Cardiac resynchronization therapy in patients with postero-lateral scar by cardiac magnetic resonance: A systematic review and meta-analysis.

BACKGROUND: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected patients with heart failure, but up to one third of patients may not respond to CRT. A transmural postero-lateral (TMPL) wall scar in the left ventricle (LV) or over the LV pacing site may attenuate clinical and echocardiographic response to CRT. METHODS AND RESULTS: We systematically searched PubMed, EMBASE, and Cochrane databases for studies examining the association between Cardiac magnetic resonance (CMR)-determined postero-lateral or LV pacing site scar and clinical and echocardiographic response to CRT. Eleven prospective studies were included. The presence of TMPL scar on pre-implant CMR was associated with a 75% lower chance of echocardiographic response to CRT, and a similarly lower chance of clinical response. Significant scar over LV pacing site on pre-implant CMR was also associated with a 46% lower chance of echocardiographic response to CRT, and a 67% lower chance of clinical response. CONCLUSIONS: The presence of transmural postero-lateral scar or significant scar within the LV pacing site detected by pre-implant CMR is associated with a lower rate of clinical or echocardiographic response to CRT.

Sleep apnea and severe bradyarrhythmia--an alternative treatment option: a case report.

INTRODUCTION: Sinus arrest, atrio-ventricular block, supraventricular, and ventricular arrhythmias have been reported in patients with sleep apnea syndrome. The arrhythmias usually occur during sleep and contribute to the cardiovascular morbidity and mortality, and the treatment of sleep apnea usually results in the resolution of the brady- arrhythmias. Weight loss, continuous positive airway pressure (CPAP), oral appliances, and upper airway surgery are the recommended treatments, however, compliance and efficacy are issues. CASE PRESENTATION: A 58-year-old Arab man presented with recurrent presyncope. He was subsequently diagnosed with sleep apnea associated with frequent and significant sinus pauses. He presented a treatment challenge because he refused continuous positive airway pressure and pacemaker, however, he was successfully treated with theophylline. CONCLUSION: Frequent and significant sinus pause associated with sleep apnea was successfully treated with theophylline in our patient when the standard treatment of care was refused.

Ceftaroline Fosamil Use in 2 Pediatric Patients With Invasive Methicillin-Resistant Staphylococcus aureus Infections.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is one of the most common pathogens causing pediatric infections including skin and soft tissue infections, pyogenic arthritis, osteomyelitis, and septic shock. For decades, patients were treated with antibiotics such as vancomycin and clindamycin, but there is an increasing incidence of resistance to these traditional therapies. We describe 2 cases of patients with CA-MRSA invasive infections with bacteremia who experienced vancomycin therapy failure but who were successfully treated with ceftaroline fosamil. Case 1 involves an 8-year-old Hispanic male who was diagnosed with CA-MRSA bacteremia, thigh abscess, and osteomyelitis. The patient was admitted to the pediatric intensive care unit in septic shock. Case 2 involves an 8-year-old Caucasian male who was diagnosed with CA-MRSA sepsis, right arm abscess, and osteomyelitis. We were able to successfully treat both patients with CA-MRSA sepsis and invasive infection-who failed vancomycin therapy-with ceftaroline fosamil with no adverse efiects. Despite the positive outcome in both pediatric patients, clinical trials with ceftaroline fosamil are needed to further support its use in pediatric patients.

Unintended Harm and Benefit of the Implantable Defibrillator in an Unfortunate 19-Year-Old Male: Featuring a Sequence of Rare Life-threatening Complications of Cardiac Procedures.

All procedures have inherent risk. Our patient endured a sequence of rare life-threatening complications from commonly preformed procedures. The sequence of these complications was; large pericardial effusion post implantable cardioverter-defibrillator (ICD) implantation with echocardiographic signs of tamponade, left main narrowing post radiofrequency ablation, and late stent thrombosis post coronary intervention with a bare metal stent. All these occurred to one unfortunate young man. Furthermore, our patient demonstrated an unintended benefit of ICD which saved his life.

