Refractory Inappropriate Sinus Tachycardia Treated with Pulsed-field Ablation of the Sinus Node: A Breath of Fresh Air.

The pathogenesis of inappropriate sinus tachycardia is not well understood, and the symptoms of inappropriate sinus tachycardia can be difficult to manage. Here, we present a case of inappropriate sinus tachycardia refractory to medical therapy and discuss our approach to sinus node modification by catheter ablation.

Acute Cardiac Manifestations of SARS-CoV-2 Infection: Spotting the Clot.

A middle-aged gentleman presented with a one-week history of progressive dyspnoea on minimal exertion, persistent haemoptysis, and right calf swelling. His only past medical history of note was a recently positive SARS-CoV-2 nasopharyngeal swab performed as part of a workplace outbreak screening. A CT pulmonary angiogram (CTPA) showed bilateral pulmonary thrombi, extensive consolidation, and a left ventricular (LV) thrombus. A transthoracic echocardiogram (TTE) showed a dilated LV with severely impaired systolic function and LV thrombus. The patient was anticoagulated with warfarin, commenced on IV diuretics and COVID-19 protocol. Cardiac magnetic resonance (CMR) imaging showed a severely dilated nonischaemic cardiomyopathy with a heavy thrombus burden and a fibrosis pattern in keeping with myocarditis. We present a case of COVID-19-related myocardial dysfunction with high thrombotic burden and a discussion of its management.

Diagnosing, imaging, and successfully treating a debilitating case of Bing-Neel syndrome: A multidisciplinary feat.

Key Clinical Message: We present a case of Bing-Neel syndrome a rare central nervous system lymphoplasmocytic lymphoma associated with Waldenstrom macroglobulinemia. Diagnosis should be considered in the context of unexplained neurological symptoms in the presence of macroglobulinemia. Abstract: Waldenstroms macroglobulinaemia (WM) is a rare B-cell lymphoma representing ~2% of all hematological malignancies. While most neurological complications of WM are secondary to the overproduction of immunoglobulin M (IgM), Bing-Neel syndrome (BNS) is an extremely rare direct central nervous system (CNS) infiltration by malignant lymphoplasmocytic lymphoma (LPL) cells. Limited information on BNS exists in the literature with sparse case reports and case series. Here, we present a diagnostically challenging BNS case successfully treated with systemic chemoimmunotherapy and ibrutinib, with remarkable clinical response.

The therapeutic benefit of upgrade to cardiac resynchronization therapy in patients with pacing-induced cardiomyopathy.

Background: Pacing-induced cardiomyopathy (PICM) is an important cause of heart failure in patients with a right ventricular pacing burden. Recent evidence suggests that an upgrade to cardiac resynchronization therapy (CRT) may confer benefit in PICM. Objective: To assess the extent and identify predictors of improvement following upgrade to CRT in patients with PICM. Methods: We retrospectively analyzed 43 patients undergoing CRT upgrade for PICM over the 10-year period of 2011 to 2021 at our center. All patients with PICM who underwent device upgrade from a dual- or single-chamber ventricular pacemaker to CRT were included. PICM was defined as a decrease of ≥10% in left ventricular ejection fraction (LVEF), resulting in an LVEF <50% among patients with ≥20% Right ventricular pacing burden without an alternative cause for cardiomyopathy. Results: LVEF significantly improved from 28.7% preupgrade to 44.3% post-CRT upgrade (P < .01). Of 37 patients with severe LV dysfunction, 34 (91.9%) improved to an LVEF >35% and 13 (35.1%) improved to an LVEF >50%. The LV end-diastolic diameter decreased from 5.9 cm preupgrade to 5.4 cm postupgrade (P < .01). Using linear regression, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use was associated with significant LVEF improvement (+7.21%, P = .05). We observed a low rate of complications, and 1 in 4 CRT upgrades required venoplasty (n = 10 of 43, 23.3%). Conclusion: We provide further evidence for the benefit of CRT upgrade in the management of patients with PICM.

