Stepwise transvenous lead extraction due to pacemaker pocket infection following lactational mastitis complicated with breast abscess.

BACKGROUND: Lactational mastitis is a common painful and debilitating inflammation of breast tissue, generally treated conservatively or with pus puncture in case of breast abscess. However, treating mastitis in patients with implantable surgical material located in the affected breast region can be extremely challenging. We present an unusual case of lactational mastitis complicated by pacemaker pocket infection in a breastfeeding mother. CASE PRESENTATION: A 35-year-old pacemaker-dependent female developed lactational mastitis seven weeks postpartum. Initially, the condition was treated conservatively with analgesics and antibiotics. After abscess formation, pus was aspirated using fine-needle aspiration technique. Four weeks after mastitis resolution, pacemaker pocket infection developed. According to current cardiovascular implantable electronic device infection treatment guidelines a complete surgical extraction of the entire electronic system, followed by targeted antibiotic treatment and reimplantation of a new device after infection resolution, was recommended. However, after thorough discussion with the young woman and her family and after detailed review of surgery-related risks, she declined a potentially high-risk surgical procedure. Thus, only the pulse generator was explanted; pacing leads positioned in the sub-pectoral pocket; new pacemaker implanted on the contralateral side and broad-spectrum antibiotic therapy continued for six weeks. After breastfeeding cessation, and with chronic fistula development at the primary pacemaker implantation site, the possibility of delayed surgical intervention including complete extraction of retained pacemaker leads was again thoroughly discussed with her. After thoughtful consideration the woman consented to the proposed treatment strategy. A surgical procedure including transvenous lead extraction through the primary implantation venous entry site, using hand-powered bidirectional rotational sheaths, was successfully performed, removing all retained leads through the left subclavian venous entry site, and leaving the fully functional and clinically uninfected pacemaker on the contralateral site intact. CONCLUSION: Although patients' decisions for delayed extraction in a case of cardiovascular implantable electronic device infection should be discouraged by attending physicians and members of interdisciplinary teams, our case shows that a stepwise treatment strategy may be successful as a bailout clinical scenario in patients with specific requests, demands and / or clinical needs.

Rapidly Growing and Ruptured Great Saphenous Vein Aneurysm in a Liver Transplant Patient.

Venous aneurysms are rare vascular malformations that can lead to significant clinical complications, including thrombosis, pulmonary embolism, rupture, and even fatal outcomes when not promptly and adequately managed. This case report presents a liver transplant patient under immunosuppressive therapy who developed a rapidly progressing great saphenous vein aneurysm, ultimately requiring urgent surgical intervention due to acute bleeding from the ruptured aneurysm. Immunosuppression emerges as a potential key factor in the formation and rapid growth of the aneurysm, with the pathophysiological mechanism potentially involving increased expression of specific matrix metalloproteinases. Further research is warranted to gain a better understanding of the role of immunosuppression in the development of venous aneurysms.

Common Complications and Cardiopulmonary Resuscitation in Patients with Left Ventricular Assist Devices: A Narrative Review.

Heart failure remains a major global burden regarding patients' morbidity and mortality and health system organization, logistics, and costs. Despite continual advances in pharmacological and resynchronization device therapy, it is currently well accepted that heart transplantation and mechanical circulatory support represent a cornerstone in the management of advanced forms of this disease, with the latter becoming an increasingly accepted treatment modality due to the ongoing shortage of available donor hearts in an ever-increasing pool of patients. Mechanical circulatory support strategies have seen tremendous advances in recent years, especially in terms of pump technology improvements, indication for use, surgical techniques for device implantation, exchange and explantation, and postoperative patient management, but not in the field of treatment of critically ill patients and those undergoing cardiac arrest. This contemporary review aims to summarize the collected knowledge of this topic with an emphasis on complications in patients with left ventricular assist devices, their treatment, and establishing a clear-cut algorithm and the latest recommendations regarding out-of-hospital or emergency department management of cardiac arrest in this patient population.

Comparison of Procedural Sedation With Propofol and Dexmedetomidine During Transcatheter Aortic Valve Replacement Using the Transfemoral Approach.

