Clinical impact of remote heart failure management using the multiparameter ICD HeartLogic alert.

INTRODUCTION AND OBJECTIVES: The multiparametric implantable cardioverter-defibrillator HeartLogic index has proven to be a sensitive and timely predictor of impending heart failure (HF) decompensation. We evaluated the impact of a standardized follow-up protocol implemented by nursing staff and based on remote management of alerts. METHODS: The algorithm was activated in HF patients at 19 Spanish centers. Transmitted data were analyzed remotely, and patients were contacted by telephone if alerts were issued. Clinical actions were implemented remotely or through outpatient visits. The primary endpoint consisted of HF hospitalizations or death. Secondary endpoints were HF outpatient visits. We compared the 12-month periods before and after the adoption of the protocol. RESULTS: We analyzed 392 patients (aged 69±10 years, 76% male, 50% ischemic cardiomyopathy) with implantable cardioverter-defibrillators (20%) or cardiac resynchronization therapy defibrillators (80%). The primary endpoint occurred 151 times in 86 (22%) patients during the 12 months before the adoption of the protocol, and 69 times in 45 (11%) patients (P<.001) during the 12 months after its adoption. The mean number of hospitalizations per patient was 0.39±0.89 pre- and 0.18±0.57 postadoption (P<.001). There were 185 outpatient visits for HF in 96 (24%) patients before adoption and 64 in 48 (12%) patients after adoption (P<.001). The mean number of visits per patient was 0.47±1.11 pre- and 0.16±0.51 postadoption (P<.001). CONCLUSIONS: A standardized follow-up protocol based on remote management of HeartLogic alerts enabled effective remote management of HF patients. After its adoption, we observed a significant reduction in HF hospitalizations and outpatient visits.

Rituximab as a First-line Treatment for Autoimmune Hemolytic Anemia in Multicentric Castleman's Disease.

Castleman´s disease (CD) is a rare lymphoproliferative disorder. Concurrent autoimmune disease and CD are uncommon, but even more so, comorbid CD and autoimmune hemolytic anemia (AIHA). To the best of our knowledge, this case represents the first successful AIHA and multicentric CD (MCD) treatment using rituximab as first-line treatment. We present the case of a 53-year-old woman with a 10-year history of plasma cell variant CD who arrived at the emergency department with signs and symptoms of anemia. On admission, we made a preliminary diagnosis of hemolytic anemia and initiated immunosuppressive therapy with rituximab and steroids. After seven days, the patient recovered according to clinical and laboratory parameters, and we discharged her early. We portray a rare occurrence of CD and AIHA successfully treated with rituximab and steroid therapy, which makes our case unique.

Metastatic Hepatoblastoma in Adolescence: A Clinical Case Report and Literature Review.

Hepatoblastoma is the most common hepatic neoplasm in children. However, its incidence is infrequent beyond age five. We present the case of a 15-year-old female diagnosed with metastatic hepatoblastoma during hospitalization for liver function deterioration. The patient presented with abdominal distension, jaundice, and other symptoms indicative of advanced disease. Imaging and biopsy confirmed stage IV epithelial hepatoblastoma with pulmonary metastases. This case underscores the importance of considering hepatoblastoma in older pediatric patients or young adults presenting with hepatic masses despite lacking traditional risk factors for liver malignancies.

Beyond the Classic Causes of Dysphagia: Bayford-Autenrieth Dysphagia.

Dysphagia lusoria (DL) is a rare clinical entity that presents with dysphagia derived from the anatomical obstruction of the esophagus by an aberrant vessel originating from the right subclavian artery. We present the case of a 64-year-old patient with a medical history of chronic, intermittent, mild, and self-limited dysphagia for over 20 years, wherein we formulated the diagnosis of DL. A 64-year-old woman arrived at the emergency department with a 24-hour history of acute progressive dysphagia, leading to intolerance to oral intake and minimal exertion dyspnea. A thorough clinical analysis and exclusion of other more common clinical entities will lead to its diagnosis. Our patient presented with respiratory symptoms, which is rare considering that these clinical presentations are more common in the pediatric population, explained by its tracheal elasticity. The combination of respiratory symptoms in an elderly patient, along with the typical mechanical dysphagia of DL, adds complexity to the diagnostic process, making this case unique.

