Electrocardiogram Electrode Positioning on the Back During Echocardiography: An Exploratory Cross-Sectional Study.

BACKGROUND: ECG interpretation is sometimes difficult due to baseline fluctuations and electrode detachments when placed on the subjects' front side, leading to misinterpretation of the rhythms and phases of the cardiac cycle. We aimed to compare the differences in the wave amplitudes and respiratory variations between conventional ECG electrode positioning on the front side of patients and an alternative position on the backs of patients. METHODS: Echocardiography was performed in 85 patients lying in the left lateral position. We attached the red electrode to the right clavicle, the yellow to the left clavicle, and the green to the left lateral abdomen on the front side of the patients; on the back, we attached the electrode to the right clavicle, the right upper posterior iliac spine, and the left upper posterior iliac spine. RESULTS: The ECG monitor amplitudes were greater on the front side compared to the back side, but the BF-breath values were smaller on the back side (6.0 pixels) compared to the front side (10.5 pixels, p<0.05). The P wave amplitude divided by the BF-breath on the back side was greater than that seen on the front side (2.8 vs. 1.8, p<0.05), whereas the QRS amplitude divided by the BF-breath was 15.0 and 16.3, respectively (p=ns). CONCLUSION: As an alternative to front-side ECG monitoring, electrodes placed on the back can help avoid misinterpretation of the ECG rhythms and the phases of the cardiac cycle due to respiration during echocardiography.

Does Adult Spinal Deformity Affect Cardiac Function? A Prospective Perioperative Study.

STUDY DESIGN: Prospective comparative study. OBJECTIVE: The objective of this study was to investigate perioperative cardiac function using echocardiography in patients undergoing surgery for the adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Corrective surgery for ASD has increased, especially in older persons. However, perioperative complication rates remain high in ASD surgery, including cardiopulmonary complications. MATERIALS AND METHODS: This study included patients with ASD who underwent surgery between May 2016 and April 2018. A cardiologist performed all echocardiography imaging preoperatively and 2 weeks postoperatively. Left ventricular contractility was measured using left ventricular ejection fraction (LVEF), and right ventricular contractility was measured using tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular peak systolic velocity (S'). Spinopelvic radiographic parameters, the apices of thoracic kyphosis and lumbar lordosis, and the inflection point where the vertebral curvature changes from kyphosis to lordosis were also measured. Differences between preoperative and postoperative measurements for continuous variables were analyzed using a paired Student t test. Differences in continuous and categorical variables between two independent groups were analyzed using an unpaired Student t test and Fisher exact test, respectively. Multivariate logistic regression analyses were performed to detect influential factors. RESULTS: Sixty-one patients were included [12 males and 49 females; average age, 64.0 (22-84) yr]. LVEF, TAPSE, and S', respectively changed from 64.4%, 24.9 mm, and 14.3 cm/s to 65.4%, 25 mm, and 15 cm/s postoperatively with no significance. However, in LVEF<59.3% (average-1 SD), TAPSE<17 mm, and S'<11.8 cm/s cases, respectively, these increased significantly from 55.7%, 17.9 mm, and 10.5 cm/s to 60.9%, 21.4 mm, and 14.2 cm/s postoperatively ( P =0.036, 0.029, and 0.022, respectively). The LVEF<59.3% group showed a significantly lower inflection point level (1.5 vs. 2.9) preoperatively ( P =0.007). The S'<11.8 cm/s group showed significantly larger thoracic kyphosis (28.3° vs. 19.4°) preoperatively ( P =0.013). CONCLUSIONS: Perioperative cardiac function did not deteriorate after surgery in patients with ASD. In those with lower cardiac function preoperatively, there were significant improvements noted postoperatively. The preoperative inflection point level was significantly lower in the lower LVEF group. Preoperative thoracic kyphosis was significantly larger in the lower tricuspid annular peak systolic velocity group.

Long-term effect of tocilizumab on left ventricular hypertrophy and systolic dysfunction in AA amyloidosis with rheumatoid arthritis.

