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Background: Although electronic health records (EHR) provide useful insights into disease patterns and patient treatment optimisation, their reliance on unstructured data presents a difficulty. Echocardiography reports, which provide extensive pathology information for cardiovascular patients, are particularly challenging to extract and analyse, because of their narrative structure. Although natural language processing (NLP) has been utilised successfully in a variety of medical fields, it is not commonly used in echocardiography analysis. Objectives: To develop an NLP-based approach for extracting and categorising data from echocardiography reports by accurately converting continuous (e.g., LVOT VTI, AV VTI and TR Vmax) and discrete (e.g., regurgitation severity) outcomes in a semi-structured narrative format into a structured and categorised format, allowing for future research or clinical use. Methods: 135,062 Trans-Thoracic Echocardiogram (TTE) reports were derived from 146967 baseline echocardiogram reports and split into three cohorts: Training and Validation (n = 1075), Test Dataset (n = 98) and Application Dataset (n = 133,889). The NLP system was developed and was iteratively refined using medical expert knowledge. The system was used to curate a moderate-fidelity database from extractions of 133,889 reports. A hold-out validation set of 98 reports was blindly annotated and extracted by two clinicians for comparison with the NLP extraction. Agreement, discrimination, accuracy and calibration of outcome measure extractions were evaluated. Results: Continuous outcomes including LVOT VTI, AV VTI and TR Vmax exhibited perfect inter-rater reliability using intra-class correlation scores (ICC = 1.00, p < 0.05) alongside high R2 values, demonstrating an ideal alignment between the NLP system and clinicians. A good level (ICC = 0.75–0.9, p < 0.05) of inter-rater reliability was observed for outcomes such as LVOT Diam, Lateral MAPSE, Peak E Velocity, Lateral E’ Velocity, PV Vmax, Sinuses of Valsalva and Ascending Aorta diameters. Furthermore, the accuracy rate for discrete outcome measures was 91.38% in the confusion matrix analysis, indicating effective performance. Conclusions: The NLP-based technique yielded good results when it came to extracting and categorising data from echocardiography reports. The system demonstrated a high degree of agreement and concordance with clinician extractions. This study contributes to the effective use of semi-structured data by providing a useful tool for converting semi-structured text to a structured echo report that can be used for data management. Additional validation and implementation in healthcare settings can improve data availability and support research and clinical decision-making.

ST2 is a circulating biomarker that is well established for predicting outcome in heart failure (HF). This is the first study to look at ST2 concentrations in optimally treated patients with stable but significant left ventricular systolic dysfunction (LVSD) compared to patients with severe aortic stenosis (AS). Two cohorts were retrospectively studied: 94 patients undergoing transcatheter aortic valve implantation for severe AS (63 with normal ejection fraction [EF] and 31 with reduced EF), and 50 patients with severe LVSD from non-valvular causes. ST2 pre-procedural samples were taken, and repeated again at 3 and 6 months. Patients were followed-up for 2 years. Data was analyzed using SPSS software. Baseline concentrations of soluble ST2 did not differ significantly between the HF group and AS group with normal EF (EF ≥ 50%). However, in the AS group with a low EF (EF < 50%) ST2 concentrations were significantly higher that the HF group (p = 0.009). New York Heart Association class IV HF, baseline N-terminal pro-B-type natriuretic peptide and gender were all independent predictors of soluble ST2 (sST2) baseline concentrations. Raised ST2 concentrations in the context of severe AS may be a marker for subclinical or clinical left ventricular dysfunction. More research is required to assess its use for assessment of prognosis and response to treatment.

Re-expansion pulmonary oedema (REPO) is a rare complication of pleural fluid thoracocentesis and has been associated with a high mortality rate. There is limited evidence to inform on its most effective management. We present two cases of large volume thoracocentesis resulting in acute respiratory decompensation that was treated by reintroducing the drained pleural fluid back into the pleural cavity. We also present a review of the literature specifically assessing the reported incidence rate of REPO after pleural fluid drainage. In both of our cases, symptoms and signs of respiratory instability were promptly reversed on reintroduction of the drained pleural fluid into the patient's pleural space—a therapy we have termed ‘rapid pleural space re-expansion’. This was not associated with any short-term adverse outcomes. The occurrence of REPO is a rare event with most cohort studies reporting an incidence of between 0% and 1%.

