Use of a taurolidine containing antimicrobial wash to reduce cardiac implantable electronic device infection.

AIMS: TauroPace (Tauropharm, Bavaria Germany), a taurolidine solution for combating cardiac implantable electronic device (CIED) infection, was compared with a historical control of 3% hydrogen peroxide (H2O2) in a prospective observational study. METHODS AND RESULTS: The device pocket was irrigated, and all hardware accessible within (leads, suture sleeves, pulse generator) was wiped with H2O2, TauroPace, or taurolidine in a galenic formulation during any invasive CIED procedure at the study centre. Only CIED procedures covered by TauroPace or H2O2 from 1 January 2017 to 28 February 2022 were included for analysis. Patients who underwent >1 procedure were censored for the last treatment group and reassigned at the next procedure. The primary endpoint was major CIED infection within 3 months. The secondary endpoints were CIED infection beyond 3 months, adverse events potentially related to the antimicrobial solutions, CIED system, procedure, and death, till the end of follow-up. TauroPace covered 654 procedures on 631 patients, and H2O2 covered 551 procedures on 532 patients. The TauroPace group had more patient risk factors for infection than the H2O2 group (P = 0.0058) but similar device and procedure-specific risk factors (P = 0.17). Cardiac implantable electronic device infection occurred in 0/654 (0%) of the TauroPace group and 6/551 (1.1%) of the H2O2 group (P = 0.0075). Death occurred in 23/654 (3.5%) of the TauroPace group and 14/551 (2.5%) of the H2O2 group (P = 0.33). Non-infection related adverse events were rarer in the TauroPace (3.8%) than the H2O2 (6.0%) group (P = 0.0802). CONCLUSION: TauroPace is safe but more effective than H2O2 in reducing CIED infection. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05576194.

Early Doppler-echocardiography evaluation of Carpentier-Edwards Standard and Carpentier-Edwards Magna aortic prosthetic valve: comparison of hemodynamic performance.

OBJECTIVES: This study was designed to describe Doppler-echocardiography values of Carpentier-Edwards Perimount Standard (CEPS) and Carpentier-Edwards Perimount Magna (CEPM) aortic prosthetic valves, evaluated by a single, experienced echo-laboratory, early in the postoperative phase. METHODS: Three-hundred-seventy-seven consecutive patients, who had had a CEPS or a CEPM implanted in our Hospital due to aortic stenosis and/or insufficiency, underwent baseline Doppler echocardiography evaluation within 7 days after surgery. Hemodynamic performances of CEPS and CEPM were accurately described, evaluating flow-dependent (transprosthetic velocities and gradients) and flow-independent (effective orifice area, indexed effective orifice area and Doppler velocity index) Doppler-echocardiography parameters. RESULTS: Out of the 377 patients 48.8% were men (n = 184), mean age was 74.63 ± 6.77 years, mean BSA was 1.78 ± 0.18 m2, mean ejection fraction was 57.78 ± 8%. Two-hundred and sixty two CEPS and 115 CEPM were implanted. Comparing size-by-size CEPS with CEPM, both prostheses showed a good hemodynamic profile, with fairly similar values of pressure gradients (PGmax and mean, in mmHg, = 37,18 ± 11.57 and 20.81 ± 7.44 in CEPS n°19 compared to 32,47 ± 7,76 and 17,67 ± 4.63 in CEPM n°19 and progressively lower in higher sized prostheses, having PGmax and mean 15 ± 3,16 and 9.15 ± 1,29 in CEPS n°29 compared to 15,67 ± 1,53 and 9 ± 1 in CEPM n°29) and EOAi (being 0,65 ± 0,33 cm²/m² in CEPS n°19 compared to 0,77 ± 0,29 cm²/m² in CEPM n°19 and progressively higher in higher sized prostheses, being 1,28 ± 0,59 cm²/m² in CEPS n°29 compared to 1,07 ± 0,18 cm²/m² in CEPM n°29), the latter resulting, however, basically less flow obstructive. CONCLUSIONS: Our data confirm the good hemodynamic performance of both aortic bioprostheses and the more favourable hemodynamic profile of CEPM compared to CEPS, pointing out the need to perform routinely an accurate baseline Doppler-echocardiography evaluation early after surgery to allow an adequate interpretation of data at follow-up.

