Dronedarone for Atrial Fibrillation Prophylaxis in Patients Undergoing Open Heart Surgical Interventions: A Case Series.

Atrial fibrillation (a-fib) is one of the most frequently encountered and studied arrhythmias in medicine. The presence of A-fib in the post-operative period of coronary artery bypass graft (CABG) surgery is of particular concern for clinicians as this presents risks of post-operative stroke, hospital readmission, or anticoagulation dilemmas depending on the patient's comorbidities. In this case study, we present 5 patients who were treated with dronedarone prior to undergoing open heart procedures. We subsequently followed each patients clinical course paying close attention for any evidence of post-operative a-fib.

Transcatheter Recanalization of Atretic Pulmonary Veins in Infants and Children.

BACKGROUND: Pulmonary vein stenosis is a progressive disease associated with a high rate of mortality in children. If left untreated, myofibroblastic proliferation can lead to pulmonary vein atresia (PVA). In our experience, transcatheter recanalization has emerged as a favorable interventional option. We sought to determine the acute success rate of recanalization of atretic pulmonary veins and mid-term outcomes of individual veins after recanalization. METHODS: We reviewed all patients with PVA at our institution between 2008 and 2020 diagnosed by either catheterization or cardiac computed tomography. All veins with successful recanalization were reviewed and procedural success rate and patency rate were noted. Competing risk analysis was performed to demonstrate outcomes of individual atretic veins longitudinally. RESULTS: Between 2008 and 2020, our institution diagnosed and treated 131 patients with pulmonary vein stenosis. Of these, 61 patients developed atresia of at least one pulmonary vein. In total, there were 97 atretic pulmonary veins within this group. Successful recanalization was accomplished in 47/97 (48.5%) atretic veins. No atretic pulmonary veins were successfully recanalized before 2012. The majority of veins were recanalized between 2017 and 2020-39/56 (70%). The most common intervention after recanalization was drug-eluting stent placement. At 2-year follow-up 42.6% of recanalized veins (20.6% of all atretic veins) remained patent with a median of 4 reinterventions per person. CONCLUSIONS: Transcatheter recanalization of PVA can result in successful reestablishment of flow to affected pulmonary veins in many cases. Drug-eluting stent implantation was the most common intervention performed immediately post-recanalization. Vein patency was maintained in 42.6% of patients at 2-year follow-up from recanalization with appropriate surveillance and reintervention. Overall, only a small portion of atretic pulmonary veins underwent successful recanalization with maintained vessel patency at follow-up. Irrespective of successful recanalization, there was no detectable survival difference between the more recently treated PVA cohort and non-PVA cohort.

Incidence of Acute Ischemic Stroke in Hospitalized Patients With Atrial Fibrillation Who Had Anticoagulation Interruption: A Retrospective Study.

BACKGROUND: Atrial fibrillation (AF) is one of the leading causes of acute ischemic stroke requiring anticoagulation. Many patients experience treatment interruption in the hospital setting. The aim of this study was to evaluate the effect of anticoagulation interruption on short-term risk of ischemic stroke in hospitalized patients with AF. METHODS: We performed a retrospective medical record review using the Hospital Corporation of America (HCA) database. We included patients admitted to our institution between December 2015 and December 2018 who had a prior history of AF. Patients were excluded if they had ischemic stroke, hemorrhagic stroke, history venous thromboembolism or mechanical valve on admission. We compared the incidence of ischemic stroke in patients in whom anticoagulation was interrupted for more than 48 h to those who continued anticoagulation. RESULTS: A total of 2,277 patients with history of AF were included in the study. In this cohort, 79 patients (3.47%) had anticoagulation interruption of more than 48 h during their hospital stay. There was no difference in incidence of stroke between the interruption and no interruption groups (1.27% (n = 1) vs. 0.23% (n = 5), P = 0.19). Interruption of anticoagulation did not associate with a significant increase in the risk of in-hospital ischemic stroke. CHA2DS2VASc score was a strong predictor of in-hospital stroke risk regardless of anticoagulation interruption (odds ratio: 7.199, 95% confidence interval: 2.920 - 17.751). CONCLUSION: In this study, the in-hospital incidence of ischemic stroke in patients with AF did not significantly increase by short-term anticoagulation interruption.

