Cardiac Arrest Research Articles

Polymorphic ventricular tachycardia and cardiac arrest from abiraterone-induced hypokalemia: a case report.

Polymorphic ventricular tachycardia (PMVT) is an unstable and often fatal cardiac tachyarrhythmia. While there are many causes of this rhythm, including electrolyte imbalances, ischemia, and genetic disorders, iatrogenic etiologies are important to recognize. Abiraterone is an androgen synthesis antagonist effective in treating prostate cancer, but here we describe a case of severe hypokalemia secondary to abiraterone resulting in polymorphic ventricular tachycardia and cardiac arrest. While this is a potential adverse effect of the medication, severe hypokalemia causing polymorphic ventricular tachycardia and cardiac arrest, as seen in our patient's case, has not been described. A 78-year-old African-American man with history of prostate cancer presents with polymorphic ventricular tachycardia and cardiac arrest. After resuscitation, he was found to be severely hypokalemic and refractory to large doses of repletion. Evaluation of secondary causes of hypokalemia identified the likely culprit to be adverse effects from prostate cancer treatment. A broad differential diagnosis for polymorphic ventricular tachycardia is essential in identifying and treating patients presenting in this rhythm. Here we present a case of iatrogenic polymorphic ventricular tachycardia secondary to oncologic treatment.

Performance of postmortem CT in the diagnosis of natural death from out-of-hospital cardiac arrest.

Postmortem CT (PMCT) is used widely to identify the cause of death. However, its diagnostic performance in cases of natural death from out-of-hospital cardiac arrest (OHCA) may be unsatisfactory because the cause tends to be cardiogenic and cannot be detected on PMCT images. We retrospectively investigated the diagnostic performance of PMCT in the diagnosis of natural death from OHCA and compared it to that of unnatural death. Our series included 450 cases; 336 were natural- and 114 were unnatural death cases. Between 2018 and 2022 all underwent non-contrast PMCT to identify the cause of death. Two radiologists reviewed the PMCT images and categorized them as diagnostic (PMCT alone sufficient to determine the cause of death), suggestive (the cause of death was suggested but additional information was needed), and non-diagnostic (the cause of death could not be determined on PMCT images). The diagnostic performance of PMCT was defined by the percentage of diagnosable and suggestive cases and compared between natural- and unnatural death cases. Interobserver agreement for the cause of death on PMCT images was also assessed with the Cohen kappa coefficient of concordance. The diagnostic performance of PMCT for the cause of natural- and unnatural deaths from OHCA was 30.3% and 66.6%, respectively (p < 0.01). The interobserver agreement for the cause of natural- and unnatural deaths on PMCT images was very good with kappa value 0.92 and 0.96, respectively. As PMCT identified the cause of natural death by OHCA in only 30% of cases, its diagnostic performance must be improved.

Cardiology: What You May Have Missed in 2023.

Cardiology and all its subspecialties continue to push the envelope in developing new treatment strategies for a wide variety of diseases. After screening more than 1300 articles, we highlight a selection of important cardiology articles published in 2023. Starting with prevention, we note articles that look at the effect of semaglutide in patients with obesity as well as a first-in-class drug, bempedoic acid, on cardiovascular outcomes. We have also examined new evidence comparing conservative management with invasive management of frail, older patients with non-ST-segment elevation myocardial infarction (NSTEMI). In patients with cardiac arrest secondary to NSTEMI, another article examines the rationale for expedited transfer to a cardiac arrest center. The STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) trial builds on looking at half-dose thrombolysis in older populations with STEMI. Emphasis is placed on guideline-directed medical therapy before hospital discharge in those with heart failure. In addition, in patients with stable symptomatic coronary artery disease, initial noninvasive testing using coronary computed tomography angiography may be a viable option compared with invasive strategies. More details have emerged on anticoagulation strategies in those with device-detected atrial fibrillation. Finally, transcatheter approaches to treat both mitral and tricuspid regurgitation have also been included.

Early diagnosis and treatment by newborn screening (NBS) or family history is associated with improved visual outcomes for long-chain 3-hydroxyacylCoA dehydrogenase deficiency (LCHADD) chorioretinopathy.

