0% to -9.4 ± 2.9%, p = 0.004) and early diastolic strain rate (0.3 ± 0.2 to 0.5 ± 0.4 s(-1), p = 0.05) also improved after treatment. On multivariate analysis, the independent predictors of LV longitudinal strain at follow-up were LV ejection fraction (p <0.001), heart rate (p = 0.005), systolic blood pressure (p = 0.04), and left atrial volume index (p = 0.05). In conclusion, as opposed to LV ejection fraction, LV systolic strain and strain rate were depressed during hypertensive crisis and significantly improved after medical treatment. LV diastolic function, assessed using conventional and speckle-tracking parameters, was also depressed and significantly improved after treatment.

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Friday, March 7, 2014

Left ventricular function by echocardiography, tissue Doppler imaging, and carotid intima-media thickness in obese adolescents with nonalcoholic fatty liver disease.

Left ventricular function by echocardiography, tissue Doppler imaging, and carotid intima-media thickness in obese adolescents with nonalcoholic fatty liver disease.
Am J Cardiol. 2013 Aug 1;112(3):436-43
Authors: Sert A, Aypar E, Pirgon O, Yilmaz H, Odabas D, Tolu I

The aims of this study were to evaluate left ventricular (LV) systolic and diastolic function in obese adolescents with nonalcoholic fatty liver disease (NAFLD) using conventional echocardiography and pulsed-wave tissue Doppler imaging and to investigate the relations between LV function and carotid intima-media thickness (CIMT). LV remodeling, tissue Doppler-derived LV velocities, and cardiovascular risk profiles in obese adolescents with NAFLD were also studied. One hundred eighty obese adolescents and 68 healthy controls were enrolled in the study. LV end-diastolic and end-systolic and left atrial diameters and LV mass were higher in the 2 obese groups compared with controls. By pulsed-wave Doppler echocardiography and pulsed-wave tissue Doppler imaging, the NAFLD group had normal LV systolic function, impaired diastolic function, and altered global systolic and diastolic myocardial performance. In patients with NAFLD, LV mass was positively correlated with homeostasis model assessment of insulin resistance and serum alanine aminotransferase. CIMT was positively correlated with homeostasis model assessment of insulin resistance, alanine aminotransferase, and LV mass. By multiple stepwise regression analysis, alanine aminotransferase (β = 0.124, p = 0.026), homeostasis model assessment of insulin resistance (β = 0.243, p = 0.0001), LV mass (β = 0.874, p = 0.0001) were independent parameters associated with increased CIMT. In conclusion, insulin resistance has a significant independent impact on CIMT and LV remodeling in the absence of diabetes in patients with NAFLD. Pulsed-wave tissue Doppler imaging is suggested to detect LV dysfunction at an earlier stage in obese adolescents with NAFLD for careful monitoring of cardiovascular risk.

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Wednesday, March 5, 2014

Can simulation help to answer the demand for echocardiography education?

Can simulation help to answer the demand for echocardiography education?
Anesthesiology. 2014 Jan;120(1):32-41
Authors: Clau-Terré F, Sharma V, Cholley B, Gonzalez-Alujas T, Galiñanes M, Evangelista A, Fletcher N

There has been a recent explosion of education and training in echocardiography in the specialties of anesthesiology and critical care. These devices, by their impact on clinical management, are changing the way surgery is performed and critical care is delivered. A number of international bodies have made recommendations for training and developed examinations and accreditations.The challenge to medical educators in this area is to deliver the training needed to achieve competence into already over-stretched curricula.The authors found an apparent increase in the use of simulators, with proven efficacy in improving technical skills and knowledge. There is still an absence of evidence on how it should be included in training programs and in the accreditation of certain levels.There is a conviction that this form of simulation can enhance and accelerate the understanding and practice of echocardiography by the anesthesiologist and intensivists, particularly at the beginning of the learning curve.

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Echocardiography is dispensable in uncomplicated Staphylococcus aureus bacteremia.

Echocardiography is dispensable in uncomplicated Staphylococcus aureus bacteremia.
Medicine (Baltimore). 2013 May;92(3):182-8
Authors: Khatib R, Sharma M

Current Staphylococcus aureus bacteremia (SAB) practice guidelines stratify treatment duration according to the likelihood of complications and recommend transesophageal echocardiography (TEE) in all cases. The benefit of TEE in uncomplicated SAB has not been validated. We performed a retrospective analysis of TEE and transthoracic echocardiography (TTE) among hospitalized adults with SAB in 3 prior observational studies (2002-2003, 2005-2006, and 2008-2009). Echocardiograms were ordered at the attending physician's discretion. SAB cases were stratified into the following types: complicated (persistent bacteremia [duration ≥3 d], relapse, and/or secondary foci); device-associated (intracardiac prosthetic devices); suspected endocarditis (the presence of murmurs or emboli); and uncomplicated (bacteremia duration ≤2 d, no device and/or secondary foci). We encountered 960 SAB cases; 83 were excluded (57 death/transfer/discharge within 48 h; 19 contaminants/no treatment; 7 care withdrawn). TEE and TTE were performed within 0-28 days of SAB onset in 177 (20.2%) and 321 (36.6%) instances, respectively. TEE was positive (with signs of endocarditis) in 42/177 (23.7%) cases: 7/39 (17.9%) community associated and 35/138 (25.4%) health care associated. It was positive in 29/120 (24.2%) complicated, 3/11 (27.3%) device-associated, 9/15 (60.0%) suspected endocarditis, and 1/31 (3.2%) uncomplicated cases of SAB. TTE was positive in 25/321 (7.8%) cases of SAB, 1 was uncomplicated; it was negative in 20/30 (66.7%) TEE-positive cases. Follow-up of ≥100 days was possible in 282/361 (78.1%) uncomplicated SAB; many (46.8%) received ≤15 days of therapy. None of them had relapses or secondary foci.These findings suggest that echocardiography is dispensable in cases of uncomplicated community-associated and health care-associated SAB. It should be limited to subsets with clinical findings of endocarditis, persistence, intracardiac devices, secondary foci, and relapse. The cost effectiveness of TTE prior to TEE among these patients is unknown.

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Monday, March 3, 2014

Simulator training enhances resident performance in transesophageal echocardiography.

Simulator training enhances resident performance in transesophageal echocardiography.
Anesthesiology. 2014 Jan;120(1):149-59
Authors: Ferrero NA, Bortsov AV, Arora H, Martinelli SM, Kolarczyk LM, Teeter EC, Zvara DA, Kumar PA

BACKGROUND: Standardized training via simulation as an educational adjunct may lead to a more rapid and complete skill achievement. The authors hypothesized that simulation training will also enhance performance in transesophageal echocardiography image acquisition among anesthesia residents.
METHODS: A total of 42 clinical anesthesia residents were randomized to one of two groups: a control group, which received traditional didactic training, and a simulator group, whose training used a transesophageal echocardiography-mannequin simulator. Each participating resident was directed to obtain 10 commonly used standard views on an anesthetized patient under attending supervision. Each of the 10 selected echocardiographic views were evaluated on a grading scale of 0 to 10, according to predetermined criteria. The effect of the intervention was assessed by using a linear mixed model implemented in SAS 9.3 (SAS Institute Inc., Cary, NC).
RESULTS: Residents in the simulation group obtained significantly higher-quality images with a mean total image quality score of 83 (95% CI, 74 to 92) versus the control group score of 67 (95% CI, 58 to 76); P = 0.016. On average, 71% (95% CI, 58 to 85) of images acquired by each resident in the simulator group were acceptable for clinical use compared with 48% (95% CI, 35 to 62) in the control; P = 0.021. Additionally, the mean difference in score between training groups was the greatest for the clinical anesthesia-1 residents (difference 24; P = 0.031; n = 7 per group) and for those with no previous transesophageal echocardiography experience (difference 26; P = 0.005; simulator n = 13; control n = 11).
CONCLUSION: Simulation-based transesophageal echocardiography education enhances image acquisition skills in anesthesiology residents.