Systemic Sirolimus Therapy for Infants and Children With Pulmonary Vein Stenosis.

BACKGROUND: Anatomic interventions for pulmonary vein stenosis (PVS) in infants and children have been met with limited success. Sirolimus, a mammalian target of rapamycin inhibitor, has demonstrated promise as a primary medical therapy for PVS, but the impact on patient survival is unknown. OBJECTIVES: The authors sought to investigate whether mTOR inhibition with sirolimus as a primary medical therapy would improve outcomes in high-risk infants and children with PVS. METHODS: In this single-center study, patients with severe PVS were considered for systemic sirolimus therapy (SST) following a strict protocol while receiving standardized surveillance and anatomic therapies. The SST cohort was compared with a contemporary control group. The primary endpoint for this study was survival. The primary safety endpoint was adverse events (AEs) related to SST. RESULTS: Between 2015 and 2020, our PVS program diagnosed and treated 67 patients with ≥moderate PVS. Of these, 15 patients were treated with sirolimus, whereas the remaining patients represent the control group. There was 100% survival in the SST group compared with 45% survival in the control group (log-rank p = 0.004). A sensitivity analysis was completed to address survival bias using median time from diagnosis of PVS to SST. A survival advantage persisted (log-rank p = 0.027). Two patients on sirolimus developed treatable AEs. Patients in the SST group underwent frequent transcatheter interventions with 3.7 catheterizations per person-year (25th to 75th percentile: 2.7 to 4.4 person-years). Median follow up time was 2.2 years (25th to 75th percentile: 1.2 to 2.9 years) in the SST group versus 0.9 years (25th to 75th percentile: 0.5 to 2.7 years) in the control group. CONCLUSIONS: The authors found a survival benefit associated with SST in infants and children with moderate-to-severe PVS. This survival benefit persisted after adjusting the analysis for survival bias. There were 2 mild AEs associated with SST during the study period; both patients were able to resume therapy without recurrence.

Aspiration Thrombectomy for Acute ST-Elevation Myocardial Infarction: Literature Review.

Over the years, aspiration thrombectomy for management of acute coronary syndrome was the center of discussion however due to multiple randomized control trials which did not provide sufficient evidence supporting use of this approach, this method is not routinely used. The benefit of this approach remains unknown, however, it is important to acknowledge the evolution of aspiration catheters and their potential in minimizing complications which were previously the set back of this approach. We provide a comprehensive review of the previous trials and how those catheters have since evolved significantly.

Use of Optical Coherence Tomography in Coronary Artery Disease: Review Article.

Optical coherence tomography is a catheter-based imaging modality in heart catheterizations, which provides a significantly higher resolution of intravascular pathology by means of using light as opposed to ultrasound. The applications of this modality may include a detailed assessment of atherosclerotic plaques, stent evaluation including coverage and restenosis and percutaneous coronary intervention optimization. In this article, we provide a review of current literature highlighting the advantages and disadvantages of the use of optical coherence tomography in the catheterization lab.

Takotsubo cardiomyopathy and its variants: a case series and literature review.

Over the years, Takotsubo Cardiomyopathy (TCMP) has become increasingly apparent, now comprising a significant portion of patients presenting with suspected acute coronary syndrome. The most common presentation of TCMP is ST segment elevation on EKG, troponin elevation, and apical ballooning in the absence of significant coronary artery disease as seen via cardiac catheterization. Although this is the most common presentation, it is important to highlight the less common variants of TCMP. In this article, we present a case series of patients presenting with the different variants of TCMP, followed by a literature review.

The role of virtual colonoscopy in colorectal screening.