Post-operative atrial fibrillation management by selective epicardial vagal fat pad stimulation.

PURPOSE: Post-operative atrial fibrillation (POAF) is a common complication after cardiac surgery and often leads to poorly tolerated fast ventricular rates. Negative dromotropic drugs are not always effective and may not be well tolerated in heart failure patients. Aim of this study is to verify if high-frequency stimulation of the right inferior fat pad (RIFPS) allows an effective decrease in ventricular rate (VR) during POAF. METHODS: We enrolled 32 consecutive patients submitted to bypass; during surgery, a temporary heart wire was implanted in a site where RIFPS evoked a functional AV block. During POAF, RIFPS was delivered from the heart wire to decrease VR. RESULTS: Intra-operative RIFPS evoked complete AV block in 29 patients (91%). Fourteen patients (44%) developed POAF (mean VR 127 +/- 12 bpm). In these patients, RIFPS achieved a 25% reduction of VR and complete AV block with 6.0 +/- 1.9 and 7.5 +/- 1.8 V (duration 0.2 ms, frequency 50 Hz), respectively. CONCLUSION: Epicardial RIFPS represents an effective and feasible technique to decrease VR during POAF.

Prognostic value of plasma myeloperoxidase concentration in patients with stable coronary artery disease.

BACKGROUND: There are no studies yet on the usefulness of myeloperoxidase (MPO) as a prognostic tool in patients with stable coronary artery disease (CAD). METHODS: The study included 382 patients with clinical and angiographic confirmation of stable CAD. Blood samples for MPO measurement were taken before angiography. Myeloperoxidase was determined using an enzyme immunoassay. The primary end point of the study was all-cause mortality. RESULTS: Patients were categorized into 2 groups: the high-MPO group included patients in the third tertile of MPO levels (>75.0 microg/L; 127 patients), and the low-MPO group included patients in the first (<52.6 microg/L) and second tertiles (52.6-75.0 microg/L) of MPO levels (255 patients). The median follow-up was 3.5 [3.3-4.8] years. There were 35 deaths (9.2%) during the follow-up. The MPO concentration was 60.1 [47.0; 83.8] microg/L in survivors and 72.7 [54.8; 105.1] microg/L in nonsurvivors (P = .06). There were 17 deaths in the high-MPO level and 18 deaths in the low-MPO group: Kaplan-Meier estimates of mortality were 18.3% and 10.5% with an odds ratio of 1.96 (95% confidence interval [1.02-3.76], P = .04). The Cox proportional hazards model adjusting for correlates of mortality showed that plasma MPO was not an independent correlate of mortality (hazard ratio 1.06, 95% confidence interval [0.71-1.59], P = .77 for 1 SD increase in the log variable). CONCLUSION: Although elevated plasma MPO concentration is associated with a more advanced cardiovascular risk profile, plasma MPO does not predict mortality independent of other cardiovascular risk factors in patients with stable CAD.

Feasibility, safety and tolerability of accelerated dobutamine stress echocardiography.

A continuous infusion of a single high dose of dobutamine has been, recently, suggested as a simple and effective protocol of stress echocardiography. The present study assesses the feasibility, safety, and tolerability of an accelerated dobutamine stress protocol performed in patients with suspected or known coronary artery disease. Two hundred sixty five consecutive patients underwent accelerated dobutamine stress echocardiography: the dobutamine was administered at a constant dose of 50 microg/kg/min for up to 10 minutes. The mean weight-adjusted cumulative dose of dobutamine used was 330 +/- 105.24 microg/kg. Total duration of dobutamine infusion was 6.6 +/- 2.1 min. Heart rate rose from 69.9 +/- 12.1 to 123.1 +/- 22.1 beats/min at peak with a concomitant change in systolic blood pressure (127.6 +/- 18.1 vs. 167.6 +/- 45.0 mmHg). Dobutamine administration produced a rapid increase in heart rate (9.4 +/- 5.9 beats/min2). The side effects were similar to those described with the standard protocol; the most common were frequent premature ventricular complexes (21.5%), frequent premature atrial complexes (1.5%) and non sustained ventricular tachycardia (1.5%); among non cardiac symptoms the most frequent were nausea (3.4%), headache (1.1%) and symptomatic hypotension (1.1%). No major side effects were observed during the test. Our data demonstrate that a continous infusion of a single high dose of dobutamine is a safe and well tolerated method of performing stress echocardiography in patients with suspected or known coronary artery disease. This new protocol requires the administration of lower cumulative dobutamine dose than standard protocol and results in a significant reduction in test time.

