Learning curve for the acquisition of 20 standard two-dimensional images in advanced perioperative transesophageal echocardiography: a prospective observational study.

BACKGROUND: Learning to perform intraoperative transesophageal echocardiography takes time and practice. We aimed to determine the cumulative success rate in the first 20 intraoperative transesophageal echocardiography cases performed by trainee anesthesiologists with no transesophageal echocardiography experience. METHODS: This prospective observational study included nine anesthesiologists (four cardiovascular and thoracic anesthesia fellows and five short-course perioperative intraoperative transesophageal echocardiography trainees). Overall, 180 studies self-performed by the trainees were reviewed by certified reviewers. A study was considered successful when at least 15 qualified images were collected within 30 min. The cumulative success of each trainee was used as a surrogate of a basic two-dimensional intraoperative transesophageal echocardiography learning curve. RESULTS: The participants comprised three male and six female anesthesiologists aged 29-43 years with 2-13 years of work experience. Most studies (146/180, 81.11%) were completed within 30 min, and the cumulative success rate was 70-90% (average 82.78 ± 6.71%). The average cumulative success rate in the short-course group (85 ± 7.07%) was higher than that in the official cardiovascular and thoracic fellow trainee group (80 ± 7.07%). The recommended caseload for a 80-100% success rate was 18-20 cases (95% confidence interval, 0.652-0.973). The CUSUM method analysis confirmed that the lower decision limit was crossed after 20 TEE studies among those achieved competence. CONCLUSIONS: We recommended a 18-20 caseload for a target success rate of 80-100% in studies performed by trainees with no previous experience. Our findings will enable the development of programs to train anesthesiologists in intraoperative transesophageal echocardiography.

Preprocedural and procedural variables that predict new-onset conduction disturbances after transcatheter aortic valve replacement.

BACKGROUND: Conduction disturbances are a common complication after transcatheter aortic valve replacement (TAVR). The aim of this study was to investigate the preprocedural and procedural variables that predict new-onset conduction disturbances post-TAVR (hereafter CD/CDs). METHODS: Consecutive patients who underwent TAVR during December 2009-March 2021 at the Faculty of Medicine Siriraj Hospital, Mahidol University-Thailand's largest national tertiary referral center-were enrolled. Patients with prior implantation of a cardiac device, periprocedural death, or unsuccessful procedure were excluded. Clinical and electrocardiographic data, preprocedural imaging, including membranous septum (MS) length, and procedural variables, including implantation depth (ID), were analyzed. CD was defined as new left or right bundle branch block, significant intraventricular conduction disturbance with QRS interval ≥ 120 ms, new high-grade atrioventricular block, or complete heart block. Multivariate binary logistic analysis and receiver operating characteristic (ROC) curve analysis were used to identify independent predictors and the optimal ∆MSID (difference between the MS length and ID) cutoff value, respectively. RESULTS: A total of 124 TAVR patients (mean age: 84.3 ± 6.3 years, 62.1% female) were included. The mean Society of Thoracic Surgeons score was 7.3%, and 85% of patients received a balloon expandable transcatheter heart valve. Thirty-five patients (28.2%) experienced a CD, and one-third of those required pacemaker implantation. The significant preprocedural and procedural factors identified from univariate analysis included intraventricular conduction delay, mitral annular calcification, MS length ≤ 6.43 mm, self-expanding device, small left ventricular cavity, and ID ≥ 6 mm. Multivariate analysis revealed MS length ≤ 6.43 mm (adjusted odds ratio [aOR] 9.54; 95% CI 2.56-35.47; p = 0.001) and ∆MSID < 0 mm (adjusted odds ratio [aOR] 10.77; 95% CI 2.86-40.62; p = < 0.001) to be independent predictors of CD. The optimal ∆MSID cutoff value for predicting conduction disturbances was less than 0 mm (area under the receiver operating characteristic curve [AuROC]: 0.896). CONCLUSION: This study identified MS length ≤ 6.43 mm and ∆MSID < 0 mm as independent predictors of CDs. ∆MSID < 0 was the strongest and only modifiable predictor. Importantly, we expanded the CD criteria to cover all spectrum of TAVR-related conduction injury to lower the threshold of this sole modifiable risk. The optimal ∆MSID cutoff value was < 0 mm. TRIAL REGISTRATION: TCTR, TCTR20210818002. Registered 17 August 2021-Retrospectively registered, http://www.thaiclinicaltrials.org/show/TCTR 20210818002.

