Absence Of Pericardial Effusion Research Articles

Improving pericardial effusion detection: evaluating sensitivity and specificity of traditional and novel ECG criteria

Abstract Funding Acknowledgements None. Introduction Historical studies have demonstrated that conventional low voltage criteria on ECG have high specificity but limited sensitivity in detecting pericardial effusion (PE). Indeed, an ECG showing low voltage can be indicative of several conditions, including PE. Purpose This study aimed to introduce new ECG criteria organized into a score called ARENA, to improve ECG diagnostic performance in detecting PE. Furthermore, we compared the sensitivity and specificity of traditional low voltage ECG criteria with the ARENA score using a test cohort. Methods This retrospective case-control study was conducted at our public University hospital from January 2022 to May 2023. Inclusion criteria were: age ≥18 years old, an available 12 lead ECG and an echocardiogram performed within 5 days from the recorded ECG. Exclusion criteria were: ventricular paced rhythm, heart transplantation, poor subcostal echocardiographic window. In the cohort of patients were selected: patients with ≥1.0 cm of PE on echocardiography and patients without effusion on echocardiography. ECG parameters were evaluated by two cardiologists blinded for the presence or absence of PE. Echocardiographic images were reviewed by an expert echocardiographer. Optimal ECG criteria with the highest ROC curve area were selected from the test cohort to develop the ARENA score. Patients were assessed using both traditional low voltage ECG criteria and the novel ARENA score. Statistical analysis showed that with 96 patients in the test cohort, there would be >90% power to detect a significant area under the curve (AUC) of 0.7 (vs. the null hypothesis of AUC of 0.5) to detect a moderate effect size. We used the AUC analysis to estimate the predicted performance of the proposed criteria. The McNemar test was used to assess the lack of agreement between the ECG criteria and the gold standard (echocardiography), and the results were reported as percentages with their respective 95% confidence intervals (CI). A p-value < 0.05 was considered statistically significant. Results The patient population consisted of 97 patients: 50 patients with PE, and 47 patients without it. The ARENA score showed a sensitivity of 52.0% (95% CI: 39.2% to 64.8%), compared to 14.0% (95% CI: 6.2% to 21.8%) of the traditional criteria. Specificity was 94% (95% CI: 84.1% to 100%) for ARENA Score and 100% (95% CI: 96.3% to 100%) for traditional criteria. Accuracy of the ARENA score was 70.0%, compared to 57% of the traditional criteria. The McNemar test indicated a p-value of <0.001 in the performance comparison. The AUC for the ARENA score was 0.781. Conclusion The novel ARENA score demonstrated an improved sensitivity while maintaining high specificity in detecting PE. This new score could become a valuable diagnostic tool for detecting PE by ECG in daily practice.ROC Curve ARENA ScoreECG criteria for pericardial effusion

Comparison of landiolol and amiodarone for the treatment of new-onset atrial fibrillation after cardiac surgery (FAAC) trial: study protocol for a randomized controlled trial

BackgroundPostoperative atrial fibrillation (PoAF) after cardiac surgery has a high incidence of 30%, but its management is controversial. Two strategies are recommended without evidence of a superiority of one against the other: rate control with beta-blocker or rhythm control with amiodarone. Landiolol is a new-generation beta-blocker with fast onset and short half-life. One retrospective, single-center study compared landiolol to amiodarone for PoAF after cardiac surgery with a better hemodynamic stability and a higher rate of reduction to sinus rhythm with landiolol, justifying the need for a multicenter randomized controlled trial. Our aim is to compare landiolol to amiodarone in the setting of PoAF after cardiac surgery with the hypothesis of a higher rate of reduction to sinus rhythm with landiolol during the 48 h after the first episode of POAF.MethodsThe FAAC trial is a multicenter single-blind two parallel-arm randomized study, which planned to include 350 patients with a first episode of PoAF following cardiac surgery. The duration of the study is 2 years. The patients are randomized in two arms: a landiolol group and an amiodarone group.Randomization (Ennov Clinical®) is performed by the anesthesiologist in charge of the patient if PoAF is persistent for at least 30 min after correction of hypovolemia, dyskalemia, and absence of pericardial effusion on a transthoracic echocardiography done at bedside.Our hypothesis is an increase of the percentage of patients in sinus rhythm from 70 to 85% with landiolol in less than 48 h after onset of PoAF (alpha risk = 5%, power = 90%, bilateral test).DiscussionThe FAAC trial was approved by the Ethics Committee of EST III with approval number 19.05.08. The FAAC trial is the first randomized controlled trial comparing landiolol to amiodarone for PoAF after cardiac surgery. In case of higher rate of reduction with landiolol, this beta-blocker could be the drug of choice used in this context as to reduce the need for anticoagulant therapy and reduce the risk of complications of anticoagulant therapy for patients with a first episode of postoperative atrial fibrillation after cardiac surgery.Trial registrationClinicalTrials.gov NCT04223739. Registered on January 10, 2020.

