Search

Although electrocardiography (ECG) is a fundamental skill for most physicians, trainees have poor diagnostic performance when interpreting ECGs. In this study, we examine a strategy to improve learning ECG interpretation: self-generation of diagnoses during online practice. We randomly assigned medical students and residents to one of 2 ECG interpretation training formats: multiple-choice (MCQ) or self-generation (SG) format, where participants free-text type their diagnosis aided by an autocomplete feature. The training phase consisted of 30 ECGs, after which participants completed an immediate post test and delayed post test (3-4 weeks later). Forty-eight participants completed the training module, 45 completed the immediate post test, and 27 completed the delayed post test. Participants assigned to the SG format scored higher on the immediate post test compared with those who practiced with the MCQ format, with a large effect size (78% vs 57%; d = 0.94; P = 0.02). There was a trend favouring SG on the delayed post test, with a moderate effect size (67% vs 56%; d = 0.65; P = 0.09). However, only 60% of participants completed the delayed post test, which hindered the detection of a statistically significant difference. The SG group made the correct primary diagnosis at a faster rate (32 vs 56 seconds; P0.001) but had a lower detection of secondary diagnoses (22 vs 42%; P = 0.007). Practicing ECG interpretation using self-generation of diagnoses improved immediate post test performance and fluency. Replication in other contexts and with other populations is required to confirm our findings and to further study retention.

Background While program director (PD) letters of recommendation (LOR) are subject to bias, especially against those underrepresented in medicine, these letters are one of the most important factors in fellowship selection. Bias manifests in LOR in a number of ways, including biased use of agentic and communal terms, doubt raising language, and description of career trajectory. To reduce bias, specialty organizations have recommended standardized PD LOR. Objective This study examined PD LOR for applicants to a cardiology fellowship program to determine the mechanism of how bias is expressed and whether the 2017 Alliance for Academic Internal Medicine (AAIM) guidelines reduce bias. Methods Fifty-six LOR from applicants selected to interview at a cardiology fellowship during the 2019 and 2020 application cycles were selected using convenience sampling. LOR for underrepresented (Black, Latinx, women) and non-underrepresented applicants were analyzed using directed qualitative content analysis. Two coders used an iteratively refined codebook to code the transcripts. Data were analyzed using outputs from these codes, analytical memos were maintained, and themes summarized. Results With AAIM guidelines, there appeared to be reduced use of communal language for underrepresented applicants, which may represent less bias. However, in both LOR adherent and not adherent to the guidelines, underrepresented applicants were still more likely to be described using communal language, doubt raising language, and career trajectory bias. Conclusions PDs used language in a biased way to describe underrepresented applicants in LOR. The AAIM guidelines reduced but did not eliminate this bias. We provide recommendations to PDs and the AAIM on how to continue to work to reduce this bias.

Ascending aortic pseudoaneurysm is a rare, life-threatening complication of cardiac surgery. Surgical management is recommended, however, transcatheter techniques offer a less invasive alternative. We describe successful percutaneous closure, guided by using multimodality imaging, in a patient with high surgical risk.

Background There are significant risks of parenteral prostacyclin use in patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD), which may limit their use. Selexipag is an oral, selective prostacyclin analogue that has been shown to reduce disease progression and improve exercise capacity in patients with PAH-CHD. Administering Selexipag in patients with PAH-CHD could potentially overcome some of the risks of parenteral therapy while improving clinical outcomes. Case summary We report five cases highlighting the clinical uses of Selexipag in patients with PAH-CHD. In the first two cases, Selexipag was initiated as part of a Treat-to-close strategy. In the third case, initiation of Selexipag improved symptoms and objective exercise capacity in a patient with Eisenmenger syndrome. In the fourth and fifth cases, rapid cross-titration protocols were used to transition from parenteral prostacyclins to Selexipag. In the fourth case, Selexipag was initiated in the context of significant side effects limiting parenteral prostacyclin use. In the fifth case, Selexipag was used to down-titrate from parenteral prostacyclins following closure of a sinus venosus atrial septal defect and redirection of anomalous pulmonary veins. Discussion Selexipag is a promising oral therapy for patients with at various stages of the spectrum of PAH-CHD to improve symptoms, exercise capacity and, in some cases, haemodynamics. Our cases also highlight practical aspects of Selexipag use including targeting the individualized maximally tolerated dose for each patient, managing side effects and managing dose interruptions.

