Reducing Inappropriate Stat Echocardiograms: A Quality Improvement Initiative (RISE-QI).

BACKGROUND: A complete transthoracic echocardiogram takes approximately 45 minutes to complete, including time for image acquisition and preliminary reporting by the sonographer. The process can take substantially longer if there are technical difficulties or if contrast must be administered due to suboptimal imaging windows. This can create a considerable echocardiogram backlog at high-volume institutions. At the authors' institution, there was a concern that ordering providers were inappropriately designating studies as stat to get their patients to the front of the bottleneck. On review, the quality improvement team found that 19.9% of all echocardiograms ordered during June 2021 were designated stat, of which 44.0% contained indications that the team determined were rarely appropriate for a stat priority designation. METHODS: The team located a flaw in the electronic health record interface that encouraged overuse of the stat designation, so an interface change was designed and implemented to create a hard stop requiring the selection of predetermined indications for any stat order. We also reduced the number of steps required to select the less-urgent ASAP priority to encourage its use over stat priority. RESULTS: Within one month postintervention, there was a statistically significant 36.3% reduction in the order of stat echocardiograms, with a concurrent 173.9% rise in ASAP orders over the same time frame. These numbers remained steady at one-year and two-year follow-up analyses. CONCLUSION: A quick and simple modification to the echocardiogram order user interface can lead to a considerable reduction in the number of stat orders.

Most hospitalized patients with significant tricuspid regurgitation have advanced disease preventing transcatheter tricuspid valve intervention.

BACKGROUND: More than moderate tricuspid regurgitation (TR) is associated with high mortality. Surgical tricuspid valve repair and replacements are rarely performed due to high operative mortality risk, mainly attributed to late presentation. Novel transcatheter tricuspid valve intervention (TTVI) devices are being developed as an alternative to surgery. The population of patients presenting to tertiary care centers who can benefit from TTVI has not been well defined. METHODS: We retrospectively analyzed 12,677 consecutive 2D echocardiograms completed at our tertiary care center between March 2021 and March 2022 and identified hospitalized patients with more than moderate TR. A total of 569 patients were included in this study. Clinical and echocardiographic data were collected by individual chart review. We used the European Society of Cardiology (ESC) guidelines on the management of valvular disease to retrospectively assign patients to medical, surgical, or transcatheter therapy. RESULTS: 458 patients (80.5 %) were assigned to medical therapy, 57 (10.0 %) were assigned to TTVI, and 54 (9.5 %) were assigned to tricuspid valve surgery. Of note, 75.7 % (431/569) of patients were precluded from any intervention due to advanced disease, and only 4.7 % (27/569) presented too early for intervention, being both asymptomatic and without RV dilatation. CONCLUSION: Only 10.0 % of patients presenting to a tertiary care center with significant TR would be candidates for TTVI when these technologies are approved in the United States. Earlier identification and treatment of TR could increase the number of patients who may benefit from interventions including TTVI.

The Impact of Midodrine on Guideline-Directed Medical Therapy in Patients Admitted With Systolic Heart Failure.

ABSTRACT: Midodrine is occasionally used off-label to treat hypotension associated with advanced heart failure (HF); however, its association with changes in prescription of guideline-directed medical therapy (GDMT) is unknown. We sought to evaluate the effect of midodrine on the GDMT prescription pattern and clinical outcomes of patients with decompensated systolic HF. We retrospectively identified 114 patients admitted to our hospital in 2020 with decompensated systolic HF who were prescribed midodrine on discharge and compared them with 358 patients with decompensated systolic HF who were not prescribed midodrine. At 6 months, the midodrine group had more initiation or up-titration of beta blockers, renin-angiotensin-aldosterone system inhibitors, and sodium-glucose cotransporter-2 inhibitors compared with the nonmidodrine group. Survival at 6 months was similar between the 2 groups, but the midodrine group had more frequent rehospitalization for HF. Our findings suggest that midodrine is associated with improved GDMT in patients with decompensated HF but may be associated with worse prognosis.

Patient-Prosthesis Mismatch in Pregnancy: A Multidisciplinary Approach.

A 24-year-old gravida 3 para 1 woman with history of bioprosthetic aortic valve replacement complicated by patient-prosthesis mismatch presented for prenatal care. Her pregnancy was managed by a multidisciplinary cardio-obstetrics team, resulting in an uncomplicated repeat cesarean section at term.

Transcatheter Aortic Valve Migration During Vascular Access Closure.

We present a novel complication of transcatheter aortic valve replacement (TAVR) involving prosthetic migration due to entanglement by a standard guidewire during non-large bore vascular access closure, followed by successful bail-out using a second transcatheter prosthesis. To our knowledge, this mechanism of prosthesis migration has not been previously described.