Cocaine-Induced Asthma and the "Crack Lung": A Case Report.

Cocaine, the second most used illicit drug, is associated with cardiovascular, pulmonary, and other complications. Lung involvement associated with cocaine use, also known as "crack lung syndrome" (CLS), can elicit new-onset and exacerbate chronic pulmonary conditions. A 28-year-old female with a history of chronic controlled asthma arrived at the Emergency Department (ED), referring to cocaine inhalation, followed by symptoms compatible with an asthmatic crisis, requiring immediate steroid and bronchodilator therapy. Radiological studies and bronchoscopy confirmed CLS diagnosis. Despite treatment with oxygen, bronchodilators, and steroids, the asthmatic crises persisted. However, after 48 hours, we observed a complete regression of the lung infiltrates. This case highlights the importance of clinical suspicion, bronchoscopy findings, and the potential co-occurrence of CLS with asthma exacerbations. While computed tomography (CT) scans can be helpful, they should not be the only tool to diagnose CLS. The successful management of CLS involves the use of bronchodilators, steroids, and oxygen therapy and abstaining from cocaine use. Researchers should conduct further studies to diagnose and treat CLS in conjunction with acute asthma symptoms to assist this patient population better.

An Unexpected Cause of Abdominal Discomfort: Non-pancreatic Mesenteric Pseudocyst.

Mesenteric cysts (MCs), rare entities of embryologic origin, predominantly affect the small bowel's mesentery. The clinical manifestations of MCs often lack specificity, which complicates diagnosis. Given their rarity, detailed reporting of MC cases is essential to enhance understanding and improve treatment strategies. We present a case of a 45-year-old male who presented to the emergency department with a one-month history of abdominal pain in the umbilical region, postprandial fullness, progressive decrease in food intake, 12 kg weight loss, and increased abdominal girth. Computed tomography (CT) imaging revealed a well-defined mass in the jejunoileal area. During the exploratory laparotomy, we identified and excised a fibrotic mass on the mesentery of the ileal jejunum, which was not adherent to the intestines. We discharged the patient with no complications following an uneventful four-day observational period. Histopathological examination, including immunohistochemical staining, confirmed the lesion as a non-pancreatic mesenteric pseudocyst. On the follow-up visit, the patient reported no complications. This case report underscores the solitary, multilocular nature of the jejunoileal MC, distinct for its serosanguineous fluid content. In conclusion, this case highlights the diagnostic challenge of MCs and illustrates the potential for successful management with a timely and multidisciplinary approach.

Beyond the Ordinary: An Atypical Guillain-Barré Syndrome Case With Unique Characteristics.

We present a patient with pharyngeal-cervical-brachial Guillain-Barré syndrome (PCB-GBS) that progressed to a severe state followed by a quick recovery after treatment. This unique clinical course has not been documented previously and provides a potentially invaluable description of a novel GBS variant. A 42-year-old man arrived at the emergency department with a 24-hour history of dysphagia, weakness in his right arm, and bilateral shoulder weakness. Nerve conduction velocity testing revealed bilateral sensory and motor polyneuropathy, leading to the diagnosis of GBS with the PCB variant. Timely diagnosis and plasmapheresis treatment contributed to a complete recovery of muscle strength and reflexes. In cases resembling ours, it is imperative to contemplate the existence of rare Guillain-Barré variants. This case underscores the necessity of recognizing and addressing rare Guillain-Barré variants in clinical settings with similar presentations.

Remote heart failure management using the HeartLogic algorithm. RE-HEART registry.