OBJECTIVES: Although procedural sedation is an established method of anesthesia for transcatheter aortic valve replacement (TAVR), reliable evidence to guide the choice of a suitable sedative agent remains scarce. Accordingly, this trial aimed to compare the effect of procedural sedation with dexmedetomidine versus propofol on postoperative neurocognitive and related clinical outcomes in patients undergoing TAVR. DESIGN: Prospective, randomized, double-blind clinical trial. SETTING: The study was conducted at the University Medical Centre Ljubljana, Slovenia. PARTICIPANTS: The study enrolled 78 patients who underwent TAVR under procedural sedation between January 2019 and June 2021. Seventy-one patients randomized into the propofol group (n = 34) and dexmedetomidine group (n = 37) were included in the final analysis. INTERVENTIONS: Patients in the propofol group received sedation with propofol (continuous intravenous infusion of 0.5-2.5 mg/kg/h), whereas patients in the dexmedetomidine group received sedation with dexmedetomidine (loading dose of 0.5 µg/kg over 10 minutes followed by continuous intravenous infusion of 0.2-1.0 µg/kg/h). MEASUREMENTS AND MAIN RESULTS: Minimental state examination (MMSE) was performed before and 48 hours after TAVR. There was no statistically significant difference in MMSE scores between groups before TAVR (p = 0.253), but the MMSE after the procedure revealed a significantly lower incidence of delayed neurocognitive recovery (p = 0.005) and thus better cognitive outcomes in the dexmedetomidine group (p = 0.022). CONCLUSIONS: Compared with propofol, procedural sedation with dexmedetomidine in TAVR was associated with a significantly lower incidence of delayed neurocognitive recovery.

Use of absorbable hemostat bolster for prevention of donor renal artery kinking in kidney transplant.

Transplant renal artery stenosis due to mechanical kinking is a rare but significant complication in kidney transplantation that can lead to graft dysfunction due to graft hypoperfusion, delayed graft function, or even global kidney infarction. When detected during surgery, re-anastomosis is usually performed after re-clamping, which inevitably prolongs the warm ischemia time, and increases the possibility of primary graft non-function. In this report, we describe a novel, noninvasive surgical technique whereby the donor renal artery is padded with absorbable hemostatic material (i.e., Surgicel) bolster, placed below the middle third of the renal artery in recipients who were found to have mechanical kinking during the implantation procedure. The bolster technique was used in 12 kidney transplant recipients who were found to have kinking of the donor artery during the primary surgery. After pillowing the renal artery with absorbable hemostatic bolster, no residual kinking was observed intra-operatively, and good allograft perfusion was confirmed with no Doppler ultrasound evidence of renal artery stenosis confirmed at 1 week, 1 month, and 1 year after transplantation.

The Effect of Aquatic Exercise Training on Heart Rate Variability in Patients with Coronary Artery Disease.

(1) Background: Aquatic exercise training is a relatively understudied exercise modality in patients with CAD; with the present study, we sought to compare the impact of short-term 14-day water- and land-based exercise training on heart rate variability (HRV). (2) Methods: We randomized 90 patients after a recent CAD event (myocardial infarction and/or revascularization within 2 months prior to inclusion) to either (i) water-based or (ii) land-based exercise training (14 days, two 30 min sessions daily), or (iii) controls. Before and after the intervention period, all participants underwent 20 min 12-channel high-resolution ECG recordings with off-line HRV analysis, including conventional linear time- and frequency-domain analysis (using the Welch method for fast-Fourier transformation), and preselected non-linear analysis (Poincaré plot-derived parameters, sample entropy, and the short-term scaling exponent α1 obtained by detrended fluctuation analysis). (3) Results: Eighty-nine patients completed the study (mean age 60 ± 8 years; 20 % women). We did not detect significant differences in baseline- or age-adjusted end-of-study HRV parameters, but aquatic exercise training was associated with a significant increase in the linear LF/HF parameter (from 2.6 [1.2-4.0] to 3.0 [2.1-5.5], p = 0.046) and the non-linear α1 parameter (from 1.2 [1.1-1.4] to 1.3 [1.2-1.5], p = 0.043). (4) Conclusions: Our results have shown that a short-term 14-day aquatic exercise training program improves selected HRV parameters, suggesting this mode of exercise is safe and may be beneficial in patients with CAD.