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Friday, February 28, 2014

Cardiac allograft vasculopathy after heart transplantation: electrocardiographically gated cardiac CT angiography for assessment.


Cardiac allograft vasculopathy after heart transplantation: electrocardiographically gated cardiac CT angiography for assessment.
Radiology. 2013 Aug;268(2):374-81
Authors: Mittal TK, Panicker MG, Mitchell AG, Banner NR

PURPOSE: To evaluate the diagnostic accuracy of cardiac computed tomographic (CT) angiography without the use of β-blockers compared with that of invasive angiography for the detection of cardiac allograft vasculopathy (CAV) in heart transplant recipients.
MATERIALS AND METHODS: The study was approved by the research ethics committee and informed consent was obtained. Heart transplant recipients (n = 138) scheduled for routine invasive angiography were prospectively enrolled to undergo CT to evaluate coronary artery calcification and retrospectively gated cardiac CT angiography with a 64-section scanner. The cardiac CT angiographic images were systematically analyzed for image quality. Degree of CAV was assessed by using a 15-coronary segments model. The area under the receiver operating characteristic curve, sensitivity, specificity, and negative and positive predictive values of cardiac CT angiography for detection of CAV with any degree of stenosis and greater than or equal to 50% stenosis were calculated.
RESULTS: Coronary artery calcification was absent in 82 patients, five (6%) of whom had CAV with 50% or more stenosis. Interpretable image quality was obtained in 130 (96%) of the 136 patients who completed the study and 1900 (98%) of 1948 segments. At the patient level, cardiac CT angiography had an area under the receiver operating characteristic curve, sensitivity, specificity, and positive and negative predictive values of 0.880 (95% confidence interval: 0.819, 0.941), 98%, 78%, 77%, and 98%, respectively, for diagnosis of CAV with any degree of stenosis, but for CAV with 50% or more stenosis, the corresponding values were 0.942 (95% confidence interval: 0.885, 1.000), 96%, 93%, 72%, and 99%, respectively. None of the 61 patients with normal cardiac CT angiographic results had CAV on the basis of invasive angiographic images.
CONCLUSION: The study results show that cardiac CT angiography compares favorably with invasive angiography in detecting CAV in heart transplant recipients and may be a preferable screening technique because of its noninvasive nature. The absence of coronary artery calcification alone is not reliable enough for excluding CAV.

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The impact of internet and simulation-based training on transoesophageal echocardiography learning in anaesthetic trainees: a prospective randomised study.

The impact of internet and simulation-based training on transoesophageal echocardiography learning in anaesthetic trainees: a prospective randomised study.
Anaesthesia. 2013 Jun;68(6):621-7
Authors: Sharma V, Chamos C, Valencia O, Meineri M, Fletcher SN

With the increasing role of transoesophageal echocardiography in clinical fields other than cardiac surgery, we decided to assess the efficacy of multi-modular echocardiography learning in echo-naïve anaesthetic trainees. Twenty-eight trainees undertook a pre-test to ascertain basic echocardiography knowledge, following which the study subjects were randomly assigned to two groups: learning via traditional methods such as review of guidelines and other literature (non-internet group); and learning via an internet-based echocardiography resource (internet group). After this, subjects in both groups underwent simulation-based echocardiography training. More tests were then conducted after a review of the respective educational resources and simulation sessions. Mean (SD) scores of subjects in the non-internet group were 28 (10)%, 44 (10)% and 63 (5)% in the pre-test, post-intervention test and post-simulation test, respectively, whereas those in the internet group scored 29 (8)%, 59 (10)%, (p = 0.001) and 72 (8)%, p = 0.005, respectively. The use of internet- and simulation-based learning methods led to a significant improvement in knowledge of transoesophageal echocardiography by anaesthetic trainees. The impact of simulation-based training was greater in the group who did not use the internet-based resource. We conclude that internet- and simulation-based learning methods both improve transoesophageal echocardiography knowledge in echo-naïve anaesthetic trainees.

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Accuracy of three-dimensional versus two-dimensional echocardiography for quantification of aortic regurgitation and validation by three-dimensional three-directional velocity-encoded magnetic resonance imaging.

Accuracy of three-dimensional versus two-dimensional echocardiography for quantification of aortic regurgitation and validation by three-dimensional three-directional velocity-encoded magnetic resonance imaging.
Am J Cardiol. 2013 Aug 15;112(4):560-6
Authors: Ewe SH, Delgado V, van der Geest R, Westenberg JJ, Haeck ML, Witkowski TG, Auger D, Marsan NA, Holman ER, de Roos A, Schalij MJ, Bax JJ, Sieders A, Siebelink HM

Quantitative assessment of aortic regurgitation (AR) remains challenging. The present study evaluated the accuracy of 2-dimensional (2D) and 3-dimensional (3D) transthoracic echocardiography (TTE) for AR quantification, using 3D 3-directional velocity-encoded magnetic resonance imaging (VE-MRI) as the reference method. Thirty-two AR patients were included. With color Doppler TTE, 2D effective regurgitant orifice area (EROA) was calculated using the proximal isovelocity surface area method. From the 3D TTE multiplanar reformation data, 3D-EROA was calculated by planimetry of the vena contracta. Regurgitant volumes (RVol) were obtained by multiplying the 2D-EROA and 3D-EROA by the velocity-time integral of AR jet and compared with that obtained using VE-MRI. For the entire population, 3D TTE RVol demonstrated a strong correlation and good agreement with VE-MRI RVol (r = 0.94 and -13.6 to 15.6 ml/beat, respectively), whereas 2D TTE RVol showed a modest correlation and large limits of agreement with VE-MRI (r = 0.70 and -22.2 to 32.8 ml/beat, respectively). Eccentric jets were noted in 16 patients (50%). In these patients, 3D TTE demonstrated an excellent correlation (r = 0.95) with VE-MRI, a small bias (0.1 ml/beat) and narrow limits of agreement (-18.7 to 18.8 ml/beat). Finally, the kappa agreement between 3D TTE and VE-MRI for grading of AR severity was good (k = 0.96), whereas the kappa agreement between 2D TTE and VE-MRI was suboptimal (k = 0.53). In conclusion, AR RVol quantification using 3D TTE is accurate, and its advantage over 2D TTE is particularly evident in patients with eccentric jets.

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Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: a prospective multicenter study.

Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: a prospective multicenter study.
J Am Coll Cardiol. 2013 Jul 23;62(4):308-16
Authors: Lin FY, Dunning AM, Narula J, Shaw LJ, Gransar H, Berman DS, Min JK

OBJECTIVES: This study sought to evaluate the impact of a multimodality-appropriate use criteria decision support tool (AUC-DST) on rates of appropriate testing and clinical decision making.
BACKGROUND: AUC have been developed to guide utilization of noninvasive imaging for individuals with suspected coronary artery disease (CAD). The effect of a point-of-order AUC-DST on rates of appropriateness and clinical decision making has not been examined.
METHODS: We performed a prospective multicenter cohort study evaluating physicians who ordered CAD imaging tests for consecutive patients insured by 1 large private payer. During an 8-month study period, each study site was granted exemption from prior authorization requirements by radiology benefits managers. An AUC-DST was employed to determine appropriateness ratings for myocardial perfusion scintigraphy (MPS), stress echocardiography (STE), or coronary computed tomographic angiography (CCTA), as well as intended downstream testing and therapy.
RESULTS: One hundred physicians used the AUC-DST for 472 patients (age 55.6 ± 9.6 years, 61% male, 52% prior known CAD) over 8 months for MPS (72%), STE (24%), and CCTA (5%). The AUC-DST required an average of 137 ± 360 s to determine the appropriateness category that, by American College of Cardiology AUC, was considered appropriate in 241 (51%), uncertain in 96 (20%), inappropriate in 85 (18%), and not addressed in 50 (11%). For tests ordered in the first 2 months compared with the last 2 months, appropriate tests increased from 49% to 61% (p = 0.02), whereas inappropriate tests decreased from 22% to 6% (p < 0.001). During this period, intended changes in medical therapy increased from 11% to 32% (p = 0.001).
CONCLUSIONS: A point-of-order AUC-DST enabled rapid determination of test appropriateness for CAD evaluation and was associated with increased and decreased testing for appropriate and inappropriate indications, respectively. These changes in test ordering were associated with greater intended changes in post-test medical therapy.

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Thursday, February 27, 2014

Aggregate plaque volume by coronary computed tomography angiography is superior and incremental to luminal narrowing for diagnosis of ischemic lesions of intermediate stenosis severity.

Aggregate plaque volume by coronary computed tomography angiography is superior and incremental to luminal narrowing for diagnosis of ischemic lesions of intermediate stenosis severity.
J Am Coll Cardiol. 2013 Jul 30;62(5):460-7
Authors: Nakazato R, Shalev A, Doh JH, Koo BK, Gransar H, Gomez MJ, Leipsic J, Park HB, Berman DS, Min JK

OBJECTIVES: This study examined the performance of percent aggregate plaque volume (%APV), which represents cumulative plaque volume as a function of total vessel volume, by coronary computed tomography angiography (CTA) for identification of ischemic lesions of intermediate stenosis severity.
BACKGROUND: Coronary lesions of intermediate stenosis demonstrate significant rates of ischemia. Coronary CTA enables quantification of luminal narrowing and %APV.
METHODS: We identified 58 patients with intermediate lesions (30% to 69% diameter stenosis) who underwent invasive angiography and fractional flow reserve. Coronary CTA measures included diameter stenosis, area stenosis, minimal lumen diameter (MLD), minimal lumen area (MLA) and %APV. %APV was defined as the sum of plaque volume divided by the sum of vessel volume from the ostium to the distal portion of the lesion. Fractional flow reserve ≤ 0.80 was considered diagnostic of lesion-specific ischemia. Area under the receiver operating characteristic curve and net reclassification improvement (NRI) were also evaluated.
RESULTS: Twenty-two of 58 lesions (38%) caused ischemia. Compared with nonischemic lesions, ischemic lesions had smaller MLD (1.3 vs. 1.7 mm, p = 0.01), smaller MLA (2.5 vs. 3.8 mm(2), p = 0.01), and greater %APV (48.9% vs. 39.3%, p < 0.0001). Area under the receiver operating characteristic curve was highest for %APV (0.85) compared with diameter stenosis (0.68), area stenosis (0.66), MLD (0.75), or MLA (0.78). Addition of %APV to other measures showed significant reclassification over diameter stenosis (NRI 0.77, p < 0.001), area stenosis (NRI 0.63, p = 0.002), MLD (NRI 0.62, p = 0.001), and MLA (NRI 0.43, p = 0.01).
CONCLUSIONS: Compared with diameter stenosis, area stenosis, MLD, and MLA, %APV by coronary CTA improves identification, discrimination, and reclassification of ischemic lesions of intermediate stenosis severity.

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Optimized prognostic score for coronary computed tomographic angiography: results from the CONFIRM registry (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry).

Optimized prognostic score for coronary computed tomographic angiography: results from the CONFIRM registry (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry).
J Am Coll Cardiol. 2013 Jul 30;62(5):468-76
Authors: Hadamitzky M, Achenbach S, Al-Mallah M, Berman D, Budoff M, Cademartiri F, Callister T, Chang HJ, Cheng V, Chinnaiyan K, Chow BJ, Cury R, Delago A, Dunning A, Feuchtner G, Gomez M, Kaufmann P, Kim YJ, Leipsic J, Lin FY, Maffei E, Min JK, Raff G, Shaw LJ, Villines TC, Hausleiter J, CONFIRM Investigators

OBJECTIVES: The aim of this study was to analyze the predictive value of coronary computed tomography angiography (CCTA) and to model and validate an optimized score for prognosis of 2-year survival on the basis of a patient population with suspected coronary artery disease (CAD).
BACKGROUND: Coronary computed tomography angiography carries important prognostic information in addition to the detection of obstructive CAD. But it is still unclear how the results of CCTA should be interpreted in the context of clinical risk predictors.
METHODS: The analysis is based on a test sample of 17,793 patients and a validation sample of 2,506 patients, all with suspected CAD, from the international CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry. On the basis of CCTA data and clinical risk scores, an optimized score was modeled. The endpoint was all-cause mortality.
RESULTS: During a median follow-up of 2.3 years, 347 patients died. The best CCTA parameter for prediction of mortality was the number of proximal segments with mixed or calcified plaques (C-index 0.64, p < 0.0001) and the number of proximal segments with a stenosis >50% (C-index 0.56, p = 0.002). In an optimized score including both parameters, CCTA significantly improved overall risk prediction beyond National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) score as best clinical score. According to this score, a proximal segment with either a mixed or calcified plaque or a stenosis >50% is equivalent to a 5-year increase in age or the risk of smoking.
CONCLUSIONS: In CCTA, both plaque burden and stenosis, particularly in proximal segments, carry incremental prognostic value. A prognostic score on the basis of this data can improve risk prediction beyond clinical risk scores.

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Monday, February 24, 2014

Stress Doppler echocardiography in systemic sclerosis: evidence for a role in the prediction of pulmonary hypertension.

Stress Doppler echocardiography in systemic sclerosis: evidence for a role in the prediction of pulmonary hypertension.
Arthritis Rheum. 2013 Sep;65(9):2403-11
Authors: Codullo V, Caporali R, Cuomo G, Ghio S, D'Alto M, Fusetti C, Borgogno E, Montecucco C, Valentini G