INTRODUCTION AND OBJECTIVES: HeartLogic is a multiparametric algorithm incorporated into implantable cardioverter-defibrillators (ICD). The associated alerts predict impending heart failure (HF) decompensations. Our objective was to analyze the association between alerts and clinical events and to describe the implementation of a protocol for remote management in a multicenter registry. METHODS: We evaluated study phase 1 (the investigators were blinded to the alert state) and phases 2 and 3 (after HeartLogic activation, managed as per local practice and with a standardized protocol, respectively). RESULTS: We included 288 patients from 15 centers. In phase 1, the median observation period was 10 months and there were 73 alerts (0.72 alerts/patient-y), with 8 hospitalizations and 2 emergency room admissions for HF (0.10 events/patient-y). There were no HF hospitalizations outside the alert period. In the active phases, the median follow-up was 16 (95%CI, 15-22) months and there were 277 alerts (0.89 alerts/patient-y); 33 were associated with HF hospitalizations or HF death (n=6), 46 with minor decompensations, and 78 with other events. The unexplained alert rate was 0.39 alerts/patient-y. Outside the alert state, there was only 1 HF hospitalization and 1 minor HF decompensation. Most alerts (82% in phase 2 and 81% in phase 3; P=.861) were remotely managed. The median NT-proBNP value was higher within than outside the alert state (7378 vs 1210 pg/mL; P <.001). CONCLUSIONS: The HeartLogic index was frequently associated with HF-related events and other clinically relevant situations, with a low rate of unexplained events. A standardized protocol allowed alerts to be safely and remotely detected and appropriate action to be taken on them.

The evolutionary history of the Caribbean magnolias (Magnoliaceae): Testing species delimitations and biogeographical hypotheses using molecular data.

The Caribbean islands provide an ideal setting for studying biodiversity, given their complex geological and environmental history, and their historical and current geographical proximity to the American mainland. Magnolia, a flagship tree genus that has 15 endemic and threatened taxa (12 species and 3 subspecies) on the Caribbean islands, offers an excellent case study to empirically test Caribbean biogeographical hypotheses. We constructed phylogenetic hypotheses to: (1) reveal their evolutionary history, (2) test the current largely morphology-based classification and assess species limits, and (3) investigate major biogeographic hypotheses proposed for the region. Nuclear and chloroplast DNA sequence data of all 15 Caribbean Magnolia taxa are included, supplemented by a selection of American mainland species, and species representing most major clades of the Magnoliaceae family. We constructed phylogenetic hypotheses in a time-calibrated Bayesian framework, supplemented with haplotype network analyses and ancestral range estimations. Genetic synapomorphies in the studied markers confirm the species limits of 14 out of 15 morphologically recognizable Caribbean Magnolia taxa. There is evidence for four colonization events of Magnolia into the Caribbean from the American mainland, which most likely occurred by overwater dispersal, given age estimates of maximum 16 mya for their presence on the Caribbean islands.

Integrating morphological and genetic limits in the taxonomic delimitation of the Cuban taxa of Magnoliasubsect.Talauma (Magnoliaceae).

An accurate taxa delimitation, based on a full understanding of evolutionary processes involved in taxa differentiation, can be gained from a combination of ecological, morphological, and molecular approaches. The taxonomy of Magnoliasubsect.Talauma in Cuba has long been debated and exclusively based on traditional morphological study of a limited number of individuals. A more accurate description of leaf morphology variation using geometric morphometrics combined with genetic data could bring consistency to taxa delimitation in this group. Leaf samples for the morphological (243) and genetic (461) analyses were collected throughout the entire distribution range. The variability of each taxon was analyzed through multivariate and geometric morphometry, and 21 genetic markers (SSR). The observed leaf morphological variability was higher than previously described. Morphological and genetic classifications were highly congruent in two out of four taxa. Our data brought evidence that Magnoliaorbiculata can be considered a true species with very clear genetic and morphological limits. The main taxonomic issues concern the north-eastern Cuban populations of Magnoliasubsect.Talauma. The data supported the existence of two clear groups: corresponding mainly to M.minor-M.oblongifolia and T.ophiticola. However, these two groups cannot be considered fully delimited since genetic markers provided evidence of genetic admixture between them. Due to the likely absence of, at least strong, reproductive barriers between these three taxa, we propose therefore to consider them as a species complex.

Genetic patterns in Neotropical Magnolias (Magnoliaceae) using de novo developed microsatellite markers.

