Publications by authors named "Jerold Shinbane"

53 Publications

Identifying, characterizing, and classifying congenital anomalies of the coronary arteries.

Radiographics 2012 Mar-Apr;32(2):453-68

South Sound Radiology, 3417 Ensign Rd NE, Olympia, WA 98506, USA.

The clinical manifestations of coronary artery anomalies vary in severity, with some anomalies causing severe symptoms and cardiovascular sequelae and others being benign. Cardiovascular computed tomography (CT) has emerged as the standard of reference for identification and characterization of coronary artery anomalies. Therefore, it is important for the reader of cardiovascular CT images to be thoroughly familiar with the spectrum of coronary artery anomalies. Hemodynamically significant anomalies include atresia, origin from the pulmonary artery, interarterial course, and congenital fistula. Non-hemodynamically significant anomalies include duplication; high origin; a prepulmonic, transseptal, or retroaortic course; shepherd's crook right coronary artery; and systemic termination. In general, coronary arteries with an interarterial course are associated with an increased risk of sudden cardiac death. Coronary artery anomalies that result in shunting, including congenital fistula and origin from the pulmonary artery, are also commonly symptomatic and may cause steal of blood from the myocardium. Radiologists should be familiar with each specific variant and its specific constellation of potential implications.
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http://dx.doi.org/10.1148/rg.322115097DOI Listing
July 2012

Incidental myocardial infarct on conventional nongated CT: a review of the spectrum of findings with gated CT and cardiac MRI correlation.

AJR Am J Roentgenol 2012 Mar;198(3):496-504

South Sound Radiology, 4217 Ensign Rd NE, Olympia, WA 98506, USA.

Objective: Myocardial infarctions (MIs) are frequently evident on routine chest or abdominal CT, even when studies are not performed for cardiac-specific indications. However, the telltale signs of an MI may be easily overlooked. Herein, we present the spectrum of appearances of MIs, including areas of fat attenuation, myocardial calcifications, focal areas of wall thinning or aneurysm formation, and perfusion abnormalities. Thrombi, especially when present at the apex of the left ventricle, may also suggest an MI.

Conclusion: The increased use of CT in the evaluation of patients for a variety of indications gives the radiologist the unique opportunity to recognize findings consistent with MI in patients who may not have a prior diagnosis of ischemic heart disease.
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http://dx.doi.org/10.2214/AJR.11.7683DOI Listing
March 2012

Unoperated congenitally corrected transposition of the great arteries, nonrestrictive ventricular septal defect, and pulmonary stenosis in middle adulthood: do multiple wrongs make a right?

World J Pediatr Congenit Heart Surg 2012 Jan;3(1):123-9

Division of Cardiovascular Medicine/Cardiovascular and Thoracic Institute, USC Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Submitted May 6, 2011; Accepted August 3, 2011. The survival into adulthood of patients with unoperated complex congenital heart disease with anomalies often considered life threatening in infancy and childhood requires a complex interplay of "balanced" defects allowing for cardiovascular physiology compatible with long-term survival. We report on a series of three cases from our advanced imaging database of middle-aged adults presenting with multiple similar defects providing a hemodynamically balanced circulation. The constellation of defects seen in each of these patients included congenitally corrected transposition of the great arteries, a large nonrestrictive ventricular septal defect, valvular pulmonary stenosis, and in two cases anomalous coronary arteries. Cardiovascular computed tomographic angiography (CCTA) and cardiovascular magnetic resonance imaging (CMR) were important to the characterization of the multiple defects and their three-dimensional relationships in these cases. Treatment decisions in patients with this constellation of findings are challenging, given the limited data due to the rarity of survival of patients with these defects into middle adulthood and the paucity of data related to decisions and approaches to medical management, surgical correction, or transplantation.
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http://dx.doi.org/10.1177/2150135111421625DOI Listing
January 2012

Magnetic resonance imaging in patients with cardiac pacemakers: era of "MR Conditional" designs.

