Immunohistological basis of the late gadolinium enhancement phenomenon in tako-tsubo cardiomyopathy.

AIMS: Tako-tsubo cardiomyopathy is characterized by transient contractile dysfunction after emotional or physical stress. Only few patients show late gadolinium enhancement (LGE) in cardiovascular magnetic resonance imaging (MRI). It was the purpose of this study to elucidate the histological basis of this phenomenon. METHODS AND RESULTS: The study included 15 patients. Tako-tsubo cardiomyopathy was diagnosed by coronary angiography and ventriculography. Cardiac MRI was performed within 24 h of admission. Endomyocardial biopsies were taken during the acute phase and after recovery. The content of fibrosis was determined by immunohistochemical staining of collagen-1. In the acute phase, cardiac MRI revealed LGE in five patients. This was completely reversed at follow-up [14, inter-quartile range (IQR) 11-14.5 days]. All patients showed a significant increase of collagen-1 compared with control tissue. Moreover, the amount of collagen-1 was significantly higher in LGE positive patients (LGE positive: 18.84, IQR 13.82-19.75 AU/microm(2); LGE negative: 7.57, IQR 5.41-9.19 AU/microm(2), P = 0.001). The presence of LGE was not associated with poorer left ventricular function. CONCLUSION: The presence of LGE cannot rule out tako-tsubo cardiomyopathy. Instead it defines a special subgroup of patients with a disproportionate increase of extracellular matrix.

Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial.

PURPOSE OF THE STUDY: Focused ultrasound is increasingly used in the emergency setting, with an ALS-compliant focused echocardiography algorithm proposed as an adjunct in peri-resuscitation care (FEEL). The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management. PATIENTS, MATERIALS AND METHODS: A prospective observational study in a pre-hospital emergency setting in patients actively undergoing cardio-pulmonary resuscitation or in a shock state. The FEEL protocol was applied by trained emergency doctors, following which a standardised report sheet was completed, including echo findings and any echo-directed change in management. These reports were then analysed independently. RESULTS: A total of 230 patients were included, with 204 undergoing a FEEL examination during ongoing cardiac arrest (100) and in a shock state (104). Images of diagnostic quality were obtained in 96%. In 35% of those with an ECG diagnosis of asystole, and 58% of those with PEA, coordinated cardiac motion was detected, and associated with increased survival. Echocardiographic findings altered management in 78% of cases. CONCLUSIONS: Application of ALS-compliant echocardiography in pre-hospital care is feasible, and alters diagnosis and management in a significant number of patients. Further research into its effect on patient outcomes is warranted.

Peri-resuscitation echocardiography: training the novice practitioner.

AIMS: Echocardiography performed in an ALS-compliant manner provides a tool whereby some of the potentially reversible causes of cardiac arrest can be diagnosed in real time by minimally trained practitioners. One of the major concerns this raises is how to deliver effective training to the required standard. The objective of this study was to determine the effectiveness of number of different educational methods used teach echocardiography to novices. This involved assessment of cognitive, psychomotor skills and affective aspects in five key areas. METHODS: The study population was a convenience sample from participants attending standardised structured one-day training courses in peri-resuscitation echocardiography (n=204). Subjects were assessed for five learning outcomes including knowledge and image interpretation, practical performance of echocardiography including time taken to obtain a diagnostic view, integration into the ALS algorithm and overall compliance with established resuscitation guidelines. RESULTS: There was a significant improvement in knowledge and interpretation of echocardiographic images before and after completion of the one-day course (pre 62%, post 78%, p<0.01). Skills acquisition resulted in 100% of participants being able to obtain a subcostal view of diagnostic quality by the end of the course, and 86% with a mean time to acquisition of <10s. On completion of the training programme, incorporation of echocardiography into current resuscitation practice did not compromise ALS-compliance. CONCLUSION: Novice echocardiographers can obtain knowledge and skills relevant to ALS-compliant peri-resuscitation echocardiography using a range of educational techniques. In addition to the standard one-day training courses available, continued mentored practice and didactic adherence to ALS algorithms is required.

Focused emergency echocardiography: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless electrical activity arrest because of cardiac tamponade.

Cardiac arrest presenting as pulseless electrical activity (PEA) is associated with poor outcome. Its major underlying causes (e.g. cardiac tamponade, pulmonary embolism, tension pneumothorax or hypovolaemia) are difficult to detect reliably in an out-of-hospital setting. We here present a case of a 14-year-old girl suffering from PEA because of cardiac tamponade 4 weeks after surgical closure of a ventricular septal defect. Immediate focused echocardiography on scene by an emergency physician showed a large pericardial effusion that had led to cardiac tamponade and finally to a PEA cardiac arrest. Immediate pericardiocentesis was carried out. The girl progressed to complete neurological recovery. This case report demonstrates that focused emergency echocardiography may be useful for the diagnosis of pericardial tamponade leading to cardiac arrest and this diagnosis can be made out-of-hospital by an appropriately trained physician.

Detection of relevant coronary artery disease using dual-source computed tomography in a high probability patient series: comparison with invasive angiography.

BACKGROUND: Computed tomography (CT) enables detection of coronary artery stenoses, but its use is limited by deficient evaluation at elevated heart rates. The accuracy of dual-source CT (DSCT) for the detection of coronary artery disease (CAD) was assessed in 76 patients at high probability of CAD without heart rate control and compared with quantitative coronary angiography (QCA). Methods and Results The 76 patients (47 males, mean age 65.5+/-10 years) underwent DSCT without preceding heart rate control. Data sets were evaluated by 2 observers in consensus with respect to stenoses >50% decreased diameter. QCA served as the standard of reference. Mean heart rate during scanning was 68+/-9 beats per min, and the average Agatston score was 337+/-560. Of 1,160 coronary artery segments, all but 3 were visualized artefact-free; 58 coronary stenoses were correctly detected by CT angiography. In the segment-based analysis, sensitivity was 98.3%, specificity 99.2% and accuracy 99%; patient based analysis revealed a sensitivity of 100%, specificity of 83.3% and overall accuracy of 92.1%. Conclusions Even at elevated heart rates, DSCT can reliably detect coronary artery stenoses and the results correlate well with those for invasive coronary angiography.

Focused Echocardiography in Life Support: The Subcostal Window : What the Surgeon Should Know for Critical Care Applications.

CONTEXT: Focused echocardiography evaluation in life support (FEEL) for emergency and critical caremedicine is an innovative approach to introducing limited-in-scope echocardiography in a timely fashion into periresuscitation care. FEEL is an advanced life support-conformed concept and a simple procedure that can be readily used in shock roomor pre-hospital scenarios as an extension of focused abdominal sonography for trauma (FAST). The subcostal window plays a pivotal role in this context, because it can easilybe applied inthesupine position, and is usually better than other windows in patients with mechanical ventilation or during resuscitation maneuvers. Most information can be obtained at a glance. AIM: As the FAST exam was not developed for implementation in resuscitation or cardiac arrest procedures, herewedescribe an accurate and easymethod that allows non-cardiologists to add FEEL to the FAST exam. As a result, it conforms to actual resuscitation guidelines. To perform the FEEL procedure and the subcostal window, a specific training seems to bemandatory. The aim of this paper is to set special emphasis on the use of the subcostal window.