Presence Of Pericardial Effusion Research Articles

Pericarditis in systemic lupus eythematosis

Pericarditis is a common cardiac manifestation in Systemic Lupus Erythematosus (SLE). However, little is known about clinical or immunological associations of pericarditis. The aim of this study is to analyze predictors’ factors of lupus pericarditis as well as the treatment response and long-term outcomes. We retrospectively reviewed the records of 238 patients with SLE, as defined by the ACR who were admitted in Fattouma Bourguiba University Hospital between 2010 and 2020. The diagnosis of pericarditis was defined as the presence of pericardial effusion by echocardiography. Forty-tow patients (17.6%, 7 men and 35 women) had pericerditis. Median age was 37 years (range 13–64). pericarditis was the first sign of SLE in 11/42 cases (26,1%). The mean duration of SLE at the time of pericarditis was 17 months. typical sharp precordial pain and dyspnea occurred in 10/42 (23.8%) cases. in patients with lupus pericarditis 50% had pleuritis. Clinical factors significantly associated with pericarditis were lupus nephritis ( P = 0.000), pulmonary hypertension ( P = 0.041), fever (0.026) and haemolytic anemia (0.046). Serological profile in patients with lupus pericarditis included; 92.7% AAN, 69% anti-DNA 69% antibodies, 29.3% anti SM antibodies, 36,6% anti SSA antibodies and 22% anti RNP antibodies. It was highly associated with antiphospholipide antibodies ( P = 0.029). Fifteen patients were treated with at least 0.5 mg/kg/day of prednisone. In tow patients with tomponad, a higher dose of corticosteroid was necessary. Pericarditis is one of the most characteristic disease manifestations. It may remain clinically silent and evidence of previous pericardial disease is often observed on echocardiography. Cardiac tamponade is a critical diagnosis to consider, though is an uncommon presentation in SLE.

Abstract 15892: Reliability of Focused Cardiac Ultrasound in the Post-Operative Assessment of Patients With Congenital Heart Disease: A Single Center Experience

Introduction: Early detection of postoperative complications in children with congenital heart disease (CHD) is crucial. The utility of focused cardiac ultrasound (FoCUS) in the assessment of post-operative congenital cardiac surgical patients is not known. Objective: To evaluate the reliability of FoCUS in the assessment of children with CHD in the early post-operative period. Methods: A prospective observational cross-sectional study was performed in a single pediatric center. All FoCUS studies were performed by one imager within two hours of the paired echocardiographic (ECHO) study performed by a different imager. FoCUS studies were obtained using Philips Lumify R and ECHO studies utilized a high-end ultrasound machine (Philips Affiniti R ). Qualitative ventricular (right and left) function, pericardial effusion, pleural effusion, and degree of mitral regurgitation (MR) and tricuspid regurgitation (TR) were compared. All FoCUS and ECHO studies were sent for review in a random and blinded fashion to two independent noninvasive imaging cardiologists. Weighted k statistics were used to determine the level of agreement between FoCUS and ECHO, and between observers. Results: Twenty-three FoCUS studies were performed in 12 patients with a mean age of 16.6 months (range 0-96 months) within two weeks postoperatively. There was inter-observer agreement for ECHO on all parameters and inter-observer agreement for FoCUS on all parameters except for TR. The intra-observer agreement between FoCUS and ECHO for the two cardiologists was fair to moderate for ventricular function (k= 0.470, p< 0.05 and 0.340, p < 0.05), substantial for pericardial effusion (k = 0.617, p< 0.05 and 0.777, p< 0.05), and fair for MR (0.400, p< 0.05). There was no statistically significant agreement for TR and pleural effusion for both observers and MR for one observer. Conclusions: FoCUS demonstrated acceptable reliability in the assessment of ventricular function and presence of pericardial effusions, with a limited value in the assessment of atrioventricular valve regurgitation. This tool is valuable in the early post-operative evaluation of pediatric patients with congenital heart disease in the cardiac intensive care unit.

Abstract 17256: Utility of Echocardiography in Acute and Recurrent Pericarditis

Background: Pericarditis usually presents with sharp chest pain, and other diagnostic features include pericardial rub, typical EKG changes (diffuse ST elevation and PR depression), and the presence of pericardial effusion (PEff). Echocardiography (ECHO) is the first-line imaging modality in pericarditis. It helps to identify PEff, constrictive physiology, and wall motion abnormalities. We sought to characterize ECHO features in a large cohort of patients with acute (AP) and recurrent pericarditis (RP). Methods: Data were collected retrospectively for patients with acute and recurrent pericarditis. Pericarditis was diagnosed based on the European Society of Cardiology pericardial disease guidelines. ECHOs were reviewed for relevant features and findings. Chi-square test statistics were used to compare AP and RP. Results: A total of 323 consecutive patients with RP (68%) and AP (32%) was identified from January 2015 to December 2018. The median age was 52 years 56% were female. Of the total patients, the most common finding on ECHO was PEff (42%). Of the patients having PEff, 65 (20%) had trivial, 42 (13%) small, 19 (6%) moderate, and 6 (2%) had large effusion. Other findings included constrictive physiology (20%), thickened pericardium (4%), and echo wall motion abnormality (3%). AP patients had higher number of PEff compared to RP (51% vs 38%; [X 2 =4.1, p=0.043]. Increased pericardial thickness was only found in patients with RP (6% in RP vs 0% in AP; [X 2 =6, p=0.014]. All the other findings were similar across RP and AP Conclusion: The most common echocardiographic finding in acute and recurrent pericarditis patients is pericardial effusion followed by constrictive physiology and thickened pericardium. Pericardial effusion appears to be more frequent in AP patients as compared to RP. These findings may be useful in the diagnostic workup of pericarditis.

