Supplementary Material for: Biventricular Rupture with Extracardiac Left-to-Right Shunt Complicating Acute Myocardial Infarction

<b><i>Background:</i></b> Simultaneous rupture of the left and right ventricles is an extremely rare mechanical complication of acute myocardial infarction (MI). When associated with the formation of a false aneurysm, an extracardiac left-to-right shunt may occur. <b><i>Methods:</i></b> We summarized all published data describing this unique condition. We searched the PubMed and Google Scholar databases for case reports in peer-reviewed journals from 1 January 1980 to 1 May 2015. We identified 16 articles describing 17 cases. <b><i>Results:</i></b> In all but 1 case, biventricular wall rupture (BVWR) resulted from an inferior MI. The clinical presentations of BVWR were variable and included cardiogenic shock, congestive heart failure and an absence of any cardiac symptoms. In most cases, there was a hemodynamically significant left-to-right shunt, with pulmonary to systemic blood flow (Qp/Qs) >2. Diagnostic difficulties were reported in most cases, and some patients were initially misdiagnosed as having ventricular septal rupture (VSR). Surgical closure of the defect was successful in most cases, and some asymptomatic patients were managed conservatively. <b><i>Conclusion:</i></b> BVWR with an intact interventricular septum and extracardiac left-to-right shunt is a rare mechanical complication of acute MI, often misdiagnosed as VSR. It has a variable clinical course, probably related to the magnitude of the shunt

Acute Effects of Insulin on Cardiac Function in Patients with Diabetes Mellitus: Clinical Applicability and Feasibility

Background. Insulin promotes glucose consumption as the main cardiac energy source, while increasing myocardial efficiency. The short-term effects of insulin on cardiac function and its potential curative role in an acute diabetological cardiology setting remain unknown. Our study evaluated the role of acute insulin administration in the diabetic heart, its corresponding effective blood insulin level, and the time-course applicability of insulin treatment in a routine clinical setting. Methods. We evaluated a case series of six male (48.1 ± 4.9 y/o) patients with controlled diabetes (HbA1c of 6.6 ± 0.3%) and disease duration of 14.4 ± 6.7 yr. Each subject was evaluated for glucose homeostasis, as well as hemodynamic and echocardiographic (systolic and diastolic) parameters at three points: baseline followed by two successive insulin loads in euglycemic hyperinsulinemic clamp study. Results were analysed using Student’s t-test. Results. The first insulin load led to a physiologic blood insulin level of 145 ± 36 μU/ml, and both systolic (7 mmHg) blood pressure and diastolic (4 mmHg) blood pressure decreased significantly. Left ventricular fractional shortening (LVFS) increased significantly by 11.8%. Diastolic function parameters of mitral annulus movement of the A′ wave increased relative to baseline by 20.0% (27.8% under the second insulin load), A′ medial increased relative to baseline by 30%, and A′ lateral increased relative to baseline by 17%, displayed by tissue Doppler imaging. Conclusions. Insulin acutely affected the diabetic heart at a physiologic level within a 2 h time course. Insulin mainly increased left ventricular systolic function and, to a second degree, improved left ventricular diastolic functions and atrial systole in diabetic subjects. These results may facilitate the development of insulin-based acute treatment in diabetic patients with cardiac morbidity. This trial is registered with NCT02962921

Accuracy of the long-axis area-length method for the measurement of left ventricular volumes and ejection fraction using multidetector computed tomography

Multidetector computed tomography (MDCT) is useful for assessing left ventricular (LV) volumes and function. Validation has mainly been carried out using Simpson's method of summing up consecutive short-axis areas. Because the latter method is time-consuming, many users prefer using a quicker method, based on a single view or a pair of views. To evaluate the accuracy of the long-axis area-length method (AL), which has not been validated for MDCT, using Simpson's method as the gold standard, as well as right anterior oblique LV angiography as a clinical standard. Twenty-three patients admitted with acute chest pain were clinically evaluated with electrocardiogram-gated MDCT and invasive LV angiography. MDCT-based end-diastolic, end-systolic and stroke volumes, and ejection fraction (EF) were calculated using Simpson's method, biplane AL and single-plane AL. For LV angiography, EF was calculated using single-plane AL. A Bland-Altman analysis showed a close agreement between biplane AL and Simpson's method for EF, with 1% underestimation, 95% CI of ±11% and a correlation of 0.89. For end-diastolic, end-systolic and stroke volumes, overestimations of 7 mL, 4 mL and 2 mL, and 95% CI of ±27 mL, ±15 mL and ±26 mL, respectively were found. Correlation coefficients were 0.95, 0.97 and 0.82, respectively. Comparisons with LV angiography were considerably weaker. The vertical long-axis AL method by MDCT correlated better with both LV angiography and Simpson's method than the horizontal long-axis AL method. The biplane AL method gives results for EF, which correspond closely with the more cumbersome Simpson's method, although volumes are slightly overestimated. La tomographie à multidétecteurs (TGMD) est utile pour évaluer les volumes et la fonction ventriculaires gauches (VG). La validation a été pour une bonne part réalisée à l’aide de la méthode de Simpson établissant la somme des aires axe court consécutives. Parce que cette dernière méthode est fastidieuse, de nombreux utilisateurs préfèrent une méthode plus rapide basée sur une ou deux perspectives. Évaluer la précision de la méthode aire-longueur (AL) long axe, qui n’a pas été validée pour la TGMD, à l’aide de la méthode de Simpson comme étalon-or et à l’aide de l’angiographie VG droite antérieure oblique comme norme clinique. Vingt-trois patients admis pour DRS aiguë ont été évalués sur le plan clinique au moyen d’une TGMD synchronisée avec l’électrocardiogramme et d’une angiographie VG effractive. Les volumes télédiastoliques, télésystoliques, le volume d’éjection systolique et la fraction d’éjection (FÉ) ont été calculés à l’aide de la méthode de Simpson AL bidimensionnelle et AL unidimensionnelle. Pour l’angiographie VG, la FÉ a été calculée à l’aide de la méthode AL unidimensionnelle. Une analyse de Bland-Altman a montré une concordance étroite entre la méthode AL bidimensionnelle et la méthode de Simpson pour la FÉ, avec une sous-estimation de 1% et un IC à 95% de ± 11% et un coefficient de 0,89. Pour les volumes télédiastoliques, télésystoliques et d’éjection systolique, on a observé des surestimations de 7 mL, 4 mL, 2 mL, et des IC à 95% de ± 27 mL, ± 15 mL et ± 26 mL. Les coefficients de corrélation étaient de 0.95, 0.97 et 0.82, respectivement. Les comparaisons avec l’angiographie VG ont été considérablement plus faibles. La méthode AL long axe par TGMD a été en meilleure corrélation avec l’angiographie VG et avec la méthode de Simpson, comparativement à la méthode AL long axe horizontale. La méthode AL bidimensionnelle donne des résultats de FÉ qui correspondent étroitement avec la méthode de Simpson, plus fastidieuse, même si les volumes sont légèrement surestimés

