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A 60-year-old woman with a past medical history of asthma presented with fulminant myocarditis 9 days after testing positive for SARS-CoV-2 and 16 days after developing symptoms consistent with COVID-19. Her hospital course was complicated by the need for veno-arterial extracorporeal membrane oxygenation, ventricular arrhythmias, and pseudomonas bacteremia. She ultimately recovered and was discharged to home with normal left ventricular systolic function. Thereafter, she developed symptomatic ventricular tachycardia, for which she received an implantable cardioverter-defibrillator and antiarrhythmic drug therapy.

In diagnosing and following patients with acute aortic syndromes and thoracic aortic aneurysms, high-quality imaging of the thoracic aorta is indispensable. Mainstay modalities for thoracic aortic imaging are echocardiography, computed tomographic angiography, and magnetic resonance angiography. For any given clinical scenario, the imaging modality and protocol chosen will have a significant impact on sensitivity and specificity for the aortic diagnosis of concern. Imaging can also provide important ancillary information regarding myocardial performance, aortic valve morphology and function, and end-organ perfusion. Surveillance of patients following thoracic aortic surgery with serial imaging studies can identify complications that may require reintervention, and imaging has played an integral role in development of new surgical and interventional methods. Emerging techniques in thoracic aortic imaging include positron emission tomography, which addresses vessel wall inflammation, and 4-dimensional magnetic resonance angiography, which illustrates flow dynamics.

Acute type A aortic dissection is a life-threatening event for which thoracic aortic aneurysm (TAA) is a major risk factor. Though current American and European guidelines provide diameter-based recommendations regarding intervention for TAA [(1,2)][1], most type A aortic dissections occur at

with the advent of real-time 3-dimensional transesophageal echocardiography (3d tee), rapid creation of high-quality, true-to-life images of mitral valve anatomy and pathology has become possible in the vast majority of patients ([1][1]). In addition to common mitral valve lesions, such as

The aim of this study was to compare appropriateness designations as determined by the updated 2011 appropriate use criteria (AUC) for echocardiography with prior versions of the AUC for transthoracic echocardiographic (TTE) imaging, transesophageal echocardiographic (TEE) imaging, and stress echocardiographic (SE) imaging. An additional goal was to define relationships between appropriateness determinations and echocardiographic findings for each modality.Previously published data sets of TTE, TEE, and SE studies were reclassified according to the 2011 AUC, and indication representation, appropriateness designations, and echocardiographic findings were compared with prior classifications according to the 2007 AUC for TTE and TEE imaging and the 2008 AUC for SE imaging.Overall, 2,247 echocardiographic studies were analyzed. The 2011 AUC addressed the vast majority of studies (98%), a marked increase compared with prior versions of the AUC (89%) (P.001). An increase in addressed studies was present in each echocardiographic modality (TTE imaging: n = 1,525, 98% vs 89%, P .001; TEE imaging: n = 405, 99.7% vs 91%, P.01; SE imaging: n = 289, 97% vs 88%, P.01). Among all echocardiographic procedures, the 2011 AUC found a lower frequency of appropriate studies compared with prior AUC (82% vs 88%, P.01), primarily because of new uncertain indications for TTE imaging. The frequency of inappropriate echocardiographic studies was unchanged (11%). Among all echocardiographic procedures, the 2011 AUC found appropriate studies to have more new abnormal echocardiographic findings compared with inappropriate studies (45% vs 13%, P.001). Interestingly, 2011 AUC inappropriate TTE studies had fewer major new echocardiographic abnormalities than 2007 AUC inappropriate TTE studies (9% vs 17%, P = .04).The updated 2011 AUC for echocardiography encompass the vast majority of echocardiographic procedures in a university hospital practice, filling virtually all of the gaps identified in prior versions of the AUC for TTE, TEE, and SE imaging. The 2011 AUC also reasonably stratify the likelihood of finding an echocardiographic abnormality, demonstrating improvement compared with the prior AUC.