Altered Heart Rate Turbulence and Variability Parameters Predict 1-Year Mortality in Heart Failure with Preserved Ejection Fraction.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is a complex and heterogeneous clinical syndrome. In the absence of effective and potent treatment strategies, the main challenge in HFpEF management remains the availability of strong predictors of unfavourable outcomes. In our study, we sought to evaluate the potential prognostic value of heart rate turbulence (HRT) and variability (HRV) parameters on mortality in ambulatory HFpEF patients. METHODS: This was a case-control study comparing HRT and HRV parameters in HFpEF survivors vs. non-survivors. Patients from the RESPOND Heart Failure Registry with HFpEF who underwent 24 h ECG monitoring (Holter) were included; HRT parameters (i.e., turbulence onset (TO) and turbulence slope (TS)) and HRV parameters (i.e., standard deviation of NN intervals (SDNN)) derived from 24 h Holter ECGs were calculated in patients who died within 12 months, and compared to their age-, gender-, LVEF-, ECHO-, aetiology-, and therapy-matched alive controls. RESULTS: A total of 22 patients (mean age 80 ± 7 years, 18% female, mean LVEF 57 ± 9%) were included in the final analysis. In deceased patients, values of TO were significantly higher, and values of TS and SDNN were significantly lower as compared to survivors. CONCLUSIONS: HRT and HRV parameters have the ability to differentiate individuals with HFpEF who are at the greatest risk of unfavourable outcomes. The extent of autonomic disbalance as determined by HRT and HRV could potentially assist in the prognostic assessment and risk stratification of HFpEF patients.

Abdominal Stent-Graft Treatment of Ascending Aortic Pseudoaneurysm Following Transcatheter Aortic Valve Implantation.

An ascending aortic pseudoaneurysm is a potentially lethal complication in aortic procedures. We present a hybrid approach using surgical innominate artery access and the endovascular insertion of an abdominal stent-graft extension to successfully treat a zone 0 ascending aortic pseudoaneurysm in a patient with a prior valve-in-valve transcatheter aortic valve implantation.

Minimising radiation exposure in catheter ablation of ventricular arrhythmias.

BACKGROUND: Conventional fluoroscopy guided catheter ablation (CA) is an established treatment option for ventricular arrhythmias (VAs). However, with the complex nature of most procedures, patients and staff bare an increased radiation exposure. Near-zero or zero-fluoroscopy CA is an alternative method which could substantially reduce or even eliminate the radiation dose. Our aim was to analyse procedural outcomes with fluoroscopy minimising approach for treatment of VAs in patients with structurally normal hearts (SNH) and structural heart disease (SHD). METHODS: Fifty-two (age 53.4 ± 17.8 years, 38 male, 14 female) consecutive patients who underwent CA of VAs in our institution between May 2018 and December 2019 were included. Procedures were performed primarily with the aid of the three-dimensional electro-anatomical mapping system and intra-cardiac echocardiography. Fluoroscopy was considered only in left ventricular (LV) summit mapping for coronary angiography and when epicardial approach was planned. Acute and long-term procedural outcomes were analysed. RESULTS: Sixty CA procedures were performed. Twenty-five patients had SHD-related VAs (Group 1) and 27 patients had SNH (Group 2). While Group 1 had significantly higher total procedural time (256.9 ± 71.7 vs 123.6 ± 42.2 min; p < 0.001) compared to Group 2, overall procedural success rate [77.4% (24/31) vs 89.7% (26/29); p = 0.20)] and recurrence rate after the first procedure [8/25, (32%) vs 8/27, (29.6%); p = 0.85] were similar in both groups. Fluoroscopy was used in 3 procedures in Group 1 where epicardial approach was needed and in 4 procedures in Group 2 where LV summit VAs were ablated. Overall procedure-related major complication rate was 5%. CONCLUSIONS: Fluoroscopy minimising approach for CA of VAs is feasible and safe in patients with SHD and SNH. Fluoroscopy could not be completely abolished in VAs with epicardial and LV summit substrate location.

Cerebral microemboli in mini-sternotomy compared to mini- thoracotomy for aortic valve replacement: a cross sectional cohort study.

BACKGROUND: Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation. METHODS: Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke's Cognitive Examination Revised Test before and 30 days after surgical procedure. RESULTS: A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p < 0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677-10.60, p = 0.027). Addenbrooke's Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001). CONCLUSION: There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline. TRIAL REGISTRY NUMBER: clinicaltrials.gov , NCT02697786 14.

Cardiac Melanoma Metastasis with ERBB2 Gene Amplification: A Potential for Future Targeted Therapy.

