Eptifibatide (Ep) induced profound thrombocytopenia (TP) has been rarely described. We report a case of acute profound TP after intravenous (IV) Ep. A 59 year old man with history of coronary artery disease and two vessel bypass was evaluated for a positive nuclear stress test. Coronary angiography

Multiple reports have demonstrated superior outcomes at high-volume hospitals in patients undergoing heart transplant. However, comprehensive analyses on trends in hospital procedure numbers in recent years are lacking. We performed analysis of the Nationwide (National) Inpatient Sample (NIS) from

A 19-year-old woman presented to the ED reporting acute onset of left-sided weakness. She was in her usual state of good health until 11 h prior to admission when she noticed left-sided weakness and fell to the floor when trying to get out of bed. Upon triage, her temperature was 36.8°C, heart rate was 88 beats/min, blood pressure was 114/69 mm Hg, and her respiratory rate was 16 breaths/min. Her physical examination was consistent with a right middle cerebral artery (MCA) cerebrovascular accident: left arm weakness (1/5 strength), left leg weakness (4/5 strength), left-sided facial droop, and right gaze preference. A noncontrast head CT scan showed evidence of an acute infarction in the territory of the right MCA. A CT angiogram of the head and neck revealed a string-like occlusion of the M1 segment of the right MCA. She was not within the therapeutic window for systemic thrombolysis or endovascular intervention, and she was admitted to the medical ICU for further management. A routine comprehensive stroke evaluation was initiated. Results of the bloodwork were notable for thrombocytopenia and a prolonged prothrombin time (Table 1). Due to the patient’s young age and lack of stroke risk factors, a bedside goal-directed echocardiogram (GDE) was performed (Video 1).Table 1Initial Diagnostic Test ResultsParameterValueCBC WBC7.6 K/μL Hemoglobin11.8 g/dL Hematocrit33.5 g/dL Platelets80 K/μL Neutrophils88%Basic metabolic panel Sodium136 mM Potassium4.2 mM Chloride102 mM CO220 mM BUN8 mg/dL Creatinine0.5 mg/dL Glucose110 mg/dLLiver function tests Total protein8.6 g/dL Albumin3.7 g/dL Total bilirubin0.3 mg/dL AST37 U/L ALT30 U/L Alkaline phosphatase64 U/LCoagulation studies Prothrombin time15 s International normalized ratio2.1 APTT74.9 sGlycosylated hemoglobin5.0%LDL cholesterol92 mg/dLTriglycerides122 mg/dLALT = alanine transaminase; APTT = activated partial thromboplastin time; AST = aspartate transaminase; LDL = low-density lipoprotein. Open table in a new tab ALT = alanine transaminase; APTT = activated partial thromboplastin time; AST = aspartate transaminase; LDL = low-density lipoprotein. Question: Based on the limited GDE, what diagnoses should be considered? Answer: The GDE revealed a large echogenic mass attached to the aortic valve. In an otherwise healthy young woman, the clinician must consider bacterial and nonbacterial endocarditis (Discussion Video). GDE is not routinely used in the initial management of acute ischemic stroke; rather, a comprehensive consultative echocardiography examination is obtained during the hospital admission if embolic stroke is suspected. In this case, GDE expedited the diagnosis of endocarditis in a young woman with no known comorbidities who presented with an acute ischemic stroke. The cardiac parasternal long-axis view revealed a large echogenic mass that