Catheter ablation of atrial fibrillation in hypertrophic cardiomyopathy: A proportional meta-analysis and systematic review of single-arm studies.

Background: Atrial fibrillation (AF) is the most common arrhythmia in patients with hypertrophic cardiomyopathy (HCM). Limited data exists about the efficacy and clinical outcomes of AF ablation in HCM. Objective: The purpose of this meta-analysis was to evaluate the role of catheter-based ablation for treatment of AF in patients with HCM. Methods: PubMed, SCOPUS, Web of Science, Embase, Cochrane library, and ClinicalTrials.gov were searched for studies discussing outcomes of catheter-based ablation for AF in patients with HCM. Two reviewers independently screened studies and extracted relevant data. Incidence rate estimates from individual studies underwent logit transformation to calculate the weighted summary proportion under the random effect model. Results: A total of 19 reports met the inclusion criteria (1183 patients). The single ablation procedure was successful in 39% patients. Up to 34% patients underwent a repeat ablation. About 41% patients in normal sinus rhythm after successful AF ablation received postprocedure antiarrhythmic drug (AAD) therapy. Patients undergoing successful AF ablation experienced a significant improvement in the New York Heart Association functional class (standardized mean difference -1.03; 95% confidence interval -1.23 to -0.83; P < .00001). Conclusion: AF ablation appears to be safe and feasible in patients with HCM. Freedom from AF after undergoing successful ablation is associated with significant improvement in heart failure symptoms.

Impella Versus Extracorporeal Membranous Oxygenation (ECMO) for Cardiogenic Shock: A Systematic Review and Meta-analysis.

The use of mechanical circulatory support (MCS) in cardiogenic shock (CS) is increasing. We conducted a systematic review and meta-analysis to compare the outcomes of Impella use with extracorporeal membranous oxygenation (ECMO) support in patients with CS. We searched the Medline, EMBASE, Cochrane, and Clinicaltrials.gov databases for observational studies comparing Impella to ECMO in patients with CS. Risk ratios (RRs) for categorical variables and standardized mean differences (SMDs) for continuous variables were calculated with 95% confidence intervals (CIs) using a random-effects model. Twelve retrospective studies and one prospective study (Impella n=6652, ECMO n=1232) were identified. Impella use was associated with lower incidence of in-hospital mortality (RR 0.88 [95% CI 0.80-0.94], P=0.0004), stroke (RR 0.30 [0.21-0.42], P<0.00001), access-site bleeding (RR 0.50 [0.37-0.69], P<0.0001), major bleeding (RR 0.56 [0.39-0.80], P=0.002), and limb ischemia (RR 0.42 [0.27-0.65], P=0.0001). Baseline lactate levels were significantly lower in the Impella group (SMD -0.52 [-0.73- -0.31], P<0.00001). There was no significant difference in mortality at 6-12 months, MCS duration, need for MCS escalation, bridge-to-LVAD or heart transplant, and renal replacement therapy use between Impella and ECMO groups. In patients with CS, Impella device use was associated with lower in-hospital mortality, stroke, and device-related complications than ECMO. However, patients in the ECMO group had higher baseline lactate levels.

Fatal Wernicke's Encephalopathy with Cardiovascular Involvement in a Young Psychiatric Patient.

Wernicke's encephalopathy (WE) is an acute neurological disorder caused by thiamine deficiency that is frequently missed in non-alcoholic patients. Coma and cardiomyopathy are uncommon presentations of WE that have been rarely reported in the literature. We report the case of a 36-year-old male with a known history of schizophrenia who presented with coma and vasopressor refractory hypotension. Initial computed tomography (CT) of the head at admission was unremarkable. Transthoracic echocardiogram showed diffuse myocardial hypokinesia with a left ventricular ejection fraction of 40-45%. Due to persistent encephalopathy, a repeat non-enhanced CT head was obtained on the second day of hospital admission followed by magnetic resonance imaging (MRI) of brain that showed findings suggestive of WE. The patient was immediately started on high-dose intravenous (IV) thiamine therapy. Although his hemodynamic parameters significantly improved following thiamine replacement, he did not show signs of neurological recovery and resulted in a dismal outcome. This case illustrates the importance of early recognition of thiamine deficiency in critically ill patients to prevent fatal outcomes. Immediate parenteral thiamine administration should be considered in all patients presenting with coma, cardiomyopathy, and refractory hypotension regardless of their body mass index, and alcohol use status.