Cardiac tumors are rare, and their treatment differs interindividually regarding the histopathological proprieties and the stage of disease. Authors present a case of symptomatic cardiac melanoma metastasis that expressed an ERBB2 (HER2) gene amplification in a course of the disease that has not yet been reported. The frail patient with a history of pulmonary and renal carcinoma, was admitted to the hospital due to a symptomatic left atrial tumor mass. The patient underwent a tumor-resecting cardiac surgery. At first mistaken for myxoma on echocardiography, the histopathological examination of the tumor revealed a melanoma of acral or mucosal origin. The melanoma metastasis was negative for common genetic mutations in BRAF, NRAS or KIT genes, and for the presence of NTRK genes fusions, but carried ERBB2 (HER2) gene amplification. The absence of standard gene mutations rendered it unresponsive to treatment with BRAF and MEK inhibitors. This molecular finding is rare in melanomas and represented a therapeutic target for off-label systemic treatment with drugs, primarily aimed at ERBB2 positive breast, gastric, and gastroesophageal junction cancers. A rare finding like this justifies molecular genetic analysis of unusual tumor specimen and guarantees optimal treatment for uncommon types of cardiac metastatic tumors.

Emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported percutaneous interventions in refractory cardiac arrest and profound cardiogenic shock.

AIMS: We investigated the spectrum of emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported interventions including percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP). METHODS AND RESULTS: Between June 2010 and February 2020, 52 consecutive patients underwent VA ECMO implantation for refractory cardiac arrest (E-CPR) and 78 for profound cardiogenic shock. Percutaneous interventions on VA ECMO included PCI (n = 29), TAVI (n = 4) and EP (n = 1). Surgical interventions were cardiac (n = 36) or non-cardiac (n = 5). During PCI, ECMO flow was maintained at 2.7 ±â€¯1.0 L/min. Of the 40 treated lesions, 48% were located on left anterior descending and 20% on the left main artery. An average 2.0 ±â€¯1.8 DES/patient with diameter 3.2 ±â€¯0.5 mm and stented length 41 ±â€¯35 mm were implanted. PCI success was 83%. TAVI was performed in 4 patients with left ventricular ejection fraction 21 ±â€¯10% and mean aortic valve gradient 41 ±â€¯5 mmHg. After successful valve implantation supported by 1.4 ±â€¯0.1 L/min ECMO flow, mean gradient decreased to 11 ±â€¯5 mmHg without significant aortic regurgitation. In one patient radiofrequency ablation of His bundle followed by permanent pacemaker implantation was performed under ECMO flow of 2.8 L/min. Overall survival to hospital discharge with good neurological recovery was 29% in E-CPR and 44% in profound cardiogenic shock. CONCLUSIONS: Our study showed feasibility and effectiveness of VA ECMO-supported percutaneous interventions in patients with profound hemodynamic collapse.

Transvenous lead extraction outcomes using a novel hand-powered bidirectional rotational sheath as a first-line extraction tool in a low-volume centre.

OBJECTIVES: Extraction of cardiovascular implantable electronic devices in low-volume medical centres with limited clinical experience and an evolving lead extraction programme may be challenging. We aimed to evaluate the safety and efficacy of stepwise transvenous lead extraction (TLE) using a novel type of hand-powered rotational sheath as a first-line tool for extraction of chronically implanted devices in a single, low-volume centre. METHODS: Sixty-seven consecutive patients undergoing a TLE procedure using the novel Evolution® RL rotational sheath as the first-line extraction tool between 2015 and 2019 at our institution were enrolled in the study. Their short-term and 30-day outcomes were observed. RESULTS: Sixty-nine devices and 131 leads were explanted. Procedural and clinical success rates were 92.4% and 98.5%, respectively. Two procedures were classified as failures due to lead remnants >4 cm remaining in patients' vascular systems. One major (1.5%) and 3 minor (4.4%) adverse events and no deaths were observed. CONCLUSIONS: TLE procedures, performed in a stepwise manner, using the Evolution RL sheath as a first-line extraction device and conducted by an experienced, surgically well-trained operator, offer excellent results with clinical and procedural success rates comparable to those, achieved in dedicated, high-volume institutions. Opting for optimal lead extraction approach in low-volume centres or institutions with evolving TLE programmes, a stepwise extraction strategy using the Evolution RL sheath by skilled operator may provide the optimal scheme with an excellent ratio between clinical and/or procedural success and complications.

Pacemaker-generated stress fracture of the second rib: a case report.

