Cerebral phaeohyphomycosis due to Cladophialophora bantiana: case report and systematic review of cases.

PURPOSE: Cladophialophora bantiana is a wonted melanized fungus causing brain abscess. In past many cases were reported from Asia, particularly from India. Of late, there is a rise in cases in places besides Asia and hence a review of the cases is warranted. METHODS: We present a case of fatal cerebral phaeohyphomycosis caused by C. bantiana and conduct a systematic review of culture confirmed brain abscess due to C. bantiana reported between 2015 and 2022. RESULTS: Of the 39 cases found, majority (68%) were immunocompromised. The various clinical presentations were headache (53%), hemiparesis (34%), visual disturbance (25%), altered sensorium (18%), aphasia/dysarthria (12%) and seizures (9%). Isolated lesion was observed in 18 (60%) patients. In the sequence of occurrence, the lesions were in frontal (30%), temporal (27%) and parietal (20%) region. There were five cases with coinfections such as concurrent detection of Nocardia pneumonia in two cases, toxoplasma DNA in brain abscess, coexisting pulmonary Cryptococcus neoformans infection and coexisting Candida in a case of brain abscess in one case each. Surgical intervention was performed in 84% cases. Antifungal therapy included voriconazole (80%), liposomal amphotericin B (76%), 5-fluorocytosine (30%), posaconazole (10%), and amphotericin B deoxycholate (6%). The overall mortality was 50% with lower mortality (42%) in regions outside Asia compared to Asia (63.6%) though not statistically significant. CONCLUSIONS: C. bantiana brain abscess is an emerging infection worldwide. Next generation sequencing is an upcoming promising diagnostic test. Early complete excision of the lesion with effective antifungals may improve the outcome.

Predictors of procedural failure of left bundle branch pacing in scarred left ventricle.

INTRODUCTION: Presence of scar at the implantation-site is considered as a major factor in determining the success of left bundle branch pacing (LBBP). We aimed at analyzing the predictors of procedural failure in patients with scarred-left ventricle (LV) as demonstrated by cardiac-magnetic resonance-imaging (CMR). METHODS: This was a retrospective, observational single-center-study that included consecutive cardiomyopathy patients with LV-scar as demonstrated by late-gadolinium-enhancement (LGE) in CMR requiring LBBP. Procedural-failure was defined as the inability to penetrate the septum to reach the LV subendocardium RESULTS: A total of 25 cardiomyopathy patients demonstrated LGE in CMR and were included in the study. LBBP was successful in 16 patients (group-I; 64% acute-procedural-success). In the remaining 9 patients (group-II) lead could not be penetrated and hence biventricular-pacing was done. LBBP resulted in reduction in QRS-duration and improvement in LV ejection fraction in group-I patients during a mean follow-up of 11.2 ± 3.7 months. Computed-tomography-angiography after LBBP showed the successful lead deployment site (LBBP-Zone) as the overlapping areas of inferior aspect of antero-septum and superior aspect of infero-septum (segment 2/3; AHA-model) in short-axis view(figure-1C). CMR showed LGE in significantly more number of LV-segments and high scar-burden in group-II as compared to group-I (figure-1). A total scar score value of >1.0 predicted failure with 100%-sensitivity and 75%-specificity. CMR revealed transmural-scar in the LBBP-Zone in all patients in group-II (n = 9; 100%). Transmural scar in LBBP-Zone by CMR had 100%-sensitivity and 100%-specificity for predicting the procedural-failure. CONCLUSION: CMR helps in predicting the procedural failure of LBBP in patients with scarred LV. Presence of transmural-LGE in the LBBP-Zone predicts failure with high sensitivity and specificity.

Right sided approach for left bundle branch pacing using lumen-less lead: Technical considerations and follow-up outcome.

