Objective We aimed to determine whether there are similar rates of regional wall motion abnormalities (RWMAs) in patients with acute coronary occlusion myocardial infarction (OMI) with and without ST-elevation myocardial infarction (STEMI) on electrocardiogram (ECG).
Methods We performed a retrospective review of a database of patients at high risk for acute coronary syndrome with previously established outcomes for the presence of OMI in order to compare rates of RWMA in patients presenting with STEMI(+) OMI versus STEMI(–) OMI. Furthermore, we compared how often the RWMA aligned with the anatomical territory observed on ECG.
Results Among 808 patients, 551 underwent formal echocardiography, including 256 of 265 OMI patients and 295 of 543 patients with no occlusion. Of the 256 OMI patients that underwent formal echocardiography, only 105 (41.0%) met STEMI criteria. Among them, 94 of 105 (89.5%) STEMI(+) OMI patients had RWMAs compared to 124 of 151 (82.1%) STEMI(–) OMI patients (P=0.10; 95 confidence interval, –1.63% to 15.6%). Both groups had a greater prevalence of RWMA than the non-OMI group (45%). RWMA matched the anatomic territory predicted by ECG in 92.5% of STEMI(+) OMI, 82.3% of STEMI(–) OMI, and 2.9% of the no-occlusion cohort.
Conclusion Location of RWMAs was well-correlated with ECG findings regardless of the presence or absence of STEMI criteria. A prospective study is warranted to determine the utility of echocardiography in the detection of STEMI(–) OMI.
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Objective To determine whether a transesophageal echocardiography (TEE) probe can accurately measure temperature and be used to monitor temperature changes over time without overheating in an experimental model of hypothermia and rewarming. Methods A 6-L water bath was heated with a sous vide immersion circulator to 24, 28, 32, and 36 °C to simulate severe hypothermia, moderate hypothermia, mild hypothermia, and normothermia, respectively. A TEE probe, esophageal temperature probe, and bladder temperature probe were used to measure temperature every 60 seconds for 15 minutes. Results The TEE probe reported temperatures with a mean difference of 0.60 °C (95% confidence interval [CI], 0.51 to 0.69 °C) compared to the sous vide immersion circulator. The esophageal probe and bladder probe reported temperatures with a mean difference of –0.19 °C (95% CI, –0.23 to –0.14 °C) and –0.20 °C (95% CI, –0.26 to –0.14 °C), respectively. Conclusion During this simulation, the TEE tip temperature did not increase beyond the expected changes produced by water temperature. The probe temperature was less accurate than the esophageal and bladder temperature probes but demonstrated precision in monitoring temperature changes and stable hypothermia. Based on this study, TEE probes should not be relied upon for an accurate initial temperature but can likely be used to monitor changes in temperature over time.
Objective This study was conducted to determine whether the presence and degree of left ventricular diastolic dysfunction (LVDD) can be predicted by the simple computed tomography -measured left atrial diameter (CTLAD). Methods Among adult patients who underwent both chest CT imaging and echocardiography in the emergency department from January 2020 to December 2021, a retrospective cross-sectional study enrolled patients in whom the time interval between the two tests was <24 hours. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic power of CTLAD for echocardiographic LVDD. Results In a study involving 373 patients, 192 (51.5%) had LVDD. Among them, 122 (63.5%) had grade 1, 61 (31.8%) had grade 2, and nine (4.7%) had ≥grade 3. Median CTLAD values were 4.1 cm for grade 1, 4.5 cm for grade 2, and 4.9 cm for ≥grade 3. The area under the ROC curve value of CTLAD in distinguishing ≥grade 1, ≥grade 2 (optimal cutoff ≥4.4 cm), and ≥grade 3 (optimal cutoff ≥4.5 cm) were 0.588, 0.657 (sensitivity, 61.4%; specificity, 66.0%, positive predictive value, 29.5%; negative predictive value, 88.1%; odds ratio, 3.1), and 0.834 (sensitivity, 88.9%; specificity, 70.1%; positive predictive value, 6.8%; negative predictive value, 99.6%, odds ratio, 18.7), respectively. Conclusion CTLAD ≥4.4 cm can be used as a rough reference value to distinguish LVDD of ≥grade 2, while CTLAD ≥4.5 cm can reliably distinguish LVDD of ≥grade 3. CTLAD might be a useful parameter for predicting LVDD in situations where echocardiography is not available.
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Objective Myocardial rupture is a fatal complication of acute myocardial infarction (AMI). Early diagnosis of myocardial rupture is feasible when emergency physicians (EPs) perform emergency transthoracic echocardiography (TTE). The purpose of this study was to report the echocardiographic features of myocardial rupture on emergency TTE performed by EPs in the emergency department (ED).
Methods This was a retrospective and observational study involving consecutive adult patients presenting with AMI who underwent TTE performed by EPs in the ED of a single academic medical center from March 2008 to December 2019.
Results Fifteen patients with myocardial rupture, including eight (53.3%) with free wall rupture (FWR), five (33.3%) with ventricular septal rupture (VSR), and two (13.3%) with FWR and VSR, were identified. Fourteen of the 15 patients (93.3%) were diagnosed on TTE performed by EPs. Diagnostic echocardiographic features were found in 100% of the patients with myocardial rupture, including pericardial effusion for FWR and a visible shunt on the interventricular septum for VSR. Additional echocardiographic features indicating myocardial rupture were thinning or aneurysmal dilatation in 10 patients (66.7%), undermined myocardium in six patients (40.0%), abnormal regional motions in six patients (40.0%), and pericardial hematoma in six patients (40.0%).
