Single-center Study Of Consecutive Patients Research Articles

Prevalence and Risk Factors of Cerebral Microbleeds among Egyptian Patients with Acute Ischemic Stroke.

Cerebral microbleeds (CMBs) are markers of underlying hemorrhage-prone cerebral small vessel disease detected on MRI. They are associated with a heightened risk of stroke and cognitive decline. The prevalence of CMBs among Egyptian patients with ischemic stroke is not well studied. Our aim was to detect the prevalence of CMBs and associated risk factors among Egyptian patients with ischemic stroke. A prospective, cross-sectional, single-center study of consecutive patients with ischemic stroke. Patients were recruited between January 2021 and January 2022 at the Assiut University Hospital in the south of Egypt. Patients with known bleeding diathesis were excluded. All participants underwent full neurological assessment, urgent laboratory investigations, and MRI with T2* sequence. The study included 404 patients, 191 (47.3%) of them were females. The mean age of the study population was 61 ± 1 years, and the mean NIHSS on admission was 12 ± 5. The prevalence of CMB was 26.5%, of whom 6.5% were young adults (age ≤45 years). CMBs were detected in 34.6% of patients with stroke caused by large artery atherosclerosis, 28.0% with small vessel disease stroke subtype, 25.2% with stroke of undetermined cause, and in 12.1% with cardioembolic stroke. History of AF, hypertension, dyslipidemia, Fazekas score >2, dual antiplatelet use, combined antiplatelet with anticoagulant treatment, and thrombolytic therapy remained independently associated with CMBs following multivariable regression analyses. The high number of identified CMBs needs to inform subsequent therapeutic management of these patients. We are unable to determine whether the association between CMBs and antithrombotic use is a causal relationship or rather confounded by indication for these treatments in our observational study. To understand more about the underlying cause of this finding, more studies are needed.

The role of gender in resting full-cycle ratio (RFR) guided coronary revascularization

BackgroundGender-based differences in clinical outcomes of patients undergoing fractional flow reserved (FFR) guided coronary revascularization is well documented. This study aimed to compare resting full-cycle ratio (RFR) values between men and women and whether this translated into difference in clinical outcomes in patients who underwent RFR-guided coronary revascularization. MethodsThis was a retrospective single-centre study of consecutive patients who underwent RFR-guided revascularization for coronary lesions with intermediate degree of stenosis. The primary endpoint was a composite of all-cause mortality, myocardial infarction (MI), unplanned revascularization, and unstable angina requiring hospital admission at one year. ResultsIn 373 consecutive patients (510 lesions, 26% women) there was no statistically significant difference in RFR value between men and women (0.90 ± 10 versus 0.90 ± 11, P = 0.95). There was no statistically significant difference between men and women in the primary endpoint, even after adjustment to the imbalance between the two groups [3.7% vs. 3.0%; HR 1.43, 95% CI (0.46 to 4.43), P = 0.54]; or its individual components of death (1.1% vs 0.8%, P = 0.76), MI (1.9% vs 0.8%, P = 0.38) or unplanned revascularization, including unstable angina admissions (2.6% vs 2.3%, P = 0.82). The comparable clinical outcomes were consistent across all different subgroups, including clinical presentation, diabetes status, left ventricle systolic function, kidney function, and the interrogated coronary artery. ConclusionOur study suggests no significant gender-based difference in the value of RFR or 1-year clinical outcomes in patients undergoing resting physiology guided coronary revascularization.

Avoiding unnecessary sentinel lymph node biopsy with the use of superparamagnetic iron oxide mapping agents (Magtrace®) in breast surgery.

Superparamagnetic iron oxide (SPIO) (Magtrace®) is a non-radioactive liquid tracer that can stay in the sentinel lymph nodes for 30 days. Injection of SPIO at time of primary breast surgery where upfront sentinel lymph node biopsy (SLNB) is not immediately indicated allows for a return to theatre if pathology then identifies invasive disease. SLNB is associated with paraesthesia, pain, seroma formation and lymphoedema risk. Hence, our study aims to assess the use of SPIO to avoid upfront SLNB in breast surgery for ductal carcinoma in situ (DCIS) and prophylaxis. Retrospective single-centre study of consecutive patients who underwent injection of SPIO tracer at time of primary breast surgery to avoid upfront SLNB at Chris O'Brien Lifehouse, Sydney, NSW, Australia over a 10-month period. SPIO was injected 38 times, with 34 at time of mastectomy and four cases at time of wide local excision. The indication for surgery was DCIS in 18 cases, risk reduction in 17 cases and other indications in three patients. Six cases (15.8%) required delayed SLNB (D-SLNB) due to the finding of invasive disease on post-operative histopathology. All patients who underwent D-SLNB had nodes successfully localized with SPIO. In our cohort, 84.2% of cases were able to avoid upfront SLNB, and hence avoid the associated complications of SLNB. SPIO injection was successful in localizing the SLN in all cases at time of surgery for D-SLNB. This technique was safe with few associated complications.

