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Background: 3D printing technology has been used to practice cardiac structural interventions in a benchtop setting. We hypothesized that practice on such models under fluoroscopy using standard ac...

Transvenous pacing leads have been implicated in tricuspid valve dysfunction, and our group has adopted routine use of His bundle pacing to mitigate this effect. Three-dimensional (3D) printing technology holds great promise for advancing medicine, but the high start-up costs can be a deterrent. Seeking confirmation of optimal lead placement relative to the tricuspid annulus, we used low-cost commercial and public domain technologies to generate 3D-printed hearts from selected patients with His bundle pacing leads. Our models successfully demonstrated that such lead placements avoided interference with the tricuspid valve apparatus in these cases. Future applications of 3D printing include facilitating research to minimize lead-valve interactions, understand complex cardiac anatomy, and plan complex surgical procedures.

Objectives: Focused assessment with sonography in trauma (FAST) can define life-threatening injuries in austere settings with remote real-time review by experienced physicians. This study evaluates vest-mounted microwave, satellite, and LifeLink communications technology for image clarity and diagnostic accuracy during remote transmission of FAST examinations. Methods: Using a SonoSite, FAST was obtained on three patients with pericardial and intraperitoneal effusions and two control subjects in a remotely located U.S. Army Combat Support Hospital. A miniature vestmounted video transmitter attached to the SonoSite sent wireless ultrasound video 20 m to a receiving antenna. The signal was then transferred over VSAT satellite systems at 512 kilobaud per second (kbps), INMARSAT satellite systems at 64 kbps, and over LifeLink on a moving ambulance through a metropolitan wireless traffic‐management network. Clarity and absence or presence of effusions were recorded by 15 staff emergency physicians. Results: Average sensitivity, specificity, and accuracy were 87% (95% confidence interval [CI] ¼ 79% to 95%), 85% (95% CI ¼ 81% to 89%), and 86% (95% CI ¼ 82% to 90%) for the Premier WirelessVest;98%(95%CI ¼97%to99%),83%(95%CI ¼75% to 91%), and 86% (95% CI ¼ 82% to 90%) for VSAT; 95% (95% CI ¼ 94% to 96%), 70% (95% CI ¼ 58% to 82%), and 75% (95% CI ¼ 70% to 80%) for INMARSAT; and 82% (95% CI ¼ 73% to 91%), 83% (95% CI ¼ 74% to 92%), and 82% (95% CI ¼ 78% to 86%) for LifeLink with clarity of 3.0 (95% CI ¼ 2.7 to 3.3), 2.9 (95% CI ¼ 2.6 to 3.2), 1.3 (95% CI ¼ 1.2 to 1.4), and 2.1 (95% CI ¼ 1.8 to 2.4), respectively. Conclusions: Accuracy correlated with clarity. Roaming vest transmission of FAST provides interpretable, diagnostic imagery at the distances used in this study. VSAT provided the best clarity and diagnostic value with the lighter, more portable INMARSAT serving a lesser role for remote clinical interpretation. LifeLink performed well, and further infrastructure improvements may increase clarity and accuracy. Key words: ultrasound; FAST; telemedicine; prehospital; satellite; VSAT; INMARSAT; LifeLink. ACADEMIC EMERGENCY MEDICINE 2003; 10:1411‐1414.

Accessory left atrial cords are a rare but clinically important finding. If not diagnosed, or left untreated, it can result in severe mitral regurgitation, valvular cardiomyopathy, atrial fibrillation, or interfere with catheter manipulation during ablation. We present a case where the diagnosis of accessory cord was made …

Several investigators have documented the successful use of oral sustained‐release theophylline in treating symptomatic bradycardia and sick sinus syndrome. This paper reports a case of chronotropic incompetence in which specific exercise indices, including the chronotropic response index, were used to measure the therapeutic efficacy of theophylline.