J Cardiovasc Magn Reson 2011 Oct 27;13:63. Epub 2011 Oct 27.

Division of Cardiovascular Medicine/Cardiovascular and Thoracic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.

Advances in cardiac device technology have led to the first generation of magnetic resonance imaging (MRI) conditional devices, providing more diagnostic imaging options for patients with these devices, but also new controversies. Prior studies of pacemakers in patients undergoing MRI procedures have provided groundwork for design improvements. Factors related to magnetic field interactions and transfer of electromagnetic energy led to specific design changes. Ferromagnetic content was minimized. Reed switches were modified. Leads were redesigned to reduce induced currents/heating. Circuitry filters and shielding were implemented to impede or limit the transfer of certain unwanted electromagnetic effects. Prospective multicenter clinical trials to assess the safety and efficacy of the first generation of MR conditional cardiac pacemakers demonstrated no significant alterations in pacing parameters compared to controls. There were no reported complications through the one month visit including no arrhythmias, electrical reset, inhibition of generator output, or adverse sensations. The safe implementation of these new technologies requires an understanding of the well-defined patient and MR system conditions. Although scanning a patient with an MR conditional device following the strictly defined patient and MR system conditions appears straightforward, issues related to patients with pre-existing devices remain complex. Until MR conditional devices are the routine platform for all of these devices, there will still be challenging decisions regarding imaging patients with pre-existing devices where MRI is required to diagnose and manage a potentially life threatening or serious scenario. A range of other devices including ICDs, biventricular devices, and implantable physiologic monitors as well as guidance of medical procedures using MRI technology will require further biomedical device design changes and testing. The development and implementation of cardiac MR conditional devices will continue to require the expertise and collaboration of multiple disciplines and will need to prove safety, effectiveness, and cost effectiveness in patient care.
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http://dx.doi.org/10.1186/1532-429X-13-63DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219582PMC
October 2011

"MR-conditional" pacemakers: the radiologist's role in multidisciplinary management.

AJR Am J Roentgenol 2011 Sep;197(3):W457-9

Department of Radiology, University of Southern California, Los Angeles, CA 90033, USA.

Objective: The recent approval of an "MR-conditional" pacemaker system by the U.S. Food and Drug Administration allows patients with that pacemaker system to undergo MRI examinations within specific conditions. These examinations must be attended by radiology health care professionals with training for the use of the pacemaker system.

Conclusion: Radiologists should be knowledgeable of the specific limitations with regard to patient isocenter and coil positioning within the required 1.5-T MR system and the importance that the pacer be programmed before and after scanning.
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http://dx.doi.org/10.2214/AJR.11.7120DOI Listing
September 2011

Impact of relaxation training on patient-perceived measures of anxiety, pain, and outcomes after interventional electrophysiology procedures.

Pacing Clin Electrophysiol 2011 Jul 28;34(7):821-6. Epub 2011 Apr 28.

Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.

Background: Electrophysiology procedures vary in invasiveness, duration, and anesthesia utilized. While complications are low and efficacy high, cases are elective and patient experiences related to anxiety, pain, and perceived outcomes are not well studied. We sought to determine if a 30-minute audio compact disc (CD) that teaches relaxation techniques and wellness perception prior to an elective procedure impacts validated measures of anxiety, pain, and procedural outcomes.

Methods: Sixty-one patients were randomly assigned to a control group (CG) (N(CG) = 31) or interventional group (IG) (N(IG) = 30). Both groups answered a baseline Hospital Anxiety and Depression Scale (HADS-A) survey consisting only of anxiety assessment questions. The IG listened to the CD the night prior to their procedure. Heart rate and blood pressure were monitored on admission and prior to the procedure. Postprocedure, both groups completed two HADS-A surveys as well as two Patient Experience Surveys (PES). There was no statistical difference in the demographics and the rate of procedural complications between the groups. The statistical significance of our data was determined using a Student's t-test and χ(2) test.