P90 CAMPYLOBACTER JEJUNI–ASSOCIATED MYOCARDITIS: A RARE BACTERIAL TRIGGER OF ACUTE MYOCARDITIS

Abstract Introduction Acute myocarditis is an important cause of chest pain in the young, with potential acute arrhythmic and hemodynamic complications and possible evolution into chronic inflammatory cardiomyopathy. Even though multiple triggers can be recognized, bacterial infections are rarely associated with myocarditis in immunocompetent patients. Case report A 22–year–old Caucasian woman presented to the Emergency Department with stabbing chest pain exacerbated by breathing, for several hours, without fever. She experienced diarrhea and gastroenteric symptoms for 4 days. One year prior she experienced identical pain during an acute myocarditis episode, with no clear trigger. The patient’s father too suffered from myocarditis a few months earlier. She underwent routine blood tests with evidence of elevated troponin HS (peak 8000 ng/L) and PCR (82mg/L). ECG showed sinus rhythm and anterolateral concave ST elevation of a maximum of 2 mm. Echocardiography showed normal bi–ventricular dimensions, thickness, regional motion, and absence of pericardial effusion. MRI exhibited inferolateral subepicardial edema and late gadolinium enhancement (LGE). The previous MRI performed 6 months after the resolution of the previous myocarditis did not show any LGE or edema. We began empirical anti–inflammatory therapy with swift benefit. Due to the persistence of gastroenteric symptoms, fecal film array and coproculture were performed and resulted positive for Campylobacter Jejuni, treated with Azithromycin 500 mg/day for 3 days. Finally, considering the recurrent event and the family history of myocarditis in the father, a genetic test was planned to exclude a “hot phase” in the context of arrhythmogenic cardiomyopathy. Discussion Up to 80% of acute myocarditis has an infectious trigger. The recent 2020 consensus advises against routine serology unless specific pathogens are suspected. In the literature, Campylobacter Jejuni is reported as a trigger of various inflammatory diseases, including acute myocarditis. We suggest investigating the presence of this bacterium in stool in case of active gastroenteric symptoms and adding targeted antibiotic therapy in case of active bacterial infection. Previous case reports excluded viral in myocarditis patients positive for Campylobacter. This may support C. Jejuni’s causal role and not as an innocent bystander.

Six-month cardiac outcomes in children with multisystem inflammatory syndrome in children.

Multisystem inflammatory syndrome in children is a rare, post-infectious complication of SARS-CoV-2 infection in children. We aimed to assess the long-term sequelae, particularly cardiac, in a large, diverse population. We performed a retrospective cohort study of all children (aged 0-20 years, n = 304) admitted to a tertiary care centre with a diagnosis of multisystem inflammatory syndrome in children from March 1, 2020 to August 31, 2021 and had at least one follow-up visit through December 31, 2021. Data were collected at hospitalisation, 2 weeks, 6 weeks, 3 months, and 1 year after diagnosis, where applicable. Cardiovascular outcomes included left ventricular ejection fraction, presence or absence of pericardial effusion, coronary artery abnormalities, and abnormal electrocardiogram findings. Population was median age 9 years (IQR 5-12), 62.2% male, 61.8% African American (AA), and 15.8% Hispanic. Hospitalisation findings included abnormal echocardiogram 57.2%, mean worst recorded left ventricular ejection fraction 52.4% ± 12.4%, non-trivial pericardial effusion 13.4%, coronary artery abnormalities 10.6%, and abnormal ECG 19.6%. During follow-up, abnormal echocardiogram significantly decreased to 6.0% at 2 weeks and 4.7% at 6 weeks. Mean left ventricular ejection fraction significantly increased to 65.4% ± 5.6% at 2 weeks and stabilised. Pericardial effusion significantly decreased to 3.2% at 2 weeks and stabilised. Coronary artery abnormalities significantly decreased to 2.0% and abnormal electrocardiograms significantly decreased to 6.4% at 2 weeks and stabilised. Children with multisystem inflammatory syndrome in children have significant echocardiographic abnormalities during the acute presentation, but these findings typically improve within weeks. However, a small subset of patients may have persistent coronary abnormalities.

190 FATAL PEMBROLIZUMAB CARDIOTOXICITY REFRACTORY TO CORTICOSTEROID THERAPY: A CASE REPORT OF CLINICALLY SUSPECTED MYOCARDITIS.

