Percutaneous thrombectomy and right ventricular mechanical circulatory support for pulmonary embolism in a coronavirus disease 2019 patient: case report, 1-year update, and echocardiographic findings.

BACKGROUND: We previously described percutaneous thrombectomy and right ventricular (RV) mechanical support of a coronavirus disease 2019 (COVID-19) patient with a massive pulmonary embolism. Here, we present a detailed echocardiographic and clinical timeline with 1-year follow-up. CASE SUMMARY: A 57-year-old female with COVID-19 went into shock from a massive pulmonary embolism. After percutaneous removal of a large thrombus burden (AngioVac system; AngioDynamics Inc., Latham, NY, USA), she became severely hypotensive, requiring cardiopulmonary resuscitation, and hemodynamic support with an Impella RP device (Abiomed, Danvers, MA, USA). A paediatric transoesophageal echocardiography (TOE) probe monitored the procedure because an adult probe would not pass (S7-3t-Philips Medical Systems, Andover, MA, USA). Post-thrombectomy, surface imaging documented gradual resolution of RV dysfunction, tricuspid regurgitation, and elevated pulmonary artery pressure. Her course was complicated by renal failure requiring temporary dialysis. She was discharged home on apixaban. Hypercoagulability work-up was negative. Two months later, vocal cord surgery was performed for persistent stridor. Esophagoscopy at that time was prevented by osteophyte obstruction. At 10 months, she received the Pfizer-BioNTech vaccine. At 1 year, the patient remains healthy on apixaban, and her echocardiogram is normal. DISCUSSION: This case illustrates the pivotal role of echocardiography in the diagnosis, percutaneous treatment, and near- and long-term follow-up and management of a patient with massive pulmonary embolism due to COVID-19 with documentation of complete recovery from severe RV dysfunction and haemodynamic collapse. A paediatric TOE probe was a crucial alternative to the adult probe because of possible osteophyte obstruction.

A practical guide to graphic communication for quality assurance, education, and patient care in echocardiography.

Graphic communication (GC) is useful for continuous quality improvement (CQI), education, and patient care when in-person discussion is not possible because of geographic and schedule constraints. In echocardiography, these constraints can be mitigated by (a) capturing screenshots and device photos or videos and sharing them by email or text message, (b) simultaneous viewing of images on digital displays, and (c) broadcasting the study real time during acquisition to other mobile or stationary devices. Screenshots are useful for CQI and education and can be acquired, annotated, and shared with minimal impact on the flow of clinical echo interpretation. Providers at different locations can employ GC for shared clinical decision making by viewing echo studies from the same server, video conferencing or accessing real-time broadcast from a device. Which GC tool is selected is determined by its ease of use, the provider's goals and whether immediate image review is needed.

Reduction in Radiation Exposure through a Stress Test Algorithm in an Emergency Department Observation Unit.

INTRODUCTION: Clinicians are urged to decrease radiation exposure from unnecessary medical procedures. Many emergency department (ED) patients placed in an observation unit (EDOU) do not require chest pain evaluation with a nuclear stress test (NucST). We sought to implement a simple ST algorithm that favors non-nuclear stress test (Non-NucST) options to evaluate the effect of the algorithm on the proportion of patients exposed to radiation by comparing use of NucST versus Non-NucST pre- and post-algorithm. METHODS: An ST algorithm was introduced favoring Non-NucST and limiting NucST to a subset of EDOU patients in October 2008. We analyzed aggregate data before (Jan-Sept 2008, period 1) and after (Jan-Sept 2009 and Jan-Sept 2010, periods 2 and 3 respectively) algorithm introduction. A random sample of 240 EDOU patients from each period was used to compare 30-day major adverse cardiac events (MACE). We calculated confidence intervals for proportions or the difference between two proportions. RESULTS: A total of 5,047 STs were performed from Jan-Sept 2008-2010. NucST in the EDOU decreased after algorithm introduction from period 1 to 2 (40.7%, 95% CI [38.3-43.1] vs. 22.1%, 95% CI [20.1-24.1]), and remained at 22.1%, 95% CI [20.3-24.0] in period 3. There was no difference in 30-day MACE rates before and after algorithm use (0.1% for period 1 and 3, 0% for period 2). CONCLUSION: Use of a simple ST algorithm that favors non-NucST options decreases the proportion of EDOU chest pain patients exposed to radiation exposure from ST almost 50% by limiting NucST to a subset of patients, without a change in 30-day MACE.

Relationship between carotid disease on ultrasound and coronary disease on CT angiography.

