PTSD and mood disorders in implantable cardioverter defibrillator patients: is more psychological assessment needed?

INTRODUCTION: The aim of this review is to identify common mood concerns in ICD patients and suggest brief psychological screeners essential for early detection and monitoring in patient care. AREAS COVERED: Reliable and valid psychological assessment tools are reviewed, including those specifically designed for ICD patient populations. EXPERT OPINION: Psychological assessment, in combination with cardiologic standard of care, can help overcome many barriers associated with poor implantable cardioverter-defibrillator (ICD) management and related cardiovascular outcomes. Earlier identification and treatment of mood concerns in ICD patients has been shown to improve quality of life (QOL) and patient outcomes. At this time, however, logistical challenges and time restraints, in addition to knowledge of appropriate treatment plans or referral options, remain central barriers to providing integrated, patient-centered care. Ultimately, all cardiology clinics would benefit from a collaborative care team that includes a mental health consultant or in-house psychologists who can provide consultations or referral services. Additionally, all patients that come to the clinics should complete proactive screening measures as routine component of care to assess the presence of mood concerns to improve patient outcomes and aid in treatment planning.

BioMonitor 2 in-office setting insertion safety and feasibility evaluation with device functionality assessment: results from the prospective cohort BioInsight study.

BACKGROUND: Insertable cardiac monitors are utilized for the diagnosis of arrhythmias and traditionally have been inserted within hospitals. Recent code updates allow for reimbursement of office-based insertions; however, there is limited information regarding the resources and processes required to support in-office insertions. We sought to determine the safety and feasibility of in-office insertion of the BioMonitor 2 and better understand in-office procedures, including patient selection, pre-insertion protocols, resource availability, and staff support. METHODS: Patients meeting an indication for a rhythm monitor were prospectively enrolled into this single-arm, non-randomized trial. All patients underwent insertion in an office setting. Two follow-up visits at days 7 and 90 were required. Information on adverse events, device performance, office site preparations, and resource utilization were collected. RESULTS: Eighty-two patients were enrolled at six sites. Insertion was successful in all 77 patients with an attempt. Oral anticoagulation was stopped in 20.8% of patients and continued through insertion in 23.4%, while prophylactic antibiotics were infrequently utilized (37.7% of study participants). On average, the procedure required a surgeon plus two support staff and 35 min in an office room to complete the 8.4 min insertion procedure. The mean R-wave amplitude was 0.77 mV at insertion and 0.67 mV at 90-days with low noise burden (2.7%). There were no procedure related complications. Two adverse events were reported (event rate 2.7% [95% CI 0.3, 9.5%]). CONCLUSIONS: In-office insertion of the BioMonitor 2 is safe and feasible. Devices performed well with high R-wave amplitudes and low noise burden. These results further support shifting cardiac monitor insertions to office-based locations. TRIAL REGISTRATION: clinicaltrials.gov, NCT02756338. Registered 29 April 2016.

Successful Biopsy and Removal of a Tricuspid Valve Papillary Fibroelastoma in Cardiac Catheterization Laboratory: A Case Report.

Papillary fibroelastomas are rare benign cardiac tumours with a predilection for cardiac valves. Because of the rarity of these tumours, management is individualized, but some recommend surgical removal of all papillary fibroelastomas due to the increased risk of embolization. We report a case of a 71-year-old man who presented with a sessile mass on the tricuspid valve. The mass, a papillary fibroelastoma, was successfully biopsied and removed in the cardiac catheterization laboratory. This report demonstrates a unique minimally invasive way of approaching a cardiac tumour wherein a major surgery was avoided.

Usefulness of transesophageal three-dimensional echocardiography in the identification of individual segment/scallop prolapse of the mitral valve.

We evaluated the potential usefulness of three-dimensional (3D) transesophageal echocardiography (TEE) in assessing individual scallop/segment prolapse in 36 adult patients with mitral valve prolapse (MVP) undergoing surgical correction. Intraoperative 3D TEE correctly identified the location of scallop/segment prolapse in 34 of 36 patients (94%). However, in 6 of these patients 3D TEE images revealed more scallops or segments with prolapse than the surgeon noted intraoperatively. Prolapse of these areas was less prominent and this could possibly explain the lack of correlation with the surgical findings in these patients. In another 2 patients areas of prolapse seen by the surgeon were missed by 3D TEE because some of those scallops/segments could not be well imaged due to image "drop out" and artifacts. Thus, perfect correlation between 3D TEE and surgery was noted in 28 of 36 (78%) patients. Noncoaptation of the MV was also identified in 2 patients. The prolapsed area of posterior (n = 28 observations) and anterior (n = 9 observations) MV leaflets ranged from 1 cm2 to 9 cm2 (mean 3.50 cm2+/- 2.14) and 1.20 cm2 to 5.99 cm2 (mean 3.21 cm2+/- 1.33), respectively. Interobserver and intraobserver agreement for location and area of MVP was excellent (r = 0.97 and r = 0.99, respectively; all P values are <0.0001). In conclusion, 3D TEE is useful in identifying the location of MVP. It may also be potentially useful in assessing the extent of individual scallop/segment prolapse and identifying sites of MV noncoaptation. This information could aid the surgeon in deciding the extent of MV resection.