Abstract We report the case of an 80 years old, fit, mildly hypertensive man receiving adjuvant immunotherapy with Pembrolizumab for stage IIIC (pT4a pN1b) cutaneous nodular melanoma, for which he had also undergone radical surgery. His preoperative ECG was unremarkable. Few days after his first Pembrolizumab dose, he started complaining of gradually worsening muscle aches and weakness and double vision, as well as of brief episodes of otherwise asymptomatic palpitations, so that he finally showed up at the Emergency Department (day 1). Clinical examination revealed mild hypertension, low-grade temperature, subtotal bilateral ophthalmoplegia, fatigable left palpebral ptosis, dysarthria, dysphagia, and neck and limb hyposthenia. Laboratory analyses indicated an inflammatory state with mild neutrophilia and elevated C reactive protein, associated to an increase in serum creatinine, creatine kinase and transaminases. Chest x-ray and brain CT demonstrated no alterations. The ECG showed sinus rhythm at 90 bpm and a previously unknown right bundle branch block (RBBB). The patient was admitted to the Internal Medicine ward in the suspect of Pembrolizumab toxicity leading to myositis and myasthenia and to hepatorenal dysfunction, and Methylprednisolone 1 mg/kg/day was administered intravenously ex adiuvantibus, together with Pyridostigmine and low flow oxygen. The next morning (day 2), dyspnea and palpitations ensued, atrial fibrillation at 130 bpm with RBBB was recorded, while the echocardiogram showed normal biventricular dimensions and systodiastolic function, mild aortic and mitral regurgitations, and the absence of pericardial effusion or inferior vena cava congestion. A single, oral, 60 mg dose of Diltiazem was administered, but suspended few hours later upon evidence of atrioventricular block (AVB) 2:1 (HR 40 bpm) quickly escalating to 3:1 (HR 40 bpm) and, later on, of atrial fibrillation with slow ventricular rate (HR 36 bpm). Given a CHA2DS2-VASc score equal to 3, anticoagulation was started. The patient was then moved to the intensive care unit for bradycardia and worsening tachydyspnea. Respiratory function as well as clinical and laboratory parameters of neuromuscular, renal and hepatic impairment began improving (day 3). However, rhythm monitoring showed progression of conduction anomalies with the appearance of sino-atrial block, left bundle branch block and alternance between Mobitz I AVB, AVB 2:1 and complete AVB. High-sensitivity cardiac troponin I remained stably highly elevated, around 25000 ng/L. Control echocardiography showed the onset of mild left ventricular systolic dysfunction with a mild pericardial effusion. A cardiac magnetic resonance was planned to corroborate the hypothesis of Pembrolizumab-induced myocarditis. However, on day 5 respiratory and hemodynamic worsening occurred, up to cardiocirculatory arrest due to an electrical storm of ventricular tachycardia and fibrillation, despite in-range electrolytes, with emergency echocardiogram revealing also a dysfunctioning right ventricle. Despite prolonged resuscitation attempts, including high-dose corticosteroid, death ensued. Widely used in cancer treatment, immune checkpoint inhibitors (ICI) bear the potential for immune-related adverse events, including cardiovascular ones: brady- and tachy- arrhythmias, acute myocardial infarction, pericarditis, myocarditis, pulmonary embolism, and vasculitis; in particular, ICI-related myocarditis, reportedly highly arrhythmogenic, often occurs together with myositis and myasthenia (“triple M rule”); despite immunosuppression, mortality still remains high.

Right atrial collapse in the absence of pericardial effusion.

A 16-year-old male with severe pectus excavatum (PEx; Panel A) was referred to our institution due to progressive exertional dyspnea, palpitations, and chest wall discomfort. Transthoracic echocardiography performed at an outside institution reported minimal compression of the right heart chambers without haemodynamic disturbances. Considering the severity of the deformity and cardiopulmonary symptoms, surgical repair with intraoperative transesophageal echocardiography (TEE) surveillance was indicated. Intraoperative TEE showed severe extrinsic compression of the right atrium (RA) due to the depression of the anterior chest wall, with RA collapse starting in early diastole and extending into end-diastole (Panel B, Video 1). No pericardial effusion was noted. After PEx repair, TEE imaging noted no further evidence of RA collapse (Panel C). On postoperative Day 2, the patient was discharged without complications, and in subsequent 6 weeks follow up, he reported significant improvement in symptoms. Sustained RA collapse is a highly sensitive and specific marker for cardiac tamponade, usually indicating emergency situations in which intrapericardial pressure transiently exceeds intracardiac pressure. In early stages of cardiac tamponade, RA collapse is observed during end-diastole when the RA pressure is at its lowest. The phenomenon gradually extends throughout most of the diastole with the increase of intrapericardial pressure. In our unique case of a PEx patient, RA collapse occupying entire diastolic period was observed due to external compression in the absence of cardiac tamponade, and completely resolved with surgical repair. This finding supports the need for a comprehensive assessment of the right-sided chambers compression in symptomatic PEx patients.

Abstract 15534: Pericardial Effusion in People With HIV in the Era of Antiretroviral Therapy

