Comparison of de novo implantation vs. upgrade cardiac resynchronisation therapy: a multicentre experience.

BACKGROUND: The clinical safety and consequences of upgrade procedures compared with de novo cardiac resynchronisation therapy (CRT) implantation in heart failure remain unclear. The present study aimed to assess clinical and procedural consequences of patients undergoing CRT upgrade as compared to de novo CRT implantations. METHODS: In this prospective cohort study, two subgroups were considered as the study population as (1) de novo group that CRT was considered on optimised medical treatment with heart failure of NYHA functional class from II to IV, left ventricular ejection fraction (LVEF) of ≤35%, and QRS width of >130 ms and (2) upgrade group including the patients with previously implantable cardioverter defibrillator (ICD) with the indications for upgrading to CRT. The two groups were compared regarding the changes in clinical outcome and echocardiography parameters. RESULTS: The procedure was successful in 95.9% of patients who underwent CRT upgrade and 100% of those who underwent de novo CRT implantation. It showed a significant improvement in LVEF, severity of mitral regurgitation and NYHA functional classification, without any difference between the two study groups. Overall procedural related complications were reported in 10.8% and 3.8% (p = .093) and cardiac death in 5.4% and 2.5% (p = .360), respectively, with no overall difference in postoperative outcome between the two groups. CONCLUSIONS: Upgrading to CRT is a safe and effective procedure regarding improvement of functional class, left ventricular function status and post-procedural outcome.

Mature teratoma of conus medullaris: A case report and review of literature.

In conus medullaris, mature teratomas are rare. We report a case of a 40-year-old man who presented with urinary incontinence, low back pain, and muscle weakness. Magnetic resonance imaging revealed a mass in conus medullaris (T11-L1), further confirmed as a mature teratoma by pathological examination. We identified 63 cases of conus medullaris teratoma over the past two decades by systematically analyzing the case reports. Findings demonstrated that most cases were diagnosed in the fourth decade of life, with the majority of cases (57.6%) being male. Lower back pain, radiating pain in the extremities, hypoesthesia, and urinary dysfunction are the most common clinical presentations among patients with teratoma of conus medullaris. Mature teratoma is the dominant pathologic subtype of teratomas in this region, comprising more than 95% of cases. Our case highlights the importance of considering spinal teratoma as a differential diagnosis in patients presenting with urinary incontinence and lumbar pain.

Clinical outcomes of subcutaneous implantable cardiac defibrillator implantation - Iran SICD registry.

BACKGROUND: The subcutaneous implantable-defibrillator (S-ICD) is a relatively new alternative to the transvenous ICD system to minimize intravascular lead-related complications. This paper presents outcome of SICD implantation in patients enrolled in Iran S-ICD registry. METHODS: Between October 2015 and June 2022, this prospective multicenter national registry included 223 patients with a standard indication for an ICD, who neither required bradycardia pacing nor needed cardiac resynchronization to evaluate the early post-implant complications and long-term follow-up results of the S-ICD system. RESULTS: The mean age of the patients was 45 ± 17 years. The majority (79.4%) were male. Ischemic cardiomyopathy (39.5%) was the most common underlying disorder among patients selected for S-ICD implant. Most study patients (68.6%) had ICD for primary prevention of sudden cardiac death. Seven patients (3.1%) were found to have suboptimal lead positions. Six patients (2.7%) developed a pocket hematoma; all were managed medically. During a mean follow-up of 2 years, the appropriate therapy was recorded in 13% of the patients and inappropriate ICD intervention mainly due to supraventricular tachycardia in 8.9%. Pocket infection was observed in four patients (1.8%) and five patients (2.2%) died mainly due to heart failure. CONCLUSION: S-ICDs were effective at detecting and treating both induced and spontaneous ventricular arrhythmias. Major clinical complications were rare.

Postural Orthostatic Tachycardia Syndrome and Orthostatic Hypotension Post COVID-19.

BACKGROUND: Novel coronavirus causes coronavirus disease -19 (COVID-19). The hallmark is acute respiratory distress syndrome, but other systems' involvement is less illustrated. Our goal was to evaluate the manifestation of COVID-19 on one of the overlaps of the cardiovascular and nervous system, namely: Postural Orthostatic Tachycardia Syndrome (POTS) and Orthostatic Hypotension (OH). METHODS: This single-center cross-sectional observational study encompassed 60 consecutive patients that were hospitalized and recovered from severe or critical COVID-19. At the time of discharge, Blood Pressure (BP) and Heart Rate (HR) in the supine and upright position (1st, 3rd, 5th and 10th minutes) were measured. Symptomatic patients were reevaluated 2 months later. RESULTS: The mean age of patients was 56.6 (± 16.2) years and 42 patients were male (70%). The most frequent cardiovascular risk factor was hypertension (35%). OH and POTS were detected in 29(48.3%) and 10(16.7%) patients, respectively, at the time of hospital discharge. The mean age of patients with OH was higher than POTS and POTS was frequent in the elderly. Two months later, among 10 patients with POTS, the sign and symptoms were resolved in 8(80%). Two (20%) patients who still had positive signs and symptoms of POTS were older than 65 years. Among 29 patients with OH, the signs and symptoms were resolved in 26 (89.7%). CONCLUSION: In our study, 65% of patients had OH or POTs on the day of hospital discharge; complete recovery is gradual and needs several additional weeks. This is one of the aspects of the entity recently named "Long COVID".

