Initial Transthoracic Echocardiogram Research Articles

Tricuspid annular plane systolic excursion to pulmonary artery systolic pressure ratio in chronic thromboembolic pulmonary hypertension improves with balloon pulmonary angioplasty.

Right ventricle (RV)-to-pulmonary artery (PA) coupling measured by the ratio of echocardiography-derived tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) is a meaningful prognostic marker in pulmonary hypertension (PH). It's unclear if balloon pulmonary angioplasty (BPA) treatment of chronic thromboembolic pulmonary hypertension (CTEPH) alters RV-PA coupling measured by TAPSE/PASP. We reviewed CTEPH patients treated with BPA at our institution who had a transthoracic echocardiogram (TTE) before BPA and a follow-up TTE at any point during BPA. TAPSE was obtained from the initial and lattermost TTE; hemodynamics were obtained before each BPA session. Between March 2015 to October 2023, there were 228 patients treated with BPA. After excluding post-PTE patients and those without PH, 67 were included. Initial TAPSE/PASP was 0.39 ± 0.21 mm/mmHg. Using previously defined TAPSE/PASP tertiles in PH (<0.19, 0.19-0.32, >0.32 mm/mmHg), there were 6 patients (9%) in low, 30 (45%) in middle, and 31 (46%) in the high tertiles at baseline. The lower TAPSE/PASP tertiles had more severe baseline hemodynamics (p < 0.001) compared to the high TAPSE/PASP cohort. At follow-up, TAPSE/PASP improved to 0.47 ± 0.20 mm/mmHg (p = 0.023), with 2 (3%), 13 (19%), and 52 (78%) patients in the low, middle, high TAPSE/PASP tertiles, respectively. As patients progress through BPA sessions, the TAPSE/PASP ratio increases, possibly reflecting improved RV mechanics and RV-PA coupling. TAPSE/PASP ratio as a marker of RV-PA coupling can improve with BPA treatment and may be an important measure to follow during treatment of CTEPH.

Meta-analysis of cardiac imaging modalities for the diagnosis of left ventricular thrombus following acute myocardial infarction

Abstract Background The formation of left ventricular thrombus (LVT) in post-acute myocardial infarction (AMI) patient carries significant risk of systemic embolism. Hence, there is a need to adopt strategies aimed at accurate and early diagnosis of LVT in order to mitigate the risk of embolic events with anti-thrombotic therapy. We aimed to conduct a systematic review and meta-analysis to appraise the current literature on the various diagnostic modalities used in post-AMI LVT detection. Methods We conducted a comprehensive search in Medline, EMBASE, and Scopus using an appropriate keyword/MeSH term search strategy up to 31 December 2021. All studies reporting a comparison between at least two imaging modalities in the diagnosis of LVT in post-AMI patients were included. Results A total of 2039 patient from 11 studies published between 2006 and 2021 were studied. Across all study populations, a majority of patients were male (82.3%) and the overall incidence of LVT was 15.2%. Using delayed-enhancement cardiac magnetic resonance imaging (DE-CMR) as the gold standard reference, transthoracic echocardiogram (TTE) with ultrasound enhancing agent (UEA) had the highest sensitivity (0.886, 95% CI 0.667-0.967) and specificity (0.980, 95% CI 0.900-0.996), while cine-CMR had the best diagnostic performance in terms of positive likelihood ratio (LR+ 437, 95% CI 37.2-1890), negative likelihood ratio (LR- 0.246, 95% CI 0.118-0.423) and diagnostic odds ratio (DOR 2050, 95% CI 134-9590). The summary receiver operating characteristic curves (SROCs) of the three studied imaging modalities were plotted and the AUC values were 0.920, 0.974 and 0.989 for TTE without and with UEA, and cine-CMR. Conclusions The diagnostic modalities used for LVT detection examined in this study had good specificity but poor sensitivity when compared to DE-CMR. Post-AMI patients at higher risk of LVT formation may benefit from further imaging studies with DE-CMR if initial TTE were negative.

Proper management of patients using doxorubicin: Request for a transthoracic echocardiogram prior to initiating therapy.