The extent of pericardial involvement evaluated by cardiac MRI in patients with ST-Segment elevation myocardial infarction: predictors and outcomes

Abstract Background The clinical diagnosis of peri-myocardial infarction pericarditis declined dramatically in the era of primary PCI and novel antiplatelet agents. However, recent data documents the presence of pericardial effusion in substantial proportion of acute MI patients, while recent randomized trial showed that anti-inflammatory drugs seem to improve cardiovascular outcomes, although the mechanism of the benefit remains uncertain. Methods We prospectively evaluated 187 consecutive patients, without known prior coronary disease, who underwent primary PCI for STEMI. All patients underwent cardiac MRI (CMR) on day 5±1 post admission. CMR was performed using a 1.5 T (n=101) and 3 T (n=86) scanners. Delayed enhancement (DE) and microvascular obstruction (MVO) were quantified as % of the left ventricular mass (LV). The presence of DE and MVO was recorded according to the AHA segments model. DE was also qualitatively assessed for the degree of transmurality in each segment. CMR pericarditis was defined as evidence of pericardial enhancement on DE images. The presence of pericardial effusion was also documented. Pericarditis extent was expressed as the number of pericardial segments with increased DE. Major adverse cardiac events were defined as the composite of death, recurrent myocardial infarction, stroke, urgent revascularization and hospitalization due to either heart failure or bleeding during the first year following STEMI. Results Pericardial effusion was found in 94 patients (50%) and enhancement of the pericardium on DE images in 120 patients (65%). In contrary, a clinical diagnosis of peri-myocardial infarction pericarditis was documented and anti-inflammatory therapy was initiated only in three patients (1%). A significant positive correlation was demonstrated between pericardial involvement and either quantitative or qualitative assessment of DE (p<0.001, r=0.34) and MVO (p<0.001, r=0.282). DE transmurality (per segment) was associated with both location of pericardial involvement and its extent (p<0.001). A multivariate logistic regression analysis revealed that DE extent and MVO were independent predictors of pericardial involvement (OR 1.07; CI 95% 1.06–1.13, p=0.02 and OR 1.29; CI 95% 1.01–1.64, p=0.04 for DE and MVO respectively). Additional parameters that were associated with CMR diagnosis of pericarditis included higher maximal CRP levels and proximal coronary lesions. The 1-year incidence of major adverse events was similar in patients with or without CMR-defined pericarditis. Conclusions In contrast to the low rate of clinically diagnosed pericarditis, CMR documented pericardial involvement in more than 65% of STEMI patients. This finding is independently associated with the extent and degree and location of myocardial damage. Funding Acknowledgement Type of funding source: None

Additional role of echocardiogram in pulmonary arterial hypertension risk stratification according to current ESC/ERS guidelines

Abstract Background Current pulmonary hypertension (PH) guidelines stratify the risk of patients with pulmonary arterial hypertension (PAH) using a multiparametric approach. A simplified risk table has been recently proposed and validated without including echocardiographic parameters. Purpose We evaluate the additional role of echocardiogram in PAH risk stratification using the recently proposed simplified risk table in patients with idiopathic/heritable (I/H) PAH and PAH associated with connective tissue disease (CTD) and congenital heart disease (CHD). Methods All patients with I/H-PAH, CTD-PAH and CHD-PAH referred to a single centre were included from 2003 to 2017. All patients were treated according to PH guidelines. The simplified risk assessment considered the following criteria: WHO functional class, 6-min walking distance, right atrial (RA) pressure or brain natriuretic peptide (BNP) plasma levels and cardiac index (CI) or mixed venous oxygen saturation (SvO2). For the last 2 criteria the worst parameter was chosen. Risk strata were defined as: Low risk= at least 3 low risk and no high-risk criteria; High risk= at least 2 high risk criteria including CI or SvO2; Intermediate risk= definitions of low or high risk not fulfilled. Then we performed a Cox analysis to evaluate the independent echocardiographic predictors of survival that were subsequently added to the simplified risk table to test their additional role in ameliorating risk stratification. Results 461 treatment-naïve patients were enrolled. Echocardiographic independent predictors of prognosis were the severity of tricuspid regurgitation [HR (95% CI) = 1.013 (1.006–1.021); p-value = 0.001], right atrial area [HR (95% CI) = 1.028 (1.012–1.045); p-value = 0.001] and the presence of pericardial effusion [HR (95% CI) = 1.533 (1.142–2.057); p-value= 0.004]. Only RA area significantly ameliorate the risk stratification power of the recently validated simplified PAH risk table (likelihood ratio chi2 increased from 63.8 to 68.1, likelihood ratio test = 0.039). Due to the significant correlation between RA area and both RA pressure (r=0.470; p<0.001) and BNP (r=0.372; p=0.004), we elaborate a second risk table in which RA area (utilizing the cut-offs proposed by the current PH guidelines) was considered together within the criteria including RA pressure and BNP (the worst parameter of the 3 was considered). Considering the second risk table including RA area the risk stratification power significantly improved (likelihood ratio chi2 increased from 63.8 to 72.7, AIC/BIC decreased from 1956/1964 to 1947/1955). Conclusions Echocardiographic RA area significantly improve the risk discrimination power of the recently proposed simplified risk table for patients with PAH. Funding Acknowledgement Type of funding source: None

