Leadless pacing: First experience and outcomes in an isolated area in the setting of the Greek financial crisis.

BACKGROUND: Leadless pacing (LP) is a novel permanent pacing modality without transvenous leads that is increasingly applied in certain circumstances. We aimed to report our preliminary experience in LP implementation. CASE SERIES: This observational study represents a simple registry of LP systems implanted in our tertiary center from April 2018 until November 2019 in the setting of the Greek financial crisis. Consecutive patients from the isolated area of Northwestern Greece referred to our center for LP were included. Patients' clinical and procedural data, as well as follow-up events, were carefully recorded. Nine patients (mean age: 75 years; six men) were included and were followed for a median period of 20 months. The commonest indication for LP implantation was increased patient infection risk (n: seven), while in the remaining patients (n: two), the indication was problematic vein access along with concomitant comorbidities that increase infection risk. Most of the patients (6/9) were in sinus rhythm, while the rest had slow atrial fibrillation. During the follow-up period, two patients with end-stage renal disease suffered sudden cardiac death, two patients died due to pneumonia, and one patient died due to metastatic cancer. However, no device-related death occurred during the follow-up. CONCLUSIONS: Our data indicate that LP's long-term cost-effectiveness is limited in patients with several comorbidities due to increased mortality. Indeed, considering its increased financial cost, well-defined patients' selection criteria should be developed and applied, especially in medium/low-income countries. HIPPOKRATIA 2021, 25 (2):75-78.

Preeclampsia and long-term coronary artery disease: How to minimize the odds?

Preeclampsia (PE) is a hypertensive disorder of pregnancy that can cause detrimental obstetric outcomes if not managed properly. Current evidence demonstrates higher risk for long-term cardiovascular disease in preeclamptic women. Even in uncomplicated pregnancies, the heart work overload often reveals subtle cardiac defects or abnormalities, which otherwise remain undiagnosed in women without a history of pregnancy. Pathophysiologic patterns occurring in PE patients resemble biochemical responses observed in cases of cardiovascular disease. It has been estimated that women with an obstetric history of PE are more likely to develop coronary artery disease in the long run. Currently, additionally to whether any approach could actually contribute to minimizing mortality and morbidity among these affected populations, there is no consensus regarding management for these patients. In this review we summarized the current scientific evidence regarding the correlation between PE and long-term coronary artery disease. Based on this knowledge, we propose postpartum and lifetime management for these high-risk patients in order to minimize morbidity and mortality within this population.

The association of hematological indices with the response to cardiac resynchronization therapy: a single-center study.

BACKGROUND: Cardiac resynchronization therapy (CRT) is an established therapeutic option for patients with heart failure (HF) and left ventricular ejection fraction (LVEF) ≤35 % who meet specific criteria according to current guidelines. However, up to 40 % of patients have no response to CRT. Our study aimed to investigate the association between different hematological and biochemical indices and response to CRT. METHODS: Patients with HF due to ischemic or dilated cardiomyopathy referred to our hospital for CRT implantation from January 2013 to November 2017 were included in the study. Response to CRT was defined as an increase in LVEF ≥10 % or a decrease in left ventricular end-systolic volume (LVESV) ≥15 % at six months of follow-up. RESULTS: A total of 48 patients (mean age: 66.2 ± 9.5 years, 81.3 % males) were included in the study. Of these HF patients, 29 (60.4 %) had ischemic cardiomyopathy, and 19 (39.6 %) had dilated cardiomyopathy. At six months of follow-up, 37 patients (77.1 %) had responded to CRT. Ten patients (20.8 %) had ventricular tachycardia (VT), 24 (50 %) patients were hospitalized, and two patients (4.2 %) died during the follow-up period. Multivariate analysis demonstrated that age (p =0.03) and creatinine levels (p =0.02) were independent predictors of the response to CRT. No significant associations between hematological markers (white blood cells, neutrophils, lymphocytes, platelets, neutrophil to lymphocyte ratio, red blood cells distribution width) and CRT response were observed. CONCLUSIONS: A smaller increase in LVEF and a smaller decrease in LVESV were predictive for VT occurrence and hospitalizations in patients receiving CRT. No significant association between hematological markers and response to CRT was found. HIPPOKRATIA 2019, 23(3): 118-125.