383 Background: Certain antineoplastic agents exhibit specific organ toxicity, such as anthracyclines which main adverse effect is cardiotoxicity. Guidelines recommend cardiac assessment prior to initiating treatment. The initial transthoracic echocardiogram (TTE), performed up to 30 days before the first dose, is essential for recognizing the clinical status of the patient and planning the treatment. Consequently, we assessed compliance with the TTE request and implemented interventions to enhance patient safety. Methods: This project aims to achieve continuous improvement through the PDSA tool. We identified low adherence to the TTE request before initiating doxorubicin by retrospectively analyzing medical records from August 2021 to July 2022. We then evaluated the effectiveness of interventions implemented from August 2022 in the Oncology and Hematology units of a large institution in Brazil, which includes private facilities and public partnerships. Results: Between August 2021 and July 2022, a total of 306 patients initiated treatment with Doxorubicin. Among them, 149 (49%) were inadequately managed without undergoing a TTE within 30 days before starting therapy. Of these, 44 (43%) were from the private site, while 105 (51%) were from the public site. The main reasons for this non-compliance were the lack of standardized protocols and knowledge among members of the care team, as well as the patients' lack of understanding and recognition regarding the importance of the test. To address these issues, initial actions were prioritized based on their impact on patient safety. Educational strategies were implemented, including meetings and the creation of alerts with decision support in electronic medical records, from August to November 2022. During this period, 166 medical records were analyzed, revealing 63 cases (38%) of non-conformities. Among these, 16 patients were from the private site, and 47 patients were from the public site. The initial analysis, guided by the implemented actions, indicated a potential shift in the process, highlighting the need for continuous efforts and ongoing effectiveness assessment. Subsequently, between December 2022 and May 2023, an additional 178 medical records were evaluated. This assessment identified 68 cases (38%) of non-compliance, with 16 patients (25%) from the private site and 52 patients (46%) from the public site. Conclusions: Based on the presented results, there is an improvement in adherence to conducting the TTE among patients treated at the private site, while the indicator shows a smaller change in the population treated at the public site. This difference underscores the necessity for a deeper understanding of the challenges and the implementation of tailored actions to address them. Cardiotoxicity is the main anthracycline adverse effect, so interventions must prioritize safe, effective, equitable treatment.

P458 AN UNUSUAL REINDEER–IS LEFT VENTRICULAR MASS

Abstract A 90–year–old woman is brought to the closest emergency room after being found in a confusional state of mind, with lateral–sided sight deviation with normal cardiovascular findings. Her past medical history is characterized by the presence of systemic hypertension, moderate–to–severe chronic disease. The 12–lead electrocardiogram showed sinus rhythm and aspecific anomalies of the left ventricular repolarization. Lab tests showed normal white blood cells count with increased creatinine levels and quite normal flogosis indices. An initial transthoracic echocardiogram (TTE) showed mild left ventricular concentric hypertrophy with preserved systolic function, but also revealed the presence of a moving posterior mitral leaflet mass, determining mild mitral regurgitation. A head CT scan was performed, showing a right temporo–insular ischemic ipodensity. Considering the echocardiographic and neuronal findings, a transesophageal echocardiogram (TEE) was indicated to look for and better describe the suspicious mass, after beginning an antibiotic therapy in an empiric regimen. TEE revelead a multi–lobular mass characterized by inhomogeneous echogenicity, leaning on the annulus and the atrial side of the posterior mitral leaflet that was fissurated, leading to mild mitral regurgitation. The left appendage showed normal emptying velocity and absence of thrombi. It was not easy to describe this mass morphology and dimensions, but in some projections, it reminded us of a reindeer with various antlers. This case could resemble a classic mitral valve endocarditis, evolved into valve fissuration and arterial embolization leading to ischemic stroke, but the unusual fact is that the laboratory tests showed no white blood cells alteration during the whole hospitalization, with a really minimal CRP change and always negative procalcitonin. That is why we came into the idea that such a mass could also not represent a classical endocarditis. Considering that the echocardiographic characteristics of a thrombus were not encountered, the mass may be a tumor. The most frequent tumors involving the heart valves are papillary fibroelastomas. Considering the absence of clinic endocarditis, some hints led to consider this differential diagnosis: fibroelastomas mostly occur during older ages, they frequently have a mitral or aortic location and they can embolize, differently from vegetations, they are located mostly on the annulus and the basal posterior mitral leaflet.