Chronic Dissection of Left Sinus of Valsalva Obscuring Left Main Coronary Artery.

Coronary angiography in a 44-year-old woman shows chronic dissection of the left sinus of Valsalva, totally obscuring the LMCA, with good collaterals supplying the left coronary system from the right coronary artery.

Effect of Breast Sling Use on Transthoracic Echocardiographic Examination Time and Image Quality in Women with Large Breasts.

BACKGROUND: Transthoracic echocardiographic examinations in women with large breasts are technically demanding and can lead to suboptimal image quality, excessive scan time, and cause pain and discomfort to patients. OBJECTIVE: Evaluate the effects of self-made breast sling used during transthoracic echocardiographic examination on scanning time, image quality, pain, and satisfaction in women with large breasts. MATERIAL AND METHOD: A self-made breast sling was developed by the study team and tested in 26 women with bra cup size of C or larger, who were scheduled for transthoracic echocardiography. Each patient underwent transthoracic echocardiographic examination twice, with and without breast sling use. The sequence of the examinations was determined at random. The primary outcome was scan time in apical views. Secondary outcomes included total scan time, image quality in apical views (qualitative scores), patients' and sonographers' pain (qualitative scores), and patients' satisfaction (qualitative scores). Outcomes were compared within individual subjects. RESULTS: The use of self-made breast sling did not reduce scan time in apical views (mean difference 2.8 minutes, p = 0.053), but it reduced total scan time (mean difference 5.9 minutes, p = 0.04). Breast sling use was not associated with improvement in image quality scores (p = 0.59), patients' pain (p = 0.21), and sonographers' shoulder-back-neck pain (p = 0.052). It improved patients' satisfaction (p = 0.01) and sonographers' wrist pain (p = 0.035). CONCLUSION: In women with large breasts who required transthoracic echocardiographic examination, the use of self-made breast sling did not improve scan time and image quality in apical views. It may improve total scan time, patients' satisfaction, and sonographers' wrist pain.

Prevalence of dyslipidemia and goal attainment after initiating lipid-modifying therapy: a Thai multicenter study.

Previous studies focused on attaining low-density lipoprotein cholesterol (LDL-C) goals after lipid-modifying therapy (LMT), but data on achieving normal levels of triglyceride and high-density lipoprotein cholesterol (HDL-C) are limited. We reviewed medical records of patients initiated on LMT. High risk was defined as patients with coronary heart disease, diabetes, or 10-year Framingham risk >20%. Among 806 patients enrolled, 429 were at high risk. Prior to initiation of LMT, 66%, 35%, and 44% overall and 69%, 35%, and 45% in the high-risk group had elevated LDL-C, elevated triglyceride, and low HDL-C, respectively. After 12 months of LMT, 21%, 32%, and 39% overall and 26%, 25%, and 43% in the high-risk group still had elevated LDL-C, elevated triglyceride, and low HDL-C, respectively. Approximately 1 of 5 patients continued to experience elevated LDL-C coupled with elevated triglyceride and/or low HDL-C. In conclusion, a substantial proportion of patients initiated on LMT continued to have lipid abnormalities.

Cardiac MR imaging of nonischemic cardiomyopathies: imaging protocols and spectra of appearances.

