Efficacy and safety of supraclavicular and pectoralis nerve blocks as primary peri-procedural analgesia for cardiac electronic device implantation: A pilot study.

BACKGROUND: Cardiac implantable electronic devices (CIEDs) are routinely implanted using intravenous drugs for sedation. However, some patients are poor candidates for intravenous sedation. OBJECTIVE: We present a case series demonstrating the safety and efficacy of a novel, ultrasound-guided nerve block technique that allows for pre-pectoral CIED implantation. The targets are the supraclavicular nerve (SCN) and pectoral nerve (PECS1). METHODS: We enrolled 20 patients who were planned for new CIED implantation. Following US-localization of the SCN and PECS1, local anesthetic (LA) was instilled at least 30-60 min pre-procedure. Successful nerve block was determined if < 5 mL of intraprocedural LA was used, along with lack of sensation with skin and deep tissue pinprick. Optional sedation was offered to patients' pre-procedure if discomfort was reported. RESULTS: Seventeen patients (85%) had a successful periprocedural nerve block, with only three patients exceeding 5 mL of LA. SCN and PECS1 success occurred in 19 (95%) and 18 (90%) patients, respectively. The overall success of nerve block by fulfilling all the criteria was demonstrated in 17 out of 20 patients (85%). Patients who reported no pain (VAS score = 0) were distributed as follows: 13 patients (65%) in the immediate post-procedure interval, 18 patients (90%) at the 1 h post-implant interval, and 14 patients (70%) at the 24 h post- implant interval. The median cumulative VAS score was 0 (IQR = 0 - 1). There were no reported significant adverse effects. CONCLUSION: SCN and PECS1 nerve blocks are safe and effective for patients undergoing CIED implantation to minimize or eliminate the use of intravenous sedation.

Wide QRS Complex Rhythm Requiring a Second Look.

This case report describes a patient in their 60s with atrial flutter ablation following admission to the hospital for heart failure exacerbation.

Impact of Clopidogrel Stop Interval on Major Adverse Bleeding Events in Cardiac Surgery.

BACKGROUND: Major societal guidelines recommend a 5-day stop interval before cardiac surgery for patients with acute coronary syndrome receiving clopidogrel. Yet, many such patients present with high acuity, generating surgeon inclination toward use of shorter stop intervals. Thus, this study aimed to determine the impact of the duration and timing of the interval of clopidogrel cessation on adverse bleeding events. METHODS: Patients who underwent cardiac surgery between 2009 and 2016 at a tertiary-care centre were included in this retrospective cohort study. Multivariable logistic regression models adjusted for clopidogrel stop interval, age, urgency of procedure, and procedure type were used to quantify the effect of clinically relevant baseline demographic characteristics on incidence of massive transfusion as well as hemorrhagic complication outcomes. RESULTS: A total of 5748 patients underwent cardiac surgery. In this cohort, 1743 patients (30.3%) received clopidogrel preoperatively, and 884 (50.7%) of these patients discontinued clopidogrel 5 days before presenting to the operating room. The administration of clopidogrel 1-2 days before surgery (odds ratio 1.97; 95% confidence interval: 1.18 to 3.29) was an independent predictor for massive transfusions and hemorrhagic complications (odds ratio 1.85; 95% confidence interval: 1.01 to 3.37). The 3-4 day group did not have an increased risk of major bleeding complications. The risk for both massive transfusions and hemorrhagic complications also increased with the urgency and complexity of surgery. CONCLUSION: A clopidogrel stop interval of 3-4 days preoperatively was not associated with an increased risk for major bleeding complications.