INTRODUCTION: Left bundle branch pacing has gained significant momentum in the last few years. The procedure involves deploying the lead deep inside the interventricular septum through left subclavian vein. We aimed at analyzing the feasibility, efficacy and long-term outcome of left bundle branch pacing (LBBP) using lumen-less lead through the right subclavian vein. METHODS: This was a retrospective-institutional, single center observational study done in consecutive patients who underwent LBBP using 3830 selectsecuretm lead. Left subclavian venous access was the primary strategy for lead implantation. Patients requiring right sided approach due to venous obstruction or persistent left superior-vena-cava (PLSVC) for LBBP were included in the study. RESULTS: Right sided approach was successful in 16 out of 19 (84%) attempted patients. C315-His catheter was used in all patients without modifying its curvature. PLSVC (n = 7), left venous obstruction (n = 7), right sided device upgradation (n = 1) and left pocket infection (n = 1) were the reasons for right sided approach. Mean follow-up duration was 17 ± 12 months. LBBP resulted in reduction in QRS duration from 137.3 ± 37.8 ms to 122.3 ± 9.5 ms (p -.13) and increase in LV ejection fraction from 46.2 ± 16.3% to 54.4 ± 11.6% (p -.11). The mean fluoroscopy duration and radiation dose were significantly high in right sided approach (n = 16) as compared to left sided approach (n = 293). In patients requiring cardiac-resynchronization therapy (CRT), right sided LBBP resulted in reduction in QRS duration from 171.8 ± 18.5 to 125.5 ± 11.9 ms (p -.0001) and increase in LVEF from 29.1 ± 3.8 to 45.1 ± 11.9% (p -.005). CONCLUSION: Right sided LBBP is feasible, safe and effective in patients requiring pacing for symptomatic bradyarrhythmia and CRT. Further development in dedicated tools for right-sided approach would help in reducing the fluoroscopy-duration and radiation-dose.

Elizabethkingia meningoseptica Infections: A Case Series from a Tertiary Hospital in South Tamil Nadu.

Elizabethkingia meningoseptica is an opportunistic pathogen increasingly reported as hospital-acquired infection. Here, we report a series of cases of eight patients with invasive E. meningoseptica infections over a period of 27 months in a tertiary teaching hospital from South India. Age range was 45 days to 84 years, median 66 years, with male preponderance. Associated risk factors included recent hospitalization with surgeries, diabetes mellitus, renal failure, mechanically ventilated, and central line. All isolates were susceptible to minocycline. Combination therapy with ciprofloxacin and piperacillin tazobactam was most common. Six recovered and two patients were lost to follow-up. How to cite this article: Ganesan V, Sundaramurthy R. Elizabethkingia meningoseptica Infections: A Case Series from a Tertiary Hospital in South Tamil Nadu. Indian J Crit Care Med 2022;26(8):958-960.

Aerococcus viridans Bacteremia: A Rare Case Report from India.

Aerococci are fastidious, gram-positive Streptococcus-like organisms widely distributed in the hospital environment. Aerococcus viridans is primarily an opportunistic pathogen. Very few cases of A. viridans bacteremia have been reported so far probably because of its misidentification as streptococci. Here we report an interesting case of A. viridans bacteremia. How to cite this article: Varshini K, Ganesan V, Charles J. Aerococcus viridans Bacteremia: A Rare Case Report from India. Indian J Crit Care Med 2022;26(1):127-128.

Risk Factors and Clinical Outcomes of Stenotrophomonas maltophilia Infections: Scenario in a Tertiary Care Center from South India.

Stenotrophomonas maltophilia, a gram-negative non-fermenter has evolved from a colonizer to a significant pathogen over the last decade. It resides in various ecological niches both inside and outside the hospital settings. Infections due to S. maltophilia can be life-threatening, especially in immunocompromised patients. S. maltophilia is intrinsically resistant to most of the antibiotics, which limits treatment options. There are several risk factors involved. The present study was done to assess the risk factors and clinical outcomes associated with S. maltophilia blood stream infections and non-blood stream infections. How to cite this article: Varshini MK, Ganesan V, Sundaramurthy R, Rajendran T. Risk Factors and Clinical Outcomes of Stenotrophomonas maltophilia Infections: Scenario in a Tertiary Care Center from South India. Indian J Crit Care Med 2022;26(8):935-937.

Melioidosis in a Tertiary Care Center from South India: A 5-year Experience.

