Silent Myocardial Ischemia Revisited, Another Silent Killer, Emphasis on the Diagnostic Value of Stress Echocardiography with Focused Update and Review.

Silent myocardial ischemia (SMI) is a relatively common phenomenon in patients with coronary artery disease (CAD). The original description of SMI dates back to the 1970s. We performed an extensive search of the literature starting from 2000, using MEDLINE or PubMed, and 676 documents were analyzed, and only 45 articles found suitable for the study were selected. Data regarding the prevalence and risk factors of SMI were discussed, along with the different mechanistic processes behind it; also, methods for screening and diagnosis are exposed, namely electrocardiographic stress test, stress echocardiography, and single-photon emission computed tomography (SPECT). The silent nature of the condition presumes that patients are diagnosed at a more advanced stage, and screening high-risk patients for early management is essential. Education of patients is necessary, and medical management along with cardiac rehabilitation is valid for mild cases, whereas patients with moderate-to-severe myocardial ischemia might require a more invasive approach. SMI is relatively common, diagnostic approach offers data regarding the presence of ischemia along with its anatomic extent, providing important prognostic value. Given its silent and critical nature, future directions for better screening and management must be searched and implemented extensively.

A polo ball in the right atrium, importance of echocardiographic characteristics of intracardiac myxomas: a case report.

BACKGROUND: Myxomas are the most prevalent type of heart tumors, mainly occurring in the left atrium, with approximately 20% of cases found in the right atrium. Timely diagnosis and appropriate management of myxomas are crucial for favorable outcomes and to minimize complications. CASE PRESENTATION: A 77-year-old Asian male with no significant medical history presented with intermittent trepopnea and palpitations. Physical examination revealed regular heart sounds and no other relevant findings. A transthoracic echocardiogram showed a large, round-shaped, smooth-edged mass with diameter of 86 mm, occupying most of the right atrium. Mild tricuspid flow obstruction and mild left ventricular systolic dysfunction were also observed. Cardiac tomography confirmed the size, smooth edges, and showed microcalcifications of the mass, with no invasion of surrounding tissues. Surgical intervention successfully removed the spheroid mass, leading to the alleviation of symptoms. Histopathology confirmed the myxoma nature of the mass. A comprehensive discussion based on relevant medical literature is provided, with emphasis on echocardiographic characteristics of the mass with relation to potential embolic disease. CONCLUSION: This case shows an atypical presentation of an exceptionally large myxoma in the right atrium, resembling the size of a polo ball, in a patient presenting with supraventricular arrhythmia and trepopnea. Early diagnosis and appropriate management played a vital role in achieving a successful outcome for the patient.

Loculated pericardial hematoma compressing the right atrium post mechanical aortic valve replacement and the role of point-of-care echocardiography: a case report.

BACKGROUND: Bleeding in the postoperative period after cardiac surgery is relatively frequent, especially in patients with early anticoagulant therapy, as in the case of mechanical valve replacement. Diffuse hemopericardium is relatively easy to diagnose; however, loculated pericardial hematomas leading to hemodynamic collapse are relatively rare and their diagnosis is more challenging. CASE PRESENTATION: This report is of a 75-year-old Asian woman who presented dyspnea, confusion and hemodynamic collapse related to loculated pericardial hematoma compressing the right atrium 3 days after mechanical aortic valve replacement. Urgent transthoracic echocardiogram performed as point-of-care approach showed right atrial compression, the aortic valve prosthesis had normal function. Surgical removal of the hematoma resulted in complete recovery. CONCLUSION: Loculated pericardial hematoma might lead to hemodynamic collapse. Close monitoring of hemodynamic parameters is essential, also point-of-care echocardiography is essential for early recognition and prompt management in patients with critical hemodynamic condition.

Impact of COVID-19 on Workload and Workflow in Echocardiography Unit in a Tertiary Care University Hospital: A Monocentric Observational Study.

