Citations

Abstract Aims To assess the performance of an artificial intelligence-enabled electrocardiogram (AI-ECG) algorithm in identifying patients with moderate to severe aortic stenosis (AS) in an Asian cohort from a tertiary care centre. Methods and results We identified a randomly selected patients ≥60 years old who underwent echocardiography and ECG within in 31 days between 2012 and 2021 at the Samsung Medical Center in Korea. Patients with previous cardiac surgery, prosthetic valves, or pacemakers were excluded. The AI-ECG model, originally developed and validated by Mayo Clinic in the USA, was applied without fine-tuning. Performance metrics, including the area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy, were calculated to compare AI-ECG predictions with TTE-confirmed AS status. Among 5425 patients, 1095 had moderate to severe AS, and 4330 age- and sex-matched patients without AS were included as controls. The AI-ECG model achieved an AUC of 0.85 (95% CI: 0.84–0.87) in detecting moderate to severe AS. Sensitivity, specificity, PPV, NPV, and accuracy were 0.83, 0.65, 0.37, 0.94, and 68.29%, respectively. The model's performance was consistent across various age and sex subgroups, with sensitivity increasing in older patients. Conclusion The AI-ECG model developed in the USA demonstrated comparable performance in detecting moderate to severe AS in an Asian cohort compared with its original validation population. These findings highlight the potential utility of AI-ECG as a non-invasive screening tool for AS across diverse patient populations.

Background: Conventional transthoracic echocardiography (TTE) is currently not recommended as an initial test to diagnose coronary artery disease (CAD) due to its insensitivity. Left ventricular (LV) strain was reported to be more sensitive than regional wall motion abnormality (RWMA). The aim of this study was to evaluate the usefulness of TTE including LV strain analysis in initial assessment of acute chest pain in emergency department (ED). Methods: Patients visiting ED with acute chest pain were included. Patients with ST elevation myocardial infarct (MI), hemodynamic instability, known CAD or cardiomyopathy, high probability of non-cardiac chest pain, and poor echocardiographic window were excluded. All the patients were initially assessed by an ED physician for pretest probability of CAD. TTE was performed including LV strain image and global and regional LV longitudinal stain (S GL and S RL ) was analyzed online. S RL abnormality was defined as decreased S RL in at least 2 adjacent segments. Diagnosis of CAD (based on coronary angiography or CT angiography) and cardiac events (cardiac death, revascularization, MI, or recurrent ED visit due to chest pain) were reviewed at 1 month after ED visit. Results: Overall 104 patients were analyzed. CAD was diagnosed in 24% (n=25) and cardiac event was detected in 25% (n=26) of patients.Diagnostic accuracy for CAD was higher when using S RL with cut-off value of -13% (sensitivity of 89%, specificity of 77%, NPV = 92%, PPV = 70%) than when using RWMA (sensitivity of 62%, specificity of 88%, NPV = 80%, PPV = 76%). S RL showed better diagnostic performance for CAD than S GL , and pretest probability (Figure). Predictive value of S RL for cardiac events was also highest in those of S GL , RWMA, and pretest probability (Figure). Conclusion: LV strain echocardiography can diagnose the CAD and predict future events with high accuracy. TTE including strain analysis can be used as an initial diagnostic tool in evaluation of acute chest pain in ED.

