Broadening Perspectives of Artificial Intelligence in Echocardiography.

Echocardiography frequently serves as the first-line treatment of diagnostic imaging for several pathological entities in cardiology. Artificial intelligence (AI) has been growing substantially in information technology and various commercial industries. Machine learning (ML), a branch of AI, has been shown to expand the capabilities and potential of echocardiography. ML algorithms expand the field of echocardiography by automated assessment of the ejection fraction and left ventricular function, integrating novel approaches such as speckle tracking or tissue Doppler echocardiography or vector flow mapping, improved phenotyping, distinguishing between cardiac conditions, and incorporating information from mobile health and genomics. In this review article, we assess the impact of AI and ML in echocardiography.

Echocardiography is the most common test in cardiovascular imaging and helps diagnose multiple different diseases. Machine learning, a branch of artificial intelligence (AI), will reduce the workload for medical professionals and help improve clinical workflows. It can rapidly calculate a lot of important cardiac parameters such as the ejection fraction or important metrics during different phases of the cardiac cycle. Machine learning algorithms can include new technology in echocardiography such as speckle tracking, tissue Doppler echocardiography, vector flow mapping, and other approaches in a user-friendly manner. Furthermore, it can help find new subtypes of existing diseases in cardiology. In this review article, we look at the current role of machine learning and AI in the field of echocardiography.

Acute Fulminant Group A Beta-Hemolytic Streptococcus-Associated Carditis: A Case Report and Literature Review.

Group A beta-hemolytic streptococcus (GAS) is a gram-positive bacteria found in the upper respiratory tract that can cause disease with a wide gamut of symptoms ranging from pharyngitis to peritonsillar abscess, pneumonia, meningitis, and acute rheumatic fever (ARF). The primary goal of antibiotic therapy is to prevent complications of the primary infection such as ARF. ARF is defined by the revised Jones criteria. The Jones criteria have been modified to account for the moderate- to high-risk populations. The mechanism of the development of ARF from pharyngitis is not well understood, but the leading theory is molecular mimicry. The host's own immune system that responds to bacterial virulence factors develops autoantibodies that attack the host tissue. ARF typically develops two to four weeks post pharyngitis. Markers such as antistreptolysin O rise by week 2-3. The rapid streptococcal antigen is often negative by the time ARF develops. We present a case of a 23-year-old male with no past medical history who presented with a chief complaint of fever and sore throat for one week associated with new-onset chest pain. The patient had a fever with normal blood pressure. Labs showed mild leukocytosis, elevated troponin I, and positive Group A strep polymerase chain reaction (PCR). He was initially treated with aspirin 81 mg, antibiotics, and non-steroidal anti-inflammatory drugs (NSAIDs) in the emergency room. The patient was subsequently started on prednisone 60 mg as he showed no clinical improvement. His initial echocardiography (ECHO) showed a left ventricular ejection fraction (LVEF) of 55%. Repeat ECHO showed LVEF of 45% with regional wall motion abnormalities (RWMA). His cardiac troponin continued to rise with EKG changes on day 7. With the addition of steroids, the patient's clinical symptoms, as well as EKG and ECHO findings, improved. The patient was discharged with penicillin benzathine for 12 weeks. Case reports of acute carditis presenting concomitantly with pharyngitis are limited. The diagnosis of post-streptococcus complications relies on antistreptolysin O titer (ASOT) serology. With the increased availability of more acute diagnostic markers such as PCR, troponin, and ECHO, GAS confirmation can potentially be obtained within one hour and maybe in the future in the diagnosis of early-onset ARF.

Applications of Machine Learning in Cardiology.

In this digital era, artificial intelligence (AI) is establishing a strong foothold in commercial industry and the field of technology. These effects are trickling into the healthcare industry, especially in the clinical arena of cardiology. Machine learning (ML) algorithms are making substantial progress in various subspecialties of cardiology. This will have a positive impact on patient care and move the field towards precision medicine. In this review article, we explore the progress of ML in cardiovascular imaging, electrophysiology, heart failure, and interventional cardiology.

