Adrian Ionescu

Bubble trouble: anaphylactic shock, threatened myocardial infarction, and transient renal failure after intravenous echo contrast for left ventricular cavity opacification preceding dobutamine stress echo.

Echo contrast agents are widely used and safe but can rarely produce serious side effects. This-to the authors knowledge-is the first detailed published case report of a patient who had a severe and complex sequence of adverse reactions within 3 min of having an intravenous infusion of Sonovue initiated, and where the causal connection between Sonovue and the adverse reaction is not diluted by potential side effects from dobutamine.

Stress Cardiomyopathy: Case Series and the Review of Literature

BACKGROUND Apical ballooning syndrome (ABS) or stress cardiomyopathy is increasingly recognized as a cause of acute coronary syndrome with unobstructed coronaries, but remains underdiagnosed. OBJECTIVES Retrospective review of the angiographic database (between January 2006 and December 2010) to obtain incidence and clinical presentation of ABS at our center. ABS was defined according to the modified Mayo Clinic criteria. CASE RESULTS Normal or unobstructed coronaries on angiography were observed in 1780 (25.4%) of a total of 6983 patients who underwent urgent or emergency coronary angiography. Twelve patients (0.17%) fulfilled the modified Mayo Clinic criteria for ABS. Eleven patients (92%) were aged ≥ 50 years (median 68 years, range 27-86 years), and 10 were female (83%). Four patients (31%) presented with ST-elevation myocardial infarction, and 1 patient presented with cardiogenic shock and acute coronary syndrome. Emotional stress was the precipitant in 4 patients (33%). Unusual precipitants like cold-water immersion and intravenous chemotherapy were observed. All 12 patients had the typical appearance of ABS on left ventriculogram (75%) or echocardiography (25%). Follow-up imaging with either echocardiography or magnetic resonance imaging (done in all 12 patients) up to 16 weeks after discharge showed that left ventricular function had normalized. CONCLUSIONS The incidence and clinical features of ABS in our tertiary center are similar to those reported in other settings. Unusual precipitants were observed, but left ventriculograms were performed less frequently and could be contributory to the under-diagnosis of ABS.

Hand-held Ultrasound Scanners in Medical Education: A Systematic Review

Background Ultrasound imaging devices are becoming popular in clinical and teaching settings, but there is no systematic information on their use in medical education. We conducted a systematic review of hand-held ultrasound (HHU) devices in undergraduate medical education to delineate their role, significance, and limitations. Methods We searched Cochrane, PubMed, Embase, and Medline using the strategy: [(Hand-held OR Portable OR Pocket OR “Point of Care Systems”) AND Ultrasound] AND (Education OR Training OR Undergraduate OR “Medical Students” OR “Medical School”). We retained 12 articles focusing on undergraduate medical education. We summarised the patterns of HHU use, pooled and estimated sensitivity, and specificity of HHU for detection of left ventricular dysfunction. Results Features reported were heterogeneous: training time (1–25 hours), number of students involved (1-an entire cohort), number of subjects scanned (27–211), and type of learning (self-directed vs. traditional lectures + hands-on sessions). Most studies reported cardiac HHU examinations, but other anatomical areas were examined, e.g. abdomen and thyroid. Pooled sensitivity 0.88 [95% confidence interval (CI) 0.83–0.92] and specificity 0.86 (95% CI 0.81–0.90) were high for the detection of left ventricular systolic dysfunction by students. Conclusion Data on HHU devices in medical education are scarce and incomplete, but following training students can achieve high diagnostic accuracy, albeit in a limited number of (mainly cardiac) pathologies. There is no consensus on protocols best-suited to the educational needs of medical students, nor data on long-term impact, decay in proficiency or on the financial implications of deploying HHU in this setting.

Low-flow low-gradient aortic stenosis: surgical outcomes and mid-term results after isolated aortic valve replacement

OBJECTIVES To analyse operative outcomes and mid-term results following isolated aortic valve replacement (AVR) in patients with low-flow low-gradient severe aortic stenosis (LFLG AS) compared with normal flow high-gradient aortic stenosis (NFHG AS). METHODS A retrospective analysis of data for all isolated AVRs performed for AS at our centre in the last 17 years (n = 846). Two groups were identified: LFLG AS (n = 198, 23%) [subdivided into: True LFLG AS (n = 66, 33%) and paradoxical LFLG AS (n = 132, 67%)] and NFHG AS (n = 648, 77%). Follow-up was done by clinical visits and telephone interviews. The mean follow-up was 5.8 ± 4.2 years. RESULTS The mean age was 71.5 ± 9.7 years in the LFLG AS group and 68.7 ± 10.8 years in the NFHG group (P = 0.01). The LFLG AS group had a mean gradient 31.2 ± 7.4 mmHg compared with 59.1 ± 16.6 mmHg in the NFHG group (P = 0.001). Diabetes, chronic obstructive pulmonary disease, previous coronary disease, peripheral vascular disease, atrial fibrillation and pulmonary hypertension were significantly more frequent in the LFLG AS patients (P < 0.01). The in-hospital mortality rate was 2% in the LFLG and 1% in the NFHG group, P = 0.13. One- and 5-year mortality rates were significantly higher in the LFLG group (13 and 28 vs 4 and 16% in the NFHG, respectively, P = 0.001). Patients with true LFLG AS also had a significantly higher long-term mortality than those with paradoxical LFLG AS (27 vs 6% at 1 year and 42 vs 20% at 5 years, P < 0.05). CONCLUSIONS AVR in patients with LFLG AS is associated with similar surgical mortality but increased mid-term mortality compared with NFHG AS. Patients with true LFLG AS have the worst outcomes. Surgery should still be offered for LFLG AS on prognostic grounds and for symptomatic benefit among survivors.