Background: The COVID-19 pandemic is a new unexpected worldwide condition with a heavy burden on health-care institutions and health-care workers. Objective: We sought to examine the impact of COVID-19 on workload and workflow in the echocardiography unit in a tertiary care university hospital. Methods: We conducted a monocentric observational study, evaluating workload and workflow during the COVID-19 year relative to the previous year. Results: The findings show a substantial reduction in workload (55.20%) along with significant changes in workflow in the echocardiography unit during the pandemic. Changes in workflow involved measures implemented for protection, changes in echo indications which became more selective, changes in echo pattern, reduction in human flow in echocardiography laboratory, delays in reporting and archiving, and changes in training and teaching. Conclusion: COVID-19 pandemic had a substantial impact on the echocardiography unit, with a significant reduction in workload and considerable changes in workflow. In the future, it is essential to be better prepared as individuals, health-care workers, health-care institutions, and the general community, to deal better with any potential "invisible enemy."

Quality Assurance and Improvement Project in Echocardiography Laboratory: The Pivotal Importance of Organizational and Managerial Processes.

Echocardiography plays a vital role in the diagnosis and management of cardiovascular conditions. Echocardiography use is progressively increasing nowadays, and this is correlated to the evolving echo indications, to the relatively new available echocardiography modes (tissue Doppler imaging, speckle tracking imaging, three-dimensional mode, etc.) and modalities (transthoracic, transesophageal, and intracardiac) along with the various available clinical approaches (point of care echo, portable echo, etc.). Quality assurance in echocardiography is correlated to appropriate use criteria, adequate equipment, standardization of performance and reporting, along with timely storage and archiving. Quality improvement plan must target strategic planning, with metrics and timeline for assessment and re-assessment of results. Improvement project aims to ensure and enhance conformity with appropriate use criteria and standardization, timely completion of exams and reports, detection of discrepancies, and continuous improvement of knowledge and skills. Strategic planning is essential in this context in order to develop organizational and managerial processes, with regular auditing for a highly professional and advanced level of echocardiography, while ensuring teamwork and standards of ethical values.

Sensing and Detection Functions in Implantable Cardioverter Defibrillators: The Good, the Bad and the Ugly.

Implantable cardioverter defibrillators are small devices that have been proven to be beneficial by preventing sudden cardiac death, whether in primary or secondary prevention. Appropriate functioning of implantable cardioverter defibrillators is mainly dependent on the "good" sensing of ventricular electrogram waves, allowing for the adequate detection of ventricular arrhythmias in order to deliver appropriate therapy of either antitachycardia pacing or by delivering a shock according to the detected rhythm. Basic sensing function in defibrillators is based on detection rate and detection duration; additional parameters that are involved in the process of adequate detection include ventricular electrogram sensing, auto-adjusting sensitivity, supraventricular arrhythmia discrimination criteria, noise detection, and various dedicated algorithms. Defective sensing may result in the delivery of inappropriate therapy (oversensing) or inappropriate withholding of therapy (undersensing); the latter of which may lead to sudden cardiac death. This paper describes different clinical scenarios and programming tips to avoid abnormal or critical clinical situations.

Stress Echocardiography: Concept and Criteria, Structure and Steps, Obstacles and Outcomes, Focused Update and Review.

Stress echocardiography (SEC) is a technique established more than 35 years ago; however, it is still poorly implemented in many countries and institutions, and this reluctance may be related to many obstacles such as operator skills, lack of awareness or institutional policy. Stress echo was initially used for assessing coronary artery disease (CAD), with respect to myocardial viability, using wall motion response; however, current use of stress echo extends beyond CAD, such as valvular heart disease and diastolic stress test. Dobutamine is a commonly used agent when pharmaceutical approach is implemented. With regard to CAD, there are four stress responses: normal, ischemic, viable and necrotic. A low dose dobutamine protocol is recommended in patients with baseline wall motion abnormalities, and a very low dose dobutamine is used in low flow low gradient aortic stenosis in order to check the flow and contractility reserve. Of note, respecting protocols, indications and contraindications are important to avoid or minimize risks of complications during the procedure. This article presents a focused update and review regarding SEC, along with an overview of the different indications, structures and steps, and obstacles and outcomes; also the article aims to highlight more awareness and sensitization on this useful technique.

Vernakalant in Atrial Fibrillation: A Relatively New Weapon in the Armamentarium Against an Old Enemy.