appeared to be attached to the aortic valve (AV) (Video 2). After the AV vegetation was identified, the patient was started on broad-spectrum antibiotics for bacterial endocarditis. Results of multiple sets of blood cultures were negative. An investigation for the etiology of nonbacterial thrombotic endocarditis was consistent with Libman-Sacks endocarditis because the patient had laboratory markers diagnostic of systemic lupus erythematosus and antiphospholipid antibody syndrome (Table 2). The patient was given 1 mg/kg of prednisone, and she was subsequently started on hydroxychloroquine and full-dose anticoagulation. A transesophageal echocardiogram confirmed the GDE findings, localizing the vegetation attachment to the left coronary cusp of the AV. No other cardiac vegetations were identified (Videos 3, 4).Table 2Subsequent Diagnostic Test ResultsParameterValueAntinuclear antibodiesPositive, 1:640Anti-double-stranded DNA antibodyPositiveAnti-SSA> 8.0 AIAnti-SSB> 8.0 AIRheumatoid factorPositiveP-ANCA< 1:20C-ANCA< 1:20RNP antibodies< 0.2 AISmith antibodies0.2 AIAnti-cardiolipin antibody12 MPL U/mL (negative)Dilute Russell viper venom timePositive, 72.6 sMixing studyAbnormalC-ANCA = cytoplasmic antineutrophil cytoplasmic antibodies; P-ANCA = perinuclear antineutrophil cytoplasmic antibodies; RNP = ribonucleoprotein; SSA = Sjögren-syndrome-related antigen A; SSB = Sjögren-syndrome-related antigen B. Open table in a new tab C-ANCA = cytoplasmic antineutrophil cytoplasmic antibodies; P-ANCA = perinuclear antineutrophil cytoplasmic antibodies; RNP = ribonucleoprotein; SSA = Sjögren-syndrome-related antigen A; SSB = Sjögren-syndrome-related antigen B. The critical care management of acute stroke encompasses close monitoring for neurologic deterioration and assessment for acutely modifiable risk factors. A cardioembolic reason is the most common cause of stroke for patients who are aged 18 to 45 years and occurs in 25% to 50% of cases.1Putaala J. Metso A.J. Metso T.M. et al.Analysis of 1008 consecutive patients aged 15 to 49 with first-ever ischemic stroke: the Helsinki young stroke registry.Stroke. 2009; 40: 1195-1203Crossref PubMed Scopus (529) Google Scholar, 2Yesilot B.N. Putaala J. Waje-Andreassen U. et al.Etiology of first-ever ischaemic stroke in European young adults: the 15 Cities Young Stroke Study.Eur J Neurol. 2013; 20: 1431-1439PubMed Google Scholar, 3Ji R. Schwamm L.H. Pervez M.A. et al.Ischemic stroke and transient ischemic attack in young adults: risk factors, diagnostic yield, neuroimaging, and thrombolysis.JAMA Neurol. 2013; 70: 51-57Crossref PubMed Scopus (135) Google Scholar The second most common cause of stroke in this population is carotid artery dissection, which was ruled out by the CT angiogram in the case patient. Atherosclerosis of large vessels and hyaline arteriolosclerosis of small vessels are both common etiologies of stroke in those patients aged > 45 years; these account for < 20% of all strokes in the younger population. A definitive etiology is not identified in up to 40% of the younger population. It has been established that bedside echocardiography performed by the critical care clinician has value for the detection of multiple cardiac pathologies, including pulmonary embolism and cardiac tamponade. In these circumstances, the expedited diagnosis provides obvious benefit to the patient.4Frazer E.E. Badillo C.P. Lam S.H. Rapid detection of intracardiac