Recent technologic advances in cardiac magnetic resonance (MR) imaging have resulted in images with high spatial and temporal resolution and excellent myocardial tissue characterization. Cardiac MR is a valuable imaging technique for detection and assessment of the morphology and functional characteristics of the nonischemic cardiomyopathy. It has gained acceptance as a standalone imaging modality that can provide further information beyond the capabilities of traditional modalities such as echocardiography and angiography. Black-blood fast spin-echo MR images allow morphologic assessment of the heart with high spatial resolution, while T2-weighted MR images can depict acute myocardial edema. Contrast material-enhanced images can depict and be used to quantify myocardial edema, infiltration, and fibrosis. This review presents recommended cardiac MR protocols for and the spectrum of imaging appearances of the nonischemic cardiomyopathies.

Prognostic value of combined magnetic resonance myocardial perfusion imaging and late gadolinium enhancement.

Late gadolinium enhancement (LGE) and myocardial perfusion study by cardiac magnetic resonance (CMR) have a diagnostic and prognostic value in patients with suspected coronary artery disease (CAD). The purpose of this study was to determine the prognostic value of combined myocardial perfusion CMR and LGE in patients with known or suspected CAD. We studied patients with known or suspected CAD. All patients underwent CMR for functional study, myocardial perfusion and LGE. Myocardial ischemia by CMR was defined as a perfusion defect in patients without LGE or a perfusion defect beyond the LGE area. Patients were followed up for cardiovascular outcomes including hard cardiac events (cardiac death or non-fatal myocardial infarction) and major adverse cardiac events (MACE) which included cardiac death, non-fatal myocardial infarction, hospitalization for unstable angina, and heart failure. There were a total of 587 men and 645 women. Average age was 64.6 ± 11.1 years. LGE was detected in 326 patients (26.5%). Myocardial ischemia by CMR was detected in 423 patients (34.3%). Average follow-up duration was 34.9 ± 15.6 months. Univariate analysis showed that age, diabetes, use of beta blocker, left ventricular ejection fraction, left ventricular mass, wall motion abnormality, LGE, and myocardial ischemia are predictors for hard cardiac events and MACE. Multivariable analysis revealed that myocardial ischemia was the strongest predictor for hard cardiac events and MACE. Other independent predictors were age, use of beta blocker, and left ventricular mass. Myocardial ischemia by CMR has an incremental prognostic value for cardiac events in patients with known or suspected CAD.

Prognostic value of late gadolinium enhancement in hypertensive patients with known or suspected coronary artery disease.

To determine the prognosis of a myocardial scar assessed by a late gadolinium enhancement (LGE) technique of cardiac magnetic resonance (CMR) in hypertensive patients with known or suspected coronary artery disease (CAD). Patients with systemic hypertension with known or suspected CAD without a clinical history of myocardial infarction were enrolled. All patients underwent CMR for assessment of cardiac function and LGE. Prognostic data was determined by the occurrence of a hard cardiac endpoint, defined as cardiac death or a non-fatal myocardial infarction, or major adverse cardiac events (MACEs), defined as cardiac death, a non-fatal myocardial infarction, or hospitalization due to heart failure, unstable angina, or life-threatening ventricular arrhythmia. A total of 1,644 patients were enrolled; 48% were males and the mean age was 65 +/- 11 years. The average follow-up time was 863 +/- 559 days. Four hundred fifty-three (28%) patients had LGE. LGE was the strongest and most independent predictor for hard events and MACEs with hazard ratios of 4.77 and 3.38, respectively. Other independent predictors of hard events and MACEs were left ventricular ejection fraction and mass, the use of a beta-blocker, and a history of heart failure. The risk of cardiac events increased as the extent of LGE increased; the hazard ratio was 12.74 for hard events for those with a LGE >20% of the myocardium. LGE is the most important and independent predictor for cardiac events in hypertensive patients with known or suspected CAD.

Cardiac tumors: optimal cardiac MR sequences and spectrum of imaging appearances.

OBJECTIVE: This article reviews the optimal cardiac MRI sequences for and the spectrum of imaging appearances of cardiac tumors. CONCLUSION: Recent technologic advances in cardiac MRI have resulted in the rapid acquisition of images of the heart with high spatial and temporal resolution and excellent myocardial tissue characterization. Cardiac MRI provides optimal assessment of the location, functional characteristics, and soft-tissue features of cardiac tumors, allowing accurate differentiation of benign and malignant lesions.