The present study was done with the objective to know the clinical presentation, microbiological features, and treatment outcome of melioidosis patients in our hospital, which is an emerging infection in India, and to know the differences in clinical course and outcome between bacteremic and nonbacteremic patients. This retrospective observational study was carried out over a period of 5 years from January 2015 to December 2019. Thirty-five cases of culture-confirmed melioidosis were identified with age range between 5 and 74 years. A large number of patients (n = 31) presented with uncontrolled diabetes mellitus. Six patients died of septic shock, and the outcome of eight patients was unknown as they were discharged against medical advice. There were no relapses observed. Melioidosis growing as a neglected tropical disease in India warrants awareness among all clinicians across the country. How to cite this article: Ganesan V, Murugan M, Sundaramurthy R, Soundaram GVG. Melioidosis in a Tertiary Care Center from South India: A 5-year Experience. Indian J Crit Care Med 2021;25(3):327-330.

Mucormycosis in a Tertiary Care Center in South India: A 4-Year Experience.

BACKGROUND: Mucormycosis is an emerging fungal infection in both developed and developing countries with different target population. Unusual isolates and unusual clinical presentations have been reported from India in recent times. OBJECTIVES: The present study was done to know the epidemiology, risk factors, diagnostic modalities, and treatment outcome of mucormycosis patients in our hospital. MATERIALS AND METHODS: The study was carried out over a period of 4 years from October 2015 to October 2019. This is a retrospective observational chart review of patients diagnosed with proven and probable mucormycosis. Information on demography, clinical features, risk factors, laboratory and radiological findings, treatment (including medical and surgical treatment), and outcome was extracted from the records. Primary outcome at 42 days was determined. RESULTS: Thirty-eight patients were diagnosed with mucormycosis based on microbiological and/or histopathological examination (HPE) of the clinical samples. Most commonly affected age-group was between 41 years and 60 years. More number of cases were reported during the months of post rainy season (September to December). A large number of patients (77%) presented with uncontrolled diabetes mellitus. Rhino-orbito-cerebral mucormycosis was the most common presentation followed by cutaneous infection. Antifungal treatment was started in around 80% of the cases. Twenty patients were managed by combined medical and surgical intervention. Eight patients died while the outcome of nine was unknown, as they left the hospital against medical advice and could not be followed up. CONCLUSION: Mucormycosis, an insidious killer, should be an important differential diagnosis in progressive soft tissue infections and deep organ infection. HOW TO CITE THIS ARTICLE: Priya P, Ganesan V, Rajendran T, Geni VG. Mucormycosis in a Tertiary Care Center in South India: A 4-Year Experience. Indian J Crit Care Med 2020;24(3):168-171.

Impact of Care Bundle Implementation on Incidence of Catheter-associated Urinary Tract Infection: A Comparative Study in the Intensive Care Units of a Tertiary Care Teaching Hospital in South India.

INTRODUCTION: Implementation of evidence-based infection control practices is the need of the hour for every institute to reduce the device-associated infections, which directly reflects the quality of care. As catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection, the study was planned to evaluate the impact of the catheter care bundle in reducing CAUTI incidence. MATERIAL AND METHODS: The prospective interventional study before and after the trial study was carried out in adult intensive care units over a period of 9 months (April-June 2017-pre-implementation phase; July-September 2017-training of healthcare worker and implementation of catheter care bundle; October-December 2017-post-implementation phase). Catheter-associated urinary tract infection rates pre- and post-implementation were expressed as incidence rates with Poisson confidence interval. RESULTS: Statistically significant reduction was found in the incidence of CAUTI (60%-from 10.7 to 4.5 per 1,000 catheter days). The key factors that contributed were significant reduction in device utilization ratio (from 0.71 to 0.56) and average catheter days per patient (from 4.8 to 3.7). This holistic approach has resulted in less incidence of CAUTI even among patients with risk factors and prolonged catheter days. Neuro ICU showed drastic improvement compared to other ICUs due to the poor baseline status of their care practices. CONCLUSION: Adherence to all elements of care bundle brought a significant decrease in CAUTI. Implementing care bundle and auditing the adherence to each element should be included as a part of routine hospital infection control committee (HICC) practices. CLINICAL SIGNIFICANCE: Hospital-acquired infection directly reflects on the quality care of the hospital. Bundle care is an "all or none" phenomenon. Adherence to each element will have some influence in reducing CAUTI in terms of reducing the device utilization ratio and average catheter days per patient. Auditing the care bundle adherence is having a positive influence on the outcome. HOW TO CITE THIS ARTICLE: Soundaram GVG, Sundaramurthy R, Jeyashree K, Ganesan V, Arunagiri R, Charles J. Impact of Care Bundle Implementation on Incidence of Catheter-associated Urinary Tract Infection: A Comparative Study in the Intensive Care Units of a Tertiary Care Teaching Hospital in South India. Indian J Crit Care Med 2020;24(7):544-550.