Background Timely identification of hemodynamic compromise in patients with acute pericardial effusion and tamponade is critical in patient management. Respiratory variability in pulse-oximetry waveforms has been correlated with pulsus paradoxus, but has not been reported with cardiac tamponade in adult patients. Hypothesis This study describes changes in respiratory variability in pulse-oximetry waveform pre and post pericardiocentesis in patients with hemodynamically significant pericardial effusions. Methods A single-center, catheterization laboratory hemodynamic database was reviewed for all patients who underwent pericardiocentesis for clinically suspected tamponade and had continuous digital pulse-oximetry, electrocardiographic, and respiration waveforms recorded during the procedure. Phasic respiratory changes in pulse-oximetry waveform amplitude (maxima-minima) were expressed as an expiratory/inspiratory ratio and compared pre and post pericardiocentesis. Results The study population consisted of 12 patients (6 men:6 women, age 60 +/- 10 years) with pericardial effusion documented by echocardiography on the day of pericardiocentesis. Phasic respiratory variability in the pulse-oximetry waveform was evident in all patients prior to aspiration (respiratory ratio = 1.9 +/- 0.5). Following pericardiocentesis (aspirated volume: 650 +/- 300 ml), the respiratory ratio decreased in all patients (1.2 +/- 0. 1, p = 0.001). Receiver operator characteristic curve analysis suggests that pulse-oximetry respiratory ratios > or = 1.5 should raise suspicion of hemodynamic compromise in high-risk populations. Conclusions Pulse-oximetry is a commonly used tool for monitoring critically ill patients. The present study suggests that increased respiratory variability in the pulse-oximetry waveform should raise suspicion for hemodynamic compromise in patients at risk for pericardial effusion.

We sought to determine the reliability of frequently used landmarks for femoral arterial access in patients undergoing cardiac catheterization. The common femoral artery (CFA) is the most frequently used arterial access in cardiac catheterization. Arterial sheath placement into the CFA has been shown to decrease vascular complications. Some authors recommend locating the inferior border of the femoral head using fluoroscopy due to the relationship of the femoral head and the bifurcation of the CFA. We performed a descriptive study in a prospective design of 158 patients undergoing catheterization from the femoral approach. A femoral angiogram was performed, and the CFA bifurcation location was recorded in relation to the inguinal ligament, middle and inferior border of the femoral head, and the inguinal skin crease. The CFA bifurcation was distal to the inguinal ligament, middle femoral head, and inferior femoral head in most patients with mean distances (cm +/- SD) of 7.5 +/- 1.7, 2.9 +/- 1.5, and 0.8 +/- 1.2, respectively. The inguinal skin crease was below the bifurcation in 78% of patients (-1.8 +/- 1.6 cm). The CFA overlies the femoral head in 92% of cases. The femoral head has a consistent relationship to the CFA, and localization using fluoroscopy is a useful landmark.

Focused assessment with sonography in trauma (FAST) can define life-threatening injuries in austere settings with remote real-time review by experienced physicians. This study evaluates vest-mounted microwave, satellite, and LifeLink communications technology for image clarity and diagnostic accuracy during remote transmission of FAST examinations.Using a SonoSite, FAST was obtained on three patients with pericardial and intraperitoneal effusions and two control subjects in a remotely located U.S. Army Combat Support Hospital. A miniature vest-mounted video transmitter attached to the SonoSite sent wireless ultrasound video 20 m to a receiving antenna. The signal was then transferred over VSAT satellite systems at 512 kilobaud per second (kbps), INMARSAT satellite systems at 64 kbps, and over LifeLink on a moving ambulance through a metropolitan wireless traffic-management network. Clarity and absence or presence of effusions were recorded by 15 staff emergency physicians.Average sensitivity, specificity, and accuracy were 87% (95% confidence interval [CI]=79% to 95%), 85% (95% CI=81% to 89%), and 86% (95% CI=82% to 90%) for the Premier Wireless Vest; 98% (95% CI=97% to 99%), 83% (95% CI=75% to 91%), and 86% (95% CI=82% to 90%) for VSAT; 95% (95% CI=94% to 96%), 70% (95% CI=58% to 82%), and 75% (95% CI=70% to 80%) for INMARSAT; and 82% (95% CI=73% to 91%), 83% (95% CI=74% to 92%), and 82% (95% CI=78% to 86%) for LifeLink with clarity of 3.0 (95% CI=2.7 to 3.3), 2.9 (95% CI=2.6 to 3.2), 1.3 (95% CI=1.2 to 1.4), and 2.1 (95% CI=1.8 to 2.4), respectively.Accuracy correlated with clarity. Roaming vest transmission of FAST provides interpretable, diagnostic imagery at the distances used in this study. VSAT provided the best clarity and diagnostic value with the lighter, more portable INMARSAT serving a lesser role for remote clinical interpretation. LifeLink performed well, and further infrastructure improvements may increase clarity and accuracy.