A rare case of echo enhancing agent anaphylaxis complicated by acute coronary syndrome.

Enhancing agents in echocardiography are used frequently to improve endocardial border visualization and assessment of structural heart disease. We present a unique case of anaphylactic shock with acute coronary syndrome following administration of sulfur hexafluoride echo enhancing agent. This case emphasizes the importance of recognizing anaphylaxis to enhancing agents, as well as recognizing the potential relationship between anaphylaxis and acute coronary syndrome with in-stent thrombosis.

Bayés syndrome secondary to atrial lipoma.

This case describes a 74-year-old male who presented with rapid atrial flutter in association with large atrial lipoma along the interatrial septum. Conversion to sinus rhythm revealed the electrocardiographic criteria for advanced interatrial block. Interatrial block results from disruption of conduction through Bachmann's bundle, most commonly due to progressive atrial fibrosis. Bayés syndrome is recognized as the association of atrial arrhythmias with underlying interatrial block. This case supports the concept that localized disruption of atrial conduction via Bachmann's bundle from an atrial lipoma can produce the electrophysiologic substrate for atrial arrhythmias and the Bayés syndrome.

Do Patients With Non-Viable Myocardium From Ischemic Cardiomyopathy Benefit From Revascularization? A Systematic Review And Meta-Analysis.

BACKGROUND: Myocardial viability assessment is used to select patients who will derive the greatest benefit from revascularization. It remains controversial whether revascularization only benefits patients with ischemic cardiomyopathy who have viable myocardium. The objective of this meta-analysis was to compare mortality between patients with ischemic cardiomyopathy and non-viable myocardium who underwent revascularization and those who underwent medical therapy alone. METHODS: The MEDLINE database was searched using PubMed to retrieve studies published up to December 2021. Inclusion criteria were 1. studies that evaluated the impact of revascularization (revascularization group) versus medical therapy alone (control group) following myocardial viability assessment; 2. patients who had coronary artery disease that was amenable to coronary artery bypass grafting or percutaneous coronary intervention; and 3. patients who had non-viable myocardium. The main outcome measure was all-cause mortality. RESULTS: A total of 12 studies were included, evaluating 1363 patients with non-viable myocardium, of whom 501 patients underwent revascularization and 862 patients received medical therapy alone. There was a significant reduction in all-cause mortality (RR 0.76, 95 % CI: 0.62-0.93, I2 = 0) in the revascularization group compared to the control group. There was no association between the type of viability imaging modality and the risk of all-cause mortality (P-interaction = 0.58). CONCLUSIONS: The findings of this meta-analysis suggest a benefit from revascularization compared to medical therapy in patients with ischemic cardiomyopathy despite the lack of myocardial viability.

Left ventricular stroke volume index following transcatheter aortic valve replacement is an early predictor of 1-year survival.

BACKGROUND: Adverse cardiac events are common following transcatheter aortic valve replacement (TAVR). Our aim was to investigate the low left ventricular stroke volume index (LVSVI) 30 days after TAVR as an early echocardiographic marker of survival. HYPOTHESIS: Steady-state (30-day) LVSVI after TAVR is associated with 1-year mortality. METHODS: A single-center retrospective analysis of all patients undergoing TAVR from 2017 to 2019. Baseline and 30-day post-TAVR echocardiographic LVSVI were calculated. Patients were stratified by pre-TAVR transaortic gradient, surgical risk, and change in transvalvular flow following TAVR. RESULTS: This analysis focuses on 238 patients treated with TAVR. The 1-year mortality rate was 9% and 124 (52%) patients had normal flow post-TAVR. Of those with pre-TAVR low flow, 67% of patients did not normalize LVSVI at 30 days. The 30-day normal flow was associated with lower 1-year mortality when compared to low flow (4% vs. 14%, p = .007). This association remained significant after adjusting for known predictors of risk (adjusted odds ratio [OR] of 3.45, 95% confidence interval: 1.02-11.63 [per 1 ml/m2 decrease], p = .046). Normalized transvalvular flow following TAVR was associated with reduced mortality (8%) when compared to those with persistent (15%) or new-onset low flow (12%) (p = .01). CONCLUSIONS: LVSVI at 30 days following TAVR is an early echocardiographic predictor of 1-year mortality and identifies patients with worse intermediate outcomes. More work is needed to understand if this short-term imaging marker might represent a novel therapeutic target.

Incidence and significance of pacemaker and implantable cardioverter-defibrillator lead masses discovered during transesophageal echocardiography.

