Reasons for successful clinical outcome following pulmonary vein isolation despite lack of persistent LA-PV conduction block.

The mechanisms of atrial fibrillation (AF) induction and maintenance, including those involved in paroxysmal atrial fibrillation, are not completely known; this limits our ablation strategies and prevents us from understanding what we are actually doing when performing pulmonary vein isolation. In this report, we focus on the commonly used ablation strategies for AF and question the importance of complete pulmonary vein isolation in achieving lasting success in the ablation of AF. We also discuss in detail the absence of durable pulmonary vein isolation in patients without arrhythmic recurrences after AF ablation and the possibility to cure paroxysmal AF without concomitant pulmonary vein isolation, provocatively questioning the dogma of pulmonary vein isolation as the cornerstone of AF ablation. Finally, a prospective personalized approach in the individual patient is advocated.

Safety and mid-term outcome of catheter ablation of ventricular tachycardia in octogenarians.

AIMS: Radiofrequency (RF) catheter ablation (CA) is superior to standard medical therapy in controlling recurrent ventricular tachycardia (VT). The majority of procedures have been performed in a middle-aged population. The outcome of VT ablation in the elderly has not been described. METHODS AND RESULTS: We retrospectively studied the outcome and safety of CA of VT in octogenarians performed in four European centres. The population consisted of patients presenting with recurrent VT refractory to medical therapy. Patients aged over 80 years were compared with younger patients undergoing CA. Clinical characteristics, procedural data, complications, and outcomes were examined. Implantable cardioverter-defibrillator (ICD) therapy data were collected. A total of 54 consecutive octogenarian patients underwent RF CA of VT and represented the study group (42 males, age 82.8 ± 2.7 years) compared with a control group of 104 younger patients (85 males, age 66.7 ± 8.9 years). Mean follow-up was 33 ± 48 months. Implantable cardioverter-defibrillators were present in 81 and 86% of patients, respectively (P = 0.93). Left ventricular ejection fraction was 29% ± 8.2 in octogenarians vs. 34% ± 10.2 in the younger group (P < 0.01). More major complications occurred in octogenarians (18 vs. 2%, P < 0.01). During follow-up, there were more ICD shocks in the octogenarians (28 vs. 15%, P < 0.01). The Kaplan-Meier curve of survival after VT ablation confirms comparable survival rates at 1 year, but the elderly have poor survival in the mid-term. Survival in the elderly post VT ablation is comparable with that in an age-matched cohort with ICDs but no VT storm. CONCLUSION: Octogenarians undergoing CA of VT have more risk factors, higher risk of complications and ICD shocks, but demonstrate comparable short-term survival rates.

The association between ICD interventions and mortality is independent of their modality: clinical implications.

BACKGROUND: Patients with severe structural heart disease have increased mortality after implantable cardioverter-defibrillator (ICD) shocks. Whether this is limited to ICD shock therapy only or extends also to no-shock therapies, such as antitachycardia pacing (ATP), is unclear. We investigated the impact of different ICD therapies on long-term mortality. METHODS: We enrolled 573 patients who underwent ICD implantation at our institution from 2004 to 2011. The population was divided into 3 groups: no device interventions (group 1), ATP interventions (group 2), and shock interventions (group 3). The endpoint was the all-cause mortality. RESULTS: Over a follow-up period of 48 months (range 1-110), 447 (78%) had no device interventions, 71 (12%) had ATP therapy only, and 55 (10%) had at least one shock intervention. All-cause mortality occurred in 94 patients in group 1 (21%), 23 patients (43%) in group 2, and 21 patients (38%) in group 3. At multivariable Cox regression analysis, ATP intervention (HR: 1.8; 95% CI 1.1-3; P < 0.001), shock intervention (HR: 1.39; 95% CI 1.09-1.77; P = 0.008), age (HR: 1.05; 95% CI 1.02-1.07; P < 0.001), and LVEF (HR: 0.95; 95% CI 0.93-0.98; P = 0.001) were predictors of all-cause mortality. No significant difference in mortality was found between group 2 and 3. CONCLUSION: Patients with ICDs who receive appropriate interventions are at increased risk of mortality. Such risk is not dependent on different types of ICD therapy, such as shocks or ATP. Our data suggest that sustained ventricular arrhythmias per se have a negative impact on prognosis rather than modality of ICD therapy.

Safety of transvenous lead extraction according to centre volume: a systematic review and meta-analysis.

