Addressing the Unmet Needs of Patients With Rapidly Progressive Neurological Disease: A Case Report of Palliative Care in Creutzfeldt-Jakob Disease (CJD).

Creutzfeldt-Jacob disease (CJD) is a rare neurodegenerative disorder that typically progresses rapidly and unrelentingly. Providing comfort and support for patients with CJD presents significant challenges for clinicians and caregivers. In comparison to the more typical disease progression experienced in dementias, the trajectory of CJD differs significantly. This case report delves into these differences and emphasizes the need for the development of guidelines for healthcare professionals and families who care for individuals with CJD. Such guidelines would help facilitate better care and support for patients and their families throughout the course of this devastating illness.

Pragmatic approach to mobilizing individuals with critical illness due to COVID-19: clinical perspective.

PURPOSE: To provide pragmatic guidance for acute rehabilitation management and implementation of early mobility for individuals with critical illness due to COVID-19. METHODS: Clinical perspective developed through reflective clinical practice and narrative review of best available evidence. RESULTS: Current clinical practice guidelines do not provide guidance for implementation of early mobility interventions for individuals with critical illness due to COVID-19 who require enhanced ventilatory support or support of inhaled pulmonary artery vasodilators. Many individuals who may benefit from implementation of early mobility interventions are excluded by strict interpretation of current guidelines. CONCLUSIONS: Risk vs benefit of implementing early mobility interventions in individuals with critical illness due to COVID-19 can be mitigated through coordinated efforts of interdisciplinary teams to promote shared decision-making through therapeutic alliances with patients and their families. Clinicians must clearly define the goals of care, understand the limitations of monitoring equipment in the intensive care unit, prepare to titrate levels of oxygen based on an individual's physiologic response to mobility interventions, and help individuals maintain external goal-directed focus of attention to optimize outcomes of early mobility interventions.

Current clinical practice guidelines do not provide guidance for implementation of early mobility interventions for individuals with critical illness due to COVID-19 who require enhanced ventilatory support or support of inhaled pulmonary artery vasodilators.Risk vs benefit of implementing early mobility interventions in individuals with critical illness due to COVID-19 can be mitigated through coordinated efforts of interdisciplinary teams to promote shared decision-making through therapeutic alliances with patients and their families.Clinicians must clearly define the goals of care, understand the limitations of monitoring equipment in the intensive care unit, prepare to titrate levels of oxygen based on an individual's physiologic response to mobility interventions, and help individuals maintain external goal-directed focus of attention to optimize outcomes of early mobility interventions.

Implementation of Early Rehabilitation in Severe COVID-19 Respiratory Failure: A Scoping Review.

The purpose of this scoping review is to describe current clinical practice guidelines (CPGs) for early rehabilitation for individuals hospitalized in an intensive care unit with COVID-19 and examine practice patterns for implementation of mobility-related interventions. Methods: PubMed, EMBASE, and CINAHL databases were searched from January 1, 2020, through April 1, 2022. Selected studies included individuals hospitalized with severe COVID-19 and provided objective criteria for clinical decision making for mobility interventions. A total of 1464 publications were assessed for eligibility and data extraction. The PRISMA-ScR Checklist and established guidelines for reporting for scoping reviews were followed. Results: Twelve articles met inclusion criteria: 5 CPGs and 7 implementation articles. Objective clinical criteria and guidelines for implementation of early rehabilitation demonstrated variable agreement across systems. No significant adverse events were reported. Conclusions: Sixty percent (3/5) of CPGs restrict mobility for individuals requiring ventilatory support of more than 60% Fio2 (fraction of inspired oxygen) and/or positive end-expiratory pressure (PEEP) greater than 10-cm H2O (positive end-expiratory pressure). Preliminary evidence from implementation studies may suggest that some individuals with COVID-19 requiring enhanced ventilatory support outside of established parameters may be able to safely participate in mobility-related interventions, though further research is needed to determine safety and feasibility to guide clinical decision making.

Vertebral Artery Interventions: A Comprehensive Updated Review.