126: A CASE REPORT OF ELECTRICAL STORM POST-COVID-19 VACCINATION

Introduction: Post-vaccination arrhythmia is reported as a possible cardiovascular side effect of COVID-19 vaccination. We present a case of ventricular tachycardia (VT) storm in a young healthy man following the 2nd dose of COVID-19 vaccination in the absence of underlying structural heart disease, myocarditis or arrhythmic syndromes. Description: A 38-year-old male with no medical history was admitted after an out-of-hospital cardiac arrest and found to be in VT storm within 24 hours of receiving his 2nd dose of COVID-19 vaccination. He received 4 shocks en route and had another episode of pulseless VT on arrival where Amiodarone was initiated. Laboratory values showed elevated inflammatory markers, and COVID tests were negative. Troponin peaked at 1.5 ng/ml. Initial transthoracic echocardiogram (TTE) revealed normal left ventricular ejection fraction (LVEF) without regional wall motion abnormality. On Day 2, he developed VT storm and was given magnesium sulfate, lidocaine and an additional bolus of amiodarone. Repeat TTE revealed a significant decrease in EF. He became hypotensive requiring inotropes and was emergently taken to the cath lab where intra-aortic balloon pump (IABP) and temporary transvenous pacing (TVP) were placed. Cardiac catheterization revealed normal coronary arteries, elevated left ventricular end diastolic pressure and mildly dilated LV with global hypokinesis and EF of 30%. His condition slowly improved without further occurrences of VT storm. Follow up TTE revealed normal LVEF, IABP and TVP were removed, and he was extubated. Cardiovascular magnetic resonance imaging showed no evidence of myocarditis with normal LV size. An automatic implantable cardioverter-defibrillator was placed. Genetic testing for Brugada syndrome was negative. Discussion: VT storm typically occurs with underlying structural heart disease, inherited arrhythmic syndromes or myocarditis, and is often difficult to identify a specific trigger. Although this is the first case report of VT storm occurring after the COVID-19 vaccine, it is important to note that the lack of a definitive test to diagnose myocarditis such as biopsy is a major limiting factor. This case report also supports the need for structured studies regarding a possible relationship between VT storm and COVID-19 vaccination.

Impact of COVID-19 pandemic healthcare restrictions on utilisation and diagnostic yield of outpatient transthoracic echocardiograms.

During the COVID-19 pandemic, Kentucky prohibited elective medical procedures from 3/18/2020-4/27/2020. We sought to determine if cessation of elective procedures in Kentucky during the COVID-19 pandemic resulted in a decrease in the proportion of rarely appropriate outpatient transthoracic echocardiograms interpreted at the open echocardiography lab at Norton Children's Hospital. A retrospective chart review was conducted comparing proportions of rarely appropriate outpatient paediatric transthoracic echocardiograms performed pre-COVID (3/21/2019-4/28/2019) and during COVID (3/19/2020-4/27/2020). Transthoracic echocardiogram indication was determined by chart review and echocardiogram reports. Indication appropriateness was evaluated using paediatric appropriate use criteria for initial outpatient transthoracic echocardiogram or CHD follow-up as applicable. Of transthoracic echocardiograms pre-COVID, 100 (37.7%) were rarely appropriate versus 18 (20.2%) during COVID. Pre-COVID, paediatric cardiologists tended to order fewer rarely appropriate transthoracic echocardiograms than paediatricians (35.9% versus 46.4%), although this difference was not statistically significant. Cardiologists ordered the majority of outpatient transthoracic echocardiograms during COVID (77/89, 86.5%), limiting the ability to compare transthoracic echocardiogram indications by provider type. There was no significant difference in diagnostic yield of initial outpatient transthoracic echocardiograms with (13.0%) abnormal studies pre-COVID versus 7 (15.5%) during COVID. While elective procedures were prohibited in Kentucky during the COVID-19 pandemic, a decrease in the proportion of rarely appropriate outpatient paediatric transthoracic echocardiograms was observed. There was no significant difference in diagnostic yield of initial outpatient transthoracic echocardiograms between time periods, suggesting that clinically significant echocardiogram findings were still detected despite more prudent utilisation of echocardiography during this time.

Surgical treatment of papillary fibroelastoma of the pulmonary valve: a case report

BackgroundCardiac papillary fibroelastoma (PFE) is a rare tumor, and especially rare when found on the pulmonary valve.Case presentationWe report the case of a 70-year-old woman patient with a pulmonary valve PFE diagnosed incidentally during a follow-up of aortic regurgitation. Computed tomography and magnetic resonance imaging showed no suggestive signs of malignant tumors, and thrombus or myxoma was initially suspected. However, an initial transthoracic and transesophageal echocardiogram did not exclude the possibility of a malignant tumor attached to the wall of the pulmonary artery. Considering the embolization risk, we opted to perform tumorectomy, in which additional surgical procedures could then be conducted if intraoperative diagnosis showed a malignant tumor. Indeed, intraoperative findings showed the tumoral mass attached on the left semilunar cusp of the pulmonary valve, and intraoperative diagnosis of the tumor showed no malignancy. Planned tumorectomy was performed concomitantly with AVR. The pathologic examination of the removed tumor confirmed the diagnosis of PFE. Her postoperative course was uneventful without any sign of recurrence.ConclusionThis case highlights the difficulty of accurate diagnostic imaging and provides valuable insight into a successful surgical treatment of pulmonary valve PFE without any complications.