Introduction: Pericardial effusion was previously described as one of the most common forms of cardiovascular involvement in People with HIV (PWH). The presence of pericardial effusion was considered a marker of advanced HIV infection and associated with a low CD4 cell count. This study describes the incidence and association of pericardial disease with HIV-related factors in an era of wider availability of antiretroviral therapy (ART). Methods: A retrospective chart review was performed of patients who received HIV care at the University of Miami/Jackson Memorial Hospital between 2017-2019 with an available echocardiogram (n=396). We stratified patients according to the presence (n=51) or absence of pericardial effusion (n=345) and compared demographic, clinical, imaging, and laboratory data. A p-value <0.05 was considered statistically significant. Results: We found a prevalence of pericardial effusion in PWH of 4.5%. There was no statistically significant difference in age, gender, or race between groups. PWH with pericardial effusion had higher creatinine (2.1 mg/dL vs. 1.6 mg/dL, p=0.025) and pro-BNP (12,088 pg/mL vs. 6364 pg/mL, p=0.021) levels, were more likely to have chronic kidney disease (43.1% vs. 18%, p<0.001), tricuspid regurgitation (64.6% vs. 44.2%, p=0.009), and mitral regurgitation (60.8% vs. 35.9%, p<0.001) compared to PWH without pericardial effusion. There was no difference in CD4 count, CD8 count, viral load, length on ART, or history of tuberculosis between groups. Conclusions: We report a lower prevalence of pericardial effusion in PWH than previous results before the wide availability of ART (around 11%). In PWH with pericardial effusion, we found no association with HIV-related factors or length on ART. In this population, pericardial effusion was associated with comorbidities like chronic kidney disease and valvular abnormalities.

C37 CONCOMITANT PARTIAL PERICARDIAL AGENESIS, PERICARDIAL CYST AND POSTERIOR MITRAL VALVE LEAFLET HYPOPLASIA: A CASE REPORT

Abstract Background Pericardial agenesis (1) is a congenital developmental disorder of the pleuro–pericardial membranes that is usually asymptomatic. A pericardial cyst (2) is a congenital cyst composed of mesothelial cells originating most often from the right pericardium. Hypoplasia of the posterior mitral leaflet (3) is congenital and it is very rarely diagnosed in adulthood. These alterations are usually sporadic and not associated. Case presentation A 53–year–old woman with obesity and bronchial asthma was referred to the emergency department for left hemiparesis and concomitant dyspnoea in new–onset atrial fibrillation. A right frontal ischemic stroke was diagnosed. During the hospitalization transthoracic echocardiography was performed showing a large prolapsed anterior mitral leaflet (AML) with an eccentric and significant regurgitation. Transesophageal echocardiography was performed. It confirmed the severity of mitral regurgitation, due to a large AML prolapse, but also showed a severely hypoplastic posterior leaflet (PML). Swinging motion was also reported in the absence of pericardial effusion. In the past the patient was surgically treated for an anterior pericardial cyst that was excised. Old CT images were reviewed and showed the absence of pericardial sheets along posterior and lateral left ventricle walls, which were not contiguous to the cyst (that was anterior). The patient was finally candidated to surgery for mitral valve replacement. Discussion The case report shows a unique case of association between partial pericardial agenesis, pericardial cyst, severe PML hypoplasia with AML prolapse and severe mitral regurgitation. The association of these three anomalies has never been described before. This could indicate a common pathogenetic denominator and therefore the need to look for this combination of structural abnormalities in carriers of even just one of them. Bibliography 1. Lopez D. et al, doi: 10.1016/j.pcad.2016.12.002 2. Khayata M. et al, doi: 10.1007/s11886–019–1153–5 3. Parato VM. et al, doi: 10.4103/jcecho.jcecho_73_17

Mycophenolate in idiopathic inflammatory myositis: outcome data of a large South Asian cohort.

Consensus on treatment of idiopathic inflammatory myositis (IIM), particularly with regard to flares and interstitial lung disease (ILD), does not exist. We studied the long-term outcome and treatment response in our large, retrospective cohort of adult South-Asian patients exclusively with IIM. Electronic records of IIM patients satisfying inclusion and exclusion criteria were studied longitudinally at presentation, at 3, 6, 12, 18 and 24 months and thereafter yearly till their last follow up (F/u) visit. Depending on clinical, imaging, and muscle enzyme profile during the F/u period, patients were categorised as complete (CR) and partial responders (PRs). Parameters favouring CR were assessed using multivariate logistic regression analysis. Outcome parameters and flares on immunosuppressants (IS) were then assessed in patients with/without ILD. Two hundred thirty-two patients with median F/u duration of 44.5 months (25-80.25) were included. ILD was seen in 40.1%. Patients with non-Jo1 anti-synthetase antibodies (n=26) were numerically more than those with Jo-1 antibody (n=24). CR status was attained by 50.9% patients. Absence of pericardial effusion (p=0.042, OR 4.223, 95% CI: 1.05-16.9) and presence of Gottron's rash (p=0.044, OR 1.78, 95% CI 1.017-3.121) at baseline predicted CR by multivariate regression. Majority received mycophenolate during the entire F/u period. Discontinuation of steroids was feasible in 51.7% after a median duration of 24 months (18-42). After excluding patients with ILD, flares were numericallylesser in patients only on mycophenolate compared with those only on methotrexate (p=0.06). Further flares were curtailed when switchedfrom other agentsto mycophenolate. Mycophenolate is an effective treatmentoption in IIM patients with and without co-existing ILD. Presence of Gottron's rash and absence of pericardial effusion were found to be predictors of favourable clinical outcome in this largest single-centre study.