Case of Supracristal Ventricular Septal Defect and Aortic Regurgitation Detected by Cardiac Auscultation but Missed by Diagnostic Imaging.

Imaging technology has diminished the reliance on cardiac auscultation as a definitive diagnostic tool. However, it retains relevance in its immediacy, minimal preparation, and power source independence. We present a case of clinically detected continuous murmur raising specific diagnostic possibilities not accounted for advanced imaging. Further testing revealed a large supracristal ventricular septal defect (VSD) and aortic regurgitation (AR), allowing the surgeon to anticipate combined septal and valvular surgery. This report highlights the value of cardiac auscultation as a guide and validation for imaging. The absence of lesions on imaging is not proof of lesion absence.

Left Bundle Branch Block Chest Pain Conundrum.

Left bundle branch block is a pattern of altered ventricular depolarization and subsequently affects repolarization. These obscure patterns can affect the traditional ST segment shift criteria for the electrocardiographic detection of coronary insufficiency syndromes. Previously, patients with coronary ischemic pain and LBBB judged to be "new" (not previously documented) were considered to have ST elevation myocardial infarction (STEMI) warranting acute thrombolytic therapy. Current STEMI management favors emergent invasive angiography; however, recent data suggests the prevalence of coronary obstructive pathology may be as low as 50%. The application of more specific, less-sensitive Sgarbossa electrocardiographic criteria may reduce angiographic assessment in an otherwise high-risk population unlikely to tolerate further myocardial injury. We present a case that may facilitate a more nuanced EKG-based approach to distinguish those who may benefit from acute invasive angiography while reducing the frequency of unnecessary angiographic evaluation.

Antibacterial Envelope Is Associated With Low Infection Rates After Implantable Cardioverter-Defibrillator and Cardiac Resynchronization Therapy Device Replacement: Results of the Citadel and Centurion Studies.

OBJECTIVES: This study sought to determine whether the nonabsorbable TYRX Antibacterial Envelope (TYRX) reduces major cardiovascular implantable electronic device (CIED) infections 12 months after implant. BACKGROUND: TYRX is a monofilament polypropylene mesh impregnated with minocycline and rifampin specifically designed to hold a CIED in place and elute antimicrobials over time. There are limited data on its ability to reduce CIED infections. METHODS: We prospectively enrolled patients who underwent generator replacement with an implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy device (CRT), treated with TYRX. The primary endpoints were major CIED infection and CIED mechanical complications. Given the differences in infection rates among ICD and CRT patients, 3 different control populations were used: a published benchmark rate for ICD patients, and both site-matched and comorbidity-matched controls groups for CRT patients. RESULTS: Overall, a major CIED infection occurred in 5 of 1,129 patients treated with TYRX (0.4%; 95% confidence interval: 0.0% to 0.9%), significantly lower than the 12-month benchmark rate of 2.2% (p = 0.0023). Among the TYRX-treated CRT cohort, the major CIED infection rate was 0.7% compared with an infection rate of 1.0% and 1.3% (p = 0.38 and p = 0.02) in site-matched and comorbidity-matched control groups, respectively. Among the ICD group, the 12-month infection rate was 0.2% compared with the published benchmark of 2.2% (p = 0.0052). The most common CIED mechanical complication in study patients was pocket hematoma, which occurred in 18 of the 1,129 patients (1.6%; 95% confidence interval: 0.8 to 2.5), which is comparable with a published rate of 1.6%. CONCLUSIONS: Use of TYRX was associated with a lower major CIED infection rate. (TYRX™ Envelope for Prevention of Infection Following Replacement With a CRT or ICD; [Centurion]; NCT01043861/NCT01043705).

Implant evaluation of an insertable cardiac monitor outside the electrophysiology lab setting.

