Prevotella bivia cardiac implantable electronic device related endocarditis.

Cases of Gram-negative, anaerobic rod bacteremia and endocarditis have been increasingly recognized in recent years. This increase has been primarily observed in patients at risk for polymicrobial infections, such as those who use injection drugs and patients with diabetes mellitus. Despite a growing incidence, there are few published case reports of cardiac implantable electronic device related endocarditis secondary to Gram negative, anaerobic organisms. We present a unique case of Prevotella bivia cardiac implantable electronic device related endocarditis in a middle-aged woman with no history of injection drug use. This case highlights the increasing incidence of polymicrobial infections and anaerobic endocarditis. Additionally, it demonstrates how Prevotella bivia has the potential to cause native valve infective endocarditis as well as cardiac implantable electronic device related endocarditis.

The proof is in the appendage: A case report of a fenestrated membrane overlying the left atrial appendage.

A 35-year-old man with history of recurrent arrhythmias presented for pulmonary vein isolation. He underwent pre-procedural screening for thromboembolism risk with transesophageal echocardiogram. He had an incidental finding of a rare fenestrated membrane overlying his left atrial appendage. Additional workup throughout his clinical course revealed genetic mutations in the LMNA and SNTA1 genes. There have been no previous reported genetic mutations reported in cases with LAA membranes.

Short and Intermediate Term Outcomes of the Convergent Procedure: Initial Experience in a Tertiary Referral Center.

PURPOSE: The Convergent procedure is a hybrid, multidisciplinary treatment for symptomatic atrial fibrillation (AF) consisting of minimally invasive surgical epicardial ablation and percutaneous/catheter endocardial ablation. We investigated outcomes following introduction of the Convergent procedure at our institution. METHODS: Retrospective study examining single-center outcomes. Demographic, procedural, and post-procedural variables were collected with follow-up data obtained at 3, 6, and 12 months. RESULTS: In all, 36 patients with paroxysmal (11%) or persistent/long-standing persistent (89%) AF underwent the Convergent procedure. 36% also underwent concomitant left atrial appendage (LAA) exclusion by thoracoscopic placement of an epicardial clip. Mean age 60.6 ± 8.0 years with mean arrhythmia burden of 3.9 ± 2.7 years. All patients had failed prior attempts at medical management, 81% had failed prior cardioversion, and 17% had failed prior catheter ablation. Convergent was performed successfully in all patients with no peri-procedural deaths or major complications. At 3 and 12 months, 77.8% and 77.3% of patients, respectively, were free from symptomatic arrhythmia. 65.8% were off anti-arrhythmic medication at 12 months. CONCLUSIONS: The Convergent procedure is safe and has good short- and intermediate-term clinical success rates. This unique hybrid approach combines strengths of surgical and catheter ablation and should be part of any comprehensive AF treatment program.

Use of an antimicrobial pouch/envelope in the treatment of Twiddler's syndrome.

BACKGROUND: "Twiddler's syndrome" occurs when a patient consciously or subconsciously manipulates their pacemaker/defibrillator pulse generator, often resulting in lead dislodgement and device system malfunction. Once dislodgement has occurred, corrective measures include resecuring the system to the pectoralis fascia with redundant anchoring sutures. Unfortunately, patients with Twiddler's syndrome tend to have a high rate of recurrence. This study presents a case series of patients with Twiddler's syndrome and evaluates the strategy of using a nonabsorbable antimicrobial pouch to prevent recurrent lead dislodgement events. METHODS: Pacemaker and defibrillator operative reports were reviewed at a single institution over a time period of 16 years. Historical, fluoroscopic, and intraoperative findings were used to identify 21 patients with strong evidence for Twiddler's syndrome. Patient charts were retrospectively analyzed, and a cohort of 13 patients who received a nonabsorbable antimicrobial pouch was compared to a cohort of eight patients who received other corrective measures. RESULTS: The rate of "retwiddling" events was 0% in the antimicrobial pouch group versus 50% in the suture-only group (P < 0.05). CONCLUSIONS: Among patients requiring device system revision for Twiddler's syndrome, the use of nonabsorbable antimicrobial pouches was associated with significantly fewer recurrences of lead dislodgement events.

Nailed It: Conservative Management of Penetrating Injury and Potential Infection of a Cardiovascular Implantable Electronic Device.

A 47-year-old man with a history of ischemic cardiomyopathy and chronic systolic heart failure presented after he inadvertently shot himself in the left upper chest with a pneumatic nail gun, penetrating his implantable cardioverter defibrillator (ICD) generator. The device was noninterrogable, consistent with device failure. A new ICD was attached to the existing right ventricular lead, which showed no evidence of traumatic damage and normal lead parameters on interrogation. Aggressive debridement and antibiotic irrigation of the ICD pocket was performed and an antibacterial envelope was used. Bacterial culture of the ICD pocket grew Bacillus species. The patient completed a course of at least 14 days of oral clindamycin. At follow-up, there were no signs or symptoms of systemic or local wound infection.

The use of warfarin for DVT prophylaxis following hip and knee arthroplasty: how often are patients within their target INR range?

The purpose of this study was to determine the percentage of time that patients are therapeutic when prescribed warfarin for chemical thromboprophylaxis following a hip or knee arthroplasty procedure. One hundred eighty-four patients receiving warfarin for 4weeks postoperatively, dosed using a Web-application accounting for patient demographics, INR levels, and concomitant medication use, were included. Patients with a target INR range between 1.7 and 2.7 were therapeutic for only 54.4% of the time (32.5% subtherapeutic, 13.0% supratherapeutic) while patients with a target INR range between 2.0 and 3.0 were therapeutic for only 45.9% of the time (39.2% subtherapeutic, 14.8% supratherapeutic). Patients receiving warfarin for chemical thromboprophylaxis are within their targeted INR range for only a limited period of time during their postoperative course.