Cardiac Point-of-Care Ultrasound (P.O.C.U.S.) Utilization for Hospitalists in the Assessment of Patients with Cardiac Complaints: An Educational Overview.

The use of cardiac point-of-care ultrasound (P.O.C.U.S.) is underutilized in the field of internal medicine for the assessment of patients with cardiac complaints. Numerous studies in emergency medicine, anesthesia, and critical care have demonstrated the successful application of cardiac P.O.C.U.S. in resident and attending physicians with limited prior exposure. This article review overviews the practical implementation of cardiac P.O.C.U.S. for hospitalists by discussing proper technique and assessment for common pathology seen in the medical ward setting. We describe how to assess for left ventricular (LV) systolic function, right ventricular (RV) systolic function, suspected acute coronary syndrome (ACS), post-myocardial infarction (MI) complications, suspected pulmonary embolus, and assessment of intravascular volume status. In each section, we overview the pertinent literature to show how cardiac P.O.C.U.S. has been used to directly impact patient care.

Premature Bioprosthetic Mitral Valve Dysfunction Due to Flail Leaflet Treated With Transcatheter Mitral Valve Replacement; a Case Report.

Early bioprosthetic mitral valve failure is uncommon, but cases can present with symptomatic heart failure and require careful attention and evaluation. Transcatheter valve replacement is a minimally invasive treatment for mitral valve dysfunction that can have a considerable impact, particularly for those who are at high surgical risk or have a history of bioprosthetic valve failure. We present a rare case of significant mitral regurgitation due to the unexpected premature failure of a bioprosthetic valve that was implanted three years prior. This patient was treated with transcatheter mitral valve replacement with the implantation of an Edwards SAPIEN Ultra (Edwards Lifesciences) valve.

Revisiting the Relationship Between Ethnicity and Outcome in Glioblastoma Patients.

BACKGROUND: Relationships between various ethnicities and glioma subtype have recently been established. As a tertiary referral center for Latin America and the Caribbean, our institution treats a diverse glioblastoma (GBM) population. We sought to clarify the role of ethnicity on patient prognosis in GBM and also compared these findings to a group consisting of elderly patients. We included 'elderly' as a group because the subgroups for ethnicities within them were too small. It allowed us to put in scope the effects of ethnicities on the overall survival.  Material and Methods: After Institutional Review Board approval, 235 patients with GBM were retrospectively identified. A total of 140 patients were separated into four groups: White adults (n = 47), Hispanic adults (n = 27), elderly (n = 58), and Black adults (n = 6). Overall survival (OS) was our primary endpoint. RESULTS: Overall survival in the White adult group was 24.3 months, compared to 13.0 months in the Hispanic adult group, 20.2 months in the Black group, and 13.8 months in the elderly group (p = 0.01). In the Hispanic group, hypertension (37.9%, p = 0.01) and diabetes (24.1%, p = 0.009) were significantly more prevalent compared to the White adult cohort. No difference in insurance status or postoperative complications was found between subgroups. CONCLUSION: Based on our analysis, Hispanic adults may have a decreased survival compared to White adults. However, the incidence of hypertension and diabetes was markedly higher in our Hispanic adult cohort; thus, estimating the risk of ethnicity and comorbidities on patient prognosis may be difficult. A prospective study correlating the genome and subgroup prognosis may help elucidate the role of ethnicity in GBM patients.

Biomechanical analysis of the different classifications of the Functional Movement Screen deep squat test.

The purpose of this study is to examine the peak sagittal plane joint angles and joint moments of the lower extremity during the deep squat (DS) movement of the Functional Movement Screen (FMS) to assess differences between the classifications (1,2,3). Twenty-eight participants volunteered for the study and were screened to assess their FMS score on the DS task. All participants underwent a quantitative movement analysis performing the FMS DS movement at a self-selected speed. The participants in Group 3 exhibited greater dorsiflexion excursion compared to those in Group 1. Participants in Group 3 had greater peak knee flexion and knee flexion excursion than those in Group 2 who exhibited more than the participants in Group 1. Group 3 also exhibited a greater peak knee extension moment compared to Group 1. At the hip, Groups 3 and 2 exhibited greater peak hip flexion, hip flexion excursion and peak hip extension moment compared to Group 1. Thus, it appears that individuals who score differently on the deep squat as determined by the FMS exhibit differences in mechanics that may be beneficial in assessing strategies for interventions. Future research should assess how fundamental changes in mobility and stability independently affect DS performance.