Real World Prescribing Strategies for Patients With an Indication for Oral Anticoagulation Undergoing Percutaneous Coronary Intervention.

BACKGROUND: Limited data are available regarding real-world prescribing in patients with an indication for oral anticoagulation (OAT) who undergo percutaneous coronary intervention (PCI). Most current guidelines recommend a period of triple therapy with OAT and dual antiplatelet (DAPT) agents over dual therapy with an OAT and DAPT but the clinical benefit is still unclear giving rise to limited evidence-based recommendations. AIM: To analyze the appropriateness of OAT and anti-platelet strategies post PCI in a real-world cohort of patients in 2 academic teaching hospitals. METHODS AND RESULTS: In total, 103 patients were retrospectively analyzed. As the initial 3 month stragey, 97 patients (94.2%) received triple therapy, 4 received Dual Therapy (3.9%) and 2 received DAPT (1.9%). Patients with predominant bleeding risk were significantly less likely to receive triple therapy (75% vs. 95.7% vs. 95.8%, P < 0.05). Apixaban was the most common OAT (65.7%) which in most cases was prescribed at an inappropriately reduced dose of 2.5 mg BD (80.4%). The MACE, bleeding and all-cause mortality rates did not differ significantly between groups. DISCUSSION: Our study demonstrates the widespread use of triple therapy for the first 3 months of treatment in 2 Irish academic hospitals. DOACs were prescribed in most cases at reduced doses not currently known to prevent stroke. This study highlights the need for more explicit management algorithms to improve evidence-based management in this area.

A systematic review of Appropriate Use Criteria for transthoracic echocardiography: are they relevant outside the United States?

INTRODUCTION: The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. Very few studies have assessed how medical centers overseas perform against AUC. Evidence is now emerging that inappropriate referral rates in Europe are similar to those reported in the US. OBJECTIVE: This study systematically reviewed published evidence to identify (1) whether the 2011 AUC are applicable to medical centers outside the US (2) the level of adherence to the AUC across multiple centers, (3) the main factors which cause deviation from AUC, (4) any changes in referral rates since the publication of AUC, and (5) any factors and/or intervention strategies which promote adherence to AUC. METHODS AND RESULTS: Electronic databases were systematically searched for papers related to AUC and cardiac imaging. Following screening and application of eligibility criteria, data was extracted from ten reports involving 8561 TTE studies. Classification rates were 99.5 and 98% for US studies and studies outside the US respectively. Overall, 7119 TTE studies were classified as appropriate (83.1%) of which 3724 were US referrals (84.7%) and 3395 originated outside the US (81.5%). Six of the included studies independently observed significantly more appropriate referrals among inpatients compared to outpatients (p < 0.001). US centers observed no significant difference in appropriate referral rates between physician specialties while one UK study showed cardiac surgeons ordered inappropriate TTEs more frequently than other specialties (p < 0.05). This review found no obvious trend in appropriate referral rates between 2012 and 2015 indicating no temporal change in physician ordering patterns. Only one educational interventional study met the author's criteria which showed that while intervention was effective during its implantation (26% reduction in TTEs ordered per day), TTE referral rates regressed to pre-intervention levels overtime. CONCLUSIONS: In conclusion, the American guideline AUC are applicable to centers outside the US and their implementation across five international centers suggest almost 1 in 5 scans could be avoided.

Biomarkers of glomerular dysfunction in pre-eclampsia - A systematic review.

