Cardiac allograft vasculopathy in heart transplant recipients from hepatitis C viremic donors.

BACKGROUND: Recent studies suggest the transplantation of Hepatitis C (HCV) hearts from viremic donors is associated with comparable 1 year survival to nonviremic donors. Though HCV viremia is a known risk factor for accelerated atherosclerosis, data on cardiac allograft vasculopathy (CAV) outcomes are limited. We compared the incidence of CAV in heart transplant recipients from HCV viremic donors (nucleic acid amplification test positive; NAT+) compared to non-HCV infected donors (NAT-). METHODS: We retrospectively reviewed annual coronary angiograms with intravascular ultrasound from April 2017 to August 2020 at two large cardiac transplant centers. CAV was graded according to ISHLT guidelines. Maximal intimal thickness (MIT) ≥ 0.5 mm was considered significant for subclinical disease. RESULTS: Among 270 heart transplant recipients (mean age 54; 77% male), 62 patients were transplanted from NAT+ donors. CAV ≥ grade 1 was present in 8.8% of the NAT+ versus 16.8% of the NAT- group at 1 year, 20% versus 28.8% at 2 years, and 33.3% versus 41.5% at 3 years. After adjusting for donor age, donor smoking history, recipient BMI, recipient, hypertension, and recipient diabetes, NAT+ status did not confer increased risk of CAV (HR.80; 95% CI.45-1.40, p = 0.43) or subclinical IVUS disease (HR.87; 95% CI.58-1.30, p = 0.49). Additionally, there was no difference in the presence of rapidly progressive lesions on IVUS. CONCLUSION: Our data show that NAT+ donors conferred no increased risk for early CAV or subclinical IVUS disease following transplantation in a cohort of heart transplant patients who were treated for HCV, suggesting the short-term safety of this strategy to maximize the pool of available donor hearts.

Refractory coronary vasospasm and recurrent cardiac arrest.

We present a case of recurrent vasospasm as an uncommon cause of ventricular fibrillation in a young female patient who was found to have a genetic mutation of unknown significance in the desmoplakin (DSP) gene and ultimately required an implantable cardiac defibrillator and percutaneous coronary intervention. Refractory vasospasm as a cause of chest pain and cardiac arrest may be under-recognised. In this manuscript, we highlight the natural history of refractory vasospasm, treatment considerations including medical therapy, implantable cardiac defibrillator and percutaneous coronary intervention. Lastly, we explore the potential correlation between the DSP mutation and her clinical presentation and the growing importance of genetic testing in unexplained cardiac arrest.

Implantable loop recorder as a strategy following cardiovascular implantable electronic device extraction without reimplantation.

BACKGROUND: Limited data exists for outcomes in patients undergoing cardiovascular implantable electronic device (CIED) transvenous lead extraction (TLE) without clear indications for device reimplantation. The implantable loop recorder (ILR) may be an effective strategy for continuous monitoring in select individuals. OBJECTIVE: This retrospective analysis aims to investigate patients who have undergone ILR implant following TLE without CIED reimplantation. METHODS: Clinical data from consecutive patients who have undergone TLE with ILR implant and without CIED reimplantation from October 2016 to May 2020 at a single center were collected. RESULTS: Among 380 patients undergoing TLE, 28 (7.7%) underwent ILR placement without CIED reimplantation. TLE indications were systemic infection (n = 13, 46.4%), pain at the site (n = 8, 28.6%), device/lead malfunction (n = 4, 14.2%), and other. Devices extracted included: dual-chamber and single-chamber pacemaker (n = 14, 50%; n = 4, 14.2%), dual-chamber implantable cardiac defibrillator (n = 10; 35.7%), and cardiac-resynchronization therapy with defibrillator (n = 1, 3.5%). Reasons for no reimplantation included no longer meeting CIED criteria (n = 14, 50%), patient preference (n = 9, 32.1%), and no clear or inappropriate indication for initial CIED implantation (n = 5, 18%). During an average of 12.3 ± 13.1 months of follow-up, there were no lethal arrhythmias, and four (13.3%) patients underwent permanent pacemaker reimplantation due to symptomatic sinus bradycardia and atrioventricular block with syncope as discovered on ILR. Three patients died due to unknown causes (n = 1), noncardiac (n = 1), and acute coronary syndrome (n = 1). CONCLUSIONS: In patients undergoing TLE without reimplantation, an ILR may be an effective monitoring strategy in patients at low risk for cardiac arrhythmia.

