Feasibility of 18FDG PET in the cardiac inflammation.

The aim of the study was to assess the feasibility of 18FDG PET in cardiac inflammation with a particular focus on the delayed scan. Thirty-five consecutive 18FDG PET scans of patients with suspected or confirmed cardiac inflammation were retrospectively reviewed. The patients were referred for PET because of endocarditis (n = 16) or sarcoidosis (n = 19). Among them four patients had two consecutive for follow up and treatment control (two patients with sarcoidosis, two with endocarditis). In all of the cases a standard head to mid-thigh scan was performed 45-60 min after 18FDG injection as well as a delayed heart scan 1 h after the standard imaging was performed. 18FDG PET confirmed active inflammation in 10 out of 35 scans. Delayed scans in positive cases showed SUVmax value increase, but did not have an impact on the result, neither they did in negative cases-no significant differences between standard and delayed scan were found. Interestingly in 5 out of 14 cases with suspected endocarditis PET revealed the extracardiac inflammation focus, thus changing initial diagnosis. 18FDG PET also indicated which prosthesis caused inflammation if there were many. In the sarcoidosis group the aim was to confirm or exclude heart involvement (13 scans) or to assess the response to the steroid therapy (6 scans) in patients with previously confirmed sarcoidosis. PET revealed active heart disease in 3 initial scans, and 1 follow up scan. 18FDG PET is a valuable imaging method for the cardiac inflammation assessment. It adequately localises the active inflammation site. Also, since it is a whole-body scan it may detect the extracardiac inflammation foci, which in some cases may change the initial diagnosis. In our study the delayed scans showed no added value.

Additional data from clinical examination on site significantly but marginally improve predictive accuracy of the Revised Trauma Score for major complications during Helicopter Emergency Medical Service missions.

INTRODUCTION: The Revised Trauma Score (RTS) accurately identifies trauma patients at high risk of adverse events or death. Less is known about its usefulness in the general population and non-trauma recipients of Helicopter Emergency Medical Service (HEMS). The RTS is a simple tool and omits a lot of other data obtained during clinical evaluation. The aim was to assess the role of the RTS to identify patients at risk of major complications (death, cardiopulmonary resuscitation, defibrillation, intubation) in the general population of HEMS patients. Clinical factors beyond the RTS were analyzed to identify additional prognostic factors for predicting major complications. MATERIAL AND METHODS: A retrospective analysis of medical records of adult patients routinely collected during HEMS missions in the years 2011-2014 was performed. RESULTS: The analysis included 19 554 HEMS missions. Patients were 55 ±20 years old and 68% were male. The most common indication for HEMS was diseases of the circulatory system - 41%. Major complications occurred in 2072 (10.6%) cases. In the general population of HEMS patients, the RTS accurately identified individuals at risk of major complications at a cut-off value of 10.5 and area under the curve (AUC) of 93.5%. In multivariate analysis, additional clinical data derived from clinical examination (ECG; skin, pupil and breathing examination) significantly but marginally improved the accuracy of RTS assessment: AUC 95.6% (p < 0.001 for the difference). CONCLUSIONS: The Revised Trauma Score accurately identifies individuals at risk of major complications during HEMS missions regardless of the indication. Additional clinical data significantly but marginally improved the accuracy of RTS in the general population of HEMS patients.

Occurrence and extraction of implantable cardioverter-defibrillator leads with conductor externalization.

BACKGROUND: The increasing number of patients with implantable cardioverter-defibrillators (ICD) contributes to the rising number of patients qualifying for a transvenous lead extraction (TLE) due to infection, vascular or lead failure related indications. The purpose of this study was to perform a retrospective analysis of the occurrence of conductor externalization in TLE patients and to assess the success rate in the extraction of these leads. METHODS: TLE procedure was performed between 2012 and 2014 of 428 electrodes in 259 patients. Out of these, 143 (33.4%) leads in 138 (52.9%) patients were ICD leads. The indications for the TLE in ICD patients were: infection in 37 patients, lead failure in 84 patients, and others in 17 patients. Conductor externalization was observed in 8 ICD leads (5.6%) in 8 (5.8%) patients. The mean dwell-ing time for externalized leads was 87.9 (55 to 132) months compared to 60.1 (3 to 246) months of the remaining 135 ICD leads (p = 0.0329). All externalized leads were successfully and completely extracted using device traction, mechanical telescopic sheaths and/or autorotational cutting sheaths. No complica-tions of lead extraction procedures were observed in 8 patients with externalization. RESULTS: Patients with lead externalization were often in a better New York Heart Association func-tional class (I or II) compared to those in the rest of the study group (p = 0.0212). CONCLUSIONS: Conductor externalization is a rare finding in patients undergoing TLE. This occurs with different manufacturers and lead types. In this complication transvenous lead extraction with the mechanical extraction tools can be safely performed.

New diagnostic pathways urgently needed. Protocol of PET Guidance I pilot study: positron emission tomography in suspected cardiac implantable electronic device-related infection.

BACKGROUND: Cardiovascular implantable electronic device (CIED) infection is a complication of increasing incidence. We present a protocol of an observational case control clinical trial "Positron Emission Tomography Combined With Computed Tomography (PET CT) in Suspected Cardiac Implantable Electronic Device Infection, a Pilot Study - PET Guidance I" (NCT02196753). AIM: The aim of this observational clinical trial is to assess and standardise diagnostic algorithms for CIED infections (lead-dependent infective endocarditis, generator pocket infection, fever of unknown origin) with PET CT in Poland. METHODS AND RESULTS: Study group will consist of 20 patients with initial diagnosis of CIED-related infection paired with a control group of 20 patients with implanted CIEDs, who underwent PET CT due to other non-infectious indications and have no data for infectious process in follow-up. All patients included in the study will undergo standard diagnostic pro-cess. Conventional/standard diagnostic and therapeutic process will consist of: medical interview, physical examination, laboratory tests, blood cultures; imaging studies: echocardiography: transthoracic (TTE), and, if there are no contraindications transoesophageal, computed tomography scan for pulmonary embolism if indicated; if there are abnormalities in other systems, decisions concerning further diagnostics will be made at the physician's discretion. As well as standard diagnostic procedures, patients will undergo whole body PET CT scan to localise infection or inflammation. Diagnosis and therapeutic decision will be obtained from the Study Committee. Follow-up will be held within six months with control visits at three and six months. During each follow-up visit, all patients will undergo laboratory tests, two blood cultures collected 1 h apart, and TTE. In case of actual clinical suspicion of infective endocarditis or local generator pocket infection, patients will be referred for further diagnostics. Endpoints for the results assessment - primary endpoints are to standardise PET CT in the diagnostic process: sensitivity, specificity, positive predictive value, and negative predictive value of the diagnosis made by PET CT; secondary endpoints are: assessment of usefulness of PET CT for detection of remote infective complications (metastatic abscesses, infected pulmonary emboli), incidence of particular localisations of infection, influence of PET CT on therapeutic decision: confirmation or change of decision based on PET CT, safety and complications of diagnostic process of CIED-related infections with PET CT. CONCLUSIONS: Evaluation of PET CT use for device-related infections in a case control study may be conclusive and improve diagnostic pathway.