INTRODUCTION: Les grandes lignes directrices sociétales recommandent une interruption de cinq jours avant l'intervention chirurgicale du cœur des patients atteints d'un syndrome coronarien aigu qui prennent du clopidogrel. Toutefois, comme il s'agit pour plusieurs d'entre eux de patients de haute acuité, le chirurgien penche vers l'utilisation d'une interruption plus courte. Par conséquent, la présente étude avait pour objectif de déterminer les conséquences de la durée et du moment de la cessation du clopidogrel sur les événements hémorragiques indésirables. MÉTHODES: La présente étude de cohorte rétrospective portait sur les patients qui avaient subi une intervention chirurgicale au cœur entre 2009 et 2016 dans un centre de soins tertiaires. Nous avons utilisé les modèles multivariés de régression logistique ajustés à l'interruption du clopidogrel, à l'âge, à l'urgence de l'intervention chirurgicale et au type d'intervention chirurgicale pour quantifier les effets des caractéristiques démographiques initiales cliniquement pertinentes sur la fréquence des transfusions massives ainsi que sur les issues des complications hémorragiques. RÉSULTATS: Un total de 5 748 patients ont subi une intervention chirurgicale au cœur. Dans cette cohorte, parmi les 1 743 patients (30,3 %) qui avaient reçu du clopidogrel avant l'opération, 884 (50,7 %) avaient cessé le clopidogrel cinq jours avant leur admission à la salle d'opération. L'administration du clopidogrel un à deux jours avant l'intervention chirurgicale (ratio d'incidence approché 1,97; intervalle de confiance [IC] à 95 % : de 1,18 à 3,29) était un prédicteur indépendant des transfusions massives et des complications hémorragiques (ratio d'incidence approché 1,85; [IC] à 95 % : de 1,01 à 3,37). Le groupe de l'interruption de trois à quatre jours n'a pas montré de risque accru de complications hémorragiques graves. Le risque de transfusions massives et de complications hémorragiques a aussi contribué à l'augmentation de l'urgence et de la complexité de l'intervention chirurgicale. CONCLUSION: Une interruption du clopidogrel de trois à quatre jours avant l'opération n'a pas été associée à un risque accru de complications hémorragiques graves.

A Novel Nerve Block Technique for a Patient Undergoing Cardiac Device Implantation.

A woman with type 1 myotonic dystrophy received an implantable cardioverter-defibrillator using a novel combination of ultrasound-guided supraclavicular nerve and pectoral nerve blocks. The entire procedure was completed without any procedural sedation or local anesthetic, and the patient did not experience any pain during or after the procedure. (Level of Difficulty: Advanced.).

Blown Wide Open: An Unusual Case of Torrential Mitral Regurgitation Resolving With a Cough.

Mitral regurgitation can have varying hemodynamic parameters dependent on factors such as pressure gradients, exercise, and/or provocative maneuvers. We present a case of unusual dynamic mitral regurgitation resolved by coughing in a patient with hypertrophic cardiomyopathy. (Level of Difficulty: Intermediate.).

Predicting acute kidney injury following nonemergent cardiac surgery: A preoperative scorecard.

OBJECTIVE: To determine the predictors of postoperative acute kidney injury (AKI) following nonemergent cardiac surgery among patients with variable preoperative estimated glomerular filtration rate (eGFR) levels. METHODS: A retrospective study of patients who underwent elective or in-hospital cardiac surgical procedures was performed between January 2006 and November 2015. The procedures included isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), or combined CABG and AVR. The primary outcome AKI (any stage) following nonemergent cardiac surgery utilizing the 2012 Kidney Disease-Improving Global Outcomes (KDIGO) criteria. Patients were categorized based on the following renal outcomes: mild AKI, severe AKI (KDIGO stage 2 or 3), and postoperative dialysis. Patients with G5 preoperative kidney function (including dialysis patients) were excluded. RESULTS: A total of 6675 patients were included in our study. The mean age was 66.8 years (SD ± 10.4), with 76.3% being males. A total of 4487 patients had normal or mildly decreased eGFR (G1 or G2) preoperatively (67.2%), while 1960 patients were in the G3 category (29.4%). Only 228 patients (3.4%) had G4 renal function. A total of 1453 (21.7%) patients experienced postoperative AKI. The need for postoperative dialysis occurred in 3.2% of the AKI subgroup. In-hospital mortality was higher among the AKI subgroup (7.2% vs. 0.5%; p < .0001). In an adjusted model, a lower preoperative eGFR category was the strongest predictor of AKI. A practical scorecard for the preoperative estimation of severe AKI for nonemergent cardiac procedures incorporating these parameters was developed. CONCLUSIONS: Preoperative eGFR is the strongest predictor of postoperative AKI in individuals undergoing nonemergent cardiac surgery. A practical scorecard incorporating preoperative predictors of AKI may allow informed decision-making and predict AKI following nonemergent cardiac surgery.