We present this case of a 22-year-old woman with congenital heart disease as the youngest reported patient, to the best of our knowledge, to successfully undergo treatment of medically refractory torrential tricuspid regurgitation with the MitraClip system as an adjunct to guideline directed therapy. (Level of Difficulty: Advanced.), Graphical abstract, We present this case of a 22-year-old woman with congenital heart disease as the youngest reported patient, to the best of our knowledge, to…

Structured Abstract Background While percutaneous closure is preferred in adults with a patent ductus arteriosus (PDA), the extent of cardiac remodeling following percutaneous PDA closure in adults is not well understood. We performed a meta-analysis to characterize cardiac remodeling following percutaneous PDA closure in adults. Methods MEDLINE and EMBASE were systematically searched for original studies that reported echocardiographic variables at baseline, immediately post-procedure (24 h), and at follow-up (>1 month) in adults undergoing percutaneous PDA closure. Additionally, we included data from patients >18 years of age that underwent percutaneous PDA closure between January 2015–December 2019 at our centre. Weighted averages were calculated for parameters with sufficient data. Pooled differences were presented as weighted mean differences (WMD). Results After screening 278 abstracts, 5 studies were identified. When combined with our cohort, our meta-analysis encompassed 244 patients. Immediately post-procedure, LVEF was the only parameter to change significantly (64 vs 52%, WMD -8.64 95%, CI -14.04 to −3.25). All parameters significantly decreased from baseline to follow-up: LVEF: 64 vs 60% (WMD -3.95, CI -5.80 to −2.09), LVEDD: 62 vs 53 mm (WMD -8.79, CI -12.78 to −4.81) LVEDVI 172 vs 123 mL/m2 (WMD -26.60, CI -45.4 to −7.85), LVESD 42 vs 36 mm (WMD -4.64, CI -9.10 to −0.17) and LA dimension: 42 vs 37 mm (WMD -5.87, CI -9.85 to −1.90). Conclusions As compared to the baseline values, left ventricular and left atrial sizes decreased. The LVEF decreased immediately following PDA closure and, while it recovers, it remained lower on follow-up testing.

ObjectiveThis tertiary centre study aims to identify factors associated with adverse outcomes in adult survivors with total cavopulmonary connection (TCPC) Fontan palliation for single ventricle.MethodsThis retrospective review of medical records identified adult (≥18 years) survivors of TCPC Fontan palliation who were followed at a single tertiary centre between 1 January 2000 and 1 July 2019. Adverse outcomes were defined as arrhythmia, pacemaker/implantable cardioverter defibrillator placement, liver cirrhosis, protein losing enteropathy, hospitalisation for heart failure, thromboembolic complication and/or death.Results160 adult TCPC patients met the inclusion criteria: 117 (73.1%) extracardiac and 43 (26.9%) lateral tunnel. The median (IQR) duration of follow-up since TCPC palliation was 17.5 (11.8–21.3) years. An adverse outcome occurred in 87 (54.4%) patients. Adverse outcome-free survival rates at 10, 20 and 25 years post TCPC were 89% (95% CI 82% to 93%), 60% (95% CI 50% to 69%) and 24% (95% CI 15% to 35%), respectively. On multivariate analysis, extracardiac Fontan (HR 2.21, 95% CI 1.20 to 4.08, p=0.011) was observed to be an independent risk factor for adverse outcomes after adjusting for age, race, morphology of the systemic ventricle and history of fenestration.ConclusionsIn this single-centre retrospective study of adult survivors of TCPC palliation, extracardiac Fontan was associated with an increased hazard for adverse outcomes. This finding could guide clinicians in developing risk modification strategies and management decisions to improve long-term outcomes in these patients.

The right ventricle has lost its designation as the ‘forgotten ventricle’ over the past decade. Clinicians recognize its prognostic significance in a wide array of disease processes and imagers are now providing an assessment of right ventricular size and function in most studies. Despite this recognition, imaging the right heart presents numerous challenges to the imager. The shape of the chamber, the unique structure, and its coupling to the pulmonary circulation mandate a different approach to its evaluation as compared to the left ventricle. Imaging may be done by several modalities, each with their own strengths and limitations. Even more so than with the left ventricle, the findings must be interpreted in the context of loading conditions and clinical setting. This chapter will focus on the two main right heart imaging modalities—echocardiography and cardiac MRI.

