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50 Clinical indications for trans-thoracic echocardiography
BackgroundTrans-thoracic echocardiography (TTE) is a commonly performed non-invasive investigation for the assessment of ventricular function and cardiac morphology. The British Society of Echocardiography have established guidance outlining twelve clinical indications in which echocardiography may provide incremental value to patient management (BSE Guidance).AimsThe aim of this study was to audit TTE requests received by the Cardiology Department and compare them against BSE Guidance. Our overall aim is to promote appropriate resource utilisation.MethodsWe retrospectively collected all TTE requests received by the Cardiology Department over a four week period from August 2019 to September 2019. We examined the clinical indications for ordering a TTE and used BSE Guidance to classify the indications as appropriate, inappropriate, or unclear.ResultsThirty-two requests for TTE were received over the study period. The median patient age was 74 years [range 32–93 years]. Just over half of the patients 17/32 (52%) were male. The most common indications for TTE were to evaluate valvular pathology 11/32 (34%); either initial assessment 5/32 (16%) or surveillance of known valvular disease 6/32 (18%). The second most common indication was to assess cardiomyopathy 8/32 (25%), followed by evaluation of arrhythmias, palpitations or syncope 4/32 (13%). When compared with BSE Guidance, 18 (56%) requests were appropriate and 11 (34%) were inappropriate. Three (9%) requests were deemed unclear due to the lack of information contained in the request.ConclusionAn almost equal number of females and males were referred for TTE. The median age reflects the older cohort of patients at our hospital. Valvular pathology; either for diagnostic assessment or repeat evaluation was the most common indication for echocardiography, More than one-third of TTE requests received were not clinically indicated and combined with unclear requests, this amounted to more than 40% of requests. We would recommend implementation of BSE Guidance at our hospital to provide guidance for physicians making requests and ensure appropriate utilisation of limited resources for clinically indicated echocardiograms.
Journal Article
Delayed Reduction in the Left Ventricular Outflow Tract Gradient After Endocardial Radiofrequency Ablation for Septal Hypertrophy in a Patient With Hypertrophic Obstructive Cardiomyopathy: A Case Report
We report a case of a 79-year-old female with hypertrophic obstructive cardiomyopathy (HOCM) who demonstrated a delayed reduction in the left ventricular outflow tract (LVOT) gradient following endocardial radiofrequency ablation of septal hypertrophy (ERASH). The patient presented with diffuse interventricular septal thickening and systolic anterior motion (SAM) of the anterior mitral valve leaflet, with a markedly reduced six-minute walking distance of less than 50 meters. To minimize procedural risks, ERASH was performed using the CARTO3 (Biosense Webster, Inc., Irvine, California, USA) and CARTOSOUND systems (Biosense Webster, Inc., Irvine, California, USA). Intraoperatively, SAM resolved and the LVOT gradient showed an immediate decline (93 mmHg to 43 mmHg). The patient experienced gradual improvement in functional status and remained asymptomatic post-procedure. Interestingly, four days post-procedure, follow-up transthoracic echocardiography (TTE) demonstrated a delayed, further reduction in the LVOT gradient. This case highlights the potential for delayed hemodynamic improvement following ERASH, potentially attributable to transient post-ablation myocardial edema, as evidenced by the increase in end-diastolic interventricular septum thickness detected by TTE. Further studies are needed to assess procedural factors such as ablation power settings, ablation lesion size, and age-related myocardial degeneration.
Journal Article
Advances in Wearable Stethoscope Technology: Opportunities for the Early Detection and Prevention of Cardiovascular Diseases
Wearable technology, including devices like Apple and Samsung watches, Fitbits, and smart rings, has become widely popular. However, while these consumer electronics are readily available, they do not yet meet the accuracy and safety standards required for medical devices by the U.S. Food and Drug Administration (FDA). The COVID-19 pandemic has spurred demand for wearable medical devices, particularly those that can support telemedicine and telehealth. Among these, wearable electronic stethoscopes hold significant promise for early detection and prevention of cardiovascular diseases, which remain the leading cause of death globally. This review highlights the potential of wearable electronic stethoscopes to transform cardiovascular health management by enabling early diagnosis and self-monitoring. Additionally, it examines the current challenges and technological advancements needed to overcome them, underscoring the vital role that wearable electronic stethoscopes could play in improving global health outcomes.
Journal Article
An essential introduction to cardiac electrophysiology
This book provides undergraduate and postgraduate students with an accessible and comprehensive overview of the fascinating area of cardiac electrophysiology. Based on lectures presented to intercalating BSc medical students, it has been designed with the undergraduate in mind, but offers enough scope to be worthwhile at the postgraduate level.
Book
Dual Coronary Artery Dissection With Contrasting Healing Patterns: Spontaneous Left Circumflex and Iatrogenic Right Coronary Artery
Spontaneous coronary artery dissection (SCAD) is an uncommon but important cause of acute coronary syndrome (ACS), particularly in postpartum women without traditional cardiac risk factors. Our case involves a 29-year-old postpartum woman who presented with severe substernal chest pain eight days after an emergency cesarean section for pregnancy-associated hypertension. Electrocardiography showed ST elevation in the inferior and posterior leads, and coronary angiography revealed a spontaneous dissection in the left circumflex artery (LCx) with an intramural hematoma, alongside a dissection of the right coronary artery (RCA) extending from the ostium to the mid-vessel. This RCA dissection was most likely catheter-induced. Patients with SCAD often have frail arterial walls that are predisposed to dissection, even with minimal trauma, as seen in this case. The patient was treated medically with aspirin, clopidogrel, and bisoprolol. After 10 months, she presented with anginal chest pain and a positive stress ECG. Coronary angiography showed complete healing of the LCx and multiple stenotic lesions in the RCA. This disparity in healing patterns may be attributed to different mechanisms underlying the dissections: spontaneous dissections, which typically involve hormonal and vascular remodeling, versus iatrogenic dissections, which can be influenced by procedural trauma. This case highlights the contrasting healing patterns of spontaneous and iatrogenic dissections and emphasizes the importance of clinical suspicion, procedural caution, and long-term follow-up.
Journal Article
Inferior Wall Myocardial Infarction Complicated With Acute Mitral Regurgitation Requiring Transcatheter Edge-to-Edge Repair
Acute ST-elevation myocardial infarction (STEMI) is a life-threatening condition often associated with significant cardiac complications, particularly in the presence of underlying multivessel coronary artery disease. Mechanical complications, such as acute mitral regurgitation (MR), can worsen the clinical course, leading to rapid hemodynamic deterioration. Recent advancements in mechanical circulatory support and percutaneous interventions have introduced new therapeutic options, offering viable alternatives to traditional surgery for high-risk patients. In this case, a 67-year-old male with a history of hypertension presented with sudden-onset chest pain and dyspnea. Electrocardiography revealed an inferior STEMI. En route to the catheterization laboratory, the patient experienced cardiac arrest and was subsequently found to have multivessel coronary artery disease and severe mitral regurgitation. The patient underwent Impella-assisted multivessel percutaneous coronary intervention, complicated by flash pulmonary edema, which necessitated transcatheter mitral valve repair. The patient remained hemodynamically stable and had a successful recovery post-intervention. This case shows the effective use of advanced percutaneous techniques and mechanical support in managing a complex cardiac emergency, highlighting their potential as alternatives to traditional surgery.
Journal Article