BACKGROUND: Pocket-related complications following the implantation of cardiovascular implantable electronic devices primarily include pocket hematoma, infection, skin erosion or decubitus, device migration, and Twiddler's syndrome, with other pathologies such as nerve impairment or bone lesions being extremely rarely encountered. We report a case of a 20-year old asthenic, non-athlete female patient presenting with a device-generated fracture of the second rib several months after sub-muscular permanent pacemaker implantation due to repeated bilateral pre-pectoral pocket infections. CASE PRESENTATION: A 20-year old female patient was readmitted to our institution 9 months following sub-pectoral implantation of a permanent pacemaker, complaining of severe pocket-related pain, which arose spontaneously in the absence of direct trauma, intense physical activity or vigorous coughing, and was associated with normal day-to-day activity. To rule out a pacemaker re-infection, a native computed tomography and a positron emission tomography-computed tomography of the thorax were performed. Both modalities excluded an infection but showed a healing fracture and a focus of enhanced metabolic activity in the anterolateral part of the right second rib, indicating a non-traumatic or stress fracture of the bone. Consequently, a complete extraction of the pulse generator and both leads was performed and the smallest available single-chamber pulse generator with a single atrial electrode was implanted in the sub-fascial, pre-muscular pocket in the now recovered and uninfected left subclavicular region, alleviating patient's severe pain symptoms and significantly enhancing her quality of life. CONCLUSIONS: In the absence of direct trauma, intense physical activity or vigorous coughing, we assume that in this asthenic girl a normal day-to-day motion of the right shoulder has persistently forced the sub-muscularly placed pulse generator toward thoracic wall, putting increased repetitive pressure force on the underlying bones, finally causing a fatigue stress fracture of the second rib. In asthenic phenotype patients with small thorax and short subclavicular distance, a sub-muscular pacemaker implantation can potentially cause unique and unexpected pocket-related adverse events necessitating advanced diagnostics and timely treatment.

Effectiveness of wound infusion of 0.2% ropivacaine by patient control analgesia pump after minithoracotomy aortic valve replacement: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Local anesthetic wound infusion has become an invaluable technique in multimodal analgesia. The effectiveness of wound infusion of 0.2% ropivacaine delivered by patient controlled analgesia (PCA) pump has not been evaluated in minimally invasive cardiac surgery. We tested the hypothesis that 0.2% ropivacaine wound infusion by PCA pump reduces the cumulative dose of opioid needed in the first 48 h after minithoracothomy aortic valve replacement (AVR). METHODS: In this prospective, randomized, double-blind, placebo-controlled study, 70 adult patients (31 female and 39 male) were analyzed. Patients were randomized to receive 0.2% ropivacaine or 0.9% saline wound infusion by PCA pump for 48 h postoperatively. PCA pump was programmed at 5 ml h- 1 continuously and 5 ml of bolus with 60 min lockout. Pain levels were assessed and recorded hourly by Numeric Rating Scale (NRS). If NRS score was higher than three the patient was administered 3 mg of opioid piritramide repeated and titrated as needed until pain relief was achieved. The primary outcome was the cumulative dose of the opioid piritramide in the first 48 h after surgery. Secondary outcomes were frequency of NRS scores higher than three, patient's satisfaction with pain relief, hospital length of stay, side effects related to the local anesthetic and complications related to the wound catheter. RESULTS: The cumulative dose of the opioid piritramide in the first 48 h after minithoracotomy AVR was significantly lower (p < 0.001) in the ropivacaine (R) group median 3 mg (IQR 6 mg) vs. 9 mg (IQR 9 mg). The number of episodes of pain where NRS score was greater than three median 2 (IQR 2), vs 3 (IQR 3), (p = 0.002) in the first 48 h after surgery were significantly lower in the ropivacaine group, compared to control. Patient satisfaction with pain relief in our study was high. There were no wound infections and no side-effects from the local anesthetic. CONCLUSIONS: Wound infusion of local anesthetic by PCA pump significantly reduced opioid dose needed and improves pain control postoperatively. We have also shown that it is a feasible method of analgesia and it should be considered in the multimodal pain control strategy following minimally invasive cardiac surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT03079830 , date of registration: March 15, 2017. Retrospecitvely registered.

Favorable Response to CD34+ Cell Therapy Is Associated with a Decrease of Galectin-3 Levels in Patients with Chronic Heart Failure.