Melioidosis-Series of Seven Cases from Madurai, Tamil Nadu, India.

We describe a case series of seven culture proven melioidosis patients presenting during 2014 to 2016 in Madurai, south Tamilnadu. Skin, soft tissue, bone and joint infections were common. All of them were middle aged men except one case. All the cases were reported during the monsoon season. Predisposing factors include diabetes and alcoholism. Despite many case reports and studies from South India, melioidosis still remains undiagnosed, hence under reported from many centers. Delayed diagnosis leads way to sepsis and other complications. Awareness about the preventive measures, earlier clinical and laboratory identification and appropriate management of severe sepsis are required to reduce the burden of this disease. HOW TO CITE THIS ARTICLE: Ganesan V, Sundaramoorthy R et al., Melioidosis-Series of Seven Cases from Madurai, Tamil Nadu, India. Indian J Crit Care Med 2019;23(3):149-151.

Fungal endocarditis in paediatrics: a review of 192 cases (1971-2016).

BACKGROUND: The aims of this article were to review the published literature on fungal endocarditis in children and to discuss the aetiology and diagnosis, with emphasis on non-invasive methods and various treatment regimes. METHODS: We systematically reviewed published cases and case series of fungal endocarditis in children. We searched the literature, including PubMed and individual references for publications of original articles, single cases, or case series of paediatric fungal endocarditis, with the following keywords: "fungal endocarditis", "neonates", "infants", "child", and "cardiac vegetation". RESULTS: There have been 192 documented cases of fungal endocarditis in paediatrics. The highest number of cases was reported in infants (93/192, 48%) including 60 in neonates. Of the neonatal cases, 57 were premature with a median gestational age of 27 weeks and median birth weight of 860 g. Overall, 120 yeast - fungus that grows as a single cell - infections and 43 mould - fungus that grows in multicellular filaments, hyphae - infections were reported. With increasing age, there was an increased infection rate with moulds. All the yeast infections were detected by blood culture. In cases with mould infection, diagnosis was mainly established by culture or histology of emboli or infected valves after invasive surgical procedures. There have been a few recent cases of successful early diagnosis by non-invasive methods such as blood polymerase chain reaction (PCR) for moulds. The overall mortality for paediatric fungal endocarditis was 56.25%. The most important cause of death was cardiac complications due to heart failure. Among the various treatment regimens used, none of them was significantly associated with better outcome. CONCLUSIONS: Non-invasive methods such as PCR tests can be used to improve the chances of detecting and identifying the aetiological agent in a timely manner. Delays in the diagnosis of these infections may result in high mortality and morbidity. No significant difference was noted between combined surgical and medical therapy over exclusively combined medical therapy.

Epidemiology and clinical spectrum of melioidosis: Analysis of cases from a tertiary care centre in southern Tamil Nadu.

Background We studied the clinical features and treatment outcome of patients with melioidosis in our hospital. Methods We did this retrospective observational chart review over a period of 7 years between December 2014 and February 2022. Results There were 59 cases and 23 deaths attributable to melioidosis over the study period. The age range was 5 to 74 years and 48 (81.3%) were men. The comorbid conditions included diabetes mellitus (68%), alcoholism (11.8%), pulmonary tuberculosis (6.7%) and chronic kidney disease (5%). Over three-fourths of patients (78%) presented during the rainy season (June to December) and were acute presentations (44 [75%]). The most common sites were liver and spleen, followed by the musculoskeletal system, skin, soft tissues, lungs and brain. Of the 21 (36%) patients with septic shock, 16 (76%) died. On the contrary, of 38 (64%) patients without septic shock, only 11% died. Of the 27 (47%) admitted to ICU, 11 (41%) died. In ICU, 18 (67%) were ventilated. Of the 23 (39%) deaths overall, median time from admission to death was 4 days. There were no relapses in the 42% patients followed up for 2-6 months. Conclusions The epidemiology of melioidosis is similar to other endemic areas with preponderance of men. There was a temporal association with the monsoon season and a higher number of acute cases. The differences included a higher proportion of deep visceral abscesses and musculo-skeletal involvement compared to lung involvement.