BACKGROUND: Pacemaker and implantable cardioverter-defibrillator device infections are feared complications. The finding of a lead-associated mass on transesophageal echocardiogram (TEE) raises concern for endocarditis. However, the incidence and clinical importance of lead masses is not currently known. METHODS: Consecutive patients with transvenous leads undergoing TEE from July 1, 2003, to June 30, 2005, were identified and assessed for a clinical diagnosis of endocarditis. An echocardiographer blinded to clinical information reviewed all TEEs. RESULTS: Of 177 TEEs performed on 153 patients, a visible mass on a device lead was observed in 25 (14%), including 11 TEEs showing a lead vegetation, 13 TEEs showing lead strands, and one study showing both. Seventeen patients were adjudicated to have endocarditis, of which eight had a mass seen on a lead during TEE. Thus, 72% of patients (18 of 25) with a lead-associated mass did not have evidence of an infection. In TEEs performed for indications other than to rule out endocarditis, lead masses were seen in 13 of 136 studies (10%), with only one patient adjudicated to clinically have an infected device. CONCLUSION: During this 2-year study of consecutive patients with a tranvenous lead undergoing TEE, lead-associated masses were found in 14% of patients. In 72% of patients, the mass did not prove to be secondary to infectious causes. Thus, masses attached to a device lead should be interpreted in the overall clinical context and, in the absence of concomitant evidence of endocarditis, should not mandate device and lead removal.

Comparison of the Limb-lead Electrocardiogram to the 12-Lead Electrocardiogram for Identifying Conditions Associated with Sudden Cardiac Death in Youth Athletes.

The optimal screening strategy to prevent sudden cardiac death (SCD) in athletes remains unknown. Pre-participation screening with electrocardiogram (ECG) remains controversial. The utility and accuracy of limb-lead (LL) ECG alone in identifying cardiac abnormalities associated with SCD has not been studied. This study was a comparative secondary data analysis, comparing the interpretation accuracy of 4 physicians evaluating publicly available ECGs of the most common cardiac conditions associated with SCD in athletes. Each physician interpreted a total of 100 ECGs: 50 normal ECGs (25 LL and 25 standard 12L) and 50 abnormal ECGs (25 LL and 25 standard 12L). The agreement between LL ECGs and 12L ECGs was assessed by Cohen's kappa coefficient and the accuracy of identifying an abnormal ECG was compared across LL and 12L ECGs using a chi-squared test. Inter-rater reliability was assessed by estimating the Fleiss's kappa coefficient. The sensitivity of LL ECG and 12L ECG was identical at 86%. The specificity of LL ECG was 75% (95% CI = 65% to 83%) and 12L ECG was 82% (95% CI = 73% to 89%). Substantial agreement was seen between LL ECG and 12L ECG interpretation across all readers (k = 0.63; 95% CI = 0.49 to 0.77). Interpretation accuracy was 81% (95% CI = 74% to 86%) and 84% (95% CI 78% to 89%) using LL ECG and 12L ECG, respectively (p = 0.43). In conclusion, the accuracy, sensitivity, and specificity were high and comparable for both LL ECG and 12L ECG in identifying cardiovascular conditions associated with SCD. Agreement between LL ECG and 12L ECG was substantial.

Uncorrected tetralogy of Fallot in an 86-year-old patient.

This report describes the presentation and evaluation of an elderly man with uncorrected tetralogy of Fallot. The patient had remained fairly asymptomatic for much of his life. He presented to the hospital at age 86 with new-onset atrial fibrillation with rapid ventricular response and a non-ST-segment elevation myocardial infarction. Transthoracic and transesophageal echocardiography revealed infundibular pulmonic stenosis with a ventricular septal defect, overriding aorta, and right ventricular hypertrophy, findings consistent with unrepaired tetralogy of Fallot. Severe right ventricular pressure overload was also present. Coronary angiography revealed nonobstructive coronary artery disease. It was felt that the rapid atrial fibrillation resulted in right ventricular subendocardial ischemia that improved following restoration of sinus rhythm. After a systematic literature search, the authors believe this case represents the oldest reported patient with the diagnosis of uncorrected tetralogy of Fallot and serves as an example of a well-balanced congenital shunt.

Polyvinyl chloride as a multimodal tissue-mimicking material with tuned mechanical and medical imaging properties.

PURPOSE: The mechanical and imaging properties of polyvinyl chloride (PVC) can be adjusted to meet the needs of researchers as a tissue-mimicking material. For instance, the hardness can be adjusted by changing the ratio of softener to PVC polymer, mineral oil can be added for lubrication in needle insertion, and glass beads can be added to scatter acoustic energy similar to biological tissue. Through this research, the authors sought to develop a regression model to design formulations of PVC with targeted mechanical and multimodal medical imaging properties. METHODS: The design of experiment was conducted by varying three factors-(1) the ratio of softener to PVC polymer, (2) the mass fraction of mineral oil, and (3) the mass fraction of glass beads-and measuring the mechanical properties (elastic modulus, hardness, viscoelastic relaxation time constant, and needle insertion friction force) and the medical imaging properties [speed of sound, acoustic attenuation coefficient, magnetic resonance imaging time constants T1 and T2, and the transmittance of the visible light at wavelengths of 695 nm (Tλ695) and 532 nm (Tλ532)] on twelve soft PVC samples. A regression model was built to describe the relationship between the mechanical and medical imaging properties and the values of the three composition factors of PVC. The model was validated by testing the properties of a PVC sample with a formulation distinct from the twelve samples. RESULTS: The tested soft PVC had elastic moduli from 6 to 45 kPa, hardnesses from 5 to 50 Shore OOO-S, viscoelastic stress relaxation time constants from 114.1 to 191.9 s, friction forces of 18 gauge needle insertion from 0.005 to 0.086 N/mm, speeds of sound from 1393 to 1407 m/s, acoustic attenuation coefficients from 0.38 to 0.61 (dB/cm)/MHz, T1 relaxation times from 426.3 to 450.2 ms, T2 relaxation times from 21.5 to 28.4 ms, Tλ695 from 46.8% to 92.6%, and Tλ532 from 41.1% to 86.3%. Statistically significant factors of each property were identified. The regression model relating the mechanical and medical imaging properties and their corresponding significant factors had a good fit. The validation tests showed a small discrepancy between the model predicted values and experimental data (all less than 5% except the needle insertion friction force). CONCLUSIONS: The regression model developed in this paper can be used to design soft PVC with targeted mechanical and medical imaging properties.

