Heart failure - An unexplored risk factor for infective endocarditis after pacemaker implantation.

BACKGROUND: With the widespread use of permanent pacemakers (PPM), and increased mortality associated with pacemaker endocarditis, it is essential to evaluate comorbidities that could potentially increase the risk of infective endocarditis (IE). Heart failure (HF), a common comorbidity, has not been well studied as an independent risk factor for development of IE in individuals with PPM. METHODS: The US National Inpatient Sample database was used to sample individuals with PPM. Patients with concomitant implantable cardioverter defibrillator, acute heart failure, history of endocarditis, intravenous drug use, prosthetic heart valves, or central venous catheter infection were excluded. Propensity matching was performed to match patients with and without HF. Pre- and post-match logistic regression was performed to assess HF as an independent risk factor for IE. A subgroup analysis was performed comparing IE rates between patients with HF with reduced (HFrEF) vs preserved (HFpEF) ejection fraction. RESULTS: Out of 333,571 patients with PPM included in the study, 121,862 (37 %) had HF. HF patients were older and had a higher prevalence of females. All comorbidities except for dental disease and cancer were more prevalent in the HF group. Patients with HF were 1.30 times more likely to develop IE [OR: 1.30 (1.16-1.47); p < 0.001]. The two cohorts were then matched for age, gender, and 20 comorbidities using a 1:1 propensity score matching algorithm. After matching, HF was still independently associated with increased risk of IE [OR: 1.62 (1.36-1.93); p < 0.001]. In our sub-group analysis, HFrEF and HFpEF patients had similar IE rates. CONCLUSION: In PPM population, HF was associated with an increased risk of IE compared to those without HF. We hypothesize that HF being a low-flow and high-inflammatory state might have contributed to this increased risk. Larger studies are required to corroborate our findings and evaluate the need for antimicrobial prophylaxis for this population.

Underutilization of left heart catheterization in kidney transplant patients presenting with non-ST segment elevation myocardial infarction.

Background: Cardiovascular disease (CVD) is the leading cause of mortality in kidney transplant (KT) patients. The perceived risk of contrast-induced nephropathy (CIN) may create a reluctance to perform coronary angiography in patients presenting with non-ST segment elevation myocardial infarction (NSTEMI). Methods: National Inpatient Sample (NIS) Database was used to sample individuals presenting with NSTEMI. Patients were stratified into KT and Non-KT cohorts. Outcomes included left heart catheterization rates, mortality, arrhythmias, acute kidney injury/acute renal failure (AKI/ARF), and extended length of hospital stay (ELOS) (>72 h). Propensity matching (1:1 ratio) and regression analyses were performed. Results: Out of 336,354 patients with NSTEMI, 742 patients were in the KT group. KT patients were less likely to have LHC relative to non-KT patients (22.0 % vs 18.3 %); a difference that persisted on post-match analysis (27.1 % vs 19.4 %). On pre-match analysis, KT transplant patients that underwent LHC had lower mortality (10.3 % vs 0.7 %), AKI/ARF (44.6 % vs 27.9 %), arrhythmias (30.4 % vs 20.6 %) and lower ELOS (58.6 % vs 41.9 %). Post-match, KT cohort patient that underwent LHC had lower arrhythmias (OR:0.60[0.38-0.96]), AKI/ARF (OR = 0.51[0.34-0.77]), ELOS (OR:0.49[0.34-0.73]). Conclusion: KT patients underwent LHC much less frequently than their non-KT counterparts for NSTEMI. Coronary angiography and subsequent revascularization were associated with a significant decrease in morbidity and mortality. This theorized risk of CIN should not outweigh the benefit of LHC in KT patients.

Health Care Utilization Following Inpatient Femoropopliteal Revascularization With Drug-Coated Balloon Angioplasty: A Nationwide Cohort Analysis.

PURPOSE: To examine nationwide variations in inpatient use of drug-coated balloons (DCBs) for treating femoropopliteal segment occlusive disease and whether DCBs are associated with reduced early out-of-hospital health care utilization. MATERIALS AND METHODS: The study included 24,022 patients who survived hospitalization for femoropopliteal revascularization using DCB angioplasty (n=7850) or uncoated balloon angioplasty (n=16,172) in the 2016-2017 Nationwide Readmissions Database. Differences in patient, hospitalization, and institutional characteristics were compared between treatment strategies. Adjusted logistic regression models were used to examine differences in 6-month rates of readmission, amputation, and repeat intervention. Results are presented as the odds ratio (OR) and 95% confidence interval (CI). RESULTS: Patients treated with DCBs had a higher prevalence of chronic limb-threatening ischemia, diabetes, hypertension, and tobacco use. Revascularization with a DCB was associated with shorter hospitalizations, lower median hospitalization costs, and fewer inpatient lower extremity amputations. Readmissions at 6 months were decreased in patients treated with DCBs compared with uncoated balloon angioplasty (OR 0.90, 95% CI 0.83 to 0.98, p=0.014). The most common reasons for readmission were complications related to procedures (15.4%) and diabetes (15.4%). Compared to patients treated with DCBs, patients treated with uncoated balloon angioplasty were more often readmitted with early procedure-related complications (13.3% vs 17.5%). There were no between-group differences in readmission for sepsis, myocardial infarction, or congestive heart failure. CONCLUSION: DCBs are less often used compared to uncoated balloons during inpatient femoropopliteal procedures. While DCB utilization is associated with more severe comorbidities and advanced peripheral artery disease, readmission rates are decreased through the first 6 months.