OBJECTIVES: The purpose of this study was to assess the relationship between carotid artery disease by ultrasound and coronary artery disease by coronary computed tomography angiography (CTA) and to identify carotid ultrasound parameters predictive of coronary artery disease. BACKGROUND: Carotid ultrasound and CTA are noninvasive modalities used to image atherosclerosis. Studies examining the relationship between the 2 tests, however, are lacking. METHODS: We performed carotid ultrasound on predominantly nondiabetic subjects referred for CTA. Carotid intima media thickness (IMT) and plaque were assessed and compared with coronary artery calcification and the number of coronary arteries with any evidence of atherosclerosis on CTA. RESULTS: A total of 150 subjects underwent both CTA and carotid ultrasound on the same day. Carotid plaque was present in 71.3% (n = 107), whereas the presence of at least 1 coronary artery with disease on CTA was present in 57.1% (n = 84). Carotid plaque was present in 47.6% (30 of 63) of subjects with a calcium score of 0 and 88.5% (77 of 87) of subjects with a calcium score >0 (p = 0.0001). Similarly carotid plaque was present in 52.4% (33 of 63) of subjects with no CTA evidence of atherosclerosis versus 85.7% (72 of 84) of subjects with any CTA evidence of atherosclerosis (p < 0.0001). Carotid plaque, IMT ≥ 1.5 mm, or averaged mean IMT >0.75 mm were associated with a calcium score >0 (odds ratio: 5.4, p < 0.0001, 2.7, p < 0.001; 2.9, p = 0.011, respectively) and disease in at least 1 vessel on CTA (odds ratio: 2.8, p = 0.03, 2.19, p = 0.073; 2.22, p = 0.058, respectively) independent of age and sex. CONCLUSIONS: Carotid plaque and increased carotid IMT are associated with the presence and severity of coronary calcification and disease on CTA in ambulatory subjects.

Usefulness of carotid ultrasound to improve the ability of stress testing to predict coronary artery disease.

Carotid ultrasound is a useful tool to detect plaque and measure carotid intimal-medial thickness (CIMT), which help identify asymptomatic patients at risk of cardiovascular events. However, the role of carotid ultrasound in stratifying risk in symptomatic patients has not been studied. We prospectively examined the hypothesis that in symptomatic patients undergoing exercise (or pharmacologic) stress testing (EST), CIMT and carotid plaque will improve the ability to identify patients with > or =50% coronary diameter stenosis. Mean and maximal CIMTs were measured in 50 symptomatic patients without known coronary artery disease (CAD) who were scheduled to undergo diagnostic angiography after EST with imaging. Pretest probability of CAD was calculated for each patient based on age, gender, and nature of symptoms. Fifty percent of patients were men, 32% were diabetic, 70% had hypertension, and 58% had dyslipidemia. CAD > or =50% was associated with CIMT in the >75th percentile (74% vs 44%, p = 0.047) and with presence of carotid plaque (96% vs 59%, p = 0.003). Of patients with an equivocal/negative EST result (n = 38), those with carotid plaque had a 46% (13 of 28) prevalence of significant CAD; in the smaller subset of patients without carotid plaque (n = 10), none had luminal stenosis > or =50% (p = 0.007). Pretest probability of CAD, presence of carotid plaque, moderately/severely abnormal EST result, and hypertension were independent predictors of significant CAD. In conclusion, carotid ultrasound appears to offer incremental value to EST in predicting presence or absence of > or =50% coronary diameter stenosis in symptomatic patients with equivocal/negative EST result.

Myocardial oxidative metabolic supply-demand relationships in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Nonischemic dilated cardiomyopathy (NIDCM) is associated with left ventricular remodeling, hypertrophy, and mitochondrial metabolic abnormalities in vitro. We evaluated the hypothesis that energy supply, as judged by the rate of myocardial oxidative metabolism, is inadequate to meet oxygen demand in patients with NIDCM compared with normal subjects. METHODS AND RESULTS: We used positron emission tomography to determine the myocardial carbon 11 acetate decay rate (kmono) as an index of energy supply, and we compared kmono with the rate-pressure product (RPP) as an index of metabolic demand in 7 patients with NIDCM and 7 normal subjects. The mean kmono value (SEM) was 0.060 +/- 0.006 min(-1) in NIDCM patients versus 0.054 +/- 0.002 in normal subjects (P = not significant). The RPP was 9949 +/- 931 beats/min.mm Hg in NIDCM patients and 6521 +/- 476 in normal subjects (P = .007). The relationship of kmono to this index of demand (kmono/RPP) was 6.2 x 10(-6) in NIDCM patients but was 8.5 x 10(-6) in normal subjects (P = .003). Thus RPP, as an index of myocardial oxygen demand, was poorly matched by the rate of oxidative metabolism in those patients with NIDCM. The kmono was closely related to RPP in normal subjects (r = 0.83, P = .02) but not in NIDCM patients. Furthermore, there was no significant relationship between kmono and wall stress as another index of oxygen demand. CONCLUSIONS: These results are consistent with a mitochondrial metabolic abnormality in heart failure. This metabolic mismatch detected by positron emission tomography may contribute to the pathophysiology of congestive heart failure and left ventricular remodeling.