OBJECTIVE: Patients with systemic sclerosis (SSc) in whom pulmonary hypertension (PH) is not suspected have been reported to develop an inappropriate increase of pulmonary artery systolic pressure as estimated by Doppler echocardiography under conditions of exercise (pulmonary artery systolic pressure under exercise). We undertook this study to investigate whether this increase or any other parameter detectable by stress Doppler echocardiography has utility in predicting the development of PH in SSc.
METHODS: We enrolled a total of 170 patients with SSc previously investigated using standard and stress Doppler echocardiography and tissue Doppler imaging. Each patient was evaluated at baseline and yearly for skin and internal organ involvement. Right-sided heart catheterization was carried out when PH was suspected. The baseline Cochin Risk Prediction Score was calculated retrospectively.
RESULTS: During followup, 6 patients (3.5%) developed PH. Compared with patients without any feature suggesting PH, the Cochin Risk Prediction Score was higher in this group (mean ± SD 4.2 ± 0.9 versus 3.4 ± 0.9; P < 0.05), as was the difference between pulmonary artery systolic pressure under exercise and pulmonary artery systolic pressure (Δpulmonary artery systolic pressure) (18.2 ± 7 mm Hg versus 9.4 ± 6.5 mm Hg; P < 0.001), even when adjusted for cardiac index changes. In multivariate analysis, Δpulmonary artery systolic pressure (hazard ratio [HR] 3.4 [95% confidence interval 1.4-8], P < 0.01) and Cochin Risk Prediction Score within the fifth quintile of the values registered in our series (HR 9.3 [95% confidence interval 1.4-63.7], P < 0.05) were the only factors independently predictive of PH during followup. A Δpulmonary artery systolic pressure cutoff of >18 mm Hg, identified by receiver operating characteristic curve analysis, had a sensitivity of 50% and a specificity of 90% for the development of PH during followup.
CONCLUSION: An inappropriate response to exercise among patients with SSC is detectable by stress Doppler echocardiography. Independently of other clinical associations, increased Δpulmonary artery systolic pressure heralds PH. Stress Doppler echocardiography may represent an additional screening tool for this severe complication.

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Focused transthoracic echocardiography during critical care medicine training: curriculum implementation and evaluation of proficiency*.

Focused transthoracic echocardiography during critical care medicine training: curriculum implementation and evaluation of proficiency*.
Crit Care Med. 2013 Aug;41(8):e179-81
Authors: Beraud AS, Rizk NW, Pearl RG, Liang DH, Patterson AJ

OBJECTIVES: We designed and implemented a focused transthoracic echocardiography curriculum for critical care medicine fellows participating in 1- and 2-year training programs. We quantitatively evaluated their proficiency in focused transthoracic echocardiography.
DESIGN: Prospective study evaluating curriculum implementation and objective assessment of focused transthoracic echocardiography proficiency.
SETTING: Medical and surgical ICUs at an academic teaching hospital. Simulation laboratory.
SUBJECTS: Eighteen critical care medicine fellows.
INTERVENTIONS: Training in focused transthoracic echocardiography followed by proficiency testing.
MEASUREMENTS AND MAIN RESULTS: We assessed the ability of critical care medicine fellows to obtain and interpret focused transthoracic echocardiography images from critically ill patients and a from transthoracic echocardiography simulator. Using a cognitive examination test, we also evaluated each fellow's knowledge with regard to focused transthoracic echocardiography and each fellow's ability to interpret prerecorded focused transthoracic echocardiography images. After training, critical care medicine fellows were able to rapidly obtain five essential focused transthoracic echocardiography views: parasternal long axis, parasternal short axis, apical four chamber, subcostal four chamber, and subcostal inferior vena cava. Fellows were also able to expeditiously identify four important abnormalities: asystole, left ventricular dysfunction, right ventricular dilation and dysfunction, and a large pericardial effusion.
CONCLUSIONS: A focused transthoracic echocardiography curriculum that includes quantitative measures of proficiency can be integrated into critical care medicine fellowship training programs.

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Sunday, February 23, 2014

Comparison of sulfur hexafluoride microbubble (SonoVue)-enhanced myocardial contrast echocardiography with gated single-photon emission computed tomography for detection of significant coronary artery disease: a large European multicenter study.

Comparison of sulfur hexafluoride microbubble (SonoVue)-enhanced myocardial contrast echocardiography with gated single-photon emission computed tomography for detection of significant coronary artery disease: a large European multicenter study.
J Am Coll Cardiol. 2013 Oct 8;62(15):1353-61
Authors: Senior R, Moreo A, Gaibazzi N, Agati L, Tiemann K, Shivalkar B, von Bardeleben S, Galiuto L, Lardoux H, Trocino G, Carrió I, Le Guludec D, Sambuceti G, Becher H, Colonna P, Ten Cate F, Bramucci E, Cohen A, Bezante G, Aggeli C, Kasprzak JD

OBJECTIVES: The purpose of this study was to compare sulfur hexafluoride microbubble (SonoVue)-enhanced myocardial contrast echocardiography (MCE) with single-photon emission computed tomography (SPECT) relative to coronary angiography (CA) for assessment of coronary artery disease (CAD).
BACKGROUND: Small-scale studies have shown that myocardial perfusion assessed by SonoVue-enhanced MCE is a viable alternative to SPECT for CAD assessment. However, large multicenter studies are lacking.
METHODS: Patients referred for myocardial ischemia testing at 34 centers underwent rest/vasodilator SonoVue-enhanced flash-replenishment MCE, standard (99m)Tc-labeled electrocardiography-gated SPECT, and quantitative CA within 1 month. Myocardial ischemia assessments by 3 independent, blinded readers for MCE and 3 readers for SPECT were collapsed into 1 diagnosis per patient per technique and were compared to CA (reference standard) read by 1 independent blinded reader.
RESULTS: Of 628 enrolled patients who received SonoVue (71% males; mean age: 64 years; >1 cardiovascular [CV] risk factor in 99% of patients) 516 patients underwent all 3 examinations, of whom 161 (31.2%) had ≥70% stenosis (131 had single-vessel disease [SVD]; 30 had multivessel disease), and 310 (60.1%) had ≥50% stenosis. Higher sensitivity was obtained with MCE than with SPECT (75.2% vs. 49.1%, respectively; p < 0.0001), although specificity was lower (52.4% vs. 80.6%, respectively; p < 0.0001) for ≥70% stenosis. Similar findings were obtained for patients with ≥50% stenosis. Sensitivity levels for detection of SVD and proximal disease for ≥70% stenosis were higher for MCE (72.5% vs. 42.7%, respectively; p < 0.0001; 80% vs. 58%, respectively; p = 0.005, respectively).
CONCLUSIONS: SonoVue-enhanced MCE demonstrated superior sensitivity but lower specificity for detection of CAD compared to SPECT in a population with a high incidence of CV risk factors and intermediate-high prevalence of CAD. (A phase III study to compare SonoVue® enhanced myocardial echocardiography [MCE] to single photon emission computerized tomography [ECG-GATED SPECT], at rest and at peak of low-dose Dipyridamole stress test, in the assessment of significant coronary artery disease [CAD] in patients with suspect or known CAD using Coronary Angiography as Gold Standard-SonoVue MCE vs SPECT; EUCTR2007-003492-39-GR).

23770168
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Cocaine-induced vasoconstriction in the human coronary microcirculation: new evidence from myocardial contrast echocardiography.