Forces applied during transvenous implantable cardioverter defibrillator lead removal.

METHODS: 17 physicians, experienced in transvenous lead removal, performed a lead extraction manoeuvre of an ICD lead on a torso phantom. They were advised to stop traction only when further traction would be considered as harmful to the patient or when--based on their experience--a change in the extraction strategy was indicated. Traction forces were recorded with a digital precision gauge. RESULTS: Median traction forces on the endocardium were 10.9 N (range from 3.0 N to 24.7 N and interquartile range from 7.9 to 15.3). Forces applied to the proximal end were estimated to be 10% higher than those measured at the tip of the lead due to a friction loss. CONCLUSION: A traction force of around 11 N is typically exerted during standard transvenous extraction of ICD leads. A traction threshold for a safe procedure derived from a pool of experienced extractionists may be helpful for the development of required adequate simulator trainings.

Safety of continuous periprocedural rivaroxaban for patients undergoing left atrial catheter ablation procedures.

BACKGROUND: This study aimed to evaluate the safety of continuous periprocedural rivaroxaban administration during left atrial radiofrequency ablation (RFA) in comparison with uninterrupted oral vitamin K antagonist administration. Data about the use of rivaroxaban in the setting of left atrial RFA procedures are lacking. METHODS AND RESULTS: The study cohort included 544 patients (mean age, 63±10 years) who underwent left atrial RFA procedures between February 2012 and May 2013. All patients (n=272) receiving uninterrupted periprocedural rivaroxaban 15 or 20 mg/d before the procedure (rivaroxaban) were matched by age, sex, and type of rhythm disorder with an equal number of patients managed with uninterrupted vitamin K antagonist phenprocoumon (international normalized ratio, 2-3). During RFA, heparin was given intravenously to maintain an activated clotting time at 270 to 300 s. The safety end point was a composite of bleeding, thromboembolic events, and death. There were no thromboembolic complications and no deaths in either group. The prevalence of major bleeding complications was similar in both groups (1 tamponade in RivG and 1 groin hematoma requiring transfusion in phenprocoumon). Minor bleeding complications occurred equally in both groups (20 of 272; 7% in the rivaroxaban versus 33 of 272, 12% in the phenprocoumon; P=0.08). In multivariable analyses, female sex was associated with a greater risk of complications (odds ratio, 1.96; 95% confidence interval, 1.10-3.49). CONCLUSIONS: In patients undergoing left atrial RFA, continuous periprocedural rivaroxaban use seems to be as safe as uninterrupted periprocedural phenprocoumon administration.

Epicardial ganglionated plexus stimulation decreases postoperative inflammatory response in humans.

BACKGROUND: Surgical cardiac revascularization produces a high degree of systemic inflammation and the secretion of several cytokines. Intensive postoperative inflammation may increase the incidence of postoperative atrial fibrillation and favor organ dysfunctions. No data documenting the anti-inflammatory properties of epicardial vagal ganglionated plexus stimulation are available. OBJECTIVE: To verify the feasibility and safety of postoperative inferior vena cava-inferior atrial ganglionated plexus (IVC-IAGP) burst stimulation and the effectiveness of this approach in reducing serum levels of inflammatory cytokines. METHODS: In 27 patients who were candidates for off-pump surgical revascularization, the IVC-IAGP was located during surgery, a temporary wire was inserted, and a negative atrioventricular node dromotropic effect was obtained in 20 patients on applying high-frequency burst stimulation. In 5 patients atrial fibrillation or phrenic nerve stimulation was induced, and the remaining 15 patients served as the experimental group. Twenty additional patients underwent off-pump surgical revascularization without IVC-IAGP stimulation and served as the control group. On arrival in the intensive care unit, the experimental group underwent IVC-IAGP stimulation for 6 hours. Blood samples were collected at different times. RESULTS: The serum levels of cytokines were not statistically different at baseline and on arrival in the intensive care unit between the groups, while they proved statistically different after 6 hours of stimulation: interleukin-6 (EG: 121 ± 71 pg/mL vs CG: 280 ± 194 pg/mL; P = .004), tumor necrosis factor-α (EG: 2.68 ± 1.81 pg/mL vs CG: 5.87 ± 3.48 pg/mL; P = .003), vascular endothelial growth factor (EG: 93 ± 43 pg/mL vs CG: 177 ± 86 pg/mL; P = .002), and epidermal growth factor (EG: 79 ± 48 pg/mL vs CG: 138 ± 76 pg/mL; P = .012). CONCLUSIONS: Prolonged burst IVC-IAGP stimulation after surgical revascularization appears to be feasible and safe and significantly reduces inflammatory cytokines in the postoperative period.

