Acute Transient Contrast-Induced Neurologic Deficit as a Complication of Percutaneous Coronary Intervention.

Acute transient contrast-induced neurologic deficit is an uncommon condition triggered by the administration of intra-arterial contrast during angiography. It can present with encephalopathy, cortical blindness, seizures, or focal deficits. This report describes a patient who presented with severe neurologic deficits after percutaneous coronary intervention, with complete symptom resolution within 72 hours.

Impact of Early Intervention on Health Status Outcomes in Peripheral Artery Disease Patients with Chronic Total Occlusion Lesions Using the PORTRAIT Registry.

OBJECTIVES: To analyze the impact of non-invasive and early invasive treatments on health status in patients with lower extremity peripheral arterial disease (PAD) without and with chronic total occlusions (CTO) after 12 months of follow-up. METHODS: Using the international (U.S., Netherlands, and Australia) observational longitudinal PORTRAIT registry, we included patients with recent PAD symptoms between June 2011 and December 2015. We assessed the PAD-specific health status at initial visit, 3-, 6- and 12-month follow-up using the Peripheral Arterial Questionnaire (PAQ). On a propensity matched-weighted cohort, we compared patients' characteristics by CTO status and treatment groups as early invasive (revascularization in the 3 months) vs. non-invasive (exercise, medical therapies, or smoking cessation). We then assessed the health status trajectory over 12 months, as 3-way interaction between CTO status, and treatment groups, and months, using a multilevel generalized linear regression model for repeated measures adjusted for baseline health status with random effects at sites- and patients-level. RESULTS: We included 581 participants, with mean age of 66.62±9.33 years, 34.3% female, and 90.8% White, of whom 353 (60.8%) without and 228 (39.2%) with a CTO lesion. Respectively, 96 (27.2%) and 70 (30.7%) patients underwent early invasive treatment (d=0.07). While patients with CTO were more likely to have lower resting ABI, multilevel disease, and to experience severe claudication vs. their counterparts (|d|≥0.20); the patients' health status at baseline with CTO was not different from those without CTO, with mean Summary scores of 45.14±20.26 vs. 45.90±21.24 (d=0.04), respectively. The trajectory did not differ by CTO status (interaction CTO status*month: p=0.517) and was higher in early invasive vs. non-invasive treatment (treatment*month: p<0.001), regardless of CTO status (CTO status*treatment: p=0.981 and CTO status*treatment*month: p=0.264). The score increased over time with the largest improvement occurring at 3 months in both non-invasive (non-CTO: +7.82 95%CI 4.03;11.60 and CTO: +9.27 95%CI 4.45;14.09) and early invasive (non-CTO: +26.17 95%CI 20.06; 32.28 and CTO: +24.52 95%CI 17.40;31.64) groups. The mean score in CTO vs. non-CTO did not differ at each timepoint, with the 12-month mean score of 70.26 (95%CI 67.87; 74.65) vs. 71.17 (95% CI 65.91; 76.44) (p=0.99) in the non-invasive treatment and 84.93 (95%CI 78.90;90.97) vs. 79.20 (95%CI 72.77;86.14) (p=0.31) in the early invasive treatment. CONCLUSIONS: Patients with symptomatic PAD undergoing early revascularization exhibited higher health status over time vs. those undergoing non-invasive treatment strategy, irrespective of the presence of CTOs. The degree of the improvement was greater in the 3 months following the initial visit, especially in patients undergoing early revascularization.

When Two Syndromes Collide: Managing Fanconi and Refeeding Syndrome in a Single Patient.

Refeeding syndrome is the potentially fatal shift in fluids and electrolytes that may occur in malnourished patients after receiving artificial refeeding. Its hallmark feature is hypophosphatemia, although other electrolytes might also be affected. Fanconi syndrome is a generalized dysfunction of the proximal tubule characterized by proximal renal tubular acidosis (RTA), phosphaturia, glycosuria, aminoaciduria, and proteinuria. The etiology of Fanconi syndrome can be either acquired or inherited, and drugs, among them tenofovir, are a common acquired cause of this disease. We present the case of a patient with AIDS and polysubstance abuse who was admitted due to pneumonia, completed treatment, was then started on antiretroviral medication (ART) that included tenofovir alafenamide (TAF) and began presenting severe episodes of hypophosphatemia along with other electrolyte imbalances, leading the workup denoted in the case, severe complications and finally to the patient's demise. Most cases of tenofovir-related Fanconi syndrome are related to tenofovir disoproxil fumarate, but very few cases have been reported with TAF. Our case highlights this rare complication of therapy with TAF and how artificial feeding can contribute to severe electrolyte abnormalities and worsen outcomes.

