S. Joshi

Analysis of clinical outcomes following in-hospital adult cardiac arrest.

Abstract

Validation of Conventional Fluoroscopic and ECG Criteria for Right Ventricular Pacemaker Lead Position Using Cardiac Computed Tomography

It is hypothesized that pacing the right ventricular (RV) septum is associated with less deleterious outcomes than RV apical pacing. Our aim was to validate fluoroscopic and electrocardiography (ECG) criteria for describing pacemaker and implantable cardioverter defibrillator RV “septal” lead position against the proposed gold standard: cardiac computed tomography (CT).

Pacing and implantable cardioverter defibrillator lead perforation as assessed by multiplanar reformatted ECG-gated cardiac computed tomography and clinical correlates.

We aimed to assess the utility of cardiac computed tomography (CT) in the evaluation of right atrial (RA) and right ventricular (RV) pacemaker and implantable cardiac defibrillator lead perforation.

Proximity of Pacemaker and Implantable Cardioverter‐Defibrillator Leads to Coronary Arteries as Assessed by Cardiac Computed Tomography

There have been rare case reports of damage to adjacent coronary arteries by screw‐in pacemaker and implantable cardioverter‐defibrillator (ICD) leads. Our aim was to assess the proximity of pacemaker and ICD leads to the major coronary anatomy using cardiac computed tomography (CT).

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes [SMART-REHAB Trial]: a randomized controlled trial protocol

BackgroundThere are well-documented treatment gaps in secondary prevention of coronary heart disease and no clear guidelines to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps. This paper describes the study design of a randomized controlled trial assessing whether a smartphone-based secondary prevention program can facilitate early physical activity and improve cardiovascular health in patients with ACS.MethodsWe have developed a multi-faceted, patient-centred smartphone-based secondary prevention program emphasizing early physical activity with a graduated walking program initiated on discharge from ACS admission. The program incorporates; physical activity tracking through the smartphone’s accelerometer with interactive feedback and goal setting; a dynamic dashboard to review and optimize cardiovascular risk factors; educational messages delivered twice weekly; a photographic food diary; pharmacotherapy review; and support through a short message service. The primary endpoint of the trial is change in exercise capacity, as measured by the change in six-minute walk test distance at 8-weeks when compared to baseline. Secondary endpoints include improvements in cardiovascular risk factor status, psychological well-being and quality of life, medication adherence, uptake of cardiac rehabilitation and re-hospitalizations.DiscussionThis randomized controlled trial will use a smartphone-phone based secondary prevention program to emphasize early physical activity post-ACS. It will provide evidence regarding the feasibility and utility of this innovative platform in closing the treatment gaps in secondary prevention.Trial registrationThe trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) on April 4, 2016. The registration number is ACTRN12616000426482.

Low rates of eligibility for lung cancer screening in patients undergoing computed tomography coronary angiography: Brief Communications

Incidental findings, including pulmonary nodules, on computed tomography coronary angiography (CTCA) are common. Previous authors have suggested CTCA could allow opportunistic screening for lung cancer, though the lung cancer risk profile of this patient group has not previously been established. Smoking histories of 229 patients undergoing CTCA at two tertiary hospitals were reviewed and only 25% were current or former smokers aged 55–80 years old. Less than half of this group were eligible for screening based on the PLCOm2012 risk model. We conclude that routine screening in the form of full thoracic field imaging, of individuals undergoing CTCA is not appropriate as it would likely result in net harm.