Because cardiac involvement of amyloid A (AA) is not frequent, little is known about the effects of tocilizumab (TCZ; a humanized monoclonal anti-interleukin-6 receptor antibody). We present the case of a 77-year-old man with cardiac AA amyloidosis due to rheumatoid arthritis (RA). He was admitted to our hospital because of gastrointestinal bleeding. Upon admission, chest radiography and electrocardiogram showed progression of cardiomegaly and atrioventricular conduction delay, respectively. Echocardiography showed diffuse left ventricular (LV) hypertrophy with reduced LV contraction. AA amyloid deposits in the myocardium were identified by Congo red staining and immunohistochemical staining with anti-AA antibody, suggesting cardiac AA amyloidosis. After starting treatment with TCZ, his condition improved. Hypertrophic LV mass was significantly reduced, and impaired LV contraction was restored after 10 months of TCZ treatment. The effects of TCZ were sustained for 2 years. Plasma N terminal pro-B-type natriuretic peptide level decreased from 2947 pg/mL (reference level, <125 pg/mL) on admission to 325 pg/mL after 2 years of TCZ treatment. The present case supports that cardiac biopsy is very important to diagnose cardiac AA amyloidosis in patients with RA complicating unexplained cardiac hypertrophy and/or dysfunction and TCZ should be administered if applicable. .

Real-time breath recognition by movies from a small drone landing on victim's bodies.

In local and global disaster scenes, rapid recognition of victims' breathing is vital. It is unclear whether the footage transmitted from small drones can enable medical providers to detect breathing. This study investigated the ability of small drones to evaluate breathing correctly after landing on victims' bodies and hovering over them. We enrolled 46 medical workers in this prospective, randomized, crossover study. The participants were provided with envelopes, from which they were asked to pull four notes sequentially and follow the written instructions ("breathing" and "no breathing"). After they lied on the ground in the supine position, a drone was landed on their abdomen, subsequently hovering over them. Two evaluators were asked to determine whether the participant had followed the "breathing" or "no breathing" instruction based on the real-time footage transmitted from the drone camera. The same experiment was performed while the participant was in the prone position. If both evaluators were able to determine the participant's breathing status correctly, the results were tagged as "correct." All experiments were successfully performed. Breathing was correctly determined in all 46 participants (100%) when the drone was landed on the abdomen and in 19 participants when the drone hovered over them while they were in the supine position (p < 0.01). In the prone position, breathing was correctly determined in 44 participants when the drone was landed on the abdomen and in 10 participants when it was kept hovering over them (p < 0.01). Notably, breathing status was misinterpreted as "no breathing" in 8 out of 27 (29.6%) participants lying in the supine position and 13 out of 36 (36.1%) participants lying in the prone position when the drone was kept hovering over them. The landing points seemed wider laterally when the participants were in the supine position than when they were in the prone position. Breathing status was more reliably determined when a small drone was landed on an individual's body than when it hovered over them.

Comparison of Chest Compression Quality Using Wing Boards versus Walking Next to a Moving Stretcher: A Randomized Crossover Simulation Study.

BACKGROUND: When a rescuer walks alongside a stretcher and compresses the patient's chest, the rescuer produces low-quality chest compressions. We hypothesized that a stretcher equipped with wing boards allows for better chest compressions than the conventional method. METHODS: In this prospective, randomized, crossover study, we enrolled 45 medical workers and students. They performed hands-on chest compressions to a mannequin on a moving stretcher, while either walking (the walk method) or riding on wings attached to the stretcher (the wing method). The depths of the chest compressions were recorded. The participants' vital signs were measured before and after the trials. RESULTS: The average compression depth during the wing method (5.40 ± 0.50 cm) was greater than during the walk method (4.85 ± 0.80 cm; p < 0.01). The average compression rates during the two minutes were 215 ± 8 and 217 ± 5 compressions in the walk and wing methods, respectively (p = ns). Changes in blood pressure (14 ± 11 vs. 22 ± 14 mmHg), heart rate (32 ± 13 vs. 58 ± 20 bpm), and modified Borg scale (4 (interquartile range: 2-4) vs. 6 (5-7)) were significantly lower in the wing method cohort compared to the walking cohort (p < 0.01). The rescuer's size and physique were positively correlated with the chest compression depth during the walk method; however, we found no significant correlation in the wing method. CONCLUSIONS: Chest compressions performed on the stretcher while moving using the wing method can produce high-quality chest compressions, especially for rescuers with a smaller size and physique.

