Remco Bergman

Ventriculo-atrial defect after bioprosthetic aortic valve replacement

We present a case of a 71-year-old Caucasian male with a ventriculo-atrial defect due to infective endocarditis, originating from his aortic root near a bioprosthetic aortic valve, implanted 4 years earlier. Ventriculo-atrial defects are rare and can occur after endocarditis with abscess formation, usually in native tissue. We report a ventriculo-atrial defect due to a paravalvular aortic prosthetic defect, secondary to inflammation, a novel third type of a Gerbode defect. Case presentation, clinical decision making and surgical approach are discusses in this report.

Manual Skill Acquisition During Transesophageal Echocardiography Simulator Training of Cardiology Fellows: A Kinematic Assessment

OBJECTIVE To investigate whether a transesophageal echocardiography (TEE) simulator with motion analysis can be used to impart proficiency in TEE in an integrated curriculum-based model. DESIGN A prospective cohort study. SETTING A tertiary-care university hospital. PARTICIPANTS TEE-naïve cardiology fellows. INTERVENTIONS Participants underwent an 8-session multimodal TEE training program. Manual skills were assessed at the end of sessions 2 and 8 using motion analysis of the TEE simulators probe. At the end of the course, participants performed an intraoperative TEE; their examinations were video captured, and a blinded investigator evaluated the total time and image transitions needed for each view. Results are reported as mean±standard deviation, or median (interquartile range) where appropriate. MEASUREMENTS AND MAIN RESULTS Eleven fellows completed the knowledge and kinematic portions of the study. Five participants were excluded from the evaluation in the clinical setting because of interim exposure to TEE or having participated in a TEE rotation after the training course. An increase of 12.95% in post-test knowledge scores was observed. From the start to the end of the course, there was a significant reduction (p<0.001 for all) in the number of probe. During clinical performance evaluation, trainees were able to obtain all the required echocardiographic views unassisted but required a longer time and had more probe transitions when compared with an expert. CONCLUSION A curriculum-based approach to TEE training for cardiology fellows can be complemented with kinematic analyses to objectify acquisition of manual skills during simulator-based training.

Long-term outcome of patients after out-of-hospital cardiac arrest in relation to treatment: a single-centre study:

Introduction: Outcome after out-of-hospital cardiac arrest (OHCA) remains poor. With the introduction of automated external defibrillators, percutaneous coronary intervention (PCI) and mild therapeutic hypothermia (MTH) the prognosis of patients after OHCA appears to be improving. The aim of this study was to evaluate short and long-term outcome among a non-selected population of patients who experienced OHCA and were admitted to a hospital working within a ST elevation myocardial infarction network. Methods: All patients who achieved return of spontaneous circulation (ROSC) (n=456) admitted to one hospital after OHCA were included. Initial rhythm, reperfusion therapy with PCI, implementation of MTH and additional medical management were recorded. The primary outcome measure was survival (hospital and long term). Neurological status was measured as cerebral performance category. The inclusion period was January 2003 to August 2010. Follow-up was complete until April 2014. Results: The mean patient age was 63±14 years and 327 (72%) were men. The initial rhythm was ventricular fibrillation, pulseless electrical activity, asystole and pulseless ventricular tachycardia in 322 (71%), 58 (13%), 55 (12%) and 21 (5%) of the 456 patients, respectively. Treatment included PCI in 191 (42%) and MTH in 188 (41%). Overall in-hospital and long-term (5-year) survival was 53% (n=240) and 44% (n=202), respectively. In the 170 patients treated with primary PCI, in-hospital survival was 112/170 (66%). After hospital discharge these patients had a 5-year survival rate of 99% and cerebral performance category was good in 92%. Conclusions: In this integrated ST elevation myocardial infarction network survival and neurological outcome of selected patients with ROSC after OHCA and treated with PCI was good. There is insufficient evidence about the outcome of this approach, which has a significant impact on utilisation of resources. Good quality randomised controlled trials are needed. In selected patients successfully resuscitated after OHCA of presumed cardiac aetiology, we believe that a more liberal application of primary PCI may be considered in experienced acute cardiac referral centres.