thrombus with bedside echocardiography.J Emerg Med. 2016; 50: 501-503Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 5Joseph D. Lee E. Tabatabai R. et al.Pulmonary embolism in transit: direct visualization of a PE passing through the heart using bedside ultrasonography.CJEM. 2016; 18: 313-314Crossref PubMed Scopus (1) Google Scholar, 6Jammal M. Milano P. Cardenas R. et al.The diagnosis of right heart thrombus by focused cardiac ultrasound in a critically ill patient in compensated shock.Crit Ultrasound J. 2015; 7: 6Crossref PubMed Scopus (8) Google Scholar In contrast, GDE is not commonly reported to be used to screen for left-sided cardiac sources of embolic events, with some reports identifying left ventricular thrombi and cardiac vegetations.7Fischer A.J. Lebiedz P. Wiaderek M. et al.Ischemic left ventricular perforation covered by a thrombus in a patient presenting with cerebral ischemia: importance of time-sensitive performance and adequate interpretation of bedside transthoracic echography.Case Rep Emerg Med. 2016; : 7565042PubMed Google Scholar, 8Seif D. Meeks A. Mailhot T. et al.Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound.Crit Ultrasound J. 2013; 5: 1Crossref PubMed Scopus (16) Google Scholar Guidelines for critical care ultrasonography recommend that GDE be performed to screen patients with suspected endocarditis because the intensivist with basic GDE training can recognize obvious cardiac vegetations.9Levitov A. Frankel H.L. Blaivas M. et al.Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography.Crit Care Med. 2016; 44: 1206-1227Crossref PubMed Scopus (220) Google Scholar In cases in which smaller vegetations are not apparent with B-mode echocardiography, the identification of valvular regurgitation with color Doppler may suggest its presence. The present case demonstrates the utility of GDE to expediently identify a cardioembolic cause of acute stroke in the critical care setting. In this case, early identification of systemic lupus erythematosus and antiphospholipid antibody syndrome led to the rapid initiation of appropriate therapies that are not routinely used for acute ischemic strokes: steroids, hydroxychloroquine, and full-dose anticoagulation. This early initiation may have reduced the patient’s risk for repeated embolic events. A transesophageal echocardiogram performed 5 weeks later showed resolution of the AV vegetation (Video 5). 1.Bedside GDE should be performed as an early screening tool for acute ischemic stroke when an embolic source is suspected.2.Echocardiographic characteristics of endocarditis include the presence of an echogenic irregular mass, motion that is independent of normal valvular motion, and attachment on the upstream side of the valve.10Otto C.M. Textbook of Clinical Echocardiography, Fifth Edition. Elsevier Saunders, Philadelphia, PA2013Google Scholar3.GDE eliminates the time dissociation of image acquisition and interpretation. Financial/nonfinancial disclosures: None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: To analyze this case with the videos, see the online version of this article. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1MjhkNzVkZmEyZDliYTc5OWM4YWYwMmI2NGZhZThiZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzMyMTc5fQ.MRpDxMHTWvJdWfVqLv9qcnRWfEKJ7v9q3YOlt1tAOo2te4dMkXzgtJycSOzrVVAqttAs5A5Yb1LjKQGBVGp3Zmh67Z3HGKh3kISmlE88SspBmrclIUtBL4BrGuGNhoBaBzqcNLzrRgVUJGpYtvsgniVfzM30xwwNkDi9EdyCm0GYvz9vjPxR7BUwTxRRk-iGHcQc3DJwXpmdXvJxn1KpOfChMVLO0wfyrXPcS6LgAIuzJ5L6684xcFTkbk44AFwsNnwUg6mmxNgSBAN_b0ZF46Pdvtb4aB-h7-ZFr4BLEBnbj4eK3iyAeFVlnkwlLGbNS7SG-85HifYWetZvnMEZtQ Download .mp4 (6.49 MB) Help with .mp4 files Video 1Cardiac parasternal long-axis view.