Lithium-Induced Bradycardia and Cardiomyopathy in a Patient With Bipolar Disorder and Paranoid Schizophrenia.

Lithium is primarily known to cause neurological and gastrointestinal side effects, however, cardiac effects have been rarely reported. We present a unique case of lithium cardiotoxicity causing bradyarrhythmia and cardiomyopathy. A 68-year-old man with a history of paranoid schizophrenia and bipolar disorder presented with altered mental status. On examination, the patient was lethargic, afebrile, with dry oral mucosa, and a regular pulse of 42 bpm. Labs revealed acute kidney injury and elevated lithium levels. Electrocardiogram (ECG) revealed a junctional escape rhythm with a right bundle morphology. Lithium toxicity was strongly suspected in the setting of raised serum lithium levels, decreased oral intake and acute kidney injury. The patient was found to have lithium-induced junctional bradycardia. Transvenous pacing was not indicated as the patient responded to fluids and atropine and had no severe hemodynamic compromise. As his serum lithium levels decreased, the bradycardia gradually improved. His echocardiogram revealed moderate left ventricular systolic dysfunction. Workup of cardiomyopathies was negative: no obstructive coronary artery disease; viral panel, and autoimmune markers were unremarkable. Thus, his cardiomyopathy was attributed to lithium toxicity. Lithium cardiotoxicity may manifest as arrhythmias and/or cardiomyopathy. Clinicians should have a high index of suspicion for lithium cardiotoxicity due to the narrow therapeutic range of lithium.

A Rare Case of Haemophilus Influenzae Serotype F Endocarditis Complicated by Concurrent Cardiogenic and Septic Shock: A Case of Challenging Management.

H. Influenza is a rare cause of endocarditis. We report a case of H. Influenza endocarditis that was complicated by cardiogenic and septic shock, active myocardial ischemia and aortic insufficiency. The goal of this report is to help recognize the signs and symptoms of endocarditis and to discuss management strategies in patients with concomitant cardiogenic and septic shock complicated by aortic insufficiency.

Hemodynamic effects of left atrial appendage occlusion.

BACKGROUND: Percutaneous left atrial appendage occlusion (LAAO) devices have emerged as alternatives to anticoagulation for embolic stroke prevention in patients with non-valvular atrial fibrillation (NVAF). The left atrial appendage is known to produce vasoactive neuroendocrine hormones involved in cardiovascular homeostasis. The hemodynamic impact of LAA occlusion on cardiac function remains poorly characterized. METHODS: This is a single-center, retrospective study of sixty-seven consecutive patients who received LAAO utilizing the WATCHMAN device from May 2017 to June 2019. All patients received a comprehensive 2D transthoracic echocardiogram (TTE) prior to the procedure and a post-procedural TTE. 2D echocardiographic pre-/post-procedural measurements including left ventricular ejection fraction, tricuspid regurgitation, estimated pulmonary artery pressure, diastolic parameters, and left atrial and right ventricular strain were statistically analyzed using the paired t-test. RESULTS: Seventy percent of study patients were male with an overall mean age of 73.0 ± 9.0 years. Analysis of post-procedural LAAO revealed statistically significant improvement in left ventricular ejection fraction (52.4 ± 12.6 vs. 56.7 ± 12.7, p < 0.001), an increase in mitral E/e' (14.1 ± 6.5 vs. 18.3 ± 10.8, p < 0.001), and a decrease right ventricular global longitudinal strain (RVGLS) (- 17.5 ± 4.6 vs. - 19.6 ± 5.7, p = 0.027) as compared to pre-procedural TTE. Peak left atrial longitudinal strain (PALS) improved post-LAAO (20.6 ± 12.2 to 22.9 ± 12.9, p = 0.040) with adjustment for cardiac arrhythmias. Post-LAAO, heart failure hospitalizations occurred in 23.9% of patients. CONCLUSIONS: Percutaneous LAAO results in real-time atrial and ventricular hemodynamic changes as assessed by echocardiographic evaluation of LV filling pressures (E/e'), PALS, RVGLS, and LVEF.

Thirty-day readmissions after atrial fibrillation catheter ablation in patients with heart failure.

BACKGROUND: Randomized clinical trial data have demonstrated catheter ablation (CA) as a viable treatment modality for atrial fibrillation (AF). Patients with heart failure (HF) undergoing AF CA appear to derive improvements in quality of life and mortality compared to those treated with medical therapy (MT). Contemporary national data on 30-day readmissions after CA compared to MT among patients with HF are lacking. METHODS: From the 2016 Nationwide Readmissions Databases, 749 776 (weighted national estimate: 1 421 673) AF HF patients were identified of which 2204 (0.3%) underwent CA and 747 572 (99.7%) received MT. Propensity matching balanced baseline clinical characteristics. Thirty-day readmission rates, causes, predictors, and costs of 30-day readmission were compared. RESULTS: Among both the unmatched and matched cohorts, 30-day readmissions were lower for patients treated with CA compared to MT (16.8% vs 20.1%, P < .001 and 16.8% vs 18.8%, P = .020). CA was associated with reduced risk of readmission compared to MT (odds ratio 0.86, 95% confidence interval [CI]: 0.77-0.97). HF exacerbation and arrhythmias were the most common cause for 30-day readmission after CA. CA costs were higher during index hospitalization but similar to MT during readmission among the matched cohort ($15 858 ± $21 636 vs $16 505 ± $29 171, P = .67). Predictors of readmission were largely nonmodifiable risk factors among both the CA and MT groups. CONCLUSIONS: Nearly one in six patients with HF is readmitted within 30-days after undergoing CA. In propensity matched analyses, CA was associated with decreased rate and risk for readmission compared to MT. CA has higher index hospitalization costs, but lower readmission costs.

