Same-Day Discharge After Left Bundle Area Pacing.

BACKGROUND: Left bundle area pacing (LBAP) has emerged as an area that appears to be an attractive alternative to other forms of physiological pacing owing to its ease and favorable pacing parameters. Same-day discharge after conventional pacemakers, implantable cardioverter defibrillators, and more recently leadless pacemakers have become routine, especially after the COVID-19 pandemic. With the advent of LBAP, the safety and feasibility of same-day discharge remain unclear. METHODS: This is a retrospective, observational case series of consecutive, sequential patients undergoing LBAP at Baystate Medical Center, an academic teaching hospital. We included all patients who underwent LBAP and were discharged on the same day of procedure completion. Safety parameters included any procedure-related complications including pneumothorax, cardiac tamponade, septal perforation, and lead dislodgement. Pacemaker parameters included pacing threshold, R-wave amplitude, and lead impedance pre-discharge the following day of implantation and up to 6 months of follow-up. RESULTS: A total of 11 patients were included in our analysis, the average age was 70.3 ± 6.74 years. The most common indication for pacemaker insertion was AV block (73%). No complications were seen in any of the patients. The average time between the procedure and discharge was 5.6 hours. Pacemaker and lead parameters were stable after 6 months of follow-up. CONCLUSIONS: In this case series, we find that same-day discharge after LBAP for any indication is a safe and feasible option. As this mode of pacing becomes increasingly more common, larger prospective studies evaluating the safety and feasibility of early discharge after LBAP will be needed.

Electrocardiogram changes as predictors for new imaging findings in repeat transthoracic echocardiography.

Aim: To determine if electrocardiogram (EKG) findings may be a useful tool to predict changes in repeat transthoracic echocardiogram (TTE). Methods: We evaluated patients who underwent TTE during hospitalization and their EKGs, and whether findings differed between studies. Results: Of 229 hospitalized patients who underwent repeat TTE, 183 (80%) were abnormal. Each minor and major EKG abnormality resulted in a 1.8 (1.2 to 2.6; p = 0.002) and 2.1 (1.3 to 3.3; p < 0.001) increased odds of abnormal imaging on TTE, respectively. The negative likelihood ratio for an unchanged EKG to predict an unchanged TTE was 0.68 (95% CI = 0.62 to 0.73). Conclusion: Among hospitalized patients with prior imaging results, an unchanged EKG predicts an unchanged TTE.

Very low tidal volume, high-frequency ventilation in atrial fibrillation ablation: a systematic review.

BACKGROUND: Ventilation strategies in atrial fibrillation ablation affect procedure outcomes by influencing catheter stability. Studies have highlighted favorable atrial fibrillation (AF) ablation outcomes with the use of high-frequency jet ventilation (HFJV) which has been shown to improve lesion durability, energy delivery, and tissue contact. However, this mode of ventilation is not readily available. In this systematic review, we highlight the available data on the use of very low tidal volume, high-frequency ventilation using standard ventilators that aim to provide settings similar to HFJV during AF ablations. METHODS: Using a combination of search terms in databases and manual searches in bibliographies of identified articles, we reviewed all published data reported in the English language on the use of very low tidal volume with high-frequency ventilation during atrial fibrillation ablation. RESULTS: A total of 4 manuscripts were identified; 3 cohort studies and 1 case report. The utilization of standard ventilators with a high-frequency, very low tidal volume ventilation strategy appears to closely mimic the catheter stability benefits that HFJV ventilators provide. Across the 3 cohort identified studies, the use of this ventilation strategy was associated with improved catheter stability, tissue contact, and a decrease in radiofrequency time. No increased risk was identified compared to standard ventilation. CONCLUSION: With a purpose of limiting thoracic excursion and cardiac movement, limited and sparse studies have shown improved outcomes with a very low tidal volume, high-frequency ventilation strategy. Additional studies are needed to solidify this easily accessible and widely available mode of ventilation.

Impact of Wire Sensor Location on Coronary Physiological Measurement.

BACKGROUND: The location of the wire sensor to measure fractional flow reserve (FFR) and diastolic pressure ratio (dPR) has not been systematically studied. Therefore, we hypothesize that the coronary physiological measurements will vary with the location of the sensor. METHODS: Fifty-four patients were screened, and 30 consecutive patients were enrolled. The OptoWire 2 or 3 generation fiberoptic pressure wire was used to assess whole cycle pressure distal/pressure aorta, dPR, and FFR. Our primary goal is to test if those measurements vary with the wire sensor placed at 10 mm (proximal), 35-45 mm (mid), and greater than or equal to 60-70 mm (distal) distal to the target lesion, respectively. We used a multilevel linear regression approach. RESULTS: Of 30 patients enrolled, 23 (76.6%) were males, mean age was 64.7 years (± 11.0 years), and mean stenosis was 61.6% (±13.4%). Adjusting for age, gender, and severity of stenosis, results showed that for all 3 measures (whole cycle pressure distal/pressure aorta, dPR, and FFR), pressure decreased in a linear fashion the further the sensor was from the target lesion ( P < 0.001). Further, pairwise comparisons of the measurements at adjacent locations similarly showed significant declines in pressure ( P < 0.001). CONCLUSIONS: This is the first study to demonstrate that the location of the pressure wire can impact the results of both resting and hyperemic pressures, which can cause a false-negative result. This is especially important where the values are near the cutoff.