Sensitive quantification of BB-22 and its metabolite BB-22 3-carboxyindole, and characterization of new metabolites in authentic urine and/or serum specimens obtained from three individuals by LC-QTRAP-MS/MS and high-resolution LC-Orbitrap-MS/MS.

PURPOSE: A synthetic cannabinoid BB-22 and its metabolite BB-22 3-carboxyindole have not yet been quantified in human urine. The aim of this study is to establish a sensitive analytical method for the quantification of BB-22 and its 3-carboxyindole in human serum and urine specimens, and the characterization of the unreported metabolites of BB-22 in authentic urine specimens from three individuals. METHODS: These compounds were extracted from ß-glucuronide-hydrolyzed and unhydrolyzed urine and/or serum via liquid-liquid extraction. The identification and quantification were performed using liquid chromatography (LC)-QTRAP-tandem mass spectrometry (MS/MS) and the characterization of the new metabolites was made by high-resolution LC-MS/MS. RESULTS: The limits of detection of BB-22 and BB-22 3-carboxyindole were 3 and 30 pg/mL in urine, respectively. The devised method was applied to quantify these compounds in authentic serum and urine obtained from two drug abusers and in urine from one drug abuser. The serum levels of BB-22 were 149 and 6680 pg/mL, and those of BB-22 3-carboxyindole were 0.755 and 38.0 ng/mL in cases 1 and 2, respectively. The urine levels of BB-22 were 5.64, 5.52 and 6.92 pg/mL and those of BB-22 3-carboxyindole were 0.131, 21.4 and 5.15 ng/mL in cases 1, 2 and 3, respectively. New monohydroxyl metabolites retaining the structure of BB-22 were found in the urine specimens. CONCLUSIONS: The synthetic cannabinoid BB-22 and its metabolite BB-22 3-carboxyindole were identified and quantified in authentic human serum and urine specimens for the first time, and new metabolites of BB-22 were tentatively identified in authentic urine specimens obtained from three drug users in this study.

Intra-cardiac distribution of late gadolinium enhancement in cardiac sarcoidosis and dilated cardiomyopathy.

Cardiac involvement of sarcoid lesions is diagnosed by myocardial biopsy which is frequently false-negative, and patients with cardiac sarcoidosis (CS) who have impaired left ventricular (LV) systolic function are sometimes diagnosed with dilated cardiomyopathy (DCM). Late gadolinium enhancement (LE) in magnetic resonance imaging is now a critical finding in diagnosing CS, and the novel Japanese guideline considers myocardial LE to be a major criterion of CS. This article describes the value of LE in patients with CS who have impaired LV systolic function, particularly the diagnostic and clinical significance of LE distribution in comparison with DCM. LE existed at all LV segments and myocardial layers in patients with CS, whereas it was localized predominantly in the midwall of basal to mid septum in those with DCM. Transmural (nodular), circumferential, and subepicardial and subendocardial LE distribution were highly specific in patients with CS, whereas the prevalence of striated midwall LE were high both in patients with CS and with DCM. Since sarcoidosis patients with LE have higher incidences of heart failure symptoms, ventricular tachyarrhythmia and sudden cardiac death, the analyses of extent and distribution of LE are crucial in early diagnosis and therapeutic approach for patients with CS.

Accidental Entrapment of Electrical Mapping Catheter by Chiari's Network in Right Atrium during Catheter Ablation Procedure.