IMPORTANCEPatients undergoing spine surgery often experience severe pain. The optimal dosage of pregabalin and gabapentin for pain control and safety in these patients has not been well established.OBJECTIVETo evaluate the associations of pain, opioid consumption, and adverse events with different dosages of pregabalin and gabapentin in patients undergoing spine surgery.DATA SOURCESPubMed/MEDLINE, Embase, Web of Science, Cochrane library, and Scopus databases were searched for articles until August 7, 2021.STUDY SELECTIONRandomized clinical trials conducted among patients who received pregabalin or gabapentin while undergoing spine surgery were included.DATA EXTRACTION AND SYNTHESISTwo investigators independently performed data extraction following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) reporting guideline. The network meta-analysis was conducted from August 2022 to February 2023 using a random-effects model.MAIN OUTCOMES AND MEASURESThe primary outcome was pain intensity measured using the Visual Analog Scale (VAS), and secondary outcomes included opioid consumption and adverse events.RESULTSTwenty-seven randomized clinical trials with 1861 patients (median age, 45.99 years [range, 20.00-70.00 years]; 759 women [40.8%]) were included in the systematic review and network meta-analysis. Compared with placebo, the VAS pain score was lowest with gabapentin 900 mg per day, followed by gabapentin 1200 mg per day, gabapentin 600 mg per day, gabapentin 300 mg per day, pregabalin 300 mg per day, pregabalin 150 mg per day, and pregabalin 75 mg per day. Additionally, gabapentin 900 mg per day was found to be associated with the lowest opioid consumption among all dosages of gabapentin and pregabalin, with a mean difference of −22.07% (95% CI, −33.22% to −10.92%) for the surface under the cumulative ranking curve compared with placebo. There was no statistically significant difference in adverse events (nausea, vomiting, and dizziness) among all treatments. No substantial inconsistency between direct and indirect evidence was detected for all outcomes.CONCLUSIONS AND RELEVANCEThese findings suggest that gabapentin 900 mg per day before spine surgery is associated with the lowest VAS pain score among all dosages. In addition, no differences in adverse events were noted among all treatments.

Study Design: Case Series and Technical Note, Objective: UBS has been extensively used in open surgery. However, the use of UBS during UBESS has not been reported in the literature. The aim of this study was to describe a new spinal surgical technique using an ultrasonic bone scalpel (UBS) during unilateral biportal endoscopic spine surgery (UBESS) and to report the preliminary results of this technique. Methods: We enrolled patients diagnosed with lumbar spinal stenosis who underwent single-level UBESS. All patients were followed up for more than 12 months. A unilateral laminotomy was performed after bilateral decompression under endoscopy. We used the UBS system after direct visualization of the target for a bone cut. We evaluated the demographic characteristics, diagnosis, operative time, and estimated blood loss of the patients. Clinical outcomes included the visual analog scale (VAS), the Oswestry Disability Index (ODI), the modified MacNab criteria, and postoperative complications. Results: A total of twenty patients (five males and fifteen females) were enrolled in this study. The mean follow-up period was 13.2 months (range 12–17 months). The VAS score, ODI, and modified MacNab criteria classification improved after the surgery. A minimal mean blood loss of 22.1 mL was noted during the operation. Only one patient experienced neuropraxia, which resolved within 2 weeks. There was no durotomy, iatrogenic pars fracture, or infection. Conclusions: In conclusion, our study represents the first report of the use of UBS during UBESS. Our findings demonstrate that this technique is safe and efficient, with improved clinical outcomes and minimal complications. These preliminary results warrant further investigation through larger clinical studies with longer follow-up periods to confirm the effectiveness of this technique in the treatment of lumbar spinal stenosis.

Abstract Aims To investigate whether left arterial reservoir strain (LASr) could predict new-onset atrial fibrillation (NOAF) in patients with light-chain-type cardiac amyloidosis (ALCA). Methods and results This study enrolled 427 patients with CA from two tertiary centres between 2005 and 2019. LASr was measured using a vendor-independent analysis programme. The primary outcome was NOAF. A total of 287 patients with ALCA were included [median age 63.0 (56.0–70.0) years, 53.3% male]. The median LASr was 13.9% (10.5–20.8%). During the median follow-up of 0.85 years, AF occurred in 34 patients (11.8%). In the receiver operating characteristics curve analysis, the optimal cut-off of LASr for predicting NOAF was 14.4%. Patients with LASr ≤14.4% had a higher risk of NOAF than those with LASr >14.4% (18.1% vs. 5.1%, P < 0.010). In the multivariate analysis adjusting for confounding factors, including left arterial volume index and left ventricular global longitudinal strain (LV-GLS), higher LASr (%) was independently associated with lower risk for NOAF [adjusted hazard ratio (aHR): 0.936, 95% confidence interval (95% CI): 0.879–0.997, P = 0.039]. Furthermore, LASr ≤14.4% was an independent predictor for NOAF (aHR: 3.370, 95% CI: 1.337–8.492, P = 0.010). This remained true after accounting for all-cause death as a competing risk. Compared with Model 1 (LV-GLS) and Model 2 (LV-GLS plus LAVI), Model 3, including LASr showed a better reclassification ability for predicting NOAF (net reclassification index = 0.735, P < 0.001 compared with Model 1; net reclassification index = 0.514, P = 0.003 compared with Model 2). Conclusion LASr was an independent predictor of NOAF in patients with ALCA.