PREVALENCE AND OUTCOMES OF INHALED, ORAL, AND PARENTERAL PROSTACYCLIN THERAPY IN PULMONARY HYPERTENSION CLINIC PATIENTS: A RETROSPECTIVE COHORT STUDY

SESSION TITLE: Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Prostacyclin therapy has become a standard of current management for patients with severe pulmonary arterial hypertension (PAH). CurrentlY therapy may be administered via inhaled, oral, and parenteral routes, however there use is often reserved for patients with severe disease. This study aimed to assess the prevalence and effect via hemodynamic evaluation and functional outcome measurements of inhaled, oral, and parenteral prostacyclin therapy among pulmonary hypertension clinic patients. METHODS: This was a retrospective cohort study of pulmonary hypertension (PH) clinic patients at Keck Medical Center. Patients were studied from time of initial clinic visit and most recent follow up. Data ranged from 2011 to 2020. Patient demographics, hemodynamics via right heart catheterization (RHC), transthoracic echocardiography findings (TTE), and functional capacity via six-minute walk testing (6MWT) were collected. Patients were then separated by presence of prostacyclin therapy and route of administration if present. RESULTS: Data was collected on 473 PH patients, 298 of which had complete therapy data and were included in the final analysis. WHO group 1 PAH patients comprised 72% (n = 214) of all patients. The composition of prostacyclin therapy was as follows 152 (51%) no prostacyclin therapy (NP), 29 (9.7%) inhaled prostacyclin therapy (IP), 25 (8.3%) oral prostacyclin therapy (OP), 85 (28.5%) parenteral prostacyclin therapy (PP), and 7 (2.3%) combination therapy. Percentage of patients in each group with PAH was as follows NP (58.6%), IP (75.9%), OP (80%), PP (90.6%), and combination (85.7%). RHC hemodynamics revealed a significant relationship between increasing pulmonary artery pressures and pulmonary vascular resistance (PVR) and therapy in order from NP to IP to OP to PP at initial and follow up visit. TTE findings showed a significant relationship between increasing right ventricular (RV) dilation, RV dysfunction, RVSP, presence of pericardial effusion, and prostacyclin therapy from NP to IP to OP to PP. 6MWT revealed the PP group had the furthest distance walked and had an increase between at follow up while the IP group had the shortest 6MWT distance and greatest reduction in average 6MWT distance at follow up. CONCLUSIONS: The cohort of patients between types of therapy differed significantly in baseline characteristics and outcomes on cardiopulmonary hemodynamics and functional status. The PP group compared to IP and OP were shown to have more severe pulmonary hypertension. Despite that, they had greater 6MWT distances and even improved values from initial to follow up testing. The increase in distance adds to the body of literature suggesting the benefit of parenteral prostacyclin long term in comparison to other modes of drug delivery. CLINICAL IMPLICATIONS: This study may contribute to identifying subsets of patients with pulmonary hypertension who would benefit from prostacyclin therapy. DISCLOSURES: No relevant relationships by Tiffany Chang, source=Web Response No relevant relationships by Lucas Cruz, source=Web Response No relevant relationships by Jared Geibig, source=Web Response No relevant relationships by Moses Koo, source=Web Response No relevant relationships by Ashil Panchal, source=Web Response Speaker/Speaker's Bureau relationship with Actelion, United therapeutic, and Bayer Please note: $20001 - $100000 Added 05/30/2020 by Bassam Yaghmour, source=Web Response, value=Honoraria

Treatment of right ventricular dysfunction and heart failure in pulmonary arterial hypertension.

Right heart dysfunction and failure is the principal determinant of adverse outcomes in patients with pulmonary arterial hypertension (PAH). In addition to right ventricular (RV) dysfunction, systemic congestion, increased afterload and impaired myocardial contractility play an important role in the pathophysiology of RV failure. The behavior of the RV in response to the hemodynamic overload is primarily modulated by the ventricular interaction and its coupling to the pulmonary circulation. The presentation can be acute with hemodynamic instability and shock or chronic producing symptoms of systemic venous congestion and low cardiac output. The prognostic factors associated with poor outcomes in hospitalized patients include systemic hypotension, hyponatremia, severe tricuspid insufficiency, inotropic support use and the presence of pericardial effusion. Effective therapeutic management strategies involve identification and effective treatment of the triggering factors, improving cardiopulmonary hemodynamics by optimization of volume to improve diastolic ventricular interactions, improving contractility by use of inotropes, and reducing afterload by use of drugs targeting pulmonary circulation. The medical therapies approved for PAH act primarily on the pulmonary vasculature with secondary effects on the right ventricle. Mechanical circulatory support as a bridge to transplantation has also gained traction in medically refractory cases. The current review was undertaken to summarize recent insights into the evaluation and treatment of RV dysfunction and failure attributable to PAH.