Patients with posterior circulation ischemia due to vertebral artery stenosis account for 20 to 25% of ischemic strokes and have an increased risk of recurrent stroke. In patients treated with medical therapy alone, the risk of recurrence is particularly increased in the first few weeks after symptoms occur, with an annual stroke rate of 10 to 15%. Additionally, obstructive disease of the vertebrobasilar system carries a worse prognosis, with a 30% mortality at 2-years if managed medically without additional surgical or endovascular intervention. Percutaneous transluminal angioplasty and stenting of symptomatic vertebral artery stenosis are promising options widely used in clinical practice with good technical results; however, the improved clinical outcome has been examined in various clinical trials without a sufficient sample size to conclusively determine whether stenting is better than medical therapy. Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis that carries a 10-20% mortality rate. Despite the advances in medical therapy and endovascular and surgical options, symptomatic vertebral artery stenosis continues to impose a high risk of stroke recurrence with associated high morbidity and mortality. This review aims to provide a focused update on the percutaneous treatment of vertebral artery stenosis, its appropriate diagnostic approach, and advances in medical therapies.

Management of a right coronary artery mycotic coronary aneurysm with percutaneous intervention with covered stents.

Coronary artery aneurysmal dilation is a rare finding with poorly understood mechanism of action that is found in small population of patients undergoing coronary angiography. Mycotic coronary aneurysm is an even rarer cause of coronary aneurysmal dilatation that develops as a potentially fatal complication of bacteremia. We present a case of mycotic right coronary artery aneurysm in a nonsurgical candidate with complex medical comorbidities treated with percutaneous coronary intervention via covered stents.

COVID-19 Myocarditis: An Emerging Clinical Conundrum.

Coronavirus Disease 2019 (COVID-19) has been a significant cause of global mortality and morbidity since it was first reported in December 2019 in Wuhan, China. COVID19 like previous coronaviruses primarily affects the lungs causing pneumonia, interstitial pneumonitis, and severe acute respiratory distress syndrome (ARDS). However, there is increasing evidence linking COVID-19 to cardiovascular complications such as arrhythmias, heart failure, cardiogenic shock, fulminant myocarditis, and cardiac death. Given the novelty of this virus, there is paucity of data on some cardiovascular complications of COVID-19, specifically myocarditis. Myocarditis is an inflammatory disease of the heart muscle with a heterogenous clinical presentation and progression. It is mostly caused by viral infections and is the result of interaction of the virus and the host's immune system. There have been several case reports linking COVID-19 with myocarditis, however the true mechanism of cardiac injury remains under investigation. In this paper we review the clinical presentation, proposed pathophysiology, differential diagnoses and management of myocarditis in COVID-19 patients.

Transaxillary TAVR Leads to Shorter Ventilator Duration and Hospital Length of Stay Compared to Transapical TAVR.

There is an increasing need for alternative access in patients with prohibitive surgical risk who have unsuitable anatomy for transfemoral transcatheter aortic valve replacement (TAVR). Data on differences in periprocedural outcomes via alternative access sites are scarce. We performed a retrospective analysis of patients who underwent Transaxillary (TAX) or Transapical (TAP) TAVR at our center from 2012 to 2019. All data was summarized and displayed as mean ± SD for continuous variables and number of patients in each group. A propensity score was created for each patient in the dataset to determine the probability of axillary vs apical access. We adjusted for propensity score using multivariate logistic regression. A total of 102 patients underwent TAVR via alternative access: 28 patients (27%) via TAX and 74 patients (73%) via transapical (TAP) access. The average time to extubation in the TAX group was 5.3 ± 3.5 hours vs 9.1 ± 8.8 hours in the TAP patients (P = 0.03). None of the TAX patients required reintubation compared to 23% of TAP TAVR (P = 0.003). The average hospital length of stay for TAX was 2.4 ± 2.0 days compared to 6.9 ± 3.3 days (P < 0.0001) for TAP. TAX TAVR patients had significantly lower re-intubation rates, shorter time to extubation and in-hospital length of stay, but higher pacemaker implantation rates. TAX TAVR had improved periprocedural outcomes compared to TAP TAVR and remains the preferred TAVR alternative access.

Low risk TAVR: Long- term considerations and appropriate patient selection.

Recent trials have shown impressive results in low-risk patients undergoing Transcatheter Aortic Valve Replacement (TAVR) with low procedural complication rates, short hospital length of stay, zero mortality, and zero disabling stroke at 30 days and have led to a Food and Drug Administration indication for TAVR in these patients. The long-term data on subclinical leaflet thrombosis, valve durability, effects of pacemaker implantation, right ventricular pacing, and progressive paravalvular leak is unclear. We describe clinical and procedural considerations for patient selection and introduce future potential procedural challenges. Finally, we discuss the importance of considering life expectancy and durability prior to TAVR in this low risk relatively young cohort and emphasize the importance of a heart team approach.