Asystole on loop recorder in patients with unexplained syncope and negative tilt testing: age distribution and clinical predictors

BackgroundApproximately 50% of patients with unexplained syncope and negative head-up tilt test (HUTT) who have an electrocardiogram (ECG) documentation of spontaneous syncope during implantable loop recorder (ILR) show an asystolic pause at the time of the event.ObjectiveThe aim of the study was to evaluate the age distribution and clinical predictors of asystolic syncope detected by ILR in patients with unexplained syncope and negative HUTT.MethodsThis research employed a retrospective, single-center study of consecutive patients. The ILR-documented spontaneous syncope was classified according to the International Study on Syncope of Uncertain Etiology (ISSUE) classification.ResultsAmong 113 patients (54.0 ± 19.6 years; 46% male), 49 had an ECG-documented recurrence of syncope during the observation period and 28 of these later (24.8%, corresponding to 57.1% of the patients with a diagnostic event) had a diagnosis of asystolic syncope at ILR: type 1A was present in 24 (85.7%), type 1B in 1 (3.6%), and type 1C in 3 (10.7%) patients. The age distribution of asystolic syncope was bimodal, with a peak at age < 19 years and a second peak at the age of 60–79 years. At Cox multivariable analysis, syncope without prodromes (OR 3.7; p = 0.0008) and use of beta blockers (OR 3.2; p = 0.002) were independently associated to ILR-detected asystole.ConclusionsIn patients with unexplained syncope and negative HUTT, the age distribution of asystolic syncope detected by ILR is bimodal, suggesting a different mechanism responsible for asystole in both younger and older patients. The absence of prodromes and the use of beta blockers are independent predictors of ILR-detected asystole.

Device infection in patients undergoing pacemaker or defibrillator surgery: risk stratification using the PADIT score

BackgroundThe use of an antibacterial envelope is cost-effective for patients at high risk of developing cardiac implantable electronic device (CIED) infection. The identification of these high-risk patients may be facilitated using a clinical risk score. The aim of the current study is to evaluate the PADIT score for identifying high-risk patients in patients undergoing a CIED procedure in a tertiary academic center.MethodsThis was a retrospective single-center study of consecutive patients undergoing a CIED procedure between January 2016 and November 2021. Patients who received an antibacterial envelope were excluded from this study. The primary endpoint was hospitalization for a CIED infection in the first year after the procedure.ResultsA total of 2333 CIED procedures were performed in the study period (mean age 61.6 ± 16.3 years, male sex 64.5%, previous CIED infection 1.7%, immunocompromised 5.4%). The median PADIT score was 4 (interquartile range, 2–6). CIED infection occurred in 10 patients (0.43%). The PADIT score had good discrimination in predicting major CIED infection (C-statistic 0.70; 95% confidence interval [CI] 0.54 to 0.86, P = 0.03). Using an optimal PADIT score cut-off value of 7, the risk of CIED infection was higher in the patients with a PADIT score of ≥ 7 in comparison to those with a lower PADIT score (1.23% vs. 0.26%, P = 0.02; odds ratio 4.8, 95% CI 1.4 to 16.6, P = 0.01).ConclusionsThe PADIT score is a clinically useful score for identifying patients at high risk of developing CIED infection. The use of an antibacterial envelope in these high-risk patients may be cost-effective.Graphical

Immediate Lymphatic Reconstruction Using a Handheld Fluorescence Imaging Device.

Immediate lymphatic reconstruction (ILR) has traditionally required a fluorescent-capable microscope to identify lymphatic channels used to create a lymphaticovenous bypass (LVB). Herein, a new alternative method is described, identifying lymphatic channels using a commercially available handheld fluorescence imaging device. This was a single-center study of consecutive patients who underwent ILR over a 1-year period at a tertiary medical center. Intradermal injection of fluorescent indocyanine green dye was performed intraoperatively after axillary or inguinal lymphadenectomy. A handheld fluorescent imaging device (SPY-PHI, Stryker) rather than a fluorescent-capable microscope was used to identify transected lymphatic channels. Data regarding preoperative, intraoperative, and outcome variables were collected and analyzed. The handheld fluorescent imaging device was successfully able to identify transected lymphatic channels in all cases (n = 15). A nonfluorescent-capable microscope was used to construct the LVB in 14 cases. Loupes were used in one case. In 13 cases, ILR was unilateral. In two cases, bilateral ILR was performed in the lower extremities. All upper extremity cases were secondary to breast cancer (n = 7). Lower extremity cases (n = 8) included extramammary Paget disease of the penis, ovarian cancer, vulvar squamous cell carcinoma, squamous cell carcinoma of unknown origin, soft tissue sarcomas, cutaneous melanoma, and porocarcinoma. ILR, using indocyanine green injection with a handheld fluorescent imaging device, is both safe and effective. This method for intraoperative identification of lymphatic channels was successful, and LVB creation was completed in all cases. This approach makes ILR feasible when a fluorescent-capable microscope is unavailable, broadening access to more patients.

Diagnostic and prognostic impact of preoperative thrombocytosis in muscle invasive bladder cancer: Any role in clinical practice?

