Early trends in leadless pacemaker implantation: Evaluating nationwide in-hospital outcomes.

BACKGROUND: Single-chamber leadless intracardiac pacemaker (LICP) implantation was approved in 2016 in the United States. However, little is known regarding trends in real-world utilization and complication rates. OBJECTIVE: The purpose of this study was to assess nationwide demographics, trends, and outcomes among hospitalizations with LICP implantation in the United States. METHODS: Using the National Inpatient Sample, we identified all hospitalizations with LICP or transvenous pacemaker implantation as a comparator between 2017 and 2019. We evaluated baseline patient characteristics, admitting diagnoses, procedural complications, lengths of stay, discharge dispositions, and all-cause mortality. RESULTS: The majority of LICP recipients were elderly (75.4 ± 12.8 years), male (55.2%), and White (76.8%) compared to Black (9.8%), or Hispanic (7.3%). Between 2017 and 2019, the average age increased along with the prevalence of heart failure, atrial fibrillation, and malignancy among recipients. Most hospitalizations were emergent (84.5%). Between 2017 and 2019, pooled procedural complications decreased significantly (10.8% vs 7.9%; P <.001), primarily due to declining infection and device retrieval rates. In-hospital mortality also decreased significantly (8.2% vs 4.2%; P <.001). History of cardiogenic shock or cardiac device infection was associated with the greatest mortality or complication risk. Compared to transvenous pacemaker, LICP implantation was associated with lower complication rates (8.6% vs 11.2%) but greater mortality (5.2% vs 1.3%; P <.001). CONCLUSION: Nationwide LICP implantations were performed in patients of increasing age, comorbidities, and acuity of illness. In-hospital mortality and procedure-related complications declined in the first 3 years after approval of LICP implantation and may reflect improving operator experience. Increased mortality compared with transvenous pacemaker implant remains a concern.

Association of SGLT2 inhibitors with arrhythmias and sudden cardiac death in patients with type 2 diabetes or heart failure: A meta-analysis of 34 randomized controlled trials.

BACKGROUND: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) reduce hospitalizations and death from heart failure (HF), but their effect on arrhythmia expression has been poorly investigated. OBJECTIVE: The purpose of this study was to evaluate the association of SGLT2is with arrhythmias in patients with type 2 diabetes mellitus (T2DM) or HF. METHODS: We searched PubMed and ClinicalTrials.gov. Two independent investigators identified randomized double-blind trials that compared SGLT2is with placebo or active control for adults with T2DM or HF. Primary outcomes were incident atrial arrhythmias, ventricular arrhythmias (VAs), and sudden cardiac death (SCD). RESULTS: We included 34 randomized (25 placebo-controlled and 9 active-controlled) trials with 63,166 patients (35,883 SGLT2is vs 27,273 control: mean age 53-67 years; 63% male). Medications included canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin. Except for 1 study of HF, all patients had T2DM. Follow-up ranged from 24 weeks to 5.7 years. The cumulative incidence of events was low: 3.6, 1.4, and 2.5 per 1000 patient-years for atrial arrhythmias, VAs and SCD, respectively. SGLT2i therapy was associated with a significant reduction in the risk of incident atrial arrhythmias (odds ratio 0.81; 95% confidence interval 0.69-0.95; P = .008) and the "SCD" component of the SCD outcome (odds ratio 0.72; 95% confidence interval 0.54-0.97; P = .03) compared with control. There was no significant difference in incident VA or the "cardiac arrest" SCD component between groups. CONCLUSION: SGLT2is are associated with significantly reduced risks of incident atrial arrhythmias and SCD in patients with T2DM. Prospective trials are warranted to confirm the antiarrhythmic effect of SGLT2is and whether this is a class or drug-specific effect.

Aortic stenosis calcium scoring in a racially mixed sample.

