Bilateral Pneumothorax Complicating Pacemaker Implantation, due to Puncture of the Left Subclavian Vein and Electrode Perforation of the Right Atrium.

Pneumothorax occurs mostly due to needle injury of the pleura when trying to get access to the subclavian vein and rarely due to electrode perforation. The present case report is the first case presented about acute simultaneous iatrogenic bilateral pneumothorax due to puncture of the left subclavian vein and electrode perforation of the atrial wall, the pericardium, and the pleura. Risk factors, and how to avoid these complications, are highlighted, and symptoms, diagnostics, and management of pneumothorax and cardiac perforation are described.

Age and Outcomes of Primary Prevention Implantable Cardioverter-Defibrillators in Patients With Nonischemic Systolic Heart Failure.

BACKGROUND: The DANISH study (Danish Study to Assess the Efficacy of ICDs [Implantable Cardioverter Defibrillators] in Patients With Non-Ischemic Systolic Heart Failure on Mortality) did not demonstrate an overall effect on all-cause mortality with ICD implantation. However, the prespecified subgroup analysis suggested a possible age-dependent association between ICD implantation and mortality with survival benefit seen only in the youngest patients. The nature of this relationship between age and outcome of a primary prevention ICD in patients with nonischemic systolic heart failure warrants further investigation. METHODS: All 1116 patients from the DANISH study were included in this prespecified subgroup analysis. We assessed the relationship between ICD implantation and mortality by age, and an optimal age cutoff was estimated nonparametrically with selection impact curves. Modes of death were divided into sudden cardiac death and nonsudden death and compared between patients younger and older than this age cutoff with the use of χ2 analysis. RESULTS: Median age of the study population was 63 years (range, 21-84 years). There was a linearly decreasing relationship between ICD and mortality with age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.003-1.06; P=0.03). An optimal age cutoff for ICD implantation was present at ≤70 years. There was an association between reduced all-cause mortality and ICD in patients ≤70 years of age (HR, 0.70; 95% CI, 0.51-0.96; P=0.03) but not in patients >70 years of age (HR, 1.05; 95% CI, 0.68-1.62; P=0.84). For patients ≤70 years old, the sudden cardiac death rate was 1.8 (95% CI, 1.3-2.5) and nonsudden death rate was 2.7 (95% CI, 2.1-3.5) events per 100 patient-years, whereas for patients >70 years old, the sudden cardiac death rate was 1.6 (95% CI, 0.8-3.2) and nonsudden death rate was 5.4 (95% CI, 3.7-7.8) events per 100 patient-years. This difference in modes of death between the 2 age groups was statistically significant (P=0.01). CONCLUSIONS: In patients with systolic heart failure not caused by ischemic heart disease, the association between the ICD and survival decreased linearly with increasing age. In this study population, an age cutoff for ICD implantation at ≤70 years yielded the highest survival for the population as a whole. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00542945.

Upregulation of Soluble HLA-G in Chronic Left Ventricular Systolic Dysfunction.

Left ventricular systolic dysfunction (LVSD) defined by ejection fraction (EF) <40% is common, serious but treatable, and correct diagnosis is the cornerstone of effective treatment. Biomarkers may help to diagnose LVSD and give insight into the pathophysiology. The immune system is activated in LVSD, and the immunomodulatory molecule human leukocyte antigen-G (HLA-G) may be involved. The primary aim was to measure soluble HLA-G (sHLA-G) in the blood in different stages of LVSD (<30% and 30-40%), in the midrange EF 40-50%, and in preserved EF ≥ 50% and to validate sHLA-G as a LVSD biomarker. The secondary aim was to examine associations between HLA-G gene polymorphisms influencing expression levels and LVSD. The 260 study participants were ≥75 years old, many with risk factors for heart disease or with known heart disease. Soluble HLA-G was significantly and uniformly higher in the groups with EF < 50% (<30, 30-40, and 40-50%) compared to EF > 50% (p < 0.0001). N-terminal fragment-pro-B-type natriuretic peptide (NT-proBNP) and uric acid values were inversely related to EF. According to Receiver Operating Characteristic (ROC) curves NT-proBNP outperformed both sHLA-G and uric acid as biomarkers of LVSD. Soluble HLA-G in blood plasma was elevated in LVSD regardless of EF. A novel finding was that a combined 14 bp ins-del/+3142 SNP HLA-G haplotype was associated with EF < 40%.

ECG as a first step in the detection of left ventricular systolic dysfunction in the elderly.