COVID-19 epidemic in Panama.

Objective: It is necessary to establish the evolution that the pandemic has had in Panama by weeks and months and to clearly establish the existence of surges or peaks, according to cases and deaths and the relationship with age groups. Methodology: We conducted a retrospective cohort study of all confirmed COVID-19 cases reported by the Ministry of Health of Panama during the first 3 years of the epidemic (March 9, 2020, March 11, 2023). All cases were obtained from information provided by the Ministry of Health. We obtained daily information of the population at the national level reported as new cases, deaths, admission to hospitals, admission to intensive care units and by age groups. The information is classified by epidemiological week and by month from the diagnosis of the first case until March 2023. Results: During the three years of the study, 1,032,316 cases of COVID-19 were registered in the Republic of Panama, and the number of deaths reported was 8,621, for a fatality rate of 0.83 % throughout that period. The number of deaths decreased over the 3 years of the pandemic; however, similar to the cases, there were periods of surges (peaks) per year in June/July and in December/January. The lethality progressively increased according to the age of the affected patients. During the first year, the lethality in those under 20 years of age was 0.05 %, and in those over 80 years old, it was 17.54 %. This pattern was maintained during the second year; however, there was a large decrease in all age groups. Conclusion: the highest lethality rate in Panama occurred in the first year of the pandemic, with a great decrease in the third year; the impact of lethality is proportional to the age of the individual, with a high possibility of death in those over 80 years of age. During each pandemic year, there are two peaks (surges of new cases and deaths) per year, which are important times to take into account to generate strategies aimed at reducing the impact.

Swimming With Sharks: Left Main Coronary Obstruction Following Transcatheter Aortic Valve Implantation.

Delayed coronary obstruction (DCO) occurs when there is obstruction of the coronary ostia following a transcatheter aortic valvular implantation (TAVI). It is an uncommon but serious complication that often leads to death, usually presents as severe hypotension after TAVI, and should be suspected if migration of the valve occurs. We report the case of a 70-year-old female patient with severe aortic stenosis who underwent TAVI using a 26-mm CoreValve Evolut Pro (Medtronic, Dublin, Ireland). Although the valve was implanted successfully, she experienced hypotension with intermittent ST elevations and had a cardiac arrest shortly after, requiring Advanced Cardiovascular Life Support (ACLS). An aortogram showed sealing of the sinotubular junction (STJ) by CoreValve, without coronary flow. CoreValve was then snared and repositioned in the ascending aorta recovering coronary flow and cardiac pulsatility. A second TAVI was performed and an Edwards 20 mm Sapiens 3 valve (Edwards Lifesciences, Irvine, CA, USA) was implanted as standard procedure.

A Glimpse Into the Future of Transcatheter Interventional Heart Failure Therapies.

Chronic heart failure is one of the most debilitating chronic conditions affecting millions of people and adding a significant financial burden to health care systems worldwide. Despite the significant therapeutic advances achieved over the last decade, morbidity and mortality remain high. Multiple catheter-based interventional therapies targeting different physiological and anatomical targets are already under different stages of clinical investigation. The present paper provides a technical overview of the most relevant catheter-based interventional therapies under clinical investigation.

Complete Revascularization of Stable STEMI Patients Offers a Significant Benefit if Done During the Index PCI, but Not if It's Done as a Staged Procedure.

BACKGROUND: Complete revascularization (CR) of hemodynamically stable STEMI improves outcomes when compared to culprit-only PCI. However, the optimal timing for CR (CR during index PCI [iCR] versus staged PCI [sCR]) is unknown. sCR is defined as revascularization of non-culprit lesions not done during the index procedure (mean 31.5±24.6 days after STEMI). Our goal was to determine whether iCR was the superior strategy when compared to sCR. METHODS: A systematic review of Medline, Cochrane, and Embase was performed for RCTs reporting outcomes of stable STEMI patients who had undergone CR. Only RCTs with a clearly defined timing of CR, for the classification into iCR and sCR, and a follow-up of at least 12 months were included. Seven RCTs comprising 6647 patients (mean age:62.9±1.4 years, male sex:79.4%) met these criteria and were included. RESULTS: After a mean follow-up of 25.1±9.4 months, iCR was associated with a significant reduction in cardiovascular mortality (risk ratio [RR] 0.48, 95% confidence interval [CI] 0.26-0.90, p=0.02, relative risk reduction [RRR] 52%) and non-fatal reinfarctions (RR 0.42, 95% CI 0.25-0.70, p=0.001, RRR: 58%). sCR showed a significant reduction in non-fatal reinfarctions only (RR 0.68, 95% CI 0.54-0.85, p=0.0008, RRR: 32%). There was no difference in the safety outcome of contrast-induced nephropathy between groups. CONCLUSION: iCR of stable STEMI patients is associated with a significant reduction in cardiovascular death and a trend towards reduction in all-cause mortality. These benefits are not seen in sCR. Both strategies are associated with a reduction in non-fatal reinfarctions.