Point-of-Care Emergency Ultrasonography in Non-Traumatic Cardiac Arrest and Near-Arrest Emergency Patients; A Pilot Trial

Background: In this study, we evaluated the applicability and interpretation of point-of-care emergency ultrasound (POCEUS) performed by an emergency physician (EP) in non-traumatic adult cardiac arrest and near-arrest patients at presentation to the Emergency Department (ED). Methods: POCEUS was performed in 5 steps on 73 adults to assess; 1. Qualitative global cardiac function, cardiac chambers and presence of pericardial effusion; 2. Presence of pleural sliding, B-lines, A-lines or consolidation on anterior-superior; 3. Presence of an abdominal aorta aneurysm and pelvic free fluid; 4. Presence of pleural effusion, consolidation, free fluid on lateral-inferior; 5. Qualitative width and collapsibility of the inferior vena cava. A fulfilled checklist and real-time images of ultrasonography were sent by WhatsApp to the head of the study to generate the evidence and collect the data. The process of patient care, in-hospital diagnosis and survival were retrieved from digital hospital records. This prospective multicenter sample study was conducted from November 16, 2015, to January 5, 2016. Results: The most common findings of POCEUS were performed and interpreted to have a first prediction of patients’ acute clinic problem by EPs were compatible with global systolic dysfunction (n = 16, 22.9%), pulmonary edema (n = 17, 23.3%), pulmonary embolus (n = 6, 8.2%), distributive/hypovolemic shock (n = 12, 16.4%), cardiac tamponade or pericardial effusion (n = 5, 6.8%), and pneumonia (n = 31, 42.5%) at presentation. The kappa correlation coefficient value of the POCEUS at presentation versus the final, traditional clinical diagnosis of the admitted ward, was 0.773 (95% CI, 0.747–0.892; p = 0.064, McNemar). Conclusions: POCEUS performed by an EP at presentation had a good agreement between in qualitative prediction of the first differential diagnosis in life-threatened patients and the last diagnosis obtained during hospitalization. Furthermore, this study showed the requirement of evidence in comparison of measurements to the qualitative manner and new descriptive processes in POCEUS for unexplained situations and questions.

Primary cardiac hydatid cyst presenting with massive pericardial effusion: a case report

BackgroundCardiac hydatidosis is a rare manifestation of Echinococcus infection. It represents 0.5 to 2% of hydatic disease (Mustafa et al., Can J Cardiol 22:2, 2006). The most common localization is the myocardium of the left ventricle but can also touch the right ventricle, atrium, pericardium, interventricular septum, and pulmonary artery. Clinical presentation is varied ranging from clinical latency or minor symptoms to cardiogenic shock and sudden death. The present case describes a primary pericardial hydatid cyst, a very exceptional localization of cardiac hydatidosis, which can lead to a delayed diagnosis or to an erroneous treatment that can expose the life of the patient to complications and death if it is not considered. Diagnosis can be established by cardiac imaging and hydatid serology. Therapy management should combine both surgery and medical treatment by albendazole or mebendazole.Case presentationWe report a 70-year-old woman from Sale, who was admitted for dyspnea New York Heart Association (NYHA) class IV evolving in a febrile context with signs of right heart failure related to a rupture of a primary pericardial hydatid cyst with pre-tamponade. The diagnosis was confirmed by echocardiography, computed tomography scan (CT scan), and hydatic serology, and the patient was operated and put on albendazole for 3 months with favorable clinical course.ConclusionsThe aims of this article are to consider the diagnosis of cardiac hydatid cysts in the presence of pericardial effusion, especially if there is a prior history of hydatid disease, a contact with animals, or when it occurs in an endemic country, and to be able to make a differential diagnosis with cardiac imaging in order to avoid its complications and to guide the management.

Rate, Causes, and Predictors of 30-Day Readmission Following Hospitalization for Acute Pericarditis

BackgroundAcute pericarditis is a frequent cause of hospitalization in the United States. Although recurrence of this condition is common, few studies have investigated hospital readmissions in this patient population. MethodsWe queried the National Readmission Database for the years 2016 and 2017 to identify adult admissions for acute pericarditis, and analyzed the data for 30-day readmission. Using multivariate Cox regression analysis, we identified clinical characteristics that were independently predictive of hospital readmission within 30 days. ResultsA total of 21,335 patients (mean age 52.5 ± 0.2 years; 38.3% women) who were discharged following hospitalization for acute pericarditis were included. The rate of 30-day readmission was 12.9% (n = 2740). Increasing age (adjusted hazard ratio [HR] 1.05 per 5-year increase; 95% confidence interval [CI], 1.02-1.09; P < 0.001), female sex (adjusted HR 1.33; 95% CI, 1.18-1.49; P < 0.001), dialysis dependence (adjusted HR 1.70; 95% CI, 1.30-2.22; P < 0.001), chronic obstructive pulmonary disease (adjusted HR 1.27; 95% CI, 1.11–1.45; P < 0.001), and presence of pericardial effusion (adjusted HR 1.24; 95% CI, 1.04-1.49; P = 0.02) were independently associated with a higher risk of readmission. In-hospital mortality was significantly higher after readmission than for the index hospitalization (3.4% vs 1.0%, P < 0.001). ConclusionAfter hospitalization for acute pericarditis, readmission within 30 days is common and is associated with increased mortality. Identification of characteristics associated with a higher risk of readmission may lead to focused interventions to improve outcomes.