The landing zone - Ground for model transfer in chemistry.

This essay proposes a new notion - the landing zone - in order to identify conceptual features that allow modelers to transfer mathematical tools across disciplinary borders. This discussion refers to the transferable models as 'templates'. Templates are functions, equations, or computational methods that are capable of being generalized from a particular subject matter. There are formal and conceptual prerequisites for the transfer of a template to a new domain. A landing zone is an ontology that contributes to the satisfaction of these conditions for successful transfer. This paper presents a case study on a model in chemistry - the Quantum Theory of Atoms in Molecules (QTAIM) - that makes use of transferred templates from physics - the virial theorem and the wave function. The landing zone in this case is a new ontological notion, that of the topological atom, which prepares ground for the use of the virial theorem and the wave function in chemistry. The virial theorem requires that there exists in-principle stability to the system that it represents, and the wave function requires transformation in its representation that is justified. The ontology of QTAIM - the landing zone for these templates - grounds the scientific use of these templates in the context of chemistry.

Distinguishing the meaning making processes of survivors of suicide loss: An expansion of the meaning of loss codebook.

Suicide loss represents particularly a difficult form of bereavement due to the challenges that volitional death poses to survivors. Understanding these challenges requires recognition of the idiosyncratic processes of meaning reconstruction for this specific group of grievers. The current study investigates such processes in survivors of suicide loss (SOSL) by utilizing the Meaning of Loss Codebook (MLC) to analyze the narratives of eight SOSL. The findings contribute to a broader understanding of meaning making following suicide, strengthen the validity of the MLC by demonstrating its appropriateness for SOSL, and illuminate unique challenges faced by SOSL, resulting in the proposal of supplemental MLC codes. Research and clinical implications are discussed.

Use of ViperSlide Lubricant to Extract Entrapped Sheath after Severe Radial Artery Spasm during Coronary Angiography.

Radial artery spasm is a known complication of transradial cardiac catheterization. However, severe spasm with sheath entrapment is rare. We describe such a case, and the condition's response to an alternative removal method after conventional efforts failed. A 68-year-old man presented for coronary angiography. We introduced a 5F sheath into the right radial artery, but, because of severe arterial spasm, we could not aspirate blood from the sheath or retract it. We sedated the patient and waited for the spasm to subside; however, the radial sheath remained entrapped. Nitroglycerin injection enabled blood aspiration and vasodilator injection, but not sheath removal. Finally, we injected ViperSlide lubricant into the sheath for its rapid, easy extraction. When sedation and vasodilator therapy fail, we recommend using ViperSlide for radial sheath removal before applying nerve block or general anesthesia.

Hybrid Procedure (Endo/Epicardial) versus Standard Manual Ablation in Patients Undergoing Ablation of Longstanding Persistent Atrial Fibrillation: Results from a Single Center.

INTRODUCTION: Ablation of longstanding persistent atrial fibrillation (LSPAF) is the most challenging procedure in the treatment of AF, either by surgical or by percutaneous approach. OBJECTIVE: We investigated the difference in success and complication rates between combined surgical epicardial and endocardial catheter ablation procedure and our standard endocardial ablation procedure. METHODS AND RESULTS: Twenty-four consecutive patients (group 1) with LSPAF and enlarged left atrium (>4.5 cm) underwent a combined procedure, consisting of surgical, closed-chest, epicardial, radiofrequency ablation (nContact, NC, USA) via pericardial access, and concomitant endocardial ablation (hybrid procedure). Procedural complications and long-term outcomes were compared to those of 35 consecutive patients who refused the hybrid procedure and underwent standard endocardial only ablation (group 2). Baseline characteristics were comparable. In group 1, 1 patient (4.2%) developed post-procedural cardio-embolic stroke and 3 (12.5%) died (1 atrio-esophageal fistula, 1 fatal stroke, 1 of unknown cause in early follow-up), while no strokes or deaths occurred in group 2. Overall complication rates were higher for group 1 (P = 0.036). At 24-month follow-up, 4 (19%) patients in group 1 and 19 (54.3%) in group 2 were arrhythmia-free after a single procedure, on or off antiarrhythmic drugs (P<0.001). Total procedural time (276.9 ± 63.5 vs. 203.15 ± 67.3 minutes) and length of hospital stay (5 [IQR 3-8] vs. 1 [IQR 1-3] days were significantly shorter for group 2 (P <0.001). CONCLUSIONS: In patients with LSPAF and enlarged left atrium, a concomitant combined surgical/endocardial ablation approach increases complication rate and does not improve outcomes when compared to extensive endocardial ablation only.