Long chain 3-hydroxyacyl-CoA dehydrogenase (LCHADD) is the only fatty acid oxidation disorder to develop a progressive chorioretinopathy resulting in vision loss; newborn screening (NBS) for this disorder began in the United States around 2004. We compared visual outcomes among 40 participants with LCHADD or trifunctional protein deficiency diagnosed symptomatically to those who were diagnosed via NBS or a family history. Participants completed ophthalmologic testing including measures of visual acuity, electroretinograms (ERG), fundal imaging, contrast sensitivity, and visual fields. Records were reviewed to document medical and treatment history. Twelve participants presented symptomatically with hypoglycemia, failure to thrive, liver dysfunction, cardiac arrest, or rhabdomyolysis. Twenty eight were diagnosed by NBS or due to a family history of LCHADD. Participants diagnosed symptomatically were older but had similar percent males and genotypes as those diagnosed by NBS. Treatment consisted of fasting avoidance, dietary long-chain fat restriction, MCT, C7, and/or carnitine supplementation. Visual acuity, rod- and cone-driven amplitudes on ERG, contrast sensitivity scores, and visual fields were all significantly worse among participants diagnosed symptomatically compared to NBS. In mixed-effects models, both age and presentation (symptomatic vs. NBS) were significant independent factors associated with visual outcomes. This suggests that visual outcomes were improved by NBS, but there was still lower visual function with advancing age in both groups. Early diagnosis and treatment by NBS is associated with improved visual outcomes and retinal function compared to participants who presented symptomatically. Despite the impact of early intervention, chorioretinopathy was greater with advancing age, highlighting the need for novel treatments.

Long-term clinical outcomes of intravascular imaging-guided percutaneous coronary intervention versus angiography-guided percutaneous coronary intervention in complex coronary lesions: a systematic review and meta-analysis.

Background: In this study, we aim to discuss the long-term clinical outcomes of intravascular ultrasound imaging-guided percutaneous intervention (IVUS-PCI) versus angiography-guided percutaneous coronary intervention (PCI) in complex coronary lesions over a mean period of 2years. Methods: A systematic search and meta-analysis were conducted to assess the efficacy of using intravascular ultrasound or optical coherence tomography guidance in coronary artery stenting compared to angiography. Results: A total of 11randomized controlled trialswith 6740 patients were included. For the primary outcome, a pooled analysis (3.2vs 5.6%). For secondary outcomes, the risk was significantly low in image-guided percutaneous intervention compared withangiography. Conclusion: Intravascular imaging-guided PCI is significantly more effective than angiography-guided PCI in reducing the risk of target lesion revascularization, target vessel revascularization, cardiac death, major adverse cardiovascular eventsandstent thrombosis.

Blood cardioplegia reduces intraoperative ventricular fibrillation and transfusion requirements compared to crystalloid cardioplegia in canine mitral valve repair.

Cardioplegic solutions are indispensable for open-heart surgeries, including mitral valve repair (MVR), a potentially curative treatment for myxomatous mitral valve disease in dogs. However, procedural methodologies are not fully established, and complications are yet to be comprehensively understood. Cardioplegic solutions contain various substances to protect the myocardium under temporal cardiac arrest. Nevertheless, ventricular fibrillation (VF) occurs as a common complication after releasing the crossclamp. Based on these backgrounds, the search for optimal cardioplegic solutions in dogs undergoing MVR is an urgent issue. This study aims to evaluate the occurrence of VF in dogs treated with blood cardioplegia (BCP) versus crystalloid cardioplegia (CCP) during MVR. A total of 251 client-owned dogs who underwent MVR from November 2015 to November 2017 were included. We retrospectively assessed the relationship between VF and type of cardioplegia (CCP or BCP) based on surgical records, including VF incidence, transfusion use, crossclamp time, and echocardiographic measurements. Logistic regression analysis showed that the CCP group was associated with the occurrence of VF (OR, 2.378; CI, 1.133-4.992; P = .022). In addition, the CCP group was associated with transfusion use (OR, 2.586; CI, 1.232-5.428, P = .022). There was no difference between the groups for the pre- and postoperative echocardiographic measurements. The BCP group had a lower incidence of VF and less transfusion use than the CCP group. This finding indicates that BCP may be a superior cardioplegic technique for MVR in dogs.

