Secondary tricuspid valve regurgitation after isolated aortic valve replacement: outcomes and predictors.

OBJECTIVES: We sought to assess the evolution of secondary tricuspid regurgitation (TR) after isolated aortic valve replacement (AVR) and its impact on mortality and to identify possible clinical and echocardiographic predictors of persisting and new-onset TR (TR de novo) after isolated AVR. METHODS: Clinical and echocardiographic data of 441 patients, consecutively operated for isolated AVR between January 2017 and January 2020, were retrospectively collected. Four time points were included: preoperative, discharge, 3-6 months and last available follow-up. We followed patients with at least moderate TR (TR ≥2) over time and monitored the impact on survival. Logistic regression analysis was performed to identify possible predictors of persistent TR and TR de novo. RESULTS: Median follow-up was 33 months. Incidence of TR ≥2 changed over the time points. Twenty-three percent of patients with preoperative TR ≥2 had persistent TR at 3-6 months follow-up, and this phenomenon was predicted by age at regression analysis. Preoperative TR ≥2 was associated with a 3-fold higher risk to die. At 3- to 6-month follow-up, 12% of patients developed TR de novo. At least moderate preoperative mitral regurgitation (≥2) was predictive of TR de novo. CONCLUSIONS: Patients with TR ≥2 undergoing isolated AVR had worse long-term survival, and this was particularly evident in the elderly. Older patients were also more prone to have persistent TR after AVR. Some patients developed TR de novo after isolated AVR, but this did not affect survival.

Pacemaker-mediated tachycardia with varying cycle length: what is the mechanism?

As new algorithms are being developed to promote intrinsic atrioventricular conduction in preventing the deleterious effects of right ventricular pacing, more complex rhythm strips can be encountered. In our patient with a dual-chamber implantable cardioverter-defibrillator, such an algorithm resulted in a pacemaker-mediated tachycardia with several changes in cycle length.

Common pitfalls and tips and tricks to get the most out of your transpulmonary thermodilution device: results of a survey and state-of-the-art review.

BACKGROUND: Haemodynamic monitoring with transpulmonary thermodilution (TPTD) is less invasive than a pulmonary artery catheter, and is increasingly used in the Intensive Care Unit and the Operating Room. Optimal treatment of the critically ill patient demands adequate, precise and continuous monitoring of clinical parameters. Little is known about staff knowledge of the basic principles and practical implementation of TPTD measurements at the bedside. The aims of this review are to: 1) present the results of a survey on the knowledge of TPTD measurement among 252 nurses and doctors; and 2) to focus on specific situations and common pitfalls in order to improve patient management in daily practice. METHODS: Web-based survey on knowledge of PiCCO technology (Pulsion Medical Systems, Feldkirchen, Germany), followed by PubMed and Medline search with review of the relevant literature regarding the use of TPTD in specific situations. RESULTS: In total, 252 persons participated in the survey: 196 nurses (78%) and 56 medical doctors (22%) of whom 17 were residents in training. Knowledge on the use of TPTD appears to be suboptimal, with an average score of 58.3%. Doctors performed better than nurses (62.7% vs 57.0%, P = 0.012). About 190 out of 252 (75.4%) scored at least 50% but only 45 respondents (17.9%) obtained a score of 70% or more. Having five years of PiCCO experience was present in 15.8% of the participants and this was correlated to passing the test, defined as obtaining a test result of ≥ 50% (P = 0.07) or obtaining a test result of ≥ 70% (P = 0.05). There were no other parameters significantly predictive for obtaining a result above 50% or above 70% such as gender or doctor versus nurse or Belgian versus Dutch residency, or years of ICU experience. High quality education of nursing and medical staff is necessary to perform the technique correctly and to analyse and interpret the information that can be obtained. Visual inspection of thermodilution curves is important as this can point towards specific pathology. Interpretation of the parameters that can be obtained with TPTD in specific conditions is discussed. Finally, a practical approach is given in ten easy steps for nurses and doctors. CONCLUSION: TPTD has gained its place in the haemodynamic monitoring field, but, as with any technique, its virtue is only fully appreciated with correct use and interpretation.

Full neurological recovery after extreme hypoglycemia during intensive insulin therapy: a case report.

Since 2000, there has been an ongoing debate regarding tightness of glycemic control in critically ill patients. An increased risk of hypoglycemia is observed in patients treated with an intensive insulin protocol targeting "normoglycemia," probably accounting for a reduction of the overall benefit. Hypoglycemia is associated with neurological side effects and is found to be an independent predictor of mortality in most trials; however, long-term sequelae are rare if glucose is administered early. We describe a case of prolonged, extreme hypoglycemia in a critically ill patient treated according to an intensive insulin protocol who recovered without any neurological deficit at discharge.

From trivial headache to life-threatening disease.

Sometimes, a clinical course that initially appears to be 'classic' turns out to be a manifestation of a rare disease. We report on a 62-year-old woman who presented initially with episodic headache, followed by cardiogenic shock. What was first thought to be an ST-segment elevation acute myocardial infarction, later to be a takostubo cardiomyopathy, finally appeared to be a catecholamine-induced cardiomyopathy due to a pheochromocytoma. This case illustrates that in a patient with presumed takotsubo cardiomyopathy and episodic headache, sweating, hypertension or tachycardia, pheochromocytoma needs to be excluded.

Idiopathic renal infarction.

BACKGROUND: Renal infarction may be an underrecognized disorder. Classical teaching holds that cardioemboli, notably in the setting of arterial fibrillation, are responsible. The expanding use of contrast enhanced computed tomography (CT) in patients with acute abdomen may change the spectrum of renal infarction. METHODS: Twenty-seven consecutive patients presenting to a single university hospital with nontraumatic CT-documented acute renal infarction were studied and stratified according to the presence or absence of cardiac disease, either obvious at presentation or detected during work-up. RESULTS: Eleven patients (41%) had obvious cardiac disease, including atrial fibrillation in all but one. Sixteen patients (59%) had no discernible structural or arrhythmic cardiac disease and were classified as idiopathic group. Patients in the idiopathic group were significantly younger (median age in years [interquartile range]: 48 [41-53] versus 75 [53-82] years, P = .003) and, besides smoking, had fewer traditional cardiovascular risk factors. CONCLUSION: Acute renal infarction may occur in individuals of middle age without risk factors for cardioembolism. In patients with renal colic without lithiasis the diagnosis of renal infarction should be considered especially if serum lactate dehydrogenase is elevated, even in the absence of atrial fibrillation.