Results: At baseline, both groups had equal amounts of anxiety prior to their procedures (P = 0.2). The patients in the IG had lower systolic blood pressures during admission and prior the administration of analgesics in comparison to the CG. Postprocedure, results from administering the HADS-A demonstrated that the IG had 33% lower anxiety (P = 0.02) than CG patients.

Conclusion: The implementation of basic relaxation teaching techniques prior to planned electrophysiology procedures lowers systolic blood pressure and postprocedural anxiety.
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http://dx.doi.org/10.1111/j.1540-8159.2011.03119.xDOI Listing
July 2011

Prospective randomized trial of venous cardiac computed tomographic angiography for facilitation of cardiac resynchronization therapy.

Pacing Clin Electrophysiol 2010 Oct;33(10):1182-7

Division of Cardiology, Harbor-UCLA Research and Education Institute, 1124 W Carson Street, Torrance, CA 90502, USA.

Background: Cardiovascular computed tomographic angiography (CTA) can visualize the coronary veins. We sought to assess the ability of CTA to facilitate resynchronization therapy (CRT) procedures using a prospective randomized single-center pilot study.

Methods: Patients underwent CTA for characterization of cardiomyopathy prior to biventricular implantable cardiac-defibrillator implant. Randomization was performed with operator review of the CTA for coronary venous anatomy prior to CRT in one-half of the cases. Invasive coronary venous angiograms were used in all procedures. Analysis included procedure times and utilization of contrast, fluoroscopy, and guide catheters.

Results: Characteristics of the 26 patients enrolled were mean age 55 ± 11 years, male 76.9%, ischemic etiology 35%, ejection fraction 25 ± 3%, class III congestive heart failure 100%, and QRS duration 179 ± 29 ms. Of patients enrolled, 22 had both CTA and procedure initiation. Three patients (two with CTA review and one without CTA review) had aborted procedures due to hemodynamic issues. Analysis of the 22 patients (nine with preprocedure CTA review and 13 without CTA review) demonstrated that preprocedure review of CTA coronary venous anatomy led to significantly decreased procedure times and utilization of contrast, fluoroscopy, and guide catheters.

Conclusions: Preprocedure review of CTA coronary venous anatomy may lead to decreased procedural times and utilization of contrast, fluoroscopy, and guide catheters. These preliminary results will need to be evaluated in larger heart failure populations undergoing CRT.
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http://dx.doi.org/10.1111/j.1540-8159.2010.02821.xDOI Listing
October 2010

Left atrial appendage: structure, function, imaging modalities and therapeutic options.

Expert Rev Cardiovasc Ther 2010 Jan;8(1):65-75

Echocardiography Laboratories, Keck School of Medicine, University of Southern California, 1510, San Pablo Street, Suite 322, Los Angeles, CA 90033, USA.

The left atrial appendage (LAA) is a common source of cardiac thrombus formation and systemic embolism. It is a 'blind' cul-de-sac and multilobed anatomic structure with variable anatomy. Therefore, it requires detailed evaluation in multiple imaging planes to evaluate for thrombus formation. Transesophageal echocardiography is the most common imaging modality used to rule out LAA thrombus. Doppler imaging enhances understanding of LAA function. 3D imaging of the LAA with live 3D transesophageal echocardiography, computed tomography and MRI may be further utilized for thrombus detection, as well as for sizing, and the development of new transcatheter occluder devices for LAA to prevent thrombus formation is needed.
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http://dx.doi.org/10.1586/erc.09.161DOI Listing
January 2010

Calcific constrictive pericarditis demonstrated on 99mTc-MDP bone scintigraphy.

J Radiol Case Rep 2009 1;3(5):11-5. Epub 2009 May 1.

USC Keck School of Medicine, Los Angeles, California, USA.