BackgroundOne determinant of failure of atrial fibrillation (AF) ablation is the lack of transmural lesions. Contact force sensing (CFS) catheters enable real-time assessment of the amount of force applied at the catheter-tissue interface, with higher contact force associated with lesions of greater size. Previous meta-analyses have pooled results from randomized controlled trials (RCTs) and observational studies (OSs) and concluded that CFS catheters improve clinical outcomes. This meta-analysis sought to compare the efficacy and safety of CFS catheters with non-CFS catheters for AF radiofrequency ablation.MethodsA total of 28 studies were identified using Embase and Medline databases; 8 RCTs and 20 OSs. For the primary outcome of atrial tachyarrhythmia recurrence, data from RCTs and OSs were analysed according to study design. Secondary outcomes included ablation time and all procedure-related complications. Summary estimates for each variable were calculated using the random-effects model based on DerSimonian and Laird’s meta-analytic statistical method.ResultsIn the 8 RCTs there were a total of 844 patients (419 in CF group and 425 in non-CF group). In the 20 OS there were 3900 patients (1523 in CF group and 2377 in non-CF group). The median age of patients was 60.3 years (59.0 years in RCTs and 60.7 years in OSs). The majority were male (74.0% in RCTs and 69.6% in OSs). The median follow-up time post-AF ablation was 12 months in both RCTs and OSs.While CFS did not lead to a significant reduction in atrial tachyarrhythmia recurrence in RCTs (n=844, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.80 to 1.19, p=0.81), a significant reduction was observed in OSs (n=2,259, RR 0.74, 95% CI 0.65 to 0.84, p<0.0001), both at a median follow-up of 12 months.Data on ablation time were available for 6 RCTs (n=751) and 14 OSs (n=3,152). The use of CFS catheters had no significant impact on ablation time in both RCTs (-0.36 minutes, 95% CI -3.32 to 2.59, p=0.81) and OSs (-3.68 minutes, 95% CI -7.91 to 0.55, p=0.09).For both RCTs (n=706) and OSs (n=3,427), the incidence of all procedure-related complications was similar in the CFS and non-CFS groups (RCTs, RR 0.99, 95% CI 0.55 to 1.78, p=0.97; OSs, RR 0.78, 95% CI 0.53 to 1.16, p=0.22).ConclusionAlthough OSs have demonstrated positive results, data from RCTs have failed to show any significant benefit from CFS catheters in terms of procedural success in AF ablation. The safety profile of CFS catheters was similar to non-CFS catheters in both RCTs and OSs.Conflict of InterestNo conflicts on interest

AimsDual-coil implantable cardioverter defibrillator (ICD) leads have traditionally been used over single-coil leads due to concerns regarding high defibrillation thresholds (DFT) and consequent poor shock efficacy. However, accumulating evidence suggests that this position may be unfounded and that dual-coil leads may also be associated with higher complication rates during lead extraction. This meta-analysis collates data comparing dual- and single-coil ICD leads.Methods and resultsElectronic databases were systematically searched for randomised controlled trials (RCT) and non-randomised studies comparing single-coil and dual-coil leads. The mean differences in DFT and summary estimates of the odds-ratio (OR) for first-shock efficacy and the hazard-ratio (HR) for all-cause mortality were calculated using random effects models. Eighteen studies including a total of 1 38 124 patients were identified. Dual-coil leads were associated with a lower DFT compared to single coil leads (mean difference –0.83J; 95% confidence interval [CI] –1.39–−0.27; p=0.004). There was no difference in the first-shock success rate with dual-coil compared to single-coil leads (OR 0.74; 95% CI 0.45–1.21; p=0.22). There was a significantly lower risk of all-cause mortality associated with single-coil leads (HR 0.91; 95% CI 0.86–0.95; p<0.0001).ConclusionThis meta-analysis suggests that single-coil leads have a marginally higher DFT but that this may be clinically insignificant as there appears to be no difference in first-shock efficacy when compared to dual-coil leads. The mortality benefit with single-coil leads most likely represents patient selection bias. Given the increased risk and complexity of extracting dual-coil leads, centres should strongly consider single-coil ICD leads as the lead of choice for routine new left-sided ICD implants.

