A meta-analysis of antibacterial envelope use in prevention of cardiovascular implantable electronic device infection.

OBJECTIVES: Cardiac implantable electronic device (CIED) infection has been a major clinical problem in addition to being a major financial burden. In spite of antimicrobial prophylaxis, CIED infection rates have been increasing disproportionately. We therefore conducted this meta-analysis to assess the role of TYRX antibiotic envelope for the prevention of CIED infection. METHODS: Using extensive online search, we conducted a meta-analysis of studies reporting CIED infections with versus without the use of TYRX antibiotic envelope. A random-effect model was used, and between studies heterogeneity was estimated with I2. All analyses were performed with RevMan (version 5.0.20). RESULTS: Five cohort studies were included in this meta-analysis. The pooled odds ratio (OR) of included studies was 0.29 [95% confidence interval (CI): 0.09-0.94; p < 0.004]. There was evidence of heterogeneity with I2 of 58%. There was also evidence of publication bias on funnel plot analysis. On sensitivity analysis, no statistically significant difference was noted when stratified by study design or duration of follow-up. CONCLUSION: The results of our study demonstrate a significant beneficial effect of TYRX antibiotic envelope for the prevention of CIED infections.

Post-reperfusion syndrome during renal transplantation: a retrospective study.

Post-reperfusion syndrome (PRS) is a serious, widely reported complication following the reperfusion of an ischemic tissue or organ. We sought to determine the prevalence, risk factors and short-term outcomes of PRS related renal transplantation. We conducted a retrospective, case-control study of patients undergoing renal transplantation between July 2006 and March 2008. Identification of PRS was based on a drop in mean arterial pressure by at least 15% within 5 minutes of donor kidney reperfusion. Of the 150 consecutive renal transplantations reviewed, 6 patients (4%) met criteria for post-reperfusion syndrome. Univariate analysis showed that an age over 60, diabetes mellitus, Asian race, and extended criteria donors increased the odds of developing PRS by 4.8 times (95% CI [1.2, 20]; P=.0338), 4.5 times (95% CI [1.11, 18.8]; P=.0378), 35.5 times (95% CI [3.94, 319.8]; P=0.0078) and 9.6 times (95% CI [1.19, 76.28] P=0.0115) respectively. Short term follow-up revealed increased graft failure rate within 6 months (6% vs. 16% P=0.0125) and almost twice the number of hospital days post-transplant in PRS cohorts (5.43 ± 2.29 vs. 10.8 ± 7.29 P=<0.0001). Despite limited reporting, PRS appears to be a relatively common complication of renal transplantation and is associated with increase morbidity.

Transmyocardial voyage of a temporary epicardial lead: an unusual long-term complication.

Although the majority of temporary epicardial leads used during cardiac surgery are removed in the perioperative period, occasionally, the wires are cut and allowed to retract into the subcutaneous tissue. Complications arising from such retained epicardial wires are rare. We present a case of transmyocardial migration of a retained epicardial wire through the right ventricular myocardium into the pulmonary artery in a patient who had undergone coronary artery bypass graft surgery 13 years ago. We describe the presentation and successful management of this case.

Endovascular therapy for radiation-induced pulmonary artery stenosis: a case report and review of the literature.

Although pulmonary artery stenosis and its treatment has been well characterized in pediatric populations, its diagnosis and even how to determine the significance of a stenosis can be difficult and optimal management is currently unknown. This case report and review of the literature outlines how we successfully diagnosed, evaluated, and stented a patient with radiation induced pulmonary artery stenosis. This case further adds support to a very limited data pool suggesting that percutaneous angioplasty of pulmonary artery stenosis may be a safe and effective treatment option for this unique patient population.

A novel approach to standard techniques in the assessment and quantification of the interventricular systolic relationship.

BACKGROUND: Blood flow between the right and left ventricles is subject to the continuity equation and systolic ventricular interdependence. Quantification of this relationship might aid in understanding inter-ventricular function. The purpose of this study was to evaluate and quantify ventricular interdependence by directly comparing right and left ventricular systolic function though echocardiographic surrogates of right and left ventricular systolic function such as MAPSE, TAPSE, RV TVI and LV TVI. METHODS: This study prospectively evaluated 51 healthy participants (mean age, 41 ± 17 years) by resting echocardiography. In addition to standard measurements, tricuspid annular plane of systolic excursion, (TAPSE), mitral annular plane of systolic excursion (MAPSE), and the peak annulus systolic velocity of the right ventricular (RVs) and left ventricular (LVs) free walls were measured by M-mode and pulsed wave Doppler tissue echocardiography and further evaluated for variance across age, gender, and body surface area. RESULTS: TAPSE (22.1 ± 2.9 mm) was over 54.5% greater than MAPSE (14.3 ± 2.6 mm) and RVs was 64.4% greater than LVs. The LV to RV systolic relationship measured by MAPSE/TAPSE and LVs/RVs ratios were 0.66 ± 0.14 and 0.76 ± 0.21 respectively. These values were not significantly affected by age, gender or body surface area (BSA). CONCLUSION: MAPSE/TAPSE and LVs/RVs ratios appear stable across age, gender, and BSA potentially making them good surrogates of systolic ventricular relationship and interdependence.

"Cardiac otalgia": acute coronary syndrome masquerading as bilateral ear pain.

Patients presenting with acute coronary syndromes are classically described as having chest pressure with radiation to the left arm. However, pain can be referred to multiple sites including the face, the neck, the abdomen and the contra-lateral arm. We present a case of sudden bilateral ear pain as the sole presentation of acute coronary syndrome in an elderly man. The importance of recognizing these atypical presentations is vital, as outcomes may be worsened as appropriate therapy may be delayed or misdirected.