Aortic Valve Calcification as a Predictor of Post-Transcatheter Aortic Valve Replacement Pacemaker Dependence.

BACKGROUND: Atrioventricular block requiring permanent pacemaker (PPM) implantation is a common complication of transcatheter aortic valve replacement (TAVR). The mechanism of atrioventricular (AV) block during TAVR is not fully understood, but it may be due to the mechanical stress of TAVR deployment, resulting in possible injury to the nearby compact AV node. Aortic valve calcification (AVC) may worsen this condition and has been associated with an increased risk for post-TAVR PPM implantation. We performed a retrospective analysis to determine if AVC is predictive for long-term right ventricular (RV) pacing in post-TAVR pacemaker patients at 30 days. METHODS: A total of 262 consecutive patients who underwent TAVR with a balloon-expandable valve were analyzed. AVC data were derived from contrast-enhanced computed tomography and characterized by leaflet sector and region. RESULTS: A total of 25 patients (11.1%) required post-TAVR PPM implantation. Seventeen patients did not require RV pacing at 30 days. Nine of these 17 patients had no RV pacing requirement within 10 days. The presence of intra-procedural heart block (P = 0.004) was the only significant difference between patients who did not require PPM and those who required PPM but they were not RV pacing-dependent at 30 days. Non-coronary cusp (NCC) calcium volume was significantly higher in patients who were pacemaker-dependent at 30 days (P = 0.01) and a calcium volume of > 239.2 mm3 in the NCC was strongly predictive of pacemaker dependence at 30 days (area under the curve (AUC) = 0.813). Pre-existing right bundle branch block (RBBB) (odds ratio (OR) 105.4, P = 0.004), bifascicular block (OR 12.5, P = 0.02), QRS duration (OR 70.43, P = 0.007) and intra-procedural complete heart block (OR 12.83, P = 0.03) were also predictive of pacemaker dependence at 30 days. CONCLUSIONS: In patients who required PPM after TAVR, quantification of AVC by non-coronary leaflet calcium volume was found to be a novel predictor for RV pacing dependence at 30 days. The association of NCC calcification and PPM dependence may be related to the proximity of the conduction bundle to the non-coronary leaflet. Further studies are necessary to improve risk prediction for long-term RV pacing requirements following TAVR.

Multimodal Imaging for the Diagnosis of Isolated Cardiac Sarcoidosis.

We report a case of isolated cardiac sarcoidosis (CS) diagnosed using a multimodality imaging approach. A patient presented after an out-of-hospital, ventricular fibrillation-mediated cardiac arrest. The use of echocardiography, cardiac magnetic resonance, and fluorodeoxyglucose-positron emission tomography enabled the diagnosis of isolated CS. (Level of Difficulty: Beginner.).

Interactive Cost-benefit Analysis: Providing Real-World Financial Context to Predictive Analytics.

Objective: Clinical implementation of predictive analytics that assess risk of high-cost outcomes are presumed to save money because they help focus interventions designed to avert those outcomes on a subset patients who are most likely to benefit from the intervention. This premise may not always be true. A cost-benefit analysis is necessary to show if a strategy of applying the predictive algorithm is truly favorable to alternative strategies. Methods: We designed and implemented an interactive web-based cost-benefit calculator, enabling specification of accuracy parameters for the predictive model and other clinical and financial factors related to the occurrence of an undesirable outcome. We use the web tool, populated with real-world data to illustrate a cost-benefit analysis of a strategy of applying predictive analytics to select a cohort of high-risk patients to receive interventions to avert readmissions for Congestive Heart Failure (CHF). Results: Application of predictive analytics in clinical care may not always be a cost-saving strategy compared with intervening on all patients. Improving the accuracy of a predictive model may lower costs, but other factors such as the prevalence and cost of the outcome, and the cost and effectiveness of the intervention designed to avert the outcome may be more influential in determining the favored strategy. Conclusion: An interactive cost-benefit analyses provides insights regarding the financial implications of a clinical strategy that implements predictive analytics.

Parvalbumin-containing chandelier and basket cell boutons have distinctive modes of maturation in monkey prefrontal cortex.

Parvalbumin (PV)-containing cortical GABA neurons include chandelier cells (PVChCs) and basket cells (PVBCs), which innervate the axon initial segment (AIS) and soma/proximal dendrites of pyramidal cells, respectively. In monkey prefrontal cortex (PFC), the density of PVChC axon cartridges detectable by PV immunoreactivity peaks prior to the onset of puberty before declining markedly to adult levels, whereas the density of PV-immunoreactive (IR) puncta (presumed PVBC boutons) increases during adolescence. These inverse developmental changes in bouton density could explain why an electron microscopy study found no change in the density of symmetric, presumably GABAergic, synapses between infancy and adulthood in monkey PFC. Alternatively, the inverse developmental trajectories of PVChC and PVBC boutons could represent cell type-specific differences in the maturation of PV protein levels. To differentiate between these two alternatives, multilabel confocal microscopy was used to quantify the number of PVChC and PVBC boutons per pyramidal neuron in the PFC of 3-month-old and adult monkeys. The mean number of PVChC boutons per pyramidal neuron AIS was, significantly, 32% lower in adult compared with 3-month-old monkeys, whereas the density of PVBC boutons per pyramidal neuron did not differ between age groups. In contrast, relative levels of PV protein were approximately twofold higher in PVBC boutons in adult animals, whereas PV levels in PVChC boutons did not differ between age groups. These findings suggest cell type-specific mechanisms of maturation of PV-containing GABAergic boutons in monkey PFC.