Conserving tree populations safeguards forests since they represent key elements of the ecosystem. The genetic characteristics underlying the evolutionary success of the tree growth form: high genetic diversity, extensive gene flow and strong species integrity, contribute to their survival in terms of adaptability. However, different biological and landscape contexts challenge these characteristics. This study employs 63 de novo developed microsatellite or SSR (Single Sequence Repeat) markers in different datasets of nine Neotropical Magnolia species. The genetic patterns of these protogynous, insect-pollinated tree species occurring in fragmented, highly-disturbed landscapes were investigated. Datasets containing a total of 340 individuals were tested for their genetic structure and degree of inbreeding. Analyses for genetic structure depicted structuring between species, i.e. strong species integrity. Within the species, all but one population pair were considered moderate to highly differentiated, i.e. no indication of extensive gene flow between populations. No overall correlation was observed between genetic and geographic distance of the pairwise species' populations. In contrast to the pronounced genetic structure, there was no evidence of inbreeding within the populations, suggesting mechanisms favouring cross pollination and/or selection for more genetically diverse, heterozygous offspring. In conclusion, the data illustrate that the Neotropical Magnolias in the context of a fragmented landscape still have ample gene flow within populations, yet little gene flow between populations.

Effects of angiotensin-neprilysin inhibition compared to angiotensin inhibition on ventricular arrhythmias in reduced ejection fraction patients under continuous remote monitoring of implantable defibrillator devices.

BACKGROUND: Angiotensin-neprilysin inhibition compared to angiotensin inhibition decreased sudden cardiac death in patients with reduced ejection fraction heart failure (rEFHF). The precise mechanism remains unclear. OBJECTIVE: The purpose of this study was to explore the effect of angiotensin-neprilysin inhibition on ventricular arrhythmias compared to angiotensin inhibition in rEFHF patients with an implantable cardioverter-defibrillator (ICD) and remote monitoring. METHODS: We prospectively included 120 patients with ICD and (1) New York Heart Association functional class ≥II; (2) left ventricular ejection fraction ≤40%; and (3) remote monitoring. For 9 months, patients received 100% angiotensin inhibition with angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), beta-blockers, and mineraloid antagonist. Subsequently, ACEi or ARB was changed to sacubitril-valsartan in all patients, who were followed for 9 months. Appropriate shocks, nonsustained ventricular tachycardia (NSVT), premature ventricular contraction (PVC) burden, and biventricular pacing percentage were analyzed. RESULTS: Patients were an average age of 69 ± 8 years and had mean left ventricular ejection fraction of 30.4% ± 4% (82% ischemic). Use of beta-blockers (98%), mineraloid antagonist (97%) and antiarrhythmic drugs was similar before and after sacubitril-valsartan. Sacubitril-valsartan significantly decreased NSVT episodes (5.4 ± 0.5 vs 15 ± 1.7 in angiotensin inhibition; P <.002), sustained ventricular tachycardia, and appropriate ICD shocks (0.8% vs 6.7% in angiotensin inhibition; P <.02). PVCs per hour decreased after sacubitril-valsartan (33 ± 12 vs 78 ± 15 in angiotensin inhibition; P <.0003) and was associated with increased biventricular pacing percentage (from 95% ± 6% to 98.8% ± 1.3%; P <.02). CONCLUSION: Angiotensin-neprilysin inhibition decreased ventricular arrhythmias and appropriate ICD shocks in rEFHF patients under home monitoring compared to angiotensin inhibition.