Nitric oxide and mitochondria injuries in kidney tissue upon a simulation of cardiopulmonary bypass and circulatory arrest: an experimental study

Introduction: Surgical interventions under cardiopulmonary bypass and circulatory arrest are complicated by impaired microcirculation in tissues; during hypoxic period the mitochondria dysfunction becomes the leading pathogenetic factor of ischemia-reperfusion injuries. In this regard, the search for methods of organ protection seems to be an extremely urgent task. The using of nitric oxide can be a promising technique given its pluripotent properties.Objective: The study was aimed to examining of mitochondria injuries in kidney biopsies stipulated by cardiopulmonary bypass and circulatory arrest when simulating cardiac surgery, as well as to assessing the potentials of organ protection with nitric oxide in the experiment.Methods: The study was carried out on Altai breed sheep and included simulating of cardiopulmonary bypass and circulatory arrest. The first group (n = 6) was provided with intraoperative nitric oxide donation. The second group (n = 6) served as a control (without nitric oxide donation). Mitochondria injuries were assessed in kidney biopsies by measuring transmembrane potential and Ca2+-binding capacity of organelles, as well as by determining ATP and lactate concentrations.Results: Nitric oxide therapy was associated with less mitochondria dysfunction in kidney biopsies compared with the control group. There was a steady trend to the amelioration of the energy maintenance in the renal parenchyma in the nitric oxide donation group.Conclusion: A steady trend towards optimizing the energy supply of tissues under cardiopulmonary bypass and circulatory arrest was revealed in an experiment against the background of NO donation at a concentration of 80 ppm. Received 11 February 2024. Revised 28 March 2024. Accepted 29 March 2024. Funding: The The study was carried out within the framework of the state assignment “Protection of organs by nitric oxide in cardiovascular surgery: technological support (synthesis and delivery devices), mechanisms for implementing protective effects and impact on clinical outcomes” (topic No. 122123000017-3). Conflict of interest: The authors declare no conflict of interest. Contribution of the authors Conception and study design: A.M. Boyko, N.O. Kamenshchikov, Yu.K. Podoksenov, L.N. Maslov, B.N. Kozlov Data collection and analysis: A.M. Boyko, Yu.S. Svirko, V.A. Lugovskiy, A.V. Mukhomedzyanov, B.A. BazarbekovaStatistical analysis: I.V. KravchenkoDrafting the article: A.M. Boyko Critical revision of the article: N.O. Kamenshchikov, A.G. Miroshnichenko, Yu.K. Podoksenov, M.L. Diakova, K.A. Petlin, D.S. Panfilov, B.N. KozlovFinal approval of the version to be published: A.M. Boyko, N.O. Kamenshchikov, A.G. Miroshnichenko, Yu.K. Podoksenov, Yu.S. Svirko, V.A. Lugovskiy, M.L. Diakova, I.V. Kravchenko, A.V. Mukhomedzyanov, L.N. Maslov, B.A. Bazarbekova, K.A. Petlin, D.S. Panfilov, B.N. Kozlov

An inherited life-threatening arrhythmia model established by screening randomly mutagenized mice

Inherited arrhythmia syndromes (IASs) can cause life-threatening arrhythmias and are responsible for a significant proportion of sudden cardiac deaths (SCDs). Despite progress in the development of devices to prevent SCDs, the precise molecular mechanisms that induce detrimental arrhythmias remain to be fully investigated, and more effective therapies are desirable. In the present study, we screened a large-scale randomly mutagenized mouse library by electrocardiography to establish a disease model of IASs and consequently found one pedigree that exhibited spontaneous ventricular arrhythmias (VAs) followed by SCD within 1 y after birth. Genetic analysis successfully revealed a missense mutation (p.I4093V) of the ryanodine receptor 2 gene to be a cause of the arrhythmia. We found an age-related increase in arrhythmia frequency accompanied by cardiomegaly and decreased ventricular contractility in the Ryr2I4093V/+ mice. Ca2+ signaling analysis and a ryanodine binding assay indicated that the mutant ryanodine receptor 2 had a gain-of-function phenotype and enhanced Ca2+ sensitivity. Using this model, we detected the significant suppression of VA following flecainide or dantrolene treatment. Collectively, we established an inherited life-threatening arrhythmia mouse model from an electrocardiogram-based screen of randomly mutagenized mice. The present IAS model may prove feasible for use in investigating the mechanisms of SCD and assessing therapies.

Certification Training and Liver Transplant Experience Improves Liver Procurement Outcomes: The Dutch Approach.