Death Certification in Northern Alberta: Error Occurrence Rate and Educational Intervention.

Errors in death certification can directly affect the decedent's survivors and the public register. We assessed the effectiveness of an educational seminar targeting frequent and important errors identified by local death certificate (DC) evaluation. Retrospective review of 1500 DCs categorized errors and physician specialty. A 60-minute didactic/case-based seminar was subsequently designed for family medicine physician (FAM) participants, with administration of presurvey, immediate post, and 2-month postsurveys. Most DCs were completed by FAM (73%), followed by internists (18%) and surgeons (3%). Error occurrence (EO) rate ranged between 32 and 75% across all specialities. Family medicine physician experienced in palliative care had the lowest EO rate (32%), significantly lower (P < 0.001) than FAM without interest in palliative care (62%), internal medicine (62%), and surgery (75%). Common errors were use of abbreviations (26%), mechanism as underlying cause of death (23%), and no underlying cause of death recorded (22%). Presurvey participants (n = 72) had an overall EO rate of 72% (64% excluding formatting errors). Immediate postsurvey (n = 75) and 2-month postsurvey (n = 24) participants demonstrated significantly lower overall EO (34% and 24%, respectively), compared with the Pre-S (P < 0.05). A 60-minute seminar on death certification reduced EO rate with perceived long-term effects.

A Prospective, Single-Arm, Multicenter Trial of Catheter-Directed Mechanical Thrombectomy for Intermediate-Risk Acute Pulmonary Embolism: The FLARE Study.

OBJECTIVES: The aim of this study was to evaluate the safety and effectiveness of percutaneous mechanical thrombectomy using the FlowTriever System (Inari Medical, Irvine, California) in a prospective trial of patients with acute intermediate-risk pulmonary embolism (PE). BACKGROUND: Catheter-directed thrombolysis has been shown to improve right ventricular (RV) function in patients with PE. However, catheter-directed thrombolysis increases bleeding risk and many patients with PE have relative and absolute contraindications to thrombolysis. METHODS: Patients with symptomatic, computed tomography-documented PE and RV/left ventricular (LV) ratios ≥0.9 were eligible for enrollment. The primary effectiveness endpoint was core laboratory-assessed change in RV/LV ratio. The primary safety endpoint comprised device-related death, major bleeding, treatment-related clinical deterioration, pulmonary vascular injury, or cardiac injury within 48 h of thrombectomy. RESULTS: From April 2016 to October 2017, 106 patients were treated with the FlowTriever System at 18 U.S. sites. Two patients (1.9%) received adjunctive thrombolytics and were analyzed separately. Mean procedural time was 94 min; mean intensive care unit stay was 1.5 days. Forty-three patients (41.3%) did not require any intensive care unit stay. At 48 h post-procedure, average RV/LV ratio reduction was 0.38 (25.1%; p < 0.0001). Four patients (3.8%) experienced 6 major adverse events, with 1 patient (1.0%) experiencing major bleeding. One patient (1.0%) died, of undiagnosed breast cancer, through 30-day follow-up. CONCLUSIONS: Percutaneous mechanical thrombectomy with the FlowTriever System appears safe and effective in patients with acute intermediate-risk PE, with significant improvement in RV/LV ratio and minimal major bleeding. Potential advantages include immediate thrombus removal, absence of thrombolytic complications, and reduced need for post-procedural critical care.

Anatomic correlates of supra-normal ankle brachial indices.