La hiponatremia como marcador de riesgo en pacientes sometidos a implante de desfibrilador en prevención primaria / Prognostic impact of hyponatremia in patients receiving implantable cardioverter in primary prevention

Introducción y objetivos: La hiponatremia es un factor de mal pronóstico en pacientes con insuficiencia cardiaca. Nuestro objetivo fue valorar el impacto de la hiponatremia en la evolución de los pacientes sometidos a implante de desfibrilador en prevención primaria. Método: Se trata de un estudio observacional retrospectivo multicéntrico en el que se valoró la natremia periimplante y los eventos adversos (la mortalidad de cualquier causa y la cardiovascular, el primer ingreso por insuficiencia cardiaca, la primera terapia apropiada e inapropiada del desfibrilador), en una cohorte española sometida a implante de desfibrilador en la prevención primaria. Se comparó la hiponatremia ligera (Na ≤ 135 mEq/l) y la moderada-severa (Na ≤ 131 mEq/l) respecto a la ausencia de la hiponatremia. Resultados: Un total de 725 pacientes, con un valor medio de sodio en la sangre periimplante de 139 ± 3,6 mEq/l y un tiempo medio de seguimiento de 34,1 ± 18,5 meses. En los pacientes con Na ≤ 135 mEq/l (n = 105) se observó una mayor incidencia de primer ingreso por insuficiencia cardiaca (odds ratio: 1,701; p = 0,031). En los pacientes con hiponatremia moderada-severa (n = 18) se observó mayor mortalidad total (hazard ratio; 3,552; p = 0,002) y mayor mortalidad cardiovascular (hazard ratio: 4,24; p = 0,003). Ninguno de los grados de la hiponatremia estudiados se asoció con mayor incidencia de terapias apropiadas o inapropiadas. Conclusiones: La hiponatremia ligera en el momento del implante de un desfibrilador se asocia a una mayor incidencia de ingreso por insuficiencia cardiaca en el seguimiento, mientras que en el caso de una hiponatremia moderada-severa, se asocia a un riesgo de muerte 4 veces mayor.

Introduction and objectives: Hyponatremia is a prognostic factor in patients with heart failure. Our objective was to assess the impact of hyponatremia in the evolution of patients undergoing cardioverter implantation in primary prevention. Method: This is a multicenter retrospective observational study in which serum sodium periimplant and adverse events (all-cause and cardiovascular mortality, first admission for heart failure, first appropriate and inappropriate therapy) were assessed in a Spanish cohort receiving cardioverter in primary prevention. Patients with mild hyponatremia (Na ≤ 135 mEq/L) and those with moderate to severe hyponatremia (Na ≤ 131 mEq/L) were compared to those without hyponatremia. Results: 725 patients, with a mean value of sodium in blood peri-implant of 139 ± 3.6 mEq/L and a mean follow-up was 34.1 ± 18.5 months. In patients with Na ≤ 135 mEq/L (n = 105), an increased incidence of first admission for heart failure was observed (Odds Ratio: 1.701; P = .031). In patients with moderate to severe hyponatremia (n = 18), higher total mortality (Hazard Ratio: 3.552; P = .002) and increased cardiovascular mortality (Hazard Ratio: 4.24; P = .003) were observed. None of those values of hyponatremia were associated with increased incidence of appropriate or inappropriate therapies Conclusions: Mild hyponatremia at the time of cardioverter implantation is related with a higher incidence of hospitalization for heart failure during follow-up, while moderate to severe hyponatremia increases the risk of death during follow-up.

Primary Prevention of Sudden Death in Patients With Valvular Cardiomyopathy.

INTRODUCTION AND OBJECTIVES: Few data exist on the outcomes of valvular cardiomyopathy patients referred for defibrillator implantation for primary prevention. The aim of the present study was to describe the outcomes of this cardiomyopathy subgroup. METHODS: This multicenter retrospective study included consecutive patients referred for defibrillator implantation to 15 Spanish centers in 2010 and 2011, and to 3 centers after 1 January 2008. RESULTS: Of 1174 patients, 73 (6.2%) had valvular cardiomyopathy. These patients had worse functional class, wider QRS, and a history of atrial fibrillation vs patients with ischemic (n=659; 56.1%) or dilated (n=442; 37.6%) cardiomyopathy. During a follow-up of 38.1 ± 21.3 months, 197 patients (16.7%) died, without significant differences among the groups (19.2% in the valvular cardiomyopathy group, 15.8% in the ischemic cardiomyopathy group, and 17.9% in the dilated cardiomyopathy group; P=.2); 136 died of cardiovascular causes (11.6%), without significant differences among the groups (12.3%, 10.5%, and 13.1%, respectively; P=.1). Although there were no differences in the proportion of appropriate defibrillator interventions (13.7%, 17.9%, and 18.8%; P=.4), there was a difference in inappropriate interventions (8.2%, 7.1%, and 12.0%, respectively; P=.03). CONCLUSIONS: All-cause and cardiovascular mortality in patients with valvular cardiomyopathy were similar to those in other patients referred for defibrillator implantation. They also had similar rates of appropriate interventions. These data suggest that defibrillator implantation in this patient group confers a similar benefit to that obtained by patients with ischemic or dilated cardiomyopathy.

