Evaluation of inter-observer variability regarding aortic and mitral valve findings on transesophageal echocardiograms ordered for suspected endocarditis.

BACKGROUND: Transesophageal echocardiography (TEE) is the gold standard for the detection of valvular vegetations (VV). Differentiating small VV from degenerative changes is challenging and prone to inter-observer variability. We evaluated inter-observer agreement regarding aortic (AV) and mitral valve (MV) findings on TEEs ordered for suspected infective endocarditis (IE). METHODS: A total of 349 consecutive TEEs were evaluated. Studies were classified as "definite, possible, or no" IE with valve masses classified further by morphology. Nine faculty echocardiographers scored randomly selected TEEs of the AV (N = 38) and MV (N = 35). Inter-reader variability was calculated using the Fleiss/Scott Kappa (Kf). RESULTS: Positive blood cultures were present in 81% and 45% had definite IE by the modified Duke criteria. There was moderate reader agreement regarding the presence of a valvular mass for both the AV (Kf = .41, 95% CI [.30-.53]) and MV (Kf = .49, 95% CI [.34-.65]). For diagnosis of IE, there was fair agreement for the AV (Kf = .29, 95% CI [.18-.42]) and moderate agreement for the MV (Kf = .53, 95% CI [.36-.70]). Masses described as large, multi-lobulated, or pedunculated were more frequently categorized as clinical IE, (p < .006, both valves), however those with filamentous lesions were not (p < .001, both valves). CONCLUSIONS: In a large academic center, the inter-observer agreement for the presence of a left sided valvular mass was moderate and agreement regarding the final diagnosis of IE was fair to moderate, with better agreement among readers evaluating the MV. Lesion morphology is associated with the clinical diagnosis of IE.

Effects of the HeartMate II left ventricular assist device as observed by serial echocardiography.

BACKGROUND: The HeartMate II is the most frequently used left ventricular assist device (LVAD) in patients with end-stage heart failure. There is a paucity of data regarding its longitudinal cardiac effects, particularly that on diastole. METHODS: This retrospective study was an evaluation of echocardiograms preoperatively and at 3, 6, and 12 months postoperatively in patients with a HeartMate II. Measurements included left ventricle (LV) dimensions, ejection fraction (EF), right ventricle (RV) size and function, parameters of diastolic function, and an analysis of mitral regurgitation (MR), tricuspid regurgitation (TR), aortic insufficiency (AI), and aortic valve thickening. RESULTS: Forty-seven patients were evaluated. LV dimensions decreased but EF, RV size, and RV function were unchanged. Right ventricular systolic pressure (RVSP) and diastolic parameters including mitral inflow E/A, deceleration time (DT), pulmonary vein inflow, left atrial size, and overall diastolic grade improved. LV relaxation measured by tissue Doppler (e') was unchanged and the E/e' ratio was also unchanged. Regarding valve function, MR decreased, TR was unchanged, and the aortic valve became increasingly thickened with increased AI severity. CONCLUSIONS: The HeartMate II unloads the LV as shown by decreased LV size, decreased MR, reduced RVSP, and improved patterns of mitral inflow. However, neither systolic function nor diastolic relaxation improves in this cohort. RV size and function also remain unchanged. The aortic valve shows increased thickening and AI likely from valve leaflet fusion. These results provide detailed functional and hemodynamic information regarding the longitudinal effects of the HeartMate II.

Classification of left ventricular diastolic function using American Society of Echocardiography Guidelines: agreement among echocardiographers.