CT-Based Biomarkers for Prediction of Chronic Thromboembolic Pulmonary Hypertension After an Acute Pulmonary Embolic Event

OBJECTIVE. The purpose of this study is to assess CT-based markers predictive of the development of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism. MATERIALS AND METHODS. Identified from a search of local registries, 48 patients who had CTEPH develop were included in the study group, and 113 patients who had complete resolution of acute pulmonary embolism were included in the control group. Baseline CT scans obtained at the time of the initial pulmonary embolism event were evaluated for the degree of clot-induced vessel obstruction, the quantitative Walsh score, the ratio of the right ventricle diameter to the left ventricle diameter, the right atrium diameter, the pulmonary artery diameter, right heart thrombus, pericardial effusion, lung infarction, and mosaic attenuation. Classification and regression tree analysis was used to create a decision tree. The decision tree was externally validated on an anonymized cohort of 50 control subjects and 50 patients with CTEPH. RESULTS. During univariable analysis, an increase in the degree occlusive clot on initial imaging, a decrease in the Walsh score, absence of pericardial effusion, presence of lung infarction, and the presence of mosaic attenuation were associated with an increased probability of CTEPH development. In the final decision tree, the occlusive nature of the clot remained. Two patients in the cohort used for external validation had nondiagnostic findings and were excluded. The decision process correctly classified 33% (16/48) of patients who had CTEPH develop and 86% (43/50) of patients who did not have CTEPH develop, for an odds ratio of 3.1 (95% CI, 1.1-8.3). CONCLUSION. The presence of an occlusive clot on initial imaging is associated with an increased probability of CTEPH development. Presence of mosaic attenuation and lung infarction may also predict CTEPH development, although additional studies are needed.

P5279Pericardial inflammation basced on cardiac magnetic resonance imaging in patients with tuberculous pericarditis

Abstract Background While constrictive pericarditis has been traditionally considered a disabling disease, reversible constrictive pericarditis has been described in previous studies. But there are limited studies on cardiac imaging of tuberculous pericarditis. In particular, no studies on cardiac magnetic resonance imaging (CMR) have been reported. We aimed to investigate CMR findings including pericardial late gadolinium enhancement (LGE) and T2 fat suppression and black blood sequences in patients with tuberculous pericarditis. Methods We retrospectively analyzed medical records of patients with tuberculous pericarditis between January 2010 and January 2017 in Samsung Medical Center. Definite diagnosis of tuberculous pericarditis is based on the identification of Mycobacterium tuberculosis in pericardial fluid or tissue; probable diagnosis was made when there was other evidence of tuberculosis elsewhere in patients with unexplained pericarditis. We performed CMR at initial diagnosis. Treatment consists of the standard 4-drug antituberculosis regimen for 6 months with or without steroids. Echocardiography was also conducted at initial diagnosis and 6 months later. Results Total 39 cases with tuberculous pericarditis in immunocompetent patients were enrolled. Ten patients were diagnosed as definite tuberculous pericarditis. CMR finding at initial diagnosis divided into five groups: 1) pericardial effusion only (n=20, 51.3%), 2) effusive constrictive pericarditis (n=5, 12.8%), 3) constrictive pericarditis (n=11, 28.2%), 4) pericardial abscess formation (n=4, 10.3%) and 5) absence of pericardial effusion and constrictive physiology (n=1, 2.6%). One of the 4 patients with pericardial abscess formation was together with pericardial effusion and the other was accompanied by effusive constrictive pericarditis. Pericardial thickness increased to more than 4mm in 25 patients (64.1%) and the mean pericardial thickness was 10.0±6.9mm. Delayed enhancement of pericardium was noticed in 29 patients (74.4%). In T2 fat suppression and black blood sequences, 30 patients showed increased T2 signal intensity indicating inflammation with extensive edema. Pericardial thickening (>4mm) with constriction (n=15) was not statistically significant in the delayed enhancement and increased T2 signal intensity compared with pericardial thickening without constrictive pericarditis (n=10) (delayed enhancement 93.8% vs. 77.8% p=0.287; increased T2 signal intensity 88.9% vs. 87.5%, p=0.713). After 6 months, only 3 patients still had constrictive pericarditis in echocardiography. Effusive constrictive pericarditis Conclusions Pericardial thickening is associated with delayed enhancement and increased T2 signal intensity in patients with tuberculous pericarditis regardless of constrictive pericarditis. Even though there were hemodynamic feature of constrictive pericarditis and pericardial inflammation with extensive edema in CMR at initial diagnosis, 80% of the patients were improved from constrictive pericarditis. Acknowledgement/Funding None

When appearances deceive: Echocardiographic changes due to common chest pathology