SARS-COV-2 infection presenting as ST-elevationmyocardial infarction.

We describe a patient presenting with chest discomfort, anterolateral ST elevation, and developing acute cardiogenic shock secondary to SARS-COV-2infection-patient zero presenting to our institution's cardiac catheterization laboratory. The emergent presentation with limited clinical information led to exposure of personnel. The diagnosis was complicated by two negative tests for SARS-COV-2, and high-clinical suspicion from the patient's occupational history led to additional testing in order to confirm the diagnosis.

An Overlap Presentation of Pericardial Decompression Syndrome and Stress Cardiomyopathy Following Therapeutic Pericardiocentesis.

Pericardial decompression syndrome, defined as paradoxical hypotension and pulmonary edema after pericardiocentesis, is a rare complication of pericardiocentesis. Stress cardiomyopathy, caused by excess catecholamine response resulting in left ventricular dysfunction and elevated cardiac enzymes, can overlap with pericardial decompression syndrome, and both might belong to the same spectrum of disease. (Level of Difficulty: Intermediate.).

Mapping and localization of the left phrenic nerve during left atrial appendage electrical isolation to avoid inadvertent injury in patients undergoing catheter ablation of atrial fibrillation.

BACKGROUND: A significant role of the left atrial appendage (LAA) in the genesis of atrial fibrillation (AF) has been described. Left atrial appendage electrical isolation (LAAEI) confers substantial long-term clinical benefits. Nevertheless, the left phrenic nerve (LPN) is in the vicinity of the LAA and can be injured during radiofrequency ablation at the ostial level. OBJECTIVE: The purpose of this study was to describe our experience mapping the LPN, its anatomic relationships to the LAA and alternative approaches to isolate this structure when the LPN is located at the LAA ostium. METHODS: Patients undergoing LAAEI for nonparoxysmal AF were included in this study. We attempted to localize the LPN with high-output pacing (20 mA/2 ms). Cases were classified into 4 groups (distal, middle, proximal segment and unmappable) based on the position of the LPN in electroanatomic mapping in the posterior wall of the LAA. RESULTS: A total of 66 cases were included in this study. The LPN was mapped in the distal segment in 27 cases (40.9%); in the middle segment in 22 (33.3%); and at the proximal segment/ostium in 3 (4.5%); the LPN was unmappable in 14 cases (21.2%). In the 3 patients in whom the LPN was at the ostial level or crossing the ostium, segmental LAAEI was attempted in 2, with successful LAAEI achieved in 1 case. There was no LPN injury. CONCLUSION: LPN mapping is feasible and should be routinely performed to prevent LPN injury during LAAEI.

Significant Benefit of Uninterrupted DOACs Versus VKA During Catheter Ablation of Atrial Fibrillation.

OBJECTIVES: This study assessed the incremental benefit of uninterrupted direct oral anticoagulants (DOACs) versus uninterrupted vitamin K antagonists (VKAs) for catheter ablation (CA) of nonvalvular atrial fibrillation (NVAF) on 3 primary outcomes: major bleeding events (MBEs), minor bleeding events, and thromboembolic events (TEs). The secondary outcome was post-procedural silent cerebral infarction (SCI) as detected by brain cardiac magnetic resonance. BACKGROUND: As a class, evidence of the benefits of DOACs versus VKAs during CA of AF is scant. METHODS: A systematic review of Medline, Cochrane, and Embase was done to find all randomized controlled trials in which uninterrupted DOACs were compared against uninterrupted VKAs for CA of NVAF. A fixed-effect model was used, except when I2 was ≥25, in which case, a random effects model was used. RESULTS: The benefit of uninterrupted DOACs over VKAs was analyzed from 6 randomized control trials that enrolled a total of 2,256 patients (male: 72.7%) with NVAF, finding significant benefit in MBEs (relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.20 to 0.99; p = 0.05). No significant differences were found in minor bleeding events (RR: 1.12; 95% CI: 0.87 to 1.43; p = 0.39), TEs (RR: 0.75; 95% CI: 0.26 to 2.14; p = 0.59), or post-procedural SCI (RR: 1.09; 95% CI: 0.80 to 1.49; p = 0.58). CONCLUSIONS: An uninterrupted DOACs strategy for CA of AF appears to be safer than uninterrupted VKAs with a decreased rate of major bleeding events. There are no significant differences among the other outcomes. DOACs should be offered as a first-line therapy to patients undergoing CA of AF, due to their lower risk of major bleeding events, ease of use, and fewer interactions.