Cocaine-induced vasoconstriction in the human coronary microcirculation: new evidence from myocardial contrast echocardiography.
Circulation. 2013 Aug 6;128(6):598-604
Authors: Gurudevan SV, Nelson MD, Rader F, Tang X, Lewis J, Johannes J, Belcik JT, Elashoff RM, Lindner JR, Victor RG

BACKGROUND: Cocaine is a major cause of acute coronary syndrome, especially in young adults; however, the mechanistic underpinning of cocaine-induced acute coronary syndrome remains limited. Previous studies in animals and in patients undergoing cardiac catheterization suggest that cocaine constricts coronary microvessels, yet direct evidence is lacking.
METHODS AND RESULTS: We used myocardial contrast echocardiography to test the hypothesis that cocaine causes vasoconstriction in the human coronary microcirculation. Measurements were performed at baseline and after a low, nonintoxicating dose of intranasal cocaine (2 mg/kg) in 10 healthy cocaine-naïve young men (median age, 32 years). Postdestruction time-intensity myocardial contrast echocardiography kinetic data were fit to the equation y=A(1-e(-βt)) to quantify functional capillary blood volume (A), microvascular flow velocity (β), and myocardial perfusion (A×β). Heart rate, mean arterial pressure, and left ventricular work (2-dimensional echocardiography) were measured before and 45 minutes after cocaine. Cocaine increased mean arterial pressure (by 14±2 mm Hg [mean±SE]), heart rate (by 8±3 bpm), and left ventricular work (by 50±18 mm Hg·mL(-1)·bpm(-1)). Despite the increases in these determinants of myocardial oxygen demand, myocardial perfusion decreased by 30% (103.7±9.8 to 75.9±10.8 arbitrary units [AU]/s; P<0.01) mainly as a result of decreased capillary blood volume (133.9±5.1 to 111.7±7.7 AU; P<0.05) with no significant change in microvascular flow velocity (0.8±0.1 to 0.7±0.1 AU).
CONCLUSIONS: In healthy cocaine-naïve young adults, a low-dose cocaine challenge evokes a sizeable decrease in myocardial perfusion. Moreover, the predominant effect is to decrease myocardial capillary blood volume rather than microvascular flow velocity, suggesting a specific action of cocaine to constrict terminal feed arteries.

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Role of transthoracic Doppler echocardiography in patients with a proximal left coronary artery lesion that cannot be diagnosed by computed tomography angiography.

Role of transthoracic Doppler echocardiography in patients with a proximal left coronary artery lesion that cannot be diagnosed by computed tomography angiography.
Am J Cardiol. 2013 Oct 1;112(7):938-42
Authors: Higashi H, Okayama H, Saito M, Morioka H, Aono J, Yoshii T, Sumimoto T, Hiasa G, Nishimura K, Inoue K, Ogimoto A, Higaki J

The diagnosis of lesions with severe calcium or in-stent stenosis using coronary computed tomography angiography (CCTA) is still difficult. The aim of the present study was to evaluate the accuracy of transthoracic Doppler echocardiography (TTDE) in patients with suspected angina pectoris, who had a proximal left coronary artery (LCA) site that could not be evaluated by CCTA. Fifty-eight patients were evaluated. The proximal LCA was defined as the left main coronary artery and proximal left anterior descending coronary artery. All patients underwent TTDE and had coronary angiography performed as a reference method. We measured the proximal left coronary flow velocity (CFV) by both color and pulse Doppler methods. Proximal coronary flow was detected in 45 (78%) of 58 patients. CFVs measured by both methods were significantly greater in the group with severe stenosis (percent diameter stenosis >70%) than in the groups with moderate stenosis (percent diameter stenosis 40% to 70%) or without stenosis (color Doppler: 148 ± 42 cm/s, 89 ± 40 cm/s, and 41 ± 22 cm/s, respectively, p <0.05; pulse Doppler: 143 ± 61 cm/s, 82 ± 33 cm/s, and 39 ± 17 cm/s, respectively, p <0.05). Receiver operating characteristic curve analysis showed that the optimal CFV cut-off values obtained by color and pulse Doppler to diagnose severe stenosis were 92 cm/s (sensitivity, 100%; specificity, 90%) and 81 cm/s (sensitivity, 100%; specificity, 85%), respectively. In conclusion, TTDE could diagnose proximal LCA stenosis with good accuracy in patients who could not be evaluated by CCTA.

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Influence of sex on risk stratification with stress myocardial perfusion Rb-82 positron emission tomography: Results from the PET (Positron Emission Tomography) Prognosis Multicenter Registry.

Influence of sex on risk stratification with stress myocardial perfusion Rb-82 positron emission tomography: Results from the PET (Positron Emission Tomography) Prognosis Multicenter Registry.
J Am Coll Cardiol. 2013 Nov 12;62(20):1866-76
Authors: Kay J, Dorbala S, Goyal A, Fazel R, Di Carli MF, Einstein AJ, Beanlands RS, Merhige ME, Williams BA, Veledar E, Chow BJ, Min JK, Berman DS, Shah S, Bellam N, Butler J, Shaw LJ

OBJECTIVES: The aim of the current analysis was to compare sex differences in the prognostic accuracy of stress myocardial perfusion rubidum-82 (Rb-82) positron emission tomography (PET).
BACKGROUND: The diagnostic evaluation of women presenting with suspected cardiac symptoms is challenging with reported reduced accuracy, attenuation artifact, and more recent concerns regarding radiation safety. Stress myocardial perfusion Rb-82 PET is a diagnostic alternative with improved image quality and radiation dosimetry. Currently, the prognostic accuracy of stress Rb-82 PET in women has not been established.
METHODS: A total of 6,037 women and men were enrolled in the PET Prognosis Multicenter Registry. Patients were followed for the occurrence of coronary artery disease (CAD) mortality, with a median follow-up of 2.2 years. Cox proportional hazards modeling was used to estimate CAD mortality. The net re-classification improvement index (NRI) was calculated.
RESULTS: The 5-year CAD mortality was 3.7% for women and 6.0% for men (p < 0.0001). Unadjusted CAD mortality ranged from 0.9% to 12.9% for women (p < 0.0001) and from 1.5% to 17.4% for men (p < 0.0001) for 0% to ≥15% abnormal myocardium at stress. In multivariable models, the percentage of abnormal stress myocardium was independently predictive of CAD mortality in women and men. An interaction term of sex by the percentage of abnormal stress myocardium was nonsignificant (p = 0.39). The categorical NRI when Rb-82 PET data was added to a clinical risk model was 0.12 for women and 0.17 for men. Only 2 cardiac deaths were reported in women <55 years of age; accordingly the percentage of abnormal myocardium at stress was of borderline significance (p = 0.063), but it was highly significant for women ≥55 years of age (p < 0.0001), with an increased NRI of 0.21 (95% confidence interval: 0.09 to 0.34), including 17% of CAD deaths and 3.9% of CAD survivors that were correctly re-classified in this older female subset.
CONCLUSIONS: Stress Rb-82 PET provides significant and clinically meaningful effective risk stratification of women and men, supporting this modality as an alternative to comparative imaging modalities. Rb-82 PET findings were particularly helpful at identifying high-risk, older women.

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Usefulness of combined bedside lung ultrasound and echocardiography to assess weaning failure from mechanical ventilation: a suggestive case*.