Guidelines for assessing diastolic function by echocardiography are continually being updated. Our ability to use available guidelines effectively has not been completely investigated. Six trained echocardiographers were asked to interpret 105 echocardiograms using current American Society of Echocardiography (ASE) algorithms for interpretation of diastolic grade and estimation of left atrial (LA) pressure. Diastolic grade was categorized as normal, mild, moderate, or severe dysfunction. The presence or absence of elevated LA pressure was determined using a second ASE algorithm. As a reference comparison for level of agreement, left ventricular ejection fraction was visually determined. By the ASE algorithm, 29 subjects (28%) met all measurement criteria in their assigned grade and 57 subjects (55%) met all or all but one criterion of their assigned grade. Of the 45 subjects (43%) for whom the guidelines disagreed by more than 1 criterion, the readers debated between normal and moderate dysfunction in 22% or mild and moderate diastolic dysfunction in 31%. Percent inter-reader agreement and kappa values were 76% (0.7) for determining diastolic grade, 84% (0.67) for determining elevated LA pressure, and 84% (0.67) for estimation of ejection fraction, the reference standard. For all subjects, if multiple echocardiographic criteria failed to fit into the proposed guidelines, agreement fell to 66% (0.58) for determining diastolic grade and 74% (0.48) for determining LA pressure. There is reasonable agreement estimating diastolic grade and LA pressure using current guidelines. Further refinements in the definition of mild and moderate dysfunction may improve agreement.

Satisfaction and emergency department revisits in patients with possible acute coronary syndrome.

BACKGROUND: Patients with possible acute coronary syndrome (ACS) are typically instructed to return to the emergency department (ED) if their condition worsens. Little is known about the relationship between patient satisfaction in the ED and subsequent return visits. OBJECTIVE: Our aim was to determine the association between satisfaction with ED care and subsequent ED return visits. METHODS: One thousand and five consecutive ED patients with symptoms of possible ACS who participated in a prospective guideline implementation trial at two university hospitals completed a telephone survey at 30-day follow-up. Satisfaction with care at the initial ED visit was measured using items from the Press Ganey satisfaction questionnaire. Logistic regression was used to determine the association between individual satisfaction items and the occurrence of any ED revisits, and the association between satisfaction items and return visits to the same ED. RESULTS: Patients who reported superior ratings of person-centered care ("staff cared about you as a person") were significantly less likely to return to any ED during 30-day follow-up: 59 vs. 71%, adjusted odds ratio = 0.57 (95% confidence interval 0.37-0.87). Among those with ED revisits, superior ratings of personal care and perceived waiting time for emergency physician evaluation were significantly associated with return to the same ED. CONCLUSIONS: Although diagnostic workup and risk stratification are the primary focus in evaluating patients with possible ACS, greater attention to the patient's experience of care may have the positive impact of reducing ED return visits and increasing the likelihood that patients will return to the same ED for re-evaluation.

Technical and clinical study of x-ray-based surface echo probe tracking using an attached fiducial apparatus.

PURPOSE: Several types of structural heart intervention (SHI) use information from multiple imaging modalities to complete an interventional task. For example, in transcatheter aortic valve replacement (TAVR), placement and deployment of a bioprosthetic aortic valve in the aorta is primarily guided by x-ray fluoroscopy (XRF), and echocardiography provides visualization of cardiac anatomy and blood flow. However, simultaneous interpretation of independent x-ray and echo displays remains a challenge for the interventionalist. The purpose of this work was to develop a novel echo/x-ray co-registration solution in which volumetric transthoracic echo (TTE) is transformed to the x-ray coordinate system by tracking the three-dimensional (3D) pose of a probe fiducial attachment from its appearance in two-dimensional (2D) x-ray images. METHODS: A fiducial attachment for a commercial TTE probe consisting of rings of high-contrast ball bearings was designed and fabricated. The 3D pose (position and orientation) of the fiducial attachment is estimated from a 2D x-ray image using an algorithm in which a virtual point cloud model of the attachment is iteratively rotated, translated, and forward-projected onto the image until the average sum-of-squares of grayscale values at the projected points is minimized. Fiducial registration error (FRE) and target registration error (TRE) of this approach were evaluated in phantom studies using TAVR-relevant gantry orientations and four standard acoustic windows for the TTE probe. A patient study was conducted to assess the clinical suitability of the fiducial attachment prototype during TTE imaging of patients undergoing SHI. TTE image quality for the task of guiding a transcatheter procedure was evaluated in a reviewer study. RESULTS: The 3D FRE ranged from 0.32 ± 0.03 mm (mean ± SD) to 1.31 ± 0.05 mm, depending on C-arm orientation and probe acoustic window. The 3D TRE ranged from 1.06 ± 0.03 mm to 2.42 ± 0.06 mm. Fiducial pose estimation was stable when >75% of the fiducial markers were visible in the x-ray image. A panel of reviewers graded the presentation of heart valves in TTE images from 48 SHI patients. While valve presentation did not differ significantly between acoustic windows (P > 0.05), the mitral valve did achieve a significantly higher image quality compared to the aortic and tricuspid valves (P < 0.001). Overall, reviewers perceived sufficient image quality in 76.5% of images of the mitral valve, 54.9% of images of the aortic valve, and 48.6% of images of the tricuspid valve. CONCLUSIONS: Fiducial-based tracking of a commercial TTE probe is compatible with clinical SHI workflows and yields 3D target registration error of less than 2.5 mm for a variety of x-ray gantry geometries and echo probe acoustic windows. Although TTE image quality with respect to target valve anatomy was sufficient for the majority of cases examined, prescreening of patients for sufficient TTE quality would be helpful.