The authors present a case of calcific constrictive pericarditis, imaged with bone scintigraphy. The patient presented with three months of shortness of breath, chest pain, and chest tightness during exercise, among other nonspecific symptoms. Although the diagnosis was made based on chest radiography and cardiac MRI, bone scintigraphy was used to corroborate the diagnosis of calcific constrictive pericarditis. Bone scintigraphy showed a pattern of tracer accumulation consistent with pericardial uptake. Calcific constrictive pericarditis was also confirmed at the time of surgery.
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http://dx.doi.org/10.3941/jrcr.v3i5.63DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303308PMC
September 2012

Taser-induced rapid ventricular myocardial capture demonstrated by pacemaker intracardiac electrograms.

J Cardiovasc Electrophysiol 2007 Aug 16;18(8):876-9. Epub 2007 Jun 16.

Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.

Introduction: A Taser weapon is designed to incapacitate violent individuals by causing temporary neuromuscular paralysis due to current application. We report the first case of a Taser application in a person with a dual-chamber pacemaker demonstrating evidence of Taser-induced myocardial capture.

Methods And Results: Device interrogation was performed in a 53-year-old man with a dual-chamber pacemaker who had received a Taser shot consisting of two barbs delivered simultaneously. Assessment of pacemaker function after Taser application demonstrated normal sensing, pacing thresholds, and lead impedances. Stored event data revealed two high ventricular rate episodes corresponding to the exact time of the Taser application.

Conclusions: This report describes the first human case of ventricular myocardial capture at a rapid rate resulting from a Taser application. This raises the issue as to whether conducted energy devices can cause primary myocardial capture or capture only in association with cardiac devices providing a preferential pathway of conduction to the myocardium.
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http://dx.doi.org/10.1111/j.1540-8167.2007.00881.xDOI Listing
August 2007

MR in patients with pacemakers and ICDs: Defining the issues.

J Cardiovasc Magn Reson 2007 ;9(1):5-13

Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.

There has been great controversy related to performance of magnetic resonance imaging in patients with pacemakers and implantable cardiac defibrillators. Recent questions have been raised regarding whether contraindications are absolute or relative. Although there are theoretical as well as documented issues relating to device malfunction, data suggest that scanning patients with devices may be feasible when important clinical questions need to be addressed by following strict guidelines. Advanced knowledge and understanding of electrophysiologic as well as magnetic resonance imaging-related issues, and a multidisciplinary, collaborative approach is required to further define the role of MR in patients with pacemakers and implantable cardiac defibrillators.
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http://dx.doi.org/10.1080/10976640601117056DOI Listing
April 2007

Multiphase contrast medium injection for optimization of computed tomographic coronary angiography.

Acad Radiol 2006 Feb;13(2):159-65

Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA 90502, USA.

Rationale And Objectives: Electron beam angiography is a minimally invasive imaging technique. Adequate vascular opacification throughout the study remains a critical issue for image quality. We hypothesized that vascular image opacification and uniformity of vascular enhancement between slices can be improved using multiphase contrast medium injection protocols.

Materials And Methods: We enrolled 244 consecutive patients who were randomized to three different injection protocols: single-phase contrast medium injection (Group 1), dual-phase contrast medium injection with each phase at a different injection rate (Group 2), and a three-phase injection with two phases of contrast medium injection followed by a saline injection phase (Group 3). Parameters measured were aortic opacification based on Hounsfield units and uniformity of aortic enhancement at predetermined slices (locations from top [level 1] to base [level 60]).

Results: In Group 1, contrast opacification differed across seven predetermined locations (scan levels: 1st versus 60th, P < .05), demonstrating significant nonuniformity. In Group 2, there was more uniform vascular enhancement, with no significant differences between the first 50 slices (P > .05). In Group 3, there was greater uniformity of vascular enhancement and higher mean Hounsfield units value across all 60 images, from the aortic root to the base of the heart (P < .05).

Conclusions: The three-phase injection protocol improved vascular opacification at the base of the heart, as well as uniformity of arterial enhancement throughout the study.
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http://dx.doi.org/10.1016/j.acra.2005.09.087DOI Listing
February 2006

Coronary venous imaging with electron beam computed tomographic angiography: three-dimensional mapping and relationship with coronary arteries.