COVID-19 and Myocarditis: What Do We Know So Far?

COVID-19 has been declared a global pandemic by the World Health Organization and is responsible for hundreds of thousands of deaths worldwide. COVID-19 is caused by SARS-CoV-2, and common clinical symptoms include fever, cough, sore throat, headache, and fatigue. Myocardial injury is relatively common in patients with COVID-19, accounting for 7%-23% of cases, and is associated with a higher rate of morbidity and mortality. There is a discrepancy in the literature about myocarditis as the etiology of myocardial injury in patients with COVID-19; although many anecdotal reports of myocarditis have been noted, there are only a handful of case reports in the literature about myocarditis related to COVID-19. In this review we summarize the most up to date literature around the association between COVID-19 and myocarditis and provide clinicians a practical framework about the clinical manifestations, diagnostic tools, and treatment options currently available. Importantly, this review will heighten suspicion for myocarditis as an etiology of myocardial injury in COVID-19 patients, therefore improving clinical outcomes and encouraging shared clinical decision-making. This will also open the door for further research to build around this review. Emergent treatment options for COVID-19 are in clinical trials and might be of benefit to COVID-19 patients with myocarditis in addition to current guideline-based recommendations.

La COVID-19 a été déclarée pandémie mondiale par l'Organisation Mondiale de la Santé et elle est responsable de centaines de milliers de décès dans le monde. La COVID-19 est causée par le SARS-CoV-2, et les symptômes cliniques courants sont la fièvre, la toux, le mal de gorge, les maux de tête et la fatigue. Les lésions myocardiques sont relativement fréquentes chez les patients atteints de la COVID-19, représentant 7 à 23 % des cas, et sont associées à un taux de morbidité et de mortalité plus élevé. Il existe des divergences dans la littérature décrivant la myocardite en tant qu'étiologie de lésions myocardiques chez les patients atteints de la COVID-19; bien que de nombreux rapports anecdotiques de myocardite aient été rapportés, il n'y a qu'un nombre limité de rapports de cas dans la littérature concernant des myocardites liées à la COVID-19. Dans cette revue de littérature, nous résumons la bibliographie la plus récente sur l'association entre COVID-19 et myocardite et fournissons aux cliniciens un cadre pratique sur les signes cliniques, les outils de diagnostic et les options de traitement actuellement disponibles. Il est important de noter que cette revue augmentera la suspicion de myocardite comme étiologie de lésions myocardiques chez les patients atteints de la COVID-19, améliorant ainsi le pronostic clinique et encourageant une prise de décision clinique partagée. Cela ouvrira également la voie à d'autres recherches qui pourront s'appuyer sur cette étude. De nouvelles options de traitement de la COVID-19 sont en cours d'essais cliniques et pourraient être bénéfiques aux patients atteints de la COVID-19 qui présentent une myocardite, tout en étant considérées pour les recommandations actuelles basées sur les lignes directrices.

Migrated fractured sternal wire in proximity to the main pulmonary artery: Case report and review.