Usefulness of combined bedside lung ultrasound and echocardiography to assess weaning failure from mechanical ventilation: a suggestive case*.
Crit Care Med. 2013 Aug;41(8):e182-5
Authors: Mongodi S, Via G, Bouhemad B, Storti E, Mojoli F, Braschi A

OBJECTIVE: Recognition of the cardiac origin of weaning failure is a crucial issue for successful discontinuation of mechanical ventilation. Bedside lung ultrasound and echocardiography have shown a potential in predicting weaning failure. Objective of this report was to describe the case of a patient repeatedly failing to wean from mechanical ventilation, where the combined use of lung ultrasound and echocardiography during a spontaneous breathing trial uncovered an unexpected cause of the failure.
DESIGN: Case report.
SETTING: General ICU of a university teaching hospital.
PATIENTS: Single case, abdominal surgery postoperative patient, not predicted to experience a difficult weaning.
INTERVENTIONS: Cardiovascular therapy adjustments consistent with lung ultrasound and echocardiography findings acquired during spontaneous breathing trials.
MEASUREMENTS AND MAIN RESULTS: All patient's standard hemodynamic and respiratory parameters, datasets from comprehensive lung ultrasound and echocardiographic examinations, and pertinent data from biochemistry exams, were collected during two spontaneous breathing trials. Data from beginning and end of each of the two ultrasound monitored weaning trials, and from the end of the successful weaning trial following therapy and the previously failed one, were analyzed and qualitatively compared. Lung ultrasound performed at the end of the failed spontaneous breathing trial showed a pattern consistent with increased extravascular lung water (diffuse, bilateral, symmetrical, homogeneous sonographic interstitial syndrome). Concurrent echocardiography diagnosed left ventricular diastolic failure. Ultrasound findings at the end of the successful weaning trial showed normalization of the lung pattern and improvement of the echocardiographic one. The patient eventually returned to spontaneous respiration and was discharged from the ICU.
CONCLUSIONS: The use of bedside lung ultrasound and echocardiography disclosed left ventricular diastolic dysfunction as unexpected cardiogenic cause of weaning failure and lead to subsequent correct patient management.

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Appropriate use and clinical impact of transthoracic echocardiography.

Appropriate use and clinical impact of transthoracic echocardiography.
JAMA Intern Med. 2013 Sep 23;173(17):1600-7
Authors: Matulevicius SA, Rohatgi A, Das SR, Price AL, DeLuna A, Reimold SC

IMPORTANCE: Transthoracic echocardiography (TTE) accounts for almost half of all cardiac imaging services and is a widely available and versatile tool. Appropriate use criteria (AUC) for echocardiography were developed to improve patient care and health outcomes. Prior studies have shown that most TTEs are appropriate by AUC. However, the associations among TTE, AUC, and their clinical impact have not been well explored.
OBJECTIVES: To describe the proportion of TTEs that affect clinical care in an academic medical center overall and in subgroups defined as appropriate and inappropriate by AUC.
DESIGN AND SETTING: Retrospective review of medical records from 535 consecutive TTEs at an academic medical center was performed. The TTEs were classified according to 2011 AUC by 2 cardiologists blinded to clinical impact and were assessed for clinical impact by 2 cardiologists blinded to AUC. Clinical impact was assigned to 1 of the following 3 categories: (1) active change in care, (2) continuation of current care, or (3) no change in care.
PARTICIPANTS: Five hundred thirty-five patients undergoing TTE.
EXPOSURE: Transthoracic echocardiography. MAIN OUTCOMES AND MEASURES Prevalence of appropriate, inappropriate, and uncertain TTEs and prevalence of clinical impact subcategories.
RESULTS: Overall, 31.8% of TTEs resulted in an active change in care; 46.9%, continuation of current care; and 21.3%, no change in care. By 2011 AUC, 91.8% of TTEs were appropriate; 4.3%, inappropriate; and 3.9%, uncertain. We detected no statistically significant difference between appropriate and inappropriate TTEs in the proportion of TTEs that led to active change in care (32.2% vs 21.7%; P= .29).
CONCLUSIONS AND RELEVANCE: Although 9 in 10 TTEs were appropriate by 2011 AUC, fewer than 1 in 3 TTEs resulted in an active change in care, nearly half resulted in continuation of current care, and slightly more than 1 in 5 resulted in no change in care. The low rate of active change in care (31.8%) among TTEs mostly classified as appropriate (91.8%) highlights the need for a better method to optimize TTE utilization to use limited health care resources efficiently while providing high-quality care.

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Impact of three-dimensional echocardiography on classification of the severity of aortic stenosis.

Impact of three-dimensional echocardiography on classification of the severity of aortic stenosis.
Ann Thorac Surg. 2013 Oct;96(4):1343-8
Authors: Jainandunsing JS, Mahmood F, Matyal R, Shakil O, Hess PE, Lee J, Panzica PJ, Khabbaz KR

BACKGROUND: Owing to its elliptical shape, the left ventricle outflow tract (LVOT) area is underestimated by two-dimensional (2D) diameter-based calculations which assume a circular shape. This results in overestimation of aortic stenosis (AS) by the continuity equation. In cases of moderate to severe AS, this overestimation can affect intraoperative clinical decision making (expectant management versus replacement). The purpose of this intraoperative study was to compare the aortic valve area calculated by 2D diameter based and three-dimensional (3D) derived LVOT area via transesophageal echocardiography (TEE) and its impact on severity of AS.
METHODS: The LVOT area was calculated using intraoperative 2D and 3D TEE data from patients undergoing aortic valve replacement (AVR) and coronary artery bypass graft (CABG) surgery using the 2D diameter (RADIUS), 3D planimetry (PLANE), and 3D biplane (π·x·y) measurement (ELLIPSE) methods. For each method, the LVOT area was used to determine the aortic valve area by the continuity equation and the severity of AS categorized as mild, moderate, or severe.
RESULTS: A total of 66 patients completed the study. The RADIUS method (3.5 ± 0.9 cm(2)) underestimated LVOT area by 21% (p < 0.05) compared with the PLANE method (4.1 ± 0.1 cm(2)) and by 18% (p < 0.05) compared with the ELLIPSE method (4.0 ± 0.9 cm(2)). There was no significant difference between the two 3D methods, namely, PLANE and ELLIPSE. Seven AVR patients (18%) and 1 CABG surgery patient (6%) who had originally been classified as severe AS by the 2D method were reclassified as moderate AS by the 3D methods (p < 0.001).
CONCLUSIONS: Three-dimensional echocardiography has the potential to impact surgical decision making in cases of moderate to severe AS.

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Poor positive predictive value of McConnell's sign on transthoracic echocardiography for the diagnosis of acute pulmonary embolism.

Poor positive predictive value of McConnell's sign on transthoracic echocardiography for the diagnosis of acute pulmonary embolism.
Hosp Pract (1995). 2013 Aug;41(3):23-7
Authors: Vaid U, Singer E, Marhefka GD, Kraft WK, Baram M

BACKGROUND: Acute pulmonary embolism (PE) is a life-threatening condition. Making a definitive diagnosis with radiologic studies may delay therapy or be unsafe for the patient. Echocardiography is readily available and can suggest PE by demonstrating right ventricular (RV) dysfunction. McConnell's sign on echocardiogram (ECHO-CG) (RV dysfunction with characteristic sparing of the apex) has been reported to have high sensitivity and specificity for the diagnosis of acute PE. It is hypothesized that McConnell's sign on ECHO-CG in patients hospitalized with suspected acute PE would have a high positive predictive value (PPV).
METHODS: Data, from 2005 to 2010, were retrospectively collected on all patients with an ECHO-CG interpreted as revealing McConnell's sign, who had undergone another diagnostic study (computed tomography pulmonary angiography, ventilation-perfusion scan, upper or lower extremity Doppler ultrasound, or autopsy) for venous thromboembolic disease (VTE). The PPV on transthoracic ECHO-CG was calculated for the diagnostic accuracy of McConnell's sign in all patients. To minimize the potential for ECHO-CG reader bias of patients already confirmed to have had a PE by another modality, the PPV was then recalculated only on the patients in whom the ECHO-GM was the first diagnostic study.
RESULTS: Seventy-three patients had findings of McConnell's sign on ECHO-CG. The PPV of McConnell's sign on ECHO-CG was 57% (CI, 45%-67%). Of the 37 patients who underwent an ECHO-CG in the first study for suspected acute PE, 15 patients had VTE confirmed; the PPV in this subset was only 40% (CI, 24%-56%). There were 20 patient deaths overall; of these, only 9 of the patients were confirmed to have VTE.
CONCLUSION: We concluded that the presence of McConnell's sign has a relatively poor PPV for the diagnosis of acute PE and should not be used in isolation when making a diagnosis of PE in patients.