Conclusion Early diagnosis of myocardial rupture after AMI is possible using echocardiographic features on emergency TTE performed by EPs.
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Objective Severe pulmonary embolism (PE) has a high mortality rate, which can be lowered by thrombolytic therapy (TT). However, full-dose TT is associated with major complications, including life-threatening bleeding. The aim of this study was to explore the efficacy and safety of extended, low-dose administration of tissue plasminogen activator (tPA) on in-hospital mortality and outcomes in massive PE.
Methods This was a single-center, prospective cohort trial at a tertiary university hospital. A total of 37 consecutive patients with massive PE were included. A peripheral intravenous infusion was used to administer 25 mg of tPA over 6 hours. The primary endpoints were in-hospital mortality, major complications, pulmonary hypertension, and right ventricular dysfunction. The secondary endpoints were 6-month mortality and pulmonary hypertension and right ventricular dysfunction 6 months after the PE.
Results The mean age of the patients was 68.76±14.54 years. The mean pulmonary artery systolic pressure (PASP; 56.51±7.34 mmHg vs. 34.16±2.81 mmHg, P<0.001) and right/left ventricle diameter (1.37±0.12 vs. 0.99±0.12, P<0.001) decreased significantly after TT. Tricuspid annular plane systolic excursion (1.43±0.33 cm vs. 2.07±0.27 cm, P<0.001), myocardial performance index (0.47±0.08 vs. 0.55±0.07, P<0.001), and systolic wave prime (9.6±2.8 vs. 15.3±2.6) increased significantly after TT. No major bleeding or stroke was observed. There was one in-hospital death and two additional deaths within 6 months. No cases of pulmonary hypertension were identified during follow-up.
Conclusion The results of this pilot study suggest that an extended infusion of low-dose tPA is a safe and effective therapy in patients with massive PE. This protocol was also effective in decreasing PASP and restoring right ventricular function.
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Determining the cause of cardiac arrest (CA) and the heart status during CA is crucial for its treatment. Transesophageal echocardiography (TEE) is an imaging method that facilitates close observation of the heart without interfering with cardiopulmonary resuscitation (CPR). Intra-arrest TEE is a point-of-care ultrasound technique that is used during CPR. Intra-arrest TEE is performed to diagnose the cause of CA, determine the presence of cardiac contraction, evaluate the quality of CPR, assist with catheter insertion, and explore the mechanism of blood flow during CPR. The common causes of CA diagnosed using intra-arrest TEE include cardiac tamponade, aortic dissection, pulmonary embolism, and intracardiac thrombus, which can be observed on a few simple image planes at the mid-esophageal and upper esophageal positions. To operate an intra-arrest TEE program, it is necessary to secure a physician who is capable of performing TEE, provide appropriate training, establish implementation protocols, and prepare a plan in collaboration with the CPR team.
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Objective This study aimed to compare the diagnostic performance of cardiac biomarkers and to evaluate the optimal cut-off values for echocardiographic cardiac injury prediction in patients with carbon monoxide (CO) poisoning.
Methods This retrospective observational cohort study included adult patients with acute CO poisoning. Patients who did not undergo transthoracic echocardiography, which was used to define patients with cardiac injury (ejection fraction <55%), were excluded. The area under the curve was used to evaluate diagnostic performance for cardiac injury prediction. Mann-Whitney U, chi-square, and Fisher exact tests were used to analyze data.
Results After excluding the 27 patients who did not undergo echocardiography, 114 patients were included in the study. Fifteen (13.2%) patients had cardiac injury. The area under the curve values for the B-type natriuretic peptide, creatine kinase-myocardial band, and troponin I were 0.711 (95% confidence interval [CI], 0.527–0.895; P=0.011), 0.766 (95% CI, 0.607–0.926; P=0.001), and 0.801 (95% CI, 0.647–0.955; P<0.001), respectively, with optimal cut-off values of 330 pg/mL, 10.1 ng/mL, and 0.455 ng/mL, respectively. The sensitivity, specificity, and positive and negative predictive values of troponin I were 67%, 91%, 53%, and 95%, respectively.
Conclusion Troponin I showed the best diagnostic performance for predicting cardiac injury in patients with CO poisoning. A cut-off value of 0.455 ng/mL appeared optimal for cardiac injury prediction. However, further studies on cardiac biomarkers and other diagnostic tools in CO poisoning are needed given the low sensitivity of troponin I.
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A previously healthy 61-year-old man presented to the emergency department with chest pain and dyspnoea for 6 hours. Examination revealed distress with an apical pansystolic murmur. Initial electrocardiogram showed sinus tachycardia and ST elevation in leads II, III, and aVF compatible with an inferior ST-elevation myocardial infarction. Point-of-care echocardiography in the emergency department showed a flail anterior mitral leaflet and severe mitral regurgitation, leading to a provisional diagnosis of papillary muscle rupture. Emergency cardiac catheterization showed 100%, 80%, and 70% occlusion of the middle right coronary, left anterior descending, and left circumflex arteries, respectively. An emergency triple vessel coronary artery bypass grafting and mitral valve replacement was performed. Posteromedial papillary muscle rupture resulting in mitral regurgitation was confirmed intraoperatively. The patient recovered uneventfully. In the absence of primary percutaneous coronary intervention, thrombolysis decisions should be made with extreme caution if mechanical complications of ST-elevation myocardial infarction are suspected.
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