Aortic stenosis (AS) is common and increasing in prevalence as the population ages. Using computed tomography (CT) to quantify aortic valve calcification (AVC) it has been reported that men have greater degrees of calcification than women among subjects with severe AS. These data, however, were derived in largely Caucasian populations and have not been verified in non-Caucasian subjects. This retrospective study identified 137 patients with severe AS who underwent valve replacement and had CT scans within 6 months prior to surgery. AVC scores were compared between men and women, both in the entire sample and in racial subgroups. 52% of subjects were male and 62.8% were non-Caucasian. Mean AVC score for the entire cohort was 3062.08±2097.87 with a range of 428-13,089. Gender differences in aortic valve calcification were found to be statistically significant with an average AVC score of 3646±2422 in men and 2433±1453 in women (p=0.001). On multivariate analysis, gender remained significantly associated with AVC score both in the entire sample (p=0.014) and in the non-Caucasian subgroup (p=0.008). Mean AVA was significantly greater in males than females but this difference disappeared when AVA was indexed to BSA (p=0.719). AVA was not different between racial groups (p=0.369). In this research we observed that among subjects with severe AS men have higher AVC scores than women regardless of racial background. This is consistent with previous studies in predominantly Caucasian populations.

Transthyretin Cardiac Amyloidosis and Aortic Stenosis: Connection and Therapeutic Implications.

BACKGROUND: There is a growing interest in the observed significant incidence of transthyretin cardiac amyloidosis in elderly patients with aortic stenosis. Approximately, 16% of patients with severe aortic stenosis undergoing aortic valve replacement have transthyretin cardiac amyloidosis. Outcomes after aortic valve replacement appear to be worst in patients with concomitant transthyretin cardiac amyloidosis. METHODS: Publications in PubMed, Cochrane Library, and Embase databases were systematically searched from January 2012 to September 2018 using the keywords transthyretin, amyloidosis, and aortic stenosis. All studies published in English that reported the prevalence, association and outcomes of transthyretin cardiac amyloidosis in patients with aortic stenosis undergoing were included. RESULTS/CONCLUSION: The relationship between aortic stenosis and transthyretin cardiac amyloidosis is not well understood. A few studies have proven successful surgical management when both conditions coexist. This systematic review suggests that transthyretin cardiac amyloidosis is common in elderly patients with aortic stenosis and tend to have high mortality rates after AVR. The significant incidence of the two diseases occurring simultaneously warrants further investigation to improve management strategies in the future.

Invasive Hemodynamic Predictors of Renal Outcomes after Percutaneous Coronary Interventions.

OBJECTIVES: To determine the association of right heart invasive hemodynamic parameters with post-percutaneous coronary intervention (PCI) acute kidney injury (AKI). BACKGROUND: AKI after PCI is associated with a high morbidity and mortality. Various mechanisms are implicated in AKI after PCI. However, the association between filling pressures and invasive hemodynamic measures of right heart function with post-PCI AKI has not been described. METHODS: This is a retrospective single-center analysis of patients of who underwent simultaneous right heart catheterization (RHC) and left heart catheterization with PCI at the Einstein Medical Center, Philadelphia, between January 2010 and December 2016. We included patients who had hemodynamic parameters from the concomitant RHC as well as measurements of kidney function up to 1 month after the procedure. We excluded patients with ST elevation myocardial infarction, end-stage renal disease, cardiogenic shock, and PCI with a need for mechanical circulatory device support. Multivariate linear regression analysis was used to analyze the association between the various right ventricular hemodynamic parameters and eGFR within 1 week and 1 month after catheterization after adjusting for age, race, gender, diabetes and hypertension, contrast volume, cardiac index, and baseline eGFR. RESULTS: Right atrial (RA) pressure was inversely associated with eGFR within 1 week (ß = -1.66; 95% CI -3.06 to -0.25; p = 0.021) and 1 month after PCI (ß = -2.14; 95% CI -4.08 to -0.20; p = 0.031). CONCLUSION: Elevated RA pressure is associated with a worsening kidney function after cardiac catheterization and PCI.

