A Review of Cardiac Implantable Electronic Device Infections for the Practicing Electrophysiologist.

Cardiovascular implantable electronic device (CIED) infections are morbid, costly, and difficult to manage. This review explores the pathophysiology, diagnosis, and management of CIED infections. Diagnostic accuracy has been improved through increased awareness and improved imaging strategies. Pocket or bloodstream infection with virulent organisms often requires complete system extraction. Emerging prophylactic interventions and novel devices have expanded preventative strategies and options for re-implantation. A clear and nuanced understanding of CIED infection is important to the practicing electrophysiologist.

Epicardial and Coronary Sinus Echocardiography.

Catheter-based ultrasonography is a widely used tool in cardiac electrophysiology practice, and intracardiac echocardiography is supplanting other forms of imaging to become the dominant imaging modality. Given advances in pericardial access, intrapericardial echocardiography can be performed using ultrasound catheters as well. Intrapericardial echocardiography and echocardiography from the coronary sinus, also an epicardial structure, allows interventionalists to obtain unique views from virtually any vantage point, compared with other forms of echocardiography. Both intrapericardial echocardiography and coronary sinus echocardiography are safe and important alternatives that can be used during complex procedures in the electrophysiology laboratory.

Parathyroid Hormone and Cardiac Electrophysiology: A Review.

Calcium has long been known to be essential to cardiac electrical activity. Parathyroid hormone (PTH) is the main regulator of serum calcium and is central to calcium homeostasis. Although there are significant data linking parathyroid disease states with changes in cardiac electrophysiology, most data have focused on how PTH modulates serum calcium to produce these effects. Close scrutiny of early literature demonstrates that the relationship between PTH and electrocardiographic changes is not straightforward, and numerous studies have linked PTH to arrhythmia. Basic science research has demonstrated that there is a basis for a direct role of PTH on cardiac electrophysiology outside of its effect on serum calcium. Later studies in secondary hyperparathyroidism indicate that PTH disturbances could have important implications for broad categories of patients with cardiovascular disease. The current review summarizes the existing literature on PTH and electrophysiology based on clinical and basic science studies of various parathyroid states, providing directions for future study.

Parathyroid hormone is related to QT interval independent of serum calcium in patients with coronary artery disease.

BACKGROUND: Elevated serum parathyroid hormone (PTH) is associated with increased risk of cardiovascular death, including sudden cardiac death, in patients with and without parathyroid disease. In small studies, PTH levels have been associated with changes in cardiac conduction and repolarization. Changes in the corrected QT interval (QTc) in particular are thought to be mediated by the effect of PTH on serum calcium. There is limited evidence to suggest PTH may affect cardiac physiology independent of its effects on serum calcium, but there is even less data linking PTH to changes in electrical conduction and repolarization independent of serum calcium. METHODS: ECG data were examined from the PULSE database-an observational cohort study designed to examine depression after acute coronary syndromes (ACS) at a single, urban American medical center. In all, 407 patients had PTH and ECG data for analysis. RESULTS: The QTc was longer in patients with elevated PTH levels compared with those without elevated PTH levels (451 ± 38.6 ms vs. 435 ± 29.8 ms; p < .001). The difference remained statistically significant after controlling for calcium, vitamin D, and estimated glomerular filtration rate (p = .007). Inclusion of left ventricular ejection fraction in the model attenuated the association (p = .054), suggesting that this finding may be partly driven by changes in cardiac structure. CONCLUSIONS: In one of the largest series to examine PTH, calcium, and QT changes, we found that elevated PTH is associated with longer corrected QT interval independent of serum calcium concentration in ACS survivors.

Relations among depressive symptoms, electrocardiographic hypertrophy, and cardiac events in non-ST elevation acute coronary syndrome patients.

AIMS: Cardiac outcomes after acute coronary syndrome (ACS) are worse in patients with depression, but identifying which depressed patients are at increased risk, and by what means, remains difficult. METHODS AND RESULTS: We analyzed inpatient electrocardiograms (ECGs) from 955 patients admitted with non-ST elevation ACS (NSTE-ACS) in the Prescription Use, Lifestyle, and Stress Evaluation (PULSE) study. Patients with QRS duration ⩾120 ms or whose rhythm was not normal sinus were excluded (sample size=769). Depressive symptoms were measured by Beck Depression Inventory score ⩾10. ECG markers included Cornell product-left ventricular hypertrophy (CP-LVH) and strain pattern in the lateral leads. In multivariable logistic regression models, depressive symptoms were associated with increased odds of CP-LVH, ECG-strain, and the combination of the two (odds ratios 1.74-2.33, p values <0.01). The combination of both CP-LVH and ECG-strain was predictive of one-year risk of myocardial infarction (MI) or death among patients with depressive symptoms (hazard ratio 4.91, 95% CI 1.55-15.61, p=0.007), but not among those without depressive symptoms (p value for interaction 0.043). CONCLUSION: In our non-ST elevation (NSTE)-ACS cohort, ECG markers of hypertrophy were both more common, and more predictive of MI/mortality, among those with depressive symptoms. Cardiac hypertrophy is a potential target for therapy to improve outcomes among depressed NSTE-ACS patients.

Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients.

