Search

Key Points Question Do treatments recommended by a heart team differ from those recommended by an original treating interventional cardiologist for patients with multivessel coronary artery disease? Findings In this cross-sectional study of 245 patients with multivessel coronary artery disease, heart team treatment recommendations indicated moderate agreement (with discordance in 30% of cases) with the original treating interventional cardiologist. Unanimous decisions within the heart team and agreement between the heart team interventional cardiologist and the original treating interventional cardiologist were less frequent in this subset of cases, while interventional cardiologist recommendations for angioplasty and medication therapy were more frequent. Meaning The study’s findings indicated that heart team recommendations differed from those of the original treating interventional cardiologist in approximately one-third of cases; this subset of cases was associated with a greater number of divergent opinions between interventional cardiologists and within the heart team., Importance Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown. Objective To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease. Design, Setting, and Participants In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center’s database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020. Main Outcomes and Measures The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist. Results Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P, This cross-sectional study examines the differences in treatment decisions between a heart team and an original treating interventional cardiologist for patients with multivessel coronary artery disease.

Left Ventricular Pseudo Aneurysm (LVPA) is a rare complication occurs in population that carries the risk. Clinical presentation of a large LVPA can be variable which make the diagnosis challenging. Given the high risk of death in such cases, high clinical suspicion in addition to the use of proper diagnostic modality may reduce the mortality rate & guide the management decision. Echocardiogram is considered the proper investigation tool to screen, diagnose the presence of LVPA & identify the high-risk feature of rupture. In this review will present catastrophic echocardiographic features in unusual clinical case presentation of a patient with large LV pseudo aneurysm presented with ischemic stroke & background of diabetes & hypertension.

a McMaster University, Department of Medicine, Hamilton, Ontario, Canada b University of Ottawa, Department of Epidemiology and Community Medicine, Faculty of Medicine, Ottawa, Ontario, Canada c McMaster University, Department of Pathology and Molecular Medicine, Hamilton, Ontario, Canada d Stephenson Cardiovascular Magnetic Resonance Centre, University of Calgary, Alberta, Canada e Universite de Sherbrooke, Department of Cardiology, Quebec, Canada f McMaster University, Department of Medicine, Division of Cardiology, Hamilton, Ontario, Canada

Purpose: Nasal septoplasty is a surgical procedure offered to patients with chronic snoring secondary to nasal obstruction. We describe a case of cardiogenic shock following the administration of metoprolol to treat hypertension, (likely) induced by systemic absorption of topical epinephrine used during a routine nasal septoplasty. Clinical features: A 29-yr-old male, with no significant medical history, was scheduled for nasal septoplasty for mild nasal obstruction. Following routine anesthetic induction, cotton balls, soaked with epinephrine (1:1000), were applied to the nasal mucosa. The patient became hypertensive with a blood pressure of 207/123 mmHg. Intravenous metoprolol was administered. Severe pulmonary edema ensued, with resulting hypoxic respiratory failure and cardiogenic shock. The patient was transferred to a tertiary care facility for percutaneous cardiopulmonary bypass. After five days of cardiopulmonary bypass support and six weeks of intensive care monitoring, the patient’s cardiac status returned to normal limits. Conclusion: A hypertensive response, following systemically absorbed topical vasoconstrictors, including both phenylephrine and epinephrine, can be associated with dire consequences when treated with a beta-adrenergic blocking drug and, possibly, calcium channel blockers. To prevent severe complications including; pulmonary edema, cardiogenic shock, cardiac arrest, and, possibly, death, these drug interactions need to be appreciated.

A 76-year-old male with a pacemaker presented with acute pulmonary oedema requiring invasive mechanical ventilation. Transthoracic echocardiography (TTE) revealed a partially flail anterior mitral leaflet, severe mitral regurgitation (MR), and pulmonary hypertension, not present on previous TTEs. Transoesophageal echocardiography (TEE) demonstrated an elongated anterior mitral valve leaflet (AMVL) with a flail A2 …

Significant hypoxemia can result from right-to-left intracardiac shunting through a patent foramen ovale, an atrial septal defect or a ventricular septal defect. Pulmonary embolus, congenital heart disease and pericardial tamponade are well-recognized causes of right-to-left shunting. However, right-to-left shunting can also follow pericardiocentesis. A case of profound hypoxemia caused by right ventricular hypokinesis precipitated by pericardial tap is reported. This under-recognized entity can be responsible for significant morbidity in the critical care setting. The clinical presentation, natural history, diagnosis and treatment of hypoxemia caused by intracardiac shunt following pericardiocentesis are discussed.