Most indications for performing echocardiography focus on the evaluation of properties intrinsic to the heart. However, numerous extra-cardiac conditions indirectly convey changes to the echocardiographic appearance through alterations in the governing physiology. Pulmonary embolism increases pulmonary arterial pressure if a sufficient cross-sectional area of the pulmonary vascular bed is occluded. This may result in dilatation of the right ventricle and, in severe cases, concomitant early diastolic septal collapse into the left ventricle. Acute respiratory failure has been shown to yield a similar echocardiographic appearance in experimental conditions due to the resultant pulmonary vasoconstriction. Echocardiography in the presence of pulmonary disease can reveal underlying cardiac pathologies such as pulmonary hypertension that contribute to the clinical severity of respiratory distress. Positive pressure ventilation affects preload, afterload, and compliance of both ventricles. The echocardiographic net result cannot be uniformly anticipated, but provides information on the deciding physiology or pathophysiology. Mediastinal pathology including tumors, herniation of abdominal content, and pleural effusion can often be visualized directly with echocardiography. Mediastinal pathologies adjacent to the heart may compress the myocardium directly, thus facilitating echocardiographic and clinical signs of tamponade in the absence of pericardial effusion. In conclusion, many pathologies of extra-cardiac origin influence the echocardiographic appearance of the heart. These changes do not reflect properties of the myocardium but may well be mistaken for it. Hence, these conditions are essential knowledge to all physicians performing echocardiography across the spectrum from advanced cardiological diagnostics to rapid point-of-care focused cardiac ultrasonography.

Evaluation of a Focused Cardiac Ultrasound Protocol in a Pediatric Emergency Department.

The objective of this study was to evaluate the implementation of a focused cardiac ultrasound (FoCUS) protocol in a pediatric emergency department (PED). We conducted a cross-sectional, observational, quality improvement project in a PED of an urban tertiary care children's hospital. A FoCUS protocol was collaboratively developed by pediatric cardiology and pediatric emergency medicine. This included a reference document with definitions, indications, image acquisition guidelines, and interpretation expectations. We measured physician-sonographer performance against pediatric cardiologist interpretation of stored cine clips as our reference standard. Focused cardiac ultrasound interpretation was dichotomized for the presence or absence of pericardial effusion, depressed left ventricular function, and chamber size abnormalities. Run charts were used to compare the number FoCUS performed each month and the quality of captured cine clips with those from the previous year. Ninety-two FoCUSs were performed by 34 different physician-sonographers from January to December 2016. The prevalence of FoCUS abnormalities was 18.5%. For pericardial effusion, sensitivity was 100% (95% confidence interval [CI], 48%-100%) and specificity was 99% (95% CI, 94%-100%). For depressed function, sensitivity was 100% (95% CI, 54%-100%) and specificity was 99% (95% CI, 94%-100%). For chamber size abnormalities, sensitivity was 100% (95% CI, 54%-100%) and specificity was 95% (95% CI, 89%-99%). The median number of monthly FoCUS increased from 1 (preprotocol) to 5 (postprotocol), and the median rate of adequate studies increased from 0% to 55%. We report the collaborative development and successful implementation of a PED FoCUS protocol. Physician-sonographer interpretation of FoCUS yielded acceptable results. Improvements in FoCUS utilization and cine clip adequacy were observed.

Focused Real-Time Ultrasonography for Nephrologists.

We propose that renal consults are enhanced by incorporating a nephrology-focused ultrasound protocol including ultrasound evaluation of cardiac contractility, the presence or absence of pericardial effusion, inferior vena cava size and collapsibility to guide volume management, bladder volume to assess for obstruction or retention, and kidney size and structure to potentially gauge chronicity of renal disease or identify other structural abnormalities. The benefits of immediate and ongoing assessment of cardiac function and intravascular volume status (prerenal), possible urinary obstruction or retention (postrenal), and potential etiologies of acute kidney injury or chronic kidney disease far outweigh the limitations of bedside ultrasonography performed by nephrologists. The alternative is reliance on formal ultrasonography, which creates a disconnect between those who order, perform, and interpret studies, creates delays between when clinical questions are asked and answered, and may increase expense. Ultrasound-enhanced physical examination provides immediate information about our patients, which frequently alters our assessments and management plans.

Right atrial emptying fraction non-invasively predicts mortality in pulmonary hypertension.

Right-sided heart failure is the most common cause of death in pulmonary hypertension (PH). Echocardiographic measurements of right atrial (RA) size are associated with worse outcome in PH, however the association between RA function and death in PH has not been well-described. 160 PH patients (World Health Organization groups 1-5) underwent cardiac magnetic resonance imaging (cMRI) and right heart catheterization (RHC) within 6 weeks of each other at a tertiary care academic medical center in the United States. We measured cMRI RA maximum and minimum volumes indexed to body surface area and calculated RA emptying fraction (RAEF). We evaluated the relationship between RAEF and clinical variables with death using Cox proportional hazard models. 57 deaths occurred during a median follow-up of 3.5 years (36 % died overall, 10 % per year). RAEF was directly correlated in univariate analyses with right ventricular (RV) ejection fraction, left ventricular (LV) ejection fraction, LV size, cardiac index, absence of tricuspid and pulmonic regurgitation, absence of pericardial effusion, estimated glomerular filtration rate, 6-minute walk distance, and pulmonary arterial oxygen saturation, whereas it was inversely correlated with death, BNP, heart rate, mean RA pressure, mean PA pressure, pulmonary and systemic vascular resistance, RV size, and RA size. Using multivariate analyses, RAEF had a robust inverse association with death after adjusting for measured risk factors (HR per 5 % change in RAEF: 0.83 [95 % CI 0.73-0.94], p = 0.003). In PH patients, decreased RAEF by cMRI is independently associated with worse survival after adjustment for other risk factors.