Three-dimensional echocardiography and mitral valve disease.

Three-dimensional echocardiography is a growing imaging modality, particularly for the evaluation of mitral valve pathology. Functional anatomy in disease states such as mitral regurgitation and stenosis as well as prosthetic valves can be effectively studied, offering superior knowledge to treating physicians. Additionally, three-dimensional echocardiography has the ability to help guide operative and percutaneous interventions, allowing for improved patient outcomes and advancement of clinical research. Continued experience with three-dimensional echocardiography will further our knowledge of the mitral valve and refine current indications for cardiovascular imaging.

Usefulness of Focused Screening Echocardiography for Collegiate Athletes.

Sudden cardiac death in a young healthy athlete is a rare but catastrophic event. The American Heart Association preparticipation screening guidelines recommend a focused history and physical without routine imaging or electrocardiogram screening. We hypothesized that a focused echocardiogram can identify structural abnormalities that may lead to sudden cardiac death in athletes, which might otherwise go undetected by history and physical. We retrospectively reviewed the charts of all incoming collegiate athletes at a single university from 2005 to 2013, all of whom had undergone a focused, 5-minute echocardiogram along with a guideline-based preparticipation history and physical (PPS H&P). Abnormal findings prompted further testing or referral. We report the prevalence of abnormal findings and the relation between an abnormal PPS H&P and screening echocardiogram. A total of 2,898 athletes were screened and 159 (5%) had findings. Forty athletes underwent further testing and evaluation. Of these athletes, 3 had newly diagnosed abnormalities that warranted restriction of participation: 1 apical-variant hypertrophic cardiomyopathy, 1 large bidirectional atrial septal defect with right ventricular dysfunction, and 1 dilated ascending aorta. Two of these athletes had a normal PPS H&P. Conversely, of the 661 athletes with an abnormal PPS H&P, only 1 (0.15%) had an abnormal screening echocardiogram. In conclusion, although the overall number was low, the 5-minute screening echocardiogram detected athletes at risk for sudden cardiac death not discovered on PPS H&P.

Lamin A/C mutation analysis in a cohort of 324 unrelated patients with idiopathic or familial dilated cardiomyopathy.

BACKGROUND: Lamin A/C mutations are a well-established cause of dilated cardiomyopathy (DCM), although their frequency has not been examined in a large cohort of patients. We sought to examine the frequency of mutations in LMNA, the gene encoding lamin A/C, in patients with idiopathic (IDC) or familial dilated cardiomyopathy (FDC). METHODS: Clinical cardiovascular data, family histories, and blood samples were collected from 324 unrelated IDC probands, of whom 187 had FDC. DNA samples were sequenced for nucleotide alterations in LMNA. Likely protein-altering mutations were followed up by evaluating additional family members, when possible. RESULTS: We identified 18 protein-altering LMNA variants in 19 probands or 5.9% of all cases (7.5% of FDC; 3.6% of IDC). Of the 18 alterations, 11 were missense (one present in 2 kindreds), 3 were nonsense, 3 were insertion/deletions, and 1 was a splice site alteration. Conduction system disease and DCM were common in carriers of LMNA variants. Unexpectedly, in 6 of the 19 kindreds with a protein-altering LMNA variant (32%), at least one affected family member was negative for the LMNA variant. CONCLUSIONS: Lamin A/C variants were observed with a frequency of 5.9% in probands with DCM. The novel observation of FDC pedigrees in which not all affected individuals carry the putative disease-causing LMNA mutation suggests that some protein-altering LMNA variants are not causative or that some proportion of FDC may be because of multiple causative factors. These findings warrant increased caution in FDC research and molecular diagnostics.