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiMjRhZjRiYzhiZGNhZTViYzVjMzU3MDRhYTMzYzU3NiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzMyMTc5fQ.hF7_0WG6La-qIVbFh43AzRDtWCn2Msd6U1rw-78wVzGPxrxQ6tHqVkvGk_UV7fXDuXCSysB0ou4d4b3DlXGEBa6B4HKL-jpbb53EV6OjfkV88MkOzAfHHcSOIk5pficeR8lTDIVpc6mHCqIfEvme2bYVGQ2wrFCvOm6tvVJG1NMx3_mBsPk8O60fwB85MP27driOd1CJ8RRQFrszDH8awYqRgB9SJkX39qkavr4p5OkXSE7uCW-uYUPDnZKQxDee0srowgZDvXP_jV0UHsDrTwOfRXqyDbXO0Bw81b1TSoF2ot3nKpVSUdWiurPpNDsx-4BgSqnRgio9h8JIqgRsPA Download .mp4 (6.57 MB) Help with .mp4 files Video 2Cardiac parasternal long-axis view with labeled structures.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4MzIzOTQxMzFlZTUwZWYzNDUzZDQwM2ZkNDgyZjdkZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzMyMTc5fQ.qMUHUwIITE-3FDhYpHpgiv4vnV9a-D493Hu4ucqidfDD6QhgbMjRr_Yw9SGw-uuoEcSQNPnxY7TtxENgHBWdIZdfzxTnRliWsIqGGsStJkpj1Vq5M4m74ax3C4iG6cIHZEv9iA6zX5eF1Ixs1OKbwxT6TLXhYIdNAO1b6zMdUKyddS315RSzb0Mc4VtBMVu1q0vcZt2XddOsZh7wD29BZ8k58ZCbbri4W7xHhTmDkc8NIPbwpl4zgNwcC37VHagAc66vsyHq9nKa8e7M0OsK_t4eRbjIYT8PxVD9-Hg0hyJxBbpQBqbhloDKJbK6FWp1t2MCedhxmuur4T0ffwHulQ Download .mp4 (7.52 MB) Help with .mp4 files Video 3Transesophageal echocardiography: mid-esophageal long-axis view with labeled structures.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiMjdjMTc3ZDYxN2FiNWFjYmEyZWMyZmUzOTE1MGZhYSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzMyMTgwfQ.TfT7KGZoBYqemKFwac40LjVQ_YqSAhsF_F3WstSFiEV5fBf_5aXYPI0mRmtWDEiTGHNVs_sSQ6UP23fHlAeN4tNw6De7TLHoMyOPyhHalfeCp6Y87QPMyD0OZOKypE9yqh1VvHo6TzqohaDRLd_dXWpFyISiMRnnwRrA2GqCPwype9pXVKge87pyl6ggD9ldKVkVFnlBHQCKnogoJ0SJsv-9io8rJ0dV2UBb1nvZ9f66c9rimUuHV4ZT3SaU1lkMIPC_kD0YEJmwbVZxp5WKf--oRN60yPhqS2UR485XOMrIiebM-nroCJIJ8ufXCnvbIXjuaH5i7eDNjLRagV6qfg Download .mp4 (7.51 MB) Help with .mp4 files Video 4Transesophageal echocardiography: mid-esophageal aortic valve short-axis view with labeled structures.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiMDA2YmJmZWE3NWRlMTg2ZWE0ZjhiNTY3NzRmNmY0NSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzMyMTgwfQ.nB7efoTelE21Z0pfFR7HQXwq0v_A8qDdYRjSpI88_ow80HHQD_HuS-Ixe1NrmkBR6g95LsYOGH09Fm3L3zlyIrGM5YWVEpJ3PD9Cv39pRzGUo5EtV73SS4h6KW-EgF4yV9yRZls5OWfZJA4ec1HE9SJbDFMhf9oXnD53A68pOuuwWI7Iahq5Bkv11ce4HeA6KiFvjjegjxrY21U_15X2LZpcDx-Thw6QFo2Q7sXREcCg5ghHwYY33rUkYpCXkMLJ-Fd7ZuC2xjnL8LKwcwJo5oSKqsykqSnJTINJ8ZnbU_hsfZuLeOjUkqyQmAwt743vph09kwzijEosSHMc87herQ Download .mp4 (7.96 MB) Help with .mp4 files Video 5Transesophageal echocardiography: mid-esophageal long-axis view and mid-esophageal aortic valve short-axis view, 5 weeks following initiation of treatment.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhMjFmZGZkNTgwYTQ2YmQwOTBmNTkzMTdlNjY1ZmRkNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzMyMTgwfQ.DSjf-1gCuT7ZwCbdyIfU5aWXfaagF4918mt7Zbm2W6tTWOJqNPKgj9V3U6NzHVqj-F78K0h_rHCLGvl7QjMjdK4Mi_UIsEMG9qRuaiA3CeOw88PP0qhg7lQ4eh_28xaWzcZmymmgQRtubJLi_3InppjFwq0yaslPm9Cnbs2lj0sAglR_OHjpz-6IKHhPl_jdxFfC2u7Stp6J6o6IIpDz9GXXAh91dZoD-0A1-OKvtsmjnG37QToWFDm6zDI9bxbkGtu9lCVZFokw3WfuunbBGdQnvTxvusOVGB-nQtVaUbdXv0AXiDihLiUd4sTxMP_1rPzGrUwFR4rdIgsLNkVeQw Download .mp4 (17.62 MB) Help with .mp4 files Discussion Video