BACKGROUND: Galectin-3 plasma levels (gal-3) were shown to correlate with the scar burden in chronic heart failure (CHF) setting. As scar burden predicts response to stem cell therapy, we sought to explore a correlation between gal-3 and response to CD34+ cell transplantation in patients with CHF. METHODS: We performed a post hoc analysis of patients, enrolled in 2 prospective trials investigating the clinical effects of CD34+ cell therapy in patients with ischemic cardiomyopathy (ICMP) and nonischemic dilated cardiomyopathy (DCMP). CD34+ cells were mobilized by G-CSF, collected via apheresis, and injected transendocardially using NOGA system. Patients were followed for 3 months and demographic, echocardiographic, and biochemical parameters and gal-3 were analyzed at baseline and at follow-up. Response to cell therapy was defined as an LVEF increase of ≥5%. RESULTS: 61 patients were included in the analysis. The mean age of patients was 52 years and 83% were male. DCMP and ICMP were present in 69% and 31% of patients, respectively. The average serum creatinine was 86 ± 23 µmol/L, NT-proBNP 1132 (IQR 350-2279) pg/mL, and LVEF 30 ± 6%. Gal-3 at baseline and at 3 months did not differ significantly (13.4 ± 5.5 ng/mL vs. 13.1 ± 5.8 ng/mL; p = 0.72), and there were no differences in baseline gal-3 with respect to heart failure etiology (15.1 ± 7.2 ng/mL in ICMP vs. 12.7 ± 4.3 ng/mL in DCMP; p = 0.12). Comparing responders (N = 49) to nonresponders (N = 18), we found no differences in baseline gal-3 (13.6 ± 5.7 ng/mL vs. 13.2 ± 4.9 ng/mL; p = 0.80). However, responders had significantly lower gal-3 at 3-month follow-up (12.1 ± 4.0 ng/mL vs. 15.7 ± 8.4 ng/mL; p < 0.05). Also, responders demonstrated a significant decrease in gal-3 over 3 months, while in nonresponders, an increase in gal-3 occurred (-1.5 ± 5.4 ng/mL vs. +2.7 ± 4.3 ng/mL; p = 0.01). CONCLUSIONS: In patients with chronic heart failure undergoing CD34+ cell therapy, a decrease in galectin-3 plasma levels is associated with beneficial response to this treatment modality. Further prospective data is warranted to confirm our findings and to deepen our understanding of the role of gal-3 in the field of stem cell therapy.

Endocan Is an Independent Predictor of Heart Failure-Related Mortality and Hospitalizations in Patients with Chronic Stable Heart Failure.

BACKGROUND: Heart failure (HF) is characterized by unfavorable prognosis. Disease trajectory of HF, however, may vary, and risk assessment of patients remains elusive. In our study, we sought to determine the prognostic impact of endocan-a novel biomarker of endothelial dysfunction and low-grade inflammation-in patients with heart failure. METHODS: In outpatients with chronic HF, baseline values of endocan were determined and clinical follow-up for a minimum of 18 months obtained. A multivariate Cox proportional hazard model was built for HF-related death or hospitalization requiring inotropic support. RESULTS: A total of 120 patients (mean age 71 years, 64% male, mean LVEF 36%) were included. During a mean follow-up of 656 ± 109 days, 50 patients (41.6%) experienced an event. On Cox multivariate analysis, endocan values emerged as an independent predictor of HF prognosis (HR, 1.471 CI 95% 1.183-1.829, p = 0.001, for each 1 ng/mL increase) even after adjustment for age, gender, HF etiology, LVEF, NYHA class, NT-proBNP, and exercise tolerance. CONCLUSIONS: Endocan is an independent predictor of HF-related events in chronic HF individuals and represents a promising tool for risk assessment of HF patients.

Swallow Syncope After Whiplash Neck Injury.

Swallow syncope is a rare dysautonomic syndrome characterized by temporary loss of consciousness upon swallowing solid foods or liquids, displaying primarily in individuals with an underlying structural or functional esophageal or cardiac pathology. However, the evidence also suggests that isolated vagal dysfunction or abnormal reactions of esophageal mechanoreceptors after mechanical irritation, demyelination, or trauma can potentially evoke  a cardioinhibitory response or vasodepression upon swallowing. We present a case of a 49-year-old otherwise healthy female patient who developed swallow syncope two weeks after whiplash neck injury acquired in a rear-end collision. After no evident anatomical and/or functional cardiac or esophageal pathology was diagnosed using several diagnostic procedures, the final diagnosis was confirmed by a provocative tilt-table test while ingesting solid food. Subsequently, a dual-chamber pacemaker was implanted, relieving the patient from troublesome symptoms. Abnormal reactions of esophageal mechanoreceptors to stimuli associated with food ingestion and/or dysfunction of afferent and efferent vagal fibers due to stretch injury and related neck trauma (acquired during the car accident) may be the leading pathophysiological mechanisms of swallow syncope in our patient.