[Electrical storm in patients with prophylactic defibrillator implantation]. / Evolución de los pacientes portadores de desfibrilador como prevención primaria tras un episodio de tormenta arrítmica.

INTRODUCTION: Little is known about the prevalence of electrical storm, baseline characteristics and mortality implications of patients with implantable cardioverter defibrillator in primary prevention versus those patients without electrical storm. We sought to assess the prevalence, baseline risk profile and survival significance of electrical storm in patients with implantable defibrillator for primary prevention. METHODS: Retrospective multicenter study performed in 15 Spanish hospitals. Consecutives patients referred for desfibrillator implantation, with or without left ventricular lead (at least those performed in 2010 and 2011), were included. RESULTS: Over all 1,174 patients, 34 (2,9%) presented an electrical storm, mainly due to ventricular tachycardia (82.4%). There were no significant baseline differences between groups, with similar punctuation in the mortality risk scores (SHOCKED, MADIT and FADES). A clear trigger was identified in 47% of the events. During the study period (38±21 months), long-term total mortality (58.8% versus 14.4%, p<0.001) and cardiac mortality (52.9% versus 8.6%, p<0.001) were both increased among electrical storm patients. Rate of inappropriate desfibrillator intervention was also higher (14.7 versus 8.6%, p<0.001). CONCLUSIONS: In the present study of patients with desfibrillator implantation for primary prevention, prevalence of electrical storm was 2.9%. There were no baseline differences in the cardiovascular risk profile versus those without electrical storm. However, all cause mortality and cardiovascular mortality was increased in these patients versus control desfibrillator patients without electrical storm, as was the rate of inappropriate desfibrillator intervention.

Prognostic impact of clopidogrel pretreatment in patients with acute coronary syndrome managed invasively.

Pretreatment with antiP2Y12 agents before angiography in acute coronary syndrome (ACS) is associated with a reduction in thrombotic events. However, recent evidences have questioned the benefits of upstream antiP2Y12, reporting a higher incidence of bleeding. We analyzed the prognostic impact of clopidogrel pretreatment in a large cohort of invasively managed patients with ACS. In hospital, safety and efficacy of clopidogrel pretreatment were retrospectively analyzed in patients included in the ARIAM-Andalucía Registry (Analysis of Delay in Acute Myocardial Infarction). Propensity score and inverse probability of treatment weighting analysis were performed to control treatment selection bias. Results were stratified by ACS type. Sensitivity analyses were used to explore stability of the overall treatment effect. Of 9,621 patients managed invasively, 69% received clopidogrel before coronary angiography. In the ST-elevation myocardial infarction group, pretreatment was associated with a significant reduction in reinfarction (odds ratio 0.53, 95% confidence interval [CI] 0.27 to 0.96; p = 0.027), stent thrombosis (odds ratio 0.15, 95% CI 0.06 to 0.38; p <0.0001), and mortality (odds ratio 0.67, 95% CI 0.48 to 0.94; p = 0.020), with an increase in minor bleeding but remained as a net clinical benefit strategy. Those benefits were not present in patients without ST elevation (non-ST elevation ACS). The weighting and propensity analysis confirmed the same results. An interaction between pretreatment duration and bleeding was observed. In conclusion, pretreatment with clopidogrel reduced the occurrence of death and thrombotic outcomes at the cost of minor bleeding. Those benefits exclusively affected ST-elevation myocardial infarction cases. The potential benefit of routine upstream pretreatment in patients with non-ST-elevation ACS should be reappraised at the present.