BackgroundWith subcutaneous ICDs (S-ICD) not offering the same range of pacing therapies as transvenous systems (T-ICD), it is unclear how many ICD recipients may be suitable for a S-ICD. In addition, the benefit from ICD therapy is dependent on non-sudden cardiac death (SCD) risk. The study aims were to [1] establish how many ICD recipients may be suitable for S-ICD implantation based on a range of selection policies, and [2] determine the impact of S-ICD use on the risk of non-SCD.MethodsWe performed a retrospective study of all ICD implants over 5 years (2009–2013). We evaluated how widely the S-ICD could be utilised using the following indications: (a) Least liberal use – S-ICD used only in patients with inherited channelopathies and idiopathic ventricular fibrillation; (b) Intermediate use – S-ICD also used for SCD primary prevention in hypertrophic cardiomyopathy; (c) Most liberal use – S-ICD also used for SCD primary prevention in coronary artery disease (CAD) and non-ischaemic dilated cardiomyopathy (DCM) who have a narrow QRS complex (120msec). Given the potential impact of age on the benefit from S-ICDs, we stratified our results by implant age (70, 60 and 50 years). Non-SCD risk was quantified using the MADIT-II risk score (score 0–5, 5 (highest risk)). Mann-Whitney U testing was used to compare risk scores.ResultsOver the 5 years, there were 402 implants (79% male, age 70±13 years). After exclusion of patients implanted with a CRT-D device or with a pacing indication, 219 remained for consideration of a S-ICD. Using our definition of least liberal use, intermediate use, and most liberal use, the number of patients considered suitable for a S-ICD was 18 (4.5%), 30 (7.5%) and 77 (19.2%), respectively. Age as a discriminator had a significant impact on the proportion of patients considered suitable for a S-ICD. This was predominantly due to a reduction in the number of patients with CAD and DCM being considered for a prophylactic device. Using the most liberal definition, the number of potential S-ICD candidates dropped from 52 (12.9%) in those 70 years old at implant, to 34 (8.5%) for 60 years, to 20 (5%) using 50 years as the cut-off.The MADIT-II score was 0.22±0.1, 0.47±0.1 and 0.96±0.1, in the least liberal, intermediate and most liberal use S-ICD groups, respectively. The score was 2.07±0.1, 2.11±0.1 and 2.24±0.1 in the respective T-ICD groups. The mean MADIT-II score in the S-ICD group was significantly lower than that in the respective T-ICD group (p<0.0001, for all three selection policies).ConclusionsWhile up to one-fifth of patients currently receiving ICDs may be suitable for a S-ICD, this result is dependent on both which patient groups the S-ICD is used in and whether an age cut-off is applied. The cohort of patients suitable for a S-ICD also have a lower risk of non-SCD compared to those receiving conventional T-ICDs.

AimsRandomised trials have shown that empiric ICD programming, using long detection times and high detection zones, reduces device therapy in ICD recipients. However, there is less data on its effectiveness in a “real-world” setting, especially secondary prevention patients. Our aim was to evaluate the introduction of a standardised programming protocol in a “real-world” setting of unselected ICD recipients.MethodsWe analysed 270 consecutive ICD recipients implanted in a single centre – 135 implanted prior to protocol implementation (Physician-Led group) and 135 after (Standardised group). The protocol included long arrhythmia detection times (30/40 or equivalent) and high rate detection zones (primary prevention lower treatment zone 200 bpm). Programming in the Physician-Led group was at the discretion of the implanter. The primary endpoint was time-to-any therapy (ATP or shocks). Secondary endpoints were time-to-inappropriate therapy and time-to-appropriate therapy. The safety endpoints were syncopal episodes, hospital admissions, and death.ResultsAt 12 months follow-up, 47 patients had received any ICD therapy (Physician-Led group, n = 31 vs. Standardised group, n = 16). There was a 47% risk reduction in any device therapy (p = 0.04) and an 86% risk reduction in inappropriate therapy (p = 0.009) in the Standardised compared to the Physician-led group. Results were consistent across primary and secondary prevention patients. There were no significant differences in the rates of syncope, hospitalization and death.ConclusionsIn unselected patients in a “real-world” setting introduction of a standardised programming protocol, using long detection times and high detection zones, significantly reduces the burden of ICD therapy without an increase in adverse outcomes.Abstract 51 Figure 1Kaplan-Meier curves for survival from any-therapy. Physician-Led (dotted) vs. Standardised (black)Abstract 51 Figure 2Kaplan-Meier curves for survival from inappropriate therapy. Physician-led (dotted) vs. Standardised (black)