BACKGROUND: Transvenous lead extraction (TLE) is a complex invasive procedure and the experience of the operator and the team is a major determinant of procedural outcomes. AIM: Because of very limited data available on minimum procedural volumes to enable training and ongoing competency for TLEs, we performed a meta-analysis aimed at assessing the outcomes of TLE in the centres with low, medium, and high volume of procedures. METHODS: Of the 280 papers initially retrieved until February 2013, 66 observational studies met inclusion criteria and were included in at least one stratified meta-analysis: 17 were prospective studies; 47 had a retrospective design; and 2 were defined 'experience studies'. We included only articles published after the introduction of laser technique (year 1999). We divided the studies in low, medium, and high volume centres utilizing either the European Heart Rhythm Association (EHRA) or Lexicon classification criteria. RESULTS: When meta-analyses were carried out separately for the studies with larger and smaller sample sizes, either using EHRA or Lexicon classification criteria, no clear differences emerged in the combined rate of major complications or intraoperative deaths. In contrast, both minor complications and mortality at 30 days decreased as centre volume increased. CONCLUSIONS: In our meta-analysis of observational studies, patients who have been treated in higher volume centres have a lower probability of minor complications and death at 30 days regardless of the infection rate, length of lead duration, type of device, and type of extraction.

Predictors of postoperative atrial fibrillation in patients with coronary artery disease undergoing cardiopulmonary bypass: a possible role for myocardial ischemia and atrial inflammation.

OBJECTIVE: To evaluate the preoperative presence of C-reactive protein (CRP) and troponin T(hs-TnT) in patients with coronary artery disease (CAD) undergoing cardiopulmonary bypass (CPB) in order to better clarify the role of atrial inflammation and/or myocardial ischemia in the development of postoperative atrial fibrillation (POAF). DESIGN: Prospective, nonrandomized study. SETTING: University hospital. PARTICIPANTS: Thirty-eight consecutive ischemic patients admitted to the authors' hospital for CAD undergoing elective on-pump coronary artery bypass grafting (CABG). INTERVENTION: Elective on-pump CABG. MEASUREMENTS AND MAIN RESULTS: Peripheral blood samples were collected from all patients before and 24 hours after CABG to assess high sensitive (hs)-CRP and troponin T (hs-TnT) levels. The patients' heart rhythm was monitored by continuous ECG telemetry. Biopsies from the right atrial appendage were obtained at the beginning of the CABG procedure in order to perform immunohistochemistry for CRP and reverse transcription polymerase chain reaction for CRP mRNA expression. Fourteen patients out of 38 (36%) developed POAF. Atrial CRP was found in 31 patients (82%), 10 with POAF and 21 with sinus rhythm (71% v 87% respectively, p = ns). None of the atrial samples was positive for CRP mRNA. Atrial CRP did not correlate with serum hs-CRP levels and with occurrence of POAF, but with the incidence of diabetes (p = 0.010). Postoperative hs-TnT levels, but not hs-CRP levels, were identified as the only predictor of POAF occurrence (p = 0.016). CONCLUSIONS: In patients undergoing CABG, neither peripheral nor tissue preoperative CRP levels, but only postoperative hs-TnT levels, correlated with POAF, suggesting the primary role of an ischemic trigger of atrial fibrillation.

Mechanical and Ballistic Properties of Epoxy Composites Reinforced with Babassu Fibers (Attalea speciosa).

The mechanical and ballistic performance of epoxy matrix composites reinforced with 10, 20, and 30 vol.% of babassu fibers was investigated for the first time. The tests included tension, impact, and ballistic testing with 0.22 caliber ammunition. The results showed an improvement in tensile strength, elastic modulus, and elongation with the addition of babassu fiber, and the 30 vol.% composite stood out. Scanning electron microscopy analysis revealed the fracture modes of the composites, highlighting brittle fractures in the epoxy matrix, as well as other mechanisms such as fiber breakage and delamination in the fiber composites. Izod impact tests also showed improvement with increasing babassu fiber content. In ballistic tests, there was an increase in absorbed energy. All composites surpassed plain epoxy by over 3.5 times in ballistic energy absorption, underscoring the potential of babassu fiber in engineering and defense applications.

How a Simple Diabetic Ketoacidosis Was Actually a Deadly Liver Abscess.

