Pattern of Cleft Lip and Palate Clefts at a Tertiary Care Hospital in Saudi Arabia.

BACKGROUND: Clefts of the lip and palate (CL/P) and cleft palate (CP) are the most common craniofacial congenital anomalies. Clefts are classified as syndromic and nonsyndromic. Nonsyndromic clefts have no known genetic causes. OBJECTIVES: This study combines prospective and retrospective studies to review the patterns of CL/P and CP and associated syndromes and conditions in patients registered for CL/P surgery at a tertiary care pediatric center in our tertiary care hospital in Saudi Arabia. METHODS: It included patient data from May 2015 through April 2023. Patient record forms and SPSS (IBM version 20.0) were used to collect and analyze data. A significance level of 5% was used, with p ≤ 0.05 considered statistically significant. RESULTS: Of the 319 patients who met our inclusion criteria, 175 were male. Of the total, 99 had a left unilateral isolated cleft lip, 61 had a right unilateral isolated cleft lip, 69 had a bilateral cleft lip, and 90 had an isolated CP. Of the total, 140 had CL/P. Around 242 were nonsyndromic. The Chi-square test revealed a significant association between the prevalence of isolated CP and CLP and gender. The prevalence of left unilateral isolated cleft lip and bilateral and isolated CP was significantly associated with syndromic and nonsyndromic cases. CONCLUSION: Males are more likely to be affected by orofacial clefts, which is consistent with the global trend. Isolated CP was the most common orofacial cleft. Within the sample, syndromes' association with orofacial clefts was significantly weaker than that of isolated and bilateral clefts.

Atrial Fibrillation Burden: Impact on Stroke Risk and Beyond.

Atrial fibrillation (AF) is an important independent risk factor for stroke. Current guidelines handle AF as a binary entity with risk driven by the presence of clinical risk factors, which guides the decision to treat with an oral anticoagulant. Recent studies in the literature suggest a dose-response relationship between AF burden and stroke risk, in both clinical AF and subclinical atrial fibrillation (SCAF), which differs from current guidance to disregard burden and utilize clinical risk scores alone. Within clinical classification and at the same risk levels in various scores, the risk of stroke increases with AF burden. This opens the possibility of incorporating burden into risk profiles, which has already shown promise. Long-term rhythm monitoring is needed to elucidate SCAF in patients with stroke. Recent data from randomized trials are controversial regarding whether there is an independent risk from AF episodes with a duration of less than 24 h, including the duration of SCAF greater than six minutes but less than 24 h.

An unusual presentation of pacifier thumb duplication with VACTERL association: Case report and review of literature.

INTRODUCTION AND IMPORTANCE: Polydactyly of the hand is a common anomaly among pediatrics, which can present in conjugation with other syndromes or on its own. Various types can be seen, ranging from the involvement of skin only to a completely formed digit. We report the first case of pacifier type thumb duplication presenting with VACTERL association. Herein, we also summarize the existing literature of the distinctive features and management of pacifier polydactyly. CASE PRESENTATION: A premature male infant with intrauterine growth restriction due to maternal type II diabetes was referred for a soft tissue attachment to the left hand. The infant showed VACTERL association signs, including a single kidney, small atrial septal defect, and ventricular septal defect. Examination revealed preaxial polydactyly with a cystic swelling connected to the palm. CLINICAL DISCUSSION: Preaxial polydactyly is the second most common congenital hand anomaly, and its pathology is thought to involve the disruption of apoptosis during embryonic development. Pacifier-type polydactyly is a unique variation characterized by severe edema of the soft tissue digit, believed to be caused by physical damage in utero. The case presented did not require surgical intervention as the duplicated thumb underwent spontaneous autoamputation as opposed to other cases in the literature. CONCLUSION: This is the first reported case of pacifier-type thumb duplication in a patient with VACTERL association. The presentation of this condition adds to the existing body of literature on VACTERL association. Surgical removal is the treatment of choice for pacifier polydactyly, but spontaneous resolution can occur.

Ultra-Low-Temperature Cryoablation for Ventricular Tachycardia: An Early Single-Centre Report of Acute Results.

Background: Endocardial catheter ablation for ventricular tachycardia (VT) may fail because of the inability to deliver transmural lesions. Ultra-low-temperature cryoablation (ULTC) uses near-critical nitrogen and can generate temperatures as low as -196 °C. We report a series of 18 patients who underwent ULTC at the McGill University Health Centre (MUHC), representing the largest single-centre experience to date. Methods: Eighteen patients with monomorphic drug-refractory VT underwent VT ablation with ULTC at our institution as part of the first-in-human CryoCure-VT trial (NCT04893317). After voltage map, the mapping catheter was replaced with the ULTC catheter, and lesions were applied over a fixed duration of time (60-180 seconds), followed by a 60-second thaw and another application at the original duration (freeze-thaw-freeze). Duration of ablation time was selected depending on the wall thickness of the left ventricle monitored with intracardiac echo to achieve tissue depths of 4.5 to 7.5 mm. Results: Baseline left ventricular ejection fraction was 32%, mean age 71 years, 94% were male. A total of 32 sustained VTs were induced in 16 of 18 patients. A total of 177 cryoablation lesions were delivered (9.8 lesions per patient). Of the 16 patients with inducible VT, 15 (94%) were rendered noninducible postablation, and 1 was inducible only for a nonclinical VT. Complications included 1 pericardial effusion that required drainage. From 18 patients, 16 (89%) were discharged within the first 24 hours postablation. Conclusions: ULTC is feasible and permits acute control of monomorphic VT during VT ablation procedures in drug-refractory patients.