Abstract Background  The Gerbode defect is a rare abnormal communication between the left ventricle (LV) and right atrium (RA). The lesion is either congenital or acquired. Acquired defects are largely iatrogenic or infective in origin. We present two cases of acquired Gerbode defects with similar clinical presentations but very different outcomes. Case summaries Patient 1 A 64-year-old male presented with features of decompensated cardiac failure and a low-grade temperature. Dehiscence of a recently implanted bioprosthetic aortic valve and high-velocity LV to RA jet (Gerbode defect) was found on echocardiography. Blood cultures grew Staphylococcus warneri and the diagnosis of infective endocarditis was established. The patient was treated with intravenous antibiotics and the aortic valve and Gerbode defect were successfully surgically repaired. Patient 2 An 81-year-old male presented after being found on the floor at home. On admission, he was clinically septic with evidence of decompensated heart failure. No clear infective focus was initially found. Transthoracic echocardiography revealed severe left ventricular impairment, with a normal bioprosthetic aortic valve. He was treated with intravenous antibiotics, but later deteriorated with evidence of embolic phenomena. Repeat echocardiography revealed a complex infective aortic root lesion with bioprosthetic valve dehiscence and flow demonstrated from the LV to RA. Unfortunately, the patient succumbed to the infection and cardiac complications. Discussion  The Gerbode defect is a rare but important complication of infective endocarditis and valve surgery. Care needs to be taken to assess for Gerbode defect shunts on echocardiogram, especially in the context of previous cardiac surgery.

Purpose Patients at high non-sudden cardiac death risk may gain no significant benefit from implantable cardioverter-defibrillator (ICD) therapy. A number of approaches have been proposed to identify these patients, including single clinical markers and more complex scoring systems. The aims of this study were to use the proposed scoring systems to (1) establish how many current ICD recipients may be too high risk to derive significant benefit from ICD therapy and (2) evaluate how well the scoring systems predict short-term mortality in an unselected ICD cohort. Methods We performed a single-centre retrospective observational study of all new ICD implants over 5 years (2009–2013). We used four published scoring systems (Bilchick, Goldenberg, Kramer and Parkash) and serum urea to identify new ICD recipients whose short-term predicted mortality risk was high. We evaluated how well the scoring systems predicted death. Results Over 5 years, there were 406 new implants (79% male, mean age 70 (60–76), 58% primary prevention). During a follow-up of 936 ± 560 days, 96 patients died. Using the scoring systems, the proportion of ICD recipients predicted to be at high short-term mortality risk were 5.9% (Bilchick), 34.7% (Goldenberg), 7.4% (Kramer), 21.4% (Parkash) and 25% (urea, cut-off of >9.28 mM). All four risk scores predicted mortality ( P  < 0.0001); however, none outperformed urea for the prediction of 1- or 3-year mortality. Conclusions Using published scoring systems, a significant proportion of current ICD recipients are at high short-term mortality risk. Although all four scoring systems predicted mortality during follow-up, none significantly outperformed serum urea.

YouTube contains a large volume of medical educational material. This study assessed the quality of respiratory auscultation videos contained in YouTube. Videos were searched for using the terms ‘breath sounds’, ‘respiratory sounds’, ‘respiratory auscultation’ and/or ‘lung sounds’. In total, 6,022 videos were located, 36 of which were considered suitable for scoring for video accuracy, comprehensiveness and quality. The average score was 3.32/6 (55.3% ± 1.30). Video score correlated with time-adjusted YouTube metadata: hits per day (0.496, p=0.002) and likes per day (0.534, p=0.001). Video score also correlated with the first search page on which the video was located in the ‘breath sounds’ and ‘lung sounds’ searches (–0.571, p=0.001; –0.445, p=0.014, respectively). The quality of videos was variable. Correlation between video score and some metadata values suggests that there is value for their use in judging video quality. However, the large number of videos found and inability to filter these results quickly makes locating educational content difficult.