Introduction: Patent ductus arteriosus (PDA) is often recognized and treated with percutaneous closure in adults. However, the impact on cardiac reverse remodeling following PDA closure in adults is not clear. We performed a meta-analysis to characterize the extent of cardiac remodeling following percutaneous PDA closure in adults. Methods: MEDLINE and EMBASE were systematically searched for original studies that reported echocardiographic variables at baseline, immediately post-procedure (within 24 hours), and at follow-up (>1 month) in adults undergoing percutaneous PDA closure. Additionally, we included echocardiographic data from a cohort of patients >18 years of age that underwent percutaneous PDA closure between 01/2015 and 12/2019 at our centre. For parameters with sufficient data for pooling, weighted averages were calculated, and pooled differences were presented as weighted mean differences. Heterogeneity was assessed using the I 2 statistic. Results: After screening 278 abstracts, 5 studies were identified. When combined with our own cohort of 13 patients, our meta-analysis encompassed 244 patients. The weighted mean age of all patients was 33 years with all studies predominantly comprised of female patients and the median follow-up was 12 months (ranging from 1 month- 5 years across the studies). When compared to baseline, left ventricular ejection fraction (LVEF) decreased significantly immediately post-procedure and all parameters significantly decreased at follow-up (Table 1). Conclusions: As demonstrated by the decreases in the left ventricular and left atrial sizes, reverse remodeling was observed in adults who underwent percutaneous PDA closure. The significantly lower LVEF immediately post-procedure could reflect withdrawal of chronic volume overload or increased afterload. The clinical significance of the statistically significant lower LVEF on follow-up testing is unclear and requires further evaluation.

A 37-year-old woman presented with chest pain and shortness of breath in the third trimester of pregnancy. Diagnostic imaging demonstrated a saddle pulmonary embolism, severe impairment of right ventricular function, and an extensive deep venous thrombus. She underwent catheter-directed thrombolysis with tissue plasminogen activator and delivered a healthy infant at term. (Level of Difficulty: Intermediate.), Graphical abstract

Graphical abstract, Highlights • A case of exertional dyspnea was found to be symptomatic right ventricular masses. • Echocardiography is the first-line imaging modality for cardiac masses. • Cardiac MRI is useful for tissue characterization of cardiac masses. • Multimodality imaging is useful in differentiating thrombus from cardiac tumors.

While diagnostic criteria were elaborated for acute myocarditis using cardiac magnetic resonance (CMR) in 2009, studies have since examined the yield of traditional and novel CMR parameters to achieve greater accuracy and to predict clinical outcomes. The purpose of this systematic review and meta-analysis was to determine the diagnostic and prognostic value of CMR parameters for acute myocarditis. MEDLINE and EMBASE were systematically searched for original studies that reported CMR parameters in adult patients suspected of acute myocarditis. Each CMR parameter's binary prevalence, mean value and standard deviation were extracted. Parameters were meta-analyzed using a random-effects model to generate standardized mean differences. After screening 1492 abstracts, 53 studies were included encompassing 2823 myocarditis patients and 803 controls. Pooled standardized mean differences between myocarditis patients and controls were: T2 mapping time 2.26 (95% CI 1.50-3.02), extracellular volume 1.64 (95% CI 0.87-2.42), LGE percentage 1.30 (95% CI 0.95-1.64), T1 mapping time 1.18 (95% CI 0.35-2.01), T2 ratio 1.17 (95% CI 0.80-1.54), and EGE ratio 0.93 (95% CI 0.66-1.19). Prolonged T1 mapping time had the highest sensitivity (82%), pericardial effusion had the highest specificity (99%). Baseline LV dysfunction and the presence of LGE were predictive of major adverse cardiac events. The results support integration of parametric mapping criteria in the diagnostic criteria for myocarditis. The presence of baseline LV dysfunction and LGE predict patients at higher risk of adverse events.

