Bedside Use of Speckle Tracking Echocardiography in the Emergency Department to Identify Acute Myocardial Infarction.

BACKGROUND: Rapid diagnosis of acute myocardial infarction (AMI) in the emergency department (ED) is often hindered by the limitations of the electrocardiogram (ECG). Speckle tracking echocardiography (STEch) is a semiautomated, computer-assisted process that provides accurate detection of regional ventricular wall motion abnormalities and can be performed at the bedside by operators with limited experience. CASE REPORTS: Two separate patients, each with history and ECG findings concerning for AMI, were evaluated using STEch performed by an emergency physician. Ventricular wall motion abnormalities found on STEch accurately reflected the findings of emergent cardiac catheterization, with one patient requiring urgent coronary artery revascularization and the other with no coronary artery occlusion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: STEch is a novel, easy-to-use form of echocardiography that can be used in the ED to identify patients with AMI who would benefit from emergent revascularization.

Thrombus in Transit: Key Echocardiography Findings in the ED.

A 32-year-old Asian male presented to the ED with a one-day history of mild pleuritic chest pain. He was diagnosed with an acute pulmonary embolus on CT Pulmonary Angiography (CT-PA). Transthoracic echocardiography (TTE) performed at the bedside in the ED demonstrated evidence of right heart strain but, most notably, a highly mobile echogenic thrombus in the right atrium, consistent with a clot-in-transit (CIT). This was not visualized on CT due to the influx of contrast in the heart. Based on this, the patient was transferred to the High Dependency Unit for IV heparin and close monitoring. The following day, he underwent clot retrieval using an Inari Flowtriever under direct TTE guidance. He was discharged on oral anticoagulation four days later and experienced no complications on follow-up. CIT is an important feature of pulmonary embolus to identify, as it can escalate the risk stratification of the patient, and management will need to be altered accordingly.

Recurrent Pericardial Effusion Secondary to Cardiac Angiosarcoma.

Cardiac angiosarcoma is a malignant cardiac tumour. We present the case of a young patient in his mid-30s with recurrent pericardial effusion. He had flu-like symptoms a month earlier and had shortness of breath, lethargy, and tightness in his throat for the past ten days. Echocardiography demonstrated global pericardial effusion > 4 cm with tamponade features, and the patient was blue-lighted to our hospital. He underwent emergency pericardiocentesis, and > 1 litre of pericardial fluid was drained. Computed tomography of the chest, abdomen, and pelvis revealed small-volume ascites and moderate right-sided pleural effusion, with associated lobar collapse. The patient presented to the hospital with global pericardial effusion requiring emergency pericardiocentesis three weeks later and underwent cardiac magnetic resonance imaging demonstrating global pericardial effusion and a 48 × 26 mm pericardial space mass adjacent to the right atrium. He underwent surgical resection of the tumour, followed by chemotherapy, and tolerated the treatment well. The patient is currently under follow-up.

Agreement on Interpretation of Point-of-Care Ultrasonography for Cardiac Tamponade Among Emergency Physicians.

STUDY OBJECTIVE: Cardiac tamponade is an impending calamitous disorder that emergency physicians need to consider and diagnose rapidly. A pericardial effusion with right atrial systolic collapse (earliest sign) or right ventricular diastolic collapse (most specific sign) and a plethoric inferior vena cava are indicators of cardiac tamponade physiology and may be identified with point-of-care ultrasonography (POCUS). The goal of this study is to assess the agreement among emergency physicians with varying levels of sonographic training and expertise in interpreting echocardiographic signs of cardiac tamponade in adult patients.  Methods: Emergency physicians at different levels of training as sonographers were surveyed at didactic conferences at three major academic medical centers in northern New Jersey. Two cardiologists were also included in the study for comparison. Survey respondents were shown 15, 20-second video clips of patients who had presented to the emergency department (ED) with or without significant pericardial effusions and were asked to rate whether tamponade physiology was present or not. Data were collected anonymously on Google Forms (Google LLC, Mountain View, CA) and included self-reported levels of POCUS expertise and level of training. Data were analyzed using Fleiss' kappa (k). All patients had an echocardiogram performed by the department of cardiology within 24 hours of the POCUS, and the results are presented in the paper.  Results: There were 97 participant raters, including attendings, fellows, and resident physicians specializing in adult emergency medicine and two cardiologists. There was a fair degree of inter-rater agreement among all participants in interpreting whether tamponade physiology was present or not. This low level of agreement persisted across self-reported training levels and self-reported POCUS expertise, even at the expert level in both emergency medicine and cardiology specialties. CONCLUSION: According to the results of our study, there appears to be a low level of agreement in the interpretation of cardiac tamponade in adult patients. The lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise. This low level of agreement seen among both specialists indicates that emergency physicians are not limited in their ability to determine cardiac tamponade on POCUS. This highlights the technical nature of POCUS clips and strengthens the importance of physical exam findings when diagnosing cardiac tamponade in emergency department patients. Further research utilizing POCUS for the diagnosis of tamponade is warranted.

