Long-term outcomes of sinus node modification in patients with severely symptomatic drug-refractory inappropriate sinus tachycardia: a single-center experience.

BACKGROUND: The purpose of the study was to evaluate the long-term outcomes of sinus node modification (SNM) in treating patients with severely symptomatic drug-refractory inappropriate sinus tachycardia (IST). METHODS: The study included 39 patients with symptomatic drug-refractory IST who have undergone SNM at Saint Louis University Hospital. Data was reviewed retrospectively. Recurrence of symptoms was assessed at 3-6-month follow-up intervals. RESULTS: The mean age of our cohort was 31.5 ± 11. The mean HR at diagnosis was 135 ± 25.4 beats per minute (BPM). Thirty-seven of 39 (94.8%) patients had complete resolution of symptoms. Of these 37 patients, 16 required 1 SNM, 17 patients required 2 SNM, and 4 patients required 3 SNM in order to achieve complete symptom resolution. Mean HR post-procedure was 78.6 ± 12.3 BPM. Thirteen of 39 patients required rate control medication post-procedure, all of whom were prescribed beta-blockers. Patients were followed every 3 to 6 months with a mean follow-up duration of 62.3 ± 42.9 months from the patient's last SNM procedure. Thirteen of those 37 patients (35.1%) developed intermittent symptomatic bradycardia requiring permanent pacemaker implantation. Two of the 39 patients had phrenic nerve injury, and 6 patients had post-procedure pericarditis. CONCLUSIONS: This study provides additional information to the limited dataset available in the literature and shows that SNM might provide patients with long-term symptomatic relief bearing in mind the potential increased risk for the need for permanent pacing.

Spontaneous Coronary Artery Dissection in a Liver Transplantation Candidate.

Spontaneous coronary artery dissection (SCAD) is an uncommon and potentially fatal cause of acute coronary syndrome, myocardial infarction, and sudden death primarily affecting women. While the exact cause of SCAD is unknown, associated risk factors are emotional or physical stress, female gender, pregnancy-related factors including hormonal changes, fibromuscular dysplasia, mixed connective tissue disorders, and inflammatory disorders. In this report, we present a middle-aged female with ulcerative colitis and cirrhosis secondary to primary sclerosing cholangitis who was found to have SCAD on cardiac evaluation for liver transplantation workup.

Patent foramen ovale prevalence in atrial fibrillation patients and its clinical significance; A single center experience.

BACKGROUND: Patent foramen ovale (PFO) has been reported in 25-30% of the general population. The most commonly used test for detecting PFO is a contrast enhanced transesophageal echocardiography (TEE). PFO presence can be confirmed during pulmonary vein isolation (PVI) procedure by passing the transseptal catheter assembly through the foramen ovale, crossing the septum from the right to the left atrium without using a trans-septal needle for puncture. METHODS: We retrospectively reviewed data from a cohort of 178 patients with AF who underwent PVI at Saint Louis University. Pre-PVI procedure, scheduled TEE reports were reviewed to assess for the presence of PFO and the PVI procedure reports were reviewed for confirmation. RESULTS: Records of 178 patients (55.6% male, mean population age 60.4 ±â€¯11.8) were reviewed. 102 of 178 patients had a PFO detected during the PVI procedure. This translates into a 57.3% prevalence of PFO in AF patients. Out of the 178 patients, 75 patients had a pre-PVI procedure TEE for whom PFO presence was reported in 18.7%. The sensitivity and specificity of TEE in detection of PFO were 36.8% and 100%, respectively. There was no statistically significant association between stroke and PFO diagnosed during PVI (RR 1.07; 95% CI, 0.53-2.19; P = 0.805). CONCLUSIONS: Our study reports a PFO prevalence of 18.7% using a pre-procedure TEE and 56.6% during the PVI procedure in AF patients. Given that TEE is the gold standard for detection of PFO, our study suggests that the prevalence of PFO may be underestimated in our AF population.

Acute Decompensated Heart Failure Secondary to Exogenous Triiodothyronine Use in a Young Non-athlete Weightlifter.

Heart failure (HF) is a common cardiovascular disorder and is associated with increased morbidity and mortality. HF is usually detected in the elderly population, in particular, in patients with coronary artery disease, valvular disease, myocarditis, and hypertension. Acute decompensated HF in previously healthy young patients should raise suspicion for other rare etiologies. We report a case of a 28-year-old male presenting with acutely decompensated HF secondary to performance-enhancing drugs (PED). The use of non-regulated, non-approved PED has become a world-wide health problem with patients often unaware of the potentially serious and fatal side effects.

Trastuzumab Emtansine for the Treatment of HER-2 Positive Carcinoma Ex-pleomorphic Adenoma Metastatic to the Brain: A Case Report.

Background: Carcinoma Ex-pleomorphic adenoma is a malignant transformation of the common benign neoplasm of the salivary glands, "pleomorphic adenoma." Only two cases were ever reported with brain metastases, with absence of good evidence guiding management of such cases. Case Presentation: A 61-year-old woman presenting with facial paralysis was found to have carcinoma ex-pleomorphic adenoma of the parotid gland. Twenty months after local treatment, she developed brain metastases, treated with whole brain radiation therapy. The patient then had progressive intracranial disease after the end of radiation therapy in addition to the appearance of liver metastases. Pathology showed overexpression of HER2, so she was treated with Trastuzumab Emtansine (TDM1). Follow-up imaging revealed significant decrease in the number and size of the metastatic brain lesions in keeping with a good response to TDM1 treatment. Conclusion: Prognosis of metastatic carcinoma ex-pleomorphic adenoma is very poor, and there is no clear management for such cases. We present a case of carcinoma ex-pleomorphic adenoma with brain and liver metastases with a very good response to TDM1 treatment.