Carcinoid Heart Disease: Review of Current Knowledge.

Carcinoid heart disease is the collective term for all cardiac manifestations in patients who have carcinoid syndrome. Carcinoid heart disease has a multifactorial pathophysiology, and the right side of the heart is usually involved. Symptoms and signs vary depending upon the affected cardiac components; most typical is right-sided heart failure secondary to diseased tricuspid and pulmonary valves. Despite no single ideal diagnostic test, strong suspicion, coupled with serologic and imaging results, usually enables diagnosis. Advances in imaging, such as speckle-tracking echocardiography and cardiac magnetic resonance, have improved the diagnostic yield. Treatment is challenging, warrants a multidisciplinary approach, and can be medical or surgical depending on the cardiac manifestations. Investigators are exploring the therapeutic use of monoclonal antibodies and new somatostatin analogues. In this review, we cover current knowledge about the pathophysiology, diagnosis, and treatment of carcinoid heart disease.

Renal implications of pulmonary arterial capacitance in acute heart failure with preserved ejection fraction.

Worsening renal function in patients with heart failure with preserved ejection fraction is associated with poor outcomes. Pulmonary arterial capacitance is a novel right heart catheterization derived hemodynamic metric representing pulmonary arterial tree distensibility and right ventricle afterload. Given the strong association between heart failure, pulmonary hypertension, and kidney function, the goal of this study is to investigate the correlation between Pulmonary arterial capacitance and long-term renal function in patients with heart failure with preserved ejection fraction. In this retrospective single center study, data from 951 patients with the diagnosis of heart failure, who underwent right heart catheterization were analyzed. Eight hundred and one patients with reduced ejection fraction, end-stage kidney disease on hemodialysis, acute myocardial infarction, and severe structural valvular disorders, were excluded. Pulmonary arterial capacitance was calculated as the stroke volume divided by pulmonary artery pulse pressure (mL/mmHg). Hemodynamic and clinical variables including baseline renal function were obtained at the time of the right heart catheterization, and renal function was also obtained at 3-5 years after right heart catheterization. The final cohort consisted of 150 subjects with a mean age 68 ( ± 14.2) years, 93 (62%) were female. The mean value for Pulmonary arterial capacitance was 2.82 ( ± 2.22) mL/mm Hg and the mean Glomerular Filtration Rate was 60.32 mL/min/l.73 m² ( ± 28.36). After multivariate linear regression analysis (including baseline Estimated Glomerular Filtration Rate as one of the variates), only age and Pulmonary arterial capacitance greater than 2.22 mL/mm Hg were predictors of long term Glomerular Filtration Rate. Pulmonary arterial capacitance as a novel right heart catheterization index could be a predictor of long-term renal function in patients with heart failure with preserved ejection fraction.

Acute Pancreatitis Mimicking ST-Segment Elevation Myocardial Infarction.

INTRODUCTION: Electrocardiographic changes imitating myocardial ischemia have been occasionally reported in patients with intra-abdominal pathology including acute pancreatitis. CASE REPORT: A 60-year-old man with no past medical history presented to the emergency department (ED) after a syncopal episode. In ED, his vitals were stable. His ECG showed sinus bradycardia at 53 beats per minute, peaked T waves, 1 mm ST-segment elevation in leads II, III, and aVF, and 2 mm ST elevation in V3 as shown in the figures. With the concern for STEMI, he was taken for left heart catheterization (LHC) emergently, showing nonobstructive coronary artery disease (CAD). His laboratory workup was remarkable for lipase of 25,304 IU/l (normal level 8-78 IU/l). His liver function test and triglyceride level were normal. Troponin was <0.01 ng/ml. A computed tomographic exam of the abdomen revealed acute interstitial pancreatitis with a small discrete fluid collection in the uncinate process. He was treated with aggressive intravenous fluid resuscitation and was discharged on day 3. DISCUSSION: Intra-abdominal pathologies like acute pancreatitis can lead to transient ECG changes mimicking STEMI. It is important to use ECG clues, echocardiographic findings, and clinical judgement to avoid cardiac catheterization, contrast exposure, and associated health care costs.

