Syncope without prodromes in patients with normal heart and normal electrocardiogram: a distinct entity.

OBJECTIVES: This study sought to investigate the clinical and laboratory findings of patients affected by sudden-onset syncope without prodromes who had a normal heart and normal electrocardiogram. BACKGROUND: The pathophysiology of syncope in these patients is uncertain. METHODS: We compared the clinical and laboratory findings of 15 patients with sudden-onset syncope without prodromes who had a normal heart and normal electrocardiogram (the study group) with those of 31 patients with established vasovagal syncope (VVS). RESULTS: The patients in the study group were older than those with VVS (age 61 ± 12 years vs. 46 ± 17 years) and had a history of fewer episodes of syncope (median of 2 [interquartile range [IQR]: 1 to 2.5] vs. 9 [IQR: 4 to 15] years) that were of more recent onset (median of 1 [IQR: 0 to 1] vs. 10.5 [IQR: 3.3 to 27] years). The study group had lower median baseline adenosine plasmatic levels than the VVS group (0.25 µmol/l [95% confidence interval: 0.10 to 1.51] vs. 0.85 µmol/l [95% confidence interval: 0.32 to 2.80]). On receiver-operating characteristic curve analysis, the adenosine plasmatic level of ≤0.36 best discriminated between groups, displaying 73% sensitivity and 93% specificity. Tilt table testing was more frequently positive in patients with VVS than in the study group (74% vs. 33%). A similarly high positivity rate of adenosine/adenosine triphosphate testing was found in both groups. CONCLUSIONS: Common clinical features and a low adenosine plasmatic level define a distinct form of syncope, distinguish it from VVS, and suggest a causal role of the adenosine pathway.

Adenosine plasma level and A2A adenosine receptor expression: correlation with laboratory tests in patients with neurally mediated syncope.

OBJECTIVES: The purpose of this study was to investigate the hypothesis that responses to the ATP test and head-up tilt test (HUT) may be correlated with different purinergic profiles. DESIGN AND SETTING: The ATP and HUT identify distinct subsets of patients with neurally mediated syncope (NMS). Adenosine and its A(2A) receptors (A(2A)R) may be implicated in the pathophysiology of NMS in patients with positive HUT. Nothing is known about the purinergic profile of patients with positive ATP. PATIENTS AND MEASURES: This prospective study includes a consecutive series of patients with suspected NMS. All patients underwent both HUT and ATP. Before testing, samples were collected for measurement of baseline adenosine plasma level (APL) and expression. RESULTS: A total of 46 patients (25 men and 21 women) with a mean age of 57±18 years were enrolled. The HUT test was positive in 27 patients and the ATP test in 20. Both tests were positive in 9 and negative in 8. High APL was associated with high probability of positive HUT while low APL was associated with high probability of positive ATP. Expression of A(2A)R was lower in patients with positive ATP than in those with positive HUT. CONCLUSION: These findings indicate that patients with NMS present different purinergic profiles and that responses to HUT and ATP are correlated with these profiles.

Long-term outcomes following infection of cardiac implantable electronic devices: a prospective matched cohort study.

OBJECTIVE: To assess long-term outcomes and predictors of mortality in patients treated according to current recommendations for cardiac implantable electronic device (CIED) infection. DESIGN: Two-group matched cohort study. SETTING: Tertiary-care institution. PATIENTS: Consecutive patients admitted for CIED infection between 2004 and 2008 were prospectively enrolled. Study subjects were matched to a cohort of uninfected CIED patients by age, sex and type of device. INTERVENTIONS: In all infected patients, the therapeutic approach consisted of complete hardware removal whenever possible, antimicrobial therapy, and implantation of a new device, if indicated. Patients were systematically followed, with standardised outcomes assessment. MAIN OUTCOME MEASURES: All-cause mortality and predictors of long-term mortality. RESULTS: 197 patients were included and matched 1:1 to controls. Pocket infections were present in 41.1% and definite or suspected infective endocarditis in 58.9%. Total or subtotal hardware removal was achieved in 98.5% of cases. Median follow up was 25 months (12-70). Mortality rates in the study group and controls were 14.3% vs 11.0% (NS) at 1 year and 35.4% vs 27.0% (p=NS) at 5 years. Independent predictors of long-term mortality were older age (HR=1.09, p<0.001), cardiac resynchronisation therapy (HR=3.70, p=0.001), thrombocytopenia (HR=5.10, p=0.003) and renal insufficiency (HR=2.66, p=0.006). In patients with reimplanted devices, epicardial right ventricular pacemakers were associated with higher mortality (HR=2.85, p=0.034). CONCLUSION: In patients with CIED infection managed by recommended therapy, long-term mortality rates are similar to comparable controls. Independent predictors include patient and disease-related factors, in addition to implantation of right ventricular epicardial pacemakers.

Tolerability of HIV postexposure prophylaxis with tenofovir/emtricitabine and lopinavir/ritonavir tablet formulation.