Clinical presentation, cardiovascular findings, etiology, and outcome of myocarditis in dogs: 64 cases with presumptive antemortem diagnosis (26 confirmed postmortem) and 137 cases with postmortem diagnosis only (2004–2017)

IntroductionThis study describes presentation, cardiovascular abnormalities, etiology, and outcome of canine myocarditis in geographic areas not endemic for Trypanosoma or Leishmania. AnimalsSixty-four (presumed antemortem diagnosis) and 137 (postmortem diagnosis only) client-owned dogs at two tertiary care facilities were included. Materials and methodsMedical records of dogs with clinical or histopathological diagnosis of myocarditis were reviewed retrospectively. ResultsCommon examination findings in dogs with a presumed antemortem diagnosis included fever (21%) and heart murmur (19%). Median cardiac troponin I was 12.2 ng/mL (range: 0.2–808.0 ng/mL), and troponin exceeded 1.0 ng/mL in 26 of 29 (90%) dogs. Ventricular ectopy was the most common arrhythmia (54%), whereas decreased left ventricular systolic function was the most common echocardiographic abnormality (56%). An infectious etiology was diagnosed in 35 of 64 (55%) dogs. Confirmed infectious etiologies included bacterial sepsis (n = 9) or extension of endocarditis (3), toxoplasmosis or neosporosis (3), parvovirus (2), and one case each of bartonellosis, trypanosomiasis, leptospirosis, and dirofilariasis. Median survival time was 4 days (range: 0–828 days) for all dogs vs. 82 days for dogs who survived at least 2 weeks after diagnosis. Presence of pericardial effusion or azotemia was a significant predictor of non-survival. The most common inflammatory infiltrate on histopathology was neutrophilic (47%), and 20 of 137 (14.5%) dogs had concurrent bacterial endocarditis on postmortem. ConclusionsBacterial infection was the most common confirmed etiology of myocarditis in this study. Prognosis for canine myocarditis is guarded and similar to that reported for infective endocarditis. Criteria for the antemortem diagnosis of canine myocarditis are suggested.

P122: The evaluation of various point of care ultrasound features in Stanford type A aortic dissections

Introduction: Type A aortic dissection(AD) is one of the most lethal diseases in medicine. Its mortality rate increases 1-2% per hour from the onset of symptoms to treatment. Timely diagnoses of ADs, therefore, are crucial to improve survival and decrease morbidity. There are various proposed clinical guidelines to help emergency physicians decide when a CTA is urgently needed with most widely quoted being the validated Aortic Dissection Detection Risk Score(ADD-RS) recommended by the American Heart Association. The addition of D-Dimer for further risk stratification has also been entertained. A recent article published in the American Journal of Emergency recommends using point of care ultrasound(POCUS) to expedite diagnosis. With the rising use of POCUS in the emergency department, it can be the missing link to timely AD diagnoses. This project aims to elucidate the prevalence of positive POCUS findings (pericardial effusion and dilated aortic root) in type A AD via a retrospective chart review. Methods: This study is a retrospective chart review of 200 patients with the diagnosis of AD treated at Southlake Regional Hospital. We included patients diagnosed with type A AD and excluded those diagnosed with type B AD. We collected data on their demographics, ADD-RS scores, investigation results, treatments, and clinical outcomes. The main focus of the chart review was on the presence of pericardial effusion or dilated aortic root on echocardiograms. Binomial statistical analysis was used to analyze the collected data. Results: We identified 126 patients with type A AD out of 200 charts reviewed. Thirteen (14% CI 8-23%, n = 93 p = 0.05) had wide mediastinum on their chest X-rays; twenty (95% CI 75-100%, n = 21 P = 0.05) had elevated D-dimer levels; and ninety-one (72% CI 64-80%, n = 126 p = 0.05) had positive ADD-RS. Only 88 out of 126 AD cases had documented echocardiograms. Sixty-eight (77% CI 67-86%, n = 88 p = 0.05) had either pericardial effusions or dilated aortic roots on their echocardiograms. Eighty-one (92% CI 84-95%, n = 88 p = 0.05) had either positive ADD-RS or positive echocardiogram findings, which is 20 (23% CI 14-33%, n = 88 P = 0.05) more cases than ADD-RS would have picked up alone. Conclusion: The absence of both pericardial effusion and dilated aortic root on echocardiogram in combination with a negative ADD-RS has a high sensitivity for ruling out type A AD. Our data support further research into the use of POCUS to expedite the diagnosis of type A AD in the emergency department.