Since earlier research suggested a link between preoperative thrombocytosis and poor oncological outcomes in several cancers, the significance of platelet count abnormalities in bladder carcinoma (BC) demands for further investigation. To assess the prognostic value of preoperative thrombocytosis (PTC) on survival in patients with bladder carcinoma treated by radical cystectomy (RC). Analytical cohort comprised a single-center series of 299 patients who underwent RC for bladder carcinoma was evaluated. A platelet count beyond the threshold of 400 × 109 /L was considered thrombocytosis. Along with the Kaplan-Meier survival probability, cox proportional hazard regression models were used. Twenty-eight (9.4%) patients had preoperative thrombocytosis. PTC was associated with gender, tumor stage, tumor grade, lymphovascular invasion, hydronephrosis, anemia (p < 0.001), and hypoalbuminemia (p < 0.001). Preoperative thrombocytosis was strongly linked to worse overall survival (OS) (p = 0.002), and cancer specific survival (CSS) (p = 0.004), according to the Kaplan-Meier method. Throughout the follow-up, a total of 198 (66.2%) patients died, including 170 (56.9%) from BC. For this study population 5-year CSS was 45.8%. Preoperative thrombocytosis was not independently associated with OS (HR 1.168; 95% CI 0.740-1.844; p = 0.504) or CSS (HR 1.060; 95% CI 0.649-1.730; p = 0.816) in multivariate Cox regression analysis. Only tumor stage (HR 2.558; 95% CI 1.675-3.908; p < 0.001), hydronephrosis (HR 1.614; 95% CI 1.173-2.221; p = 0.003), lymph node metastasis (HR 1.555; 95% CI 1.076-2-2.248; p = 0.019), anemia (HR 1.454; 95% CI 1.034-2.046; p = 0.032) and ASA grade (HR 1.375; 95% CI 1.006-1.879; p = 0.046) were independently associated with CSS. In a single-center study of consecutive patients who underwent radical cystectomy for bladder cancer, preoperative thrombocytosis was unable to predict outcomes.

Imaging in gynecological disease (25): clinical and ultrasound characteristics of intramural pregnancy.

To describe the clinical and sonographic characteristics of intramural pregnancy, as well as the available management options and treatment outcomes. This was a retrospective single-center study of consecutive patients with a sonographic diagnosis of intramural pregnancy between November 2008 and November 2022. An intramural pregnancy was diagnosed on ultrasound when a pregnancy was implanted within the uterine corpus, above the level of the internal cervical os and separate from the interstitial section of the Fallopian tube, and extended beyond the decidual-myometrial junction. Clinical, ultrasound, relevant surgical and histological information and outcomes were retrieved from each patient's record and analyzed. Eighteen patients were diagnosed with an intramural pregnancy during the study period. Their median age was 35 (range, 28-43) years and the median gestational age at diagnosis was 8 + 1 (range, 5 + 5 to 12 + 0) weeks. Vaginal bleeding with or without abdominal pain was the most common presenting symptom, recorded in eight patients. Nine (50%) patients had a partial and nine (50%) had a complete intramural pregnancy. Embryonic cardiac activity was present in eight (44%) pregnancies. The majority of pregnancies (n = 10 (56%)) were initially managed conservatively, including expectant management in eight (44%) cases, local injection of methotrexate in one (6%) and embryocide in one (6%). Conservative management was successful in nine of the 10 (90%) pregnancies, with a median time to serum human chorionic gonadotropin resolution of 71 (range, 35-143) days. One patient with an ongoing live pregnancy had an emergency hysterectomy for a major vaginal bleed at 20 weeks' gestation. No other patient managed conservatively experienced any significant complication. The remaining eight (44%) patients had primary surgical treatment, comprising transcervical suction curettage in seven (88%) of these cases, while one patient presented with uterine rupture and underwent emergency laparoscopy and repair. We describe the ultrasound features of partial and complete intramural pregnancy, demonstrating key diagnostic features. Our series suggests that, when intramural pregnancy is diagnosed before 12 weeks' gestation, it can be managed either conservatively or by surgery, with preservation of reproductive function in most women. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Neurotransmitters Disorders with Mild Hyperphenylalaninemia: The Ones That Should Not Be Missed.

