Transbronchial Lung Cryobiopsy Performed with Cone Beam Computed Tomography Guidance Versus Fluoroscopy: A Retrospective Cohort Review.

PURPOSE: Determining the cause of interstitial lung disease (ILD) remains challenging. While surgical lung biopsy remains the gold standard approach, risks associated with it may be prohibitive. Transbronchial lung cryobiopsy (TBLC) is a minimally invasive alternative with an improved safety profile and acceptable diagnostic accuracy. We retrospectively assessed whether the use of Cone Beam computed tomography guidance for TBLC (TBLC-CBCT) improves safety and diagnostic yield compared to performing TBLC with fluoroscopic guidance (TBLC-F). METHODS: A retrospective cohort review of 120 patients presenting for evaluation of newly diagnosed ILD was performed. Demographic data, pulmonary function test values, chest imaging pattern, procedural information, and final multidisciplinary discussion (MDD) diagnosis were recorded. RESULTS: 62 patients underwent TBLC-F and 58 underwent TBLC-CBCT. Patients undergoing TBLC-CBCT were older (67.86 ± 10.97 vs 61.45 ± 12.77 years, p = 0.004) and had a higher forced vital capacity percent predicted (73.80 ± 17.32% vs 66.00 ± 17.45%, p = 0.03) compared to the TBLC-F group. The average probe-to-pleura distance was 5.1 ± 2.3 mm in the TBLC-CBCT group with 4.0 ± 0.3 CBCT spins performed. Pneumothorax occurred more often in the TBLC-F group (n = 6, 9.7%) compared to the TBLC-CBCT group (n = 1, 1.7%, p = 0.06). Grade 2 bleeding only occurred in the TBLC-F group (n = 4, 6.5%). A final MDD diagnosis was obtained in 89% (n = 57) of TBLC-F patients and 95% (n = 57) of TBLC-CBCT patients. CONCLUSIONS: TBLC-CBCT appears to be safer compared to TBLC-F with both approaches facilitating an MDD diagnosis. Further studies from multiple institutions randomizing patients to each modality are needed to confirm these findings.

Left atrial appendage structural characteristics predict thrombus formation.

INTRODUCTION: Nonvalvular atrial fibrillation (NVAF) is a highly prevalent arrhythmia where loss of synchronized atrial contraction increases the risk of intracardiac thrombus particularly within the left atrial appendage (LAA). Anticoagulation is the mainstay of stroke prevention based on the CHA2 DS2 -VASc score; however, it does not account for LAA structural characteristics. METHODS: The research comprises a retrospective matched case-control study of 196 subjects with NVAF who underwent transesophageal echo (TEE). The control group, without thrombus (n = 117), was selected from two different groups, both pools had: NVAF and CHA2 DS2 -VASc score ≥ 3. One group underwent screening TEE before Watchman closure device placement from January 2015 to December 2019 (n = 74) the second underwent TEE before cardioversion from February to October 2014 (n = 43). The study group, with thrombus (n = 79), included patients with NVAF, TEE study performed between February 2014 and December 2020, and LAA thrombus. The propensity score method was utilized to determine the matched controls while accounting for confounding from prognostic variables resulting in 61 matched pairs included in the analysis data set. LAA ostial area (OA) (calculated from orthogonal measurements 0°, 90° or 45°, 135°), LAA maximal depth, and peak LAA outflow velocity were measured. RESULTS: Patient characteristics and TEE data were collected and compared using the t test or χ2 analysis. We observed a lower LAA peak exit velocity in the thrombus group as compared to the control group. Additionally, we found that patients in the thrombus group had smaller LAA OA at 0° and 90°, at 45° and 135°, using largest diameter, as well as using aggregate OA, and smaller maximum LAA depth compared to patients in the control group. Candidate conditional logistic regression models for the outcome of the presence of thrombus were evaluated. Statistical results from the best-fitting conditional regression model were calculated showing a significant association between aggregate OA and LAA exit velocity with presence of thrombus. CONCLUSION: Utilizing LAA structural characteristics to predict thrombus formation may help refine current cardioembolic stroke (CES) risk estimation.

Cardiac MRI as an Imaging Tool in Titin Variant-Related Dilated Cardiomyopathy.

Dilated Cardiomyopathy is a common myocardial disease characterized by dilation and loss of function of one or both ventricles. A variety of etiologies have been implicated including genetic variation. Advancement in genetic sequencing, and diagnostic imaging allows for detection of genetic mutations in sarcomere protein titin (TTN) and high resolution assessment of cardiac function. This review article discusses the role of cardiac MRI in diagnosing dilated cardiomyopathy in patients with TTN variant related cardiomyopathy.

Real-world utility of a genomic classifier in establishing a diagnosis of newly identified interstitial lung disease.