OBJECTIVE: To evaluate the tolerability of HIV postexposure prophylaxis (PEP) with tenofovir/emtricitabine and lopinavir/ritonavir tablet formulation (TDF/FTC+LPV/r). DESIGN: Multicentric observational prospective study. METHOD: Adults with an HIV transmission risk in the past 48 h were eligible. Baseline sociodemographic characteristics, description of exposure event, and HIV serostatus of the source patient were collected. Laboratory monitoring for toxicity and a clinical evaluation were performed; adherence and side effects were recorded using a standardized form on day 0, 15, and 28. RESULTS: Between November 2006 and June 2008, 249 participants were included in 10 French hospitals. Mean age was 31.5 +/- years. Sex ratio male/female was 1.96. Exposure events are as follows: occupational exposure, 40 (16%); sexual intercourse, 204 (82%); and other, 5 (2%). Tolerability could be evaluated in 188 cases. In 22 cases, PEP was discontinued for adverse effects before day 28, including two cases of skin rash related to TDF/FTC prescription, one renal lithiasis related to LPV/r prescription, and one rhabdomyolysis. One hundred and sixty-six persons completed the 28 days of PEP with tolerability judged as good in 96 (58%) individuals. Among everyone who experienced at least one side effect, 78% reported diarrhea, 78% asthenia, and 59% nausea and/or vomiting. CONCLUSION: Considering data of previous studies performed using similar methodology, the dropout rate due to adverse events appeared significantly lower in TDF/FTC+LPV/r tablet formulation than those in zidovudine/lamivudine (ZDV/3TC)+nelfinavir (P < 0.0001), ZDV/3TC+lopinavir/ritonavir soft gel capsules (P < 0.01), and 3TC+TDF+atazanavir boosted by ritonavir (P < 0.05) and should be considered as standard of care concerning HIV PEP.

Extraction of old pacemaker or cardioverter-defibrillator leads by laser sheath versus femoral approach.

BACKGROUND: Some operators routinely extract chronically implanted transvenous leads from a femoral, whereas others prefer a superior approach. This prospective study compared the safety and effectiveness of laser sheaths versus femoral snare extractions. METHODS AND RESULTS: The single-center study comprised 101 patients referred for unequivocal indications to extract > or =1 transvenous lead(s). Patients were >4 years of age and were randomly assigned to extractions with a laser sheath (group 1: n=50) versus a snare via femoral approach (group 2: n=51). The multicenter study comprised 358 patients who underwent extraction of old transvenous leads using laser sheaths (n=218, group 3) in 3 centers and from a femoral approach (n=138, group 4) in 3 other centers. In the single-center study, the success and complications rates were similar in groups 1 and 2. No patient died of a periprocedural complication. The procedural duration (51+/-22 versus 86+/-51 minutes) and duration of total fluoroscopic exposure (7+/-7 versus 21+/-17 minutes) were significantly shorter (each P<0.01) in group I than in group 2. In the multicenter study, we observed 2 procedure-associated deaths in group 3 versus 1 in group 4. Major procedural complications were observed in 3% of patients in group 3, versus 3% in group 4 (P=NS). The rates of complete, partial, and unsuccessful extractions were similar in groups 3 and 4. CONCLUSIONS: Old transvenous leads were extracted with similar success and complication rates by the femoral and laser approaches. However, the femoral approach was associated with longer procedures and a longer duration of fluoroscopic exposure.

Incidence, risk factors, and outcome of traumatic tricuspid regurgitation after percutaneous ventricular lead removal.

OBJECTIVES: This study sought to evaluate the incidence, risk factors, and outcome of traumatic tricuspid regurgitation (TTR) induced by percutaneous removal of chronically implanted transvenous leads. BACKGROUND: Although lead removal using modern tools has been shown to be highly effective and safe, TTR has not been systematically evaluated. METHODS: All patients undergoing ventricular lead removal at our center were studied. Lead removal was performed by simple traction, laser sheath, and/or lasso technique. Presence of a new TTR after removal was assessed by transthoracic echocardiography. Pre-defined clinical and technical parameters were studied for their association with TTR. Patients were followed up by outpatient visits. RESULTS: We removed 237 ventricular leads in 208 patients. Median time from lead implantation was 46.4 months (range 0.7 to 260.5 months). A TTR occurred in 19 patients (9.1%), severe in 14. Three independent risk factors of TTR were found: use of laser sheath (p = 0.004), use of both laser sheath and lasso (p = 0.02), and female sex (p = 0.02). After a follow-up of 4,130 person-months (median 17.9 months), 5 TTR patients were medically treated for new right-sided heart failure symptoms, 2 had undergone surgical repair of the tricuspid valve, and 6 had died (2 from heart failure and 4 from noncardiac causes). Right-sided heart failure occurred only in patients with severe TTR. CONCLUSIONS: This study found that TTR is not uncommon after percutaneous lead removal. It is strongly associated with the use of additional tools beyond simple traction and also with female sex. In the long term, right-sided heart failure is frequent in patients with severe TTR.