Oral anticoagulation after catheter ablation of atrial fibrillation and the associated risk of thromboembolic events and intracranial hemorrhage: A systematic review and meta-analysis.

AIMS: We sought to examine whether continuing oral anticoagulation (OAC) after catheter ablation (CA) for atrial fibrillation (AF) is associated with improved outcomes. OAC reduces morbidity and mortality in patients with AF. However, the continuation of OAC following the blanking period of CA is controversial due to conflicting published data. METHODS: A systematic review of Medline, Cochrane, and Embase was performed for studies comparing patients who were continued on OAC (ON-OAC) vs those in which OAC was discontinued (OFF-OAC). CHA2 DS2 VASc score had to be available for the classification of patients into high- or low-risk cohorts (CHA2 DS2 VASc ≥ 2 and ≤ 1, respectively). The primary efficacy outcome was thromboembolic events (TE). Intracranial hemorrhage (ICH) was the primary safety outcome. RESULTS: Five studies comprising 3956 patients were included (mean age, 61.1 ± 2.9 years; 72.4% male, CHA2 DS2 VASc ≤ 1 50.1%; CHA2 DS2 VASc ≥ 2 49.9%). After a mean follow-up of 39.6 ± 11.7 months, OAC-continuation was associated with a significant decrease in risk of TE in the high-risk cohort (CHA2 DS2 VASc ≥ 2) (risk ratio [RR] 0.41, 95% confidence interval [CI] 0.21-0.82, P = .01) with a RR reduction of 59%. ICH was significantly higher in the ON-OAC group (RR, 5.78; 95% CI, 1.33-25.08; P = .02). No significant benefit was observed in the low-risk cohort ON-OAC after the blanking period. CONCLUSION: Continuation of OAC after CA of AF with CHA2 DS2 VASc ≥ 2 is associated with a significant decreased TE risk and a favorable net clinical benefit in spite of ICH being significantly increased in the ON-OAC group. Continued OAC offers no benefit with CHA2 DS2 VASC ≤ 1.

Combined Endocardial-Epicardial Versus Endocardial Catheter Ablation Alone for Ventricular Tachycardia in Structural Heart Disease: A Systematic Review and Meta-Analysis.

OBJECTIVES: This study sought to determine whether combined endocardial-epicardial (endo-epi) ablation was superior to endocardial only ablation in patients with scar-related ventricular tachycardia (VT). BACKGROUND: Limited single-center studies suggest that combined endo-epi ablation strategy may be superior to endocardial ablation (endo) alone in patients with nonischemic cardiomyopathy (NICM) and arrhythmogenic right ventricular cardiomyopathy (ARVC), and ischemic cardiomyopathy (ICM). METHODS: A systematic review of Medline, Cochrane, and Embase databases was performed for studies that reported outcomes comparing endo-epi with endo VT ablation alone. RESULTS: Seventeen studies consisting of 975 patients were included (mean 56 ± 10 years of age; 79% male; NICM in 36.6%; ICM in 32.8%; and ARVC in 30.6%). After a mean follow-up of 27 ± 21 months, endo-epi ablation was associated with a 35% reduction in risk of VT recurrence compared with endocardial ablation alone (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.55 to 0.78; p < 0.001). Sensitivity analysis showed lower risk of VT recurrence in ICM (RR: 0.43; 95% CI: 0.28 to 0.67; p = 0.0002) and ARVC (RR: 0.59; 95% CI: 0.43 to 0.82; p = 0.0002), with a nonsignificant trend in NICM (RR: 0.87; 95% CI: 0.70 to 1.08; p = 0.20). Endo-epi, compared with endo ablation, was associated with reduced all-cause mortality (RR: 0.56; 95% CI: 0.32 to 0.97; p = 0.04). Acute procedural complications were higher with the endo-epi approach (RR: 2.62; 95% CI: 0.91 to 7.52; p = 0.07). CONCLUSIONS: This meta-analysis suggests that a combined endo-epi ablation is associated with a lower risk of VT recurrence and subsequent mortality than endo only VT ablation in patients with scar-related VT. Procedural complications, however, are higher with the endo-epi approach.

Bundle branch reentrant ventricular tachycardia: review and case presentation.