A Case of a Large Malignant Pericardial Effusion on Computed Tomography Without Electrocardiographic Gating.

A 67-year-old female was admitted due to dyspnea. A computed tomography (CT) disclosed a suspicious pulmonary mass and a pericardial effusion. A transthoracic echocardiogram confirmed a large-volume circumferential pericardial effusion. A pericardiocentesis was performed, and the cytological and histochemical studies later confirmed the diagnosis of pulmonary adenocarcinoma. This case report highlights the casualty of having found a cardiac tamponade through a CT not synchronized with an electrocardiogram.

A Case Report of a Young Patient Presenting With Syncope Secondary to Arrhythmogenic Ventricular Cardiomyopathy.

Arrhythmogenic ventricular cardiomyopathy is an inherited condition mainly affecting adults. A 35-year-old Asian male patient presented with syncope while walking home. He experienced a number of episodes of light-headedness and dizziness over the past few weeks. A clinical examination found visible injuries to his face and hands. An electrocardiogram showed right axis deviation and right bundle branch block. Echocardiography showed normal biventricular function and the left ventricular ejection fraction was > 55%. A computerized tomography scan of the head and face showed a small fracture to the superior maxillary wall and a computerized tomography pulmonary angiogram demonstrated an inflammatory nodule with right upper and middle lobes changes as well as right hilar lymphadenopathy, suggestive of possible tuberculosis. Blood tests were unremarkable, and troponin was negative. Cardiovascular magnetic resonance imaging showed preserved biventricular function, mild bi-atrial dilatation, and extensive, crescentic-shaped, subepicardial late gadolinium enhancement from basal to apical inferior, basal to apical lateral, and mid to apical anterior segments of the left ventricle suggestive of arrhythmogenic ventricular cardiomyopathy. The patient was commenced on bisoprolol and had an implantable cardioverter defibrillator fitted. He was discharged home with outpatient cardiology follow-up.

Subacute Cardiac Tamponade With Massive Pericardial Effusion.

Subacute cardiac tamponade is a diagnostic challenge for clinicians because the symptoms would be non-specific upon presentation. The onset of cardiac tamponade may vary depending on the rate of accumulation and compensatory mechanism of the fibroelastic pericardial sac. In the case of subacute tamponade with effusion without cardiac arrest, it is usually challenging for the clinician to make the decision for urgent drainage. Usually, cardiac tamponade is treated as a medical emergency, and it occurs when fluid accumulated in the pericardial sac compresses the heart causing haemodynamic compromise and cardiac arrest. In our case, a 40-year-old man presented with a seven-day history of significant shortness of breath. He presented to the emergency department and the chest X-ray showed a large cardiac silhouette, which suggested a large pericardial effusion. ECG revealed minor changes in the heights of QRS complexes. Point-of-care echocardiography showed a large pericardial effusion, and he was immediately admitted to the cardiac unit. Urgent departmental echocardiography confirmed massive pericardial effusion with features of subacute tamponade. The patient was sent to the cardiac catheterisation lab and a total of approximately 4.2 litres of pericardial effusion was drained, while he was closely monitored for the risk of rapid physiologic decompensation after drainage. Pericardial fluid culture did not show any evidence of microorganism growth. The connective tissue disease screen was negative. CT scan did not show any stigmata of occult malignancy or features of infection. The coronavirus disease 2019 (COVID-19) polymerase chain reaction test was negative. He had rapid symptomatic improvement after the effusion was drained and recovery was uneventful. He was discharged from the hospital with a follow-up plan. We concluded that it was a case of subacute cardiac tamponade due to a massive pericardial effusion of idiopathic or subclinical viral causes. Clinical presentation of subacute cardiac tamponade could be easily missed, and a detailed assessment of the effusion with echocardiography was very helpful in making decisions for the management.

Traumatic Left Anterior Descending Artery Dissection in a Case of Pediatric Blunt Chest Trauma.

Despite the reserve for recovery in pediatric trauma, blunt force chest trauma can cause insidious injuries that are easy to miss. Coronary artery dissection is a rare injury associated with blunt force chest trauma in the pediatric population and can present with vague or atypical symptoms. Pediatric patients can be unreliable in reporting symptoms, and providers can mistake coronary artery injuries for myocardial contusion, especially with improving laboratory tests and equivocal imaging. We report a case showing the importance of a high index of suspicion when presented with this trauma pattern in a pediatric patient.

Concurrent Primary Cardiac Tumors in a High-Risk Patient Presenting With Tamponade.

Primary cardiac tumors are rare, particularly in the elderly population. The patient described in this report presented with symptoms of dyspnea on exertion, leg swelling, and weight gain and was found to have two histologically distinct cardiac masses: atrial myxoma with concurrent aortic fibroelastoma. Given her history of cirrhosis and end-stage renal disease, the patient was a poor surgical candidate but opted for excision of both masses. The patient eventually succumbed to her cirrhosis six weeks after presentation. In this report, we advocate for further research into medical management for the unique presentation of concurrent primary cardiac tumors in high-operative-risk patients, particularly those whose symptoms are mostly due to tamponade.