Planned Bone Resections Using an MRI-Based Custom Cutting Guide System Versus 3-Dimensional, Weight-Bearing Images in Total Knee Arthroplasty.

Potential sources of alignment variability not yet investigated with the use of custom cutting guides (CCG) in total knee arthroplasty (TKA) are weight-bearing and lower extremity rotation. This study compared the preoperative planned bone resections created using an MRI-based CCG system to those from 3-dimensional, weight-bearing, full-length lower extremity images in 53 patients undergoing TKA. The angular difference between the proposed resections of the two systems was greater than 2° in 30.2% of patients for the distal femur, and 52.8% for the proximal tibia. An increased preoperative varus alignment had a slight association with an increased angular difference for the tibial resection (r=0.4). This study demonstrates weight-bearing and lower extremity rotation to be potential sources of alignment variability when using MRI-based CCGs.

A perioperative management algorithm for cardiac rhythm management devices: the PACED-OP protocol.

BACKGROUND: Limited data are available regarding the perioperative management of cardiac rhythm management devices (CRMDs) exposed to intraoperative electromagnetic interference. We postulated that implementation of a simple, standardized approach to CRMD management using our own institution's Pacing And Cardioverting Electronic Devices peri-Operative Protocol (the PACED-OP protocol) would be associated with a reduction in the amount of device reprogramming without an increase in CRMD-related complications. METHODS: Records of patients with CRMDs undergoing 497 consecutive surgical procedures were analyzed retrospectively. Roughly half (51%, n = 254) of these procedures occurred before implementation of the PACED-OP protocol, when patients were generally treated according to the American Society of Anesthesiologists' 2005 guidelines. These cases were compared to the remaining surgeries that occurred after implementation of the PACED-OP protocol. Records were screened for evidence of intraoperative CRMD malfunction that was directly associated with the use of electrocautery. Postoperative complications that could be indirectly or possibly linked to electrocautery-mediated CRMD malfunction were also identified. RESULTS: Implementation of the PACED-OP protocol was associated with a significant reduction in the odds of device reprogramming (adjusted odds ratio [aOR] 0.19, P < 0.001). There was no direct evidence of CRMD malfunction in either cohort. The rate of postoperative complications that could be indirectly or possibly linked with electrocautery-mediated CRMD damage did not differ significantly between cohorts (aOR = 1.37, 95% confidence interval 0.56-3.3, P = 0.49). CONCLUSION: The PACED-OP protocol implementation was associated with a significant reduction in the odds of device reprogramming without a significant difference in the odds of CRMD-related complications.

Aorto-right atrial fistula following transseptal catheterization and catheter ablation for atrial fibrillation.

Aorto-cameral fistula, either congenital or acquired, is an abnormal connection between the ascending aortic root and one of the cardiac chambers. We report a case of a 61-year-old male with history of atrial fibrillation and 2 radiofrequency ablation procedures, referred to us for surgical Cox Maze procedure. Preoperative cardiac computerized tomography revealed a fistulous connection between the aortic root and the right atrium. Later, the patient underwent successful surgical closure of the fistula during the Cox Maze procedure. In this paper, we also discuss the clinical presentation, natural history, anatomy of the interatrial septum, and management of aorto-cameral fistula.

Unusual complication of pacemaker implantation/revision: secondary endocarditis due to fracture and embolization of an introducer sheath.

We report a 48-year-old male with a rare complication of pacemaker revision-fracture, migration, and secondary endocarditis due to a venous introducer sheath. We illustrate the possible mechanism of injury and discuss approaches to management.

Polarization-insensitive high-dispersion total internal reflection diffraction gratings.

We report the first experimental realization of total internal reflection (TIR) diffraction gratings. Performance of less than 0.7-dB insertion loss (IL) for both TE and TM polarizations and 0.5-dB polarization-dependent loss (PDL) are predicted over a 50-nm spectral bandwidth with simultaneous fabrication tolerances on the depth and the duty cycle of binary gratings of +/-5% and +/-14%, respectively. Nineteen gratings were fabricated that met these specifications, yielding IL and PDL values less than 0.6 and 0.2 dB, respectively, across the entire 50-nm bandwidth. Measurements made under the Littrow configuration resulted in high efficiency and low PDL across a 100-nm bandwidth, with up to 100% diffraction efficiency within the experimental measurement error.

Optical measurement of depth and duty cycle for binary diffraction gratings with subwavelength features.

We describe a new and unique method for simultaneous determination of the groove depth and duty cycle of binary diffraction gratings. For a near-normal angle of incidence, the +1 and -1 diffracted orders will behave nearly the same as the duty cycle is varied for a fixed grating depth. The difference in their behavior, quantified as the ratio of their respective diffraction efficiencies, is compared to a look-up table generated by rigorous coupled-wave theory, and the duty cycle of the grating is thus obtained as a function of grating depth. Performing the same analysis for the orthogonal probe-light polarization results in a different functional dependence of the duty cycle on the grating depth. By use of both TE and TM polarizations, the depth and duty cycle for the grating are obtained by the intersection of the functions generated by the individual polarizations. These measurements can also be used to assess qualitatively both the uniformity of the grating and the symmetry of the grating profile. Comparison with scanning electron microscope images shows excellent agreement. This method is advantageous since it can be carried out rapidly, is accurate and repeatable, does not damage the sample, and uses low-cost, commonly available equipment. Since this method consists of only four fixed simple measurements, it is highly suitable for quality control in a manufacturing environment.