Optical Coherence Tomographic Evaluation of Hyperacute Bivalirudin-Induced Coronary Stent Thrombosis.

Thrombus formation after stent deployment has been linked to the use of heparin and of antithrombotic agents, such as bivalirudin, during percutaneous coronary intervention. Fluoroscopy has been used to identify stent thrombosis, typically after patients become symptomatic. We describe our use of optical coherence tomography to diagnose and evaluate intraprocedural stent thrombosis in a 68-year-old man who was given bivalirudin just before a percutaneous coronary procedure. This imaging method enabled immediate therapeutic intervention.

Percutaneous Closure of 2 Paravalvular Leaks and a Gerbode Defect after Mitral Valve Replacement for Infective Endocarditis.

Surgical valve replacement after infective endocarditis can result in local destructive paravalvular lesions. A 30-year-old woman with infective endocarditis underwent mitral valve replacement that was complicated postoperatively by 2 paravalvular leaks. During percutaneous closure of the leaks, a Gerbode defect was also found and closed. We discuss our patient's case and its relation to others in the relevant medical literature. To our knowledge, we are the first to describe the use of a percutaneous approach to close concomitant paravalvular leaks and a Gerbode defect.

Yamaguchi syndrome presenting as atrioventricular nodal re-entrant tachycardia in an African-American patient.

Apical hypertrophic cardiomyopathy (Yamaguchi syndrome) is a rare subtype of hypertrophic cardiomyopathy. The syndrome is more common in Japan where it was first described. Outside Asia, it is a very rare cause of hypertrophic cardiomyopathy. Apical hypertrophic cardiomyopathy is usually detected incidentally and has a good long-term outcome. We present a case of apical hypertrophic cardiomyopathy in an African-American patient manifesting as atrioventricular nodal re-entrant tachycardia.

Ethanol for the treatment of cardiac arrhythmias.

INTRODUCTION: Ethanol infusion was an early mode of ablative treatment for cardiac arrhythmias. Its initial descriptions involved coronary intra-arterial delivery, targeting arrhythmogenic substrates in drug-refractory ventricular tachycardia or the atrioventricular node. Largely superseded by radiofrequency ablation (RFA) and other contact-based technologies as a routine ablation strategy, intracoronary arterial ethanol infusion remains as an alternative option in the treatment of ventricular tachycardia when conventional ablation fails. Arrhythmic foci that are deep-seated in the myocardium may not be amenable to catheter ablation from either the endocardium or the epicardium by RFA, but they can be targeted by an ethanol infusion. RECENT FINDINGS: Recently, we have explored ethanol injection through cardiac venous systems, in order to avoid the risks of complications and limitations of coronary arterial instrumentation. Vein of Marshall ethanol infusion is being studied as an adjunctive procedure in ablation of atrial fibrillation, and coronary venous ethanol infusion for ventricular tachycardia. CONCLUSION: Ethanol ablation remains useful as a bail-out technique for refractory cases to RFA, or as an adjunctive therapy that may improve the efficacy of catheter ablation procedures.

Importancia de la planificación en la rehabilitación implantológica / Importance of planning in implantologic rehabilitation

