Aortic root fistula complicating Austrian syndrome.

Austrian syndrome occurs in 1.2% of all patients with pneumococcal infective endocarditis. It presents with the triad of meningitis, pneumonia, and endocarditis. It is commonly seen in elderly males with a history of alcohol abuse, an immunocompromised state, or recent valve surgery. We present a case of Austrian syndrome presenting with paravalvular complications in the form of aortic root fistula. In this report, we describe the second patient with the community-acquired, pneumococcal, native, aortic valve, endocarditis with Austrian syndrome complicated by the development of an aortic fistula.

In-hospital outcomes of angiography versus intravascular ultrasound-guided percutaneous coronary intervention in ST-elevation myocardial infarction patients.

BACKGROUND: We compared the in-hospital complications, outcomes, cost, and length of stay (LOS) between angiography-guided percutaneous coronary intervention (PCI) and intravascular ultrasound (IVUS)-guided PCI in patients with ST-elevation myocardial infarction (STEMI) in the USA. METHODS: A nationwide inpatient database was queried to identify patients >18 years with STEMI who underwent angiography-guided and IVUS-guided PCI from January 2016 to December 2016. We compared the in-hospital mortality, complications, cost, and LOS between the two groups. RESULTS: We identified 100,485 patients who underwent angiography-guided PCI and 5,460 patients who underwent IVUS-guided PCI. In-hospital mortality was not statistically different (odds ratio [OR] 0.76, 95% CI 0.46 - 1.22, P = 0.24). Patients who underwent PCI with IVUS were more likely to have coronary artery dissection (OR 4.26, 95% CI 2.34 - 7.7, p = <0.01), and both groups had a similar incidence of acute kidney injury requiring hemodialysis. The mean LOS was similar, but the mean total cost was higher in the group that underwent PCI under IVUS guidance. CONCLUSIONS: The in-hospital mortality, hemodialysis, and the use of support devices did not reach a statistical difference between the two groups. However, we observed higher rates of coronary dissection with the use of IVUS in STEMI management.

Meta-Analysis of Transcatheter Aortic Valve Replacement in Low-Risk Patients.

PURPOSE: This study evaluated the efficacy and safety of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) in low surgical risk patients. METHODS: An electronic database search was conducted for randomized controlled trials (RCTs). We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) using a random-effects model. RESULTS: Five RCTs were identified with a total of 3,072 patients (mean age 74.5 ± 6.1 and 64.8% male). Compared with SAVR, TAVR was associated with a significantly reduced rate of death or disabling stroke (HR = 0.52; 95% CI = 0.27-0.99; P = .049), atrial-fibrillation (HR = 0.28; 95% CI = 0.18-0.46; P < .01), and post-procedure bleeding (HR = 0.38; 95% CI = 0.31-0.46; P < .01), along with a significantly improved quality-of-life at 1-year. However, TAVR was associated with significantly increased rates of paravalvular leak (HR = 4.09; 95% CI = 1.92-8.69; P < .01) and pacemaker insertion (HR = 2.81; 95% CI = 1.85-4.28; P < .01) compared with SAVR. CONCLUSION: Among older low-risk patients with severe aortic stenosis, TAVR is associated with a lower rate of death or disabling stroke compared with SAVR. Transcatheter aortic valve replacement is also associated with improved quality-of-life, reduced bleeding and atrial fibrillation, but higher paravalvular leak and pacemaker implantation rates.

Impact of an integrated care program on glycemic control and cardiovascular risk factors in patients with type 2 diabetes in Saudi Arabia: an interventional parallel-group controlled study.

