Regional wall motion abnormalities in transthoracic echocardiography in patients with significant coronary artery disease and coronary collateral circulation in adults.

BACKGROUND: Coronary collateral circulation is a common finding in patients with chronic total occlusions (CTOs) resulting from chronic coronary artery disease (CAD). Regional wall motion abnormalities (RWMA) on transthoracic echocardiography (TTE) can be used for the diagnosis of CAD. However, little work has been done to investigate the impact of collateral vessels on the diagnostic accuracy of resting TTE for CAD. METHODS: A retrospective chart review was conducted of adults who received a resting TTE and cardiac catheterization within 30 days over a 4-year period at the Temple Baylor Scott & White echocardiography laboratory. Exclusion criteria included catheterization without coronary angiography and prior history of CAD, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG). We analyzed RWMA on TTE in patients with CAD and coronary collateral circulation on cardiac catheterization to assess for correlation. RESULTS: Of the 753 patients were included in this study, 453 had CAD, 272 had both CAD and RWMA, 111 had collateral circulation, and 73 had collateral circulation and RWMA. There was no significant difference in RWMA in patients with CAD with and without collateral circulation. There was no significant difference in the sensitivity (60.0 % vs 59.2 %) and specificity (78.4 % vs 73.9 %) after collateral-adjusted interpretation of RWMA and CAD (p = 0.3). DISCUSSION: Our results suggest the average coronary collateral system is of insufficient clinical significance to prevent the development of RWMA on resting TTE.

Acute Coronary Syndrome Revascularization Strategies With Multivessel Coronary Artery Disease.

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multivessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multicentered, retrospective observational study from a large hospital system in the United States. We abstracted data in patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG, or medical management (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and gender. There were 295 patients with CABG (median age 66 years [interquartile range 59.7 to 73.1]; 73% male), 1,559 patients with PCI (median age 68.3 years [interquartile range 60 to 76.6]; 69.1% male], and 307 patients with MM (median age 70 years [60.9 to 77.1] 74% male]. Patients revascularized with PCI had greater all-cause mortality at 1 year (14.1% vs 5.1%; hazard ratio 2.4, confidence interval [1.5 to 3.8], p <0.001) and similar mortality to MM (13.4%). CABG also showed a reduced 1-year MI rate compared with PCI (1.7% vs 3.9%; hazard ratio 0.36, confidence interval 0.21 to 0.61, p ≤0.001), with a similar 1-year rate of MI to MM (3.9%). In conclusion, CABG is associated with lower mortality than are PCI and MM, and repeat ACS events at 1 year in patients with ACS and MV-CAD.

Aortic valve perforation secondary to blunt force trauma.

Blunt chest trauma has seldom been reported as a cause of rupture of an aortic valve cusp. We report the case of a 63-year-old man who had a motor vehicle collision resulting in transection of the descending thoracic aorta, splenic pseudoaneurysm, and rupture of an aortic valve cusp causing severe aortic regurgitation. Despite replacement of the aortic valve, he died of multiorgan failure.

Dual antiplatelet compared to triple antithrombotic therapy in anterior wall acute myocardial infarction complicated by depressed left ventricular ejection fraction.

Current guidelines recommend triple antithrombotic therapy (TT) consisting of warfarin, aspirin, and a P2Y12 inhibitor following an anterior ST elevation myocardial infarction (STEMI) complicated by extensive wall motion abnormalities. This recommendation, however, is based on data collected before percutaneous coronary intervention (PCI) became the standard of care for the treatment of STEMI. We designed a retrospective study of patients who received PCI for anterior STEMI over an 8-year period to compare rates of thromboembolic and bleeding events between patients receiving dual antiplatelet therapy (DAPT) and those receiving TT, including warfarin. Patients were included if the predischarge echocardiogram showed extensive wall motion abnormality and an ejection fraction ≤35%. Patients with known left ventricular thrombus were excluded. A total of 124 patients met the criteria, with 80 patients in the DAPT group and 44 in the TT group. The median age was 58 years in the TT group and 64 years in the DAPT group (P < 0.04), with an average ejection fraction of 31%. Thromboembolic events occurred in 4 patients (5%) in the DAPT group compared with 3 patients (6.8%) in the TT group (P = 0.70). Bleeding occurred in 2 patients in the DAPT group and 4 patients in the TT group (2.5% in DAPT vs. 9.1% in TT group, P = 0.18). No differences in rates of clinical embolism or left ventricular thrombus were found. Our data support recent findings that warfarin may not be indicated for patients following PCI for anterior STEMI, even when significant wall motion abnormalities and reduced ejection fraction ≤35% are present.