Abstract 367: Are We Over-utilizing Echocardiogram for the Evaluation of Syncope Patients?

Background: Syncope is one of the most common reasons for emergency department visits. The most common causes of syncope include vasovagal, orthostatic, neurogenic and cardiogenic. In some cases, history and physical examination can point towards a specific cause. While in most cases, history and physical alone are insufficient to indicate an obvious etiology. Patients with cardiogenic syncope have an increased rate of all-cause mortality as well as mortality associated with cardiovascular events. The risk of missing these serious conditions often results in low-risk patients being admitted for further workup and undergoing extensive investigation including a transthoracic echocardiogram (TTE). However, the utility of such testing including TTE in patients with a negative initial evaluation with history, physical exam and ECG is uncertain. The aim of this study was to assess the utility of TTE in the evaluation of patients admitted with syncope with an initial negative evaluation Methods: It is a retrospective study. Data was collected from all the patients admitted to the hospital for the workup of syncope from January to October 2019. Baseline characteristics including age, sex and ethnicity were collected for each patient. Data was also collected in regard to their significant cardiac past medical and family history. History of present illness and physical examination at the time of admission was noted. Patients were divided into two groups based on if the medical evaluation indicated a cardiogenic etiology. Cardiac testing data including EKG and TTE were included in the analysis. Abnormal EKG was defined by the presence of bradycardia, arrhythmia, QT prolongation, bundle branch blocks, heart blocks and left ventricular hypertrophy. Positive TTE findings were defined as low ejection fraction, significant left ventricular outflow tract obstruction, significant valvular abnormalities, wall motion abnormality and presence of pericardial effusion. Collected data were analyzed using Chi-square test and multiple linear regression. Results: The mean age of the study group was 72 years with 45% of males. Out of the total of 93 patients included in the study, 57(61%) patients had a TTE done. Out of this only 10(17%) patients had positive TTE. Only 2 patients with positive TTE had a negative EKG. In these two patients, the history was, however suspicious for cardiogenic syncope. A significant association of positive TTE findings with abnormal EKG (p-value: 0.003) was found. The odds of having a positive TTE finding when the EKG was negative was only 6%. These results remained significant with multiple linear regression analyses. Conclusions: TTE is being overutilized in the evaluation of patients presenting with syncope to rule out cardiac etiology. A thorough history and complete physical examination along with the basic cardiac testing including EKG can help reduce the overutilization

Role of Echocardiogram in Predicting Prognosis in Pulmonary Arterial Hypertension: A Meta-Analysis

Right ventricular (RV) failure is the most common cause of mortality in PAH. RV structure & function is commonly assessed using transthoracic echo (TTE) but its role in estimating prognosis is limited to small-scale studies, evaluating a limited range of parameters. Therefore, we sought to conduct an updated meta-analysis to investigate the role of various TTE parameters in predicting PAH outcomes. Scopus, PubMed & Cochrane Central databases were searched by 2 independent reviewers from inception of these databases through Jan 2019 for original studies reporting TTE parameters & outcomes in adult PAH patients. Studies enrolling >50 patients, including >95% PAH, either prospectively or retrospectively were included. Primary outcomes were mortality & clinical worsening. Hazard ratios (HRs) with 95% confidence intervals were extracted & pooled using a random-effects model. P<0.05 was considered significant. From 44 studies that met inclusion criteria, presence of pericardial effusion on TTE was significantly associated with increased mortality (HR 2.13 [95% CI 1.61-2.83]; p < 0.01). Higher right atrial pressure (RAP) was also significantly associated with increased mortality (HR 1.31 [95% CI 1.04-1.65]; p=0.02). However, RV fractional area change, TR severity, TAPSE, RA size & RV systolic pressure did not significantly predict outcomes. TTE parameters such as pericardial effusion & higher RAP can help in risk stratify PAH patients. These should be used in conjunction with clinical presentation, laboratory findings & invasive hemodynamics to assess patients' prognosis.

Predictive Features of Thymic Carcinoma and High-Risk Thymomas Using Random Forest Analysis.

To determine the predictive features of thymic carcinomas and high-risk thymomas using random forest algorithm. A total of 137 patients with pathologically confirmed high-risk thymomas and thymic carcinomas were enrolled in this study. Three clinical features and 20 computed tomography features were reviewed. The association between computed tomography features and pathological patterns was analyzed by univariate analysis and random forest. The predictive efficiency of the random forest algorithm was evaluated by receiver operating characteristic curve analysis. There were 92 thymic carcinomas and 45 high-risk thymomas in this study. In univariate analysis, patient age, presence of myasthenia gravis, lesion shape, enhancement pattern, presence of necrosis or cystic change, mediastinal invasion, vessel invasion, lymphadenopathy, pericardial effusion, and distant organ metastasis were found to be statistically different between high-risk thymomas and thymic carcinomas (all P < 0.01). Random forest suggested that tumor shape, lymphadenopathy, and the presence of pericardial effusion were the key features in tumor differentiation. The predictive accuracy for the test data and whole data was 94.73% and 96.35%, respectively. Further receiver operating characteristic curve analysis showed the area under the curve was 0.957 (95% confidence interval, 0.986-0.929). The random forest model in the present study has high efficiency in predictive diagnosis of thymic carcinomas and high-risk thymomas. Tumor shape, lymphadenopathy, and pericardial effusion are the key features for tumor differentiation. Thymic tumors with irregular shape, the presence of lymphadenopathy, and pericardial effusion are highly indicative of thymic carcinomas.

