Cardiac papillary fibroelastomas (CPF) are rare, benign tumors with thromboembolic potential. We present a 40-year-old male with a right atrial CPF, referred with acute chest pain. Advanced imaging and surgical excision with tricuspid valve repair were crucial, emphasizing the need for early detection and intervention in symptomatic and asymptomatic cases.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second leading cause of death due to traumas in young patients. The primary presentation might be chest or interscapular pain, difficulty in breathing, and, in severe cases, hypotension. Considering the rapid deterioration of these patients\' clinical conditions, prompt diagnosis and treatment initiation are crucial. In these injuries, the most involved parts of the aorta are the isthmus (distal to the left subclavian artery) and the descending part in the thorax. Therefore, the main diagnostic strategies include transthoracic echocardiography, CT angiography, and endovascular diagnostic approaches. Case presentation The patient was a 19-year-old male presenting with the symptoms of chest pain, dyspnea, and extremities excruciating pain after a car turnover. The initial evaluation showed no abnormal cardiovascular finding except bilateral hemothorax, addressed with chest tubes. Twelve hours later, when the patient was under observation for orthopedic surgeries, his chest pain and dyspnea started, and TTE and CTA showed a grade three descending aneurysm of the aorta. The patient was treated immediately with an endovascular procedure of stent implantation. A delayed debranching surgery was also performed, which resulted in desirable outcomes and uneventful follow-up.
CONCLUSIONS: Although open thoracic surgery is the main and almost the only option for treating aneurysms of the aorta in hemodynamically unstable patients, the endovascular procedure has shown superior outcomes in selected patients with appropriate anatomy. Debranching surgery, which can be done simultaneously or with delay after the initial procedure, has proven protective against thromboembolic cerebral events.
UNASSIGNED: Patients with an aneurysm of the aorta should be transported to a medical center with a multidisciplinary team for an urgent evaluation and treatment. The initial resuscitation and diagnosis are challenging, considering the fatal nature of these injuries, and the selection of the treatment is based on the patient\'s clinical condition and evaluated anatomy in cardiovascular imaging.