Pyogenic liver abscesses (PLA) are rare causes of infection in immunocompetent individuals in developed countries. In this report, we discuss a rare presentation and the risk factors associated with developing PLA. Our aim is to raise awareness about PLA developing in patients with uncommon risk factors, enabling early identification and appropriate treatment. The case involves a male patient who presented to the hospital with generalized weakness, was admitted for diabetic ketoacidosis (DKA), and incidentally had elevated liver enzymes that required further investigation. It is important to note that risk factors such as diabetes mellitus, proton pump inhibitors, and colon malignancies are very rare but have been reported in isolated cases as potential risks for developing PLA. Early diagnosis of PLA is crucial due to its high mortality rate, even with intervention.

A Unique Presentation of Jaundice.

Obstructive jaundice has many common etiologies, which might cause us to overlook diagnoses that are far worse. This is a case of a Hispanic male who presented with jaundice and worsening liver function. During his hospitalization, he was erroneously diagnosed before being diagnosed with gastric cancer. Even though biliary obstruction has many common etiologies, there are cases that can't be explained, which warrants further investigation such as malignant etiologies.

A Case of Disappearing Ascites: Late Presentation of Acute Portal Vein Thrombosis After a Motor Vehicle Accident.

Portal vein thrombosis (PVT) has been usually diagnosed as a complication secondary to cardiac, hepatic, and malignant etiologies, but it has rarely been described in the setting of blunt abdominal trauma. This case depicts an older male who presented to the emergency department with progressive ascites and lower extremity edema within two weeks after a motor vehicle accident (MVA). Ascitic fluid analysis indicated the presence of portal hypertension, which prompted extensive evaluation to determine the etiology. Further workup, including hypercoagulable and malignancy screening, unveiled the diagnosis of acute PVT secondary to abdominal blunt force trauma, showing a rather rare presentation.

Necrotizing Pancreatitis Secondary to Hydrochlorothiazide and Alogliptin: A Case Report.

Drug-induced pancreatitis occurs rarely but should be considered when more common causes have been ruled out. While simple to treat, mortality increases should it progress to a necrotizing process. Here, we present the case of a patient simultaneously using two drugs associated with pancreatitis, which we considered acted synergistically and consequently worsened the patient's outcome.

Tracheal Diverticulum Mimicking Pneumomediastinum: A Case Report Emphasizing the Importance of Differential Diagnosis in Chest Imaging Evaluation.

A tracheal diverticulum (TD) is a generally benign medical condition, where there is an outpouching of the tracheal wall. Additionally, it is generally asymptomatic but there have been reported cases of adverse outcomes linked to TD. Here we present a case of a tracheal diverticulum that was incidentally found during the workup for stroke in a patient. Moreover, due to its radiologic appearance, there was concern for pneumomediastinum. We highlight the presentation and clinical importance of TD owing to the complications one is predisposed to from having this condition.

Mechanical Properties Optimization of Hybrid Aramid and Jute Fabrics-Reinforced Graphene Nanoplatelets in Functionalized HDPE Matrix Nanocomposites.

Natural lignocellulosic fibers (NLFs) have been used as a reinforcement for polymer matrix composites in the past couple of decades. Their biodegradability, renewability, and abundance make them appealing for sustainable materials. However, synthetic fibers surpass NLFs in mechanical and thermal properties. Combining these fibers as a hybrid reinforcement in polymeric materials shows promise for multifunctional materials and structures. Functionalizing these composites with graphene-based materials could lead to superior properties. This research optimized the tensile and impact resistance of a jute/aramid/HDPE hybrid nanocomposite by the addition of graphene nanoplatelets (GNP). The hybrid structure with 10 jute/10 aramid layers and 0.10 wt.% GNP exhibited a 2433% increase in mechanical toughness, a 591% increase in tensile strength, and a 462% reduction in ductility compared to neat jute/HDPE composites. A SEM analysis revealed the influence of GNP nano-functionalization on the failure mechanisms of these hybrid nanocomposites.

Update on phase II studies of erythropoietin in acute myocardial infarction. Rationale and design of Exogenous erythroPoietin in Acute Myocardial Infarction: New Outlook aNd Dose Association Study (EPAMINONDAS).