Successful transvenous lead extraction of abandoned lead implanted through persistent left superior vena cava.

Persistent left superior vena cava, the most common thoracic venous anomaly, may complicate transvenous lead extraction (TLE). We report a successful case of TLE in a patient with persistent left superior vena cava, despite a long dwelling time and several pocket revisions due to pocket infection. The lead was removed via a hand-powered mechanical extraction sheath, and postoperative complications did not occur. Complicated TLE cases may have a better outcome if performed in a high-volume center with experienced specialists.

Association between exposure to Efavirenz and substrates of dysrhythmia in HIV-infected young adults.

BACKGROUND: Dysrhythmia and sudden cardiac arrest occur more likely in HIV patients than healthy subjects. Thus, we need to examine dysrhythmias adverse effects of medications including Efavirenz as early as possible especially in young subjects. HYPOTHESIS: Efavirenz might have contributed to increased risk of developing common types of dysrhythmia in young HIV infected patients. METHODS: We performed a retrospective cohort study among 62 patients on Efavirenz and 38 controls. All participants were under 40 years old without cardiovascular disease. Total significant dysrhythmia in 24-hour ECG monitoring was the primary endpoint determined as the composite of high premature ventricular contraction (PVC) (>500 beats per 24 hours), high premature atrial contraction (PAC) (>500 bp24h), sinus pause, atrioventricular blocks, ventricular tachycardia, prolonged QTc, and low heart rate variability (HRV). Modified composite dysrhythmia consisted of low HRV (SD of normal-to-normal [SDNN]), high PVC and prolonged QT. RESULTS: Mean heart rate, Efavirenz regimen, male gender, and CD4 count predicted total dysrhythmia. Odds ratios were 1.108, 2.90, 4.36, and 0.96, respectively. The incidence of total dysrhythmia, high PVC, high PAC, low HRV(SDNN), and prolonged QTc were 54.8%, 41.85%, 9.71%, 45.2%, and 12.9% in patients on Efavirenz against 42.11%, 31.64%, 0%, 34.2%, and 7.91% in controls, respectively (p-values: .031, .001, <.0001, .063, and .043 respectively). Modified composite dysrhythmia was also more frequent in Efavirenz group than that of control group (69.42% vs. 52.60%, respectively p = .032). CONCLUSIONS: We found that patients with Efavirenz had higher prevalence of frequent PVC, frequent PAC, total significant dysrhythmia, Low HRV and prolonged QTc than controls.

Effect of cardiac resynchronization therapy on ambulatory blood pressure monitoring indices in patients with heart failure and hypertension.

OBJECTIVE: Blood pressure (BP) variability is associated with increased mortality in patients with hypertension and heart failure. The aim of our study was to evaluate the effect of cardiac resynchronization therapy (CRT) on different parameters of 24-h ambulatory blood pressure monitoring (ABPM) in patients with hypertension and heart failure. METHODS: Patients with heart failure and hypertension who were candidate for CRT implantation were enrolled in our study. Twenty-four hour ABPM was performed before, and 6 months after CRT implantation. BP variables and average real variability (ARV) were compared in all patients. RESULT: Sixteen consecutive patients entered our study. There was a significant increase in ARV following CRT implantation (P value = 0.009). CONCLUSION: CRT implantation is associated with increased ARV, but the effect of this improvement on cardiovascular outcome needs more investigation.

Worldwide Survey of COVID-19-Associated Arrhythmias.

[Figure: see text].

Imaging data in COVID-19 patients: focused on echocardiographic findings.