A 78-year-old male was admitted to our hospital due to frequent palpitation. His electrocardiogram (ECG) presented regular narrow QRS tachycardia with 170 bpm, and catheter ablation was planned. During electroanatomical mapping of the right atrium (RA) with a multiloop mapping catheter, the catheter head was entrapped nearby the ostium of inferior vena cava. Rotation and traction of the catheter failed to detach the catheter head from the RA wall. Exfoliation of connective tissue twined around catheter tip by forceps, which were designed for endomyocardial biopsy, succeeded to retract and remove the catheter. Postprocedural echocardiography and pathologic examination proved the existence of Chiari's network. The handling of complex catheters in the RA has a potential risk of entrapment with Chiari's network.

Intra-left ventricular flow dynamics in patients with preserved and impaired left ventricular function: Analysis with 3D cine phase contrast MRI (4D-Flow).

PURPOSE: To examine how left ventricular (LV) volume and function affect flow dynamics by analyzing 3D intra-LV vortex features using 4D-Flow. MATERIALS AND METHODS: Twenty-one patients with preserved (LVEF > 60%) and 14 with impaired LV function (LVEF < 40%) underwent 4D-Flow (at 3T). RESULTS: In patients with preserved LV function, the intra-LV vortices developed in both the early and late diastolic phases. The shift of inflow vectors at the basal LV toward the posterior-lateral side of the LV and the mid-ventricular turn of inflow vectors toward the LV outflow could explain clearer vortex formation in the late diastolic phase. In patients with impaired LV function, the intra-LV vortices during the diastolic phase located at the more apical LV were larger and more spherically shaped. Both the distance to the vortex core and the vortex area correlated significantly with LV end-diastolic volume (r = 0.66 and 0.73), LVEF (r = -0.74 and -0.68), LV sphericity index (r = -0.60 and -0.65), and peak filling rate (r = -0.61 and -0.64), respectively (P < 0.01). The intra-LV vortices developed during the systolic phase in 10 cases. In those, some of the particles at the apical LV rotated within the LV, whereas in patients with preserved LV function, all of the particles were directed straight to the ascending aorta with accelerated flow velocity (256.8 ± 120.2 cm/s vs. 414.3 ± 88.2 cm/s, P < 0.01). CONCLUSION: Vortex formation during the diastolic phase may be critical for both LV filling and ejection. 4D-Flow showed the 3D alterations of intra-LV flow dynamics by LV dilatation and dysfunction in a noninvasive and comprehensive manner. J. Magn. Reson. Imaging 2016;44:1493-1503.

Impact of energy loss index and valvuloarterial impedance in patients with aortic stenosis using three-dimensional echocardiography.

BACKGROUND: Energy loss index (ELI) and valvuloarterial impedance (Z(va)) have been evaluated with a lack of three-dimensional (3D) information regarding the left ventricular outflow tract (LVOT) and sino-tubular junction (STJ). Our aim of this study is to compare the difference of ELI and Z(va) between two-dimensional (2D) and 3D echocardiography. METHODS: In 74 patients with moderate-to-severe aortic stenosis, the effective orifice area index (EOAI: EOA/body surface area) was calculated by continuity equation based on both 2D transthoracic echocardiography (2DTTE) and 3D transesophageal echocardiography (3DTEE). The areas of the LVOT and the STJ were calculated with the assumption of π × (dimension/2)(2) by 2DTTE and were measured directly by 3DTEE. Severe AS was defined as EOAI or ELI <0.6 cm(2) /m(2) or Z(va) ≥ 4.5 mmHg/mL per m(2) . RESULTS: Both the LVOT and STJ were elliptical, and LVOT was more elliptical than STJ. The ELI by 3DTEE (0.58 cm(2) /m(2) [median]) was larger than the other 3 values: EOAI on 2DTTE = 0.41, P < 0.01; EOAI on 3DTEE = 0.49, P < 0.01; and ELI on 2DTTE = 0.49, P < 0.01. Furthermore, Z(va) by 2DTTE, 4.7 mmHg/mL per m(2), was larger than that by 3DTEE (3.8, P < 0.01). CONCLUSIONS: 2DTTE underestimated EOAI and ELI relative to 3DTEE and overestimated Z(va) relative to 3DTEE.

Characteristics of intra-left atrial flow dynamics and factors affecting formation of the vortex flow ­ analysis with phase-resolved 3-dimensional cine phase contrast magnetic resonance imaging.