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Wednesday, February 19, 2014

Malignant incidental extracardiac findings on cardiac CT: systematic review and meta-analysis.


Malignant incidental extracardiac findings on cardiac CT: systematic review and meta-analysis.
AJR Am J Roentgenol. 2013 Sep;201(3):555-64
Authors: Flor N, Di Leo G, Squarza SA, Tresoldi S, Rulli E, Cornalba G, Sardanelli F

OBJECTIVE: The objective of our study was to systematically review the evidence on incidental extracardiac findings on cardiac CT with a focus on previously unknown malignancies.
MATERIALS AND METHODS: A systematic search was performed (PubMed, EMBASE, Cochrane databases) for studies reporting incidental extracardiac findings on cardiac CT. Among 1099 articles initially found, 15 studies met the inclusion criteria. The references of those articles were hand-searched and 14 additional studies were identified. After review of the full text, 10 articles were excluded. Nineteen studies including 15,877 patients (64% male) were analyzed. A three-level analysis was performed to determine the prevalence of patients with incidental extracardiac findings, the prevalence of patients with major incidental extracardiac findings, and the prevalence of patients with a proven cancer. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% CI were calculated.
RESULTS: The prevalence of both incidental extracardiac findings and major incidental extracardiac findings showed a high heterogeneity (I2>95%): The pooled prevalence was 44% (95% CI, 35-54%) and 16% (95% CI, 14-20%), respectively. No significant explanatory variables were found for using or not using contrast material, the size of the FOV, and study design (I2>85%). The pooled cancer prevalence for 10 studies including 5082 patients was 0.7% (95% CI, 0.5-1.0%), with an almost perfect homogeneity (I2<0.1%). Of 29 reported malignancies, 21 (72%) were lung cancers; three, thyroid cancers; two, breast cancers; two, liver cancers; and one, mediastinal lymphoma.
CONCLUSION: Although the prevalence of reported incidental extracardiac finding at cardiac CT was highly variable, a homogeneous prevalence of previously unknown malignancies was reported across the studies, for a pooled estimate of 0.7%; more than 70% of these previously unknown malignancies were lung cancers. Extracardiac findings on cardiac CT require careful evaluation and reporting.

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Tuesday, February 18, 2014

Effect of body mass index on outcome in patients with suspected coronary artery disease referred for stress echocardiography.

Effect of body mass index on outcome in patients with suspected coronary artery disease referred for stress echocardiography.
Am J Cardiol. 2013 Nov 1;112(9):1355-60
Authors: Weinberg CR, Supariwala A, Mian Z, Otokiti A, Sangli S, Thammaiah Y, Pai P, Yao SS, Chaudhry FA

In patients with hypertension, heart failure, or coronary artery disease (CAD), obese patients have been shown to have a lower cardiac event rate compared with normal weight counterparts. This phenomenon has been termed the "obesity paradox." We sought to determine whether the obesity paradox exists in a cohort of patients referred for stress echocardiography. We evaluated 4,103 patients with suspected CAD (58 ± 13 years; 42% men) undergoing stress echocardiography (52% exercise and 47% dobutamine). Patients were divided into 3 groups on the basis of body mass index (BMI): 18.5 to 24.9, 25 to 29.9, and >30 kg/m(2). During the follow-up of 8.2 ± 3.6 years, there were 683 deaths (17%). Myocardial ischemia was present in 21% of the population. Myocardial ischemia was more prevalent in patients with a BMI of 18.5 to 24.9 kg/m(2) (26%) than those with a BMI of 25 to 29.9 kg/m(2) (21%) and >30 kg/m(2) (18%). Patients with a BMI of >30 kg/m(2) had the lowest death rate (1.2%/year) compared with those with a BMI of 25 to 29.9 kg/m(2) (1.75%/year) and 18.5 to 24.9 kg/m(2) (2.9%/year; p <0.001). After adjusting for significant clinical variables including exercise capacity, patients with higher BMI (>30 kg/m(2) and 25 to 29.9 kg/m(2)) had less risk of mortality compared with those with a BMI of 18.5 to 24.9 kg/m(2) (hazard ratio 0.58, 95% confidence interval 0.47 to 0.72, p <0.0001 and hazard ratio 0.69, 95% confidence interval 0.57 to 0.82, p <0.0001, respectively). In conclusion, higher survival rate in patients with higher BMI as previously described in patients with hypertension, heart failure, and CAD extends to patients with suspected CAD referred for stress echocardiography, independent of exercise capacity.

23993126
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Prognostic importance of coronary anatomy and left ventricular ejection fraction despite optimal therapy: assessment of residual risk in the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation Trial.

Prognostic importance of coronary anatomy and left ventricular ejection fraction despite optimal therapy: assessment of residual risk in the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation Trial.
Am Heart J. 2013 Sep;166(3):481-7
Authors: Mancini GB, Hartigan PM, Bates ER, Chaitman BR, Sedlis SP, Maron DJ, Kostuk WJ, Spertus JA, Teo KK, Dada M, Knudtson M, Berman DS, Booth DC, Boden WE, Weintraub WS

BACKGROUND: It is unknown if baseline angiographic findings can be used to estimate residual risk of patients with chronic stable angina treated with both optimal medical therapy (OMT) and protocol-assigned or symptom-driven percutaneous coronary intervention (PCI).
METHODS: Death, myocardial infarction (MI), and hospitalization for non-ST-segment elevation acute coronary syndrome were adjudicated in 2,275 COURAGE patients. The number of vessels diseased (VD) was defined as the number of major coronary arteries with ≥50% diameter stenosis. Proximal left anterior descending, either isolated or in combination with other disease, was also evaluated. Depressed left ventricular ejection fraction (LVEF) was defined as ≤50%. Cox regression analyses included these anatomical factors as well as interaction terms for initial treatment assignment (OMT or OMT + PCI).
RESULTS: Percutaneous coronary intervention and proximal left anterior descending did not influence any outcome. Death was predicted by low LVEF (hazard ratio [HR] 1.86, CI 1.34-2.59, P < .001) and VD (HR 1.45, CI 1.20-1.75, P < .001). Myocardial infarction and non-ST-segment elevation acute coronary syndrome were predicted only by VD (HR 1.53, CI 1.30-1.81 and HR 1.24, CI 1.06-1.44, P = .007, respectively).
CONCLUSIONS: In spite of OMT and irrespective of protocol-assigned or clinically driven PCI, LVEF and angiographic burden of disease at baseline retain prognostic power and reflect residual risk for secondary ischemic events.

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Appropriate test selection for single-photon emission computed tomography imaging: association with clinical risk, posttest management, and outcomes.