In Patients with Light-Chain (AL) Amyloidosis Myocardial Contraction Fraction (MCF) Is a Simple, but Powerful Prognostic Measure That Can be Calculated from a Standard Echocardiogram (ECHO)

Background: Amyloidosis is a multisystem disease with extracellular deposition of pathological insoluble beta-fibrillar proteins. Involvement of the heart is seen in more than one-half of the patients with systemic AL amyloidosis and it is the most important determinant of clinical outcome. Cardiac amyloidosis is a restrictive infiltrative cardiomyopathy in which, despite declines in stroke volume that accompany disease progression, the ejection fraction (EF) often remains preserved even in advanced stages of the disease. King et al. proposed a novel index of myocardial function, the myocardial contraction fraction (MCF), defined as the ratio of stroke volume (SV) to myocardial volume (MV). MCF is a measure of myocardial shortening, which differentiated myocardial performance in patients with similar degrees of hypertrophy and in a recent small cohort of AL amyloidosis patients appeared superior to left ventricular ejection fraction (EF) in predicting overall survival (OS). It was our goal to assess the prognostic role of MCF in a large cohort of patients with AL amyloidosis in the context of other prognostic variables.Methods: Patients seen between 4/1/1999 and 2/1/2015 were eligible for this retrospective study if they had an ECHO at the Mayo Clinic, Rochester, MN within 30 days of their AL amyloidosis diagnosis with measurements of left ventricular chamber size and wall thickness needed to calculate MCF, EF, and the presence or absence of pericardial effusion. To capture the full cohort, modeling was done first excluding Mayo (2012) staging and global averaged left ventricular longitudinal peak systolic strain (LV strain) since limited numbers of patients had these studies, 342 and 294, respectively. Thresholds of continuous variables were chosen based on receiver operator curves targeting death at 1-year. Cox proportional hazards analysis was used to identify factors that were prognostic for OS. Statistical analyses were done using JMP 9.0 (SAS, Cary, NC).Results: Among the 722 patients satisfying entry criteria,median age was 64 years (range 32-94) and 66% were male. The best cutoff for MCF was 21% (sensitivity: 74%, specificity: 60%; AUC=0.699) and distinguished two groups with different OS (median 53 vs. 9 months, P<0.0001; Figure). On univariate analysis the baseline ECHO variables predicting OS were interventricular septum thickness (IVS) >12 mm (RR 1.8, P=0.0002), EF <60% (RR 1.7), MCF ≤21% (RR 2.1), and presence of pericardial effusion (RR 2.0), all with P<0.0001. On multivariate MCF ≤21% (RR 1.6, P <0.0001), EF <60% (RR 1.4, P=0.0007) and the presence of pericardial effusion (RR 1.3, P=0.002) were independent predictors of OS.Additional modeling was done with the subset of 342 patients who were assessable for Mayo (2012) staging, (i.e. measurements of immunoglobulin free light chain, NT-proBNP, and troponin T). On univariate analysis, patients with a Mayo (2012) stage ≥ 3 had a RR 2.1, p<0.0001. On multivariate, only MCF ≤21% (RR 1.5, P =0.01), Mayo (2012) stage ≥ 3 (RR 1.5, P=0.01) and EF<60% (RR 1.7, P=0.0006) were independent prognostic determinants.Finally, we addressed LV-strain among the 294 patients in whom the study was performed. There was a significant correlation between MCF and LV strain (rho =-0.86, P<0.0001). On univariate, LV-strain less negative than -13 generated a RR of 2.3, p<0.0001. In contrast to the model containing MCF, on LV-strain multivariate, EF was no longer significant, but LV-strain less negative than -13 (RR 2.0, P=0.008) and Mayo (2012) stage ≥ 3 (RR 2.0, P=0.008) predicted independently OS.Conclusions: MCF ≤21% identified a subgroup of patients with a high mortality risk, and it was independent of the Mayo (2012) staging but highly correlated with LV strain. An advantage of MCF, which is a novel volumetric measurement of the left ventricular chamber, is that, unlike LV-strain, MCF is simple to calculate from routine ECHO measures. [Display omitted] DisclosuresKumar:AbbVie: Research Funding; Celgene: Research Funding; Janssen: Research Funding; Skyline, Noxxon: Honoraria; Celgene, Millenium, Sanofi, Skyline, BMS, Onyx, Noxxon,: Other: Consultant, no compensation,; Sanofi: Research Funding; Millenium/Takeda: Research Funding; Onyx: Research Funding.