This study investigates the impact of certification training and liver transplant experience on procurement outcomes of deceased donor liver procurement in the Netherlands. Three groups (trainee, certified, and master) were formed, with further subdivision based on liver transplant experience. Three key outcomes-surgical injury, graft discard after injury, and donor hepatectomy duration-were analyzed. There were no significant differences in surgical graft injury in the three groups (trainee, 16.9%; certified, 14.8%; master, 18.2%; P = 0.357; 2011 to 2018). The only predictor for surgical graft injury was donation after cardiac death (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.10-2.02). Of the three groups, the master group had the highest discard rate after surgical injury (trainee, 0%; certified, 1.3%; master, 2.8%; P = 0.013). Master group without liver transplant experience (OR, 3.16; 95% CI, 1.21-8.27) and male donor sex (OR, 3.58; 95% CI, 1.32-9.73) were independent risk factors for discarding livers after surgical injury. Independent predictors for shorter hepatectomy durations included donors older than 50 years (coefficient [Coeff], -7.04; 95% CI, -8.03 to -3.29; P < 0.001), and master group (Coeff, -9.84; 95% CI, -14.37 to -5.31; P < 0.001) and certified group with liver transplant experience (Coeff, -6.54; 95% CI, -10.83 to -2.26; P = 0.003). On the other hand, master group without liver transplant experience (Coeff, 5.00; 95% CI, 1.03-8.96; P = 0.014) and donation after cardiac death (Coeff, 10.81; 95% CI, 8.32-13.3; P < 0.001) were associated with longer hepatectomy durations. Training and certification in abdominal organ procurement surgery were associated with a reduced discard rate for surgical injured livers and shorter hepatectomy times. The contrast between master group with and without liver transplant experience underscores the need for specialized training in this field.

Ischemia-Guided Coronary Revascularization Following Lower-Extremity Revascularization Improves 5-Year Survival of Patients With Chronic Limb-Threatening Ischemia.

To determine whether diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with targeted coronary revascularization of ischemia-producing coronary lesions following lower-extremity revascularization can reduce adverse cardiac events and improve long-term survival of patients with chronic limb-threatening ischemia (CLTI). Prospective cohort study of CLTI patients with no cardiac history or symptoms undergoing elective lower-extremity revascularization. Patients with pre-operative coronary computed tomography angiography (CTA) and FFRCT evaluation with selective post-operative coronary revascularization (FFRCT group) were compared with patients with standard pre-operative evaluation and no post-operative coronary revascularization (control group). Lesion-specific coronary ischemia was defined as FFRCT≤0.80 distal to a coronary stenosis with FFRCT≤0.75 indicating severe ischemia. Endpoints included all-cause death, cardiac death, myocardial infarction (MI) and major adverse cardiovascular (CV) events (MACE=CV death, MI, stroke, or unplanned coronary revascularization) during 5 year follow-up. In the FFRCT group (n=111), FFRCT analysis revealed asymptomatic (silent) coronary ischemia (FFRCT≤0.80) in 69% of patients, with severe ischemia (FFRCT≤0.75) in 58%, left main ischemia in 8%, and multivessel ischemia in 40% of patients. The status of coronary ischemia in the control group (n=120) was unknown. Following lower-extremity revascularization, 42% of patients in FFRCT had elective coronary revascularization with no elective revascularization in controls. Both groups received guideline-directed medical therapy. During 5 year follow-up, compared with control, the FFRCT group had fewer all-cause deaths (24% vs 47%, hazard ratio [HR]=0.43 [95% confidence interval [CI]=0.27-0.69], p<0.001), fewer cardiac deaths (5% vs 26%, HR=0.18 [95% CI=0.07-0.45], p<0.001), fewer MIs (7% vs 28%, HR=0.21 [95% CI=0.10-0.47], p<0.001), and fewer MACE events (14% vs 39%, HR=0.28 [95% CI=0.15-0.51], p<0.001). Ischemia-guided coronary revascularization of CLTI patients with asymptomatic (silent) coronary ischemia following lower-extremity revascularization resulted in more than 2-fold reduction in all-cause death, cardiac death, MI, and MACE with improved 5 year survival compared with patients with standard cardiac evaluation and care (76% vs 53%, p<0.001). Silent coronary ischemia in patients with chronic limb-threatening ischemia (CLTI) is common even in the absence of cardiac history or symptoms. FFRCT is a convenient tool to diagnose silent coronary ischemia perioperatively. Our data suggest that post-surgery elective FFRCT-guided coronary revascularization reduces adverse cardiac events and improves long-term survival in this very-high risk patient group. Randomized study is warranted to finally test this concept.