BACKGROUND: To date, insertable cardiac monitors (ICM) have been implanted in the hospital without critical evaluation of other potential settings. Providing alternatives to in-hospital insertion may increase access to ICM, decrease waiting times for patients awaiting diagnosis, and reduce hospital resources. METHODS: This was a prospective, non-randomized, clinical trial involving nine clinical sites throughout the United States designed to assess the feasibility of ICM implants in a non-hospital setting. Other than the Reveal® ICM, implant supplies and techniques were left to physician discretion in patients who met indications. Patients were followed up to 90 days post-implant. The primary objective was to characterize the number of procedure-related adverse events that required surgical intervention within 90 days. RESULTS: Sixty-five patients were implanted at nine out-of-hospital sites. The insertion procedure was well tolerated by all patients. There were no deaths, systemic infections or endocarditis. There were two (3%) procedure-related adverse events requiring device explant and four (6%) adverse events not requiring explant. ICM use led to 16 diagnoses (24.6%) with 9 patients proceeding to alternate cardiac device implants during the course of the 90-day follow up. CONCLUSION: Out-of-hospital ICM insertion can be accomplished with comparable procedural safety and represents a reasonable alternative to the in-hospital setting. CLINICALTRIALS.GOV REGISTRATION NUMBER: NCT01168427.

Cardiac device implant wound closure with 2-octyl cyanoacrylate.

2-Octyl Cyanoacrylate (2-OCA) is a tissue adhesive developed for skin laceration closure that has not been previously evaluated for cardiac device implant wound closure. We reviewed 460 consecutive device implants with 475 incisions between November 1993 and May 2001. From November 1993 to December 1998, all patients (n 335) had a 3-layer reabsorbable suture closure with the application of topical bacitracin and dressing material. They were advised to avoid exposure to moisture for 10 days. From January 1999 to May 2001, the superficial suture layer was replaced with 2-OCA (n=125). No topical bacitracin or dressing was applied and patients were allowed to shower within 72 hours. The two groups did not differ significantly with respect to age (69 +/- 12 vs 70 +/- 13 years, P=NS), sex (59% vs 62% male, p=NS) or device type (77% vs 68% pacemakers/loop recorders, p=NS). All incisions were evaluated at 24 hours, 7-14 days, and 6-12 weeks postprocedure. The 2-OCA and suture groups did not differ significantly with respect to allergic reaction (0% vs 1.4%, P=NS), cellulitis (0% vs 0.9%, P=NS), and infection requiring explant (0.8% vs 0.3%, P=NS), respectively. Total adverse events occurred in 1 of 125 (0.8%) of the 2-OCA group versus 9 of 350 (2.6%) of the suture group (P=NS). In cardiac device implant closure 2-OCA obviated the need for topical antibiotics and dressing materials while facilitating wound care without increased complications.

ICD nocardiosis.

We present an initial report of Nocardia asteroides implantable cardioverter defibrillator infection. Systemic infection persisted despite pulse generator explant and several years of appropriate antibiotic therapy. Without epicardial lead system removal, chronic pleuropericardial disease developed.

Audible implantable cardioverter defibrillator alarms detect intermittent conductor discontinuity.

The lead conductor integrity of implantable cardioverter defibrillator devices is inferred from impedance measurements; however, intermittent discontinuity can be difficult to detect or confirm. Newer devices can perform daily lead impedance self-testing, and some even have audible alarms that promptly warn patients of anomalies. In the present case, the audible alarms were solely responsible for the timely identification of an intermittent, otherwise clinically nonreproducible, form of potentially fatal implantable cardioverter defibrillator system failure.

Innovative endovascular defibrillator lead use in superior vena cava obstruction.

BACKGROUND: We describe an unusual case of severe heart failure (HF) and rapid atrial fibrillation (AF) improved through ablation and pacemaker implant despite superior vena cava obstruction (SVCO). METHODS: SVCO precluded upper body venous access to the heart for procedural rate control. Both AV Junctional ablation and permanent endovascular lead placement were achieved through the inferior vena cava (IVC). RESULTS: Clinical improvement from NYHA Class IV to Class II HF was observed with effective nonpharmacologic ventricular rate control. CONCLUSIONS: HF patients with rapid AF and SVCO can achieve ventricular rate control through lower body venous access to the heart utilizing 100-cm endovascular defibrillator rate sensing leads.