Are valve clinics a sound investment for the health service? A cost-effectiveness model and an automated tool for cost estimation

Background Valve disease is using up an important, growing proportion of the resources allocated for healthcare. Clinical care is often suboptimal and while multidisciplinary clinics are the ‘gold standard’, their adoption has been patchy and inhomogeneous. Methods We hypothesised that adoption of valve clinics can deliver financial savings and set out to estimate differences in cost between a standard model in which the cardiologist sees every case and a multidisciplinary model in which some cases are devolved to sonographer-led or nurse-led clinics, assuming usage of various tests in accordance with practice at our institutions and to published data. We developed a tool that allows the modelling of limitless permutations in order to assess costs. Results Seeing 100 new patients in a valve clinic is more expensive than seeing them in the conventional set-up (excess cost £2700,

Outcome of isolated aortic valve replacement in patients with classic and paradoxical low-flow, low-gradient aortic stenosis

4252). Follow-up of both patients with native valve disease (maximal savings/100 patients—£5166,

The Use of Multidimensional Modeling of the Aorta in Planning the Resection of an Aortic Angiosarcoma

8135) and with operated valves (maximal savings/100 patients—£5090,

Quadricuspid aortic valve

8015) is cheaper in a valve clinic than in a general cardiology clinic and the savings offset the increased cost of seeing new patients in the valve clinic. Conclusions The costing implications of valve clinics need to be worked out carefully. Our analysis suggests that important savings in healthcare costs could be achieved by their adoption. Clarifying the economic implications of this new model of care should become one of the priorities for the ‘heart valve community’.

Hand-held ultrasonography: An opportunity for “hands-on” teaching of medicine

Objective To analyze operative outcomes and mid‐term results after isolated aortic valve replacement (AVR) in low‐flow, low‐gradient aortic stenosis (LFLG AS) by comparing the 2 subcategories (classic low‐flow, low‐gradient aortic stenosis [CLFLG] and paradoxical low‐flow, low‐gradient aortic stenosis [PLFLG]). Methods This was a retrospective analysis of prospectively collected data for all isolated AVR in LFLG AS performed in our center during the last 13 years (n = 198; CLFLG AS, n = 66, 33% and PLFLG AS, n = 132, 67%). Median follow‐up was 3.7 ± 3.3 years. Results Preoperative mean gradient was 30.2 ± 8.8 mm Hg in the CLFLG AS group and 31.4. ± 7.0 mmHg in the PLFLG AS group (P = .001). Female sex, hypertension, and neurologic and renal disease were more frequent in the PLFLG AS group (P < .01) whereas advanced New York Heart Association class, atrial fibrillation, and pulmonary hypertension were more frequent in the CLFLG AS group (P < .01). In‐hospital mortality was 3% in the CLFLG AS group and 2.3% in the PLFLG AS group, P = .08. One‐ and five‐year mortality rates were significantly greater in the CLFLG AS group (27% and 42% vs 6% and 20% in the PLFLG AS group, respectively, P = .001). On follow‐up, 90% of the total survivors were in New York Heart Association class I‐II, and 51% of the patients in the CLFLG AS group had an improvement in their ventricular function. Conclusions AVR can be performed in LFLG AS with low in‐hospital mortality. CLFLG AS carries similar in‐hospital mortality to PLFLG AS but greater mid‐term mortality. Surgery provided excellent functional status among survivors.

The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging (2018 update)

PURPOSE We report a technique of finite-element multidimensional modeling that was used to help with the planning of and the resection of an angiosarcoma in a single patient. DESCRIPTION A patient was referred to our department with suspected aortic angiosarcoma. We visualized and reconstructed the computed tomography and magnetic resonance imaging scans of this patient to create finite-element multidimensional models of his diseased aorta. EVALUATION This technique and the multidimensional models were very helpful in assessing the tumor size and its extension. It also facilitated preoperative planning of the aortic resection and repair. CONCLUSION Finite-element multidimensional modeling is a useful technique for preoperative planning of aortic operations in patients with angiosarcoma.