BACKGROUND: We present a case of a 83-year-old man with a prior history of coronary artery bypass who presented to his family physician with progressive symptoms that raised concern for heart failure exacerbation. A chest X-ray was performed, which showed a fractured topmost sternal wire in the lateral projection and indicated that the sternal wire had migrated into the anterior mediastinum. An emergent electrocardiogram-gated flash computed tomography angiography confirmed the location of the fractured wire to be in close proximity to the main pulmonary artery. A discussion of migrated sternal wires with a literature review of cases is provided as well. AIMS: To present a case of a migrated sternal wire and a literature review. METHODS: An extensive literature review using pubmed and medline with relevant keywords was preformed. RESULTS: 11 known cases of migrated sternal wires with various complications, as detailed in the review table. The mortality rate is low but can be associated with significant morbidity. DISCUSSION: Fractured wires are quite common and are usually a benign radiographic finding. However, migration of sternal wires is an extremely rare phenomenon. Only a few reported cases in the literature were sternal wires have migrated beyond the sternum, leading to catastrophic clinical consequences, as detailed in the review table. CONCLUSION: Sternal wire complications secondary to migration beyond the sternum are rare but potentially fatal. Precise wire location and risk assessment with CT are more appropriate when wire location cannot be clearly delineated by plain film radiography.

When is the optimal time to discontinue clopidogrel before in-hospital coronary bypass surgery? A closer look at the current literature.

BACKGROUND: Clopidogrel and other P2Y12 inhibitors have become the standard of care among patients presenting with acute coronary syndromes. A substantial proportion of these patients require surgical revascularization during index hospitalization. HYPOTHESIS: Guidelines recommend a 5-day waiting period off clopidogrel before coronary artery bypass grafting (CABG) to reduce hemorrhagic complications. These recommendations are not routinely followed in clinical practice, while recent studies also propose shorter waiting periods off clopidogrel for patients awaiting in-hospital CABG. METHODS: A preliminary PubMed search was conducted using the following MeSH terms under the publication type "Hemorrhage:" "Clopidogrel," AND "Coronary Artery Bypass." Relevant studies and guidelines were then reviewed and selected based on a predetermined criteria. Studies that formulated the current recommendations for stopping clopidogrel preoperative to CABG are discussed in detail this review. RESULTS: A comprehensive review of recent evidence illustrates mixed bleeding and transfusion outcomes among CABG patients with preoperative exposure to clopidogrel in less than 5 days. CONCLUSIONS: The optimal discontinuation time of clopidogrel before CABG is still poorly defined. The recommendation of a 5-day washout period for clopidogrel should be reconsidered to be on par with current clinical practice.

Cardiac troponin T is an important predictor of mortality after cardiac surgery.

PURPOSE: Serum troponin (cTnT) levels, a commonly measured biomarker of myocardial injury, has rarely been considered in risk models after cardiac surgery. MATERIALS AND METHODS: Retrospective study of patients undergoing any cardiac surgery between 2004 and 2012. Patients with a history of recent myocardial injury (<21 days) were excluded. The minimum P value approach was used to determine categories of peak cTnT associated with in-hospital death. A multivariable analysis was performed to identify independent predictors of mortality. RESULTS: A total of 5318 patients without evidence of preoperative ischemia underwent a number of cardiac surgical interventions ranging from isolated coronary revascularization to combined valve coronary artery bypass grafting. The unadjusted in-hospital mortality rate was 3.3% (n = 175 patients). Four categories of peak cTnT were identified using the minimum P value approach: less than or equal to 0.6 ng/mL, 0.7 to 1.9 ng/mL, 2.0 to 3.1 ng/mL, and greater than 3.1 ng/mL with unadjusted mortality rates of 1.0%, 3.6%, 10.1%, and 33.1%, respectively. Multivariate logistic regression demonstrated that all peak cTnT levels greater than 0.6 ng/mL were independent predictors of in-hospital mortality in a dose-dependent manner. CONCLUSIONS: We demonstrate that in patients without preoperative myocardial ischemia, the demonstration of myocardial injury (>0.6 ng/mL) in the postoperative period is highly predictive of in-hospital death.