Ceftazidime-Avibactam resistance in clinical isolates of carbapenem-resistant Klebsiella pneumoniae: A phenotypic and genotypic analysis.

OBJECTIVE: To find the prevalence of Ceftazidime-Avibactam (CAZ-AVI) resistant Klebsiella pneumoniae in clinical isolates and to determine the genes responsible for Ceftazidime-Avibactam resistance using PCR. METHODS: A total of 89 carbapenem resistant Klebsiella pneumoniae from various clinical samples were included in the study. CAZ-AVI resistance was tested using E-test. CAZ-AVI resistant strains were subjected to conventional PCR for detection of carbapenamase genes blaNDM- 1, blaOXA-48, blaVIM, blaIMP, blaKPC. RESULTS: Of the 89 isolates screened for CAZ-AVI resistance, 45(50.5%) isolates were found to be resistant. 42 isolates were subjected to PCR for detection of ß lactamase genes.34 isolates were positive for blaNDM-1 and all 42 isolates were positive for blaOXA-48. Co-expression of NDM-1 and OXA-48 was seen in 34 isolates. Sensitivity of mCIM test to identify a carbapenamse compared to PCR was 61.9%. Sensitivity of eCIM test to identify NDM-1 was 80%. CONCLUSION: CAZ-AVI was effective in vitro in 49.4% of the isolates. Indicating that CAZ-AVI is a promising addition to antibiotics against CRE as well as a carbapenem sparing drug in ESBL producing organisms. ß-Lactamase-related mutations are the main mechanism leading to CAZ-AVI resistance.

Feasibility, safety, and short-term follow-up of defibrillator lead at left bundle branch area pacing location: A pilot study.

BACKGROUND: Left bundle branch area pacing (LBBAP) has been increasingly adopted as an alternative modality to cardiac resynchronization therapy (CRT). The feasibility and safety of using an LBBAP lead to provide sensing of ventricular arrhythmia in patients receiving an implantable cardioverter-defibrillator (ICD) with CRT has been demonstrated recently. OBJECTIVES: The purpose of our study was to analyze the feasibility, safety, and short-term follow-up of a traditional defibrillator lead at the LBBAP location. METHODS: Patients who underwent successful LBBAP defibrillator using DF-1/DF-4 lead and delivery catheter were included in the study. Defibrillation threshold (DFT) testing was performed after implantation to assess the ability of the LBBAP defibrillator lead to sense and provide appropriate therapy for ventricular arrhythmia. RESULTS: Although the ICD lead could be successfully deployed in the left bundle branch area in 7 of 8 patients, it was repositioned to the right ventricular (RV) apex because of atrial oversensing in 1 patient and cheesy septum in another patient. Acute procedural success was 62.5% (5/8 patients). Mean patient age was 62.6 ± 21.6 years. Mean procedural duration was 115.6 ± 38.1 minutes, with LBBAP defibrillator lead fluoroscopy duration of 10.6 ± 3.5 minutes. Mean capture threshold was 0.58 ± 0.23V/0.4 ms, sensed R-wave amplitude 9.6 ± 2.2 mV, pacing impedance 560 ± 145 Ω, and shock impedance 65.4 ± 5.5 Ω. Defibrillation testing was successful in inducing ventricular fibrillation and could be sensed and reverted promptly by the shock delivered through the lead. During mean follow-up of 3.8 ± 2.2 months, pacing parameters remained stable. No episodes of inappropriate arrhythmia detection or therapy delivery occurred during follow-up. CONCLUSION: LBBAP defibrillator is feasible, safe, and effective during short-term follow-up. DFT testing at the time of implantation will help to ensure appropriate sensing and treatment of ventricular arrhythmias.

