Swallow Syncope Associated With Intermittent Sinus Pause and High-Degree Atrioventricular Block: A Case Report.

Swallow syncope, also known as deglutition syncope, is a relatively rare neurogenic disorder that is triggered by oral intake. When diagnosed, swallow syncope is treatable, but it is challenging to identify without proper history and prior knowledge of this disorder. Here, we describe the case of a 68-year-old female with a complex history who presented to the emergency room with complaints of worsening long-term intermittent lightheadedness and dizziness associated with swallowing. During her hospital stay, the patient was noted to have a high-degree atrioventricular block on telemetry during dinner time. A repeat electrocardiogram (ECG) demonstrated a prolonged P-R interval, and a temporal relationship between swallowing cold water and electrocardiogram (ECG) changes was demonstrated. A diagnosis of swallow syncope was confirmed. Electrophysiology was consulted and a pacemaker was placed. Symptoms of swallow-associated arrhythmias completely resolved after pacemaker implantation. This case illustrates the challenging problem of swallow syncope. While swallow syncope is highly treatable once identified, the challenge lies in identifying the disorder.

A Rare Case of Neurosyphilis with Ocular Involvement in a Patient with HIV Infection and New Onset Syphilis.

Neurosyphilis (NS) is more frequently seen in patients with human immunodeficiency virus (HIV) infection, especially those not on antiretroviral therapy or with a low CD4 cell count. Ocular syphilis is an unusual and early form of neurosyphilis. Lumbar puncture should be considered in all HIV infected patients who present with neurologic or ocular disease. A 47-year-old homosexual male with HIV-1 infection, on antiretroviral therapy (last CD4 cell count 1022 cells/µL) presented to our emergency department with a five-day history of headache, blurry vision, pain and redness of the left eye. He had unprotected anal sex with a new partner four months before presentation. Based on the fundoscopy findings as well as the cerebrospinal fluid (CSF) analysis on initial evaluation, a repeat serum rapid plasma reagin (RPR) along with microhemagglutination assay for treponema pallidum (MHA-TP) were done due to high suspicion of syphilis, even though an RPR five months prior to this visit was negative. Both RPR and MHA-TP were positive and the patient was treated for neurosyphilis. The patient's symptoms as well as the RPR titers improved significantly thereafter. A high index of suspicion for neurosyphilis should be maintained in HIV-infected patients presenting with ocular symptoms even if they are compliant with retroviral therapy with good CD4 cell counts. Physicians must be mindful of this uncommon presentation and consider a lumbar puncture in any patient with suspicion of neurosyphilis for prompt diagnosis and treatment to avoid further neurological complications.

Initial real world experience with a novel insertable (Reveal LinQ(@Medtronic)) compared to the conventional (Reveal XT(@Medtronic)) implantable loop recorder at a tertiary care center - Points to ponder!

INTRODUCTION: Limited data is available regarding the novel Reveal LinQ (LinQ) which is a new generation implantable loop recorders (ILRs). METHODS: We performed a prospective, observational study of all consecutive patients undergoing conventional (Reveal XT; XT) and LinQ devices at our institution between January 2012 and December 2014. RESULTS: A total of 217 patients underwent ILR implantation. XT was implanted in 105 and LinQ in 112 patients. There were no significant differences in baseline characteristics between the two groups. LinQ implantation using the manufacturer's technique termed, "manufacturer's method" group had significantly higher incidence of pocket infection compared to XT (6/50, 12% vs 3/105, 3%, p=0.032). With modifications to the LinQ implantation technique (using a conventional scalpel and placing a suture when needed to the incision) termed "modified method" group, the rate of infection has decreased significantly compared to "manufacturer's method group" (0/62, 0% vs 6/50, 12%, p=0.004) (Table 3). In multivariate regression analysis, the only independent predictors of infection were younger age (OR 0.95; p=0.04), insertion of LinQ device (OR 30.02; p=0.006) and procedure time (OR 1.07; p=0.03). CONCLUSION: In our single-center, prospective, observational study we found that with the current implantable techniques, the novel insertable LinQ device is associated with increased risk of complications.