BACKGROUND: The intra-left atrial (LA) blood flow from pulmonary veins (PVs) to the left ventricle (LV) changes under various conditions and might affect global cardiac function. By using phase-resolved 3-dimensional cine phase contrast magnetic resonance imaging (4D-Flow), the intra-LA vortex formation was visualized and the factors affecting the intra-LA flow dynamics were examined. METHODS AND RESULTS: Thirty-two patients with or without organic heart diseases underwent 4D-Flow and transthoracic echocardiography. The intra-LA velocity vectors from each PV were post-processed to delineate streamline and pathline images. The vector images revealed intra-LA vortex formation in 20 of 32 patients. All the vortices developed during the late systolic and early diastolic phases and were directed counter-clockwise when viewed from the subjects' cranial side. The flow vectors from the right PVs lengthened predominantly toward the mitral valves and partly toward the LA appendage, whereas those from the left PVs directed rightward along the posterior wall and joined the vortex. Patients with vortex had less organic heart diseases, smaller LV and LA volume, and greater peak flow velocity and volume mainly in the left PVs, although the flow directions from each PV or PV areas did not differ. CONCLUSIONS: 4D-Flow can clearly visualize the intra-LA vortex formation and analyze its characteristic features. The vortex formation might depend on LV and LA volume and on flow velocity and volume from PVs.

Characteristics and clinical relevance of late gadolinium enhancement in cardiac magnetic resonance in patients with systemic sclerosis.

Cardiac involvement in systemic sclerosis (SSc) is considerably frequent in autopsy, but the early identification is clinically difficult. Recent advantages in cardiac magnetic resonance (CMR) enabled to detect myocardial fibrotic scar as late gadolinium enhancement (LGE). We aimed to examine the prevalence and distribution of LGE in patients with SSc, and associate them with clinical features, electrocardiographic abnormalities and cardiac function. Forty patients with SSc (58 ± 14 years-old, 35 females, limited/diffuse 25/15, disease duration 106 ± 113 months) underwent serological tests, 12-lead electrocardiogram (ECG) and CMR. Seven patients (17.5 %) showed LGE in 26 segments of left ventricle (LV). LGE distributed mainly in the basal to mid inter-ventricular septum and the right ventricular (RV) insertion points, but involved all the myocardial regions. More patients with LGE showed NYHA functional class II and more (71 vs. 21 %, p < 0.05), bundle branch blocks (57 vs. 6 %, p < 0.05), LV ejection fraction (LVEF) < 50 % (72 vs. 6 %, p < 0.01), LV asynergy (43 vs. 0 %, p < 0.01) and RVEF < 40 % (100 vs. 39 %, p < 0.01). There was no difference in disease duration, disease types, or prevalence of positive autoimmune antibodies or high serum NT-proBNP level (>125 pg/ml). When cardiac involvement of SSc was defined as low LVEF, ECG abnormalities or high NT-proBNP, the sensitivity, specificity positive and negative predictive values of LGE were 36, 92, 71 and 72 %, respectively. We could clarify the prevalence and distribution of LGE in Japanese patients with SSc. The presence of LGE was associated with cardiac symptom, conduction disturbance and impaired LV/RV contraction.

Functional, morphological and electrocardiographical abnormalities in patients with apical hypertrophic cardiomyopathy and apical aneurysm: correlation with cardiac MR.

