Abstract Background Preliminary data comparing 3‐dimensional computed tomography (3D‐CT) to transesophageal echocardiography (TEE) for left atrial appendage occlusion (LAAO) indicates that 3D‐CT provides more accurate measurements and improves case planning. Therefore, we conducted a pilot study comparing 3D‐CT to TEE in occluder selection accuracy and procedural efficiency. Methods From May 2016 to February 2017, 24 patients were prospectively randomized to undergo LAAO using either TEE or 3D‐CT. The primary endpoint was device accuracy while the secondary endpoints included # devices per case, # guide catheters used per case, # fluoroscopy angles used, procedure time, fluoroscopy time, radiation dose, and major adverse events (stroke, MI, device embolization, perforation, death). Results Procedure success was 100% and 92% for the 3D‐CT and 2D‐TEE cohorts respectively. Accuracy for 1st device selection 92% and 27% ( P = .01) for 3D‐CT and 2D‐TEE respectively but with intra‐procedural upsizing in the 2D‐TEE cohort, the 2D‐TEE cohort accuracy increased to 64% while the 3D‐CT groups 92% was accurate ( P = .33). Case planning using 3D‐CT was significantly more efficient with respect to device utilization (CT 1.33 ± 0.7 vs. 2D‐TEE 2.5 ± 1.2 P = .01), guide catheters (CT 1 vs. 2D‐TEE 1.7 ± 0.8 P = .01) and procedure time (3D‐CT 55 ± 17 min vs. 2D‐TEE 73 ± 24 min P < .05). One major adverse event, a stroke occurred in the 2D‐TEE group. Conclusion In this single‐center pilot study, CT guided LAAO case planning was associated with improved device selection accuracy and procedural efficiency. This study data supports the notion that comprehensive 3D assessment significantly simplifies LAAO, minimizing the time and number of steps needed.
Myocardial abscess is an extremely rare entity and is often deadly in nature. We present a case of a patient with recent orthotopic liver transplant, on immunosuppression, who presented with cardiac tamponade due to Aspergillus fumigatus pericarditis and associated myocardial abscess. The diagnosis was made based on computed tomography imaging, culture of pericardial fluid for Aspergillus, and transthoracic echocardiography. The patient received antifungal therapy with clinical improvement and documented reduction in abscess size based on repeat echocardiogram. Aspergillus myocardial abscess is an extremely rare diagnosis but should be considered in an immunosuppressed patient presenting with pericardial effusion or ventricular mass.
BackgroundAs the Watchman device is new, no studies have yet reported on healthcare disparity issues in this population. We sought to investigate socioeconomic and racial disparities among select atrial fibrillation (AF) patients who did or did not receive Watchman device placement.MethodsThis retrospective case-control study included patients with non-valvular AF requiring long-term anticoagulation who underwent left atrial appendage (LAA) exclusion with the Watchman device at our institution from June 2015 to December 2016. A control group was designed by medical records query for patients with non-valvular AF requiring long-term anticoagulation with an elevated risk of bleeding (defined by hospital admission for major bleeding episodes and discharged off anticoagulation), but not referred for LAA closure within the study period. Differences in median income, type of insurance coverage, race, sex, and age were analyzed.ResultsOf 201 patients, 98 received the Watchman device (intervention) and 103 did not (control). The mean estimated income was significantly higher for intervention than control patients ($70,908.50 ± $25,847.20 vs. $56,569.90 ± $17,730.90; p < 0.001). African-American patients were less likely to receive the Watchman insertion (5% vs. 27%; p < 0.001). Control patients had a higher percentage with Medicaid by both primary (6% vs. 0; p = 0.029) and dual coverage of Medicare and Medicaid (13% vs. 4%; p = 0.041). No significant difference occurred in gender.ConclusionSocioeconomic and racial disparities exist in patients with non-valvular AF at elevated risk of bleeding. African-American patients with lower income and Medicaid are less likely to be referred for the Watchman device.
Objective Cardiac angiosarcoma is the most common primary malignant cardiac tumor. The dismal prognosis and nonspecific symptomatology underscore the need for an accurate and cost‐effective approach to the identification and characterization of this rare tumor. Methods Mayo Clinic tissue registry archives were queried for all histologically confirmed cases of cardiac angiosarcoma (1976–2013) with available imaging data. Echocardiograms were retrospectively reviewed. Results Thirty‐three cases of cardiac angiosarcoma were identified; of these, 17 had echocardiograms available (mean age, 46 years; six men). Transthoracic echocardiography ( TTE ) as the initial diagnostic test had 75% sensitivity for visualizing primary cardiac angiosarcoma (9/12 patients). Tumor extension into the pericardium was common and pericardial effusion was present in 15 patients (88%); however, pericardial fluid cytology was negative for malignancy in all tested patients (n = 15). Left ventricular ejection fraction ( LVEF ) was preserved in 16 patients (94%) (average LVEF , 62%). Right ventricular function was mildly reduced in two patients (12%) at initial presentation. Tricuspid valve obstruction was present in three patients (18%; mean diastolic gradient, 6.3 mmHg [range, 3–11 mmHg]). Conclusion The sensitivity of TTE as the first diagnostic imaging modality compared favorably with computed tomography. Pericardial effusion was common, but pericardial fluid cytology was negative in all patients who underwent pericardiocentesis. The absence of a stalk was a universal finding that may help distinguish angiosarcoma from benign, primarily pedunculated tumors such as myxoma and papillary fibroelastoma.