Phenylalanine (PHE) is an essential amino acid. Dietary PHE converts to tyrosine by phenylalanine hydroxylase (PAH) activity. Phenylketonuria (PKU) is an autosomal-recessive disorder resulting from PAH enzyme deficiency. Elevations of PHE in plasma are classified based on the degree of enzyme deficiency into classic PKU (PHE≥1200 μmol/l), mild PKU (PHE>600 μmol/l and <1200 μmol/l), and non-PKU-hyperphenylalaninemia (HPA) or mild hyperphenylalaninemia (MHP) (PHE≤600 μmol/l). This is a single-center study of consecutive patients managed at the Pediatric Neurology Department and the outpatient clinic at Children's Welfare Teaching Hospital, Medical City, Baghdad, Iraq, from the 1st of October 2019 to the 1st of October 2020. Five patients were selected who were proven to have non-PKU-HPA (PHE<600 µmol/L) confirmed by the high-performance liquid chromatography analysis and assured to have sapropterin response by the sapropterin loading test which showed >30% decrease in PHE level. All patients presented with a neurological complaint, they were between three months and 15 years, and they were treated with sapropterin, Levodopa (L-Dopa), and 5-hydroxytryptamine (5-HT). The study included the demographic and clinical profile, biochemical response to sapropterin, and clinical response to treatment according to the development quotient. The five patients enrolled in this study had a gross motor developmental delay as their main symptom. One case also had a seizure and dystonia, another had a fluctuation of symptoms, four had a consanguineous marriage, and two had a family history of the same condition. Moreover, all cases had a higher than 30% decrease in PHE level by the tetrahydrobiopterin (BH4) loading test, and all of them showed significant clinical improvements after treatment except for one that showed only a moderate improvement. The BH4 therapy significantly enhanced dietary PHE tolerance and permitted a PHE-free medical formula to be discontinued in all patients with PHE within an achieved therapeutic target (120-300 μM]. MHP is not a mild disease as it may be related to neurotransmitter disorders. Sapropterin, L-DOPA, and 5-HT are always used for patients suspected of having neurotransmitter diseases, particularly those with MHP.

Real-world evaluation of glucose-lowering therapies and the use of weight-adjusted variable rate intravenous insulin infusion in the management of hyperglycaemia in patients with acute coronary syndrome (REGULATE-ACS)

IntroductionAdmission hyperglycaemia in acute coronary syndromes (ACS) is a strong independent predictor of adverse clinical outcomes post-ACS. We examined the safety, efficacy, and feasibility of a modified, weight-adjusted variable rate intravenous insulin infusion (VRIII) and evaluated current practice of prescribing novel cardio-protective glucose-lowering therapies in patients presenting with acute hyperglycaemia across the ACS spectrum. MethodsREGULATE-ACS was an observational single-centre study of consecutive patients admitted with acute hyperglycaemia post-ACS between 2020 and 2021. Following updated local guidance on a modified VRIII, we evaluated its safety and efficacy in glycaemic control, cardio-metabolic complications including hypoglycaemia (blood glucose <3 mmol/L) and 30-day mortality. We also determined the prescription of glucose-lowering therapies pre-discharge. ResultsOut of 107 patients, mean age was 64.9 ± 12.2 years, 82% had known diabetes, and 15% newly diagnosed diabetes. 86.9% (n = 93) had an admission glucose ≥11 mmol/L. In patients treated with VRIII (n = 63/93, 67.7%), glucose improved from 17.5 to 9.0 mmol/L (IQR 7.1–12.1), which was 3 mmol/L lower (p = 0.03) than in patients not treated with VRIII (n = 30/93, 32.3%) where median glucose reduced from 12.6 to 12 mmol/L (IQR 8.6–13.9). No significant hypoglycaemia, arrhythmia or worsening pulmonary oedema associated with VRIII was found. Novel glucose-lowering therapies were initiated in 20/71 (28.2%) and 3/15 (20.0%) of patients with prior and newly diagnosed diabetes, respectively. ConclusionThis real-world analysis provides further support of efficacy, safety, and feasibility of a modified, weight-adjusted VRIII in managing acute hyperglycaemia in ACS. Despite established cardio-protective benefits of novel glucose-lowering therapies, <1/3 of eligible patients received such agents pre-discharge, demanding further research and awareness.

CAD in kidney transplant recipients: a real-world assessment pre-ISCHEMIA-CKD

Abstract Background The ISCHEMIA-CKD trial has shown that an initial invasive strategy, as compared to conservative treatment, did not reduce the risk of death and non-fatal myocardial infarction, nor did it improve quality-of-life in patients with advanced chronic kidney disease (CKD) and coronary artery disease (CAD) with moderate-to-severe ischemia. Similar findings were reported in patients with CKD enlisted for kidney transplantation (KT). We aimed to evaluate screening and treatment CAD strategies in patients who ultimately underwent KT at our center. Methods This is a single-center study of consecutive patients who received a KT from 2015 to 2020. Obstructive CAD was defined whenever one of the following criteria was met: lesion with a stenosis &amp;gt;70% (or &amp;gt;50%, if left main disease) or CAD requiring revascularization, as per the Heart Team discussion. CAD evaluation refers to non-invasive or invasive coronary angiography and/or stress testing, irrespective of clinical scenario. Results A total of 324 patients underwent KT [mean age 55±12 years; 65.1% male; CKD most often due to hypertensive or diabetic nephropathy and polycystic kidney disease – 41.8%; median time from renal replacement therapy (RRT) to KT – 60 (40–88) months]. A flow-chart summarizing CAD diagnosis over time is depicted in Figure 1. Overall, 119 (36.7%) patients had CAD evaluation prior to KT, of whom 21 underwent myocardial revascularization – 8, 12 and 1 patients with acute coronary syndrome (ACS), chronic coronary syndrome (CCS) and silent ischaemia, respectively. At a median time of 46 (25–66) months after KT, 36 (11.1%) more patients had CAD evaluation, of whom 8 underwent percutaneous myocardial revascularization – 6 and 2 for ACS and CCS, respectively. Those with obstructive CAD were older (64 vs 54 years-old; p&amp;lt;0.001), with a higher burden of cardiovascular (CV) risk factors (p&amp;lt;0.001) and more likely to have had a CV death (9.5 vs. 1.0%; p=0.025) or CV hospitalization (38.1 vs. 13.4%; p=0.007). CAD status (revascularized vs. non-revascularized) was not associated with improved major outcomes at follow-up. We found no strong predictors of CAD requiring revascularization post-KT, including time from RRT to KT. There were no patients with refractory angina, left main disease or reduced left ventricular ejection fraction (&amp;lt;40%) in need of myocardial revascularization over follow-up. Conclusions Obstructive CAD was uncommon in our cohort of patients who received a KT, most of whom with asymptomatic or mildly (monthly angina) symptomatic CCS or non-fatal ACS. These findings, together with the most recent evidence, may argue against routine CAD screening in all patients being enlisted for KT. Notwithstanding, randomized evidence is eagerly awaited to further guide treatment decisions in the post-ISCHEMIA-CKD era. Funding Acknowledgement Type of funding sources: None.