Background Clinical application of the American College of Cardiology Foundation Appropriate Use Criteria (AUC) represents a potentially feasible alternative to third-party pre-certification for imaging procedures and will soon be required as part of the accreditation process for imaging laboratories. Electronic tools that rapidly apply the AUC are needed in clinical practice. We developed and tested a web-based application of the AUC to track appropriateness of transthoracic echocardiography (TTE). Methods Indications for outpatient TTE studies performed in a university hospital echocardiography laboratory were assessed prospectively at the point of service using a prototype web-based AUC application (Echo AUC App). The Echo AUC App was developed on the basis of our own prior published data regarding indication frequency to minimize time and screens required for completion. Echo AUC App-determined indications were compared with blinded investigator-determined indications based on review of relevant medical records. Echo AUC App characteristics, including Echo AUC App entry time, were recorded. Results Of the 258 studies enrolled, Echo AUC App-determined TTE indications were Appropriate (A) in 77% ( n = 198), Inappropriate (I) in 9% ( n = 23), and Not Classified (NC) by the AUC in 14% ( n = 37). Agreement between Echo AUC App- and investigator-determined classifications was excellent (94%, kappa statistic 0.83). Mean Echo AUC App study entry time was 55 seconds (range 25-280 seconds). Conclusion The use of an electronic application allows rapid and accurate implementation of the AUC for TTE at the point of service. Such an application could be installed in echocardiography laboratories to track appropriateness in accordance with soon-to-be-implemented accreditation requirements. Further study of this Echo AUC App at the point of order may provide an alternative to third-party pre-certification procedures.

Background The aim of this study was to evaluate the clinical application of the American College of Cardiology Foundation and American Society of Echocardiography appropriateness criteria for stress echocardiography (SE) in a single-center university hospital. Methods Indications were determined for consecutive studies by two reviewers and categorized as appropriate, uncertain, or inappropriate. Results Of 477 studies for which primary indications could be determined, 188 specifically related to university transplantation programs were excluded. Of the remaining 289 studies, 88% were addressed in the appropriateness criteria for SE. Of these, 71% were appropriate, 9% were uncertain, and 20% were inappropriate. Inappropriate studies were more likely to be ordered on younger patients and women and were less likely to be ordered by cardiologists. Abnormal results on SE were more frequent among appropriate than inappropriate studies. Conclusions The appropriateness criteria for SE encompass and effectively characterize the majority of studies ordered in a single-center university hospital and appear to reasonably stratify the likelihood of abnormal results on SE. However, revisions will be required to fully capture and stratify appropriate clinical practice of SE.

Direct oral anticoagulants (DOACs) reduce the thromboembolic risk in general populations with atrial fibrillation (AF), but their safety and effectiveness in dialysis patients is not well known and their use is discouraged due to a lack of empirical data. We identified dialysis patients with non

Cardiac chamber quantification from 3D transthoracic echocardiography (3D TTE) has been shown to be superior to measurements obtained from 2D studies. However, integration of 3D TTE into routine clinical practice has been limited by the time-consuming workflow and need for 3D expertise. We assessed

A 54-year-old female with a HeartMate II (Thoratec, Pleasanton, California) left ventricular assist device (LVAD) presented 3 months after implantation with new-onset severe aortic insufficiency (AI) and cardiogenic shock. A reoperation for surgical aortic valve closure was too high risk, so the

Purpose Both cardiovascular magnetic resonance (CMR) and 3D transthoracic echocardiography (3DE) can quantify right ventricular (RV) end diastolic volume (EDV) and ejection fraction (EF) accurately. This study was designed to estimate sample sizes and imaging costs to detect changes in RV EDV and EF using 3DE and CMR for future pulmonary arterial hypertension (PAH) drug trials. Methods and Materials Same day CMR and 3DE were performed on 20 PAH patients (age: 53±13 yrs, 19 females) at 0 and 6 months. Consecutive short axis cines spanning the entire RV (Philips 1.5-T scanner) and full-volume acquisitions of the RV (Philips iE33+TomTec 4D RV-Function software) were used to measure EDV and EF. Sample size calculations using two-sample repeated measures to account for changes over time were performed modeling a placebo-controlled trial (Stata v12.1). Cost estimates were made using the 2012 Medicare physician fee schedule. Results No significant differences were noted between 0- and 6-month RV EF and EDV measurements with either CMR or 3DE, but the relatively large SDs reflected variable progression of disease in individual patients on standard therapy. Sample sizes required for 3DE were roughly 3 times greater than CMR. Although the per-study cost of CMR (~$400) is approximately double that of 3DE (~$200), the total cost of a trial using CMR is considerably lower. Conclusions Both CMR and 3DE can be used to detect the effects of new PAH therapies on RV EDV and EF, but CMR is more cost-effective. Population characteristics (average ± SD) Baseline 6 months CMR 3DE CMR 3DE RV EF (%) 34 ± 15 32 ± 12 36 ± 11 33 ± 9 RV EDV (mL) 245 ± 58 195 ± 59 244 ± 71 199 ± 48 Estimated per-group sample sizes (placebo-controlled trial - 90% power) Estimated cost (US$) CMR 3DE CMR 3DE EF: 3% change 54 169 89,000 143,000 EF: 5% change 20 61 33,000 52,000 RVEDV: 20 mL change 44 138 73,000 117,000 RVEDV: 30 mL change 20 61 33,000 52,000