Atrial fibrillation is the most common sustained cardiac arrhythmia, and its prevalence is increasing with age; also it is associated with significant morbidity and mortality. Rhythm control is advised in recent-onset atrial fibrillation, and in highly symptomatic patients, also in young and active individuals. Moreover, rhythm control is associated with lower incidence of progression to permanent atrial fibrillation. Vernakalant is a relatively new anti-arrhythmic drug that showed efficacy and safety in recent-onset atrial fibrillation. Vernakalant is indicated in atrial fibrillation (⩽7 days) in patients with no heart disease (class I, level A) or in patients with mild or moderate structural heart disease (class IIb, level B). Moreover, Vernakalant may be considered for recent-onset atrial fibrillation (⩽3 days) post cardiac surgery (class IIb, level B). Although it is mainly indicated in patients with recent-onset atrial fibrillation and with no structural heart disease, it can be given in moderate stable cardiac disease as alternative to Amiodarone. Similarly to electrical cardioversion, pharmacological cardioversion requires a minimal evaluation and cardioversion should be included in a comprehensive management strategy for better outcome.

Unfortunate Hand Positioning Yielding Inappropriate Defibrillator Shock: Another Paradigm of a Guilty Association Between Patient Awareness and Occupational Hazard.

A 64-year-old patient had a cardiac resynchronization therapy defibrillator implanted 4 years ago for dilated cardiomyopathy. He recently had an inappropriate shock as a result of an electrical leak from a refrigerator causing electromagnetic interference. An analysis of the patient case and a discussion of the features of this specific paradigm of inappropriate therapy are presented.

Predictors of Undiagnosed and Uncontrolled Hypertension in the Local Community of Byblos, Lebanon.

OBJECTIVE: This study aimed to determine the prevalence and predictors of undiagnosed and uncontrolled hypertension (HTN) in a local community in Lebanon. DESIGN AND METHODS: In this cross-sectional study, we interviewed 911 adults in the local community of Byblos, Lebanon, and 691 were enrolled in the study. Blood pressure (BP), height, and weight were measured. The diagnosis of HTN was based on the 2013 European Society of Hypertension (ESH)/ European Society of Cardiology (ESC) guidelines (systolic BP ⩾140 mm Hg and/or diastolic BP ⩾90 mm Hg). The data collected were analyzed using "Statistical Package for the Social Sciences" software (SPSS). RESULTS: A total of 260 participants were found to be hypertensive, either previously diagnosed or undiagnosed, yielding an overall prevalence of HTN of 37.62%. Of these participants, 149 (57.31%) were previously diagnosed and had controlled BP, and 111 (42.69%) had undiagnosed or uncontrolled HTN. Of these 111 participants, 44 had undiagnosed HTN and 67 were previously documented as hypertensive but had uncontrolled BP. Younger age and the absence of associated cardiovascular comorbidities were found to be associated with undiagnosed HTN, whereas high body mass index, smoking, and nonadherence to therapy were found to be associated with uncontrolled HTN. CONCLUSION AND IMPLICATIONS: This study revealed a relatively high prevalence of HTN in the studied population, along with a high prevalence of undiagnosed and uncontrolled HTN. These findings emphasize the need for wider and more efficient screening strategies to better diagnose and control HTN in the general population.

Knowing About Device Algorithms to Understand the Rhythm and Role of Managed Ventricular Pacing.

A 66-year-old patient with a DR pacemaker for intermittent atrioventricular block presented with an electrocardiogram (ECG) showing some P waves non followed by QRS complexes, raising suspicion of device dysfunction. The device was equipped with a special algorithm (Managed Ventricular Pacing; Medtronic), and the observed ECG tracing was a normal consequence of the function of such algorithms. Being aware of the function of specific algorithms is essential to adequately analyze rhythms.

Role of Biomarkers in the Diagnosis, Risk Assessment, and Management of Pulmonary Hypertension.

Pulmonary hypertension is a severe and debilitating disease with no definite cure, and the domain of targeted therapies is a promising field for better management of this severe condition. The disease comprises pulmonary arterial remodeling, hypoxia, endothelial dysfunction, and inflammation, with subsequent organ damage including right heart and liver dysfunction. Biomarkers have a valuable role at different levels of the disease, from diagnosis to risk assessment and management, in order to decrease the burden of the disease in terms of both morbidity and mortality.

Double Trouble in a Patient with Coronary Ectasia, Bradycardia with Angina: Epiphenomenal or Mechanistic Association.