A 51-year-old man with a history of ischemic cardiomyopathy who underwent a recent three-vessel coronary artery bypass graft and Dor procedure was admitted to a tertiary care hospital with ventricular tachycardia and congestive heart failure. He underwent a transthoracic echocardiogram, which demonstrated a noticeable aneurysm at the left ventricular apex (A) with patch closure (arrow) in the apical four-chamber view, consistent with a previous Dor procedure (Figure 1). Doppler flow studies suggested a patch leak with communication between the left ventricular cavity and apical aneurysm. A cardiac computed tomography scan demonstrated a communication across the patch closure (arrow in Figure 2), between the left ventricular cavity (LV) and the aneurysm (A). Figure 1 Figure 2 The Dor procedure was first performed in 1984 (1). It is a reasonable surgical ventricular restoration option for patients with severe left ventricular dysfunction and aneurysm. The Dor procedure involves endoventricular patch plasty closure of an apical aneurysm to reduce left ventricular cavity size, resulting in improved left ventricular function and cardiac output (2). The present patient, however, had disruption of the repair procedure, resulting in worsening cardiac function and heart failure without appreciable benefit. He eventually underwent successful cardiac transplantation and remained well two years later.

Staphylococcus aureus is a relatively common pathogen causing pneumonia in the community, hospital ward and intensive care unit. Although pneumonia is responsible for significant morbidity and mortality, especially in elderly and immunocompromised patients, it is usually uncomplicated and resolves without complications. The case of a woman who developed a para-aortic abscess after a community-acquired S aureus pneumonia infection is presented. A number of diagnostic imaging modalities were used to reach the diagnosis. This complication has not been reported previously and it is likely secondary to suppurative lymphadenitis of a station 5 or 6 node. The patient was successfully managed nonsurgically with computed tomography-guided drainage and intravenous antibiotics.

Apical hypertrophic cardiomyopathy (AHCM), first described by Sakamoto et al (1), is typically characterized by ‘giant negative T waves’ (larger than 10 mm), particularly in the precordial leads, asymmetrical left ventricular (LV) apical hypertrophy on echocardiogram and spade-shaped LV configuration on left ventriculography (2). An asymptomatic 55-year-old woman had repolarization abnormalities noted on a routine preoperative electrocardiogram (Figure 1A). The initial echocardiogram was normal, with no evidence of LV hypertrophy or segmental wall motion abnormalities. Subsequent investigations, including coronary catheterization and cardiac magnetic resonance imaging, led to the diagnosis of AHCM with LV apical aneurysm (Figures 1B and ​and1C1C). Figure 1) A Resting 12-lead electrocardiogram demonstrating voltage criteria for left ventricular hypertrophy and negative T waves of 2 mm to 4 mm in leads II, III, aVF and V3 to V6. B Left ventricular angiogram demonstrating apical aneurysm. C Left ventricular ... The present case illustrates that although the electrocardiogram and echocardiogram are commonly used in clinical practice, these tests may not be sufficient to exclude the diagnosis of AHCM. Further investigations, including cardiac magnetic resonance imaging, are essential to the diagnosis of this rare condition (3,4). The second point illustrated by the present case is that patients with AHCM are at risk of developing an aneurysm at the LV apex, which can potentially lead to increased incidence of embolic complications, arrhythmias and congestive heart failure (5).

s S119 pericardial effusion (PeriE), and in severe cases cardiac tamponade. Echocardiograms are routinely obtained following PVI to rule out PeriE. The V-Scan unit is a novel handheld ultrasound unit capable of limited echocardiographic imaging. It is lighter,more portable and less expensive to function than a traditional echocardiogram. We aimed to learn if V-Scan can safely be used to rule out PeriE in post PVI patients when compared to traditional echocardiogram. METHODS: Seventeen consecutive patients undergoing PVI for AF treatment at the Kingston General Hospital were included. All patients underwent limited echocardiogram protocol immediately following PVI with both VScan and traditional echocardiogram devices. Limited imaging protocol included 5 imaging planes in 4 chamber, 2 chamber, parasternal long-axis, parasternal short axis and subcostal views. A total of 34 sets (17 2) of patient and device specific images were obtained. All images were edited to eliminate deviceidentifying features and randomized for the evaluating cardiologist. Image quality and diagnostic power were compared. RESULTS: Quality: Among images rated excellent quality, 28.6% were from VScan, compared to 71.4% from traditional echocardiogram. Among all images rated poor quality, 75.0% were from VScan, compared to 25.0% from traditional echocardiogram. 82.4% of VScan images were rated adequate diagnostic quality or better. Among studies in which all 5 imaging planes could be satisfactorily obtained, 40% were obtained from VScan, compared to 60% from traditional echocardiogram. Diagnostic Power: There were 3 non-diagnostic studies, all of which are from VScan images. VScan images identified 2 pericardial effusions that did not match with the conclusion from the traditional echocardiogram images, in that no pericardial effusions were identified in the traditional echo images. CONCLUSION: 1 Traditional echocardiogram is superior in imaging quality and in ability to obtain multiple diagnostic imaging planes. 2 VScan led to more non-diagnostic studies and a tendency to over-diagnose pericardial effusion. 3 Nevertheless, VScan was able to obtain satisfactory diagnostic quality images in over 82.4% of patients. 079 THE UTILITY OF PORTABLE ECHOCARDIOGRAPHY AS A CLINICAL TOOL IN INTERNATIONAL MEDICINE: AN EXPLORATORY STUDY IN UGANDA DS Wright, MB Tsang, Z Khalid, J Schwalm, J Kayima, A Mulji, O Salehian