Tricuspid Valve: An Intraoperative Echocardiographic Perspective

From the *Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; †Department of Anesthesia, Hospital Mexico, University of Costa Rica, San Jose, Costa Rica; ‡Department of Anesthesiology, University Medical Center, Groningen, University of Groningen, Groningen, Netherlands; and §Department of Anesthesia and Pain Medicine, Peking University People’s Hospital, Beijing, China. Address reprint requests to Feroze Mahmood, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Anesthesia, Critical Care, and Pain Medicine, One Deaconess Road, CC 470, Boston, MA 02215. E-mail: fmahmood@bidmc.harvard.edu

Sutureless management of left ventricle wall rupture; a series of three cases

Treatment of left ventricle wall rupture is very challenging, ruptured myocardial tissue is usually of poor quality and has a high risk of total rupture when being sutured. Furthermore, rapid decision-making is needed under stressful conditions. We present a series of three cases demonstrating the feasibility of using only hemostatic collagen sponges for the management of left ventricle wall rupture. All patients we Caucasian males, two patients were 65 years and one patient was 67 years old at the time of surgery. This report contains the first video images of solely use of hemostatic collagen sponges to seal a left ventricle wall rupture. Implication of our case series could be that the indication to use hemostatic collagen sponges, could be broadened towards other surgical specialties where suturing ruptured tissue can be difficult.

Imaging skills for transthoracic echocardiography in cardiology fellows: The value of motion metrics

Background: Proficiency in transthoracic echocardiography (TTE) requires an integration of cognitive knowledge and psychomotor skills. Whereas cognitive knowledge can be quantified, psychomotor skills are implied after repetitive task performance. We applied motion analyses to evaluate psychomotor skill acquisition during simulator-based TTE training. Methods and Results: During the first month of their fellowship training, 16 cardiology fellows underwent a multimodal TTE training program for 4 weeks (8 sessions). The program consisted of online and live didactics as well as simulator training. Kinematic metrics (path length, time, probe accelerations) were obtained at the start and end of the course for 8 standard TTE views using a simulator. At the end of the course TTE image acquisition skills were tested on human models. After completion of the training program the trainees reported improved self-perceived comfort with TTE imaging. There was also an increase of 8.7% in post-test knowledge scores. There was a reduction in the number of probe accelerations [median decrease 49.5, 95% CI = 29-73, adjusted P < 0.01], total time [median decrease 10.6 s, 95% CI = 6.6-15.5, adjusted P < 0.01] and path length [median decrease 8.8 cm, 95% CI = 2.2-17.7, adjusted P < 0.01] from the start to the end of the course. During evaluation on human models, the trainees were able to obtain all the required TTE views without instructor assistance. Conclusion: Simulator-derived motion analyses can be used to objectively quantify acquisition of psychomotor skills during TTE training. Such an approach could be used to assess readiness for clinical practice of TTE.

Long-term outcome of elderly out-of-hospital cardiac arrest survivors as compared with their younger counterparts and the general population

Background: Over the past decade, prehospital and in-hospital treatment for out-of-hospital cardiac arrest (OHCA) has improved considerably. There are sparse data on the long-term outcome, especially in elderly patients. We studied whether elderly patients benefit to the same extent compared with younger patients and at long-term follow up as compared with the general population. Methods: Between 2001 and 2010, data from all patients presented to our hospital after OHCA were recorded. Elderly patients (⩾75 years) were compared with younger patients. Neurological outcome was classified as cerebral performance category (CPC) at hospital discharge and long-term survival was compared with younger patients and predicted survival rates of the general population. Results: Of the 810 patients admitted after OHCA, a total of 551 patients (68%) achieved return of spontaneous circulation, including 125 (23%) elderly patients with a mean age of 81 ± 5 years. In-hospital survival was lower in elderly patients compared with younger patients with rates of 33% versus 57% (p < 0.001). A CPC of 1 was present in 73% of the elderly patients versus 86% of the younger patients (p = 0.031). In 7.3% of the elderly patients, a CPC >2 was observed versus 2.5% of their younger counterparts (p = 0.103). Elderly patients had a median survival of 6.5 [95% confidence interval (CI) 2.0–7.9] years compared with 7.7 (95% CI 7.5–7.9) years of the general population (p = 0.019). Conclusions: The survival rate after OHCA in elderly patients is approximately half that of younger patients. Elderly patients who survive to discharge frequently have favorable neurological outcomes and a long-term survival that approximates that of the general population.

Erratum: Ventriculo-atrial defect after bioprosthetic aortic valve replacement

After publication of the article [1] it was discovered that this manuscript was mistakenly given a duplicated citation number. The correct citation of 9:199 has now been updated in all versions of this manuscript. We apologise for any inconvenience caused by this error.