OBJECTIVE: Hypotension after induction of general anesthesia is common and is associated with significant adverse events. Identification of patients at high risk can inform the use of preoperative mitigation strategies. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the inferior vena cava collapsibility index (IVC-CI) and maximal diameter (dIVCmax) in predicting postinduction hypotension and to identify their predictive performance across different threshold ranges.
METHODS: We searched MEDLINE, PubMed®, and Embase from inception to March 2023 for prospective observational studies exploring the performance of IVC-CI and dIVCmax in predicting postinduction hypotension in adults presenting for elective surgery under general anesthesia. We excluded studies reporting on IVC parameters predicting postinduction hypotension in the obstetric patient population or exclusively in patients with obesity. Trials screening and data extraction were conducted independently. We performed meta-analyses to identify the performance of IVC parameters in predicting postinduction hypotension, followed by subgroup analyses that sought the IVC-CI range with the highest hierarchical summary receiver-operating characteristic area under the curve (HSROC-AUC). We used a bivariate random effects model to calculate summary estimates. We evaluated study quality using Newcastle-Ottawa scores and certainty of evidence using the GRADE framework.
RESULTS: We included 14 studies involving 1,166 patients. Pooled sensitivity and specificity of the IVC-CI to predict postinduction hypotension was 0.68 (95% confidence interval [CI], 0.55 to 0.79; coverage probability, 0.91) and 0.78 (95% CI, 0.69 to 0.85; coverage probability, 0.9), respectively, with an HSROC-AUC of 0.80 (95% CI, 0.68 to 0.85, high quality of evidence). An IVC-CI threshold range of 40-45% had an HSROC-AUC of 0.86 (95% CI, 0.69 to 0.93, high quality of evidence).
CONCLUSIONS: Preoperative IVC-CI is a strong predictor of postinduction hypotension. We recommend that future studies use an IVC-CI threshold of 40-45% (low certainty of evidence). Future studies are needed to establish whether ultrasound-guided preoperative optimization improves outcomes in high-risk patients.
BACKGROUND: PROSPERO ( CRD42022316140 ); first submitted 10 March 2022.
RéSUMé: OBJECTIF: L’hypotension après l’induction de l’anesthésie générale est fréquente et est associée à des effets indésirables importants. L’identification des patient•es à haut risque peut éclairer l’utilisation de stratégies préopératoires d’atténuation. Nous avons réalisé une revue systématique et une méta-analyse pour évaluer la précision diagnostique de l’indice de collapsibilité de la veine cave inférieure (IC-VCI) et du diamètre maximal (dVCImax) pour prédire l’hypotension post-induction et identifier leurs performances prédictives dans différentes plages de seuils. MéTHODE: Nous avons fait des recherches dans les bases de données MEDLINE, PubMed® et Embase de leur création jusqu’en mars 2023 pour en extraire les études observationnelles prospectives explorant les performances de l’IC-VCI et du dVCImax pour la prédiction de l’hypotension post-induction chez des adultes se présentant pour une chirurgie non urgente sous anesthésie générale. Nous avons exclu les études rapportant des paramètres de VCI prédisant l’hypotension post-induction dans la population obstétricale ou exclusivement chez des personnes obèses. Le tri des études et l’extraction des données ont été menés indépendamment. Nous avons réalisé des méta-analyses pour identifier la performance des paramètres de VCI dans la prédiction de l’hypotension post-induction, suivies d’analyses de sous-groupes qui ont recherché la plage d’IC-VCI avec le plus haut niveau de hiérarchie de l’aire sous la courbe de la courbe ROC (HSROC-AUC). Nous avons utilisé un modèle bivarié à effets aléatoires pour calculer des estimations sommaires. Nous avons évalué la qualité des études à l’aide des scores de Newcastle-Ottawa et la certitude des données probantes à l’aide de l’outil GRADE. RéSULTATS: Quatorze études portant sur 1166 patient·es ont été incluses. La sensibilité et la spécificité combinées de l’IC-VCI pour prédire l’hypotension post-induction étaient de 0,68 (intervalle de confiance [IC] à 95 %, 0,55 à 0,79; probabilité de couverture, 0,91) et 0,78 (IC 95 %, 0,69 à 0,85; probabilité de couverture, 0,9), respectivement, avec une HSROC-AUC de 0,80 (IC 95 %, 0,68 à 0,85, données probantes de haute qualité). Une plage de seuils d’IC-VCI de 40 à 45 % avait une HSROC-AUC de 0,86 (IC 95 %, 0,69 à 0,93, haute qualité des données probantes). CONCLUSION: L’IC-VCI préopératoire est un bon prédicteur de l’hypotension post-induction. Nous recommandons que les études futures utilisent un seuil d’IC-VCI de 40 à 45 % (faible certitude des données probantes). De futures études sont nécessaires pour déterminer si l’optimisation préopératoire échoguidée améliore les devenirs chez la patientèle à risque élevé. ENREGISTREMENT DE L’éTUDE: PROSPERO ( CRD42022316140 ); première soumission le 10 mars 2022.

BACKGROUND: Transthoracic echocardiography (TTE) is currently recognized as the potential first-line imaging test for patients with suspected acute type A aortic syndrome (AAAS). Direct TTE sign for detecting AAAS is positive if there is an intimal flap separating two aortic lumens or aortic wall thickening seen in the ascending aorta. Indirect TTE sign indicates high-risk features of AAAS, such as aortic root dilatation, pericardial effusion, and aortic regurgitation. Our aim is to summarize the existing clinical evidence regarding the diagnostic accuracy of TTE and to evaluate its potential role in the management of patients with suspected AAAS.
METHODS: We included prospective or retrospective diagnostic cohort studies, written in any language, that specifically focused on using TTE to diagnose AAAS from databases such as PubMed, EMBASE, MEDLINE, and the Cochrane Library. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio [1], and hierarchical summary receiver-operating characteristic (HSROC) curve were calculated for TTE in diagnosing AAAS. We applied Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality assessment criteria.
RESULTS: Ten studies (2886 patients) were included in the meta-analysis. The pooled sensitivity and specificity of direct TTE signs were 58% (95% CI, 38-76%) and 94% (95% CI, 89-97%). For any TTE signs, the pooled sensitivity and specificity were 91% (95% CI, 85-94%) and 74% (95% CI, 61-84%). The diagnostic accuracy of direct TTE signs was significantly higher than that of any TTE signs, as measured by the area under the HSROC curve [0.95 (95% CI, 0.92-0.96) vs. 0.87 (95% CI, 0.84-0.90)] in four studies.
CONCLUSIONS: Our study suggests that TTE could serve as the initial imaging test for patients with suspected AAAS. Given its high specificity, the presence of direct TTE signs may indicate AAAS, whereas the absence of any TTE signs, combined with low clinical suspicion, could suggest a lower likelihood of AAAS.