To assess imaging data in COVID-19 patients and its association with clinical course and survival and 86 consecutive patients (52 males, 34 females, mean age = 58.8 year) with documented COVID-19 infection were included. Seventy-eight patients (91%) were in severe stage of the disease. All patients underwent transthoracic echocardiography. Mean LVEF was 48.1% and mean estimated systolic pulmonary artery pressure (sPAP) was 27.9 mmHg. LV diastolic dysfunction was mildly abnormal in 49 patients (57.6%) and moderately abnormal in 7 cases (8.2%). Pericardial effusion was present in 5/86 (minimal in size in 3 cases and mild- moderate in 2). In 32/86 cases (37.2%), the severity of infection progressed from "severe" to "critical". Eleven patients (12.8%) died. sPAP and computed tomography score were associated with disease progression (P value = 0.002, 0.002 respectively). Tricuspid annular plane systolic excursion (TAPSE) was significantly higher in patients with no disease progression compared with those who deteriorated (P value = 0.005). Pericardial effusion (minimal, mild or moderate) was detected more often in progressive disease (P = 0.03). sPAP was significantly lower among survivors (P value = 0.007). Echocardiographic findings (including systolic PAP, TAPSE and pericardial effusion), total CT score may have prognostic and therapeutic implication in COVID-19 patients.

J wave syndrome: Benign or malignant?

J wave syndrome is an electrical disease of the heart due to pathologic early repolarization. It encompasses a clinical spectrum from aborted sudden cardiac death due to ventricular arrhythmia (VA) usually in young affected patients to self-terminating ventricular ectopies, and finally, asymptomatic relatives of probands detected during electrocardiography acquisition (early repolarization pattern). This syndrome consists of 2 phenotypes, early repolarization and Brugada syndrome. Herein, we first describe 2 patients with early repolarization and Brugada syndrome, then, discuss their definition, epidemiology, genetics, cellular mechanism, diagnosis, risk stratification, and finally, therapeutic challenges and options one by one in detail.

Metabolic risk factors and risk of Covid-19: A systematic review and meta-analysis.

OBJECTIVE: Based on the epidemiologic findings of Covid-19 incidence; illness and mortality seem to be associated with metabolic risk factors. This systematic review and meta-analysis aimed to assess the association of metabolic risk factors and risk of Covid-19. METHODS: This study was designed according to PRISMA guidelines. Two independent researchers searched for the relevant studies using PubMed, Web of Science, Cochrane Library, and Scopus. The search terms developed focusing on two main roots of "Covid-19" and "metabolic risk factors". All relevant observational, analytical studies, review articles, and a meta-analysis on the adult population were included in this meta-analysis. Meta-analysis was performed using the random effect model for pooling proportions to address heterogeneity among studies. Data were analyzed using STATA package version 11.2, (StataCorp, USA). RESULTS: Through a comprehensive systematic search in the targeted databases we found 1124 papers, after running the proses of refining, 13 studies were included in the present meta-analysis. The pooled prevalence of obesity in Covid-19 patients was 29% (95% CI: 14-47%). For Diabetes and Hypertension, these were 22% (95% CI: 12% 33%) and 32% (95% CI: 12% 56%), respectively. There was significant heterogeneity in the estimates of the three pooled prevalence without any significant small-study effects. Such warning points, to some extent, guide physicians and clinicians to better understand the importance of controlling co-morbid risk factors in prioritizing resource allocation and interventions. CONCLUSION: The meta-analysis showed that hypertension is more prevalent than obesity and diabetes in patients with Covid-19 disease. The prevalence of co-morbid metabolic risk factors must be adopted for better management and priority settings of public health vaccination and other required interventions. The results may help to improve services delivery in COVID-19 patients, while helping to develop better policies for prevention and response to COVID-19 and its critical outcomes.

Adverse electrocardiographic effects of rituximab infusion in pemphigus patients.

Pemphigus encompasses a group of chronic autoimmune blistering diseases of the skin and/or mucosa. Rituximab (RTX) has shown promising efficacy for the treatment of pemphigus in the past decade. Considering potential cardiac side effects, this study was conducted to assess the effects of RTX on electrocardiogram (ECG) parameters in pemphigus patients. This observational cross-sectional study was conducted in 80 consecutive patients with pemphigus who were eligible for RTX infusion. The patients' heart rhythm was monitored before, during and after RTX infusion and ECG parameters were compared before and after the infusion. Eighty patients were included in the study. The median age of the patients was 42 years. The mean and maximum heart rate (HR) increased significantly after RTX infusion compared with pre-infusion mean and maximum HR. The mean corrected QT (QTc) interval, premature atrial contraction (PAC), and premature ventricular contraction (PVC) counts increased significantly after RTX infusion (P value: 0.009, 0.004 and 0.007 respectively). According to the results of this study, RTX has potential arrhythmogenic side effects including increased mean and maximum HR, QTc interval, PAC and PVC count. However, these findings are minor and should not prevent eligible patients from receiving RTX infusion.