Characterization of the mitofusin 2 R94W mutation in a knock-in mouse model.

Charcot-Marie-Tooth disease (CMT) comprises a group of heterogeneous peripheral axonopathies affecting 1 in 2,500 individuals. As mutations in several genes cause axonal degeneration in CMT type 2, mutations in mitofusin 2 (MFN2) account for approximately 90% of the most severe cases, making it the most common cause of inherited peripheral axonal degeneration. MFN2 is an integral mitochondrial outer membrane protein that plays a major role in mitochondrial fusion and motility; yet the mechanism by which dominant mutations in this protein lead to neurodegeneration is still not fully understood. Furthermore, future pre-clinical drug trials will be in need of validated rodent models. We have generated a Mfn2 knock-in mouse model expressing Mfn2(R94W), which was originally identified in CMT patients. We have performed behavioral, morphological, and biochemical studies to investigate the consequences of this mutation. Homozygous inheritance leads to premature death at P1, as well as mitochondrial dysfunction, including increased mitochondrial fragmentation in mouse embryonic fibroblasts and decreased ATP levels in newborn brains. Mfn2(R94W) heterozygous mice show histopathology and age-dependent open-field test abnormalities, which support a mild peripheral neuropathy. Although behavior does not mimic the severity of the human disease phenotype, this mouse can provide useful tissues for studying molecular pathways associated with MFN2 point mutations.

Does periprocedural anticoagulation management of atrial fibrillation affect the prevalence of silent thromboembolic lesion detected by diffusion cerebral magnetic resonance imaging in patients undergoing radiofrequency atrial fibrillation ablation with open irrigated catheters? Results from a prospective multicenter study.

BACKGROUND: Silent cerebral ischemia (SCI) has been reported in 14% of cases after catheter ablation of atrial fibrillation (AF) with radiofrequency (RF) energy and discontinuation of warfarin before AF ablation procedures. OBJECTIVE: The purpose of this study was to determine whether periprocedural anticoagulation management affects the incidence of SCI after RF ablation using an open irrigated catheter. METHODS: Consecutive patients undergoing RF ablation for AF without warfarin discontinuation and receiving heparin bolus before transseptal catheterization (group I, n = 146) were compared with a group of patients who had protocol deviation in terms of maintaining the therapeutic preprocedural international normalized ratio (patients with subtherapeutic INR) and/or failure to receive pretransseptal heparin bolus infusion and/or ≥2 consecutive ACT measurements <300 seconds (noncompliant population, group II, n = 134) and with a group of patients undergoing RF ablation with warfarin discontinuation bridged with low molecular weight heparin (group III, n = 148). All patients underwent preablation and postablation (within 48 hours) diffusion magnetic resonance imaging. RESULTS: SCI was detected in 2% of patients (3/146) in group I, 7% (10/134) in group II, and 14% (21/148) in group III (P <.001). "Therapeutic INR" was strongly associated with a lower prevalence of postprocedural silent cerebral ischemia (SCI). Multivariable analysis demonstrated nonparoxysmal AF (odds ratio 3.8, 95% confidence interval 1.5-9.7, P = .005) and noncompliance to protocol (odds ratio 2.8, 95% confidence interval 1.5-5.1, P <.001] to be significant predictors of ischemic events. CONCLUSION: Strict adherence to an anticoagulation protocol significantly reduces the prevalence of SCI after catheter ablation of AF with RF energy.

WITHDRAWN: Hybrid Procedure (Endo/Epicardial) Versus Standard Manual Ablation in Patients Undergoing Ablation of Longstanding Persistent Atrial Fibrillation: Results from a Single Center.

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Efficacy of catheter ablation in nonparoxysmal atrial fibrillation patients with severe enlarged left atrium and its impact on left atrial structural remodeling.