BACKGROUND: Diagnosing interstitial lung disease (ILD) remains challenging. Guidelines recommend utilizing a multidisciplinary discussion (MDD) to review clinical and radiographic data and if diagnostic uncertainty persists, then to obtain histopathology. Surgical lung biopsy and transbronchial lung cryobiopsy (TBLC) are acceptable methods, but risks of complications may be prohibitive. The Envisia genomic classifier (EGC) represents another option to determine a molecular usual interstitial pneumonia (UIP) signature to facilitate an ILD diagnosis at MDD with high sensitivity and specificity. We evaluated the concordance between TBLC and EGC at MDD and the safety of this procedure. METHODS: Demographic data, pulmonary function values, chest imaging pattern, procedural information, and MDD diagnosis were recorded. Concordance was defined as agreement between the molecular EGC results and histopathology from TBLC in the context of the patient's High Resolution CT pattern. RESULTS: 49 patients were enrolled. Imaging demonstrated a probable (n = 14) or indeterminate (n = 7) UIP pattern in 43% and an alternative pattern in 57% (n = 28). EGC results were positive for UIP in 37% (n = 18) and negative in 63% (n = 31). MDD diagnosis was obtained in 94% (n = 46) with fibrotic hypersensitivity pneumonitis (n = 17, 35%) and IPF (n = 13, 27%) most common. The concordance between EGC and TBLC at MDD was 76% (37/49) with discordant results seen in 24% (12/49) of patients. CONCLUSIONS: There appears to be reasonable concordance between EGC and TBLC results at MDD. Efforts clarifying the contributions of these tools to an ILD diagnosis may help identify specific patient populations that may benefit from a tailored diagnostic approach.

Transbronchial Lung Cryobiopsy is Safe and Effective for Diagnosing Acutely Ill Hospitalized Patients with New Diffuse Parenchymal Lung Disease.

INTRODUCTION: Transbronchial lung cryobiopsy (TBLC) is an accepted alternative to surgical lung biopsy (SLB) for diagnosing diffuse parenchymal lung disease (DPLD) that is less invasive and results in comparable diagnostic yields. Performing lung biopsies on hospitalized patients, however, has increased risk due to the patient's underlying disease severity. Data evaluating the safety and efficacy of TBLC in hospitalized patients are limited. We present a comparison of TBLC for hospitalized and outpatients and provide the safety and diagnostic yields in these populations. METHODS: Demographic data, pulmonary function values, chest imaging pattern, procedural information, and diagnosis were recorded from enrolled patients. Complications from the procedure were the primary outcomes and diagnostic yield was the secondary outcome. RESULTS: 77 patients (n = 22 hospitalized vs n = 55 outpatient) underwent TBLC during the study period. Comparing adverse events between hospitalized and outpatients revealed no statistically significant differences in pneumothorax (9%, n = 2 vs 5%,n = 3), tube thoracostomy placement (5%, n = 1 vs 2%, n = 1), grade 2 bleeding (9%, n = 2 vs 0%, n = 0), escalation in level of care (5%, n = 1 vs 0%, n = 0), 30-day mortality (9%, n = 2 vs 2%, n = 1), and 60-day mortality (9%, n = 2 vs 4%, n = 2) (p > 0.05 for all). No deaths were attributed to the procedure. 95% of cases received a multidisciplinary conference diagnosis (hospitalized 100%, n = 22 vs outpatients 93%, n = 51, p = 0.32). CONCLUSION: Our experience supports that TBLC may be a safe and effective modality for acutely ill-hospitalized patients with DPLD. Further efforts to enhance procedural safety and to determine the impact of an expedited tissue diagnosis on patient outcomes are needed.

Accuracy of arrhythmia detection in implantable cardiac monitors: A prospective randomized clinical trial comparing Reveal LINQ and Confirm Rx.

BACKGROUND: Implantable cardiac monitors (ICMs) are increasingly used to detect arrhythmias in various clinical situations. However, the data transmission time and accuracy of detecting cardiac arrhythmias are unclear. OBJECTIVE: The objective of this study was to compare the efficiency of data transmission and arrhythmia detection accuracy of the Reveal LINQ with TruRhythm Detection with the Confirm Rx with SharpSense Technology. METHODS: In this prospective study, 142 patients were randomized 1:1 to receive Reveal LINQ or Confirm Rx ICM system. Arrhythmic events include atrial fibrillation (AF), pauses, and bradycardia. Data transmission time is defined as the time from event occurrence to physician notification. All the arrhythmic events are adjudicated for accuracy. RESULTS: A total of 3510 events were transmitted in 61 patients over 7.1 ± 3.5 months. The transmission time both for all events (448 ± 271 vs 610 ± 515 minutes, P = .02) and for patient activated triggers (24 ± 103 vs 475 ± 426 minutes, P < .0001) was significantly shorter in the Confirm Rx group. The total number of events was also higher in the Confirm Rx group (25.5 ± 45.6 vs 0.9 ± 1.1 events per patient-month, P < .01), which is likely due to event transmission setting differences between the two groups. Kaplan-Meier analysis showed that the Confirm Rx group detected true arrhythmic episodes sooner with higher percentage of diagnosed patients during 6-month follow-up (P = .006). Patient-averaged true positive detection rates were not statistically significant in the two groups (Reveal LINQ vs Confirm Rx, AF: 52% vs 38%; bradycardia: 67% vs 59%; pause: 24% vs 20%; tachycardia: 81% vs 94%). CONCLUSION: Compared to the Reveal LINQ, Confirm Rx has shorter event transmission time, more frequent event detections, shorter duration to diagnose true arrhythmic events, and higher percentage of diagnosed patients. The accuracy of arrhythmia detection in both ICMs remains suboptimal.