Colorectal cancer is the second leading cause of cancer-related deaths in the United States. The earlier colorectal cancer is detected, the better chance a person has of surviving 5 years after being diagnosed, emphasizing the need for effective and regular colorectal screening. Computed tomographic colonography has repeatedly demonstrated sensitivities equivalent to the current gold standard, optical colonoscopy, in the detection of clinically relevant polyps. It is an accurate, safe, affordable, available, reproducible, quick, and cost-effective option for colorectal screening and should be considered for mass screening.

Cell division in Apicomplexan parasites is organized by a homolog of the striated rootlet fiber of algal flagella.

Apicomplexa are intracellular parasites that cause important human diseases including malaria and toxoplasmosis. During host cell infection new parasites are formed through a budding process that parcels out nuclei and organelles into multiple daughters. Budding is remarkably flexible in output and can produce two to thousands of progeny cells. How genomes and daughters are counted and coordinated is unknown. Apicomplexa evolved from single celled flagellated algae, but with the exception of the gametes, lack flagella. Here we demonstrate that a structure that in the algal ancestor served as the rootlet of the flagellar basal bodies is required for parasite cell division. Parasite striated fiber assemblins (SFA) polymerize into a dynamic fiber that emerges from the centrosomes immediately after their duplication. The fiber grows in a polarized fashion and daughter cells form at its distal tip. As the daughter cell is further elaborated it remains physically tethered at its apical end, the conoid and polar ring. Genetic experiments in Toxoplasma gondii demonstrate two essential components of the fiber, TgSFA2 and 3. In the absence of either of these proteins cytokinesis is blocked at its earliest point, the initiation of the daughter microtubule organizing center (MTOC). Mitosis remains unimpeded and mutant cells accumulate numerous nuclei but fail to form daughter cells. The SFA fiber provides a robust spatial and temporal organizer of parasite cell division, a process that appears hard-wired to the centrosome by multiple tethers. Our findings have broader evolutionary implications. We propose that Apicomplexa abandoned flagella for most stages yet retained the organizing principle of the flagellar MTOC. Instead of ensuring appropriate numbers of flagella, the system now positions the apical invasion complexes. This suggests that elements of the invasion apparatus may be derived from flagella or flagellum associated structures.

Incidence of new cardiovascular events in patients with and without peripheral arterial disease seen in a vascular surgery clinic.

BACKGROUND: To investigate the incidence of death and of new cardiovascular events at long-term follow-up of patients with and without PAD seen in a vascular surgery clinic. MATERIAL/METHODS: We investigated the incidence of death, new stroke/transient ischemic attack, new myocardial infarction, new coronary revascularization, new carotid endarterectomy, new peripheral arterial disease (PAD) revascularization, or at least one of the above outcomes at long-term follow-up of patients with and without PAD followed in a vascular surgery clinic. RESULTS: At least one of the above outcomes occurred in 259 of 414 patients (63%) with PAD at 33-month follow-up and in 21 of 89 patients (24%) without PAD at 48-month follow-up (p<0.0001). Death occurred in 112 of 414 patients (27%) with PAD and in 10 of 89 patients (11%) without PAD (p=0.002). Stepwise Cox regression analysis for the time to at least one of the 6 outcomes showed that significant independent risk factors were men (hazard ratio =1.394; 95% CI, 1.072-1.813; p=0.013), estimated glomerular filtration rate (hazard ratio =0.992; 95% CI, 0.987-0.997; p=0.003), and PAD (hazard ratio =3.520; 95% CI, 2.196-5.641; p<0.0001). Stepwise Cox regression analysis for the time to death showed that significant independent risk factors were age (hazard ratio =1.024; 95% CI, 1.000-1.049; p=0.048), estimated glomerular filtration rate (hazard ratio =0.985; 95% CI, 0.974-0.996; p=0.007), and PAD (hazard ratio =2.157; 95% CI, 1.118-4.160; p=0.022). CONCLUSIONS: Patients with PAD have a significantly higher incidence of cardiovascular outcomes, especially death, new PAD revascularization, and new carotid endarterectomy, than patients without PAD followed in a vascular surgery clinic.