Technical aspects of diastology: why mitral inflow and tissue Doppler imaging are the preferred parameters?

Doppler methods for assessing left ventricular (LV) diastolic function have increased in number and complexity. However, time constraints may prevent measurement of all parameters during routine transthoracic echocardiography. Therefore, we designed a study to determine which Doppler parameters could be most successfully and quickly obtained. The recording success rate and time required to record different LV diastolic function parameters were evaluated in 80 patients. A specific recording protocol was followed by an experienced, credentialed sonographer and time intervals to record each parameter were measured. In comparison with color Doppler M-mode of LV inflow propagation velocities (Vp) and pulmonary venous (PV) flow measurements, transmitral valve (MV) flow and tissue Doppler imaging (TDI) of the mitral annulus had the highest recording success rate and required the shortest time to record. PV flow and Vp took longer to obtain (80.1+/-34.3 sec and 57.1+/-29.1 sec, respectively) than did mitral valve inflow (36.3+/-20.7 sec) and mitral valve annular TDI (29.3+/-18.4 sec for septal and 33.3+/-14.5 sec for lateral). MV flow velocities, Vp, and TDI were successfully recorded in virtually all patients (99-100%). In comparison, the PV flow velocities and durations were successfully recorded less often. The range of success rates for the six PV flow parameters was 49-84%. Since MV flow and TDI also have been shown by us to have the lowest interreader variability, measurement of these two parameters may be preferred for routine clinical evaluation of LV diastolic function in a busy echocardiography laboratory.

Can transthoracic echocardiography with subcostal view predict abdominal aortic atherosclerosis?

BACKGROUND: Prompt detection of atherosclerosis (ATH) may profoundly impact therapy and patient outcome. During transthoracic echocardiography (TTE), subcostal views may suggest abdominal (ABD) aortic (AO) ATH, but this diagnosis may be inaccurate due to suboptimal images, which may in part relate to use of nonlinear probes. Therefore, we investigated the accuracy of TTE assessment of ABD AO ATH relative to transesophageal (TEE) AO images. METHODS: Routine clinical TTE and TEE studies of 100 patients (44 men), aged 30-92 years old, were reviewed retrospectively and blindly. ABD AO ATH by TTE was graded qualitatively as grade (GR) 0 = smooth wall surface; GR 1, 2, and 3 = mild, moderate, and severe irregularities, respectively; and GR 4 = mobile/complex plaque. TEE images were graded quantitatively as the maximal intimal-medial, or plaque thickness, imaged in the AO arch or descending AO, as: GR 0 4 mm, or GR 4 = mobile/complex plaque >4 mm. TTE ability to detect the presence (>GR 0) of ABD AO ATH on TEE was measured in terms of sensitivity (SN), specificity (SP), positive (PPV) and negative (NPV) predictive accuracy-in patients with adequate and suboptimal images-compared to TEE. RESULTS: TTE image quality was adequate in 75 patients and suboptimal in 25. SP and PPV of grading ATH by TTE were directly related to grading by TEE; however, SN and NPV demonstrated an inverse relationship with increasing grading of ATH. TTE correlated with TEE grading with an r = 0.42 (P = 0.0001) for patients (n = 75) with adequate TTE and r = 0.32 (P = 0.001) for all patients (n = 100), including those with suboptimal TTE images. CONCLUSION: Routine TTE imaging is usually correct in predicting ATH on TEE, but with modest error, it should generally not be relied on as a definitive test for ATH. Adequate image quality improves the correlation of TEE and TTE grading of ABD ATH, and more severe ATH on TTE is more predictive of ATH on TEE.

Which echocardiographic Doppler left ventricular diastolic function measurements are most feasible in the clinical echocardiographic laboratory?

Numerous measures of left ventricular diastolic function are currently in clinical use. To determine which echo-Doppler left ventricular diastolic function measurements are most feasible in the clinical echocardiographic laboratory, the success rate, recording time taken by the sonographer, and inter-reader variability were calculated for transmitral valve inflow, pulmonary vein flow, tissue Doppler imaging, and color M-mode flow propagation velocity in 80 inpatients.

Both diastolic and systolic function alternate in pulsus alternans: a case report and review.

Pulsus alternans is occasionally seen in the setting of heart failure. This case describes a patient with both these findings, and alternating diastolic and systolic left ventricular function on color Doppler and Doppler tissue imaging.