Recurrent primary cardiac lymphoma on aortic valve allograft: implications for therapy.

Primary malignant cardiac lymphomas associated with grafts are extremely rare: to our knowledge, only 6 cases of prosthesis-associated B-cell lymphoma have been reported. Ours is the first report of recurrent diffuse large B-cell lymphoma associated with aortic valve allografts. We treated a 60-year-old man who presented in early 2007 with aortic valve endocarditis. He underwent aortic valve replacement with an allograft; the resected native valve showed active endocarditis without tumor. In January 2011, the patient underwent repeat aortic valve replacement because of symptomatic aortic regurgitation. The explanted valve specimen displayed diffuse large B-cell lymphoma. In September 2011, the patient presented with fever and a mass around the aortic valve. He died in January 2012. On autopsy, the explanted replacement valve displayed recurrent diffuse large B-cell lymphoma. The recurrent lymphoma on a new graft leads us to believe that this tumor is more aggressive than had been thought. We propose early systemic chemotherapy, in addition to tumor resection, for the possibility of a better prognosis. We discuss our patient's case and review the relevant medical literature.

The pocket echocardiograph: a pilot study of its validation and feasibility in intubated patients.

BACKGROUND: The clinical use of miniaturized echocardiograph devices is expanding due to the potential to rapidly assess cardiac function in the critically ill patient. Novice echocardiographers have used the pocket echocardiograph (PE) to estimate ejection fraction in ambulatory patients, but have not evaluated intubated patients. We hypothesize that a novice echocardiographer can use PE to acquire interpretable cardiac images, and provide an accurate tool for estimating ejection fraction. METHODS: Subjects scheduled for cardiac surgery underwent blinded transesophageal echocardiography (TEE) and PE during a hemodynamically stable period after endotracheal intubation prior to incision. A single cardiology fellow acquired all PE images. The fellow and an experienced echocardiographer interpreted PE studies offline in a blinded fashion, visually estimating ejection fraction and assigning an image quality grade. Comparisons were made to the TEE study. RESULTS: Subjects (n = 22) were 81% male; age 69 ± 9 years, and had a mean ejection fraction of 51% ± 10.0%. Parasternal images were adequate in the vast majority of patients (77%), limited in 14%, and unacceptable in 9%, while apical (41%, 45%, and 14%) and subcostal (36%, 32%, and 32%) image quality was inferior. Ejection fraction showed fair correlation, bias, and limits of agreement for the fellow's interpretation (r = 0.50, 4.9%, ± 20.7%), with stronger association for the experienced echocardiographer (r = 0.76, 3.3%, ± 16.6%). CONCLUSION: A novice echocardiographer using PE can acquire interpretable images in the majority of intubated patients. Novice and expert echocardiographers can reasonably estimate ejection fraction using PE. PE may allow novice echocardiographers to rapidly assess cardiac function in intubated patients.

Effect of renal function on survival after implantable cardioverter defibrillator placement.