Bicuspid Aortic Valve Morphology and Outcomes After Transcatheter Aortic Valve Replacement.

BACKGROUND: Bicuspid aortic stenosis accounts for almost 50% of patients undergoing surgical aortic valve replacement in the younger patients. Expanding the indication of transcatheter aortic valve replacement (TAVR) toward lower-risk and younger populations will lead to increased use of TAVR for patients with bicuspid aortic valve (BAV) stenosis despite the exclusion of bicuspid anatomy in all pivotal clinical trials. OBJECTIVES: This study sought to evaluate the association of BAV morphology and outcomes of TAVR with the new-generation devices. METHODS: Patients with BAV confirmed by central core laboratory computed tomography (CT) analysis were included from the international multicenter BAV TAVR registry. BAV morphology including the number of raphe, calcification grade in raphe, and leaflet calcium volume were assessed with CT analysis in a masked fashion. Primary outcomes were all-cause mortality at 1 and 2 years, and secondary outcomes included 30-day major endpoints and procedural complications. RESULTS: A total of 1,034 CT-confirmed BAV patients with a mean age of 74.7 years and Society of Thoracic Surgeons score of 3.7% underwent TAVR with contemporary devices (n = 740 with Sapien 3; n = 188 with Evolut R/Pro; n = 106 with others). All-cause 30-day, 1-year, and 2-year mortality was 2.0%, 6.7%, and 12.5%, respectively. Multivariable analysis identified calcified raphe and excess leaflet calcification (defined as more than median calcium volume) as independent predictors of 2-year all-cause mortality. Both calcified raphe plus excess leaflet calcification were found in 269 patients (26.0%), and they had significantly higher 2-year all-cause mortality than those with 1 or none of these morphological features (25.7% vs. 9.5% vs. 5.9%; log-rank p < 0.001). Patients with both morphological features had higher rates of aortic root injury (p < 0.001), moderate-to-severe paravalvular regurgitation (p = 0.002), and 30-day mortality (p = 0.016). CONCLUSIONS: Outcomes of TAVR in bicuspid aortic stenosis depend on valve morphology. Calcified raphe and excess leaflet calcification were associated with increased risk of procedural complications and midterm mortality. (Bicuspid Aortic Valve Stenosis Transcatheter Aortic Valve Replacement Registry; NCT03836521).

Transcatheter Aortic Valve Replacement Outcomes in Patients With Native vs Transplanted Kidneys: Data From an International Multicenter Registry.

BACKGROUND: Chronic kidney disease (CKD) has a negative impact on outcomes after transcatheter aortic valve replacement (TAVR). Data on outcomes in renal transplant recipients (RTRs) undergoing TAVR are scarce. We compared the outcomes in RTRs undergoing TAVR with matched patients who have native kidneys and similar kidney function. METHODS: This retrospective cohort study used data from 16 TAVR centres (13,941 patients). The study cohort included 216 patients (72 RTRs and 144 matched controls). RESULTS: The mean estimated glomerular filtration rate (eGFR) was 39.2 ± 23.6 vs 44.5 ± 23.6 mL/min for RTRs and control patients (P = 0.149), with a similar CKD stage distribution. After TAVR, the eGFR declined among RTRs but remained stable for up to 1 year in controls (P = 0.021). Long-term hemodialysis was required in 19 (26.4%) RTRs and 20 (13.8%) controls (hazard ratio [HR] = 2.09 95% confidence interval [CI], 1.03-3.86; P = 0.039) and was most often initiated during the periprocedural period (14 RTRs vs 16 controls; P = 0.039). After a median follow-up of 2.3 years, risk of death (29.2% vs 31.9%) and death/hemodialysis (40.3% vs 36.8%) was similar between the groups. The contrast volume/eGFR ratio was the strongest predictor of hemodialysis initiation (odds ratio [OR] = 1.64; 95% CI, 1.36-1.97 per 1 unit increase; P < 0.001), with a greater effect among RTRs than controls (P for interaction = 0.022). CONCLUSION: s: TAVR appears safe in RTRs with mortality rates similar to matched patients with native kidneys. However, RTRs carry an increased risk of progressive renal impairment and need for hemodialysis initiation after TAVR. Our data highlight the importance of minimizing contrast load during TAVR, particularly in RTRs.

Ovotestis in Adolescence: 2 Case Reports.