Electrolyte and hemodynamic changes following percutaneous left atrial appendage ligation with the LARIAT device.

PURPOSE: The left atrial appendage (LAA) is a well-known source of atrial natriuretic peptide (ANP) and therefore plays an important role in homeostasis. The neurohormonal impact of epicardial exclusion of the LAA with the LARIAT procedure is unknown. In this proof-of-concept study, we postulated that LAA exclusion would impact homeostasis as evidenced by changes in electrolytes and blood pressure (BP). METHODS: A total of 76 patients who underwent successful LAA exclusion were enrolled in this retrospective observational study utilizing a prospective registry. Electrolytes, BP, and heart rate (HR) were monitored before LARIAT and post-LARIAT (24 and 72 h and 6 months). RESULTS: There was a significant reduction of systolic BP (mmHg) at 24 h (113.3 ± 16.0; p < 0.0001) and 72 h (119.0 ± 18.4 mmHg; p < 0.0001) post-LARIAT when compared with pre-LARIAT BP (138.2 ± 21.3). The reduction in systolic BP persisted at 6-month follow-up (128.8 ± 17.3; p = 0.0005). There was significant reduction in serum sodium (mmol/L) at 24 h (135.4 ± 3.6; p < 0.0001) and 72 h (136.3 ± 3.7; p < 0.001) post-LARIAT when compared to pre-LARIAT (138.7 ± 3.2). The reduction in sodium was not persistent at 6-month follow-up (138.4 ± 3.3; p = 0.453). CONCLUSIONS: LAA exclusion results in an early and persistent decrease in systolic BP. Additionally, there is an early decline in serum sodium, which normalizes at long-term follow-up. The underlying mechanism leading to these changes is not entirely clear; however, it is likely related to neurohormonal changes post LAA exclusion.

Alternative medicine in atrial fibrillation treatment-Yoga, acupuncture, biofeedback and more.

The last decade has seen a significant improvement in the management of atrial fibrillation (AF) with the development of newer medications and improvement in catheter ablation techniques. Recurrence of AF remains a significant problem in these patients and medications offer limited supportive role. Complementary and alternative treatment strategies therefore remain a viable option for these AF patients. Several studies have shown improvement in AF symptoms with yoga therapy, acupuncture and biofeedback. There are also several herbal medicine and supplements such as omega-3 fatty acids, antioxidant vitamins, barberry, motherwort, cinchona, Shensongyangxin, hawthorn, Kella and Wenxin Keli that have been evaluated as potential therapeutic options in AF. These studies are however limited by small sample sizes with mixed results. Besides the pharmacological action, metabolism, interactions with other medications and the adverse effects of the herbal medications and supplements remain poorly understood. In spite of the above limitations, complementary therapies remain a promising option in the management of AF and further studies are necessary to validate their safety and efficacy.

Pulmonary vein isolation for atrial fibrillation in the postpneumonectomy population: a feasibility, safety, and outcomes study.

BACKGROUND: Pulmonary vein isolation (PVI) of the remnant pulmonary vein (PV) stumps in pneumonectomy patients has not been well characterized. METHODS: This is a multicenter observational study of patients with a remnant PV stump after pneumonectomy. Consecutive patients with a history of pneumonectomy and who had undergone RF ablation for drug refractory AF were identified from the AF database at the participating institutions. RESULTS: There were 15 patients in whom pneumonectomy was performed, for resection of tumors in 10, infection in 4, and bullae in 1 patient and who underwent RF ablation for AF. The mean age was 63 ± 7 years. The stumps were from the right lower PV in 5, left upper PV in 5, left lower PV in 3, and right upper PV in 2 patients. All the PV stumps were electrically active with PV potentials and 9 (60%) of them had triggered activity. PVI was performed in 14 and focal isolation in 1 patient. At 1-year follow-up, 80% were free of AF, off of antiarrhythmic medications. CONCLUSION: PV stumps in AF patients with previous pneumonectomy are electrically active and are frequently the sites of active firing. Isolation of these PV stumps can be accomplished safely and effectively using catheter ablation with no practical concern for PV stenosis or compromising PV stump integrity.