BACKGROUND: Long intervals between patient visits and limited time with patients can result in clinical inertia and suboptimal achievement of treatment goals. These obstacles can be improved with a multidisciplinary care program. The present study aimed to assess the impact of such a program on glycemic control and cardiovascular risk factors. METHODS: In a randomized, parallel-group trial, we assigned 263 patients with poorly controlled type 2 diabetes mellitus (T2DM) to either a control group, standard care program, or a multidisciplinary care program involving a senior family physician, clinical pharmacy specialist, dietician, diabetic educator, health educator, and social worker. The participants were followed for a median of 10 months, between September 2013 and September 2014. Glycated hemoglobin (HbA1c), fasting blood glucose (FBG), lipid profiles, and blood pressure (BP) were measured. The assignment was blinded for the assessors of the study outcomes. The study registry number is. RESULTS: In the intervention group, there were statistically significant (p < 0.05) post-intervention (relative) reductions in the levels of HbA1c (-27.1%, 95% CI = -28.9%, -25.3%), FBG (-17.10%, 95% CI = -23.3%, -10.9%), total cholesterol (-9.93%, 95% CI = -12.7%, -7.9%), LDL cholesterol (-11.4%, 95% CI = -19.4%, -3.5%), systolic BP (-1.5%, 95% CI = -2.9%, -0.03%), and diastolic BP (-3.4%, 95% CI = -5.2%, -1.7%). There was a significant decrease in the number of patients with a HbA1c ≥10 (86 mmol/mol) from 167 patients at enrollment to 11 patients after intervention (p < 0.001). However, the intervention group experienced a statistically significant increase in body weight (3.7%, 95% CI = 2.9%, 4.5%). In the control group, no statistically significant changes were noticed in different outcomes with the exception of total cholesterol (-4.10%, p = 0.07). In the linear regression model, the intervention and the total number of clinic visits predicted HbA1c improvement. CONCLUSIONS: Implementation of a patient-specific integrated care program involving a multidisciplinary team approach, frequent clinic visits, and intensified insulin treatment was associated with marked improvement in glycemic control and cardiovascular risk factors of poorly controlled T2DM patients in a safe and reproducible manner. TRIAL REGISTRATION: ISRCTN Identifier: ISRCTN83437562 September 19, 2016 Retrospectively registered.

Arrhythmias and Electrocardiographic Changes in Systolic Heart Failure.

BACKGROUND: Heart failure is a common condition that that leads to hospitalization. It is associated with various atrial and ventricular arrhythmias. AIM: The aim of this study is to find common arrhythmias and electrocardiographic changes in hospitalized patients who have systolic heart failure. MATERIALS AND METHODS: This is a retrospective study of medical records, and electrocardiograms (EKGs) of 157 patients admitted to our hospital who had systolic heart failure with ejection fraction (EF) <50% on echocardiogram. Based on EF, the patients were divided into two groups; one with EF ≤ 35% and the other with EF > 35%. Twelve-lead EKG of these patients was studied to identify common arrhythmia and demographic variables; laboratory results were compared to identify the differences. RESULTS: A total of 157 patients with systolic heart failure, 63.7% had an EF ≤ 35%. Hypertension 82.8%, diabetes 49%, coronary artery disease 40.8%, chronic obstructive pulmonary disease or bronchial asthma 22.3%, and stroke 12.1% were common associated co-morbidities. On analysis of EKG, 28.6% had tachycardia, 21.9% had prolonged PR > 200 ms, 16.3% had wide QRS > 120 ms, 70.7% had prolonged corrected QT (QTc), and 42.2% had left axis deviation. The most common arrhythmias were sinus tachycardia and atrial fibrillation/flutter which were found in 14.6% and 13.4%, respectively. The left ventricular hypertrophy was a common abnormality found in 22.4% followed by ventricular premature contractions 18.4%, atrial premature contractions 9.5%, and left bundle branch block 6.1%. Patients with severe systolic heart failure had prolonged QRS (P = 0.02) and prolonged QTc (P = 0.01) as compared to the other group. CONCLUSIONS: Sinus tachycardia and atrial fibrillation/flutter were common arrhythmias in patients with systolic heart failure. Patients with severe systolic heart failure had statistically significant prolongation of the QRS duration and QTc interval.

Tricuspid valve endocarditis complicated by Mobitz type II heart block - a case report and literature review.

We present a case of a middle-aged male who manifested with low-grade fever and lower back pain. MRI and bone scan of the spine were suggestive of vertebral osteomyelitis. Blood cultures were persistently positive for Enterococcus faecalis and echocardiogram revealed tricuspid valve endocarditis. There was no history of IV drug use and urine toxicology was negative. EKG showed Mobitz type II AV block and a transesophageal echocardiogram revealed no valve ring or septal abscesses. The heart block persisted despite antibiotic therapy and an epicardial pacemaker was placed. This is a rare presentation of high-grade AV block with tricuspid endocarditis in the absence of echocardiographic evidence of perivalvular extension of infection. Also, unique in this case is the finding of E. faecalis hematogenous vertebral osteomyelitis.

Takotsubo cardiomyopathy precipitated by delirium tremens.

A 57-year-old woman presented with alcohol withdrawal symptoms, which later progressed to delirium tremens. During hospitalization, she developed respiratory distress with acute pulmonary edema. Electrocardiogram (ECG) showed diffuse ST elevation with elevated cardiac enzymes. Echocardiogram showed estimated ejection fraction of 20-25% with characteristic apical ballooning. After several days of supportive care, the patient showed significant clinical improvement with normalization of ECG, cardiac enzymes, and echocardiographic findings. Coronary angiogram revealed no coronary abnormalities. Although Takotsubo cardiomyopathy has been associated with diverse forms of physical or emotional stress, only a few cases have been described with delirium tremens in the medical literature.