What is Clinical Efficacy of Transesophageal Echocardiography in Patients With Cryptogenic Stroke?: A Critically Appraised Topic.

BACKGROUND: Adults with cryptogenic stroke often undergo transesophageal echocardiogram (TEE) because this is the gold-standard for evaluation of potential proximal sources of emboli. The risks of performing this invasive test must be weighed against its clinical efficacy and limitations, determined by the rate of positive findings, and the impact on clinical outcome for the patient. OBJECTIVE: To critically appraise current evidence regarding the rate of positive TEE findings in cryptogenic stroke patients, and analyze the implications of these findings on management decisions and outcomes. METHODS: The objective was addressed through the development of a structured, critically appraised topic. We incorporated a clinical scenario, background information, a structured question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, and vascular neurology and cardiology content experts. RESULTS: TEE commonly identifies abnormalities, including aorta atherosclerosis in 51%, patent foramen ovale in 43%, and atrial septal aneurysm in 13% of patients. Findings such as left-sided chamber thrombus or intracardiac tumor that definitively warrant a change in management by guideline-supported use of anticoagulation are less common, occurring in ∼3% of patients. CONCLUSIONS: TEE identifies potential causal sources of embolus in patients with cryptogenic stroke that leads to changes in management and outcomes at least 3% of the time. Other findings, particularly aorta atherosclerosis, are identified much more commonly but the causal link to stroke is uncertain, thus changes in management in these cases is variable and data describing resulting outcomes are lacking.

Inhaled nitric oxide mitigates need for extracorporeal membrane oxygenation in a patient with refractory acute hypoxemic respiratory failure due to cardiac and pulmonary shunts.

We present a case of refractory acute hypoxemic respiratory failure due to influenza B pneumonia with concomitant large intra-atrial shunt (IAS) and severe pulmonary regurgitation in a patient with Saethre-Chotzen syndrome with prior pulmonary homograft placement. Our patient's hypoxemia improved with inhaled nitric oxide as an adjunct to mechanical ventilation without requiring extracorporeal membrane oxygenation, and eventually a percutaneous closure with a 30 mm CardioSeal patent foramen ovale closure device was accomplished. However, his peri-procedural hospital course was complicated by occluder device migration, which was retrieved with eventual surgical closure of the PFO. Nitric oxide has not demonstrated any statistically significant effect on mortality and only reported to transiently improved oxygenation in patients with hypoxemic respiratory failure. Our case demonstrates that inhaled nitric oxide may have a role in acute hypoxemic respiratory failure in a case with significant cardiac and pulmonary shunts.

Bortezomib-based Chemotherapy for Multiple Myeloma Patients Without Comorbid Cardiovascular Disease Shows No Cardiotoxicity.

BACKGROUND: Proteasome inhibitors used in the treatment of multiple myeloma act primarily through the disruption of intrinsic cellular protein quality maintenance, resulting in proteotoxic stress, cellular dysfunction, and, ultimately, cell death. We assessed whether evidence has shown off-target myocardial dysfunction related to the administration of bortezomib-based chemotherapy for multiple myeloma. PATIENTS AND METHODS: Patients aged 18 to 70 years who were free of significant cardiovascular disease were included. They underwent evaluations before and after each dose of bortezomib to assess for clinical, subclinical, and transient cardiotoxicity using echocardiography and serum biomarker measurement. Cardiac magnetic resonance imaging was performed at 3 separately defined intervals. The primary modality for determining subclinical myocardial dysfunction was echocardiographic assessment of the global longitudinal strain (GLS). RESULTS: Eleven patients (7 men) with an average age of 55 years were included. No evidence of cumulative myocardial dysfunction was found using echocardiographic markers, primarily GLS (average change in absolute GLS, -1.17; P = .064). Additionally, no echocardiographic evidence of transient cardiotoxicity was found. The left ventricular ejection fraction (LVEF) also did not show any significant changes (ΔLVEF, -2.17%; P = .15). Magnetic resonance imaging confirmed no changes in structure or function (ΔLVEF, -2.6%; P = .54) and extracellular volume fraction (Δ = 2%; P = .46). The serum biomarker levels also did not change significantly over time. CONCLUSION: We did not observe cardiotoxicity from bortezomib-based chemotherapy despite very intensive evaluation with multiple modalities. Neither cumulative nor transient alterations were found in our metrics, suggesting that bortezomib is safe from a cardiovascular standpoint for patients free of cardiovascular disease.

Comparison of the Utility of Transesophageal Echocardiography in Patients With Acute Ischemic Stroke and Transient Ischemic Attack Stratified by Age Group (<60, 60 to 80, ≥80 Years).

The objective was to study the utility of transesophageal echocardiography (TEE) in affecting acute ischemic stroke treatment of older adults (age ≥80 years). Patients hospitalized in January 2010 and February 2015 were included who had TEE ordered as part of their diagnostic workup at a tertiary medical center. We studied 515 hospitalized patients with acute stroke or transient ischemic attack who underwent TEE. The proportion of patients with important TEE findings was 35%. However, TEE changed management in only 2.5% of cases. When anticoagulation for proximal mobile aorta atheroma was excluded, no change in management resulted from TEE for patients older than 80 years. In conclusion, TEE has a low likelihood of a pathologic finding that resulted in a change in treatment strategy, especially in patients ≥80 years of age.

Conus artery occlusion causing isolated right ventricular outflow tract infarction: novel application of cardiac magnetic resonance in anterior STEMI.

Acute ST elevation in the anterior precordial leads typically suggests an anteroseptal infarction due to left anterior descending coronary artery obstruction, but the differential can be broad. Conus branch artery occlusion is a potentially overlooked cause of anteroseptal ST elevation myocardial infraction. Cardiac magnetic resonance (CMR) imaging is an emerging technology which can differentiate the etiology of anterior ST elevation in patients with no apparent coronary abnormalities on coronary angiography and normal echocardiography.

Lung function and gas exchange in Eisenmenger syndrome and their impact on exercise capacity and survival.

BACKGROUND: Eisenmenger physiology may contribute to abnormal pulmonary mechanics and gas exchange and thus impaired functional capacity. We explored the relationship between lung function and gas exchange parameters with exercise capacity and survival. METHODS: Stable adult patients with Eisenmenger syndrome (N=32) were prospectively studied using spirometry, lung volumes, diffusion capacity, and blood gas analysis, as well as same day measurement of 6-minute walk distance and cardiopulmonary maximal treadmill exercise. Patients were followed prospectively to determine survival (7.4 ± 0.5 years). Abnormalities were identified and appropriate comparisons were made between affected and unaffected individuals between respiratory mechanics, exercise function, and survival. RESULTS: Obstruction (FEV1/FVC ratio <0.70) was found in 13 patients (41%), who were older but not otherwise different. Restriction was uncommon. Diffusion transfer coefficient, which was <80% in half the patients, correlated with exercise duration (r=0.542, P=0.005), and was worse in non-survivors (N=6). Nearly all patients had a compensated respiratory alkalosis (PaCO2 32 ± 4.4 mm Hg). PaCO2 was less reduced in older patients (r=0.438, P=0.022), and correlated independently with exercise duration (R=-0.463, P=0.03), yet PaO2, not PaCO2, was associated with survival. CONCLUSIONS: Eisenmenger patients show evidence of obstructive lung disease, diffusion abnormalities, and hypocapnia; likely from hyperventilation. Understanding expected lung mechanics and gas exchange may facilitate more appropriate clinical management.