Invasive Fungal Disease in Patients with Myeloid Malignancies: A Retrospective Cohort Study of a Diagnostic-Driven Care Pathway Withholding Mould-Active Prophylaxis

Objectives: Patients receiving remission induction therapy for acute myeloid leukaemia (AML) are at high risk of developing invasive fungal disease (IFD). Newer therapies with targeted antileukemic agents and the emergence of azole resistance pose a challenge to the strategy of primary antifungal prophylaxis. We report the experience of a diagnostic-driven care pathway (DCP) for the management of IFD in these patients, using only culture-directed mould inactive prophylaxis. Methods: Retrospectively, we used a single-centre study of consecutive patients receiving intensive chemotherapy for myeloid malignancies between 2014 and 2021. DCP consisted of serial cultures and serum galactomannan (sGM) screening, CT imaging, and bronchoscopy to direct targeted antifungal treatment. IFD was classified according to the 2020 EORTC/MSGERC criteria. Results: A total of 192 patients with myeloid malignancies received 300 courses of intensive chemotherapy. There were 14 cases of invasive yeast infections and 18 of probable/proven invasive mould disease (IMD). The incidence of probable/proven IMD during the first cycle of remission-induction chemotherapy was 4.6% (n = 9). sGM remained negative in all cases of invasive aspergillosis (IA), with positive mycology findings in bronchoalveolar lavage. All-cause mortality was 9.4% (n = 18) 100 days after starting chemotherapy and was comparable between patients with or without IFD. The fungal-related mortality was 1% (n = 2). Conclusion: Diagnostic-driven based management without universal mould active prophylaxis is a feasible strategy in the management of IFD and limits unnecessary antimould treatment during intensive chemotherapy. The poor performance of serial serum galactomannan screening in detecting IA warrants further investigation.

Carotid intima-media thickness predicted the presence but not the severity or complexity of coronary artery disease in a South Asian population

BackgroundCarotid intima-media thickness (CIMT) is considered a marker of atherosclerosis, but the data is lacking from the South Asian population. We aimed to study the relation of CIMT with the presence and severity of coronary artery disease (CAD) in this population. MethodsThis was a prospective, single-center study of consecutive patients undergoing elective coronary angiography. Participants with >50% luminal stenosis in any major coronary artery were included in the CAD group and those with normal coronaries in the non-CAD group. Multivariate linear regression analysis was done to determine independent predictors of CAD. Pearson's correlation coefficients assessed correlations between CIMT and Syntax and Gensini score. ResultsThe mean CIMT was significantly much higher in the CAD group when compared to the non-CAD group (0.83±0.16 vs 0.61±0.14mm, p<0.001). On multivariable linear regression analysis only diabetes (β=0.208 and p=0.024), waist–hip ratio (β=0.178 and p=0.043), current smoker (β=0.293 and p=<0.001) and CIMT (β=0.217 and p=0.031) were independent predictors of CAD. The mean Gensini score in the CAD group was 48.59±34.25 and the mean Syntax score was 19.45±10.24. No significant relation was found between CIMT and Gensini score (r=0.009 and p=0.89), and Syntax score (r=−0.087 and p=0.171). ConclusionMean CIMT is an independent predictor of CAD along with diabetes, waist–hip ratio, and smoking. However, CIMT was not related to the severity and complexity of the CAD as assessed by the Gensini score and Syntax score, respectively.