Coronary artery ectasia is a rare angiographical finding, and it accounts for less than 5% of all coronary angiograms. We report a case of a 55-year-old male patient who presented with fatigue and exertional chest pain. Paraclinical tests revealed cardiac ischemia and sinus node dysfunction, as well as coronary artery ectasia without significant coronary stenosis. Factors involved in cardiac ischemia in this context comprise slow flow, poor collateral circulation, microcirculatory dysfunction, lack of adequate exertional coronary vasodilatation, and endothelial dysfunction. Moreover, poor collaterals with rudimentary sinus node artery may explain sinus node dysfunction. Discussion is made in light of the relevant medical literature.

Appropriate Use Criteria in Echocardiography: An Observational Institutional Study with the Perspective of a Quality Improvement Project.

BACKGROUND: Appropriate use criteria (AUC) in echocardiography are essential tools for aligning the indications of echocardiography with the best clinical standards, improving clinical outcome, restraining abuse, and preserving health-care resources. OBJECTIVES: The aim of this study was to ascertain the AUC for transthoracic echocardiography in a university hospital and create a quality improvement project (QIP). METHODS: The assessment of 501 inpatients who received transthoracic cardiac echo was conducted according to the 2011 AUC report. Indications were classified as appropriate, uncertain, or inappropriate, and patients not matching any of the abovementioned divisions were grouped in the nonfitting category. RESULTS: Of the 501 eligible patients, 374 patients (74.66%) were in the appropriate group, 85 patients (16.96%) in the inappropriate group, 20 patients (3.99%) in the uncertain group, and 22 patients (4.39%) in the nonfitting category. DISCUSSION: Interpretation and analysis of the obtained results are presented, along with the results of many comparable studies; moreover, a QIP was set up accordingly. CONCLUSION: AUC are useful to assess local practice, preserve health-care resources, and improve clinical outcome.

Echocardiographic Assessment of the Right Ventricle, from the Conventional Approach to Speckle Tracking and Three-Dimensional Imaging, and Insights into the "Right Way" to Explore the Forgotten Chamber.

BACKGROUND: The right ventricle (RV) has an essential function in cardiovascular physiology and pathology. Currently, it is gaining an increasing interest given its recognized role in many cardiovascular conditions. However, echocardiographic assessment of the RV in daily practice is frequently based on qualitative estimation, and it has been regarded as a neglected chamber. OBJECTIVE: We sought to review and discuss the appropriate approach and latest methods of assessment of the RV by echocardiography. METHODS: A MEDLINE/Pubmed search was performed, and 55 relevant articles were selected; articles addressing right ventricular assessment by echocardiography, along with the latest recommendations, have been reviewed and discussed. RESULTS: A RV diameter >42 mm at the base and >35 mm at the mid-cavitary level indicates right ventricular dilatation; a longitudinal myocardial velocity (S') <9.5 mm/s, a tricuspid annular plane systolic excursion <17 mm, and a fractional area change <35% are indices of right ventricular systolic dysfunction. A right ventricular ejection fraction of >45% and an absolute value of global longitudinal strain of >21% reflect normal systolic function. The significance of dp/dt, the right myocardial performance index and isovolumic myocardial acceleration, is also discussed along with the parameters of right ventricular diastolic function. The use of novel echocardiographic approaches, such as three-dimensional echo and speckle tracking imaging, allows practitioners to overcome the challenges encountered with conventional echocardiography. CONCLUSION: Accurate assessment of the RV by echocardiography yields early detection of cardiac diseases, enhances risk stratification, and allows timely initiation of appropriate therapy.

Assessment of heart rate turbulence in hypertensive patients: rationale, perspectives, and insight into autonomic nervous system dysfunction.

BACKGROUND: Heart rhythm turbulence is classically impaired in patients with previous myocardial infarction and congestive heart failure and is poorly investigated in patients with essential hypertension. OBJECTIVE: To evaluate heart rhythm turbulence parameters (turbulence onset, (TO); turbulence slope, (TS) in a series of hypertensive patients while gaining insight into autonomic nervous system dysfunction. SETTING AND DESIGN: University hospital, cross-sectional monocentric study. MATERIALS AND METHODS: Heart rhythm turbulence was assessed in 50 hypertensive (case group) and 40 normotensive patients (control group). RESULTS: TO and TS were found independently correlated with hypertension. The mean TO was found at -1.64% ± 2.85% in the normotensive patients compared to 1.21% ± 1.95% in the hypertensive patients; the mean TS was found at 4.29 ± 3.18 ms/RR in the normotensive patients compared to 2.27 ± 0.93 ms/RR in the hypertensive patients. Hypertension has a predictive value on heart rhythm turbulence impairment (OR 4.99, 95% CI 1.28-19.41, P = 0.02). Insights into the role of autonomic nervous system dysfunction for the management of hypertensive patients and prevention of malignant ventricular arrhythmia are presented and discussed with regard to heart rhythm turbulence. CONCLUSION: Essential hypertension is correlated with blunted heart rhythm turbulence parameters.