Impact of baseline renal function on all-cause mortality in patients who underwent cardiac resynchronization therapy: A systematic review and meta-analysis.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves both morbidity and mortality in selected patients with heart failure and increased QRS duration. However, chronic kidney disease (CKD) may have an adverse effect on patient outcome. The aim of this systematic review was to analyze the existing data regarding the impact of baseline renal function on all-cause mortality in patients who underwent CRT. METHODS: Medline database was searched systematically, and studies evaluating the effect of baseline renal function on all-cause mortality in patients who underwent CRT were retrieved. We performed three separate analyses according to the comparison groups included in each study. Data were analyzed using Review Manager software (RevMan version 5.3; Oxford, UK). RESULTS: We included 16 relevant studies in our analysis. Specifically, 13 studies showed a statistically significant higher risk of all-cause mortality in patients with impaired baseline renal function who underwent CRT. The remaining three studies did not show a statistically significant result. The quantitative synthesis of five studies showed a 19% decrease in all-cause mortality per 10-unit increment in estimated glomerular filtration rate (eGFR) [HR: 0.81, 95% CI (0.73-0.90), p<0.01, 86% I2]. Additionally, we demonstrated that patients with an eGFR<60 mL/min/1.73 m2 had an all-cause mortality rate of 66% [HR: 1.66, 95% CI (1.37-2.02), p<0.01, 0% I2], which was higher than in those with an eGFR≥60 mL/min/1.73 m2. CONCLUSION: Baseline renal dysfunction has an adverse effect on-all cause mortality in patients who underwent CRT.

Cardiac troponin I versus creatine kinase-MB in the detection of postoperative cardiac events after coronary artery bypass grafting surgery.

AIM: Several studies suggest that postoperarive concentrations of cardiac troponin-I (cTnI) may increase in patients undergoing aorto-coronary bypass grafting (CABG). The degree and pattern of release appears to be associated with perioperative myocardial damage. METHODS: This was a prospective observational study with serial sampling conducted at the Departments of Cardiothoracic Surgery and Anesthesiology, University Hospital of Ioannina, Ioannina, Greece. The levels of cTnI and creatine kinase-MB (CK-MB) preoperatively, upon admission to the intensive care unit and at 12, 24, 36 and 48 hours after surgery, as well as daily from postoperative days 3-7 were determined in 41 consecutive patients (33 males and 8 females, aged 64.8+/-6.1 years) who underwent CABG with cardiopulmonary bypass. The Authors compared the patterns and variation of cTnI and creatine kinase (CK)-MB after CABG in patients with or without postoperative cardiac events (PCEs). RESULTS: Eleven patients experienced a PCE (postoperative ventricular and supraventricular arrhythmia, need for intra-aortic balloon pump (IABP) for >12 hours, or postoperative myocardial infarction, [MI]). In patients without PCE the elevation of cTnI peaked at 24 hours after surgery, while in patients with PCE maximal values of cTnI occurred after 36 hours. CTnI levels correlated with CK-MB after the procedure. Receiver-operating characteristic (ROC) curve analysis indicated that cTnI is superior to CK-MB with regard to PCE diagnosis following CABG (area under the ROC curve, 0.73, 95% CI (0.53-0.93) versus 0.54, 95% CI, (0.25-0.83). CONCLUSION: CTnI seems to be more valuable compared to CK-MB in the detection of PCEs in patients undergoing coronary surgery.

Atrial fibrillation and marijuana smoking.

Marijuana is the most commonly used illicit drug while its abuse and dependence has an increasing prevalence among the young population. Marijuana smoking affects the circulatory system triggering various cardiovascular events. Of note, recent case reports indicate a possible association with atrial fibrillation (AF). In this article, we provide a brief systematic review of all reported cases implicating marijuana smoking in AF development and we concisely discuss the potential underlying mechanisms as well as the clinical implications of this emerging association.

Oxidative stress in hepatic ischemia-reperfusion injury: the role of antioxidants and iron chelating compounds.

Ischemia-reperfusion (IR) injury is a multifactorial process triggered when the liver or other organs are transiently subjected to reduced blood supply followed by reperfusion. It has been shown that "reactive oxygen species" (ROS) are generated during ischemia and reperfusion and may represent pivotal mediators of the ensuing pathological complications. In some cases, however, moderate production of ROS may exert protective effects, a phenomenon presumably related to "ischemic preconditioning". This review will focus mainly on: a) describing the sources and the biochemical mechanisms of ROS generation during ischemia and reperfusion, b) discussing current developments in understanding the biochemical pathways by which ROS may induce toxic or protective effects, c) critically evaluating the results of previous attempts to counteract the toxic effects of ROS by using a variety of antioxidant and transition metal-chelating agents, and d) if feasible, proposing potential new pharmaceutical agents aimed at ameliorating ROS-inducing deleterious effects during reperfusion. It is concluded that ROS are generated from different sources, at different periods during IR, and may act by a variety of not well understood biochemical mechanisms which ultimately lead to cell damage and tissue failure.