A Case of Isolated Pulmonary Valve Endocarditis: The Importance of Repeat Echography and Microbiology in Diagnosis

A 64-year-old man presented to our centre with a one month history of fatigue, exertional dyspnoea, and worsening lower limb oedema on a background of known HFrEF. Following successful diuresis persistently raised inflammatory markers and intermittent fevers prompted investigation for infective endocarditis (IE). Serial blood cultures grew staphylococcus epidermis which were all, unusually, CO2 dependant and likely from a common source. An initial transthoracic echocardiogram (TTE) showed no evidence of endocarditis and normal Tricuspid (TV) and Pulmonary valves (PV). A subsequent transoesophageal echocardiogram (TOE) showed no significant new valvular abnormality.

54-Year-Old Man With Acute Dyspnea on Exertion

54-Year-Old Man With Acute Dyspnea on Exertion

Incidence, Predictors, and Reversibility of Left Ventricular Dysfunction After Brain Death: The Donor Heart Study

<h3>Purpose</h3> Left ventricular (LV) dysfunction after brain death often prompts non-use of potential donor hearts for transplant, but little is known regarding its incidence, reversibility, and impact on outcomes. Shedding light on these unknowns was a primary aim of the Donor Heart Study -a first-of-its-kind, multisite, prospective study of potential heart donors. <h3>Methods</h3> We enrolled potential donors (n = 4333) at 8 organ procurement organizations across the United States from February 2015-May 2020. Data were collected on donor management, serial labs, and diagnostic tests. These included a transthoracic echocardiogram (TTE) performed within 48 hours after brain death and, if LV dysfunction was present, a repeat TTE 24 ± 6 hours later. LV dysfunction was defined as an ejection fraction (LVEF)<50%, as ascertained by a single expert reviewer, and was considered reversible if LVEF was >50% on the second TTE. LASSO models identified predictors of initial LV dysfunction and its reversibility. A conditional inference ("decision") tree was fit to identify threshold values that predict reversibility. <h3>Results</h3> An initial TTE was performed and interpretable for 3794 donors, and 493 (13%) had LV dysfunction. Significant predictors of LV dysfunction included: higher levels of troponin, nt-pro B-type natriuretic peptide (nt-proBNP), and lactate; higher mean arterial pressure, body temperature, use of vasopressors, and thyroid hormone; younger age; low body mass index (BMI≤ 20 kg/m2); and elevated blood urea nitrogen:creatinine ratio. A second TTE was performed for 224 donors with LV dysfunction and 130 (58%) of these demonstrated reversibility. Donors with baseline nt-proBNP levels >11,137 pg/ml were less likely to have LVEF improvement (30% vs 62%, p=0.008). Low BMI and reductions in serial nt-proBNP and lactate levels were the strongest predictors of reversibility. 59% of donor hearts with normal LV function were accepted for transplant, compared to 47% with reversible dysfunction and 29% with persistently low LVEF. <h3>Conclusion</h3> LV dysfunction after brain death is common among potential heart donors, but is reversible in the majority of cases. Commonly measured clinical variables are predictive of LV dysfunction and its subsequent improvement. Our results can better inform decisions made during donor management and evaluation, and can help guide donor heart acceptance.