The lebanese society of cardiology: plans and perspectives, navigating against contrary winds and progressing against all odds.

Scientific societies in medicine theoretically aim to improve a medical field as a science; however, this role is expanding nowadays to seeking also the improved practice of a certain medical field. In this regard, the current Lebanese Society of Cardiology (2013-2015) has laid many plans and considered many perspectives. These concern mainly, but not exclusively, the increase of public awareness regarding prevention, investment in research, implementation of guidelines, support of continuous medical education, organization of cardiology symposia and congresses, and achievement of national registries regarding main cardiac conditions, as well as the society's main objective of decreasing the burden of cardiovascular diseases in Lebanon. Nonetheless, the implementation of such plans and perspectives is facing contrary winds related to a multifaceted phenomenon: the dominance of private medicine with a subsequent lack of teamwork, the dominance of private media, the social and political unrest in Lebanon, significant discrepancies in the scientific background of cardiologists, and the absence of a standardized national cardiology licensing exam. Importantly, the implementation of such plans and perspectives requires individual commitment, along with the cooperation of the Order of Physicians, the Syndicate of Hospitals in Lebanon (representing private hospitals) and the Ministry of Health. Moreover, industry must be more committed to medical scientific societies; the support of cardiology events organized without the auspices of the Lebanese Society of Cardiology is not encouraged because of the presence of significant conflict of interest.

Concealed Sinus Node Dysfunction and Paradoxical Effect of Atropine during Arrhythmia Diagnostic Pharmacological Testing.

A 78-year-old male patient presented with repetitive fainting episodes. His electrocardiogram showed sinus rhythm with persistent ventricular bigeminy. Concealed sinus node dysfunction (SND) with consecutive bradycardia-induced ventricular hyperexcitability was suspected. Pharmacological testing with atropine resulted in accelerated junctional rhythm along with nearly total disappearance of the ventricular ectopy. The diagnosis of SND was retained, a dual chamber pacemaker was implanted, and consequently, ventricular hyperexcitability disappeared. The junctional rhythm was a paradoxical effect of atropine, and many explanations were provided. Discussion was made accordingly taking into account relevant data from the literature.

Echocardiographic assessment of mitral valve regurgitation, pattern and prevalence, expanding clinical awareness through an institutional survey with the perspective of a quality improvement project.

BACKGROUND: Mitral regurgitation (MR) is frequently reported in everyday echocardiograms; accurate assessment is essential for appropriate management and decision making. OBJECTIVE: We performed a self-audit in order to define the prevalence and pattern of MR and to evaluate methods of assessment with the perspective of developing a quality improvement project. METHODS AND SETTING: This retrospective analytical study was conducted in a university hospital. INCLUSION CRITERIA: age more than 18 years and medical records available within the facility, including a "complete" medical history. Using the picture archiving and communication system, we reviewed 961 echocardiograms performed over a 6-month period. The methods of assessment of native mitral valve regurgitation were reported, and also relevant medical data were collected using an electronic archiving system. RESULTS AND DISCUSSION: Among the 961 patients reviewed, 322 (33.50%) had MR, with variable grades. MR pattern (organic versus functional) was not specified in 49.68% of cases. "Eyeball" assessment and "color jet area" were the most frequently used methods for MR assessment (90.06% and 27.95%, respectively), while "vena contracta" and "flow convergence" methods were rarely implemented (1.55% and 2.17%, respectively). Discussion is made according to current guidelines, while showing the strengths and weaknesses of each method. CONCLUSION: The prevalence of MR was 33.50%, and in nearly half of cases, the MR pattern was not specified. Qualitative and semi-quantitative methods of assessment were mostly used; quantitative assessment should be implemented more frequently, in accordance with current guidelines. Increasing clinical awareness by creating and implementing a quality improvement project is essential in this context.