1095 Effective image-guided medical management in effusive constrictive pericarditis

Abstract A 59 year old man was admited to hospitalization for persistent chest pain related to acute pericarditis. Within the admision tests, a transthoracic echography was performed, showing a moderate pericardial effusion with ventricular septal bounce and significant respiratory variations in mitral and tricuspid inflows, all of it consistent with effusive-constrictive pericarditis (Panel A). Anti-inflammatory treatment with ibuprofen and colchicine was started. During the first 48 hours of admission there was a clinical and hemodinamic worsening in the patient’s condition that forced the performance of a pericardial window, obtaining a very little quantity of dense pericardial fluid. Looking for a more accurate study of the pericardium, a cardiovascular magnetic resonance (CMR) was performed, revealing a thick heterogeneous pericardial effusion (Panel B) and a significant late gadolinium enhancement of both pericardial layers (Panel C). All these findings where consistent with an effusive constrictive pericarditis with persistent inflammatory activity despite high doses of conventional inflammatory treatment. Furthermore, the growth of Propionibacterium acnes in the pericardial fluid disclosed the etiology of this condition. Medical treatment was enhanced with high doses of intravenous corticosteroid, ceftriaxone and doxycycline. During the following days, the patient showed an excellent response achieving the complete clinical and echocardiographic relief of constrictive signs (Panel D). Effusive constrictive pericarditis is characterized by the presence of pericardial effusion and constriction secondary to an inflammatory process of the pericardium. Pericardiectomy might be necessary in case of failure of medical treatment, a very common scenario in this kind of .pericarditis. Our case is remarkable because it demonstrates the value of CMR to detect persistent inflammation of pericardium despite high doses of conventional medical treatment for pericaricarditis guiding the successful escalation to intravenous corticosteroid and avoiding the risk of an unnecessary cardiac surgery. Abstract 1095 Figure.

P190 Chest pain and syncope in Turner"s syndrome: going beyond the obvious to not miss the critical diagnosis. Role of multimodality imaging approach

Abstract Clinical Presentation: a 18-year-old woman with Turner’s syndrome (TS), with history of hypothyroidism treated with L-thyroxin, asymptomatic moderately stenotic bicuspid aortic valve (AV) and without any known cardiovascular risk factor, was admitted to our emergency department (ED) because of syncope and typical chest pain after dinner associated with dyspnea. Chest pain lasted for an hour with spontaneous regression. In the ED the patient (pt) was normotensive. An ECG showed sinus rhythm (88 bpm), nonspecific repolarization anomalies (T wave inversion) in the inferior and anterior leads. Myocardial necrosis biomarkers were negative. A 3D transthoracic echocardiography showed normal biventricular systolic function with left ventricular hypertrophy, dilatation of the ascending aorta, unicuspid AV with severe aortic stenosis (peak/mean gradient 110/61 mmHg, aortic valve area 0,88 cm2-0,62 cm2/m2), mild pericardial effusion (Figure Panel A, B, C). Five days after, the pt had a new episode of typical chest pain without ECG changes. A computerized tomography (CT) was performed to rule out the hypothesis of aortic dissection and showed a dilation of the ascending aorta and pericardial effusion localized in the diaphragmatic wall, no signs of dissection or aortic hematoma. However, CT was of suboptimal quality because of sinus tachycardia (120 bpm) and so the pt underwent a coronary angiography and aortography that ruled out coronary disease, confirmed the dilatation of ascending aorta (50 mm) and showed images of penetrating atherosclerotic ulcer of the ascending aorta (Figure panel D). The pt underwent urgent transesophageal echocardiography (TOE) that confirmed the severely stenotic unicuspid AV and showed a localized type A aortic dissection (Figure Panel E, F, G). The pt underwent urgent AV and ascending aorta replacement (Figure Panel H). Learning points Chest pain and syncope are challenging symptoms in pts presenting in ED. AV pathology and aortic dissection should be always suspected and ruled out. TS is associated with multiple congenital cardiovascular abnormalities and is the most common established cause of aortic dissection in young women. 30% of Turner’s pts have congenitally AV abnormalities, and dilation of the ascending aorta is frequently associated. However, unicuspid AV is a very rare anomaly, usually stenotic at birth and requiring replacement. The presence of pericardial effusion in a pt with chest pain and syncope should raise the suspicion of aortic dissection, even if those symptoms usually accompany severe aortic stenosis. Even if CT is the gold standard imaging technique to rule out aortic dissection, the accuracy of a test is critically related to the image quality. When the suspicion of dissection is high and the reliability of the reference test is low, it’s reasonable to perform a different test to rule out the pathology. Aortography and TOE were pivotal to identify the limited dissection of the ascending aorta. Abstract P190 Figure.