Penetrating cardiac trauma is a fatal condition and can result in the injury of various parts of the heart. Ventricular Septal Defect (VSD) following these traumas occurs only in 1-5% of cases. The patients\' conditions depend on location, size, and concomitant injuries. One of the uncommon coincidences with the VSD is Mitral Regurgitation (MR) due to injury to sub-valvular structures. In this study, we report a case of concomitant traumatic-induced VSD and MR in a 14-year-old boy following a stab wound to his chest. The patient was a teenage boy coming to the Rajaei Cardiology Hospital emergency room following a stab wound to the anterior and left part of his chest. Despite primary urgent surgery, his breathlessness had continued for three more months. Evaluations with Transthoracic Echocardiography (TTE) revealed VSD with concomitant MR, but there was no papillary muscle rupture. Cardiac Magnetic Resonance Imaging (MRI) and angiographic evaluation confirmed the provisional diagnosis. The Amplatzer VSD occluder repaired the VSD, and the patient was discharged following the resolution of his symptoms. Although the MR has been present in the follow-up echocardiography, the patient has been asymptomatic. Since the initial presenting symptoms and signs of VSD and MR might be subtle or delayed, imaging modalities such as TTE and Transesophageal Echocardiogram (TEE) are beneficial in determining the diagnosis and the optimal treatment.

BACKGROUND: Given the limited access to invasive vasospastic reactivity testing in Western Countries, there is a need to further develop alternative non-invasive diagnostic methods for vasospastic angina (VSA). Hyperventilation testing (HVT) is defined as a class IIa recommendation to diagnose VSA by the Japanese Society of Cardiology.
METHODS: In this systematic review and meta-analysis reported according to the PRISMA statement, we review the mechanisms, methods, modalities and diagnostic accuracy of non-invasive HVT for the diagnostic of VSA.
RESULTS: A total of 106 articles published between 1980 and 2022 about VSA and HVT were included in the systematic review, among which 16 were included in the meta-analysis for diagnostic accuracy. Twelve electrocardiogram-HVT studies including 804 patients showed a pooled sensitivity of 54% (95% confidence intervals [CI]; 30%-76%) and a pooled specificity of 99% (95% CI; 88%-100%). Four transthoracic echocardiography-HVT studies including 197 patients revealed a pooled sensitivity of 90% (95% CI; 82%-94%) and a pooled specificity of 98% (95% CI; 86%-100%). Six myocardial perfusion imaging-HVT studies including 112 patients yielded a pooled sensitivity of 95% (95% CI; 63%-100%) and a pooled specificity of 78% (95% CI; 19%-98%). Non-invasive HVT resulted in a low rate of adverse events, ventricular arrhythmias being the most frequently reported, and were resolved with the administration of nitroglycerin.
CONCLUSIONS: Non-invasive HVT offers a safe alternative with high diagnostic accuracy to diagnose VSA in patients with otherwise undiagnosed causes of chest pain.

BACKGROUND: Transthoracic echocardiography (TTE) plays a key role in the initial work-up of myocarditis where the identification of pathologic structural and functional changes may assist in its diagnosis and management. The aim of this systematic review was to appraise the evidence for the utility of echocardiographic parameters of cardiac structure and function in the diagnosis of myocarditis in adult populations.
METHODS: A systematic literature search of medical databases was performed using PRISMA principles to identify all relevant studies assessing TTE parameters in adult patients with myocarditis (1995-2020; English only; PROSPERO registration CRD42021243598). Data for a range of structural and functional TTE parameters were individually extracted and those with low heterogeneity were then meta-analyzed using a random-effects model for effect size, and assessed through standardized mean difference (SMD).
RESULTS: Available data from six studies (with a pooled total of 269 myocarditis patients and 240 controls) revealed that myocarditis can be reliably differentiated from healthy controls using echocardiographic measures of left ventricular (LV) size and systolic function, in particular LV end-diastolic diameter, LV ejection fraction (LVEF) and LV global longitudinal strain (LV-GLS) (p ≤ .01 for all). LV-GLS demonstrated the highest overall effect size, followed by LVEF and LVEDD (SMD: |0.46-1.98|). Two studies also demonstrated that impairment in LV-GLS was associated with adverse cardiovascular outcomes in this population, irrespective of LVEF.
CONCLUSIONS: LV-GLS demonstrated the greatest overall effect size and therefore ability to differentiate myocarditis populations from healthy controls. GLS was also shown to be a predictor of adverse cardiovascular outcomes, in this population.
CONCLUSIONS: What is already known on this subject? Myocarditis is a disease process that is often a diagnosis of exclusion, as it frequently mimics other acute cardiac pathologies. Transthoracic echocardiography is traditionally the initial imaging modality used for noninvasive structural assessment in populations with myocarditis. What might this study add? This study demonstrates that left ventricular (LV) global longitudinal strain, LV ejection fraction and LV end-diastolic diameter can differentiate between myocarditis patients and healthy controls. LV-GLS demonstrated the greatest overall effect size when comparing these two populations, in comparison to the other measures. How might this impact on clinical practice? This study demonstrates that assessment of myocardial deformation indices allows for sensitive discrimination between myocarditis patients from healthy controls. Routine assessment of LV-GLS may serve as an important diagnostic tool in the acute care setting.