Comparison of diagnostic and prognostic value of different electrocardiographic criteria to delayed-enhancement magnetic resonance imaging for healed myocardial infarction.

The accuracy of various electrocardiographic (ECG) criteria for the diagnosis of healed myocardial infarction (MI) has never been validated. The objective of this study was to determine the accuracy and prognostic value of standard ECG criteria for the diagnosis of healed MI compared with cardiac magnetic resonance (CMR). Consecutive patients with known or suspected coronary artery disease who were referred for CMR were studied. Twelve-lead electrocardiography and CMR were performed the same day. A standard CMR protocol including a delayed-enhancement (DE) technique was performed. The prognostic value of using various ECG criteria and DE-CMR was assessed for the occurrence of cardiac death, nonfatal MI, or major adverse cardiac events. We studied 1,366 patients. Average follow-up was 31.4 +/- 15.8 months. Myocardial scar was detected in 507 patients (37.1%) using DE-CMR. Healed MI using various ECG criteria had sensitivity, specificity, and accuracy of 44% to 59%, 91% to 95%, and 75% to 79% compared with DE-CMR, respectively. Multivariable Cox regression analysis showed that myocardial scar using DE-CMR was the most powerful predictor for cardiac events, followed by left ventricular ejection fraction. In the absence of DE-CMR data, MI using European Society of Cardiology/American College of Cardiology (ESC/ACC) 2000 criteria was the most powerful predictor. In conclusion, various ECG criteria had limited sensitivity, but high specificity, for the diagnosis of healed MI compared with myocardial scar using DE-CMR. Myocardial scar, left ventricular ejection fraction, and MI using ESC/ACC 2000 criteria were important predictors for cardiac events.

Comparison of cardiovascular magnetic resonance of late gadolinium enhancement and diastolic wall thickness to predict recovery of left ventricular function after coronary artery bypass surgery.

BACKGROUND: The objective was to compare the value of late gadolinium enhancement (LGE) and end-diastolic wall thickness (EDWT) assessed by cardiovascular magnetic resonance (CMR) in predicting recovery of left ventricular function after coronary artery bypass surgery (CABG). METHODS: We enrolled patients with coronary artery disease and left ventricular ejection fraction < 45% who were scheduled for CABG. Regional contractility was assessed by cine CMR at baseline and 4 months after CABG. EDWT and LGE were assessed at baseline. Predictors for improvement of regional contractility were analyzed. RESULTS: We studied 46 men and 4 women with an average age of 61 years. Baseline left ventricular ejection fraction was 37 +/- 13%. A total of 2,020 myocardial segments were analyzed. Abnormal wall motion and the LGE area were detected in 1,446 segments (71.6%) and 1,196 segments (59.2%) respectively. Wall motion improvement was demonstrated in 481 of 1,227 segments (39.2%) that initially had wall motion abnormalities at baseline. Logistic regression analysis showed that the LGE area, EDWT and resting wall motion grade predicted wall motion improvement. Comparison of Receiver-Operator-Characteristic (ROC) curves demonstrated that the LGE area was the most important predictor (p < 0.001). Adding information from LGE to the EDWT can decrease the number of false predictions by EDWT alone from 483 to 127 segments. CONCLUSION: LGE and EDWT are independent predictors for functional recovery after revascularization. However, LGE appears to be a more important factor and independent of EDWT.

Quantification of nonculprit coronary lesions: comparison of cardiac 64-MDCT and invasive coronary angiography.