Do emergency department patients with possible acute coronary syndrome have better outcomes when admitted to cardiology versus other services?

STUDY OBJECTIVE: Emergency physicians need to consider potential differences in quality of care across admitting services in their triage decisions. For emergency department (ED) patients with possible acute coronary syndrome who require hospitalization, there are relatively few data to guide emergency physicians in deciding whether admission to a cardiology service bed yields better outcomes than admission to a noncardiology service. METHODS: We enrolled 544 ED patients who were admitted for symptoms of possible acute coronary syndrome after a nondiagnostic initial evaluation during a quality improvement trial at 2 university hospitals. Adverse events, inhospital treatment, and follow-up care were assessed by 30-day telephone interview and medical record review. We used a modified version of the Medical Outcomes Study Short Form 20 and the Duke Activity Status Index to assess functional status. To account for selection bias, we analyzed process and outcome variables after adjustment for the estimated propensity of being admitted to cardiology and predicted probability of acute cardiac ischemia. RESULTS: Overall, 34% of admitted patients had confirmed acute coronary syndrome. Patients admitted to a cardiology service were significantly more likely to undergo evaluation for ischemic heart disease than those admitted to a noncardiology service (adjusted odds ratio for noninvasive testing 2.7; 95% confidence interval 1.7 to 4.2) but were not more likely to receive recommended therapies. The incidence of ED revisits and rehospitalizations, functional status, and adverse cardiovascular events were similar in both groups. CONCLUSION: ED patients admitted for evaluation of possible acute coronary syndrome do not experience worsened short-term outcomes if admitted to a noncardiology service bed.

Does concordance with guideline triage recommendations affect clinical care of patients with possible acute coronary syndrome?

BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline recommends outpatient management for patients at low risk and admission to a monitored bed for patients at intermediate-high risk of adverse short-term outcomes, but the clinical consequences of adhering to these recommendations are unclear. METHODS: This analysis included 7466 adults who presented to the emergency department (ED) with symptoms of possible acute coronary syndrome (ACS) and who participated in 3 prospective clinical effectiveness trials during the period 1993 to 2001. The authors used logistic regression to assess the impact of concordance with guideline triage recommendations on subsequent diagnostic testing, follow-up care, and 30-day mortality and applied propensity score methods to adjust for selection bias. RESULTS: Among low-risk patients (n = 1099), ED discharge was not associated with higher mortality and did not increase the need for emergency care or hospitalization during follow-up (adjusted odds ratio [OR] = 1.0, 95% confidence interval [CI] = 0.63-1.6 for ED revisits); however, 1.7% of discharged low-risk patients had confirmed ACS. Among intermediate- to high-risk patients (n = 6367), admission to a monitored bed was not associated with reduction in 30-day mortality but significantly reduced the need for follow-up ED care (adjusted OR = 0.81, 95% CI = 0.69-0.96). CONCLUSIONS: This analysis supports the practice of discharging low-risk ED patients with symptoms of possible ACS but highlights the need to arrange timely follow-up (or to perform additional risk stratification in the ED prior to discharge). It also confirms the benefit of admitting ED patients with intermediate- to high-risk characteristics to a monitored bed.

Taser dart-to-heart distance that causes ventricular fibrillation in pigs.

