No abstract

Simultaneous recordings of apex cardiogram, phonocardiogram, indirect carotid pulse, and electrocardiogram were made in 12 patients with acute myocardial infarction and in I2 normal subects of comparable age.The apex cardiogram showed in the patients increased amplitude and duration of the 'a' wave and in 40 per cent a notching. Half of the cases had a flat systolic plateau and over 8o per cent a systolic 'bulge'.The a-E interval and the time to the systolic peak of the apex cardiogram were significantly shortened. The systolic time intervals showed shortening of the pre-ejection period i, isovolumetric contraction time, electromechanical systole, and ejection time along with the E-J interval which represents the phase of maximum ventricular ejection. The changes observed were thought to be due to an increase in circulating catecholamines. Estimation of the urinary excretion of adrenaline and noradrenaline in two cases showed three times normal values.Apex cardiography is a technique for recording low frequency praecordial movements. It was introduced by Marey as early as I863 but was not generally used until about two decades ago. Since then it has been studied in different heart diseases, e.g. mitral valvular disease (Benchimol et al., i960), hypertrophic subaortic stenosis (Wolfe, I966), angina pectoris (Dimond and Benchimol, I963), ischaemic heart disease (Benchimol and Dimond, I962; R6rvik, i963), and left ventricular aneurysm (Ahuja, Gutierrez, and Manning, i967), but its value in acute myocardial infarction has so far not been explored. Apex cardiograms, phonocardiograms, and indirect carotid pulse tracings are now being commonly used to time the various systolic time intervals (Oreshkov, I968; Spodick and Kumar, I968). These are thought to give information about myocardial function from studies on patients with heart failure (Weissler, Harris, and Schoenfeld, i968), hypertension, coronary heart disease, cardiomyopathy, etc. (Tarazi, Frohlich, and Dustan, I969; Weissler, Harris, and Schoenfeld, I969). The purpose of this work is to study the apex cardiogram and systolic time intervals during the early stage of acute myocardial infarction.

Transposition of great vesselsAnomalous right pulmonary artery a b s t r a c t This report describes a rare case with hemitruncus with large left sided patent ductus arteriosus with severe pulmonary hypertension with reversal of shunt across patent ductus simulating transposition of great arteries. The case illustrates the role of echocardiography and cardiac multidetector CT in diagnosing such complex congenital heart disease.A 40-day-old female baby was referred for evaluation of repeated respiratory tract infection and hurried breathing and progressive weight loss. On clinical examination she was underweight (2.5 kg) and had central cyanosis. The respiratory rate was 55/min and heart rate was 175/min. Oxygen saturation was 76%. Precordial examination revealed loud second sound and mid systolic murmur at pulmonary area. There was S3 gallop. The electrocardiogram revealed right ventricular hypertrophy with right axis deviation. A chest roentgenogram showed marked cardiomegaly with a cardiothoracic ratio of 70% and bilateral increased pulmonary vascularity.Transthoracic echocardiography showed situs solitus with levocardia. There was biventricular dilatation. The subcostal 5 chamber view showed a great artery arising from the left ventricle which was branching at short distance from the origin (Fig. 1 A, Video 1). In short axis view another nonbranching great vessel was seen arising from the right ventricle (Fig. 1B, Video 2). In a modified subcostal view the great artery arising from the right ventricle appeared to continue as descending thoracic aorta (Fig. 1C) which was later confirmed to be large PDA connecting LPA and descending thoracic aorta on CT aortogram. The origins of

In the United States, the positive predictive value (PPV) of cardiac troponin for type 1 myocardial infarction is substantially lower than in Europe (15% vs. 50%). Further, even with publication of the 4 th Universal Definition of Myocardial Infarction, recent studies have shown that inaccurate classification of myocardial injury is common among clinicians in the United States. These findings are at least partly attributable to clinicians’ knowledge and attitudes about cardiac troponin testing; a survey of these parameters has never been conducted. Clinicians at the University of Colorado completed a brief 8-question multiple-choice survey related to troponin use, definitions of myocardial infarction and clinical assessment of elevated troponin levels. The survey was distributed via secure email and administered electronically using the Qualtrics™ platform. Responses were anonymous, completion was estimated to take 3 minutes and a lottery award system was used as an incentive for participation. Respondents included trainees, advanced practice providers and attending physicians from internal medicine, emergency medicine and medical subspecialties. We plan to obtain a total of 300 responses with descriptive findings of preliminary results included below. The survey was completed by 114 clinicians: 37 interns (32%), 45 residents (39%), 9 advanced practice providers (8%), 11 fellows (10%), and 12 attending physicians (11%). Regarding indications for troponin testing, 93% (106/114) indicated that they “usually” or “always” check troponin levels in patients with chest pain. More interestingly, 46% (52/112) reported checking troponin on “undifferentiated patients” at least half the time. For troponin interpretation, 97% (110/114) of participants identified that troponin levels alone cannot rule in or rule out coronary artery disease. In contrast, only 36% (41/114) and 55% (63/114), respectively, identified the NPV and PPV of a contemporary troponin assay for type 1 MI. Further, only 50% (57/114) of respondents identified that the likelihood of type 1 MI increases as troponin levels increase. Three brief clinical vignettes revealed that, while 78% (89/114) and 74% (45/61) of participants, respectively, identified type 1 MI and type 2 MI presentations, only 40% (21/53) of respondents correctly identified a vignette for non-ischemic myocardial injury. Concordant with this finding, 54% (61/114) of clinicians correctly identified the 4 th Universal Definition of Myocardial Infarction. These preliminary findings highlight important facets of clinician attitudes and knowledge about troponin testing that help explain the poor PPV for troponin and diagnostic misclassification observed among U.S. clinicians. These results could help guide curricular and clinical decision support interventions designed to improve the use and interpretation of cardiac troponin testing.

Left ventricular non-compaction (LVNC) is a congenital cardiomyopathy characterized by deep ventricular trabeculations thought to be due to an arrest of myocardial morphogenesis. Integration of various cardiac imaging modalities such as echocardiography, cardiac computed tomography and cardiac magnetic resonance imaging help in the diagnosis of this rare clinical entity. We describe a child with rare variant of LVNC with predominant involvement of interventricular septum resulting in multiple ventricular septal defects.