Clinical applicability of echocardiographic strict negative criteria for suspected infective endocarditis

Abstract Introduction Infective endocarditis (IE) is an uncommon but potentially lethal disease that requires a timely diagnosis. Echocardiography has a pivotal role in EI diagnosis, but this may lead to an overuse of this technology in clinical daily practice, and it is unclear which patients can benefit from a follow-up study if the initial transthoracic echocardiogram (TTE) shows no signs of IE. The strict negative criteria (good ultrasound quality and no high-risk features such as significant valvular regurgitations or stenosis, pericardial effusion or intracardiac devices) have been recently proposed to avoid unnecessary follow-up echocardiograms. Purpose The objective of this study is to review the contemporary, real-world use of echocardiography in patients with suspected IE and analyze the potential applicability of the strict negative criteria. Methods We retrieved all the echocardiograms that were performed in our center for suspected or confirmed IE between January 2014 and December 2018. We defined different groups according to the strict negative criteria and reviewed the electronic clinical history to check if a definitive diagnosis of IE was established or not. Results We included a total of 905 TTEs. 451 (49.8%) of them fulfilled the strict negativity criteria (Group 1). In this group, IE was seldom diagnosed (n=4, 0.9%). In 338 (37.4%) patients no signs of IE were evident but they didn't fulfill the strict negative criteria (Group 2). A follow-up echocardiogram and definitive diagnosis of IE were more frequent (n=48, 14.2% and n=20, 5.9%). Finally, in 116 (12.8%) patients the initial TEE showed typical or suggestive signs of IE, in whom the diagnosis was confirmed in 48 (41.4%). The independent predictors of follow-up echocardiography were the previous history of valvular heart disease (HR 2.38 [1.39–3.89], p=0.001) or cancer (HR 0.47 [0.27–0.84], p=0.01), positive blood cultures for Enterococcus (HR 5.01 [2.34–10.73], p&amp;lt;0.001), methicillin-sensitive Staphylococcus aureus (HR 2.8 [1.27–6.17], p=0.011) or Streptococcus (HR 2.36 [1.12–5], p=0.024), and the presence of typical or suggestive signs of infective endocarditis on initial TTE (HR 13.77 [8.6–22.05], p&amp;lt;0.001). A definitive diagnosis of IE was confirmed in a minority of the study population (n=72, 8%). Only one readmission for underdiagnosis of IE during index hospitalization was noted on Group 2. Conclusions In a real-life, observational setting only a minority of patients in whom IE was suspected had a definite diagnosis. An initial TTE for suspected IE fulfilling the strict negative criteria predicts both a low probability of requesting a follow-up study and of a definitive diagnosis of IE. Further research should be performed to rationalize echocardiogram requests for suspected IE. Funding Acknowledgement Type of funding sources: None.

Infective endocarditis after transcatheter aortic valve implantation

Abstract Introduction Infective endocarditis (IE) is a potentially serious complication in patients with prosthetic heart valves. The objective of this study is to analyze and describe the incidence, baseline characteristics, risks factors and in-hospital evolution in IE after Transcatheter Aortic Valve Implantation (IE-TAVI). Methods All the TAVI implanted in our center since the beginning of the program have been included consecutively. Patients with a confirmed diagnosis of IE according to the “ESC Guidelines for the management of infective endocarditis” are identified and analyzed. Results 331 TAVI have been implanted in our center from June 2009 to February 2021. IE-TAVI incidence in our series is 2.7% (n=9 cases). In baseline analysis, we observed that insulin dependent diabetes mellitus, Barthel Score and Pulmonary systolic pressure &amp;gt;50mmHg are significantly associated with the appearance of IE-TAVI (TABLE 1). The most frequently microorganism is Enterococcus faecalis (44.4%; n=4) followed by Staphylococcus aureus (22.2%; n=2), Coagulase-negative staphylococci (22.2%; n=2) and Streptococcus viridans (11.1%; n=1). 77.8% of IE-TAVI (n=7) are Nosocomial IE or non-nosocomial healthcare-associated IE. 2 of them have been related to implantation (1 Enterococcus faecalis and 1 Coagulase-negative staphylococci) and 5 have been related to other interventions (2 after gastroscopy, 1 after percutaneous vascular intervention, 1 hemodialysis catheter infection and 2 unknown focus). 44.4% of IE-TAVI (n=4) were confirmed after performing Positron Emission Tomography (PET) scan. 3 cases (33.3%) were diagnosed with the initial Transthoracic Echocardiogram (TTE) and 2 cases (22.2%) were diagnosed after performing a Transesophageal Echocardiogram (TEE) (TABLE 2) 4 patients had an indication for surgery according to the ESC Guidelines (3 for persistent bacteremia and 1 for severe aortic regurgitation), but all were ruled out due to high surgical risk. Hospital mortality was 44.4% (n=4). The main predictor of hospital mortality was having an indication for surgery (p=0.028), which was present in 3 of the 4 deaths. The other death was due to digestive bleeding during hospitalization. Conclusions IE-TAVI is a serious disease with high in-hospital mortality. Insulin dependent diabetes mellitus, Barthel Score and Pulmonary systolic pressure &amp;gt;50mmHg are risk factors for IE-TAVI. PET-scan is the imaging test of choice when there were no echocardiographic findings. The main predictor of mortality is having an indication for surgery according to the ESC Guidelines. Funding Acknowledgement Type of funding sources: None.