Three-dimensional transesophageal echocardiographic demonstration of anatomical defects in AV septal defect patients presenting for reoperation.

We present two- and three-dimensional transesophageal echocardiographic findings of two adult patients who presented for reoperation after previous repair of a partial atrioventricular (AV) septal defect. Both patients had a cleft in the left AV valve with severe regurgitation. One patient had an additional 10 x 5 mm defect connecting the left ventricle to the right atrium through the AV junction. Three-dimensional echocardiography was superior to two-dimensional echocardiography in comprehensively delineating the anatomical defects in the left AV valve and the AV junction.

Normal lymph nodes mimicking a mediastinal mass during transesophageal echocardiography.

We report a transesophageal echocardiographic (TEE) study in an adult patient with ischemic stroke, in whom a nodular mass lesion consistent with tumor or mediastinal lymphadenopathy appeared to be interposed between the esophageal probe and the proximal descending aorta/aortic arch. Computed tomography (CT) scan of the chest revealed no pathologic lesions, only the presence of normal mediastinal lymph nodes and a rightward displaced esophagus. This unusual, but normal rightward position of the esophagus appears to have facilitated the visualization of these normal mediastinal lymph nodes on TEE. CT scan of the chest helped clarify the benign nature of these lymph nodes, which mimicked a mediastinal mass on TEE.

Volume quantification of intracardiac mass lesions by transesophageal three-dimensional echocardiography.

As compared with two-dimensional (2-D) transesophageal echocardiography (TEE), 3-D echocardiography now permits more realistic visualization of cardiac anatomy and of intracardiac lesions. The aim of this study was to apply newer 3-D echocardiographic techniques to quantify volumes of intracardiac masses undergoing surgical resection seen during an intraoperative TEE. The calculated volumes were compared with actual in vitro measurements of surgically resected masses. A total of 14 patients (9 men; 5 women; age range between 21 and 77 years) with intracardiac mass lesions (4 tumors: 3 left atrial myxomas and 1 mitral valve fibroelastoma, and 10 vegetations: 5 aortic valve, 3 mitral valve, 1 tricuspid and 1 pulmonary valve) were studied. Using commercially available 3-D reconstruction software (TomTec v. 4.1), the volumes of intracardiac masses were estimated using both the average rotation (rotation around the long axis, AR) and disk summation (parallel short axis cuts, DS) methods. Volumes of these lesions were also measured in vitro by water submersion. They ranged from 0.20 mL to 24 mL (mean +/- SD = 8.07 +/- 9.21 mL). Both 3-D TEE AR and 3-D TEE DS calculated volumes correlated excellently with in vitro measured volumes (r = 1.00 and r = 0.98, respectively, p = < 0.0001). The correlation between 3-D TEE AR and 3-D TEE DS calculated volumes was also excellent (r = 0.98, p = < 0.0001). In conclusion, the volume assessments by 3-D TEE of intracardiac mass lesions correlated well with in vitro measured volumes of surgical specimens. This technique may prove to be valuable in further defining intracardiac pathology and is a further advancement toward the application of clinically useful 3-D echocardiography.

Rupture of both papillary muscles after acute myocardial infarction: a case report.

The authors report a case of transthoracic echocardiographic left ventriculography and surgical pathology findings of a patient with rupture of both papillary muscles after acute myocardial infarction.

Transesophageal two- and three-dimensional echocardiographic diagnosis of combined left ventricular pseudoaneurysm and ventricular septal rupture.

Two- (2-D) and three-dimensional (3-D) transesophageal echocardiography (TEE) were useful in making the diagnosis of combined left ventricular pseudoaneurysm and ventricular septal rupture in an elderly patient presenting with mediastinitis and worsening heart failure following coronary artery bypass graft surgery. The diagnosis was not suspected clinically. Three-dimensional TEE served to increase the confidence level with which the diagnosis of this combined lesion was made. Additionally, 3-D TEE proved superior to 2-D TEE in assessing the size of the left ventricular rupture site.