VDD leadless pacemaker: atrioventricular synchrony predictors

Abstract Funding Acknowledgements Type of funding sources: None. Background Leadless pacemaker technology has shown a reduction of the complications associated with conventional pacemakers. The development of the VDD mode has allowed us to extend the use of leadless pacemakers to patients in need of pacing due to atrioventricular (AV) block. Maintaining AV synchrony (AVS) in cardiac pacing improves cardiac output and quality of life and reduces the risk of atrial fibrillation (AF) and pacemaker syndrome. In previous analyses, it was observed that the low amplitude of the A4 signal was associated with low AVS. Methods Prospective single-center study of consecutive patients who received a VDD leadless pacemaker (Micra AV), and who remained in VDD mode throughout the follow-up. Our purpose was to analyze the possible predictors of A4 signal amplitude and AVS in the first month of follow-up. We tested univariate association with A4 signal and AVS of echocardiographic data, clinical variables, implant parameters, and pacemaker function. Results We included data from the first 21 patients who received a VDD leadless pacemaker (Micra AV) between Jun/20 and Apr/21. 18 patients remained in VDD mode after the first month of follow-up. There was no significant association between ventricular filling waves (E and A) and Tissue-Doppler diastolic waves (E ’and A’) with the A4 signal and the percentage of AVS. Only the E / A ratio showed a trend of association with the percentage of AVS, although it did not reach statistical significance (p = 0.09), showing an inverse relationship (Pearson’s correlation coefficient of -0.396). None of the clinical variables analyzed showed an association with the A4 signal or with the percentage of AVS. Only the A4 signal was significantly associated with the percentage of AVS (Pearson´s correlation coefficient of 0.524, p = 0.02). Considering 85% as an adequate discriminator for correct AVS, the mean signal of A4 was significantly lower (p = 0.03) in those with AVS &amp;lt; 85% (2.63 ± 1.73) compared with those with AVS≥85% (4.37± 1.34). Regarding implant factors, there seems to be a tendency to worse AVS with higher number of releases (p = 0.06, Pearson’s correlation coefficient of -0.460), as well as when implanting in positions further away from the atrium (medium interventrcular septum vs. high interventricular septum / proximal right ventricular outflow tract; p = 0.06, Pearson’s correlation coefficient of -0.463). Conclusions Although this is a short case series, our results are aligned with the data from the MARVEL2 AVS predictors substudy. It appears that the main predictor of higher AVS is the A4 signal. Device position, as well as the number of releases, could also play a role. Nevertheless, it is necessary to continue the analysis with the data of future patients to corroborate these preliminary findings.

Programming VDD leadless pacemakers: relation of algorithm settings of A3 and A4 signals with atrioventricular synchrony

Abstract Funding Acknowledgements Type of funding sources: None. Background The development of VDD mode in leadless pacemakers (Micra AV) has allowed the use of leadless pacing in patients with an atrioventricular (AV) block. Keeping AV synchrony (AVS) on pacing improves cardiac output and quality of life and reduces the risk of atrial fibrillation (AF) and PM syndrome. The AVS of the pivotal study with Micra AV (MARVEL2), in a post-implant situation of low activity was 89%. Methods Prospective single-center study of consecutive patients who received a VDD leadless pacemaker (Micra AV), and who remained in VDD mode throughout the follow-up. The initial programming changes were conducted following the standard recommendation for problems resolution, and further changes were made based on experience. Univariate association was tested for different programming parameters with the percentage of AVS. Our goal was to find the best possible programming for the Micra AV pacemaker with the scope of achieving high percentages of AVS in real life. Results We included 26 patients who received a VDD leadless pacemaker (Micra AV) between Jun/20 and Nov/21 and were kept in VDD mode at least during the first month of follow-up. We made an intermediate analysis from the first 18 patients who reached the first month after implant, and a significant association was found between the adjustment of the end of the window of A3 (VE) with the percentage of AVS: in the group in which automatic VE adjustment was maintained after implantation (4 patients), the mean AVS was 76.9 ± 6.0% (VE 702± 60 ms), while in the group in which the automatic adjustment was deactivated and the VE was set at 600-650 ms (14 patients), AVS was 84.9 ± 7.2% (VE 614 ± 23 ms), p = 0.04 (Figure 1). When discriminating by AVS ≥ 85%, the deactivation of the automatic adjustment of VE had an OR of 5.6 compared to maintaining automatic adjustment (p = 0.018), with a χ2 of 4.1 (p = 0.043). Moreover, when we analyzed the data until the sixth month of follow-up for those patients in VDD mode, we found that the shorter the interval of VE window we programmed, the larger the AVS percentage was (1st month, 26 patients: VE 631±46 ms, AVS 83.8±6.9%; 3rd month, 24 patients: VE 621±35 ms, AVS 86.2±6.6%; 6th month, 19 patients: VE 614±25 ms, AVS 88.3±6.5%, p&amp;lt;0.001; Figure 2). On the other side, there was no significant association between the modification of the A4 threshold (p = 0.104), adjustment of the rate smoothing (p = 0.331), or signal vector change (p = 0.276) with the percentage of AVS. Conclusions In real life, AVS percentages can vary considerably from the data obtained in resting situations and short follow-up time. Even though our series is not extensive, the preliminary data suggest the importance of adding modifications in the standard programming, especially in the algorithm for adjusting the A3 window, altogether with the standard recommendations for problem-solving to achieve high AVS percentages.