En implantología existen diferentes etapas del diagnóstico que garantizan el estudio minucioso del caso. Conseguir una rehabilitación estética, funcional y biomecánicamente estable a largo plazo, que coincida con las expectativas del paciente es el deseo prioritario. El objetivo fue presentar un caso clínico con resultados exitosos por la adecuada planificación de la rehabilitación implantológica. Se presentó una paciente femenina de 53 años que perdió un incisivo central superior y el lateral adyacente presentaba discromía, gran pérdida ósea irrecuperable y vestibularización. Se llevaron a cabo cada una de las etapas del diagnóstico implantológico: confección de historia clínica, evaluación del estado de salud del paciente, toma de impresiones para el estudio de las relaciones intermaxilares en el articulador, confección de encerado diagnóstico y de férula quirúrgica y, finalmente, se realizó cirugía electiva y se colocó a nivel de 11 y 12 dos implantes; este último posextracción y ambos con carga inmediata. Se utilizó técnica de regeneración ósea y manejo de los tejidos blandos adecuadamente por ser una zona de alto compromiso estético, todo esto en una sola fase quirúrgica. Con esto se demostró que un diagnóstico y plan de tratamiento adecuados constituyen la clave de todo procedimiento implantológico(AU)

In dental implantology, there are different phases of diagnosis that provide a meticulous study of each case. Obtaining an esthetical, functional, biomechanical and long lasting rehabilitation that meets the patient´s expectations is our priority. This paper was intended to present a clinical case with successful results from an adequate planning of the implantological rehabilitation. A 53 years old female patient, who lost the11th tooth, had adjacent dischromy in the 12th tooth and significant bone loss and vestibularization. Every phase of the implant diagnosis were carried out: making of the medical history, the evaluation of the patient´s health, taking of maxillary impressions to study the intermaxillary ratios assisted by the articulator equipment, diagnostic waxing and surgical splint were made and, finally, elective surgery was performed to place two dental implants, one of them after removal and both with immediate charge. Bone regeneration technique and the gentle handling of soft tissues allowed making all this in a single surgical phase, since this is a highly compromised area from the esthetical viewpoint. It was proved that correct diagnosis and treatment are the key of every dental implant procedure(AU)

Importancia de la planificación en la rehabilitación implantológica / Importance of planning in implantologic rehabilitation

En implantología existen diferentes etapas del diagnóstico que garantizan el estudio minucioso del caso. Conseguir una rehabilitación estética, funcional y biomecánicamente estable a largo plazo, que coincida con las expectativas del paciente es el deseo prioritario. El objetivo fue presentar un caso clínico con resultados exitosos por la adecuada planificación de la rehabilitación implantológica. Se presentó una paciente femenina de 53 años que perdió un incisivo central superior y el lateral adyacente presentaba discromía, gran pérdida ósea irrecuperable y vestibularización. Se llevaron a cabo cada una de las etapas del diagnóstico implantológico: confección de historia clínica, evaluación del estado de salud del paciente, toma de impresiones para el estudio de las relaciones intermaxilares en el articulador, confección de encerado diagnóstico y de férula quirúrgica y, finalmente, se realizó cirugía electiva y se colocó a nivel de 11 y 12 dos implantes; este último posextracción y ambos con carga inmediata. Se utilizó técnica de regeneración ósea y manejo de los tejidos blandos adecuadamente por ser una zona de alto compromiso estético, todo esto en una sola fase quirúrgica. Con esto se demostró que un diagnóstico y plan de tratamiento adecuados constituyen la clave de todo procedimiento implantológico(AU)

In dental implantology, there are different phases of diagnosis that provide a meticulous study of each case. Obtaining an esthetical, functional, biomechanical and long lasting rehabilitation that meets the patient´s expectations is our priority. This paper was intended to present a clinical case with successful results from an adequate planning of the implantological rehabilitation. A 53 years old female patient, who lost the11th tooth, had adjacent dischromy in the 12th tooth and significant bone loss and vestibularization. Every phase of the implant diagnosis were carried out: making of the medical history, the evaluation of the patient´s health, taking of maxillary impressions to study the intermaxillary ratios assisted by the articulator equipment, diagnostic waxing and surgical splint were made and, finally, elective surgery was performed to place two dental implants, one of them after removal and both with immediate charge. Bone regeneration technique and the gentle handling of soft tissues allowed making all this in a single surgical phase, since this is a highly compromised area from the esthetical viewpoint. It was proved that correct diagnosis and treatment are the key of every dental implant procedure(AU)