Secondary Cardiac T-Cell Lymphoma Presenting with Syncope and Refractory Complete Atrioventricular Block: A Case Report.

Cutaneous T-cell lymphomas constitute a rare category of non-Hodgkin lymphomas, which may involve the heart in the timeline of their natural course as an infrequent picture with a poor prognosis. Syncope, either due to outflow obstruction or conduction block, is also an uncommon presentation of cardiac metastasis. We herein describe a 35-year-old man, who presented with weight loss, dyspnea of 6 months' duration, an indolent skin ulcer in the left flank, lower limb deep vein thrombosis (DVT), and recurrent syncope. He underwent implantation of a permanent pacemaker due to a complete heart block and received anticoagulants for the DVT. Skin biopsy demonstrated a T-cell lymphoma. The syncopal episodes ceased thereafter. Echocardiography and computed tomography scan revealed cardiac metastasis, which responded to systemic chemotherapy. In the first follow-up visit after 3 months, he was still pacemaker-dependent. However, the DVT was partially resolved, and the symptoms had disappeared.

Complete heart block in a boy with hyperostosis-hyperphosphataemia syndrome: a case report.

BACKGROUND: Hyperostosis-hyperphosphataemia syndrome (HHS) is a rare metabolic disorder characterized by recurrent painful swelling of long bones and periosteal new bone formation. CASE SUMMARY: A 6-year-old boy was referred to our centre due to bradycardia. He was diagnosed with HHS 3 years' prior, after investigation for the cause of joint pain and genu valgum. During medical follow-up in 2013-16, the paediatric cardiologist discovered thickened and calcified mitral and aortic valves and progression of cardiac conduction disturbance from 1st degree to 3rd degree atrioventricular block (AVB). The patient died in 2017 due to multiorgan failure caused by hyperphosphataemia and ectopic calcification. DISCUSSION: Our case is unique in that ectopic calcification occurred in the aortic, mitral valve and cardiac conduction system, and AVB progressed from 1st degree to 3rd degree over time despite treatment with high-dose phosphate binders.

Gerbode type defect after trans-septal puncture for ablation of left-sided accessory pathway.

BACKGROUND: Trans-septal puncture (TSP) is a safe and effective method to approach left atrium and ventricle. Nowadays, cardiac electrophysiologists perform this procedure routinely to treat left-sided arrhythmias. CASE REPORT: A 45-year-old man was referred to our center due to Wolff-Parkinson-White (WPW) syndrome. After trans-septal puncture, contrast injection into the sheath showed that it was in the left ventricle (LV) rather than left atrium. Trans-esophageal echocardiography confirmed left ventricle outflow tract to right atrial (RA) jet. Follow-up echocardiography showed that the tract was present up to 18 months, but considering that the patient was asymptomatic, endovascular or surgical closure was not done. CONCLUSION: Our case with an 18-month follow-up period, highlights the conservative approach in asymptomatic patients with this complication.

Cardiac Resynchronization Therapy Device Implantation in a Patient with Congenitally Corrected Transposition of Great Vessels.

A 29-year-old woman was referred to our hospital due to exacerbation in dyspnea on exertion and easy fatigability. A known case of congenitally corrected transposition of the great vessels and congenital complete heart block, she had already received a permanent single-chamber pacemaker. Decision was made to implant a biventricular pacemaker for the treatment of the failing heart. Excellent coronary sinus lead implantation was done, conferring amelioration of symptoms, QRS narrowing in the electrocardiogram, and improvement of systemic ventricular systolic function in echocardiography. Over a 15-month follow-up period, she had no dyspnea on exertion. This case highlights the significance of upgrading pacemakers in patients with heart failure.

Efficacy of Intravenous Acetaminophen in Periimplantation Pain of Cardiac Electronic Devices: A Randomized Double-Blinded Study.

PURPOSE: Although intravenous acetaminophen has been administered to reduce postoperative pain, it has not been used during cardiac implantable electronic devices (CIEDs) implantation. DESIGN: This was a randomized double-blinded interventional study. METHODS: Thirty-two patients who were referred for new CIED implantation during July 2012 until April 2013 randomly received placebo or 1 g of intravenous acetaminophen. All patients were treated with local anesthesia. Pain score during incision, pocket creation, and in the recovery room, and the patients' need for analgesics during the 6 hours after the procedure were recorded in both groups. FINDINGS: Seventeen and 15 patients received acetaminophen and placebo, respectively. Pain scores in patients treated with acetaminophen were significantly lower (4.4 vs 2.9, P = .004), and they received less analgesics (17% vs 60%, P = .014). CONCLUSIONS: Intravenous administration of acetaminophen is effective for pain relief in patients undergoing CIED implantation and decreases the need for postoperative analgesics.