Changing the Way We “See” Scar: How Multimodality Imaging Fits in the Electrophysiology Laboratory

Substrate characterization is the mainstay of ablation for ventricular tachycardia (VT). Although the use of electroanatomic voltage mapping (EAVM) in the electrophysiology (EP) laboratory has enabled real-time approximation of myocardial scar, it has limitations. This is related to the subjective and tedious nature of voltage mapping and the challenges of defining the transmurality of scar. Various noninvasive methods of scar assessment have emerged, with magnetic resonance imaging (MRI) being the most accurate. Integrated MRI and electroanatomic voltage mapping studies demonstrate good correlation. Nonetheless, MRI has advantages. These include (1) preprocedure identification of epicardial and intramural scar, (2) assessment of ablative lesion formation after unsuccessful ablations, (3) identification of heterogeneous regions of scar, where critical conducting channels are likely to occur, and (4) predictive value in the assessment of sudden cardiac death (SCD). Integration of scar imaging in ventricular tachycardia ablation and risk stratification has great potential to advance the practice of arrhythmia management

Simulation-based training of transesophageal echocardiography for cardiology fellows.

Methods We created a curriculum on a TEE simulator (HeartWorks, Inventive Medical Ltd., London, UK) that applied B-mode imaging and a three-dimensional model (Fig. 1); Doppler functions and pathology cases were not available. The curriculum was divided into four sessions of 1–2 h duration; each session was a one-on-one between one experienced echocardiographer (DW, AW, RD, or CS) and one fellow. The topics for the four sessions were: (1) basic imaging planes and ventricular function; (2) aortic and mitral valve imaging; (3) pulmonary and tricuspid valve imaging; and (4) other structures (pulmonary veins, great vessels, interatrial septum). Fellows assessed the curriculum and TEE self-confidence with a five-point scale and narrative responses. The fellows’ curriculum evaluations were anonymized and their use was authorized for research purposes by our Institutional Review Board; the requirement for informed consent was waived. Results Between 2012 and 2014, 17 fellows completed the curriculum, of which 15 completed the assessment. All fellows were encouraged to complete the assessment; however, because they were anonymous, we could not directly encourage them further. The median self-confi- dence increased from 3 to 4 (P = 0.02, Wilcoxon signedrank test). After the training, all fellows reported that their self-confidence in TEE skills was at least ‘‘moderate’’ (Fig. 2). All fellows agreed or strongly agreed that the curriculum was ‘‘a valuable addition to my training’’; 86.7% felt the duration was appropriate. Multiple fellows indicated a preference for additional training on pathologic conditions. No negative comments were received. Discussion Cardiology fellows report value and increased self-confi- dence in TEE skills after completing a simulator-based training curriculum. Reports from other institutions using TEE simulators have found improvements in image acquisition and self-reported confidence [1–4]

Comparative accuracy of supine-only and combined supine-prone myocardial perfusion imaging in men.

BACKGROUND: Combined supine-prone myocardial perfusion imaging (CSP MPI) has been shown to reduce attenuation artifact in comparison to supine-only (SU) MPI in mixed-gender populations with varying risk for coronary artery disease (CAD), often where patients served as their own controls. However, there is limited direct comparison of these imaging strategies in men. METHODS: 934 male patients underwent CSP or SU MPI. Diagnostic certainty of interpretation was compared. Within the cohort, 116 were referred for left heart catheterization (LHC) to assess for CAD. Sensitivity, specificity, and area under the curve (AUC) were compared with additional analysis based on body mass index (BMI). RESULTS: 597 patients completed the SU protocol and 337 patients completed the CSP protocol. Equivocal studies were seen more frequently in the SU group (13%) than in the CSP group (4%, P \u3c .001). At catheterization, the specificity for CSP MPI of 70% was higher than 40% for SU MPI (P = .032). The CSP AUC (0.80 ± 0.06) was significantly larger than SU AUC (0.57 ± 0.05, P = .004). CSP specificity was significantly higher in obese patients. CONCLUSIONS: CSP MPI increases diagnostic certainty and improves test accuracy for CAD detection in men with CAD risk factors, especially obese patients, compared to SU MPI