John M. Dent

American society of echocardiography recommendations for quality echocardiography laboratory operations

Michael H. Picard, MD, FASE, David Adams, RDCS, FASE, S. Michelle Bierig, RDCS, MPH, FASE, JohnM.Dent,MD,FASE, Pamela S.Douglas,MD,FASE,LindaD.Gillam,MD,FASE,AndrewM.Keller,MD,FASE, David J. Malenka, MD, FASE, Frederick A. Masoudi, MD, MSPH, Marti McCulloch, RDCS, FASE, Patricia A. Pellikka, MD, FASE, Priscilla J. Peters, RDCS, FASE, Raymond F. Stainback, MD, FASE, G.Monet Strachan, RDCS, FASE, andWilliam A. Zoghbi,MD, FASE, Boston, Massachusetts; Durham,North Carolina; St. Louis, Missouri; Charlottesville, Virginia; New York, New York; Danbury, Connecticut; Lebanon, New Hampshire; Denver, Colorado; Houston, Texas; Rochester, Minnesota; Pennsauken, New Jersey; San Diego, California

Diagnostic Value of Echocardiography in Suspected Endocarditis An Evaluation Based on the Pretest Probability of Disease

BACKGROUND We hypothesized that for the diagnosis of endocarditis, (1) transthoracic echocardiography (TTE) would be most valuable in patients with an intermediate clinical probability of the disease and (2) transesophageal echocardiography (TEE) would be most useful in patients with an intermediate probability when TTE either does not yield an adequate study or indicates an intermediate probability of endocarditis. We also sought to investigate the influence of echocardiographic results on antibiotic usage and its duration. METHODS AND RESULTS TTE and TEE were performed in 105 consecutive patients with suspected endocarditis. Patients were classified as having either low, intermediate, or high probability of endocarditis on the basis of clinical criteria and separately on the basis of both TTE and TEE findings. TTE and TEE classified the majority (82% and 85%, respectively) of the 67 patients with a low clinical probability of endocarditis as having a low likelihood of the disease. Of the 14 patients with intermediate clinical probability, 12 had technically adequate TTE studies; 10 of these (83%) were classified as either high or low probability. All patients with intermediate clinical probability were classified as high or low probability by TEE. The majority of the 24 patients with high clinical probability were placed in the low-likelihood category by echocardiography (15 by TTE and 12 by TEE). There was concordance between TTE and TEE in 83% of all cases. TEE was useful for the diagnosis of endocarditis in patients with prosthetic valves and in those in whom TTE indicated an intermediate probability; these constituted < 20% of patients in our study. The course of antibiotic therapy was influenced only by the clinical profile and not by the echocardiographic results. CONCLUSIONS Echocardiography should not be used to make a diagnosis of endocarditis in those with a low clinical probability of the disease. In those with an intermediate or high clinical probability, TTE should be the diagnostic procedure of choice. TEE for the diagnosis of endocarditis should be reserved only for patients who have prosthetic valves and in whom TTE is either technically inadequate or indicates an intermediate probability of endocarditis.

Enhancement of Left Ventricular Cavity Opacification by Harmonic Imaging After Venous Injection of Albunex

Venous injection of Albunex does not consistently produce left ventricular (LV) cavity opacification during conventional echocardiography. We postulated that by increasing the signal-to-noise ratio, harmonic imaging will result in more successful LV cavity opacification and provide a better assessment of regional LV systolic function. Forty-two patients with poor baseline endocardial delineation were given 10 ml intravenous injections of Albunex during continuous fundamental and harmonic imaging. Change in segmental wall-thickening scores and the confidence levels for these scores were assessed for 3 observers with various levels of experience. Compared with fundamental imaging, harmonic imaging significantly improved the success of LV cavity opacification (83% vs 62%, p <0.05). The background-subtracted video intensity within the central two thirds of the LV cavity increased threefold (from 10 +/- 15 to 31 +/- 29, p <0.05) with harmonic imaging. The spatial extent of opacification increased from 40% of the LV cavity during fundamental imaging to 65% with harmonic imaging (p <0.001). The confidence level for assessing regional LV systolic function improved (p <0.05) after contrast administration, particularly when observer experience was limited. We conclude that in patients with poor endocardial definition, injection of intravenous Albunex should be combined with harmonic imaging to improve LV cavity opacification.

ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging

Joseph P. Drozda, Jr, MD, FACC, Chair Vincent J. Bufalino, MD, FACC Joseph G. Cacchione, MD, FACC Christopher P. Cannon, MD, FACC W. Don Creighton, MD Pamela S. Douglas, MD, MACC T. Bruce Ferguson, Jr, MD, FACC Raymond J. Gibbons, MD, FACC Harlan M. Krumholz, MD, FACC Frederick A. Masoudi

Cardiac Findings during Uncomplicated Acute Influenza in Ambulatory Adults

BACKGROUND Previous studies have reported abnormal cardiac findings in up to 43% of ambulatory adults with influenza. This study was conducted to determine the frequency, magnitude, and duration of myocardial dysfunction in such persons. METHODS We enrolled 30 previously healthy young adults without known cardiovascular disease who presented to the clinic <or=72 h after onset of influenza symptoms and had a positive influenza antigen test. Most patients received antiviral therapy, and all underwent serial electrocardiography and had blood specimens collected on days 1, 4, 11, and 28 after presentation for measurement of total creatine kinase (CK) level, CK isoenzyme MB (CK-MB) level, troponin I level, and selected cytokine levels. Echocardiography was performed on days 4, 11, and 28. RESULTS None of the patients had an elevated CK-MB index or troponin I level. Abnormal electrocardiogram findings were noted in 53%, 33%, 27%, and 23% of patients on days 1, 4, 11, and 28, respectively, but none of the findings were considered to be clinically significant. No patient had significant changes in the ejection fraction or abnormal wall motions. CONCLUSIONS Most ambulatory young adults with acute influenza have clinically insignificant abnormal electrocardiogram findings early during the illness. These abnormalities resolve promptly and are not associated with changes in cardiac markers or echocardiogram findings.

EVEREST II randomized clinical trial: Predictors of mitral valve replacement in de novo surgery or after the MitraClip procedure

OBJECTIVE The Endovascular Valve Edge-to-Edge Repair Study (EVEREST II) is a prospective, multicenter, randomized controlled trial comparing percutaneous repair with the MitraClip device to mitral valve (MV) surgery in the treatment of mitral regurgitation. The present study analyzed the patient characteristics and treatment effects on mitral repair versus replacement. METHODS Of 279 patients enrolled, 80 surgical patients underwent 82 MV operations and 178 underwent an initial MitraClip procedure, of whom 37 underwent a subsequent MV operation within 1 year of their index the MitraClip procedure. A logistic regression model was used to predict MV replacement according to valve pathology, etiology of mitral regurgitation, age, previous cardiac surgery, and treatment group. RESULTS The rate of percutaneous or surgical MV repair at 1 year was 89% (158/178) in patients initially receiving the MitraClip device versus 84% (67/80) in the surgical patients (P = .36). Surgical repair was performed after the MitraClip procedure in 20 (54%) of 37 patients (P < .001 vs surgery). In both the MitraClip device and surgery groups, MV replacement was significantly associated with anterior leaflet pathology (P = .035). Logistic regression analysis showed that anterior leaflet pathology predicted MV replacement. In 5 (13.5%) of 37 patients undergoing surgery after MitraClip therapy, replacement was performed in part because of MV injury associated with the MitraClip procedure. CONCLUSIONS These data suggest that anterior leaflet pathology is strongly associated with MV replacement in patients undergoing either de novo MV surgery or surgery after MitraClip therapy. MitraClip therapy has a repair rate similar to surgery through 1 year but also imparts a risk of replacement of a potentially repairable valve.

Cost and yield of adding electrocardiography to history and physical in screening Division I intercollegiate athletes: A 5-year experience

BACKGROUND Electrocardiographic screening of intercollegiate athletes is controversial because the costs and yield are not well defined. Both the American Heart Association (AHA) and the European Society of Cardiology (ESC) have different criteria for screening, partly because the populations being screened are different. OBJECTIVE The purpose of this study was to determine the cost and yield of a 5-year ECG screening program at a United States Division I college. METHODS At the University of Virginia, all 1,473 competitive athletes over the course of 5 years were screened with history and physical and with ECGs using ESC guidelines with follow-up testing as dictated by clinical symptoms and ECG findings. RESULTS History and physical alone uncovered five significant cardiac abnormalities. ECGs were abnormal in 275 (19%), resulting in 359 additional tests. Additional testing confirmed eight significant cardiac abnormalities that were not found by history and physical: 1 bicuspid aortic valve, 4 rapidly conducting accessory pathways, 1 long QT patient, 1 with frequent premature ventricular contractions and low ejection fraction, and 1 with frequent premature ventricular contractions but normal ejection fraction. No cases of hypertrophic cardiomyopathy were found. Total cost of the program was US

ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/ SCCT/SCMR/SIR 2008 Key Data Elements and Definitions for Cardiac Imaging

894,870. Cost of history and physical screening alone was

Efficient utilization of echocardiography for the assessment of left ventricular systolic function

343,725 or

Three-Dimensional Echocardiography: Is it Ready for Everyday Clinical Use?

68,745 per finding. The marginal cost of adding ECG screening, including resulting tests and procedures. was US