OBJECT NSAIDs are effective perioperative analgesics. Many surgeons are reluctant to use NSAIDs perioperatively because of a theoretical increase in the risk for bleeding events. The authors assessed the effect of routine perioperative ketorolac use on intracranial hemorrhage in children undergoing a wide range of neurosurgical procedures. METHODS A retrospective single-institution analysis of 1451 neurosurgical cases was performed. Data included demographics, type of surgery, and perioperative ketorolac use. Outcomes included bleeding events requiring return to the operating room, bleeding seen on postoperative imaging, and the development of renal failure or gastrointestinal tract injury. Variables associated with both the exposure and outcomes (p < 0.20) were evaluated as potential confounders for bleeding on postoperative imaging, and multivariable logistic regression was performed. Bivariable analysis was performed for bleeding events. Odds ratios and 95% CIs were estimated. RESULTS Of the 1451 patients, 955 received ketorolac. Multivariate regression analysis demonstrated no significant association between clinically significant bleeding events (OR 0.69; 95% CI 0.15-3.1) or radiographic hemorrhage (OR 0.81; 95% CI 0.43-1.51) and the perioperative administration of ketorolac. Treatment with a medication that creates a known bleeding risk (OR 3.11; 95% CI 1.01-9.57), surgical procedure (OR 2.35; 95% CI 1.11-4.94), and craniotomy/craniectomy (OR 2.43; 95% CI 1.19-4.94) were associated with a significantly elevated risk for radiographically identified hemorrhage. CONCLUSIONS Short-term ketorolac therapy does not appear to be associated with a statistically significant increase in the risk of bleeding documented on postoperative imaging in pediatric neurosurgical patients and may be considered as part of a perioperative analgesic regimen. Although no association was found between ketorolac and clinically significant bleeding events, a larger study needs to be conducted to control for confounding factors, because of the rarity of these events.

Spindle cell sarcoma of the vulva with myofibroblastic differentiation.

OBJECTIVE: Primary vulvar sarcomas are rare lesions of the lower genital tract. We report the case of a patient with a spindle cell sarcoma of the vulva. MATERIALS AND METHODS: A 44-year-old woman presented with a painless vulvar mass. Vulvar biopsy demonstrated a spindle cell sarcoma with myofibroblastic differentiation. RESULTS: Pretreatment evaluation revealed no evidence of metastatic disease, and magnetic resonance imaging found no local masses. The patient underwent right radical vulvectomy with negative margins and tolerated the procedure well. CONCLUSIONS: Women undergoing gynecologic care should have routine evaluation of the vulva to detect these rare neoplasms.

Late repair of ischemic mitral regurgitation does not prevent left ventricular remodeling: importance of timing for beneficial repair.

BACKGROUND: Ischemic mitral regurgitation (MR) is a frequent complication of myocardial infarction associated with left ventricular (LV) dilatation and dysfunction, which doubles mortality. At the molecular level, moderate ischemic MR is characterized by a biphasic response, with initial compensatory rise in prohypertrophic and antiapoptotic signals, followed by their exhaustion. We have shown that early MR repair 30 days after myocardial infarction is associated with LV reverse remodeling. It is not known whether MR repair performed after the exhaustion of compensatory mechanisms is also beneficial. We hypothesized that late repair will not result in LV reverse remodeling. METHODS AND RESULTS: Twelve sheep underwent distal left anterior descending coronary artery ligation to create apical myocardial infarction and implantation of an LV-to-left atrium shunt to create standardized moderate volume overload. At 90 days, animals were randomized to shunt closure (late repair) versus sham (no repair). LV remodeling was assessed by 3-dimensional echocardiography, dP/dt, preload-recruitable stroke work, and myocardial biopsies. At 90 days, animals had moderate volume overload, LV dilatation, and reduced ejection fraction (all P<0.01 versus baseline, P=NS between groups). Shunt closure at 90 days corrected the volume overload (regurgitant fraction 6 ± 5% versus 27 ± 16% for late repair versus sham, P<0.01) but was not associated with changes in LV volumes (end-diastolic volume 106 ± 15 versus 110 ± 22 mL; end-systolic volume 35 ± 6 versus 36 ± 6 mL) or increases in preload-recruitable stroke work (41 ± 7 versus 39 ± 13 mL mm Hg) or dP/dt (803 ± 210 versus 732 ± 194 mm Hg/s) at 135 days (all P=NS). Activated Akt, central in the hypertrophic process, and signal transducer and activator of transcription 3 (STAT3), a critical node in the hypertrophic stimulus by cytokines, were equally depressed in both groups. CONCLUSIONS: Late correction of moderate volume overload after myocardial infarction did not improve LV volume or contractility. Upregulation of prohypertrophic intracellular pathways was not observed. This contrasts with previously reported study in which early repair (30 days) reversed LV remodeling. This suggests a window of opportunity to repair ischemic MR after which no beneficial effect on LV is observed, despite successful repair.

Patterns of care for craniopharyngioma: survey of members of the american association of neurological surgeons.

BACKGROUND: Initial therapy for craniopharyngioma remains controversial. Population-based datasets indicate that traditional algorithms [gross total resection (GTR) vs. subtotal resection (STR) +/- radiation therapy (XRT)] are often not employed. We investigated neurosurgical practice patterns. METHODS: A ten-question survey was electronically distributed to members of the American Association of Neurological Surgeons. Responses were analyzed using standard statistical techniques. RESULTS: 102 responses were collected, with a median of 25 craniopharyngiomas managed per respondent. 36% estimated that their practice included ≥75% pediatric patients and 61% had an academic practice. 36% would recommend observation or XRT for a suspected craniopharyngioma in the absence of a tissue diagnosis, with 46% of these indicating this recommendation in ≥10% of the cases. Following STR, 35% always recommend XRT and 59% recommend it in over half of the cases. However, following STR or biopsy alone, 18 and 11% never recommend XRT. There was no association between the type of practice (i.e. academic or ≥75% pediatric patients) and practice patterns. CONCLUSIONS: This survey verifies that a deviation from established algorithms is common, underscoring the clinical complexity of these patients and recent secondary data analyses. This should influence clinical researchers to investigate outcomes for patients treated using alternative methods. It will lend insight into appropriate treatment options and contribute to quality of life outcomes studies for craniopharyngioma.