Implantable cardioverter defibrillators (ICDs) are effective at reducing arrhythmic death in patients with left ventricular dysfunction, but few studies have investigated the outcomes after ICD implantation in patients with chronic kidney disease (CKD). We conducted a 2-center retrospective study of 958 patients who had undergone ICD placement for primary prevention from the 2000 to 2006. The patients were stratified into 5 groups according to the CKD stage (stage 1, glomerular filtration [GFR] 90 to 120 ml/min; stage 2, GFR 60 to 89 ml/min; stage 3, GFR 30 to 59 ml/min; stage 4, GFR 15 to 29 ml/min; and stage 5, GFR 0 to 14 ml/min). The primary end point was death at 1 year. Of the 958 patients included in our analysis, 73 (7.6%) had died at 1 year. The mortality rate at 1 year increased with worsening CKD (1.8%, 5.3%, 9.0%, 22%, and 38% for stage 1 to 5, respectively, p <0.0001 for group). CKD was an independent predictor of mortality; hazard ratio 1.0, 1.075 (95% confidence interval 0.578 to 2.0), 1.372 (95% confidence interval 0.736 to 2.556), 3.092 (95% confidence interval 1.52 to 6.29), and 10.15 (95% confidence interval 4.25 to 24.23) for stage 1 to 5, respectively (p <0.0001 for group). Patients with CKD and left ventricular dysfunction have a poor prognosis despite ICD placement. The 1-year mortality increased as the renal function decreased. In conclusion, physicians should be cognizant of the prognosis when considering whether an ICD should be implanted in patients with CKD.

The pocket echocardiograph: validation and feasibility.

BACKGROUND: A new, miniaturized ultrasound device, the pocket echocardiograph (PE), is highly portable and can be carried inside a lab-coat pocket. Studies of this device are limited and have not examined the use by novice echocardiographers. We hypothesize that a novice echocardiographer can use PE to produce interpretable cardiac images, and that both novice and expert echocardiographers can use PE to accurately quantify ejection fraction. METHODS: Unselected subjects (n = 40) in an echocardiography laboratory underwent blinded formal transthoracic echocardiography (TTE) and PE (Acuson P10, Siemens, Mountain View, CA, USA). A cardiology fellow with 2 months of echocardiography training acquired PE images. The fellow and an experienced echocardiographer interpreted the PE studies offline in a blinded fashion. To assess adequacy, studies were graded as technically adequate, limited, or inadequate. A visual estimation of ejection fraction was made. Comparisons were made to the formal reported TTE. RESULTS: Subjects were heterogeneous, 43% male; age 64 ± 17 years, and ejection fraction 52.4%± 12.3%. All PE studies were interpretable, and the vast majority of PE and TTE images were considered technically adequate (77.5% and 85% respectively; P = 0.32). Ejection fraction showed a good correlation, bias, and limits of agreement for the fellow's interpretation (r = 0.78, -5.9%, ±16.6%) with stronger association for the experienced echocardiographer (r = 0.88, -0.8%, ±11.4%). CONCLUSION: Novice echocardiographers using the PE can produce adequate quality images. Both expert and novice echocardiographers can use PE to quantify ejection fraction over a broad range of patients. The device's low cost and portability may greatly expand the availability of bedside echocardiography for routine or urgent cardiovascular assessment.

Echocardiographic tamponade in severe left ventricular dysfunction: the impact of small pericardial effusion and the absence of pulsus paradoxicus.

Cardiac tamponade is a commonly encountered clinical entity. It is a clinical syndrome characterized by elevated filling pressures, pulsus paradoxicus, and eventually, hypotension. It occurs as intrapericardial pressure exceeds intracardiac pressures altering ventricular filling. Generally tamponade occurs with moderate or large accumulations of pericardial fluid that result in an increase in pericardial pressure. It is well known that rapid accumulation of relatively small volumes of fluid can cause tamponade pathophysiology. We report a less well-recognized phenomenon. In the setting of severe left ventricular dysfunction, small volumes of pericardial fluid can result in excessive intrapericardial pressure and echocardiographic tamponade in the absence of a significant pulsus paradoxicus.