Am Heart J 2005 Aug;150(2):315-22

Division of Cardiology, Harbor-UCLA Research and Education Institute, Torrance, CA 90502-2064, USA.

Background: The coronary venous system can provide vascular access for diagnostic and therapeutic procedures. Visualization of the coronary veins and their relationship to other cardiac structures may play an important role in facilitating these procedures. We sought to assess the ability of electron beam computed tomographic angiography (EBCTA) to characterize 3-dimensional (3-D) coronary venous anatomy.

Methods: Two hundred thirty-one consecutive EBCTA coronary studies were analyzed. The coronary venous system was mapped and analyzed using 2- and 3-D images with definition of diameter and angulations of branch vessels and distance from CS os.

Results: The coronary sinus (CS), great cardiac, middle cardiac, left ventricular (LV) anterior interventricular, LV marginal, LV posterior, left atrial, and right atrial veins were visualized in 100%, 100%, 100%, 100%, 78%, 81%, 6%, and 8% of the studies, respectively, with definition of diameter and angulations of branch vessels and distance from CS os. There was a significant linear correlation between CS diameter and right atrial end systolic volume (R = 0.244, n = 81, P < .05). No significant correlation existed between CS os diameter and other cardiac size or function parameters. The 3-D spatial arrangements between the coronary veins and the coronary arteries in relation to the epicardium were able to be defined, on the basis of the vessel closer to the epicardium in overlapping segments.

Conclusions: EBCTA can provide 3-D visualization of most components of the coronary venous system and definition of the spatial relationships with coronary arteries. EBCTA may potentially serve as a useful noninvasive tool for coronary venous imaging for procedures involving coronary veins, such as resynchronization therapy.
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http://dx.doi.org/10.1016/j.ahj.2004.09.050DOI Listing
August 2005

Detection of small vessels with electron beam computed tomographic angiography using 1.5 and 3 mm collimator protocols.

Int J Cardiovasc Imaging 2006 Apr 23;22(2):275-82. Epub 2005 Jul 23.

Division of Cardiology, Harbor-UCLA Research and Education Institute, Torrance, CA 90502, USA.

Objectives: To evaluate the effect of scanner collimation on the ability to detect small cardiac vessels using electron beam CT coronary angiography (EBA).

Materials And Methods: EBA scans from 40 patients who underwent study on two separate occasions with 3 mm (initial scan) and 1.5 mm (follow-up scan) collimation protocols were analyzed. Vessels of <2 mm in diameter were identified.

Results: The 1.5 mm collimation allowed 3-D visualization of 129 vessels<2 mm in diameter, while 3 mm collimation only allowed visualization of 89 vessels (p<0.001). The right coronary artery branches and distal LAD segments though were not displayed satisfactorily in almost half of the 3-D studies with either protocol.

Conclusions: There was significant improvement in detection of small cardiac vessels with a 1.5 mm collimation EBA protocol compared to a 3 mm protocol. Both protocols though were insufficient for reliable visualization of the right coronary artery branches and distal LAD segments.
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http://dx.doi.org/10.1007/s10554-005-9002-6DOI Listing
April 2006

Computed tomographic cardiovascular imaging.

Stud Health Technol Inform 2005 ;113:148-81

University of California, Los Angles, CA.

The chapter presents the Cardiac CT for the assessment of cardiovascular pathology with an emphasis on the detection of coronary atherosclerosis. Cardiac CT is a robust technology for the non-invasive assessment for a spectrum of cardiovascular disease processes. This imaging modality can provide assessment of atherosclerotic plaque burden and coronary artery disease risk through coronary calcium scoring. Advances in spatial and temporal resolution, electrocardiographic triggering methodology, and image reconstruction software have helped in the evaluation of coronary artery anatomy and vessel patency, providing the ability to noninvasively diagnose or rule out significant epicardial coronary artery disease. This technique also allows the 3-Dimensional simultaneous imaging of additional cardiac structures including coronary veins, pulmonary veins, atria, ventricles, aorta and thoracic arterial and venous structures, with definition of their spatial relationships for the comprehensive assessment of a variety of cardiovascular disease processes.
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April 2016

Comparison of coronary artery calcium screening image quality between C-150 and e-Speed electron beam scanners.