Coronary stent fracture: a cause of cardiac chest pain?

Inherent risks of coronary artery stenting include restenosis and thrombosis. More recently, stent fractures (SF) have emerged as a complication. Lengthy coronary stents, overlapping stents, saphaneous vein graft stents, and right coronary artery lesions treated with sirolimus-eluting stents (SES; Cypher, Cordis, Miami Lakes, Florida, USA) are some of the predisposing factors that have been linked to fractures. Early detection and management may help alleviate the complications of SF including acute thrombosis and restenosis at the site of fracture. We present an interesting case of a SES fracture in the left main coronary artery.

A retrospective analysis and case series of glycoprotein IIb/IIIa inhibitor associated diffuse alveolar hemorrhage: two case reports.

INTRODUCTION: Glycoprotein IIb/IIIa inhibitors have a key role in the treatment of patients with acute coronary syndromes undergoing percutaneous interventions. Although, an increased risk of bleeding complications is well recognized, its association with diffuse alveolar hemorrhage is much less recognized. Previous authors have suggested that the incidence of glycoprotein IIb/IIIa inhibitor associated diffuse alveolar hemorrhage has been significantly underestimated due to under reporting. CASE PRESENTATIONS: In order to help better determine the incidence of GP IIb/IIIa inhibitor associated DAH, a retrospective review of medical records was conducted over a 1 year period at a single high volume medical hospital. The medical records of all patients diagnosed with diffuse alveolar hemorrhage were evaluated for treatment with a GP IIb/IIIa inhibitor within 48 hours of its diagnosis. Each patient meeting the inclusion and exclusion criteria were included in the case series. This number was compared with the total number of patients receiving a GP IIb/IIIa inhibitor during the same time period and an incidence of the complication was calculated. 292 patients received either abciximab or eptifibatide during the one year review period and two patients were diagnosed with diffuse alveolar hemorrhage confirmed by serial bronchiolar lavage for an incidence of 0.68%. Of the total 292 patients receiving GP IIb/IIIa inhibitors, 172 patients received abciximab with one occurrence of diffuse alveolar hemorrhage for an incidence of 0.58% while 120 patients received eptifibatide with one occurrence for an incidence of 0.83%. Both patients developed significant morbidity as a result of the complication and 1 of the 2 patients died as a complication of the disease. CONCLUSIONS: Our findings support the claim that the incidence of GP IIb/IIIa induced diffuse alveolar hemorrhage is substantially higher than initially suggested by drug manufacturer studies. Although these drugs have proven mortality benefits, its association with diffuse alveolar hemorrhage is likely under-recognized leading to significant under-reporting. The best way to more accurately determine the true incidence of this complication and decrease its morbidity and mortality is to increase awareness as well as include diffuse alveolar hemorrhage as a serious complication in product labeling.

Pneumopericardial tamponade resulting from a spontaneous gastropericardial fistula.

Pneumopericardium is a rare but serious cause of morbidity and mortality. Untreated, it can lead to cardiac tamponade and thus must be promptly identified to treat the underlying etiology. Here, we report a case of spontaneous pneumopericardium secondary to gastric ulcer perforation in association with a hiatal hernia. The diagnosis of pneumopericardium was first made under fluoroscopy during cardiac catheterization and a follow-up CT of the chest revealed a gastropericardial fistula as the initiating event. The patient underwent emergent thoracotomy and partial esophagogastrectomy which eventually resulted in a full recovery and discharge on postoperative day 19. Our unique experience with this rare and often fatal disease suggests that early diagnosis combined with an early and aggressive surgical strategy is critical for minimizing morbidity and mortality.

Ligand-dependent complex formation between the Angiotensin II receptor subtype AT2 and Na+/H+ exchanger NHE6 in mammalian cells.

Involvement of Angiotensin II (Ang II) in the regulation of sodium levels by modulating the Na+/H+ exchangers is demonstrated in many tissues. Screening of a mouse 17-day fetus cDNA library with the Angiotensin II receptor AT2 as the bait in yeast two-hybrid assay led us to identify an AT2-interacting mouse fetus peptide that shared 98% amino acid identity with the corresponding region of the human NHE6. NCBI Blast search showed that the clone 6430520C02 (GenBank Accession # AK032326) of the mouse genome project carried the complete sequence of this new mouse NHE6 isoform. The human and mouse NHE6 peptides share 97% overall homology. Further analysis showed that the region spanning the third intracellular loop and C-terminal cytoplasmic tail of the AT2 directly interacted with a 182 amino acid region that spans the predicted 5th intracellular loop and the initial part of the C-terminus of the mouse NHE6 in yeast two-hybrid assay. This 182-amino acid region that interacted with the AT2 also shares 98% homology with the corresponding region of rat NHE6 and therefore is highly conserved across species. We detected widespread expression of this NHE6 isoform in several rat tissues including 10-day fetus, 17-day fetus, and 30-day post-natal tissues of heart, brain, kidney and muscle. Moreover, the AT2 co-immunoiprecipitated with a hemagglutinin tagged NHE6 when expressed in human cell line MCF-7, and activated by AngII. This ligand-dependent complex formation between the AT2 and NHE6 suggests that the hormone Ang II may act as a regulator of NHE6, and Ang II-mediated direct protein-protein interaction between AT2 and NHE6 could be a mechanism for modulating the functions of the ubiquitously expressed NHE6 in different tissues.