Genetics in the diagnosis and treatment of cardiovascular diseases

Cardiovascular diseases (CVDs) remain one of the leading causes of morbidity and mortality worldwide, with genetics being a major risk factor. Genetic cardiovascular disease can occur either because of single variant (Mendelian) or polygenic influences and has been linked to inherited cardiovascular conditions (ICC) such as arrhythmias, cardiomyopathies, dyslipidemias, and aortopathies which are significant factors leading to sudden cardiac death in young adults. Timely screening, diagnosis, and management of ICC can not only provide life-saving treatment to a patient, but also identify at-risk family members. The field of pharmacogenomics (PGx) helped to understand the variable action of medications such as clopidogrel, aspirin, warfarin, and statin according to genotype. Newer technologies such as multi-omics can combine data from multiple sources such as genomics, epigenomics, transcriptomics, proteomics, metabolomics, and microbiome. These advancements can contribute to the development of polygenic prediction scores and precision medicine tailored to individual genotypes. Substantial strides have been made in genetic-based therapeutics, gene editing technologies, and drug delivery systems, which have significantly expanded treatment options for patients with acquired or inherited CVDs. Although variable, the country- and society-specific guidelines on genetic testing for ICC and PGx and treatment are being continuously updated to keep up with ongoing research in the field. Along with appropriate knowledge, other factors including cost and availability of genetic testing play a vital role in the usage by both physicians and patients. With the advent of newer genetic testing for CVDs, a key factor is the availability of genetic counselors (GCs) who are specifically trained in cardiovascular genomics. The current review provides a concise summary of the major influences of genetics in the diagnosis and treatment of CVDs.

Sinus arrest during thoracic drain placement in a dog

AbstractA 5‐year‐old female neutered Podenco Canario dog presented with a moderate pleural effusion and subsequently underwent placement of bilateral thoracic drains. Pre‐medication consisted of intravenous medetomidine (2 µg/kg) and methadone (0.2 mg/kg), followed by induction with propofol (2.1 mg/kg, via intravenous administration). Anaesthesia was maintained with isoflurane in 100% oxygen. The modified Seldinger technique was used to place bilateral small‐bore, wire‐guided thoracic drains. During placement of the first chest drain, the dog developed sinus arrest. It is suspected that there was direct vagal nerve stimulation by the guide wire during placement, leading to severe bradycardia and subsequent sinus arrest that was responsive to atropine. It is important to note that the definitive cause of the transient cardiac arrest could not be ascertained. It is possible that this is a rare complication of thoracic drain placement, warranting further research in this area.

Near-Infrared Spectroscopy in Pediatric Cardiac Arrest: A Piece of the Clinical Picture.

Near-Infrared Spectroscopy in Pediatric Cardiac Arrest: A Piece of the Clinical Picture.

Successful Implantation of Rapid Deployment Aortic Valve after TAVR Explantation.

Transcatheter aortic valve replacement (TAVR) has become widely used in recent years, However, there is also an increasing need for removal of TAVR valves due to prosthetic valve dysfunction (PVD) and the development of infective endocarditis. Surgical aortic valve replacement (AVR) for these patients is risky due to the original patient background and anatomic conditions. Intuity rapid deployment aortic valve (Edwards Lifesciences, Irvine, CA) replacement would be useful for such high risk patients to prevent longer cardiac arrest time and obtain good hemodynamic results. However, there are few reports which present Intuity valve replacement after TAVR explantation. Herein, We report two cases in which we have achieved good hemodynamics with shorter cardiac arrest times by using a rapid deployment valve after TAVR explantation. We present 2 cases of successful implantation of the Intuity rapid deployment valve after TAVR explantation. The 84- and 88-year-old female patients had previously received TAVR for severe aortic stenosis with SAPIEN XT (Edwards Lifesciences, Irvine, CA) and developed PVD during follow-up. The TAVR valve was removed carefully, then an Intuity valve was implanted with cardiac arrest times of 69 and 41min. Both patients had good echocardiographic results with effective orifice area of 2.0cm2 and 1.2cm2 and mean trans-aortic plessure gradient of 9 mmHg and 15 mmHg respectively without aortic regurgitation. They were discharged without major complications. Surgical AVR using a rapid deployment valve is a useful alternative to sutured AVR after TAVR valve explantation. It allows for shorter cardiac arrest times and better postoperative hemodynamics without major complication.