Acad Radiol 2005 Mar;12(3):309-12

Division of Cardiology, Harbor-UCLA Research and Education Institute, 1124 W. Carson Street, RB2, Torrance, California 90502, USA.

Rationale And Objective: The newest generation of electron beam tomographic scanner (e-Speed) has increased spatial and temporal resolution compared with the C-150 XP scanner. The aim of this study was to evaluate coronary artery calcium screening image quality between the e-Speed and C-150 scanners (GE Imatron, San Francisco, CA).

Materials And Methods: Studies from 41 patients (14 women and 27 men) who underwent serial coronary artery calcium screening with the C-150 (first study) and the e-Speed (second study) were analyzed. Individual computed tomography (CT) slices were assessed for coronary artery motion artifacts, and CT Hounsfield units (HU) and noise values (CT HU standard deviation) at 16 discrete cardiac sites were measured and averaged.

Results: With the e-Speed scanner, there were significant decreases in right coronary artery motion artifacts compared with the C-150 scanner (0.3% versus 1.8%, P < .001) as well as decreased noise values (24.3 versus 32.0 HU, P < .001).

Conclusion: Image quality is significantly improved with use of the e-Speed scanner, due to its improved temporal and spatial resolution, compared with the C-150 scanner.
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http://dx.doi.org/10.1016/j.acra.2004.09.014DOI Listing
March 2005

Three-dimensional computed tomography imaging of left atrial anatomy for atrial fibrillation ablation.

Clin Cardiol 2005 Feb;28(2):100

Division of Cardiology, Harbor-UCLA Research and Education Institute, Torrance, California, USA.

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http://dx.doi.org/10.1002/clc.4960280211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6654560PMC
February 2005

Methodology for improved detection of coronary stenoses with computed tomographic angiography.

Am Heart J 2004 Dec;148(6):1085-90

Department of Medicine, Division of Cardiology, Harbor-UCLA Medical Center and Saint John's Cardiovascular Research Center, Torrance 90502, USA.

Background: Noninvasive angiography is a promising technique for visualization of the coronary lumen; however, current methodologies lead to limited accuracy. We assessed the accuracy of electron beam computed tomographic angiography (EBA) for detection of coronary stenoses, using improved triggering techniques and thinner slice collimation.

Methods: Eighty-six patients with suspected coronary disease were studied with EBA and conventional invasive coronary angiography. Electrocardiographic triggering was performed at a fixed time in end systole to reduce cardiac motion. Thin (1.5 mm) slices were obtained with 1.5 mm table incrementation. In axial (2-dimensional) EBA images and 3-dimensional reconstructions, all coronary arteries and side branches with a diameter of >or=1.5 mm were assessed for the presence of stenoses with >50% diameter reduction. Both EBA and invasive angiographic images were assessed in a blinded manner.

Results: In comparison to invasive coronary angiography, EBA correctly classified 49 of 53 patients (92%) as having at least 1 coronary stenosis. Overall, 103 stenoses with >50% diameter reduction were present, and 93 of these lesions were correctly detected by EBA (sensitivity 90%, specificity 93%, positive predictive value 84%, and negative predictive value 96%). Only 5% of vessels could not be assessed, predominantly due to significant calcification.

Conclusions: Thinner slice collimation and end-systolic electrocardiographic triggering improves accuracy and assessment of coronary EBA for the detection of obstructive coronary artery disease, making this study clinically useful in the evaluation of obstructive coronary artery disease.
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http://dx.doi.org/10.1016/j.ahj.2004.04.043DOI Listing
December 2004

Thebesian valve imaging with electron beam CT angiography: implications for resynchronization therapy.

Pacing Clin Electrophysiol 2004 Nov;27(11):1566-7

Division of Cardiology, Harbor-UCLA Research and Education Institute, Torrance, California 90502-2064, USA.