OBJECTIVE: The prognosis of apical hypertrophic cardiomyopathy (APH) has been benign, but apical myocardial injury has prognostic importance. We studied functional, morphological and electrocardiographical abnormalities in patients with APH and with apical aneurysm and sought to find parameters that relate to apical myocardial injury. STUDY DESIGN: a multicentre trans-sectional study. PATIENTS: 45 patients with APH and 5 with apical aneurysm diagnosed with transthoracic echocardiography (TTE) in the database of Hamamatsu Circulation Forum. MEASURE: the apical contraction with cine-cardiac MR (CMR), the myocardial fibrotic scar with late gadolinium enhancement (LGE)-CMR, and QRS fragmentation (fQRS) defined when two ECG-leads exhibited RSR's patterns. RESULTS: Cine-CMR revealed 27 patients with normal, 12 with hypokinetic and 11 with dyskinetic apical contraction. TTE misdiagnosed 11 (48%) patients with hypokinetic and dyskinetic contraction as those with normal contraction. Apical LGE was apparent in 10 (83%) and 11 (100%) patients with hypokinetic and dyskinetic contraction, whereas only in 11 patients (41%) with normal contraction (p<0.01). Patients with dyskinetic apical contraction had the lowest left ventricular ejection fraction, the highest prevalence of ventricular tachycardia, and the smallest ST depression and depth of negative T waves. The presence of fQRS was associated with impaired apical contraction and apical LGE (OR=8.32 and 8.61, p<0.05). CONCLUSIONS: CMR is superior to TTE for analysing abnormalities of the apex in patients with APH and with apical aneurysm. The presence of fQRS can be a promising parameter for the early detection of apical myocardial injury.

Distribution of late gadolinium enhancement in various types of cardiomyopathies: Significance in differential diagnosis, clinical features and prognosis.

The recent development of cardiac magnetic resonance (CMR) techniques has allowed detailed analyses of cardiac function and tissue characterization with high spatial resolution. We review characteristic CMR features in ischemic and non-ischemic cardiomyopathies (ICM and NICM), especially in terms of the location and distribution of late gadolinium enhancement (LGE). CMR in ICM shows segmental wall motion abnormalities or wall thinning in a particular coronary arterial territory, and the subendocardial or transmural LGE. LGE in NICM generally does not correspond to any particular coronary artery distribution and is located mostly in the mid-wall to subepicardial layer. The analysis of LGE distribution is valuable to differentiate NICM with diffusely impaired systolic function, including dilated cardiomyopathy, end-stage hypertrophic cardiomyopathy (HCM), cardiac sarcoidosis, and myocarditis, and those with diffuse left ventricular (LV) hypertrophy including HCM, cardiac amyloidosis and Anderson-Fabry disease. A transient low signal intensity LGE in regions of severe LV dysfunction is a particular feature of stress cardiomyopathy. In arrhythmogenic right ventricular cardiomyopathy/dysplasia, an enhancement of right ventricular (RV) wall with functional and morphological changes of RV becomes apparent. Finally, the analyses of LGE distribution have potentials to predict cardiac outcomes and response to treatments.

Valvuloarterial impedance, but not aortic stenosis severity, predicts syncope in patients with aortic stenosis.

BACKGROUND: The presence of syncope in patients with aortic valve stenosis (AS) predicts a grave prognosis. However, the evaluation of AS severity has been limited to valve-specific factors such as aortic valve area and mean transaortic pressure gradient. Recently, valvuloarterial impedance (Zva) was proposed for the estimation of global left ventricular afterload. Therefore, because predictors of syncope in patients with AS have not been investigated in recent years, we assessed the effect of clinical characteristics and echocardiographic parameters, including Zva, on syncope in patients with AS. METHODS AND RESULTS: We retrospectively studied 451 patients with moderate and severe AS without low left ventricular ejection fraction (<40%). Patients with syncope (n=79; 18%) had higher Zva (5.1±0.9 versus 4.4±0.9 mm Hg/mL per m(2); P<0.001) than those without (n=372; 82%). However, no significant differences existed in the mean transaortic pressure gradient (P=0.076) or the aortic valve area (P=0.160) between the 2 groups. In the multivariable analysis, only Zva was an independent predictor of syncope in patients with AS (odds ratio, 2.02; 95% confidence interval, 1.54-2.64; P<0.001). However, systolic blood pressure, relative wall thickness, the early transmitral flow velocity to peak early diastolic mitral annular velocity ratio, and mean transaortic pressure gradient were not identified as independent predictors. Receiver operating characteristic curve analysis identified Zva ≥4.7 mm Hg/mL per m(2) as the cutoff value associated with syncope in patients with AS. CONCLUSIONS: Our study suggests that high Zva, but not conventional parameters of AS, identifies AS patients with an increased risk of syncope.