Outcomes and survival of patients undergoing percutaneous vegetectomy for right heart endocarditis.

Backgrounds: AngioVac is used for the percutaneous removal of vegetations and for debulking of large vegetations in patients who are not surgical candidates.This study aims to identify the demographics, echocardiographic features, indications, improvement of the tricuspid valve regurgitation, and survival outcomes of patients who have undergone AngioVac vegetectomy reported in the literature. Methods: A systematic review was performed to identify articles reporting suction thromectomy or vegetation removal using the AngioVac system for RSIE (right sided infective endocarditis). Survival on discharge was our primary outcome. Additionally, we evaluated indications for suction thrombectomy and TR improvement. Categorical variables were expressed as percentages and ratios. Results: A total of 49 studies were identified. The most common risk factor was intravenous drug abuse seen in 45% (20/49) and cardiovascular implantable electronic device (CIED) in 45% (20/49). Circulatory shock was seen in 35% of patients. The causative organism was gram positive cocci (86%). Moderate to severe TR was present in 74% of cases with documented echocardiograms. Indications for AngioVac were poor surgical candidacy (81%) or to reduce septic emboli risk (19%). Survival at discharge was 93%. TR improvement was reported only in 16% cases and remained unchanged/worsened in 84%. Conclusion: AngioVac procedure is an alternative treatment for critically ill patients who cannot undergo surgery. To understand the survival, safety and candidacy of patients undergoing this procedure, further randomized control studies and literature reviews are needed. The improvement or worsening of tricuspid regurgitation in patients with TR valve involvement is another factor to be investigated.

Implementation of the 2017 American College of Cardiology/American Heart Association Guidelines on Hypertension in Clinical Practice.

Background: The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on hypertension recommend a threshold blood pressure (BP) of ≥130/80 mmHg for diagnosis of hypertension and treating hypertension to a goal BP of <130/80 mmHg. For this study, we assessed the rate of compliance to the 2017 ACC/AHA hypertension guidelines by internal medicine residents and cardiology fellows in clinics affiliated with a teaching hospital in New York, New York. Methods: We conducted a retrospective medical records review for patients who had a clinical encounter at the internal medicine resident and cardiology fellow clinics from January to February 2019. To distinguish from adherence with prior guidelines, patients with BP of 130-139/80-89 mmHg (unless age ≥60 years and systolic blood pressure [SBP] 140-149 mmHg without chronic kidney disease or diabetes) were included. The primary outcome was accurate assessment of uncontrolled BP in accordance with the 2017 ACC/AHA guidelines. Results: Included in the analysis were 435 patients from the internal medicine resident clinic and 127 patients from the cardiology fellow clinic. Accurate assessment of uncontrolled BP was higher in the cardiology fellow clinic compared to the internal medicine resident clinic (29.1% vs 10.3%, P<0.001), even after adjusting for baseline characteristics differences between the 2 clinics. Multivariate regression analysis revealed that the type of clinic (internal medicine, odds ratio [OR] 0.27, 95% CI 0.16-0.47; P<0.001), established diagnosis of hypertension (OR 2.06, 95% CI 1.06-3.99; P<0.001), and SBP (OR 1.16 per mmHg, 95% CI 1.11-1.22; P=0.031) were independently associated with the primary outcome. Conclusion: Cardiology fellows were better at identifying hypertension diagnosis thresholds and BP treatment goals in accordance with 2017 ACC/AHA guidelines compared to internal medicine residents.

Sepsis-induced cardiomyopathy is associated with higher mortality rates in patients with sepsis.

BACKGROUND: Patients with sepsis are at risk for developing sepsis-induced cardiomyopathy (SIC). Previous studies offer inconsistent results regarding the association of SIC and mortality. This study sought to assess whether SIC is linked to mortality in patients with sepsis and to evaluate predictors of the development of SIC. METHODS: In this retrospective study, patients admitted to the medical intensive care unit with a diagnosis of sepsis in the absence of acute coronary syndrome were included. SIC was identified using transthoracic echo and was defined by a new onset decline in left ventricular ejection fraction (LVEF) ≤50%, or ≥10% decline in LVEF compared to baseline in patients with a history of heart failure with reduced ejection fraction. Multivariable logistic regression analysis was performed using the R software program. RESULTS: Of the 359 patients in the final analysis, 19 (5.3%) had SIC. Eight (42.1%) of the 19 patients in the SIC group and 60 (17.6%) of the 340 patients in the non-SIC group died during hospitalization. SIC was associated with an increased risk for all-cause in-hospital mortality (odds ratio [OR], 4.46; 95% confidence interval [CI], 1.15-18.69; P=0.03). Independent predictors for the development of SIC were albumin level (OR, 0.47; 95% CI, 0.23-0.93; P=0.03) and culture positivity (OR, 8.47; 95% CI, 2.24-55.61; P=0.006). Concomitant right ventricular hypokinesis was noted in 13 (68.4%) of the 19 SIC patients. CONCLUSIONS: SIC was associated with an increased risk for all-cause in-hospital mortality. Low albumin level and culture positivity were independent predictors of SIC.

Perclose ProGlide embolization as a complication: case report and review of literature.

Background: Vascular closure devices have replaced mechanical compression for closure of femoral access sites after endovascular procedures. Case: We present an 87-year-old male with symptomatic infrarenal aortic aneurysm measuring 4.8 cm presenting for elective endovascular repair of the aortic aneurysm. A Perclose ProGlide Suture-Mediated Closure was used for closure. The closure was complicated by a separation of the ProGlide device resulting in the migration of the footplate to the descending aorta. Correction required snare retrieval via radial access, and the patient recovered without complications. Discussion: We highlight an important complication of the Perclose ProGlide Suture-Mediated Closure device that is rare but important to know when performing endovascular closures with this device.

Simultaneous dual AV node antegrade conduction (2 for 1) and lower common pathway (2-1) block illustrate AVNRT physiology.

We report a rare case of spontaneous initiation of Atrioventricular nodal reentry tachycardia (AVNRT) via 2 for 1 phenomenon, into a 2:1 AV block due to lower common pathway block and finally transition to 1:1 tachycardia. The premature atrial p wave traverses down both the fast and slow pathway simultaneously during 2 for 1 initiation and is met with subsequent typical AVNRT with 2:1 block. Infranodal location of the block is confirmed on electrophysiologic testing and is also cured by intervention. This rare electrographic presentation is not only pathognomonic for AVNRT with lower common pathway block but also illustrates its dual conduction physiology.

Hyperkalemia Presenting as Sinus Bradycardia, Junctional Rhythm and Atrial Bigeminy.

The spectrum of electrocardiographic changes seen with hyperkalemia is known to progress gradually with increasing serum levels of potassium. Initial changes are limited to peaked T waves and QT shortening, which subsequently progress to prolonged QRS/QT intervals, and finally sinus arrest, sinus bradycardia and asystole. We report a unique case of severe sinus bradycardia with atrial bigeminy and junctional rhythm in the setting of moderate hyperkalemia, a rarely reported electrocardiographic finding.