The relationship between glycosylated hemoglobin and myocardial perfusion imaging.

BACKGROUND: The relationship between long-term glucose control (measured by glycosylated hemoglobin [HgbA1C]) and myocardial perfusion imaging (MPI) abnormalities in symptomatic diabetic patients has not been studied. HYPOTHESIS: We hypothesized that diabetic patients with poorly controlled HgbA1C would have more abnormal MPI compared to both patients without diabetes and diabetic patients with tighter glycemic control. METHODS: This was a retrospective evaluation of 1037 consecutive patients referred for MPI. All patients completed a 1-day MPI protocol. The electronic medical records were accessed for demographics and relevant medical history. RESULTS: Diabetic patients had a higher risk of abnormal MPI (including ischemia, infarction, and mixed ischemia/infarction) compared to nondiabetic patients (relative risk [RR] = 1.77). The populations with suboptimal (HgbA1C ≥ 7%) and poor (HgbA1C ≥ 8%) glycemic control had significantly higher risk of abnormal MPI (RR = 1.78 and 2.17, respectively) compared to nondiabetic patients. Coronary angiography supported the MPI results; 66% of diabetic patients had coronary artery disease (CAD), which was higher than the 53% of patients without diabetes found to have CAD. CONCLUSIONS: The importance of strict glycemic control to reduce cardiovascular complications in diabetic patients is well known. Our study shows a significantly higher risk of abnormal MPI and CAD in diabetic patients with suboptimal and poor long-term glycemic control, further emphasizing the need for aggressive risk factor modification to minimize vascular complications from DM.

Low-density lipoprotein cholesterol target achievement in patients at high risk for coronary heart disease.

OBJECTIVES: Although improvement in target lipid achievement has been observed in recent studies, a significant proportion of patients still do not reach their recommended low-density lipoprotein (LDL-C) targets. We conducted a study in high-risk patients to evaluate the success rate in attaining LDL-C goals. METHODS: Medical records of patients referred for cardiac stress testing were reviewed. Demographic data, coronary heart disease (CHD) risk factors, and the most recent lipid profile were recorded. The patients who did not achieve LDL-C target on initial evaluation were reassessed in 12 months. RESULTS: A total of 765 patients were classified as high-risk CHD. The average age was 66 ± 12 years; 62% were men, and 29% had a previous history of CHD. The mean LDL-C was 96 ± 35 mg/dL and the LDL-C goal of less than 100 mg/dL was achieved in 62%. In 217 patients with very high CHD risk, 83% had LDL-C less than 100 mg/dL and 37% had LDL-C less than 70 mg/dL. At month 12, data from 267 patients were reviewed, and 161 patients (60%) reached LDL-C less than 100 mg/dL. The mean LDL-C was 131 ± 27 mg/dL and 100 ± 29 mg/dL (P < .001) at month 0 and 12, respectively. Antihyperlipidemics were initially prescribed in 49% of these patients and 71% at month 12 (P < .001). CONCLUSION: Our study confirms an improving trend in lipid goal attainment in high and very high CHD-risk patients, but despite this, certain high- and very high-risk patients may require more aggressive intervention.

Aspergillus prosthetic valve endocarditis causing functional aortic stenosis: initial case report.

In the modern surgical era, postoperative prosthetic valve endocarditis persists as a potentially devastating complication of valve replacement surgery. While generally resulting in valvular destruction and regurgitation, prosthetic valve endocarditis may also result in valvular obstruction. The diagnosis of prosthetic valve endocarditis may be difficult due to technical limitations affecting the diagnostic capability of transthoracic echocardiography in patients with prosthetic valves and the indolent nature of the infectious process. We describe the first reported case of Aspergillus endocarditis leading to obstruction of a prosthetic valve in a patient with recent aortic valve replacement.

Echocardiographic diagnosis of air embolism associated with central venous catheter placement: case report and review of the literature.

Transthoracic echocardiography (TTE) is a valuable tool in the evaluation of patients with suspected air embolism. This report describes the presentation and evaluation of a critically ill woman with spontaneous air embolism occurring during a central venous catheter replacement. Bedside TTE established the diagnosis of air embolism, allowing prompt initiation of appropriate therapy. This case report highlights this uncommon but potentially life-threatening complication of central line placement and the utility of echocardiography in its evaluation.