Intracardiac abscess resulting in complete heart block is an infrequent complication of infective endocarditis. Most presentations of endocarditis are limited to valvular and perivalvular structures, with varying degrees of heart block occurring in the minority of cases. We report a case of endocarditis manifesting as chest pain associated with ST segment elevation and complete heart block. The patient expired unexpectedly within a few hours of presentation. Postmortem examination revealed an atrial septal abscess, purulent pericardial collection, and fibrinous pericarditis. Spread of the abscess into the atrial septum was postulated to be the cause of the complete heart block. In endocarditis, the ominous development of heart block and a poor response to antibiotic therapy imply significant extension of the infection. Management therefore requires prompt ventricular pacing with consideration for valve replacement and possible pericardial drainage.
Introduction Echocardiography is commonly performed in the evaluation of patients with pulmonary hypertension (PH). The report summary often serves to guide the future evaluation of these patients. Our aim was to explore the relationship between the echocardiography reports of patients with PH and referral to a PH specialty clinic. Methods A random sample of 500 echocardiographic reports of patients with an estimated right ventricular systolic pressure (RVSP) greater than 40 mm Hg between 2006 and 2014 was selected from the institutional database of a single academic center. Referral to the PH clinic was determined by evaluating the electronic medical record. Univariate and multivariate logistic regression analyses were performed to identify characteristics associated with referral. Results Pulmonary hypertension was mentioned in 31% of the report summaries, and only 4.6% were referred to the PH clinic. Variables associated with referral were younger age, indication for echocardiography, higher right atrial and ventricular (RV) systolic pressures, RV dilatation, mention of PH in the summary, and higher left ventricular ejection fraction. Mention of PH in the summary was the variable most strongly associated with referral (adjusted odds ratio 4.6, 95% CI 1.5–14.2). Conclusion Pulmonary hypertension was infrequently mentioned in the summary of echocardiography reports of patients with RVSP >40 mm Hg. Referral to the PH clinic was rare but occurred more often following the mention of PH in the summary. Explicit mention of the presence of PH in the echocardiography report summary may facilitate referral to a specialty clinic and allow more comprehensive evaluation of PH.
Introduction: Pulmonary hypertension (PH) is a common and often ominous finding in the echocardiographic evaluation of patients with cardiopulmonary complaints. As with all diagnostic imaging, the report summary may influence future evaluation. Our aim was to explore the relationship between the echocardiographic reports of patients with PH and subsequent referral to a PH clinic. Methods: From the institutional database of a single academic medical center, we randomly selected 500 reports of patients with an estimated RVSP > 40 mm Hg between 2006 and 2014. Demographic and echocardiographic data were recorded prospectively. Referral to the only PH clinic in the region was determined by searching the electronic medical record. We used multivariable logistic regression to identify demographic and echocardiographic characteristics associated with referral. Results: The mean age of the population was 74 years and 54% (269 of 500) were women. The mean RVSP was 53 mm Hg. Pulmonary hypertension was mentioned in only 31% (153 of 500) of the report summaries and only 4.6% (23 of 500) of all patients were referred to the PH clinic. Referral was associated with younger age, indication for the echo, right atrial and right ventricular (RV) pressure, RV dilatation, and mention of PH in the summary. Mention of PH in the summary was the variable most strongly associated with referral (adjusted OR 4.6, 95% CI 1.5-14.2). Over the time period studied, there was no trend in the frequency of mentioning PH in the summary. The sonographer’s coding of PH as a preliminary finding was strongly associated with physician mention of PH in the summary, persisting after adjustment for RV systolic pressure, RV dilatation, and RV systolic function (adjusted OR 11.3, 95% CI 6.2-20.3). Conclusion: In this single institution study, PH was infrequently mentioned in the echo report summary of patients with an RVSP exceeding 40 mm Hg. Referral to the only PH clinic in the region was relatively rare but occurred more often following mention of PH in the summary. Explicitly stating the presence of pulmonary hypertension in the summary of patients with elevated RSVP may facilitate referral for comprehensive evaluation.
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