Is ß-d-glucan Relevant for the Diagnosis and Follow-Up of Intensive Care Patients with Yeast-Complicated Intra-Abdominal Infection?

The usefulness of (1,3)-ß-d-glucan (BDG) detection for the diagnosis of intra-abdominal candidiasis and treatment monitoring is unknown. A prospective, single-center study of consecutive patients admitted to an ICU with complicated intra-abdominal infection (IAI) over a 2-year period was conducted. BDG was measured in the peritoneal fluid and serum between day 1 (D1) and D10. Patients with a positive peritoneal fluid yeast culture (YP) were compared to those with a negative yeast culture (YN). The evolution of serum BDG was compared in the two groups. Seventy patients were included (sixty-five analyzed): YP group (n = 19) and YN group (n = 46). Median peritoneal BDG concentration during surgery was 2890 pg.mL−1 [IQR: 942–12,326] in the YP group vs. 1202 pg.mL−1 [IQR: 317–4223] in the YN group (p = 0.13). Initial serum BDG concentration was 130 pg.mL−1 [IQR: 55–259] in the YP group vs. 88 pg.mL−1 [IQR: 44–296] in the YN group (p = 0.78). No difference in evolution of serum BDG concentrations was observed between the groups (p = 0.18). In conclusion, neither peritoneal BDG nor serum BDG appear to be good discriminating markers for the diagnosis of yeast IAI. In addition, monitoring the evolution of serum BDG in yeast IAI did not appear to be of any diagnostic value.

Autoimmune markers in screening for orbital inflammatory disease

PurposeImmunogenic causes of inflammation may be difficult to differentiate in the work-up of orbital inflammatory disease. The study aims to investigate the utility of autoimmune markers in the screening for orbital inflammation. Markers studied included angiotensin-converting enzyme (ACE), antinuclear antibody (ANA), anti-neutrophilic cytoplasmic autoantibodies (ANCA), extractable nuclear antigen (ENA), anti-cyclic citrullinated peptide (Anti-CCP) and anti-double stranded DNA antibody (Anti-dsDNA antibody).MethodsA retrospective single-centre study of consecutive patients with non-infective orbital inflammation screened for autoimmune markers at presentation. Serology was interpreted alongside clinical course and other investigations (e.g. radiographic features and histopathology). Tabulated data and Pearson’s Chi-square allowed analysis of trends between serology, diagnosis and the decision to biopsy.Results79 patients, between 1999 and 2021, were included (50 females, mean age was 50.4 ± 17.4 years). 28 (34.6%) patients had specific orbital inflammation and 53 (65.4%) patients had non-specific orbital inflammation (NSOI). Of the 12 patients with positive serology and a specific diagnosis, only 5 (41.7%) patients had concordant serological results. There was no association between serology results and the patient undergoing biopsy (P = 0.651). Serology was unable to exclude nor differentiate NSOI from other specific conditions and ANA had limited discriminatory value between specific conditions and NSOI.ConclusionSerological testing alone may not provide a clear direction for further investigation of orbital inflammation and a biopsy may occur independently of the serological results. The value of autoimmune markers may lie in subsequent follow-up as patients may develop suggestive symptoms after an indeterminate positive result or initially seronegative disease.