Spontaneous Bilateral Subdural Hematomas in a Patient With Cryptogenic Liver Cirrhosis.

Spontaneous subdural hematoma (SDH) in cirrhotic patients is a rarely described condition in the literature and carries a high mortality rate. Several factors can potentially contribute to SDH development in cirrhosis, including coagulation cascade defects, thrombocytopenia, arteriovenous malformations, and cerebral atrophy. Clinicians should always keep spontaneous development of SDH in the differential diagnosis of acute encephalopathy in patients with end-stage liver disease, and prompt head imaging should be considered. We report a unique case of a 64-year-old patient with cryptogenic liver cirrhosis who was found to have spontaneous, bilateral SDHs while undergoing workup for acute encephalopathy.

Septic discitis and septic pulmonary emboli: rare complications of Proteus mirabilis urinary tract infection.

Proteus mirabilis is a gram-negative bacterium frequently considered a pathogen of the urinary tract. Septic discitis and septic pulmonary emboli resulting from P. mirabilis urosepsis is a rare phenomenon. We report a 39-year-old woman who was admitted to our hospital with a complicated urinary tract infection resulting in bacteraemia, septic discitis, paraspinal abscesses and septic emboli. She was treated with a prolonged course of intravenous antibiotics resulting in the clinical resolution of her symptoms. Based on our PubMed search of the English literature, this is only the second reported case of septic discitis caused by P. mirabilis This paper illustrates that physicians should include septic discitis caused by P. mirabilis as a possible aetiology of low back pain in patients with active or recently treated urinary tract infection. Additionally, this article discusses the pathogenesis and other complications resulting from P. mirabilis bacteraemia.

The First Reported Case of Post-Atrioventricular Node Ablation Enterococcus Faecalis Bacteremia in a Patient With Colonic Tubular Adenomas and Chronic Steroid Use.

We present the case of a 73-year-old immunosuppressed male with a history of multiple benign, colonic adenomas who was admitted to our hospital with Enterococcus faecalis (E. faecalis) bacteremia. The patient also had a prior history of dual-chamber pacemaker placement for sick sinus syndrome. Two days before the admission, the patient had undergone radiofrequency ablation of the atrioventricular (AV) node for refractory atrial flutter without receiving any peri-procedural antibiotic prophylaxis. Despite high-grade bacteremia and a high NOVA (Number of positive blood cultures, Origin of the bacteremia, previous Valve disease, Auscultation of heart murmur) score, there was no evidence of infective endocarditis on transesophageal echocardiogram (TEE). The patient was treated successfully with appropriate intravenous antibiotics, and he recovered well. To the best of our knowledge, this is the first reported case of post-AV node ablation E. faecalis bacteremia. We conclude that the presence of colonic lesions and immunosuppression can increase the risk of peri-procedural E. faecalis bacteremia, and clinicians should consider antibiotic prophylaxis in this high-risk patient group.

Bilateral Epiploic Appendagitis: A Rather Benign but Diagnostically Challenging Cause of Acute Abdominal Pain.

Epiploic appendagitis (EA) is a rare and often misdiagnosed cause of acute abdominal pain. It is a benign and self-limited condition but mimics other underlying causes of acute abdominal pain like acute diverticulitis, acute appendicitis, acute cholecystitis, etc. Inaccurate diagnosis can lead to iatrogenic adverse outcomes. To the best of our knowledge, the present report represents the first case of bilateral EA involving both cecum and descending colon. The patient presented with symptoms of bilateral iliac fossa pain. Conservative management and close outpatient follow up resulted in a successful clinical outcome with no recurrence of symptoms. This article illustrates that clinicians and radiologists should include this etiology among differential diagnoses of patients presenting with acute abdominal pain, as it might prevent unnecessary hospitalizations, antibiotic therapy, and unwarranted surgical interventions.