An unusual case of blunt thoracic injury is presented, highlighting the importance of echocardiography in the assessment of patients with suspected cardiac trauma.

Incidence of penetrating cardiac trauma is on the rise. With improved trauma care, an increasing number of these patients arrive at the hospital alive. An unusual case of penetrating cardiac trauma is presented that highlights the importance of thorough echocardiographic assessment of such patients.

Cardiologists' expertise in managing traumatic heart disease will be increasingly sought as the incidence of both firearm and motor vehicle accidents soars. Knowledge of mechanisms of injury, as well as appropriate use of diagnostic tools, will aid in rapid recognition of complications related to cardiac injury.

Fourteen patients with atrial fibrillation or flutter and a ventricular rate of greater than or equal to 120 beats/min occurring after cardiac surgery entered a double-blind placebo-controlled conditional crossover trial of intravenous propafenone. Patients randomly received either propafenone (2 mg/kg body weight) or placebo during a 10 minute intravenous infusion. If 20 minutes after the initiation of this infusion there was no conversion to sinus rhythm, the patient received a second intravenous infusion over 10 minutes (either propafenone or placebo, whichever was not given first). The electrocardiogram was recorded continuously throughout the study. Fourteen patients received propafenone and 10 received placebo. No patient's rhythm converted to sinus rhythm after placebo. In six patients (43%) (p less than 0.001), the arrhythmia converted to sinus rhythm between 5 and 10 minutes after the end of the propafenone infusion. After propafenone, the ventricular response to atrial fibrillation or flutter decreased significantly from 141.6 +/- 15.2 to 116.0 +/- 15.5 beats/min. Ventricular rate did not change after placebo. The mean propafenone plasma concentration was 3.46 +/- 2.17 mg/liter. The only side effect of propafenone noted was a decrease in systolic blood pressure of 9 +/- 9 mm Hg. Propafenone was useful for management of atrial fibrillation after cardiac surgery both for control of rapid ventricular response and for conversion to sinus rhythm.

We performed a double-blind randomized trial comparing high doses of subcutaneous heparin (12,500 units every 12 hours) with low doses (5000 units every 12 hours) for 10 days in the prevention of left ventricular mural thrombosis in 221 patients with acute anterior myocardial infarction. Left ventricular mural thrombosis was observed by two-dimensional echocardiography on the 10th day after infarction in 10 of 95 patients (11 percent) in the high-dose group and in 28 of 88 patients (32 percent) in the low-dose group (P = 0.0004). One patient in the high-dose group and four in the low-dose group had nonhemorrhagic strokes (P = 0.17). One patient in the low-dose group had a fatal pulmonary embolism. There was no difference in the frequency of hemorrhagic complications, which occurred in six patients in the high-dose group and four in the low-dose group. The mean (+/- SEM) plasma heparin concentration was 0.18 +/- 0.017 U per milliliter in the high-dose group and 0.01 +/- 0.005 U per milliliter in the low-dose group (P less than 0.0001). In the high-dose group, the mean plasma heparin concentration was 0.10 +/- 0.029 U per milliliter among patients with abnormal two-dimensional echocardiograms, as compared with 0.19 +/- 0.019 U per milliliter among patients with normal echocardiograms (P = 0.01). We conclude that heparin administered subcutaneously in a dosage of 12,500 units every 12 hours to patients with acute anterior transmural myocardial infarction is more effective than a lower dosage (5000 units every 12 hours) in preventing left ventricular mural thrombosis.