We report visualization of a prominent coronary sinus os valve (Thebesian valve), by electron beam computed tomographic angiography, which impeded an endocardial approach to left ventricular pacing. Resynchronization therapy was therefore performed with an epicardial approach to left ventricular lead placement. Electron beam computed tomographic angiography can provide detailed information for coronary sinus instrumentation, including anomalies potentially affecting the approach to resynchronization therapy.
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http://dx.doi.org/10.1111/j.1540-8159.2004.00678.xDOI Listing
November 2004

Thebesian valve imaging with electron beam CT angiography: implications for resynchronization therapy.

Pacing Clin Electrophysiol 2004 Sep;27(9):1331-2

Division of Cardiology, Harbor-UCLA Research and Education Institute, Torrance, California 90502-2064, USA.

We report visualization of a prominent coronary sinus os valve (Thebesian valve), by electron beam computed tomographic angiography, which impeded an endocardial approach to left ventricular pacing. Resynchronization therapy was therefore performed with an epicardial approach to left ventricular lead placement. Electron beam computed tomographic angiography can provide detailed information for coronary sinus instrumentation, including anomalies potentially affecting the approach to resynchronization therapy.
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http://dx.doi.org/10.1111/j.1540-8159.2004.00632.xDOI Listing
September 2004

Triage practice guideline for patients hospitalized with congestive heart failure: improving the effectiveness of the coronary care unit.

Am J Med 1993 May;94(5):483-490

From the Department of Medicine, UCLA School of Medicine, Los Angeles, California U.S.A.; From the Department of Medicine UCLA School of Medicine, Los Angeles, California U.S.A.

Background: Decisions regarding the appropriate timing for transfer of patients hospitalized with congestive heart failure from the coronary care unit (CCU) to the medical ward are often not based on well-founded medical data. We investigated the potential safety and effectiveness of a practice guideline recommending early "step-down" transfer of low-risk patients with congestive heart failure.

Patients And Methods: We studied the use of a practice guideline for 384 patients hospitalized with congestive heart failure in a hypothetic experiment. The guideline stated that patients without any of the following conditions may be suitable for transfer to a nonmonitored bed 24 hours after admission: acute myocardial infarction or ischemia, complications, active or planned cardiac interventions, unstable comorbidity, worsening clinical status, or lack of response to diuretic therapy. Patients with any of the above conditions were classified as higher risk and potentially not suitable for early transfer.

Results: Life-threatening complications were 15.2 times more likely (95% confidence interval [CI] 2.2, 70, p = 0.001) and death 14.6 times more likely (95% CI 2.1, 68, p = 0.001) if the patient was classified as "high risk" rather than "low risk" by the guideline. The negative predictive value and sensitivity of the practice guideline for detecting patients who had life-threatening complications were 99.2% and 96.4%, respectively. Thirty-one percent of patients with congestive heart failure hospitalized in either the CCU or intermediate care unit were at low risk and potentially suitable for transfer to a nonmonitored bed 24 hours after admission. Use of the guideline would have reduced intermediate care unit lengths of stay from 2.91 days to 2.22 days and CCU length of stay from 2.06 to 2.04 days had it been used to triage patients with congestive heart failure. This reduction in length of stay would have resulted in 172 more intermediate care unit bed-days available per year to accommodate additional patients. On initial review, at least one cardiologist reviewer judged that use of the guideline may have adversely affected quality of care for 4% (95% CI 1%, 7%) of patients. After a consensus among the cardiologist reviewers, it was judged that the guideline may have adversely affected care for only 0.8% of patients (95% CI, 0%, 2.3%), and that no patient (95% CI 0%, 2.3%) would have had an unexpected life-threatening complication because of the guideline.

Conclusions: Use of a practice guideline has the potential to reduce the intermediate care unit lengths of stay for selected low-risk patients with congestive heart failure.
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http://dx.doi.org/10.1016/0002-9343(93)90082-ZDOI Listing
May 1993
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