INTRODUCTION: The effect of catheter ablation on severe left atrial enlargement especially in nonparoxysmal atrial fibrillation (NPAF) patients is not well understood. Whether reverse remodelling may occur after ablation has not been evaluated in this setting. METHODS AND RESULTS: Fifty consecutive patients with left atrial diameter (LAD) ≥50 mm, and LA volume >200 cc undergoing catheter ablation for drug-refractory NPAF were included in this study. Transthoracic echocardiographic measurements were performed at baseline and at 12-months postprocedure. Left ventricular end-diastolic and end-systolic dimensions were indexed by body surface area (LVEDDI, LVESDI). Electroanatomic mapping system (Carto or NavX system) and computed tomography (CT) were used for 3-dimensional reconstruction of the LA. All patients underwent posterior wall isolation and pulmonary vein (PV) antrum and extra PV trigger ablations. Long-term follow-up was monitored by event recordings, 7-day Holter monitors and office visits. The mean age was 65 ± 10 years, 78% male, persistent AF 22 (44%), longstanding AF 28 (56%), LAD diameter 56.9 ± 7.8 mm, left ventricular ejection fraction (LVEF) 53 ± 14 and median AF duration 72 (49-96) months. At 12-month follow-up, 27 patients (54%) remained arrhythmia-free off antiarrhythmic drugs. Significant reduction in LAD at follow-up (≥10% reduction) was observed in 52% (26/50) of the total population and among the 63% (17/27) of recurrence-free patients. Magnitude of LA reduction was identically distributed among the persistent and longstanding persistent AF cohorts (16 ± 12% vs 14 ± 16%, respectively, P = 0.15). A significant 20% improvement in LVEF (from 53 ± 14 to 58 ± 9, P = 0.03) was found in the overall population. Improvement was noted in recurrence-free patients. No significant change in LVEDDI and LVESDI was noted. After adjusting for baseline risk factors in a multivariable model, a reduction in LAD was identified as a strong predictor of long-term success (beta = -11.1, P = 0.013). Preexisting LA scarring was associated with increased LAD (beta = 2.7, P = 0.023). No periprocedural or long-term complications were reported. CONCLUSION: Our results show that atrial fibrillation ablation is effective in NPAF patients with severe LA enlargement and is associated with LA reverse remodeling and improvement in LVEF.

Advances in catheter ablation: atrial fibrillation ablation in patients with mitral mechanical prosthetic valve.

Atrial fibrillation (AF) is common in patients with mitral valve replacement (MVR). Treatment of AF in these subjects is challenging, as the arrhythmia is often refractory to antiarrhythmic drug therapy. Radiofrequency catheter ablation (RFCA) is usually avoided or delayed in patients with MVR due to the higher perceived risks and difficulty of left atrial catheter manipulation in the presence of a mechanical valve. Over the last few years, several investigators have reported the feasibility and safety of RFCA of AF in patients with MVR. Five case-control studies have evaluated the feasibility and safety of RFCA of AF or perimitral flutter (PMFL) in patients with MVR. Overall, a total of 178 patients with MVR have been included (21 undergoing ablation of only PMFL), and have been compared with a matched control group of 285 patients. Total procedural duration (weighted mean difference [WMD] = +24.5 min, 95% confidence interval [CI] +10.2 min to +38.8 min, P = 0.001), and fluoroscopy time (WMD = +13.5 min, 95% CI +3.7 min to +23.4 min, P = 0.007) were longer in the MVR group. After a mean follow-up of 11.5 ± 8.6 months, 64 (36%) patients in the MVR group experienced recurrence of AF/PMFL, as compared to 73 (26%) patients in the control group, accounting for a trend toward an increased rate of recurrences in patients with MVR (odds ratio [OR] = 1.66, 95% CI 0.99 to 2.78, P = 0.053). Periprocedural complications occurred in 10 (5.6%) patients in the MVR group, and in 8 (2.8%) patients in the control group (OR = 2.01, 95% CI 0.56 to 7.15, P = 0.28). In conclusion, a quantitative analysis of the available evidence supports a trend toward a worse arrhythmia-free survival and a higher absolute rate of periprocedural complications in patients with MVR undergoing RFCA of AF or PMFL, as compared to a matched control group without mitral valve disease. These data would encourage the adoption of RFCA of AF in MVR patients mostly by more experienced Institutions.