Erythropoietin (Epo) is a hematopoietic hormone produced mainly by the kidneys in response to hypoxia. Recent acquisitions in the fields of hematology, neurology, cardiology, and experimental medicine show cytoprotective, angiogenetic and antiinflammatory effects of Epo. Exogenous erythroPoietin in Acute Myocardial Infarction: New Outlook aNd Dose Association Study (EPAMINONDAS, EudraCTno. 200500485386) is one of four ongoing randomized controlled trials, each testing the effects of Epo in >or=100 patients with STEMI. EPAMINONDAS is a multicenter, prospective, double-blind, placebo-controlled, dose-finding study assessing intravenous moderate doses of human recombinant Epo (epoietin-alpha, 100 or 200 IU/kg/die) versus placebo, given on the first 3 days, in 102 patients with first ST-segment elevation myocardial infarction. Initial dosing is within 12 h of primary percutaneous coronary revascularization. The primary endpoint is infarct size, quantified by CK-MB time-concentration curve, left ventricular wall motion score index, and pattern of contrast-enhanced magnetic resonance imaging. Secondary endpoints are ischemic recurrences, ventricular remodelling, and safety events, assessed in-hospital and at 12 months' follow-up. The results of current phase II studies will help define the safety/efficacy profile of Epo for patients with STEMI.

[Body mass index and cardiovascular events: the "obesity paradox"]. / Recenti acquisizioni sui rapporti tra indice di massa corporea e danno cardiovascolare: il "paradosso dell'obesità".

Excessive body mass among healthy subjects carries an increased risk of subsequent cardiovascular events. Excess weight implies the presence of white, viscero-abdominal fat, that promotes insulin-resistance, is infiltrated by macrophages, and is less differentiated compared to subcutaneous or brown fat. Conversely, among patients with cardiovascular disease, slim patients have a greater risk of recurrent atherothrombotic events than fatter patients ("obesity paradox"). Lean patients with cardiovascular disease, on average, have more comorbidities and haemorrhagic complications than their heavier counteparts, and probably they conceal predisposing factors that are still unknown and therefore difficult to treat.

Complex Arrhythmias Due to Reversible Causes.

Abnormalities in cardiac rhythm are caused by disorders of impulse generation, conduction, or a combination of the 2, and may be life-threatening because of a reduction in cardiac output or myocardial oxygenation. Cardiac arrhythmias are commonly classified as tachycardias (supraventricular or ventricular) or bradycardias. Bradycardias are uncommon in the critically ill patient and often are caused by an underlying reversible disorder (eg, hyperkalemia, drug toxicity). Supraventricular and ventricular tachycardias are more often encountered in the critically ill patient and often have underlying treatable disorders that precipitate their development (eg, hypokalemia, hypomagnesemia, antiarrhythmic proarrhythmia, myocardial ischemia).

A Challenging Case Of Ventricular Arrhythmia In A Patient With Myocarditis: ICD Yes/No After Ablation.

In patients with myocarditis, early diagnosis and appropriate therapy are mandatory, as well as close clinical follow-up with particular regard to progression of disease and ventricular arrhythmia recurrences. The management of ventricular arrhythmias should follow current guidelines for ICD implantation, but new therapeutic options could be evaluated in these patients, such as combined epicardial/endocardial ablation and external wearable defibrillator. Particularly, depressed left ventricular ejection fraction (LVEF) represents the only risk marker for sudden cardiac death currently used in myocarditis, although the use of a single risk factor has limited utility. On this regard, combined analysis of myocardial tissue structure by cardiac magnetic resonance (CMR) and endomyocardial biopsy, in association with resting cardiac systolic function, could improve predictive accuracy for SCD in patients with myocarditis.

[Pathophysiology of ischemic heart disease in women]. / Aspetti fisiopatologici della malattia coronarica nella donna.

Ischemic heart disease (IHD) is the leading cause of death in women as in men. Several disease mechanisms, however, differ between genders. Women with IHD more frequently than men have normal or non-obstructive epicardial arteries, plaque erosion, spontaneous coronary dissection, microvascular dysfunction, stress cardiomyopathy, and heart rupture after acute infarction. Compared to men, IHD presents 7-10 years later with a heavier burden of cardiovascular risk factors, even after correction for age. The typical woman with IHD is old and frail, with comorbidities such as renal failure. Another vulnerable group comprises those with acute coronary syndromes before the age of 60 in whom hospital mortality is reported to be almost twice that of age-matched men. Such vulnerabilities in women, in apparent contrast with the delayed onset and lesser extent of epicardial atherosclerosis, may be attributable to biases in prevention, presentation, diagnosis and treatment of female IHD, but also to gender-related differences in disease mechanisms.