Therapeutic hypothermia after cardiac arrest: a literature review

Cardiac arrest is an event that provides an elevated mortality rate. When not fatal, it can lead to neurological and other systems impairment, which may affect the prognosis of the patient. To avoid cerebral damage related to the event, some methods are indicated including therapeutic hypothermia. However, it remains unknown yet how effective is this procedure to mitigate such risk. The purpose of this literature review consisted in the systematic review of current data in order to collect what is most relevant about hypothermia as a therapeutic modality in patients after cardiac arrest. Online databases like SCIELO, MEDLINE, LILACS and PUBMED were used for the development of this review. The choice of hypothermia as a therapeutic measure in the moment post-cardiac arrest has appeared as an effective choice, especially after the analysis of biological and biochemical markers and imaging exams, which are important neurologic outcomes predictors. The achievement of a lower temperature at a specific time has showed itself as an important aspect in the neurologic outcome improvement. Therefore, it contributes to the consolidation of the hypothermia as an effective approach post-cardiac arrest. Therefore, it is possible to determine that its use has been proven as beneficial.

Open aortic arch repair without circulatory arrest by frozen elephant trunk in Ishimaru zone 0

BackgroundOpen arch surgery is technically demanding for the surgeon and surgically and biologically invasive for the patient, requiring a variably long period of hypothermic circulatory arrest.Case presentationHere we present a case of an elderly patient with chronic renal failure and multiple splanchnic artery disease successfully treated for a rupturing pseudoaneurysm of the aortic arch with a technique that we developed for particularly frail patients. The procedure includes: triple supra-aortic vessel perfusion; distal thoracic aorta antegrade perfusion; balloon endo-clamping of the descending aorta; and anastomosis of an off-the-shelf hybrid arch prosthesis in Ishimaru zone 0. These maneuvers allowed to maintain an extracorporeal circulation in the phase of distal anastomosis, instead of a period of circulatory arrest, employing just mild hypothermia: technical details are depicted and discussed also in comparison with other methods proposed in the literature.ConclusionsBeing able to take advantage of both open surgery advancements and endovascular methods is the key to cardiovascular surgery success today in front of complex pathologies of the aorta: increasing safety and reducing invasiveness of therapeutic options may progressively extend surgical candidacy to the frailest patients.

A silent scream in the pediatric emergency department: child abuse and neglect.

Child abuse and neglect includes any behavior that harms the child or hinders the child's development. The aim of this study was to determine the demographic and clinical characteristics of patients with suspected child abuse or neglect in the pediatric emergency department. Between July 2017 and July 2022, patients admitted to our pediatric emergency department and consulted to the medical social services unit with a preliminary diagnosis of neglect and/or abuse were retrospectively scanned through the registry system. The patients were divided into five groups according to their victimization: physical, sexual, and emotional abuse; neglect; and medical child abuse (MCA)-Munchausen by proxy. A total of 371 children were included in the study. Two hundred twenty-two (59.8%) of the patients were female and the median age was 161months [IQR (46-192)]. Then, 56.3% of the patients were in the adolescent age group. The most common admission time period was between 16.00 and 24.00 (n 163, 43.9%). Then, 24.2% of the patients were exposed to physical abuse, 8.8% to sexual abuse, 26.1% to emotional abuse, 50.4% to neglect, and 3.2% to MCA. One hundred eight (29.1%) patients were followed up as inpatients in the pediatric intensive care unit. Four of the patients (1%) had out-of-hospital cardiac arrest, and the deaths were in patients under 2years of age. Conclusion: Pediatric emergency departments are one of the important units visited by child maltreatment patients. Victimized children may reflect their silent screams with various clinical presentations. Infants are at the greatest risk of suffering serious or fatal injuries. Health professionals working in the emergency department have an important role in detecting, treating, and preventing recurrence of child neglect and abuse. What is Known: • The pediatric emergency department is an important entry point in the health care system for children who experience maltreatment. • It has a wide spectrum of physical, sexual, emotional abuse and neglect. What is New: • A high index of suspicion is required to diagnose cases of child maltreatment. • Infants are at the greatest risk of suffering serious or fatal injuries.