Very late bare metal stent thrombosis with concomitant patent drug eluting stent in the same vessel: a case for a suggestive hypothesis.

We report a case of very late stent thrombosis of a bare metal stent with a concurrent drug eluting stent's patency in the same coronary vessel, in a patient undergoing primary angioplasty who discontinued his clopidogrel regimen a few weeks after successful deployment of the stents.

Infective endocarditis on mitral annular calcification: a case report.

INTRODUCTION: Mitral annular calcification is a common finding in elderly patients; it is considered a benign cardiac abnormality but it can be a predisposing factor for infective endocarditis. Although described in numerous necropsy studies, endocarditis on mitral annular calcification has rarely been reported during life, and the frequency of sepsis can be underestimated because of difficult diagnosis. CASE PRESENTATION: We present a case of infective endocarditis on mitral annulus calcification in a patient with acute coronary syndrome, diagnosed with transthoracic echocardiography. CONCLUSION: Transthoracic echocardiography may contribute to a correct diagnosis, showing typical findings of infective endocarditis on mitral annular calcification in order to administrate an adequate antibiotic prophylaxis in patients undergoing endoscopic or invasive procedures.

An unusual case of ST-segment elevation myocardial infarction following a late bare-metal stent fracture in a native coronary artery: a case report.

INTRODUCTION: A bare-metal stent fracture as a cause of acute coronary thrombosis and consequently of acute coronary syndrome is a rare clinical event that, to the best of our knowledge, has previously not been reported. A stent fracture is a rare complication arising from percutaneous coronary intervention. CASE PRESENTATION: We present, to the best of our knowledge, the first documented case of ST-segment elevation myocardial infarction in a patient following a late bare-metal stent fracture and thrombosis in a native coronary artery. The patient, a 51-year-old Caucasian man, was treated successfully with primary percutaneous coronary intervention and a new stent implantation. CONCLUSION: A coronary stent fracture is a rare complication that has been described in venous bypass grafts deploying either a drug-eluting stent or a bare-metal stent. Stent fractures rarely occur in coronary arteries. In light of the non-specific presentation of stent fracture, it is also an easily missed complication. Patients may present with a non-specific symptom of angina. The angina could either be stable or unstable as a result of restenosis or in-stent thrombosis, or both. Our case demonstrates the most severe consequences of a bare-metal stent fracture (sudden coronary thrombosis and subsequent myocardial infarction) in a native coronary artery. It was diagnosed angiographically and treated early and effectively.

Caseous calcification of the mitral annulus with mitral regurgitation and impairment of functional capacity: a case report.

INTRODUCTION: Mitral annular calcification is a common echocardiographic finding, especially in the elderly. Caseous calcification of the mitral annulus, however, is a relatively rare variant, having an echocardiographic prevalence of 0.6% in patients with mitral annular calcification. Caseous calcification needs to be differentiated from infected mitral annular calcification, mitral annular abscess and tumours. It is not malignant, and medical therapy with clinical follow-up is the therapeutic option. Surgery should be reserved for co-existent mitral valve dysfunction. CASE PRESENTATION: We report the case of a 69-year-old woman, in whom caseous calcification of the mitral annulus was found at transthoracic echocardiography. Cardiac surgery was performed because of significant mitral regurgitation and impairment of functional capacity. CONCLUSION: Caseous calcification of the mitral annulus needs to be considered and confirmed by transthoracic echocardiography since there is potential for diagnostic confusion or misdiagnosis. This lesion appears to have a benign prognosis but, when associated with mitral valve dysfunction, cardiac surgery appears to be the best therapeutic option.