OBJECTIVE: The objective of this narrative review was to address common obstacles encountered in the ICU to acquiring quality and interpretable images using point-of-care echocardiography.
METHODS: Detailed searches were performed using PubMed and Ovid Medline using medical subject headings and keywords on topics related to patient positioning, IV echo contrast, alternative subcostal views, right ventricular outflow tract (RVOT) hemodynamics, and point-of-care transesophageal echocardiography. Articles known to the authors were also selected based on expert opinion.
METHODS: Articles specific to patient positioning, IV echo contrast, alternative subcostal views, RVOT hemodynamics, and point-of-care transesophageal echocardiography were considered.
METHODS: One author screened titles and extracted relevant data while two separate authors independently reviewed selected articles.
RESULTS: Impediments to acquiring quality and interpretable images in critically ill patients are common. Notably, body habitus, intra-abdominal hypertension, dressings or drainage tubes, postoperative sternotomies, invasive mechanical ventilation, and the presence of subcutaneous emphysema or lung hyperinflation are commonly encountered obstacles in transthoracic image acquisition in the ICU. Despite these obstacles, the bedside clinician may use obstacle-specific maneuvers to enhance image acquisition. These may include altering patient positioning, respiratory cycle timing, expanding the subcostal window to include multilevel short-axis views for use in the assessment of RV systolic function and hemodynamics, coronal transhepatic view of the inferior vena cava, and finally point-of-care transesophageal echocardiography.
CONCLUSIONS: Despite common obstacles to point-of-care echocardiography in critically ill patients, the beside sonographer may take an obstacle-specific stepwise approach to enhance image acquisition in difficult-to-image patients.

Aortic regurgitation (AR) is the third most frequently encountered valve lesion and may be caused by abnormalities of the valve cusps or the aorta. Echocardiography is instrumental in the assessment of AR as it enables the delineation of valvular morphology, the mechanism of the lesion and the grading of severity. Severe AR has a major impact on the myocardium and carries a significant risk of morbidity and mortality if left untreated. Established and novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, allow an estimation of this risk and provide invaluable information for patient management and prognosis. This narrative review summarises the epidemiology of AR, reviews current practices and recommendations with regards to the echocardiographic assessment of AR and outlines novel echocardiographic tools that may prove beneficial in patient assessment and management.

OBJECTIVE: Right ventricular dysfunction (RVD) is common in the critically ill. To date studies exploring RVD sequelae have had heterogenous definitions and diagnostic methods, with limited follow-up. Additionally much literature has been pathology specific, limiting applicability to the general critically unwell patient.
UNASSIGNED: We conducted a systematic review and meta-analysis to evaluate the impact of RVD diagnosed with transthoracic echocardiography (TTE) on long-term mortality in unselected critically unwell patients compared to those without RVD. A systematic search of EMBASE, Medline and Cochrane was performed from inception to March 2022. All RVD definitions using TTE were included. Patients were those admitted to a critical or intensive care unit, irrespective of disease processes. Long-term mortality was defined as all-cause mortality occurring at least 30 days after hospital admission. A priori subgroup analyses included disease specific and delayed mortality (death after hospital discharge/after the 30th day from hospital admission) in patients with RVD. A random effects model analysis was performed with the Dersimionian and Laird inverse variance method to generate effect estimates.
RESULTS: Of 5985 studies, 123 underwent full text review with 16 included (n = 3196). 1258 patients had RVD. 19 unique RVD criteria were identified. The odds ratio (OR) for long term mortality with RVD was 2.92 (95% CI 1.92-4.54, I2 76.4%) compared to no RVD. The direction and extent was similar for cardiac and COVID19 subgroups. Isolated RVD showed an increased risk of delayed mortality when compared to isolated left/biventricular dysfunction (OR 2.01, 95% CI 1.05-3.86, I2 46.8%).
CONCLUSIONS: RVD, irrespective of cause, is associated with increased long term mortality in the critically ill. Future studies should be aimed at understanding the pathophysiological mechanisms by which this occurs. Commonly used echocardiographic definitions of RVD show significant heterogeneity across studies, which contributes to uncertainty within this dataset.