Contexte: L'ablation endocardique par cathéter pour traiter la tachycardie ventriculaire (TV) peut être un échec, en raison de l'incapacité à créer des lésions transmurales. La cryoablation à ultra-basse température (ULTC, pour ultra-low-temperature cryoablation) réalisée au moyen d'azote près de son point critique liquide-vapeur peut produire des températures aussi basses que ­196 °C. Nous faisons état d'une série de 18 patients ayant subi une ULTC au Centre universitaire de santé McGill (CUSM), ce qui représente la plus importante expérience menée dans un seul établissement jusqu'à ce jour. Méthodologie: Au total, 18 patients atteints de TV monomorphe pharmacorésistante ont subi une ablation de la TV par ULTC à notre établissement, dans le cadre du premier essai mené chez l'humain sur la guérison par cryothérapie de la TV (NCT04893317). Après l'obtention de la carte électrophysiologique, le cathéter de cartographie a été remplacé par le cathéter d'ULTC, qui a permis de créer des lésions par l'application de froid pendant une durée fixe (de 60 à 180 secondes), suivie d'une période de dégel de 60 secondes, puis d'une autre application de froid pendant la même durée que la première application (cycle gel-dégel-gel). La durée de l'ablation a été déterminée en fonction de l'épaisseur de la paroi du ventricule gauche surveillée par échocardiographie endocavitaire afin d'obtenir des profondeurs tissulaires de 4,5 à 7,5 mm. Résultats: La fraction d'éjection du ventricule gauche initiale était de 32 %, l'âge moyen des sujets était de 71 ans et 94 % d'entre eux étaient de sexe masculin. Au total, 32 TV soutenues ont été induites chez 16 patients sur 18. Dans l'ensemble, 177 lésions de cryoablation ont été créées (soit 9,8 lésions par patient). Après l'ablation, nous avons été incapables d'induire une TV chez 15 (94 %) des 16 patients chez qui nous en avions induit avant l'intervention et, chez le patient restant, nous avons pu induire une TV non clinique seulement. Les complications comprenaient un cas d'épanchement péricardique ayant nécessité un drainage. Au total, 16 (89 %) des 18 patients ont reçu leur congé de l'hôpital dans les 24 heures suivant l'ablation. Conclusions: L'ULTC est réalisable et permet une maîtrise rigoureuse de la TV monomorphe lors des interventions d'ablation de la TV chez les patients dont la TV est pharmacorésistante.

Meta-analysis evaluating apixaban in patients with atrial fibrillation and end-stage renal disease requiring dialysis.

Background: Warfarin is considered the primary oral anticoagulant for patients with atrial fibrillation and end-stage renal disease (ESRD) requiring dialysis. Although warfarin can offer significant stroke prevention in this population, the accompanying major bleeding risks make warfarin nearly prohibitive. Apixaban was shown to be superior to warfarin in preventing stroke or systemic embolism, with a lower risk of bleeding and mortality in a large, randomized trial of individuals with mostly normal renal function but none with ESRD. Methods: We systematically reviewed evidence comparing apixaban versus warfarin for atrial fibrillation in this population, and evaluated outcomes of stroke or systemic embolism, and major bleeding using random-effects models. The main safety outcome was major bleeding, and the main effectiveness outcome was stroke or systemic embolism. Results: We found five observational studies of 10 036 patients (2638 receiving apixaban, and 7398 receiving warfarin) meeting inclusion criteria. Pooled analysis demonstrated a significant reduction in major bleeding with apixaban as compared to warfarin (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42-0.61; p < .0001). Apixaban was also associated with a reduction in intracranial bleeding (OR 0.58, 95% CI 0.37-0.92; p = .02) and in gastrointestinal bleeding (OR 0.61, 95% CI 0.51-0.73; p < .0001). Furthermore, apixaban was associated with a reduction in stroke/systemic embolism (OR 0.64, 95% CI 0.50-0.82; p < .0001). Conclusion: Apixaban was associated with superior outcomes and reduced adverse events compared to warfarin in observational studies of patients with atrial fibrillation on dialysis. Randomized controlled studies are needed to confirm these findings.

Cardioneuroablation as a strategy to prevent pacemaker implantation in young patients with vasovagal syncope.

Background: Cardioneuroablation (CNA) is an ablation technique that targets epicardial ganglionic plexi to reduce syncope burden and avoid pacemaker implantation in patients with cardioinhibitory vasovagal syncope (VVS). This study aims to demonstrate feasibility and safety of CNA in high-risk refractory VVS patients using continuous monitoring with an implantable loop recorder (ILR). Methods: Data was collected prospectively for patients undergoing CNA. Patients were required to have recurrent syncope with documented asystole, refractory to conservative measures. Ganglionic plexi (GPs) were identified by fragmented signals and high frequency stimulation (HFS). Ablation was performed until loss of positive response to HFS, Wenckebach cycle shortening was achieved, or an increase in sinus rate of > 20 bpm. Follow-up was performed through remote and clinic follow-up of their ILRs. Results: Between December 2020 and July 2023 six patients (mean age 29 ± 3, 67 % female)underwent CNA. The baseline heart rate and Wenckebach cycle length was 63.2 ± 15 bpm and 582 ms before and 91 ± 5 bpm and 358 ms after ablation respectively. During a median follow-up of 13.4 months, 3/5 patients had no further syncopal episodes, 1 had a recurrence, underwent repeat CNA with no further episodes at 1 year, and 1 had 5 syncopal events, which was a dramatic reduction from nearly daily episodes pre-CNA. There were no procedure related complications. Conclusions: A dramatic reduction in documented pauses and syncope burden was noted post CNA. Appropriate patient selection with rigorous objective follow-up in an experienced center is necessary. Larger studies are required to confirm these findings.