Clozapine Intoxication in a Patient on Chronic Use With a Short-Term Noncompliance.

Clozapine has been associated with various adverse effects at both subtherapeutic and standard doses. These adverse effects are most commonly seen during the initiation of therapy in treatment-naïve patients. However, reports of intoxication in patients with long-term use of clozapine are yet to be documented. We highlight the case of a 42-year-old gentleman who had been on long-term clozapine use and presented with an altered mental status after being resumed on full standard doses without careful titration of clozapine after a short period of medication noncompliance. His workup in the hospital was largely unremarkable, and his presentation was attributed to the resumption of clozapine without medication titration. This is the first case to demonstrate the necessity of careful titration regardless of previous treatment history and highlights that patients should be started on clozapine at low levels to avoid the possibility of acute intoxication.

Staphylococcus Toxin-Mediated Motor Polyneuropathy.

Staphylococcus aureus infection is known to cause a variety of neurologic complications, most involving the CNS, however, rarely have cases of S. aureus affecting the peripheral nervous system been reported in literature. We report a case of S. aureus toxin-mediated motor polyneuropathy in a patient presenting with acute flaccid quadriplegia. CASE SUMMARY: A 64-year-old female with mantle cell lymphoma on oral chemotherapy with ibrutinib presents with malaise and progressive ascending bilateral lower extremity weakness. Blood cultures resulted positive for methicillin-sensitive S. aureus, and she was initiated on antibiotics. Imaging studies and laboratory workup were negative for other causes of acute flaccid quadriplegia. Patient had complete resolution of her neurologic deficits with antibiotic therapy. It was determined that the likely diagnosis was Staphylococcus toxin-mediated motor polyneuropathy. CONCLUSIONS: Staphylococcal-mediated motor polyneuropathy resulting in acute flaccid quadriplegia is a rare but treatable complication of bacteremia and should remain a diagnosis of exclusion.

Murine Typhus Presenting with Acute Psychosis and Disseminated Intravascular Coagulation: A Case Report.

Murine typhus is an endemic infectious disease caused by Rickettsia typhi and is transmitted by fleas. It typically causes a mild illness with symptoms of fever, rash, headache, chills, and non-specific gastrointestinal complaints. However, there have been no reported cases in the literature of murine typhus infection causing symptoms of acute psychosis and disseminated intravascular coagulation (DIC). A 30-year-old female with a history of gastric bypass and chronic pain syndrome presented to the emergency department with altered mental state and fever. She developed vivid visual hallucinations, DIC, and hypoxia with pulmonary opacities, ultimately requiring intubation. Magnetic resonance imaging (MRI) showed leptomeningeal enhancement with unremarkable cerebrospinal fluid (CSF) studies. Serum murine typhus serology came back positive. Doxycycline therapy was initiated, which resulted in complete patient recovery. This case shows that murine typhus infection may present with acute psychosis and can mimic DIC, leading to diagnostic confusion. MRI sequences may show leptomeningeal enhancement, which has never been reported before in patients with typhus. Early neurological imaging using advanced MRI sequences for patients presenting with altered sensorium, visual hallucinations, and symptoms similar to thrombotic thrombocytopenic purpura (TTP) may help with early diagnosis, decreased hospital stay, and better prognosis.

A Rare Presentation of Cardiac Aspergilloma in an Immunocompetent Host: Case Report and Literature Review.

Cardiac aspergilloma is exceptionally rare with only a handful of cases reported and majority of them being in immunocompromised patients. Here, we present a case of cardiac aspergilloma involving the right and left ventricle in an immunocompetent patient that initially presented with acute limb ischemia. He was later found to have a cardiac mass with histopathological diagnosis confirming Aspergillus species. Despite aggressive medical and surgical interventions, the patient had an unfavorable outcome due to low suspicion of invasive fungal endocarditis given his immunocompetent status. Cardiac aspergilloma should remain in the differential diagnosis of immunocompetent patients as early clinical suspicion will result in early treatment and decreased mortality. Novel therapies are required to decrease mortality in the future from this fatal disease.