Misguided diversions: coronary artery fistulae

A 66-year-old female with acute coronary syndrome presented for coronary angiography (cTnI peak 1.15 ug/L; n< 0.04 ug/L). Angiography showed smooth arteries but the unexpected finding of late diastolic opacification of the left ventricular (LV) cavity via fistulous drainage from a tortuous left anterior descending artery (LAD) (Panel C, Supplementary material online, Video S1). Left ventriculogram revealed the etiologic cause of presentation as mid wall TakoTsubo cardiomyopathy (Supplementary material online, Video S2). The intercurrent emotional stressor of unexpected spousal death was later recognized, along with lifelong poor exercise tolerance. The patient’s ECG appearance evolved typically for Tako-Tsubo cardiomyopathy with inferolateral T wave inversion and QT prolongation (Panels A and B). A 61-year-old female with progressive exertional dyspnoea, underwent coronary angiography following positive stress echocardiocardiography. Angiography did not reveal obstructive disease but showed a dilated, serpiginous left circumflex artery (LCx), draining to the coronary sinus (CS) (Supplementary material online, Videos S3 and S4). Anatomic characterisation with CT demonstrated LCx dilatation with drainage proximal to the CS orifice (Panels D–F). Coronary artery fistulae are anomalous connections between epicardial coronary arteries and cardiac chambers or systemic/pulmonary vasculature. The prevalence is estimated at 0.2% and the majority involve the right coronary artery and right sided structures, with left to right shunting. Physiologically different causing left to left shunting, left sided fistulae to the left ventricle are very rare and represent abnormal Thebesian venous prominence. The prime pathologic significance of larger fistulae is ‘coronary steal’, with myocardial hypoperfusion distal to the fistulous connection. Progressive ‘steal’ may trigger aneurysmal coronary dilatation with consequences including thrombosis and rupture.

No node to pace and parts out of place

A 46-year-old woman with a history of exertional dysponea and palpitations was referred to our hospital with a severely dilated aortic root and unrestricted bicuspid aortic valve with mild regurgitation and normal left ventricular size and function. History was significant for polysplenia with follow-up computed tomographic (CT) studies following splenic vessel coiling noting an interrupted inferior vena cava with azygous continuation. Baseline electrocardiogram in this case showed an inferior, ectopic atrial rhythm (positive P wave in V1 and negative P waves inferiorly) and intermittent slow narrow complex junctional bradycardia with retrograde atrial activation seen (Panel A). Repeated CT angiogram of the chest, abdomen, and pelvis revealed features consistent with heterotaxy syndrome with left isomerism: bilateral left atrial appendages (Panel B), interrupted inferior vena cava (IVC) with azygous continuation (Panel C), bilateral, bi-lobed lungs with hyp-arterial long mainstem bronchi (Panels D and G) and polysplenia and right-sided pancreas and duodeno-jejunal flexure (Panel E). A large serpinginous major aorto-pulmonary collateral artery (MAPCA) was present on the proximal descending aorta communicating with both lungs (Panel F). Aortic valve was bicuspid with severely dilated aortic root (measured 55 mm). Heterotaxy syndrome encompasses a spectrum of malformations involving abnormal leftright axis determination. If alteration occurs during the early stage of embryogenesis, typically complete inversion of left-right axis results (situs inversus) whereas if affected in the later phases of embryogenesis, random positioning of left-right axis (heterotaxy) or mirror image duplication of organs (isomerism) occurs. Beyond the anatomical abnormalities of atrial isomerism are the associated conduction changes. With duplicate left atria, left isomerism patients lack a normal atrial pacemaker (Panel H), usually resulting in varying degrees of atrioventricular block associated with escape rhythms or need for pacemaker implantation. Although our patient currently has no AV block, progression to more advanced conduction disease is possible. Block in left isomerism typically manifests in childhood, although cases are described where pacing is not necessary due to robust escape rhythms.

The Burden of Australian Indigenous Cardiac Disease and the Emerging Role of Cardiac Imaging

Cardiac imaging frequently serves as a gatekeeper to triage management decisions. Utilization trends differ not only globally but also within individual countries and may be directed by the presence of an indigenous population with unique needs. We reviewed the current state of Australian indigenous cardiovascular health, and contributing factors to outcome disparity with mainstream Australia are discussed. We also considered the utility of contemporary cardiac imaging modalities and their established and potential roles in the assessment of cardiovascular disease in both the indigenous and wider Australian community. An imaging-based approach to evaluate cardiovascular disease in the Australian indigenous population is suggested.

Ruptured giant major aortopulmonary collateral artery

A 47-year-old female with pulmonary atresia ( Panel E ) and ventricular septal defect (VSD) presented to our hospital with severe chest pain and dyspnoea. Her diagnosis had been established in early infancy at which time it was deemed inoperable, and she had since been declined transplantation. She had a single giant major aortopulmonary collateral artery (MAPCA) arising from an aneurysmal brachiocephalic artery and connecting distally …