BACKGROUND: Early detection of pre-eclampsia remains one of the major focuses of antenatal obstetric care. There is often a delay in the diagnosis, mainly due to the non-specific nature of the condition. Podocytes which play a pivotal role in glomerular function become injured in pre-eclampsia leading to subsequent proteinuria. Our aim was to review available studies to determine the clinical utility of biomarkers of podocyte injury in pre-eclampsia. METHODS: We used QUADAS (Quality Assessment of Diagnostic Accuracy Studies) criteria to perform a systematic review of the literature to determine the clinical utility of podocyte injury biomarkers in predicting pre-eclampsia. RESULTS: This study identified five potential renal biomarkers including podocytes, nephrin, synaptopodin, podocin and podocalyxin. The pooled sensitivity of all biomarkers was 0.78 (95% CI 0.74-0.82) with a specificity of 0.82 (95% CI 0.79-0.85). The area under the Summary of Receiver Operating Characteristics Curve (SROC) was 0.926 (SE 0.30). Urinary nephrin achieved the highest diagnostic values with a sensitivity of 0.81 (95% CI 0.72-0.88) and specificity of 0.84 (95% CI 0.79-0.84). CONCLUSION: Biomarkers of glomerular injury show promise as diagnostic aids in pre-eclampsia. A large-scale prospective cohort study is warranted before these biomarkers can be recommended for routine clinical care.

Appropriate use criteria for transthoracic echocardiography: Are they relevant to European centers?

BACKGROUND: There is a growing interest in appropriate use criteria (AUC) for cardiovascular imaging referrals in Europe. These criteria, developed by American subspecialty societies, have been in use since 2007 and show a temporal reduction in inappropriate transthoracic echocardiogram (TTE) requests. When applied to European centers, inappropriate referral rates as high as 15% have been observed. METHODS: A retrospective analysis of TTE referrals for appropriateness and major abnormality detection was conducted over a two-month period at Cork University Hospital (CUH). RESULTS: Overall, 1277 requests were assessed, of which 97.7% were classifiable. Of the 1235 classifiable studies, 1049 (84.9%) were appropriate, 135 (10.9%) were inappropriate, and 51 (4.1%) were uncertain. Main indications were the evaluation of cardiac structure and function (496, 40.2%), hypertension, heart failure or cardiomyopathy (349, 28.3%), and valvular function (228, 18.5%). Inappropriate referral rates were significantly higher for outpatients compared to inpatients (13.8% vs 7.1%, P < .05) and cardiologist referrals compared to noncardiologists (13.1 vs 8.0%, P < .05), while one in three requests for the evaluation of valvular function (32.5%) were inappropriate. Compared to inappropriate studies, appropriate and uncertain scans had a greater prevalence of ≥1 major abnormalities (33.6% vs 19.3%, P < .001) and greater detection rates of new abnormalities (27.6% vs 13.3%, P < .001). CONCLUSION: Application of the 2011 AUC yields similar results to those reported from the US. The application of said criteria to our center could avoid one of every ten scans currently ordered.

The potential therapeutic effects of ergothioneine in pre-eclampsia.

Ergothioneine (ERG), is a water-soluble amino acid that is derived entirely from dietary sources. It has received much attention as a therapeutic agent due to its anti-oxidant properties, and there are claims of preferential accumulation within high oxidative stress organs. Pre-eclampsia, a condition accompanied by increased oxidative stress, is one of the leading causes of maternal morbidity and mortality. Despite intense research efforts, its aetiologies remain somewhat unclear and there are still no effective treatment options. Clinical trials of the anti-oxidants vitamin C and vitamin E have proven largely ineffective with little improvement in clinical outcome or even a negative response. This could be explained in part by their inability to permeate the plasma and mitochondrial membranes and scavenge mitochondria-derived superoxide species, and for the former by the fact that it is actually a pro-oxidant in the presence of unliganded iron. ERG accumulates within tissues through the action of a specific organic cation transporter, SLC22A4 (previously referred to as OCTN1), which is possibly also expressed in mammalian mitochondria. Mitochondrial dysfunction has been implicated in a variety of vascular diseases including pre-eclampsia. This review discusses the use of ERG as a possibly mitochondrial-targeted anti-oxidant, focusing on its physical properties, potential mechanisms of action, safety profile and administration in relation to pregnancies complicated by pre-eclampsia.