Propafenone added to ibutilide increases conversion rates of persistent atrial fibrillation.

OBJECTIVE: To assess the effectiveness and safety of pharmacological conversion of persistent atrial fibrillation (AF) with a combined propafenone plus ibutilide regimen. METHODS AND RESULTS: 100 consecutive patients (66 men, mean (SD) age 65 (10) years) with persistent AF (mean (SD) duration 99 (92) days) admitted for elective pharmacological cardioversion were randomly assigned to treatment with either intravenous ibutilide (1 mg plus an additional 1 mg, if required; n = 51) or oral propafenone (600 mg) plus intravenous ibutilide at the same dose (n = 49). Success rates were 41.1% (21 of 51 patients) for ibutilide alone and 71.4% (35 of 49 patients) for propafenone plus ibutilide (p = 0.0044). However, cardioversion occurred earlier in the ibutilide alone group (55 (20) minutes) compared with the combination group (81 (32) minutes, p = 0.0019). A comparable increase in the QTc interval was observed in both groups but one case of sustained torsade de pointes, requiring electrical cardioversion, was observed in the propafenone plus ibutilide group. No other complications were noted during the hospitalisation period. CONCLUSION: Concurrent administration of propafenone plus ibutilide for pharmacological cardioversion of persistent AF is safe and more effective than ibutilide alone.

Microscopic polyangiitis complicated by the development of prostate cancer and flutamide-induced hepatitis.

We report a case of a 65-year-old man with microscopic polyangiitis who developed prostate cancer and gastric adenocarcinoma after prolonged oral use of cyclophosphamide. Acute hepatitis with jaundice and marked increase in aminotranferases occurred after 6 months of flutamide treatment for metastatic prostate carcinoma. It is suggested that patients with vasculitis or other autoimmune disorders should avoid prolonged use of cyclophosphamide and other cytotoxic drugs in order to minimize long-term adverse effects, of which the risk of cancer is by far the most important. In patients on flutamide treatment, careful monitoring of flutamide administration with repeated liver function tests should be undertaken, and the drug must be immediately discontinued in patients with abnormal results to avoid progression of liver injury.

Variation of inflammatory indexes after electrical cardioversion of persistent atrial fibrillation. Is there an association with early recurrence rates?

Inflammation has been recently implicated in the pathophysiology of atrial fibrillation (AF). The aim of this study was to examine the variation of inflammatory indexes during the first week after successful electrical cardioversion of persistent AF. Successive measurements of white blood cell (WBC) count, C-reactive protein (CRP) and fibrinogen levels were performed in 30 cardioverted patients. At the end of the 7-day follow-up period, AF had recurred in 30% of patients. A significant variance was found in serial measurements of fibrinogen levels in the two groups (non-relapse and relapse, p = 0.005). Fibrinogen levels increased significantly in patients who relapsed into AF, but remained stable in patients who remained in sinus rhythm. In the latter patients, CRP values tended to decrease post-cardioversion, but WBC count was significantly lower (p < 0.001) on the 7th day (6083 +/- 1335), compared with baseline values (6648 +/- 1395). The variation of inflammatory indices post-cardioversion might have prognostic implications with regard to sinus rhythm maintenance.

Physical activity and stroke risk.

Stroke represents a leading cause of morbidity and mortality especially among the elderly people, and therefore the need for effective preventive strategies is imperative. The value of physical activity for stroke prevention is not as well established as for other cardiovascular diseases. Despite some conflicting results, the majority of published studies have demonstrated a negative association between physical activity and stroke risk. In this article, we provide a concise overview of the epidemiological studies that investigate this association as well as a comprehensive analysis of the most relevant underlying pathophysiological mechanisms.

Disseminated tuberculosis complicating anti-TNF-alpha treatment.

An unusually large number of cases of tuberculosis, often of miliary or disseminated form, have been reported in patients receiving infliximab therapy for rheumatoid arthritis or Crohn's disease. We describe a patient with rheumatoid arthritis who was treated with infliximab and became systemically ill with Mycobacterium tuberculosis-disseminated infection. Patients who are candidates for treatment with tumour necrosis factor-alfa inhibitors should be evaluated for the presence of latent or active

Subdural empyema and cerebellar abscess due to chronic otitis media.