Impact of Contrast Echocardiography on Outcomes in Critically Ill Patients

Limited data suggests ultrasound enhancing agent (UEA) use is associated with changes in clinical management and lower mortality in intensive care unit (ICU) patients. We conducted a retrospective observational study to determine if contrast echocardiography (vs non-contrast echocardiography) is associated with differences in length of stay (LOS) and subsequent resource utilization in the ICU setting. The Premier Healthcare Database (Charlotte, NC) was analyzed to identify patients receiving Definity vs. no use of contrast during the initial rest transthoracic echocardiogram (TTE) in an ICU setting. The primary outcomes of interest were subsequent TTE and transesophageal echocardiography (TEE) during the index hospitalization, and ICU LOS. Propensity scoring was used to statistically model treatment selection to minimize selection bias. A total of 1,538,864 patients from 773 hospitals were identified as undergoing resting TTE in the ICU with use of DEFINITY in 51,141 (3.3%) patients and no contrast agent use in 1,487,723 (96.7%) patients. After adjusting for patient, clinical, and hospital characteristics, patients in the Definity cohort were less likely to undergo a subsequent TTE or TEE as compared to those in the no contrast cohort (odds ratio = 0.704 for TTE, odds ratio = 0.841 for TEE; p < 0.0001 for both). Adjusted mean ICU LOS for the Definity cohort was shorter than that of the no contrast cohort (4.59 vs 4.15 days, p < 0.0001). In conclusion, Definity-enhanced echocardiography in the ICU setting (in comparison with non-contrast TTE) is associated with lower rates of subsequent TTE and TEE during the index hospitalization, and shorter ICU LOS.

Abstract 16996: Relationship of Paravalvular Leak and Mean Platelet Volume With Stroke Risk Following Transcatheter Aortic Valve Replacement

Introduction: Stroke remains a major complication patients may face following Transcatheter Aortic Valve Replacement (TAVR). It has been hypothesized that turbulent flow across persistent paravalvular leak (PVL) may lead to low level hemolysis, a state known to heighten serum thrombotic potential and increase stroke risk. We hypothesized that the presence of paravalvular leak would lead to elevations in serum mean platelet volume (MPV), a marker of platelet activation and aggregation, and thus would heighten stroke risk after TAVR. Methods/Results: We retrospectively reviewed the charts of 322 patients who underwent TAVR at Montefiore Medical Center from January 2015 to January 2019. Stroke was seen in 24 patients (7%) following TAVR and was associated with higher overall mortality (p=&lt;0.001). PVL was recorded in scaling severity of “none”, “trace”, “mild”, “moderate”, and “severe”. “Significant PVL”, defined as the presence of “mild” or greater PVL on initial post-op transthoracic echocardiogram, was found in 72 patients (22.4%). No associations were seen between the presence of significant PVL and stroke after TAVR. Serum MPV values after TAVR were not associated with the presence of significant PVL, nor with an increase in the observed rate of stroke or death on follow-up. Conclusions: Stroke after TAVR is significantly associated with increased mortality. In our dataset, the presence of significant PVL was not associated with increased rate of stroke or elevated serum MPV levels post-TAVR. Moderate and severe PVL are known to generate the greatest amount of hemolysis and were rare in our dataset (combined 1.5%), likely contributing to the lack of significant findings.

A Quality Initiative to Improve Appropriate Use of Initial Outpatient Echocardiography Among Pediatric Cardiologists.