Clinical evaluation of a fully automated model-based algorithm to calculate left ventricular volumes and ejection fraction using multidetector computed tomography

Objectives: To evaluate feasibility and accuracy of a fully automatic algorithm (FAA) for calculating left ventricular volumes and ejection fraction (LVEF) from multidetector computed tomography (MDCT) studies versus a previously validated method based on Simpson's method serving as our reference standard (RS), and left ventriculography (LVG), in patients with acute chest pain (ACP). Methods: 23 patients admitted with ACP underwent ECG-gated MDCT, as well as LVG during their hospitalization. MDCT based end-diastolic, end-systolic and stroke volumes (EDV, ESV, SV) and LVEF were calculated using the RS and the FAA. Results: One patient was excluded after FAA failure to detect contours. In the remaining 22 patients, mean±SD LVEF measurements were RS 61±11%, FAA 59±11% (r = 0.91 versus RS), LVG 57±16% (r = 0.6 versus RS). In comparison to RS, FAA overestimated EDV by 10.1±8.5 ml, ESV by 7.3±6.4 ml and SV by 3.6±8.6 ml, and underestimated LVEF measurements by 2.7±4.6%, related to contour smoothing. LVEF by FAA was within 8% of RS for all patients except one. In contrast, LVG differed significantly from RS. Conclusions: The evaluated FAA obtained accurate, clinically relevant results for left ventricular volumes and LVEF relative to the RS

The effect of TEE on treatment change in patients with acute ischemic stroke.

Background and purposeIschemic stroke is a widespread disease carrying high morbidity and mortality. Transesophageal echocardiography (TEE) is considered an important tool in the work-up of patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients; its utility is limited by a semi-invasive nature. The purpose of this study was to evaluate the probability of treatment change due to TEE findings (yield) in the work-up of AIS and TIA patients.MethodsRetrospective data on patients with AIS or TIA who underwent TEE examination between 2000-2013 were collected from the institutional registry.ResultsThe average age of 1284 patients who were included in the study was 57±10.4, 66% of patients were male. The most frequent TEE findings included aortic plaques in 54% and patent foramen ovale (PFO) in 15%. TEE findings led to treatment change in 135 (10.5%) patients; anticoagulant treatment was initiated in 110 of them (81%). Most common etiology for switch to anticoagulation was aortic plaques (71 patients); PFO was second most common reason (26 patients). Significant TEE findings (thrombus, endocarditis, tumor) were found in 1.9% of patients, they were more common in young patients (ConclusionsThe beginning of anticoagulation treatment in patients with thick and complicated plaques was found frequently in our study. Significant TEE findings, were infrequent, constituted an absolute indication for treatment change and were more common in younger patients

Current Perspectives on Coronary Chronic Total Occlusions The Canadian Multicenter Chronic Total Occlusions Registry

ObjectivesThe purpose of this study was to determine the prevalence, clinical characteristics, and management of coronary chronic total occlusions (CTOs) in current practice.BackgroundThere is little evidence in contemporary literature concerning the prevalence, clinical characteristics, and treatment decisions regarding patients who have coronary CTOs identified during coronary angiography.MethodsConsecutive patients undergoing nonurgent coronary angiography with CTO were prospectively identified at 3 Canadian sites from April 2008 to July 2009. Patients with previous coronary artery bypass graft surgery or presenting with acute ST-segment elevation myocardial infarction were excluded. Detailed baseline clinical, angiographic, electrocardiographic, and revascularization data were collected.ResultsChronic total occlusions were identified in 1,697 (18.4%) patients with significant coronary artery disease (>50% stenosis in ≥1 coronary artery) who were undergoing nonemergent angiography. Previous history of myocardial infarction was documented in 40% of study patients, with electrocardiographic evidence of Q waves corresponding to the CTO artery territory in only 26% of cases. Left ventricular function was normal in >50% of patients with CTO. Half the CTOs were located in the right coronary artery. Almost half the patients with CTO were treated medically, and 25% underwent coronary artery bypass graft surgery (CTO bypassed in 88%). Percutaneous coronary intervention was done in 30% of patients, although CTO lesions were attempted in only 10% (with 70% success rate).ConclusionsChronic total occlusions are common in contemporary catheterization laboratory practice. Prospective studies are needed to ascertain the benefits of treatment strategies of these complex patients