Facilitation of transvenous lead extraction using site-specific delivery of electrosurgical energy

IntroductionExcimer laser energy is often required to extract chronically indwelling pacemaker and defibrillator leads from the vasculature and myocardium. This technique can be associated with vascular and right ventricular (RV) injuries. We sought to develop a safer, more effective method by applying site-specific delivery of electrosurgical energy (EE). MethodsUtilizing a polyacrylamide gel model to simulate soft tissue density, active and passive fixation defibrillator and pacemaker leads were implanted and manually extracted with and without EE delivered to the cathode. The amount of force required for complete removal was measured using a force transducer. The procedure was then repeated in an acute pig model to demonstrate proof of safety. Post mortem gross and histologic specimens were collected from the implantation site. ResultsIn the gel model, the force required for extraction, using manual traction in the active (83.7 g) and passive (74.6 g) fixation ICD leads, was reduced by 37.8% and 33.5%, respectively with EE (both p < 0.01). The force required for extraction, using manual traction in the active (85.2 g) and passive (71.9 g) fixation pacemaker leads, was reduced by 64.4% and 42.6%, respectively with EE (both p < 0.01). In an acute implantation pig model using an active fixation lead, delivery of EE to the cathode (n = 6) reduced the force required to manually extract the lead (140 g +/− 32.5 versus 82 g +/− 14.7, p = 0.03). Post mortem analysis of the RV displayed formation of an epicardial hemorrhagic lesion that was also present after manual traction and EE. There was absence of pericardial effusion, perforation, and ventricular arrhythmia. ConclusionsSite-specific delivery of EE to areas of exposed metal along the lead decreased the force necessary for lead extraction in an in vitro and in vivo model. Further studies are needed to evaluate its application in clinical care.

Risk Factors for Pericardial Effusion in Native Valve Infective Endocarditis and Its Influence on Outcome

Data on the incidence, associated factors, and prognosis of pericardial effusion (PE) in patients with infective endocarditis (IE) are scarce. Patients with native valve IE were prospectively followed in our center from 1990 to 2007. A logistic regression analysis was performed to identify independent variables associated with PE and mortality. We included 479 episodes of IE from 459 patients (70% men, mean age 51 years). Small-to-moderate PE was observed in 109 episodes (23%) and large-to-very large PE was observed in 9 episodes (2%). Patients with small-to-moderate PE had a greater prevalence of intravenous drug use (38% vs 23%) and more frequent right-sided IE than patients without PE (33% vs 17%). Patients with large-to-very large PE had a higher rate of systemic emboli (22% vs 18%) and periannular abscess (22% vs 6%) than patients without PE. Renal failure was associated with a higher risk of PE (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.3 to 3.3); age was associated with a lower risk of PE (OR 0.98, 95% CI 0.97 to 0.99). One-year mortality of patients with IE with large-to-very large PE was higher than that of patients with small-to-moderate and absence of PE (56%, 18%, and 24%, respectively, p = 0.033). Large-to-very large PE increases the 1-year mortality of IE (OR 3.0, 95% CI 1.2 to 7.9). In conclusion, renal failure and younger age are associated with a higher risk of PE. Large-to-very large PE was associated with an increase in 1-year mortality.

Point-of-Care Echocardiography by Pediatric Emergency Physicians

Currently, pediatric emergency medicine (PEM) physicians have limited data on point-of-care echocardiography (POCE). Our goals were to (1) determine the overall accuracy of POCE by PEMs in assessing left ventricular (LV) systolic function visually, presence or absence of pericardial effusion, and cardiac preload by estimating inferior vena cava (IVC) collapsibility, in acutely ill children in the pediatric emergency department; and (2) assess interobserver agreement between the PEM physician and pediatric cardiologist. This is a prospective, observational study conducted in an urban, tertiary pediatric facility with an annual census of 67,000 emergency department visits. Patients between the ages of 0 and 18 years meeting 1 or more of the following inclusion criteria were recruited: (1) cardiopulmonary arrest, (2) fluid refractory shock requiring vasoactive infusions, (3) undifferentiated cardiomegaly on chest radiography, and (4) receiving emergent formal echocardiography. All eligible patients underwent POCE by 1 of 2 trained PEM physicians. Dynamic video clips were recorded and reviewed by a pediatric cardiologist who was unaware of the clinical condition of the study patients. For a period of 18 months, we recruited 70 patients. Diminished LV function was noted in 17, pericardial effusion in 16, and abnormal IVC collapsibility in 35 patients. The κ statistics of agreement between the PEM and the cardiologist for detection of LV function, IVC collapsibility, and effusion were 0.87 (95% confidence interval [CI], 0.73-1.00), 0.73 (95% CI, 0.59-0.88), and 0.77 (95% CI, 0.58-0.95), respectively. The overall sensitivity and specificity of POCE compared with a formal echocardiogram was 95% (95% CI, 82%-99%) and 83% (95% CI, 64%-93%), respectively. With goal-directed training, PEM physicians may be able to perform POCE and accurately assess for significant LV systolic dysfunction, vascular filling, and the presence of pericardial effusion. The model may be expanded to train physicians to use POCE.

Heart Failure

Heart Failure