330 Echocardiographic Parameters Predictive of a Positive 99mTc-PYP Scan in Patients with Suspected Cardiac ATTR-Amyloidosis

Cardiac ATTR-amyloidosis is associated with significant morbidity and mortality. 99mTc-pyrophosphate (PYP) scanning has a high positive predictive value however identifying patients for referral can be challenging due to the older age of this cohort and frequent finding of comorbidities associated with left ventricular hypertrophy including hypertension. We aimed to identify echocardiographic parameters predictive of a positive PYP scan. Patients referred to a teaching hospital for PYP scan (July 2016-December 2019) and in whom echocardiography was also performed were retrospectively identified. Echocardiographic parameters were compared between patients with a positive (+PYP) and negative (-PYP) scan. 33 consecutive patients (mean age 76.3+/-14.3, 70% male) were included in the analysis (22 -PYP, 11 +PYP). Patients with a +PYP scan were significantly older (84.5 +/-5.3 years vs 72.2 +/-15.76, p value 0.001). E wave deceleration time and E’septal were decreased in +PYP compared to -PYP patients (164 vs 213ms; 3.8cm/s vs 5.05cm/s; p<0.05 for both). While apical sparing in strain imaging was observed in both groups, average basal longitudinal strain (GLSav-basal) was significantly decreased in patients with +PYP scan (-7.98% vs 11.96%; p=0.009). There was no significant difference in average wall thickness, biplane LV volume and ejection fraction or the presence of pericardial effusion between groups. A GLSav-basal of <-11.15% was 69% sensitive and 89% specific for predicting +PYP scan. E' septal tissue doppler velocity, E wave deceleration time and average basal longitudinal strain are significantly lower in patients with a +PYP scan and may be helpful in diagnosing cardiac ATTR-amyloidosis.

Management of cardiac tamponade due to contrast nephropathy: A case report

Pericardial effusion secondary to contrast nephropathy is a very rare clinical condition. Patients have a volume load increase secondary to acute renal failure. In such a case, the progression of pericardial effusion with tamponade may follow a very rapid course contrary to what is believed.&#x0D; In this case, a 78-year-old male patient with diabetes mellitus and hypertension was admitted to the emergency department with complaints of decreased urine output, nausea, and vomiting. The patient was diagnosed with acute renal failure secondary to contrast nephropathy. Pericardial effusion amount was found to be 2 cm by thorax tomography.&#x0D; As the patient who had no urine output when his vital signs were stable became unstable during dialysis preparation and manifested clinical symptoms of cardiac tamponade, immediate pericardiocentesis was performed. Following that, he became stable and was transferred to the intensive care unit. In current guidelines regarding indications for pericardiocentesis, it is stated that drainage should be performed when the amount of effusion is more than 2 cm in the absence of tamponade, suspected bacterial infection or neoplastic etiology. However, in contrast to the standard approach to patients with acute renal failure, our suggestion is that the indications for pericardiocentesis may be broader in the presence of pericardial effusion.

Pediatric systemic lupus erythematosus patients in South Africa have high prevalence and severity of cardiac and vascular manifestations

BackgroundPediatric onset of systemic lupus erythematosus (SLE) is associated with major organ involvement, and African patients tend to develop more aggressive disease than patients of European descent. Although cardiovascular involvement is common in pediatric SLE, there are few published reports on the subject. This study describes the frequency and characteristics of cardiac and vascular manifestations of pediatric SLE in a multi-ethnic South African cohort.MethodsDemographic, clinical, and echocardiographic data were collected from pediatric SLE patients at two centers in Cape Town, South Africa. At the time of investigation, this cohort consisted of 93 participants diagnosed with SLE according to international classification criteria prior to the age of 19. Individuals with cardiac and/or vascular involvement were identified by retrospective chart review. Cardiac manifestations were defined as presence of pericardial effusion, myocarditis, cardiomyopathy, cardiac failure, Libman-Sacks endocarditis, myocardial infarction, and arrhythmia. Vascular manifestations included deep vein thrombosis, pulmonary embolism, sinus thrombosis, stroke, critical limb ischemia, cerebral vasculitis and systemic vasculitis. Statistical analysis was performed using R (v3.4.1).ResultsCardiac and vascular involvement was present in 47% of the cohort. Previous studies have reported prevalence of 5%—50%. Demographic features of those with cardiac/vascular involvement did not differ from the overall cohort. Echocardiographic data were available for 23 participants. The most common cardiac manifestations were pericardial effusion (n = 24) and cardiac failure (n = 8), while the most common vascular manifestations were cerebral vasculitis (n = 9), stroke (n = 7), and pulmonary embolism (n = 7). Cardiovascular manifestations were frequently severe; one third of pericardial effusion cases required intervention, including three cases of cardiac tamponade. Cardiac and vascular involvement conferred an increased risk of mortality (31.1% versus 10.4%).ConclusionsCardiac and vascular involvement were highly prevalent in this South African cohort. The mortality rate was high, and severe manifestations were frequent. Prospective research is needed to improve knowledge of pediatric SLE in Africa and to improve outcomes for this high-risk population.