Extra-intestinal salmonellosis in a tertiary care centre in South India.

Background and Objectives: Extra-intestinal salmonellosis is associated with higher case fatality and is underestimated in the developing countries like India. Here we present a case series of bacteriologically proven extra-intestinal salmonellosis managed at our institute over the past two years. Materials and Methods: Retrospective analysis of bacteriologically proven extra-intestinal salmonellosis over two years between January 2020 to December 2021 was carried out. Medical records were reviewed for site of infection, evidence of any underlying or predisposing illnesses and antimicrobial susceptibility report. Results: Eight patients were diagnosed with extra-intestinal salmonellosis. Male to female ratio was 3:1. Mean age was 44 years. Four were typhoidal and four were nontyphoidal Salmonellae. The extra-intestinal sites involved were purulent aspirates from scrotum, caecum, perianal region, intraperitoneal collection, synovium, and urine. Predisposing factors include chronic myeloid leukemia, HIV and gastric malignancy. All deep seated abscess required surgical intervention. All typhoidal Salmonella (n=4) were sensitive to cotrimoxazole, ampicillin, ceftriaxone. Among nontyphoidal Salmonella, one was resistant to cotrimoxazole; two were resistant to ampicillin, ceftriaxone and three resistant to ciprofloxacin. Conclusion: The diagnosis of extra-intestinal salmonellosis requires a high degree of clinical suspicion and should be included in the differential diagnosis in patients with deep-seated abscesses.

Left bundle branch pacing lead for sensing ventricular arrhythmias in implantable cardioverter-defibrillator: A pilot study (LBBP-ICD study).

BACKGROUND: Left bundle branch pacing (LBBP) has been suggested as an alternative modality for biventricular pacing in cardiac resynchronization therapy (CRT)-eligible patients. As it provides stable R-wave sensing, LBBP has been recently used to provide sensing of ventricular arrhythmia in patients receiving implantable cardioverter-defibrillator (ICD) with CRT. OBJECTIVE: The aim of this study was to analyze the long-term safety and efficacy of the LBBP lead for appropriate detection of ventricular arrhythmia and delivery of antitachycardia pacing (ATP) in patients requiring defibrillator therapy with CRT. METHODS: CRT-eligible patients who underwent successful LBBP-optimized ICD and LBBP-optimized CRT with defibrillator were enrolled. The LBBP lead was connected to the right ventricular-P/S port after capping the IS-1 connector plug of the DF-1-ICD lead. LBBP-optimized ICD or LBBP-optimized CRT with defibrillator was decided on the basis of correction of conduction system disease. Documented arrhythmic episodes and therapy delivered were analyzed. RESULTS: Thirty patients were enrolled. The mean age was 59.7 ± 10.5 years. LBBP resulted in an increase in left ventricular ejection fraction from 29.9% ± 4.6% to 43.9% ± 11.2% (P < .0001). During a mean follow-up of 22.9 ± 12.5 months, 254 ventricular arrhythmic events were documented. Appropriate events (n = 225 [89%]) included nonsustained ventricular tachycardia (VT) (n = 212 episodes [94%]), VT (n = 8 [3.5%]), and ventricular fibrillation (n = 5 [2.5%]). ATP efficacy in terminating VT was 75%. Eleven percent of episodes (n = 29) were inappropriately detected because of T-wave oversensing. Inappropriate therapy (ATP) was delivered for 14 episodes (5.5%). Three patients (10%) had worsening of tricuspid regurgitation. CONCLUSION: Sensing from the LBBP lead for arrhythmia detection is safe as ∼90% of the episodes were detected appropriately. Future studies with a dedicated LBBP-defibrillator lead along with algorithms to avoid oversensing can help in combining defibrillation with conduction system pacing.

New-Onset Left Ventricular Dysfunction After Left Bundle Branch Pacing.