Hemoglobinopatias S diagnosticadas en dos centros de Buenos Aires / Hemoglobinopathies S diagnosed in 2 Buenos Aires centers

La hemoglobina HbS constituye yba hemoglobinoacídica punrual en la cadena globínica ß. Su incorporación en américa se asocia al tráfico de esclavos negros africanos y, en menos escala, a la inmigración originaria del área del Mediterráneo. Este trabajo, elaborado por dos centros de Buenos Aires, incluye 124 casos: 85 con rasgo depanocítico (AS), 19 con S-ßTalasemia (S-ßTal), 10 con anemia drepanocítica (SS), 1 SC, 1 SD y 8 no determinados (S-ßTal O SS). Se destacan las seguientes observaciones: a) la totalidad de los casos provenían de las zonas centro y norte del país; (b) pudo rastrearse origen italiano (n = 10), árabe (n = 8) y algunos casos de países limítrofes, salvo Bolivia; (c) los AS presentaron valores hematológicos medios normales, de acuerdo al grupo etario estudiado, así se halló: Hb para > ou = 15 a, 14,2 g/dl; para < 15 a, 12,0 g/dl; hematíaes > ou = 15 a, 5,05 x 10**12/1; para < 15 a, 4,64 x 10*12/1; VGR para > ou = 15 a, 42,7%; para < 15 a, 36%; reticulocitos, 1,1%, Hbfetal, 0,9%; HbA2, 2,2%; (d) el valor promedio de Hb S fue de 39,5%; (e) en 20 AS se constató hipocromía y/o microcitosis de variada severidad; (f) en nuestro medio fue segnificativamente más frecuente la asociación s/ßTal que la SS. La distribución geográfica de la HbS obedecería a las corrientes migrtorias diversas provenientes de Africa, Europa y Asia, donde existen áreas con alto porcentaje de HbS, coincidente con entorno endémico de malaria

Hemoglobinopatias S diagnosticadas en dos centros de Buenos Aires / Hemoglobinopathies S diagnosed in 2 Buenos Aires centers

La hemoglobina HbS constituye yba hemoglobinoacídica punrual en la cadena globínica ß. Su incorporación en américa se asocia al tráfico de esclavos negros africanos y, en menos escala, a la inmigración originaria del área del Mediterráneo. Este trabajo, elaborado por dos centros de Buenos Aires, incluye 124 casos: 85 con rasgo depanocítico (AS), 19 con S-ßTalasemia (S-ßTal), 10 con anemia drepanocítica (SS), 1 SC, 1 SD y 8 no determinados (S-ßTal O SS). Se destacan las seguientes observaciones: a) la totalidad de los casos provenían de las zonas centro y norte del país; (b) pudo rastrearse origen italiano (n = 10), árabe (n = 8) y algunos casos de países limítrofes, salvo Bolivia; (c) los AS presentaron valores hematológicos medios normales, de acuerdo al grupo etario estudiado, así se halló: Hb para > ou = 15 a, 14,2 g/dl; para < 15 a, 12,0 g/dl; hematíaes > ou = 15 a, 5,05 x 10**12/1; para < 15 a, 4,64 x 10*12/1; VGR para > ou = 15 a, 42,7%; para < 15 a, 36%; reticulocitos, 1,1%, Hbfetal, 0,9%; HbA2, 2,2%; (d) el valor promedio de Hb S fue de 39,5%; (e) en 20 AS se constató hipocromía y/o microcitosis de variada severidad; (f) en nuestro medio fue segnificativamente más frecuente la asociación s/ßTal que la SS. La distribución geográfica de la HbS obedecería a las corrientes migrtorias diversas provenientes de Africa, Europa y Asia, donde existen áreas con alto porcentaje de HbS, coincidente con entorno endémico de malaria (AU)