Electromuscular incapacitating devices (EMDs), such as Tasers, deliver high current, short duration pulses that cause muscular contractions and temporarily incapacitate the human subject. Some reports suggest that EMDs can kill. To help answer the question, "Can the EMD directly cause ventricular fibrillation (VF)?", ten tests were conducted to measure the dart-to-heart distance that causes VF in anesthetized pigs [mass = 64 kg +/- 6.67 standard deviation (SD)] for the most common X26 Taser. The dart-to-heart distance that caused VF was 17 mm +/- 6.48 (SD) for the first VF event and 13.7 mm +/- 6.79 (SD) for the average of the successive VF events. The result shows that when the stimulation dart is close enough to the heart, X26 Taser current will directly trigger VF in pigs. Echocardiography of erect humans shows skin-to-heart distances from 10 to 57 mm (dart-to-heart distances of 1-48 mm). These results suggest that the probability of a dart on the body landing in 1 cm2 over the ventricle and causing VF is 0.000172.

Comparison of Outcomes of Atrial Fibrillation in Patients With Reduced Versus Preserved Left Ventricular Ejection Fraction.

Patients with newly diagnosed atrial fibrillation (AF) and a rapid ventricular response may present with a reduced left ventricular ejection fraction (LVEF). We compared long-term outcomes of these patients with those with preserved LVEF. This retrospective cohort study included 385 consecutive adults with newly diagnosed AF with rapid ventricular response, presenting to a single medical center from January 2006 to August 2014. Patients with a history of coronary artery disease or known cardiomyopathy were excluded. Patients were divided into 2 groups: those with an LVEF ≤55% (n = 147) (REF) and those with an LVEF >55% (n = 238) (PEF). Echocardiographic parameters, all-cause mortality, cardiovascular mortality, and stroke rates were compared between both groups at baseline and a minimum of 1-year follow-up. The mean age of patients was 68 ± 1.1 in REF versus 60 ± 7.4 in PEF (p = 0.39). There were no significant differences in baseline co-morbidities between both groups. The mean LVEF during the index admission was 47.7 ± 0.8% in REF versus 65.5 ± 0.3% in PEF. The average duration of follow-up was 2.8 years. Patients with REF had higher all-cause mortality (32.7% REF vs 20.6% PEF, odds ratio 2.17, p = 0.008). Patients with REF had higher rates of subsequent clinic or ER visits for AF with a rapid ventricular response (32% REF vs 22.7% PEF, p = 0.044). The incidence of stroke was similar between both groups (17% REF vs 18.9% PEF, p = 0.639). Of the patients with REF, 64% had subsequent EF recovery and had similar outcomes compared with patients with PEF. Baseline LV end-diastolic diameter predicted all-cause mortality (odds ratio 1.14, p = 0.003) in the REF group. None of the echocardiographic parameters predicted EF recovery. In conclusion, in patients with new AF with rapid ventricular response, REF was associated with higher long-term all-cause mortality. Those with subsequent LVEF recovery after medical therapy appear to have a similar prognosis compared with those with initial PEF.

Emergency physicians' fear of malpractice in evaluating patients with possible acute cardiac ischemia.

STUDY OBJECTIVE: We evaluate the association between emergency physicians' fear of malpractice and the triage and evaluation patterns of patients with symptoms suggestive of acute coronary syndrome. METHODS: We surveyed 33 emergency physicians of 2 university hospitals during the preintervention phase of an implementation trial of the Agency for Health Care Policy and Research Unstable Angina guideline in 1,134 study patients. The survey included a 6-item instrument that addressed concerns about malpractice and a measure of general risk aversion. We used hierarchical logistic regression to model emergency department (ED) triage decisions and diagnostic testing as a function of fear of malpractice, with adjustment for patient characteristics, Agency for Health Care Policy and Research guideline risk group, study site, and clustering by emergency physician. RESULTS: Overall, emergency physicians in the upper tertile of malpractice fear were less likely to discharge low-risk patients compared with emergency physicians in the lower tertile (adjusted odds ratio [OR] 0.34; 95% confidence interval [CI] 0.12 to 0.99; P=.05). Patients treated by emergency physicians in this group were also more likely to be admitted to an ICU or telemetry bed (adjusted OR 1.7; 95% CI 1.2 to 2.4). In addition, emergency physicians in the upper tertile of malpractice fear were more likely to order chest radiography, as well as cardiac troponin. Malpractice fear accounted for a similar amount of variance after controlling for emergency physicians' risk aversion. CONCLUSION: Malpractice fear accounts for significant variability in ED decisionmaking and is associated with increased hospitalization of low-risk patients and increased use of diagnostic tests.