BACKGROUND: Left bundle branch pacing (LBBP) provides stable pacing parameters and has been suggested as an alternative for right ventricular pacing and cardiac resynchronization therapy. OBJECTIVES: The aim of the study was to assess the incidence and etiology of new-onset left ventricular dysfunction (NOLVD) following LBBP in patients with baseline normal left ventricular (LV) function and cardiomyopathy patients with normalized LV function. METHODS: Patients undergoing successful LBBP for symptomatic bradyarrhythmia or as an alternative to cardiac resynchronization therapy were included. Normalization of LV function was defined as improvement in LV ejection fraction to ≥50%. Patients with baseline normal LV function and those with recovered LV function after LBBP constituted the study group. Loss of conduction system capture (LOCSC) was defined as complete or partial loss of right bundle branch delay pattern along with inability to demonstrate capture transition during threshold assessment. RESULTS: A total of 426 patients were included; 59% (n = 250) had baseline normal LV function (group I) and 41% (n = 176) had recovered LV function after LBBP (group II). Mean follow-up duration of 28.3 ± 16.7 months. NOLVD was noted in 3.75% (n = 16; group I = 5 and group II = 11) of patients. The etiologies for NOLVD were LOCSC in 62.5% (n = 10), suboptimal atrioventricular (AV) delay in 18.7% (n = 3), atrial fibrillation in 6.3% (n = 1), and idiopathic in 12.5% (n = 2). LOCSC occurred at a mean interval of 9.2 ± 6.4 months after the initial implantation. Reinterventions (n = 6) including lead repositioning, AV delay optimization, and AV junction ablation resulted in renormalization of LV function in all 6 patients. CONCLUSIONS: Periodic assessment in device clinic is required because NOLVD from reversible causes can occur during follow-up in patients after LBBP.

Retrograde Conduction in Left Bundle Branch Block: Insights From Left Bundle Branch Pacing.

BACKGROUND: Biventricular pacing is a well-established therapy for patients with heart failure (HF), left bundle branch block (LBBB) and left ventricular (LV) dysfunction. Left bundle branch pacing (LBBP) has emerged as an alternative to biventricular pacing. OBJECTIVES: The aim of this study was to assess the retrograde conduction properties of the left bundle branch in patients with nonischemic cardiomyopathy and LBBB during LBBP and its clinical implications. METHODS: Patients undergoing successful LBBP for nonischemic cardiomyopathy with LV ejection fraction (LVEF) ≤35% and LBBB were included. Continuous recording of His potential was performed using a quadripolar catheter. Unidirectional block was defined as retrograde His bundle activation during LBBP with stimulus to His potential (SH) duration less than or equal to antegrade HV interval and bidirectional block as VH dissociation or SH duration greater than HV interval. HF hospitalization, ventricular arrhythmias, and mortality were documented. RESULTS: A total of 165 patients were included. The mean follow-up duration was 21.8 ± 13.1 months. Bidirectional block (group I) was observed in 82% (n = 136), and these patients were noted to have advanced HF stage and prolonged baseline QRS duration. Unidirectional block (group II) with intact retrograde conduction was observed in 18% (n = 29) and was associated with narrow paced QRS duration and higher LVEF during follow-up. Super-response (LVEF ≥50%) was observed in 54.4% (n = 74) in group I compared with 73.3% (n = 22) in group II (P = 0.03). The OR for LVEF normalization was 4.1 (95% CI: 1.26-13.97; P = 0.02), with unidirectional block compared with bidirectional block in patients with LBBB and LV dysfunction. Adverse clinical outcomes as measured by a composite of HF hospitalization, ventricular arrhythmias, and mortality were significantly higher in group I compared with group II (12.5% vs 0%; P = 0.04). CONCLUSIONS: Bidirectional block in LBBB was characterized by advanced HF symptoms, while unidirectional block was associated with better clinical outcomes after cardiac resynchronization therapy by LBBP.

Third-generation cephalosporin-resistant Vibrio cholerae, India.

Vibrio cholerae resistance to third-generation cephalosporins is rarely reported. We detected a strain that was negative for extended-spectrum ß-lactamase and positive for the AmpC disk test, modified Hodge test, and EDTA disk synergy test and harbored the blaDHA-1 and blaNDM-1 genes. The antimicrobial drug susceptibility profile of V. cholerae should be monitored.