The modified World Health Organization (mWHO) classification is known to estimate the risk of maternal cardiovascular (CV) events in pregnancy and up to 6 months (mo) postpartum among women with congenital heart disease (CHD). However, predictors of maternal CV events > 6 mo after delivery have not

There are expanding indications for cardiac magnetic resonance imaging (CMR) in patients with cardiac implantable electronic devices (CIEDs). The presence of a CIED had been regarded as a contraindication to CMR due to concerns of arrhythmias, significant changes to lead parameters, and detrimental changes to device programming. The risk of these potential adverse events is theoretically higher in patients undergoing CMR as compared with other anatomic sites. Recent studies have observed low rates of adverse events in patients undergoing CMR (< 1% to 2%), prompting a shift in the recommendations on CMR in patients with CIEDs. The 2017 Heart Rhythm Society Expert Consensus Statement now states that CMR can be performed in patients with both conditional and nonconditional CIEDs at a magnetic strength of 1.5 T, provided there are no fractured, abandoned, or epicardial leads and modifications to MRI parameters are made. The purpose of this review is to (a) outline the potential concerns of performing CMR in patients with CIEDs, (b) define categories of CIEDs as they pertain to MRI safety, (c) summarize the emerging data on adverse events, and (d) provide a practical approach, integrating the key modifications required to perform CMR in patients with CIEDs.

Although instruction using expert-generated schemas is associated with higher diagnostic performance, implementation is resource intensive. Learner-generated schemas are an alternative, but may be limited by increases in cognitive load. We compared expert- and learner-generated schemas for learning ECG rhythm interpretation on diagnostic accuracy, cognitive load and knowledge acquisition. Fifty-seven medical students were randomized to two experiments. Experiment 1 (n = 29) compared use of traditional teaching frameworks to expert generated schemas. Participants randomly received either a traditional framework or an expert-generated schema to practice each of two content areas in a crossed design. Learning accuracy and cognitive load were measured during the training phase. Discriminating knowledge and diagnostic accuracy were tested immediately after the training phase and 1–2 weeks after. Using the same methodology, experiment 2 (n = 28) compared use of learner-generated versus expert-generated schemas. In experiment 1, learning from expert-generated schemas was associated with lower cognitive load (13 vs 16, p < 0.001), higher diagnostic accuracy on immediate testing (40 vs 29 %, p = 0.018), and higher discriminating knowledge (81 vs 71 %, p < 0.001). Both groups performed similarly on delayed testing (14 vs 8 %, p = 0.6). In experiment 2, use of learner-generated schemas reduced diagnostic accuracy during the training phase (55 vs 77 %, p < 0.001), with similar performance on the immediate (30 vs 33 %, p = 0.89) and delayed (7 vs 5 %, p = 0.79) testing phases.. Learner-generated schema generation was associated with increased cognitive load (17.1 vs 13.5, p < 0.001). When compared to traditional frameworks, use of an expert-generated schema improved learning of ECG rhythm interpretation. Participants generating their own schemas perform similarly to those using expert-generated schemas despite reporting higher cognitive load.

Background Many medical students find choosing a residency challenging. There are several steps involved, including determining one's own priorities, arranging electives, choosing a training program and site, and preparing an in-depth application and a rank order list. Many resources are available to assist students, including the Canadian Resident Matching Service website, program websites, career counselors, career information sessions, mentors, peers, family/friends, and the Canadian Medical Residency Guide. Our study explored the relative impact of these resources on the career decision-making process. Method We invited medical students in their final year at 12 Canadian medical schools to complete an online survey. Questions included identifying the relative utility of resources in the context of each component of the decision-making process. Responses were analyzed using descriptive statistics. Results The response rate was 71% (1076 of 1518). Overall, mentors, family/friends, and peers had the most impact on students' decision making. Career counselors, websites, and the Canadian Medical Residency Guide had much less impact. Family/friends were most frequently cited as essential to the process; however, family/friends and peers were equal in having some impact. Conclusions Our findings suggest that students are most influenced by family, friends, and peers, who are not involved in the formal residency selection effort. Appreciating the impact of these influences on students' decision making is important to understanding how they decide on their future careers. The study supports continuation of mentorship programs. Future work could focus on qualitative research to further characterize resource use.