Introduction:Appropriate use criteria (AUC) guide initial transthoracic echocardiogram (TTE) use in outpatient pediatrics. We sought to improve pediatric cardiologist TTE ordering appropriateness (mean AUC score) with a quality improvement initiative.Methods:The outcome of interest was the prospective AUC score for all initial outpatient TTEs ordered between November 2016 and August 2017, categorized per the AUC: “appropriate” (score 7–9), “may be appropriate” (4–6), “rarely appropriate” (1–3). Interventions included a didactic review of 2014 AUC and participant documentation of AUC criteria for each TTE. Participants met quarterly to evaluate outcome, process, and balancing measures, intervention effectiveness, and to identify and mitigate barriers.Results:Twenty-two pediatric cardiologists participated. TTE appropriateness level before (n = 216) and after (n = 557) intervention was high. There was no significant difference in mean baseline and post-intervention AUC score (7.42 ± 1.87 versus 7.16 ± 2.87, P = 0.1), nor in TTE sensitivity (27% versus 25%, P > 0.1) as a balancing measure. Among baseline studies, 81% were “appropriate,” and 6% “rarely appropriate.” Among post-intervention studies, 76% were “appropriate,” and 11% “rarely appropriate.” Barriers identified to implementing AUC include TTE indications not specified by current AUC, expectations of referring provider or parent to perform TTE, consistent provider application of AUC, and ability of AUC to capture comprehensive clinical judgment.Conclusions:Although the mean AUC appropriateness level was high, we were able to identify significant barriers to the implementation of AUC. Future efforts should focus on the reduction of “rarely appropriate” TTE ordering.

A rare case of pulmonary valve infective endocarditis in a patient with ventricular septal defect

Right-sided infective endocarditis (IE) is rare and often affects the tricuspid valve. We report a unique case of pulmonary valve IE in a patient with a predisposing congenital heart defect – a ventricular septal defect (VSD). A 23-year old man with a VSD was admitted following 3 months’ history of fever and malaise. An initial transthoracic echocardiogram (TTE) failed to reveal any visible vegetations or mass. However, blood cultures revealed persistent methicillin-sensitive S taphylococcus aureus (MSSA). A transoesophageal echocardiogram (TOE) showed multiple hyperechoic structures in the entirety of the anterior cusp of the pulmonary valve, suggestive of vegetations. In view of his young age and subacute presentation, a trial of prolonged antibiotics was opted for. The patient was commenced on intravenous cloxacillin for 6 weeks, which was successful. Common risk factors for right-sided IE include intravenous drug abuse, central venous catheterization and alcoholism. Less common risk factors include left-to-right shunts, including VSD. Proposed mechanisms include turbulent jet flow causing damage to the valve and vegetation formation. Although response to antibiotics and prognosis in right-sided IE tend to be better than in left-sided IE, surgical intervention may still be indicated, and unfortunately, evidence remains scarce on the appropriate patient selection for surgical intervention. Isolated pulmonary valve IE due to predisposing VSD remains a rare entity. It is important to consider this diagnosis in prolonged pyrexia of unknown origin in individuals with known congenital heart defects.

Interventricular septal hematoma complicating placement of a ventricular assist device in an infant and support with bi-atrial cannulation.

Interventricular septal hematoma complicating placement of a ventricular assist device in an infant and support with bi-atrial cannulation.

431 Very Long Term Follow-Up (>3000 Days) of Aortopathy Patients - Surgical Intervention/Dissection is Predicted by Accelerated Annualised Aortic Growth Rate

Very long term follow-up data and rates of progressive aortic dilatation for patients with aortopathy with prediction of events is lacking in the literature. We performed analysis of aortic growth rates in a cohort of patients with known or suspected aortopathy followed for 4-15 years. Patients referred to our aortopathy clinic with a minimum follow-up period of 1460 days from initial digital transthoracic echocardiogram (TTE) were included for analysis. Aortic dilatation was defined as any measurement >36mm and/or >20mm/m2. Sequential measurements were compared between patients with surgery/dissection (n=18) and those with no events (n=80). The average follow-up was 8±3.1 yrs. Mean age was 53.5±19.8 yrs (71% male). The 18 surgery/dissection patients (43±15 yrs), 16 had aortic surgery, 1 Type B dissection, and 1 death from Type A dissection, with an annual rate of growth of sinotubular junction (STJ 0.7mm±1.0mm/yr) and ascending aorta (AscAo 0.7±1.2mm/yr). Patients with no surgery/dissection were significantly older (55±20yrs, p=0.01), with significantly slower rates of progression (STJ 0.3mm±0.4mm/yr, p=0.006; AscAo 0.3±0.3mm/yr, p=0.004). The annual growth of the trans-sinus dimension was not statistically significant, however, in the surgical group the dimension at initial TTE was significantly greater (45±4mm vs 39±4mm, p<0.001). In very long term follow-up most patients with aortopathy demonstrate extremely slow rates of expansion. Elective surgery and dissection are manifest in patients with significantly more rapid rates of progression. These data may allow customisation of surveillance protocols in individual patients in the future.