AIMS: Due to the demographic development there is an increasing number of senior citizens with left ventricular systolic dysfunction (LVSD), defined as ejection fraction (EF) < 40%. Unfortunately there are under-diagnosis and under-treatment in the elderly of this serious condition. Echocardiography is the gold standard to diagnose LVSD, but access is limited. Simple screening methods may ensure reduction of undetected cases, and this study investigates if electrocardiogram (ECG) can be used to screen for LVSD in the geriatric population. METHODS AND RESULTS: A total of 260 persons aged 75 to 92 years had an echocardiography, a 12 leads ECG, and NT-proBNP; 61 had EF < 40%, and of these 60 had an abnormal ECG. EF < 40% was significantly related to atrial fibrillation (A), pacing (P), LBBB (L), Q-waves (Q), and QRS duration ≥ 120 ms (D). EF < 40%, atrial fibrillation, pacing, and LBBB were related to NT-proBNP > 35 pmol/L. When APL was absent, NT-proBNP had discriminatory value regarding LVSD in the presence of Q-waves or QRS duration > 120 ms. Algorithms to screen for LVSD had sensitivity >90% and specificity >80% and claimed at least one of five (A/P/L/Q/D), one of 4 (A/P/L/Q), or one of three (A/Q/D) ECG changes. The optimal algorithm to reduce the need for diagnostic echocardiographies included four (A/P/L/Q) ECG changes and measurement of NT-proBNP when Q-waves were the only ECG change present. CONCLUSIONS: Ninety percent of LVSD may be detected, and when there is atrial fibrillation, pacing or LBBB, or QRS ≥ 120 ms/Q-waves and NT-proBNP>35 pmol/L, a diagnostic echocardiography should be considered.

Hand-held echocardiography is useful for diagnosis of left systolic dysfunction in an elderly population.

INTRODUCTION: Hand-held echocardiography (echo) (HE) was compared with standard echo (SE) to evaluate the quality of HE and to determine if it is safe to use HE to screen for left ventricular systolic dysfunction (LVSD) in the elderly. METHODS: A total of 260 high-risk persons aged 75 years and older with and without heart disease participated. SE (GE Vingmed 7/E9) and HE (GE Vscan) were performed in all 260 persons by separate, blinded and experienced echocardiographers who followed guidelines from the Danish Society of Cardiology and completed a structured data sheet. Another blinded echocardiographer revised HE (HR) and SE twice (SR). Data were analysed using STRATA and Cohen's Kappa statistic, and intra- and inter-observer variations and predictive values were calculated. RESULTS: Comparison of HR and SR, and HE and SE showed modest intra- and interobserver variation and good agreement in diagnosing LVSD and other changes in cardiac function and morphology (significant valvular disease), corresponding to a low inter-method variation and a good safety; thus, HE can be used to screen for LVSD and other cardiac abnormalities. Besides, the negative predictive values were high; thus, HE can be relied upon to omit persons with normal echoes from referral to SE. CONCLUSION: According to this study, HE is a valuable tool to screen for LVSD and other changes in cardiac function and morphology in a high-risk population aged 75+ years; nothing very important is missed by HE and the experienced echocardiographers; and in case of a normal HE, it is safe not to refer to SE. FUNDING: Puljen til Tvaersektorielle Projekter (Research fund of cross-sectional health-projects), TrygFonden (Danish foundation TrygFonden) and Den Regionale Forskningsfond (Region Zealand Health Scientific Research Foundation). TRIAL REGISTRATION: not relevant.

[The Danish National Quality Project about heart failure indicates lack of reporting and treatment of the elderly].

The Danish National Quality Project about heart failure has improved care for the patients considerably by insisting on evidence-based treatment in hospitals and heart failure clinics. Regrettably, according to data there is marked underrepresentation of patients 75-year-old and older, and especially a lack of women in this age group in the project. This discrimination towards the elderly and especially towards elderly women could possibly be solved by out-of-hospital-screening for heart failure among these patients.

[Takotsubo stress cardiomyopathy with mural thrombosis]. / Et tilfaelde af Takotsubo-stresskardiomyopati med muraltrombe.

Takotsubo-cardiomyopathy is a stress-related acute cardiac disorder characterized by reversible systolic ballooning and hypokinesia of the distal part of the left ventricle, cardiac symptoms, and ECG-changes, but no coronary artery stenosis, and no other causable disease. In the present case, heart disease was suspected because of tachycardia and dyspnoea which continued after treatment for severe asthma. A mural thrombosis was an extraordinary finding in this otherwise typical case.