Atrioventricular dyssynchrony from empiric device settings is common in cardiac resynchronization therapy and adversely impacts left ventricular morphology and function.

BACKGROUND: Echocardiographic atrioventricular (AV) optimization after cardiac resynchronization therapy (CRT) is uncommon due to time constraints and the use of vendor-specific device algorithms. It remains unclear whether optimization of mitral inflow velocities can still be useful. We aimed to investigate post implantation left ventricular (LV) inflow patterns to determine the incidence of AV dyssynchrony from empirically set devices. METHODS: This was a retrospective study of patients undergoing CRT using empiric device settings. Forty-eight patients with clinical, echocardiographic, and pacemaker follow-up were grouped by their post implantation LV filling pattern. Baseline characteristics and echocardiographic measurements were compared with post implantation findings at median 6.3 months (interquartile range [IQR], 3.9-17.0). RESULTS: Twenty-four patients demonstrated AV dyssynchrony (Group 1) after CRT, and 24 patients did not (Group 2). Group 1 patients had less LV reverse remodeling compared to Group 2 patients (ΔLV end-diastolic volume: -3.6 mL vs -49.5 mL, P<.05; ΔLV end-systolic volume: -16.9 mL vs -53.5 mL, P<.05) and did not experience significant improvements in LV outflow tract velocity time integral, stroke volume, or LV ejection fraction. There were no differences in new-onset atrial fibrillation, heart failure readmissions, or mortality between groups. CONCLUSION: Our study suggests that up to 50% of patients with empiric device settings have AV dyssynchrony at 6 months despite atrioventricular delay optimization (AVO) algorithms. As AV dyssynchrony is common and has proven to be modifiable, a strategic approach to Doppler echocardiography-guided AVO after CRT is warranted, particularly in nonresponders where the LV filling pattern is fused or truncated.

Infective Endocarditis Complicated by Mitral Valve Aneurysm: Pathologic and Echocardiographic Correlations.

Infective endocarditis is a well-described cardiovascular disease that causes significant morbidity and mortality despite medical and surgical advances. Complications of endocarditis include heart failure, systemic embolization, and valvular destruction including valve aneurysms which increase morbidity and mortality. Mitral valve aneurysms are rarely encountered in the clinical setting. We present eight mitral valve aneurysm cases and discuss a new potential pathogenesis of this deadly endocarditis complication. Pathologic evaluation suggests that neovascularization of the anterior mitral valve leaflet predisposes this territory to abscess and aneurysm formation. In conclusion, mitral valve aneurysms appear to be another form of intravalvular abscess which has expanded and should be approached aggressively with surgical intervention if indicated.

Rhabdomyolysis precipitated by possible interaction of ticagrelor with high-dose atorvastatin.

OBJECTIVE: To report a case of rhabdomyolysis possibly caused by interaction of ticagrelor with high-dose atorvastatin. SUMMARY: A 62-year-old woman originally from India underwent uncomplicated percutaneous coronary intervention following ST-elevation myocardial infarction. The patient was discharged on a secondary prevention drug regimen that included ticagrelor 90 mg twice daily, atorvastatin 80 mg once daily, metoprolol 25 mg twice daily, and aspirin 81 mg daily. Two months later, the patient was readmitted with complaints of muscle pain, nausea, vomiting, and poor oral intake. The patient was diagnosed with rhabdomyolysis based on her symptoms combined with elevated creatine kinase, urine myoglobin, and serum creatinine. Intravenous fluids were initiated and atorvastatin held. Throughout the second hospital stay, serial laboratory values revealed a decrease in creatine kinase and resolution of acute kidney injury and muscle pain. The patient was discharged on aspirin and clopidogrel. Low-dose statin therapy was started at a follow-up appointment with close monitoring without recurrence of rhabdomyolysis. RESULTS: A drug interaction between the cytochrome P450 3A4 inhibitor ticagrelor and substrate atorvastatin 80 mg may have precipitated development of rhabdomyolysis in this patient. The probability of this drug interaction is rated as "possible" on both the Naranjo Adverse Drug Reaction Probability Scale and the Drug Interaction Probability Scale. CONCLUSION: Rhabdomyolysis was observed possibly because of a drug interaction between once-daily ticagrelor and atorvastatin 80 mg. Clinicians need to be aware of this possible drug interaction via CYP3A4 and potential complications.

The changing 'face' of endocarditis in Kentucky: an increase in tricuspid cases.

BACKGROUND: Advancements in medical technology and increased life expectancy have been described as contributing to the evolution of endocarditis. We sought to determine whether there has been a change in the incidence, demographics, microbiology, complications, and outcomes of infective endocarditis over a 10-year time span. METHODS: We screened 28,420 transthoracic and transesophageal echocardiogram reports performed at the Gill Heart Institute for the following indications: fever, masses, emboli (including stroke), sepsis, bacteremia, and endocarditis in 2 time periods: 1999 to 2000 and 2009 to 2010. Data were collected from diagnosed endocarditis cases. RESULTS: Overall, 143 cases of infective endocarditis were analyzed (48 in 1999-2000 and 95 in 2009-2010). The endocarditis incidence per number of admissions remained nearly constant at 0.113% for 1999-2000 and 0.148% for 2009-2010 (P = .153). However, tricuspid valve involvement increased markedly from 6% to 36% (P < .001). Also, reported history of intravenous drug use increased from 15% to 40% (P = .002). Valvular complications doubled from 17% to 35% (P = .031). Septic pulmonary emboli increased from 10% to 25% (P = .047). Despite these noted differences, inpatient mortality remained unchanged at 25% and 28% (P = .696) for the 2 time periods, respectively. CONCLUSIONS: The incidence of endocarditis at the University of Kentucky Medical Center has not changed and mortality remains high, but the "face of endocarditis" in Kentucky has evolved with an increased incidence of tricuspid valve involvement, valvular complications, and embolic events.

Management of transplant renal artery stenosis.

End-stage renal disease (ESRD) was universally fatal until dialysis (peritoneal and hemodialysis) and renal transplantation were introduced. However, there are multiple complications associated with transplantation including transplant renal artery stenosis (TRAS). Transplant renal artery stenosis is an important cause of premature renal failure, uncontrolled hypertension, and allograft loss. There are 3 treatment modalities available for TRAS: optimal medical therapy alone, percutaneous intervention, and surgical revascularization both with optimal medical therapy. Percutaneous transluminal angioplasty (PTA) has now become the initial treatment of choice for TRAS. However, there are conflicting data regarding the efficacy of PTA, with growing evidence showing lack of significant benefit in blood pressure (BP) or renal function in patients undergoing PTA versus medical management. However, there have been no randomized control studies that have established the superiority of either method. We review the existing data and analyze management of TRAS as reported in multiple case series including findings from our center.