The infratentorial variety of the subdural empyema, with or without coexisting cerebellar abscess, is a rare clinical entity that carries a high mortality rate. We briefly describe the case of a 49-year-old man presented with severe debility, fever and an obviously neglected chronic otitis media. The patient had refused surgical treatment several months ago. After admission, his level of consciousness began to deteriorate, and the radiological studies showed infratentorial subdural suppuration extending into the right cerebellar hemisphere, along with chronic pyogenic infection of the middle ear and the mastoid process. Radical mastoidectomy was performed first, followed by extensive right posterior fossa craniectomy. The two subdural collections and the cerebellar abscess were successfully evacuated. Subsequently, he received post-operative antibiotic treatment for 6 weeks. At follow-up, 10 months after surgery, his neurological recovery was complete except for a minor residual cerebellar dysfunction on the right. This unusual case highlights that in patients presented with severe intracranial complications of chronic otitis media, early diagnosis and radical surgical intervention may be life saving.

An epidemiologic study of acute coronary syndromes in northwestern Greece.

Acute coronary syndromes (ACS) represent the most common cause of morbidity and mortality in the Western world. Relative epidemiologic data for Greece, a Mediterranean country, are sparse. The aim of the study was to determine the incidence and the clinical presentations of ACS. Over a 1-year period we conducted a prospective, population-based survey of ACS cases in an isolated area of northwestern (NW) Greece with 170,000 inhabitants. Every patient living in the study area, aged <80 years, without history of coronary artery disease, who presented with symptoms suspicious for ACS and was hospitalized for at least 24 hours was eligible for inclusion in the study. For sudden cardiac deaths, relative information was obtained from the autopsy report or the physician who documented death. Additional information regarding timing and associated conditions was obtained from relatives. The diagnosis and classification of the studied cases was performed according to World Health Organization and European Society of Cardiology criteria. The authors identified 352 patients (265 men, 87 women, mean age 62.5 +/-10 and 68 +/-9.5 years, respectively) with first-appeared ACS (174 non-ST elevation, 105 ST elevation, 73 sudden cardiac deaths). Fifty-six patients with other forms of ischemic heart disease (stable angina, heart failure, and silent ischemia) were not included in the analysis. Moreover, 154 patients with chest pain and normal appearing EGG at rest, normal values for enzymes (CK, troponin), and negative exercise testing, as well as 77 patients with normal findings from coronary angiography studies, were also excluded. The annual incidence for the age group of 30-79 was 39/10,000 inhabitants (60.6 for men and 19 for women). The incidence of ACS increased with age in both sexes and was higher in men even after the age of 70. About one third of the ACS and half of the sudden cardiac deaths occurred in the age group of 70-79. Only 3 patients were successfully resuscitated. ACS are common in this area of NW Greece and the majority of them present in a form amenable to therapeutic manipulations. Twenty percent of patients died suddenly, and a very small percentage of these were successfully resuscitated. Preventive measures and acute management facilities need to be improved, even in a Mediterranean country where the incidence of ischemic heart disease is relatively lower than in northern European countries.

Solitary extramedullary plasmacytoma of the maxillary sinus. Case report.

Solitary extramedullary plasmacytomas are rare tumors that often affect head and neck region. Because of the non-specific associated symptomatology, they frequently are misdiagnosed. We briefly describe a 69-year-old woman who developed solitary plasmacytoma in the left maxillary sinus and was initially treated as having sinusitis. We also report the diagnostic work-up that is necessary to establish a correct diagnosis in such cases. This case highlights that an appropriate investigation for neoplastic disease should be performed in patients presenting with persistent symptoms that resemble those of sinusitis, especially if these do not resolve after conservative medical treatment.

Acute rhabdomyolysis due to prolonged exposure to the cold.

Rhabdomyolysis represents an acute skeletal muscle injury and may be accompanied by acute renal failure due to myoglobinuria. This disorder has many potential causes. We describe the case of a 75-year-old man who developed rhabdomyolysis after prolonged exposure to cold but without associated hypothermia. This unusual case highlights that an appropriate investigation for rhabdomyolysis such as serum CK measurement should be performed in patients presenting with a history of prolonged exposure to cold, even in the absence of an obvious precipitating factor.