Clinical and temporal patterns of severe pneumonia causing critical illness during Hajj.

BACKGROUND: Pneumonia is a leading cause of hospitalization during Hajj and susceptibility and transmission may be exacerbated by extreme spatial and temporal crowding. We describe the number and temporal onset, co-morbidities, and outcomes of severe pneumonia causing critical illness among pilgrims. METHOD: A cohort study of all critically ill Hajj patients, of over 40 nationalities, admitted to 15 hospitals in 2 cities in 2009 and 2010. Demographic, clinical, and laboratory data, and variables necessary for calculation of the Acute Physiology and Chronic Health Evaluation IV scores were collected. RESULTS: There were 452 patients (64.6% male) who developed critical illness. Pneumonia was the primary cause of critical illness in 123 (27.2%) of all intensive care unit (ICU) admissions during Hajj. Pneumonia was community (Hajj)-acquired in 66.7%, aspiration-related in 25.2%, nosocomial in 3.3%, and tuberculous in 4.9%. Pneumonia occurred most commonly in the second week of Hajj, 95 (77.2%) occurred between days 5-15 of Hajj, corresponding to the period of most extreme pilgrim density. Mechanical ventilation was performed in 69.1%. Median duration of ICU stay was 4 (interquartile range [IQR] 1-8) days and duration of ventilation 4 (IQR 3-6) days. Commonest preexisting co-morbidities included smoking (22.8%), diabetes (32.5%), and COPD (17.1%). Short-term mortality (during the 3-week period of Hajj) was 19.5%. CONCLUSION: Pneumonia is a major cause of critical illness during Hajj and occurs amidst substantial crowding and pilgrim density. Increased efforts at prevention for at risk pilgrim prior to Hajj and further attention to spatial and physical crowding during Hajj may attenuate this risk.

Acute myocardial infarction in a 56-year-old female patient treated with sulfasalazine.

Drug rash, eosinophilia, and systemic symptoms (DRESS) syndrome represents one pattern of the cutaneous involvement in type IV hypersensitivity reaction to drugs. It is a severe, delayed, idiosyncratic reaction presented as rash with fever, lymphadenopathy, and visceral involvement. There are several reported cases of sulfasalazine-induced DRESS syndrome, but myocardial involvement was rare. High index of suspicion is needed in every patient receiving these drugs for prompt diagnosis and early management. We report a case of a 56-year-old woman treated with sulfasalazine for ankylosing spondylitis for 3 weeks, which was discontinued after development of DRESS syndrome. Despite treating her with high dose of steroid and cyclosporine, her symptoms persisted, and ultimately, she developed toxic myocarditis with a misleading presentation of acute ST-elevated myocardial infarction. The diagnosis was made based on postmortem histopathologic finding.

Outcome after implantable cardioverter-defibrillator in patients with Brugada syndrome: the Gulf Brugada syndrome registry.

BACKGROUND AND OBJECTIVE: Among patients with Brugada syndrome (BS) and aborted cardiac arrest, syncope, or inducible ventricular fibrillation at electrophysiologic study (EPS), the only currently recommended therapy is an implantable cardioverter-defibrillator (ICD), but these are not without complications. We assessed the total number of shocks (appropriate and inappropriate) and complications related to ICD in patients with BS. METHODS AND RESULTS: Twenty-five patients implanted with ICD for BS in 6 Gulf centers between January 1, 2002, and December 31, 2010, were reviewed. Implantable cardioverter-defibrillator indication was based on aborted cardiac arrest (24%), syncope (56%), or in asymptomatic patients with positive EPS (20%). During a follow-up of 41.2 ± 17.6 months, 3 patients (all with prior cardiac arrest) had appropriate device therapy. Four patients developed complications; 3 of them had inappropriate shocks. CONCLUSION: In our cohort, appropriate device therapy was limited to cardiac arrest survivors, whereas none of those with syncope and/or positive EPS had arrhythmias. Overall complication rate was relatively high, including inappropriate ICD shocks.