Bridge To Decision Or Destination With Impella 5.0 And 5.5 In Cardiogenic Shock

Introduction The Impella (ABIOMED, Danvers, MA) is a temporary left ventricular support device, intended for short-term circulatory support of an INTERMACS class 1 patient in cardiogenic shock (CS). It can be used as a bridge therapy to allow for time for decision making, as a bridge to a destination, or as a bridge to definitive therapy. Limited data from others show an improved survival rate with the use of these pumps in small cohorts. Methods We conducted a retrospective, single-center study of consecutive patients who received support with either the Impella 5.0 or 5.5 between January 2017 and December 2020. Baseline characteristics and outcomes at 30 days and 1 year were analyzed. Results A total of 61 patients were included in the study. Baseline characteristics, including comorbidities, and outcomes are presented (Table 1). The mean age was 59 years, and 85% were male. The Impella 5.0 was implanted in 40 (66%) patients, while Impella 5.5 was used in 21 (34%) patients. Patients had a mean left ventricular ejection fraction of, 22% ± 5% at the time of device implantation. CS from worsening chronic systolic heart failure occurred in 35 (57%) patients, and acute myocardial infarction was the precipitator in 26 (43%) patients. Device support was sustained for a median of 17 days (interquartile range 8 - 32). Death occurred in 32 (53%) patients while on Impella support. At 30 days, 24 (39%) patients were alive, and 16 (26%) survived to the 1-year follow-up time point. Complications occurred in 14 patients and were most commonly thromboembolic events (35%), ventricular tachycardia (28%), and need for repositioning (21%). Conclusion These hemodynamic devices are useful in supporting patients who need a bridge to decision and might be too sick to proceed with definitive therapies. At the same time, these devices offer durable support for those eligible for destination therapy. Despite adequate hemodynamic support, the overall mortality of CS in this patient population remains high. The Impella (ABIOMED, Danvers, MA) is a temporary left ventricular support device, intended for short-term circulatory support of an INTERMACS class 1 patient in cardiogenic shock (CS). It can be used as a bridge therapy to allow for time for decision making, as a bridge to a destination, or as a bridge to definitive therapy. Limited data from others show an improved survival rate with the use of these pumps in small cohorts. We conducted a retrospective, single-center study of consecutive patients who received support with either the Impella 5.0 or 5.5 between January 2017 and December 2020. Baseline characteristics and outcomes at 30 days and 1 year were analyzed. A total of 61 patients were included in the study. Baseline characteristics, including comorbidities, and outcomes are presented (Table 1). The mean age was 59 years, and 85% were male. The Impella 5.0 was implanted in 40 (66%) patients, while Impella 5.5 was used in 21 (34%) patients. Patients had a mean left ventricular ejection fraction of, 22% ± 5% at the time of device implantation. CS from worsening chronic systolic heart failure occurred in 35 (57%) patients, and acute myocardial infarction was the precipitator in 26 (43%) patients. Device support was sustained for a median of 17 days (interquartile range 8 - 32). Death occurred in 32 (53%) patients while on Impella support. At 30 days, 24 (39%) patients were alive, and 16 (26%) survived to the 1-year follow-up time point. Complications occurred in 14 patients and were most commonly thromboembolic events (35%), ventricular tachycardia (28%), and need for repositioning (21%). These hemodynamic devices are useful in supporting patients who need a bridge to decision and might be too sick to proceed with definitive therapies. At the same time, these devices offer durable support for those eligible for destination therapy. Despite adequate hemodynamic support, the overall mortality of CS in this patient population remains high.

Pocket hematoma after pacemaker or defibrillator surgery: Direct oral anticoagulants versus vitamin K antagonists.

BackgroundDirect oral anticoagulants (DOACs) are the preferred choice of oral anticoagulation in patients with atrial fibrillation (AF). Randomized trials have demonstrated the efficacy and safety of DOAC in patients undergoing a cardiac implantable electronic device procedure (CIED); however, there is limited real-world data.ObjectiveTo evaluate the outcome of patients undergoing an elective CIED procedure in a tertiary referral center with an interrupted DOAC or continued vitamin K antagonist (VKA) regimen.MethodsThis was a retrospective single-center study of consecutive patients with AF undergoing an elective CIED procedure between January 2016 and June 2019. The primary endpoint was a clinically significant pocket hematoma < 30 days after surgery. The secondary endpoint was any systemic thromboembolic complication < 30 days after surgery.ResultsOf a total of 1,033 elective CIED procedures, 283 procedures were performed in patients with AF using oral anticoagulation. One-third of the procedures were performed under DOAC (N = 81, 29%) and the remainder under VKA (N = 202, 71%). The DOAC group was younger, had less chronic renal disease, more paroxysmal AF and a lower HAS-BLED score. The VKA group more often underwent a generator change only in comparison to the DOAC group. Clinically significant pocket hematoma occurred in 5 patients (2.5%) in the VKA group and did not occur in the DOAC group (P = 0.33). There were no thromboembolic events reported.ConclusionIn patients with AF undergoing an elective CIED procedure, the risk of a pocket hematoma and a systemic thromboembolic event is comparably low when using either continued VKA or interrupted DOAC.

Carotid intima-media thickness predicted the presence but not the severity or complexity of coronary artery disease in a South Asian population

BackgroundCarotid intima-media thickness (CIMT) is considered a marker of atherosclerosis, but the data is lacking from the South Asian population. We aimed to study the relation of CIMT with the presence and severity of coronary artery disease (CAD) in this population. MethodsThis was a prospective, single-center study of consecutive patients undergoing elective coronary angiography. Participants with >50% luminal stenosis in any major coronary artery were included in the CAD group and those with normal coronaries in the non-CAD group. Multivariate linear regression analysis was done to determine independent predictors of CAD. Pearson's correlation coefficients assessed correlations between CIMT and Syntax and Gensini score. ResultsThe mean CIMT was significantly much higher in the CAD group when compared to the non-CAD group (0.83±0.16 vs 0.61±0.14mm, p<0.001). On multivariable linear regression analysis only diabetes (β=0.208 and p=0.024), waist–hip ratio (β=0.178 and p=0.043), current smoker (β=0.293 and p=<0.001) and CIMT (β=0.217 and p=0.031) were independent predictors of CAD. The mean Gensini score in the CAD group was 48.59±34.25 and the mean Syntax score was 19.45±10.24. No significant relation was found between CIMT and Gensini score (r=0.009 and p=0.89), and Syntax score (r=−0.087 and p=0.171). ConclusionMean CIMT is an independent predictor of CAD along with diabetes, waist–hip ratio, and smoking. However, CIMT was not related to the severity and complexity of the CAD as assessed by the Gensini score and Syntax score, respectively.