Transapical intramyocardial septal microwave ablation in treatment of hypertrophic obstructive cardiomyopathy: 12-month outcomes of a swine model

BackgroundTo date, the extended Morrow procedure is considered the gold standard treatment for patients with obstructive hypertrophic cardiomyopathy who experience severe symptoms and are unresponsive to medication treatment. We therefore aimed to perform transapical intramyocardial septal microwave ablation to reduce the thickness of the interventricular septum myocardium in a minimally invasive method.MethodsFourteen swine were divided to form either a microwave ablation group (n = 7) or a sham group (n = 7). In the microwave ablation group, a transapical microwave antenna was inserted into the septum to ablate each myocardial segment at 40 W for 1 min, while in the sham group, the same operation was performed but without power output. We used echocardiography, electrocardiogram, during the operation. And added computerized tomography, cardiac nuclear magnetic resonance during follow-up.ResultsSegment hypokinesis was observed in all swine immediately following ablation. Compared with the sham group, the thickness of ablated segments in the ablation group decreased significantly 1 month post-operation (ablation group, 5.53 ± 1.00 mm vs. 8.03 ± 1.15 mm, respectively, P < 0.01; sham group, 8.40 ± 0.94 mm vs. 8.21 ± 1.09 mm, respectively, P = 0.081), and the outcome was still observed 1 year post-operation (ablation group, 3.36 ± 0.85 mm vs. 8.03 ± 1.15 mm, respectively, P < 0.01). No perforation of the septum was observed during the procedure or follow-up, and no heart failure or sudden cardiac death occurred during postoperative feeding.ConclusionsTransapical intramyocardial septal microwave ablation can effectively and safely produce a large region of necrosis. This technique can potentially mimic surgical myectomy while avoiding cardiopulmonary bypass and median sternotomy in high-risk hypertrophic obstructive cardiomyopathy patients.

The Physiologically Difficult Airway and Management Considerations

Abstract Purpose of Review This paper evaluates the recent literature regarding the physiologically difficult airway. Recent Findings Adverse events mainly desaturation, cardiovascular collapse, and cardiac arrest remain common complications. This risk is greatly increased in patients with altered physiology prior to intubation. Studies published over the last 5 years have explored many aspects surrounding the epidemiology, risks, and approach to managing the physiologically difficult airway. Summary Important work has been done to identify directly modifiable risks of complications related to the physiologically difficult airway, but a large percentage of patients remain at high risk despite optimizing induction agents, preoxygenation, and first attempt success.

Arrhythmogenesis in Fabry Disease.

Fabry Disease (FD) is a rare lysosomal storage disorder characterised by multiorgan accumulation of glycosphingolipid due to deficiency in the enzyme α-galactosidase A. Cardiac sphingolipid accumulation triggers various types of arrhythmias, predominantly ventricular arrhythmia, bradyarrhythmia, and atrial fibrillation. Arrhythmia is likely the primary contributor to FD mortality with sudden cardiac death, the most frequent cardiac mode of death. Traditionally FD was seen as a storage cardiomyopathy triggering left ventricular hypertrophy, diastolic dysfunction, and ultimately, systolic dysfunction in advanced disease. The purpose of this review is to outline the current evidence exploring novel mechanisms underlying the arrhythmia substrate. There is growing evidence that FD cardiomyopathy is a primary arrhythmic disease with each stage of cardiomyopathy (accumulation, hypertrophy, inflammation, and fibrosis) contributing to the arrhythmia substrate via various intracellular, extracellular, and environmental mechanisms. It is therefore important to understand how these mechanisms contribute to an individual's risk of arrhythmia in FD. In this review, we outline the epidemiology of arrhythmia, pathophysiology of arrhythmogenesis, risk stratification, and cardiac therapy in FD. We explore how advances in conventional cardiac investigations performed in FD patients including 12-lead electrocardiography, transthoracic echocardiography, and cardiac magnetic resonance imaging have enabled early detection of pro-arrhythmic substrate. This has allowed for appropriate risk stratification of FD patients. This paves the way for future work exploring the development of therapeutic initiatives and risk prediction models to reduce the burden of arrhythmia.