We present 2 patients found to have ovotesticular disorder of sexual development (otDSD) in late adolescence. Two 15-year-old phenotypically male patients presented to a large pediatric hospital with different complaints: 1 with concern for testicular rupture after a straddle injury; 1 with gynecomastia. Further workup, including imaging and laboratory tests, was performed before surgical exploration. The first patient had unilateral ovotestis, contralateral testis, and SRY-negative 46,XX karyotype. The second patient with gynecomastia had unilateral ovotestis with hemi-uterus and fallopian tube, contralateral ovarian tissue, and 46,XX/47,XXY Klinefelter mosaic karyotype. Although rare, phenotypically normal male patients may present later with ovotesticular disorder of sexual development.

Delayed Diagnosis of Iatrogenic Bladder Perforation in a Neonate.

Iatrogenic bladder injuries have been reported in the neonate during umbilical artery/vein catheterization, voiding cystourethrogram, urinary catheterizations, and overwhelming hypoxic conditions. Patients with iatrogenic bladder perforations can present with acute abdomen indicating urinary peritonitis, septic-uremic shock, or subtle symptoms like abdominal distension, pain, hematuria, uremia, electrolyte imbalances, and/or difficulty urinating. The following neonatal case report of perforated bladder includes a review of the signs, symptoms, diagnostic tools, and management of bladder injury in neonates.

Diagnosis and Monitoring of Prostatic Lesions: A Comparison of Three Modalities: Multiparametric MRI, Fusion MRI/Transrectal Ultrasound (TRUS), and Traditional TRUS.

PURPOSE:  Transrectal ultrasound (TRUS) has been the gold standard of imaging for diagnosing prostate cancer for decades but is plagued by user error and undersampling. We aim to explore imaging modalities that are now being used in combination or alone for screening, diagnosis, and/or active surveillance of prostate cancer. METHODS: A PubMed literature search was performed to include articles published up to April 2016. Data were extracted and analyzed. RESULTS: Several large-scale studies have found an increased cancer detection rate in MRI-targeted lesions with an improved ability to target anterior lesions as well as an increased cancer detection in high-risk cancers using fusion platforms vs TRUS alone. CONCLUSIONS: To date, there have been few head-to-head trials to directly compare the use of multiparametric MRI (mpMRI), transrectal ultrasound, and MRI-ultrasound fusion modalities for accurate and reliable detection, active surveillance, or biopsy procedure success rates. Further investigation utilizing these modalities are needed before they can be relied upon in active surveillance management, although mpMRI appears to be currently the most reliable in monitoring and diagnosing prostate lesions.

Medical Care in a Free Clinic: A Comprehensive Evaluation of Patient Experience, Incentives, and Barriers to Optimal Medical Care with Consideration of a Facility Fee.

Free and charitable clinics are important contributors to the health of the United States population. Recently, funding for these clinics has been declining, and it is, therefore, useful to identify what qualities patients value the most in clinics in an effort to allocate funding wisely. In order to identify targets and incentives for improvement of patients' health, we performed a comprehensive analysis of patients' experience at a free clinic by analyzing a patient survey (N=94). The survey also assessed patient opinions of a small facility fee, which could be used to offset the decrease in funds. Interestingly, our patients believed it is appropriate to be charged a facility fee (78%) because it increases involvement in their care (r = 0.69, p < 0.001) and self-respect (r = 0.66, p < 0.001). Incentives to medical care include continuity of care, faith-based care, having a patient medical provider partnership, and charging a facility fee. Barriers include affordable housing, transportation, medication, and accessible information. In order to improve medical care in the uninsured population, our study suggested that we need to: 1) offer continuity of medical care; 2) offer affordable preventive health screenings; 3) support affordable transportation, housing, and medications; and 4) consider including a facility fee.

Synthesis and antibacterial evaluation of amino acid-antibiotic conjugates.

Amino acid conjugates of quinolone, metronidazole and sulfadiazine antibiotics were synthesized in good yields using benzotriazole methodology. All the conjugates were screened for their antibacterial activity using methods adapted from the Clinical and Laboratory Standards Institute. Antibiotic conjugates were tested for activity in four medically relevant organisms; Staphylococcus aureus (RN4220), Escherichia coli (DH5α), Pseudomonas aeruginosa (PAO1), and Bacillus subtilis (168). Several antibiotic conjugates show promising results against several of the strains screened.