Objectives We investigated haemodynamics and clinical outcomes according to type of pulmonary hypertension (PH) in patients with constrictive pericarditis (CP). Background As the prevalence of CP with concomitant myocardial disease (mixed CP) grows, PH is more commonly seen in patients with CP. However, haemodynamic and outcome data according to the presence or absence of PH are limited. Methods 150 patients with surgically confirmed CP who underwent echocardiography and cardiac catheterisation within 7 days at two tertiary centres were divided into three groups: no-PH, isolated postcapillary PH (Ipc-PH) and combined postcapillary and precapillary PH (Cpc-PH). Primary outcome was all-cause mortality during follow-up. Result In this retrospective cohort study, 110 (73.3%) had PH (mean pulmonary artery pressure ≥25 mm Hg). Cpc-PH, using defined cut-offs for pulmonary vascular resistance (>3 Wood units) or diastolic pulmonary gradient (≥7 mm Hg), was seen in 18 patients (12%). The Cpc-PH group had a higher prevalence of comorbidities (diabetes and atrial fibrillation) and concomitant myocardial disease as an aetiology of CP than other groups. Pulmonary vascular resistance had a significant direct correlation with medial E/e′ by Doppler echocardiography (r=0.404, p<0.001). Survival rate was significantly lower in the Cpc-PH than the no-PH (p=0.002) and Ipc-PH (p=0.024) groups. On multivariable analysis, age, New York Heart Association functional class IV, medial e′ velocity, Cpc-PH and Ipc-PH were independently associated with long-term mortality. Conclusion Combined postcapillary and precapillary PH develops in a subset of patients with CP and is associated with long-term mortality after pericardiectomy.

OBJECTIVE The nature of the volume-outcome relationship in cases with severe traumatic brain injury (TBI) remains unclear, with considerable interhospital variation in patient outcomes. The objective of this study was to understand the state of the volume-outcome relationship at different levels of trauma centers in the United States. METHODS The authors queried the National Trauma Data Bank for the years 2007–2014 for patients with severe TBI. Case volumes for each level of trauma center organized into quintiles (Q1–Q5) served as the primary predictor. Analyzed outcomes included in-hospital mortality, total hospital length of stay (LOS), and intensive care unit (ICU) stay. Multivariable regression models were performed for in-hospital mortality, overall complications, and total hospital and ICU LOSs to adjust for possible confounders. The analysis was stratified by level designation of the trauma center. Statistical significance was established at p < 0.001 to avoid a type I error due to a large sample size. RESULTS A total of 122,445 patients were included. Adjusted analysis did not demonstrate a significant relationship between increasing hospital volume of severe TBI cases and in-hospital mortality, complications, and nonhome hospital discharge disposition among level I–IV trauma centers. However, among level II trauma centers, hospital LOS was longer for the highest volume quintile (adjusted mean difference [MD] for Q5: 2.83 days, 95% CI 1.40–4.26 days, p < 0.001, reference = Q1). For level III and IV trauma centers, both hospital LOS and ICU LOS were longer for the highest volume quintile (adjusted MD for Q5: LOS 4.6 days, 95% CI 2.3–7.0 days, p < 0.001; ICU LOS 3.2 days, 95% CI 1.6–4.8 days, p < 0.001). CONCLUSIONS Higher volumes of severe TBI cases at a lower level of trauma center may be associated with a longer LOS. These results may assist policymakers with target interventions for resource allocation and point to the need for careful prehospital decision-making in patients with severe TBI.