Development of Aortic Valve Disease in Familial Hypercholesterolemic Swine: Implications for Elucidating Disease Etiology.

BACKGROUND: Familial hypercholesterolemia (FH) is a prevalent hereditary disease associated with increased atherosclerosis and calcific aortic valve disease (CAVD). However, in both FH and non-FH individuals, the role of hypercholesterolemia in the development of CAVD is poorly understood. This study used Rapacz FH (RFH) swine, an established model of human FH, to investigate the role of hypercholesterolemia alone in the initiation and progression of CAVD. The valves of RFH swine have not previously been examined. METHODS AND RESULTS: Aortic valve leaflets were isolated from wild-type (0.25- and 1-year-old) and RFH (0.25-, 1-, 2-, and 3-year-old) swine. Adult RFH animals exhibited numerous hallmarks of early CAVD. Significant leaflet thickening was found in adult RFH swine, accompanied by extensive extracellular matrix remodeling, including proteoglycan enrichment, collagen disorganization, and elastin fragmentation. Increased lipid oxidation and infiltration of macrophages were also evident in adult RFH swine. Intracardiac echocardiography revealed mild aortic valve sclerosis in some of the adult RFH animals, but unimpaired valve function. Microarray analysis of valves from adult versus juvenile RFH animals revealed significant upregulation of inflammation-related genes, as well as several commonalities with atherosclerosis and overlap with human CAVD. CONCLUSIONS: Adult RFH swine exhibited several hallmarks of early human CAVD, suggesting potential for these animals to help elucidate CAVD etiology in both FH and non-FH individuals. The development of advanced atherosclerotic lesions, but only early-stage CAVD, in RFH swine supports the hypothesis of an initial shared disease process, with additional stimulation necessary for further progression of CAVD.

Relation of "inotropic reserve" to functional capacity in heart failure secondary to ischemic or nonischemic cardiomyopathy.

Exercise capacity in patients with dilated cardiomyopathy, measured by peak oxygen consumption (VO(2)) during exercise, has virtually no relation to resting left ventricular (LV) function. We hypothesized that exercise-induced inotropic reserve may explain some of the variation between peak VO(2) and resting LV function. Treadmill stress echocardiography was performed simultaneously with peak VO(2) measurements in 35 patients with dilated cardiomyopathy. Resting and immediate postexercise echocardiographic images were scored for change in segmental contractility using the American Society of Echocardiography 16-segment system. Segment scores were summed and divided by 16 to determine the wall motion index. Right ventricular (RV) function was quantified on a 4-point scale. Patients had a mean age of 52 +/- 12 years (8 women) and a mean ejection fraction of 30 +/- 10 (25 nonischemic patients). Average peak VO(2) was 17.0 +/- 6 ml/kg/min. Patients were divided into 2 groups by peak VO(2): a high VO(2) group, >17 ml/kg/min (17 patients) and a low VO(2) group, < or =17 ml/kg/min (18 patients). LV ejection fraction was similar between the high and low VO(2) groups (31 +/- 9% vs 28 +/- 11%, p = NS) as were etiology of heart failure, medications used, and LV volume. In the high VO(2) group, wall motion index improved from 2.28 +/- 0.20 to 2.12 +/- 0.31 during exercise (p = 0.009). There was no improvement in the low VO(2) group. Resting RV function was significantly better in the high VO(2) group (1.4 +/- 0.8 vs 0.6 +/- 0.6 p = 0.004). Therefore, in patients with dilated cardiomyopathy and similar resting LV function, the presence of demonstrable LV inotropic reserve and preserved RV function partially account for variation in exercise performance.