OBJECTIVE: The purpose of our study was to evaluate the accuracy of cardiac 64-MDCT to quantify the grade of stenosis of nonculprit lesions. SUBJECTS AND METHODS: Twenty-nine consecutive patients (23 men and six women; mean age, 62 +/- 10 years) presenting with acute coronary syndrome (ACS) had nonculprit coronary lesions of >or= 30% stenosis quantified on quantitative coronary angiography (QCA). Five 64-MDCT postprocessing techniques (maximum intensity projection [MIP], multiplanar reformat [MPR], cross-sectional area [CSA], and diameter and area derived from semiquantitative coronary software) were used to grade lesions. Two separate groups of two independent readers analyzed QCA and cardiac CT images using a 17-segment model. Coronary angiography was the reference standard. RESULTS: Nonculprit lesions were identified in 46 analyzable coronary segments. Subgrouping lesions on the basis of reference vessel diameter resulted in strong correlations for quantifying nonculprit lesions in vessels > 3 mm (R = 0.78-0.91, p < 0.01) but poor correlations for nonculprit lesions in vessels

64-slice multidetector computed tomography (MDCT) for detection of aortic regurgitation and quantification of severity.

BACKGROUND: Recent advances in 64-slice multidetector computed tomography (MDCT) provide an opportunity to assess coronary artery disease, left ventricular function and, potentially, valvular heart disease. OBJECTIVE: To determine the ability of 64-MDCT to both detect and to quantify the severity of aortic regurgitation (AR), as compared with transthoracic echocardiography (TTE). METHODS: We evaluated a total of 64 patients (43 males, mean age 63+/-11 years), 30 with varying severities of AR as assessed by TTE and 34 matched controls. The severity of AR by TTE was determined using the vena contracta, the ratio of jet to left ventricular outflow tract (LVOT) height, and the ratio of the jet to LVOT cross-sectional area. AR by MDCT was defined as a lack of coaptation of the aortic valve leaflets in diastole and, if detected, the maximum anatomic aortic regurgitant orifice was determined. RESULTS: All 34 control patients without AR were correctly identified by MDCT. There were 14 patients with mild AR, 10 with moderate AR, and 6 with severe AR by TTE. Of these patients, MDCT correctly identified 21 patients with AR (sensitivity 70%, specificity 100%, positive predictive value [PPV] 100%, and negative predictive value [NPV] 79%). Anatomic regurgitant orifice area measured by MDCT correlated well with the TTE-derived vena contracta (r=0.79, P<0.001), ratio of jet to LVOT height (r=0.79, P<0.001), and ratio of jet to LVOT cross-sectional area (r=0.75, P<0.001). CONCLUSIONS: Direct planimetric measurement of the aortic valve anatomic regurgitant orifice area on 64-MDCT provides an accurate, noninvasive technique for detecting and quantifying AR.

Culture-negative suppurative endocarditis causing severe mitral valve obstruction: complementary use of transesophageal and transthoracic echocardiography.

Infective endocarditis causes a myriad number of serious complications. Mitral valve obstruction is a rare complication. We report a 48-year-old Asian female who presented with two-week duration of fever and rapidly developed acute pulmonary edema and cardiogenic shock. Sequential transthoracic and transesophageal echocardiography revealed a rapidly growing vegetation on the anterior mitral leaflet with severe stenosis of the valve. All the blood cultures were negative. The patient underwent a successful mitral valve replacement. A review of 21 previously reported cases of mitral valve obstruction from endocarditis demonstrates the poor prognosis of this entity and supports early surgery.

Peripartum acute myocardial infarction: management perspective.

Acute myocardial infarction in pregnancy and puerperium is an uncommon event with substantial morbidity and mortality rates. Atherosclerosis may be the cause, but often the coronary arteries are healthy at angiography. In such cases, the suggested mechanism is a decreased coronary perfusion related to coronary spasm or in situ thrombosis. Most pregnant women who died after myocardial infarction did so at the time of initial infarction, and maternal mortality was greatest if the infarction was late in pregnancy. Increasing cardiovascular stresses of late pregnancy, especially when intensified by parturition, seriously compromise women with ischemic heart disease. Therefore, there should be efforts to limit myocardial oxygen demand throughout pregnancy, and particularly during parturition. It is important for diagnosis to have increased awareness of its possible occurrence. Although principles of management can be generalized, it is necessary to provide individualized care for these high-risk patients by a multidisciplinary team of cardiologists, anesthesiologists, and obstetricians.