Extracorporeal membrane oxygenation (ECMO) has been frequently used for cardiopulmonary support in patients with cardiac arrest. The purpose of this study is to determine the trends in mortality and differences in demographics in patients managed with ECMO for cardiac arrest. The National Inpatient

Percutaneous ventricular assist devices (PVAD) and intra-aortic balloon pump (IABP) provide mechanical support for patients in cardiogenic shock (CS). However, comparative outcomes of these therapies in a large real-world study remains unclear. Data was obtained from the National Inpatient Sample,

Objective: To investigate the frequency and predictors of in-hospital complications among patients undergoing coronary artery bypass grafting (CABG) in the United States.Design: Retrospective national database analysisSettings: United States hospitals.Participants: A weighted sample of 1,910,236 patients undergoing CABG surgery identified from the National (Nationwide) Inpatient Sample from 2008 to 2012.Interventions: CABG surgery Measurements and Main Results: The number of CABG surgeries decreased from 436,275 in 2008 to 339,749 in 2012. The Deyo comorbidity index showed a steady increase from 2008 to 2012. The rate of in-hospital mortality decreased from 2.7% in 2008 to 2.2% in 2012 (p <0.001). The most common in-hospital complication was postoperative hemorrhage (30.4%), followed by cardiac (11.34%) and respiratory complications (2.3%). During the 5-year period, the rates of in-hospital cardiac, respiratory and infectious complications decreased (p < 0.001), while the rate of postoperative hemorrhage showed a 35.8% relative increase in 2012 compared to 2008.Conclusion: The annual number of CABG surgeries is declining in the United States. While the burden of comorbidities is increasing, the rates of mortality and most in-hospital complications are improving. The increasing rate of postoperative bleeding necessitates the need to develop strategies to improve the risk of bleeding in this patient population. (C) 2017 Elsevier Inc. All rights reserved.

Objectives: To describe national trends in the incidence and outcomes of patients with chordae tendineae rupture (CTR).Methods: Patients who were diagnosed with CTR between 2000 and 2012 were identified in National (Nationwide) Inpatient Sample (NIS) registry. CTR was defined using validated International Classification of Diseases, 9th Edition, Clinical Modification diagnosis (ICD9-CM) codes.Results: A total of 37,287 (14,833 mitral valve repair, 7780 mitral valve replacement) CTR cases were identified. Overall, in-hospital mortality in CTR decreased by 3% from 2000 to 2012 (P < 0.001). From 2000 to 2012, the rate of mitral valve repair increased from 27.2% to 46.4%, (P < 0.001) with a concurrent decrease in the rate of mitral valve replacement (from 27.8 to 17.7%, P < 0.001). After multivariate adjustment, patient age (OR = 1.04, 95% CI 1.03-1.06, P < 0.001), congestive heart failure (CHF) (OR = 2.08, 95% CI 1.19-3.64, P = 0.01), myocardial infarction (MI) (OR = 3.58, 95% CI 2.10-6.11, P < 0.001), Deyo/Charlson comorbidity index (OR = 1.23, 95% CI 1.07-1.41, P < 0.003) and use of the intra aortic balloon pump (IABP) (OR = 4.81 95% CI 2.71-8.55, P < 0.001) were found to be independently associated with greater odds of mortality in these patients. Additionally, mitral valve replacement was significantly associated with higher costs of hospitalization (coefficient 15693, 95% CI 12638-18749, P < 0.001)Conclusion: Mitral valve repair is associated with reduced inpatient mortality and costs compared with mitral valve replacement. A substantial increase in the percentage of cases undergoing mitral valve repair with a concurrent decrease in cases undergoing mitral valve replacement were observed. Increasing age and comorbidity index, history of CHF and MI, and use of IABP were identified as factors that could increase the risk of mortality in patients with CTR.