P875 A suspected case of extra-pulmonary tuberculosis presenting as effusive-constrictive pericarditis

Abstract Case presentation A 33 year-old black female, born in Angola, staying in Portugal 1 week before admission presented to the emergency department of our hospital with a history of worsening but recurring pleuritic chest accompanied by dyspnea, fatigue, peripheral oedema and sweating in the past 4 years. Initial workup in Angola and more recently in Namibia was unrevealing. The patient had taken 3 months of antituberculous agents and a systemic corticosteroid and was medicated with furosemide and spironolactone. Since then the symptoms persisted and multiple admissions for decompensated heart failure followed. At presentation median blood pressure was 60mmHg, heart rate 90 beats per minute, temperature 37,6ºC. Auscultation had signs of pulmonary congestion and muffled heart sounds, the neck veins were distended. An electrocardiogram showed sinus rhythm and low-voltage complexes in limb and precordial leads. Initial transthoracic echocardiogram revealed a thickened pericardium with circunferencial effusion and marked respiratory variation (&amp;gt;25%) of the mitral and tricuspid inflow doppler velocities. Pericardiocentesis was performed with improved dyspnea and blood pressure after drainage of 650 mL of serohematic fluid. Echocardiographic follow-up showed a mild circunferencial pericardial effusion and extensive areas of thickened crypted pericardium with fibrin strands containing heterogeneous fluid (figure 1). There were signs of constriction. A cardiac CT revealed no calcium deposition. Fluid cytology was predominant for lymphocytes and biochemistry, cultures, polymerase chain reaction and immunochemistry were inconclusive and no pathologic agent was isolated. The image findings in the transthoracic echocardiogram coupled with the demographics and past clinical history of the patient prompt the initiation of antituberculous therapy in association with systemic corticosteroids in an attempt to ameliorate the pericardial constriction. Despite initial therapeutic response, constriction was deemed irreversible and pericardiectomy was performed. The workup for definitive diagnosis is still undergoing. Discussion Effusive-constrictive pericarditis is defined by a pericardial effusion with signs of concurrent pericardial constriction. In these cases the scarred pericardium not only constricts cardiac volume but can also accommodate pericardial fluid under increased pressure leading to signs of cardiac tamponade. The initial approach should be the treatment of the underlying condition but if such remains ineffective, pericardiectomy is the remaining option and is reserved for patients in which constriction becomes severe and/or persistent. This condition is more prevalent with tuberculous pericarditis and when suspected presumptive treatment should be initiated in immunocompetent patients from endemic regions. Antituberculous treatment regimens in conjunction with systemic corticosteroids have shown to prevent complications from pericardial constriction. Abstract P875 Figure.

422 Transoesophageal Echocardiography in Diagnosing Acute Aortic Dissection not Evident on CT Aortogram

CT aortogram is considered the gold-standard for diagnosing acute aortic dissection, but false-negative studies can occur. A 43-year-old male presented with sharp central chest pain radiating to his neck with associated dyspnoea, a viral prodrome and low-grade temperature (37.4°C). There was no documented blood pressure differential or audible murmur, ECG was unremarkable, and troponin-T was mildly elevated (22ng/L). CT pulmonary angiogram showed no pulmonary embolism, and a transthoracic echocardiogram (TTE) with suboptimal image quality indicated normal left ventricular (LV) size and systolic function, normal aorta size, mild aortic regurgitation (AR) and a small pericardial effusion. He was treated for suspected pericarditis, however developed acute kidney injury and acute pulmonary oedema requiring admission for ten days. He re-presented three days later with worsening dyspnoea, and a repeat transthoracic echocardiogram showed severe LV dilatation, dilated aortic root (45mm) and severe AR. An ECG-gated CT aortogram showed no evidence of aortic dissection. A transoesophageal echocardiogram (TOE) was performed to exclude endocarditis, and showed a Type A aortic dissection, dilated ascending aorta (48mm) and severe AR. He urgently underwent successful mechanical Bentall’s repair. This is an atypical presentation of acute aortic dissection diagnosed two weeks after initial presentation, with the dissection flap clearly visualised on TOE but not evident on CT aortogram. In retrospect, M-mode on the initial TTE identified fluttering of the anterior mitral valve leaflet consistent with an Austin-Flint murmur, and pulsed-wave Doppler indicated elevated stroke volume consistent with acute severe AR which was underappreciated on colour-flow Doppler.