Bundle branch reentrant ventricular tachycardia (BBRVT) is characterized by a unique, fast (200-300 beats/min), monomorphic wide complex tachycardia (WCT) associated with syncope, hemodynamic compromise, and cardiac arrest. It is challenging to diagnose, requiring a His bundle recording and specific pacing maneuvers. The overall incidence has been reported to be up to 20% among patients with non-ischemic cardiomyopathy (NICM) undergoing electrophysiologic studies. We report a case of BBRVT in a patient with ischemic cardiomyopathy (ICM) presenting as a WCT with recurrent implantable-cardioverter-defibrillator (ICD) shocks. We describe all the characteristic features of BBRVT and discuss its differential. We also discuss the role of ablation for this condition.

Uninterrupted direct oral anticoagulants vs. uninterrupted vitamin K antagonists during catheter ablation of non-valvular atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials.

Aims: To assess the incremental benefit of uninterrupted direct oral anticoagulants (DOACs) vs. uninterrupted vitamin K antagonists (VKA) for catheter ablation (CA) of non-valvular atrial fibrillation (NVAF) on three primary outcomes: major bleeding, thrombo-embolic events, and minor bleeding. A secondary outcome was post-procedural silent cerebral infarction (SCI) as detected by brain magnetic resonance imaging. Methods and results: A systematic review of Medline, Cochrane, and Embase was done to find all randomized controlled trials (RCTs) in which uninterrupted DOACs were compared against uninterrupted VKA for CA of NVAF. A fixed-effect model was used, with the exception of the analysis regarding major bleeding events (I2 > 25), for which a random effects model was used. The benefit of uninterrupted DOACs over VKA was analysed from four RCTs that enrolled a total of 1716 patients (male: 71.2%) with NVAF. Of these, 1100 patients (64.1%) had paroxysmal atrial fibrillation. No significant benefit was seen in major bleeding events [risk ratio (RR) 0.54, 95% confidence interval (95% CI) 0.29-1.00; P = 0.05]. No significant differences were found in minor bleeding events (RR 1.11, 95% CI 0.82-1.52; P = 0.50), thrombo-embolic events (RR 0.74, 95% CI 0.26-2.11; P = 0.57), or post-procedural SCI (RR 1.06, 95% CI 0.74-1.53; P = 0.74). Conclusion: An uninterrupted DOACs strategy for CA of NVAF appears to be as safe as uninterrupted VKA without a significantly increased risk of minor or major bleeding events. There was a trend favouring DOACs in terms of major bleeding. Given their ease of use, fewer drug interactions and a similar security and effectiveness profile, DOACs should be considered first line therapy in patients undergoing CA for NVAF.

Vancomycin-resistant Enterococcus faecium bacteraemia as a complication of Kayexalate (sodium polystyrene sulfonate, SPS) in sorbitol-induced ischaemic colitis.

We present the case report of an 80-year-old woman with chronic kidney disease stage G5 admitted to the hospital with fluid overload and hyperkalaemia. Sodium polystyrene sulfonate (SPS, Kayexalate) in sorbitol suspension was given orally to treat her hyperkalaemia, which precipitated an episode of SPS in sorbitol-induced ischaemic colitis with the subsequent complication of vancomycin-resistant Enterococcus (VRE) bacteraemia. SPS (Kayexalate) in sorbitol suspension has been implicated in the development of intestinal necrosis. Sorbitol, which is added as a cathartic agent to decrease the chance of faecal impaction, may be primarily responsible through several proposed mechanisms. The gold standard of diagnosis is the presence of SPS crystals in the colon biopsy. On a MEDLINE search, no previous reports of a VRE bacteraemia as a complication of biopsy-confirmed SPS in sorbitol ischaemic colitis were found. To the best of our knowledge, ours would be the first such case ever reported.

Internal carotid artery occlusion and stroke as a complication of cisplatin-based chemotherapy for metastatic testicular germ cell tumour.

Testicular tumours are the most common tumours in young men. Germ cell tumours (GCTs) account for 95% of all testicular cancers, and the non-seminomatous type (NSGCT) accounts for 50% of all GCTs. Cisplatin-based chemotherapy is curative in up to 90% of patients, but it is not without its inherent risks. Ischaemic stroke is a very uncommon, but severe complication of cisplatin-based chemotherapy. Strokes in young patients cause a disproportionately large economic impact by leaving victims disabled during their most productive years and strains the healthcare system with expensive hospital stays. We present a case of a young male patient with past medical history of metastatic NSGCT with the sudden onset of dysarthria, left hemiplegia and ipsilateral hemisensory loss 3 days after receiving cisplatin-based chemotherapy. Subsequent studies revealed a stroke involving the right middle cerebral artery territory secondary to an acute right internal carotid occlusion.