Appropriate test selection for single-photon emission computed tomography imaging: association with clinical risk, posttest management, and outcomes.
Am Heart J. 2013 Sep;166(3):581-8
Authors: Aldweib N, Negishi K, Seicean S, Jaber WA, Hachamovitch R, Cerqueira M, Marwick TH

BACKGROUND: Appropriate use criteria (AUC) for stress single-photon emission computed tomography (SPECT) are only one step in appropriate use of imaging. Other steps include pretest clinical risk evaluation and optimal management responses. We sought to understand the link between AUC, risk evaluation, management, and outcome.
METHODS: We used AUC to classify 1,199 consecutive patients (63.8 ± 12.5 years, 56% male) undergoing SPECT as inappropriate, uncertain, and appropriate. Framingham score for asymptomatic patients and Bethesda angina score for symptomatic patients were used to classify patients into high (≥5%/y), intermediate, and low (≤1%/y) risk. Subsequent patient management was defined as appropriate or inappropriate based on the concordance between management decisions and the SPECT result. Patients were followed up for a median of 4.8 years, and cause of death was obtained from the social security death registry.
RESULTS: Overall, 62% of SPECTs were appropriate, 18% inappropriate, and 20% uncertain (only 5 were unclassified). Of 324 low-risk studies, 108 (33%) were inappropriate, compared with 94 (15%) of 621 intermediate-risk and 1 (1%) of 160 high-risk studies (P < .001). There were 79 events, with outcomes of inappropriate patients better than uncertain and appropriate patients. Management was appropriate in 986 (89%), and appropriateness of patient management was unrelated to AUC (P = .65).
CONCLUSION: Pretest clinical risk evaluation may be helpful in appropriateness assessment because very few high-risk patients are inappropriate, but almost half of low-risk patients are inappropriate or uncertain. Appropriate patient management is independent of appropriateness of testing.

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Sunday, February 16, 2014

Impact of choice of imaging modality accompanying outpatient exercise stress testing on outcomes and resource use after revascularization for acute coronary syndromes.

Impact of choice of imaging modality accompanying outpatient exercise stress testing on outcomes and resource use after revascularization for acute coronary syndromes.
Am Heart J. 2013 Oct;166(4):783-791.e4
Authors: Federspiel JJ, Shah BR, Shaw LJ, Masoudi FA, Chang PP, Stearns SC, Mudrick DW, Cowper PA, Green CL, Douglas PS

BACKGROUND: Exercise stress testing is commonly obtained after percutaneous coronary intervention (PCI) performed for acute coronary syndromes (ACS). We compared the relationships between exercise echocardiography and nuclear testing after ACS-related PCI on outcomes and resource use.
METHODS: Longitudinal observational study using fee-for-service Medicare claims to identify patients undergoing outpatient exercise stress testing with imaging within 15 months after PCI performed for ACS between 2003 and 2004.
RESULTS: Of 63,100 patients undergoing stress testing 3 to 15 months post-PCI, 31,731 (50.3%) underwent an exercise stress test with imaging. Among 29,279 patients undergoing exercise stress testing with imaging, 15.5% received echocardiography. Echocardiography recipients had higher rates of repeat stress testing (adjusted hazard ratio [HR] 2.60, CI 2.19-3.10) compared with those undergoing nuclear imaging in the 90 days after testing, but lower rates of revascularization (adjusted HR 0.87, CI 0.76-0.98) and coronary angiography (adjusted HR 0.88, CI 0.80-0.97). None of these differences persisted subsequent to 90 days after stress testing. Rates of death and readmission for myocardial infarction rates were similar. Total Medicare payments were lower initially after echocardiography (incremental difference $498, CI 488-507), an effect attributed primarily to lower reimbursement for the stress test itself, but not significantly different after 14 months after testing.
CONCLUSIONS: In this study using administrative data, echocardiography recipients initially had fewer invasive procedures but higher rates of repeat testing than nuclear testing recipients. However, these differences between echo and nuclear testing did not persist over longer time frames.

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Saturday, February 15, 2014

Characteristics and outcomes of patients who achieve high workload (10 metabolic equivalents) during treadmill exercise echocardiography.

Characteristics and outcomes of patients who achieve high workload (≥10 metabolic equivalents) during treadmill exercise echocardiography.
Mayo Clin Proc. 2013 Dec;88(12):1408-19
Authors: Fine NM, Pellikka PA, Scott CG, Gharacholou SM, McCully RB

OBJECTIVE: To determine the frequency and prognostic significance of abnormal exercise echocardiographic results for patients achieving a workload of 10 or more metabolic equivalents during treadmill exercise echocardiography.
PATIENTS AND METHODS: Patients who underwent treadmill exercise echocardiography from November 1, 2003, through December 31, 2008, and exercised for 9 or more minutes using the Bruce protocol (N=7236) were included. Clinical and exercise echocardiographic characteristics and outcomes were evaluated. Variables associated with abnormal exercise echocardiographic results and mortality were identified.
RESULTS: Exercise echocardiographic results were positive for ischemia in 862 patients (12%). Extensive ischemia developed in 265 patients (4%). For patients with normal exercise echocardiographic results, all-cause and cardiovascular mortality rates were 0.30% and 0.05% per person-year of follow-up, respectively. For patients who had extensive ischemia, all-cause and cardiovascular mortality rates were 0.84% and 0.25% per person-year of follow-up, respectively. Patients at highest risk were those who had extensive and severe regional wall motion abnormalities at rest (n=58), and their all-cause and cardiovascular mortality rates were 2.65% and 0.76% per person-year of follow-up. Exercise echocardiographic variables did not identify sizable patient subgroups at risk for death and did not provide incremental prognostic information (C statistic was 0.74 compared with 0.73 for the clinical plus exercise electrocardiography model).
CONCLUSION: Patients achieving a workload of 10 or more metabolic equivalents during treadmill exercise testing do not often have extensive ischemic abnormalities on exercise echocardiography. Although exercise echocardiographic results provide some prognostic information, it is not of incremental value for these patients, whose short-term and medium-term prognosis is excellent.

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Effects of ventricular insertion sites on rotational motion of left ventricular segments studied by cardiac MR.

Effects of ventricular insertion sites on rotational motion of left ventricular segments studied by cardiac MR.

Br J Radiol. 2013 Nov;86(1031):20130326

Authors: Codreanu I, Robson MD, Rider OJ, Pegg TJ, Dasanu CA, Jung BA, Clarke K, Holloway CJ


OBJECTIVE: Obtaining new details for rotational motion of left ventricular (LV) segments using velocity encoding cardiac MR and correlating the regional motion patterns to LV insertion sites.
METHODS: Cardiac MR examinations were performed on 14 healthy volunteers aged between 19 and 26 years. Peak rotational velocities and circumferential velocity curves were obtained for 16 ventricular segments.
RESULTS: Reduced peak clockwise velocities of anteroseptal segments (i.e. Segments 2 and 8) and peak counterclockwise velocities of inferoseptal segments (i.e. Segments 3 and 9) were the most prominent findings. The observations can be attributed to the LV insertion sites into the right ventricle, limiting the clockwise rotation of anteroseptal LV segments and the counterclockwise rotation of inferoseptal segments as viewed from the apex. Relatively lower clockwise velocities of Segment 5 and counterclockwise velocities of Segment 6 were also noted, suggesting a cardiac fixation point between these two segments, which is in close proximity to the lateral LV wall.
CONCLUSION: Apart from showing different rotational patterns of LV base, mid ventricle and apex, the study showed significant differences in the rotational velocities of individual LV segments. Correlating regional wall motion with known orientation of myocardial aggregates has also provided new insights into the mechanisms of LV rotational motions during a cardiac cycle. Advances in knowledge: LV insertion into the right ventricle limits the clockwise rotation of anteroseptal LV segments and the counterclockwise rotation of inferoseptal segments adjacent to the ventricular insertion sites. The pattern should be differentiated from wall motion abnormalities in cardiac pathology.

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