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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