BACKGROUND: Supra-normal ankle brachial index (ABI) (>1.40), poses diagnostic challenges to determine the presence, location, and severity of peripheral artery disease (PAD). The anatomic distribution of PAD in patients with elevated ABI has not been previously described. METHODS: A retrospective review of all patients referred to the Massachusetts General Hospital vascular diagnostic laboratory from 5 January 2006 to 12 January 2011 who had both a supra-normal ABI and contrast arteriography (CA) within 3 months of each other is reported. Angiographic patterns were described using the Trans Atlantic Inter Society Consensus II (TASC II) classification. RESULTS: One-hundred sixteen limbs were analyzed in 92 patients. Mean age was 71.6 years (± 11.2); 81.5% (75/92) were male; 85.9% Caucasian (79/92); 67.4% diabetics (62/92); 78.3% hypertensive (72/92); 67.4% hypercholesterolemic (62/92); and 64.1% were current or former tobacco users (59/92). Chronic hemodialysis was present in 18.5% (17/92) and 15.2% (14/92) received chronic corticosteroids. Intermittent claudication was present in 46.7% (43/92) and critical limb ischemia in 52.2% (48/92). Aortoiliac, femoral and infra-popliteal involvement per angiography occurred in 14.9% (15/101), 56.1% (60/107), and 84.0% (84/100), respectively. Multilevel disease was present in 48.8% (42/86) of patients. PAD was absent in 4.7% (4/86) of patients. Toe brachial index <0.7 was found in 92% (92/100) of patients with angiographically confirmed PAD. CONCLUSION: In symptomatic patients referred to a vascular laboratory who were found to have supra-normal ABI, nearly one half exhibited multilevel PAD, and over 80% had infrapopliteal involvement. A supra-normal ABI in such patients mandates evaluation for the presence and extent of PAD.

Peripheral artery disease. Part 2: medical and endovascular treatment.

The treatment of peripheral artery disease (PAD) focuses on risk factor modification, cardiovascular event reduction, limb viability, and symptom improvement. Hypertension, hyperlipidemia, and diabetes mellitus should all be controlled to recommended target levels, and smoking cessation is vital. Antiplatelet therapies, such as aspirin or clopidogrel, should be administered in all patients unless contraindicated. Whenever possible, patients who present with claudication should be offered a regimen comprised of both medical and exercise therapy, which often results in substantial improvement in symptoms. For patients presenting with more-advanced disease, such as acute limb ischemia, critical limb ischemia, and severely-limiting symptoms of PAD, revascularization is often necessary. As a result of the rapid evolution in endovascular revascularization technology and expertise, many patients with PAD can be treated percutaneously. Therefore, in this Review, we will focus on medical therapy and endovascular revascularization of patients with PAD, with reference to surgical bypass in specific clinical scenarios.

Fatal case of tumor-associated hemorrhage in a large vestibular schwannoma.

Vestibular schwannomas are benign neoplasms that arise from Schwann cells of the eighth cranial nerve. Most manifest clinically with tinnitus, unilateral sensorineural hearing loss, and dysequilibrium secondary to compression of the vestibulocochlear nerve; major adverse events such as intratumoral hemorrhage causing acute neurologic deterioration are rare. We report the case of a 69-year-old man with a large vestibular schwannoma who required anticoagulation for several medical comorbidities. The patient began having progressively worsening neurologic symptoms, including facial nerve paralysis and dysequilibrium, which confined him to a wheelchair. After presentation, the patient was admitted to the hospital. Several days after alteration of his anticoagulation therapy in preparation for surgery, he developed intracranial hemorrhage. Attempts were made to stabilize the patient, including posterior fossa craniectomy and evacuation of hematoma; however, the intracranial hemorrhage ultimately resulted in a fatal outcome. During this procedure, a biopsy specimen was obtained, showing benign vestibular schwannoma. The literature for intratumoral hemorrhage into vestibular schwannoma and the pathologic findings in our case are reviewed.

Ethnic neutropenia and treatment delay in African American women undergoing chemotherapy for early-stage breast cancer.

Disparities in breast cancer survival have been observed between African American and white women. There are also known differences in mean baseline white blood cell (WBC) count among racial and ethnic groups. If the WBC count falls below conventionally defined treatment thresholds for patients undergoing adjuvant chemotherapy, reduced doses or treatment delays may occur, which could lead to race-based differences in treatment duration. We used the tumor registry at Columbia-Presbyterian Medical Center to identify 1178 women with newly diagnosed stage I and II breast cancer from whom we collected base-line information for 73 African American women and 126 age- and tumor stage-matched white women. Of these women, 43 African American and 93 white women underwent adjuvant chemotherapy. African American women had statistically significantly lower WBC counts than white women at diagnosis (6.2 x 10(9)/L for African American women versus 7.4 x 10(9)/L for white women, difference = 1.2, 95% confidence interval [CI] = 0.2 to 1.2; P =.02) and after treatment (5.3 x 10(9)/L for African American women versus 6.4 x 10(9)/L for white women, difference = 1.1, 95% CI = 0.2 to 2.5; P =.03). Overall, African American women required a statistically significantly longer duration of treatment than white women (19 weeks versus 15 weeks, respectively, difference = 4 weeks, 95% CI = 0.5 to 7.2 weeks; P =.03). The lower baseline WBC counts and longer duration of treatment for early-stage breast cancer in African American women compared with those in white women result in lower dose intensity of treatment for African American women, possibly contributing to observed racial differences in breast cancer survival.