Association Between Inpatient Echocardiography Use and Outcomes in Adult Patients With Acute Myocardial Infarction.

IMPORTANCE: Guidelines recommend that patients with acute myocardial infarction (AMI) undergo echocardiography for assessment of cardiac structure and ejection fraction, but little is known about the association between echocardiography as used in routine clinical management of AMI and patient outcomes. OBJECTIVE: To examine the association between risk-standardized hospital rates of transthoracic echocardiography and outcomes. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study of data from 397 US hospitals that contributed to the Premier Healthcare Informatics inpatient database from January 1, 2014, to December 31, 2014, used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify 98 999 hospital admissions for patients with AMI. Data were analyzed between October 2017 and January 2019. EXPOSURES: Rates of transthoracic echocardiography. MAIN OUTCOMES AND MEASURES: Inpatient mortality, length of stay, total inpatient costs, and 3-month readmission rate. RESULTS: Among the 397 hospitals with more than 25 admissions for AMI in 2014, a total of 98 999 hospital admissions for AMI were identified for analysis (38.2% women; mean [SD] age, 66.5 [13.6] years), of which 69 652 (70.4%) had at least 1 transthoracic echocardiogram performed. The median (IQR) hospital risk-standardized rate of echocardiography was 72.5% (62.6%-79.1%). In models that adjusted for hospital and patient characteristics, no difference was found in inpatient mortality (odds ratio [OR], 1.02; 95% CI, 0.88-1.19) or 3-month readmission (OR, 1.01; 95% CI, 0.93-1.10) between the highest and lowest quartiles of echocardiography use (median risk-standardized echocardiography use rates of 83% vs 54%, respectively). However, hospitals with the highest rates of echocardiography had modestly longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41; P = .01) and higher mean costs ($3164; 95% CI, $1843-$4485; P < .001) per admission compared with hospitals in the lowest quartile of use. Multiple sensitivity analyses yielded similar results. CONCLUSIONS AND RELEVANCE: In patients with AMI, hospitals in the quartile with the highest rates of echocardiography showed greater hospital costs and length of stay but few differences in clinical outcomes compared with hospitals in the quartile with the lowest rates of echocardiography. These findings suggest that more selective use of echocardiography might be used without adversely affecting clinical outcomes, particularly in hospitals with high rates of echocardiography use.

Ruptured Sinus of Valsalva Aneurysm Associated with Situs Ambiguus, Isolated Levocardia, and Polysplenia.

Aneurysm of the sinus of Valsalva, a rare cardiac condition, results from dilation of an aortic sinus. Sudden aneurysm rupture can trigger rapidly progressive heart failure. We discuss the case of a 57-year-old woman with situs ambiguus, isolated levocardia, and polysplenia who presented with acute-onset heart failure. Transesophageal echocardiograms revealed an aneurysm of the right coronary sinus of Valsalva that had ruptured into the right atrial cavity. The patient underwent successful surgical repair. To our knowledge, this is the first report of a sinus of Valsalva aneurysm in a patient with this combination of congenital abnormalities. We briefly review the association between congenital heart disease, situs ambiguus, and ciliary dysfunction.

Cardio-embolic stroke following remote blunt chest trauma.

A cardio-embolic stroke as a sequela of remote blunt chest trauma is a rare clinical presentation. Blunt chest trauma can cause various acute cardiac complications like arrhythmias, cardiac contusion etc. However, delayed consequences such as left ventricular thrombus resulting in thromboembolic phenomena are reported infrequently. A 30-year-old healthy man presented to an outside facility with transient neurological deficits. An MRI brain showed lesions suggestive of embolic etiology. A trans-thoracic echocardiogram (TTE) showed a 1.5 × 1.5 cm mass present in the left ventricular (LV) apex. Patient was transferred to our institution for cardiac surgery evaluation. On detailed questioning, he reported an incident of blunt chest trauma during a martial arts exhibition fight that took place 2 years back. Given this history, a cardiac catheterization was done, which showed 30% stenosis in mid-left anterior descending artery (LAD) without any other significant obstructive lesion. A trans-esophageal echocardiogram (TEE) showed akinesis of the LV apex and confirmed TTE finding of a mass, consistent with an apical thrombus. Surgery was deferred and patient was started on anticoagulation. A cardiac MRI done 2 weeks later showed evidence of apical infarction in the LAD territory. LAD is the most commonly affected coronary vessel by blunt traumatic injuries, likely due to its vulnerable anatomical position on the anterior aspect of the heart. A variety of mechanisms including intimal tear, rupture and spasm have been implicated in the pathogenesis of myocardial infarction after blunt chest trauma.

Allometric model improves scaling of left atrial size in obese population: the use of body weight containing variables is challenged.

BACKGROUND: Scaling left atrial (LA) size remains a challenge. An allometric model using body weight (BW) as scaling variable was recently proposed. We sought to examine the performance of this model in an obese population. METHODS: A total of 266 consecutive overweight (110) and obese subjects (class I, II, and III obese 81, 47, and 28, respectively) were studied; 46 normal subjects with normal body mass index (BMI) served as controls. LA dimension (LAD) was scaled to BW, body surface area (BSA), BMI and height, respectively, using both isometric and allometric models. RESULTS: There were no significant differences in age, gender, or height among the five groups. The prevalence of comorbid conditions, wall thickness, E/E' and LAD measures increased significantly with increasing weight group (P < 0.01-0.001). With the isometric model, LAD corrected by BW, BSA, and BMI significantly but paradoxically decreased across the groups (P < 0.05-0.001). With the allometric model, LAD overcorrection by BM, BSA, and BMI was improved, but remained in the class III obese group. In contrast, scaling LAD to height showed significant and graded increase across the five groups in accordance with the increases of BMI, E/E' and the prevalence of comorbid conditions. CONCLUSION: All isometric models that correct LAD by BW or BW containing variables underestimate LA size in overweight and obese groups. The allometric model using height provides more consistent results and should be preferred to models using BW or BW containing variables in scaling LAD in obese population.

Nonobstructive membranes of the left atrial appendage cavity: report of three cases.

A membranous structure causing functional stenosis at the mouth of the left atrial appendage (LAA) has been reported. In this study we describe the presence of nonobstructive membranes traversing the cavity of the LAA found incidentally on transesophageal echocardiography (TEE).