Background: The latest American Heart Association guidelines have recommended palliative/hospice care in selected patients with end-stage heart failure (HF). However, limited information exists regarding the trends in utilization of hospice care in this patient population. Methods: Data from the

Paroxysmal autonomic instability with dystonia (PAID) is a syndrome commonly related to traumatic brain injury (TBI) and rarely to anoxia associated with symptoms of dystonia, tachycardia, tachypnea, and diaphoresis. This is a case of a 20-year-old man who was stabbed in the heart. He underwent surgical repair of a ventricular septal defect and mitral valve replacement. Postoperatively, he developed dystonia with tachycardia and tachypnea consistent with PAID syndrome, secondary to prolonged hypoxia. Traditionally, this poorly understood syndrome is treated with morphine, clonazepam, and nonselective β-blockers. Second-line medications commonly used are baclofen, dantrolene, and gabapentin, which are aimed at the dystonia itself. In this case, both first- and second-line agents were ineffective. A 72-hour dexmedetomidine infusion resulted in complete resolution of symptoms. This is the first case of anoxia-induced PAID syndrome to be effectively treated with dexmedetomidine, which was previously used in a case induced by TBI.

Introduction: Limited evidence exists regarding the impact of annual hospital volume on outcomes in patients receiving heart transplant. Hypothesis: To quantify the impact of annual hospital volume on in-hospital mortality among patients receiving heart transplantation. Methods: Data from the National (Nationwide) Inpatient Sample (years 2008 to 2012) were analyzed to identify 11,104 patients receiving heart transplant. The study population was identified using validated international Classification of Diseases, Ninth Revision, Clinical Modification diagnosis (ICD-9-CM) and procedure codes. Annual hospital volume was calculated using unique hospital identifiers. Hospitals were divided into tertiles based on the volume of transplant cases admitted over the study period (low: 1-65, medium: 65-125, high> 125). Multivariate regression analysis was used to identify independent predictors of mortality in patients undergoing heart transplant. Results: Between the years of 2008 and 2012, a total of 519 (4.67%) in-hospital deaths occurred among recipients of heart transplantation. In-hospital mortality was highest (5.8%) in the low hospital volume and lowest (3.9%) in hospitals with high annual volume (p Conclusion: Hospital volume is an independent determinant for in-hospital mortality among patient receiving heart transplants.

Unicuspid aortic valve is a rare congenital malformation that usually presents in the 3rd to 5th decade of life—and usually with severe aortic stenosis or regurgitation. It often requires surgical correction. Diagnosis can be made with 2- or 3-dimensional transthoracic or transesophageal echocardiography, cardiac computed tomography, or cardiac magnetic resonance imaging. We report the case of a 31-year-old man who presented with dyspnea on exertion due to severe aortic stenosis secondary to a unicuspid unicommissural aortic valve. After aortic valve replacement, this patient experienced complete heart block that required the placement of a permanent pacemaker.

We have previously reported significant reductions in door-to-balloon (D2B) and recognition-to-reperfusion (R2R) times by use of a fully automated wireless network that transmits 12-lead ECG of patients with suspected ST elevation myocardial infarction (STEMI) from emergency medical services (EMS)

We have previously reported from our institution outcomes in patients with ST-elevation myocardial infarction (STEMI) based on mode of arrival i.e., fully automated pathway for pre-hospital ECG transmission (STAT-MI pathway) versus other. We now report on the use of ECG Selvester score (SS) in