Incidence, predictors, and clinical outcomes of permanent pacemaker insertion following transcatheter aortic valve implantation in an Arab population.

PURPOSE: Conduction defects requiring permanent pacemaker insertion (PPI) are one of the most common complications after transcatheter aortic valve implantation (TAVI). The purpose of this study was to identify the incidence and predictors of this complication as well as to assess clinical outcomes of patients requiring PPI after TAVI in an Arab population. METHODS: In this single-center, retrospective cohort analysis, all patients who underwent TAVI from 2010 to 2018 were reviewed; seventy-four independent variables were collected per patient, and multivariate analysis was performed to identify predictors. In-hospital outcomes were examined as well as 30-day and 1-year endpoints as defined by the Valve Academic Research Consortium-2. RESULTS: There were 48 of 170 patients (28.2%) who required PPI within 30 days of TAVI. The median time from TAVI to PPI was 2 days (interquartile range: 0 to 5 days). Positive predictors of 30-day PPI were prior right bundle branch block (odds ratio [OR]: 4.10; 95% confidence interval [CI]: 0.37 to 0.79; p < 0.001), post-procedural development of new right bundle branch block (OR: 3.59; 95% CI: 1.07 to 12.03; p = 0.038), post-procedural development of new left bundle branch block (LBBB) (OR: 1.85; 95% CI: 1.21 to 2.84; p = 0.005), post-procedural prolongation of PR interval (OR: 1.02; 95% CI: 1.01 to 1.02; p < 0.001), and post-procedural QRS duration (OR: 1.01; 95% CI: 1.00 to 1.03; p = 0.02). However, post-procedural development of new LBBB no longer remained a significant predictor of PPI after excluding six patients with LBBB who underwent prophylactic PPI (p = 0.093). Negative predictors of 30-day PPI were the presence of diabetes (OR: 0.54; 95% CI: 037 to 0.79; p = 0.001), the use of prosthesis size 29 compared to 23 (OR: 0.55; 95% CI: 0.35 to 0.87; p = 0.010), and the use of prosthesis size 26 compared to 23 (OR: 0.31; 95% CI: 0.20 to 0.50; p < 0.001). PPI was associated with longer median hospital stay, but the result was borderline significant after multivariate adjustment (19 vs. 14 days; p = 0.052). There was no statistically significant difference in 30-day and 1-year clinical outcomes. CONCLUSION: One-third of patients required PPI after TAVI. Several risk factors can identify patients at risk for PPI particularly pre-existing right bundle branch block. Further studies are needed to assess the association between PPI and negative clinical outcomes.

Splenic Infarcts and Pulmonary Renal Syndrome in a Young Patient with Double-Positive Anti-GBM and ANCA-Associated Vasculitis.

Double-positive disease, defined by double-seropositivity for serum anti-glomerular basement membrane (GBM) antibodies and anti-neutrophil cytoplasmic antibodies (ANCA) is a rare cause of pulmonary-renal syndrome. Here, we present an exceptional course of a 20-year-old male with seropositivity for anti-myeloperoxidase anti-neutrophil cytoplasmic antibodies and anti-GBM antibody, who presented first with renal impairment due to focal necrotizing crescentic glomerulonephritis. After receiving treatment, he presented two years later with a relapse manifesting with diffuse alveolar hemorrhage and multiple splenic infarcts. We discuss the clinical presentation patterns and treatment strategies of this entity.

Acute ST-Segment Elevation Myocardial Infarction Following Intramuscular Diclofenac: A Case of Kounis Syndrome.

BACKGROUND: Kounis syndrome (allergic myocardial infarction) is the rare occurrence of systemic anaphylaxis with spontaneous electrocardiographic changes in response to an exogenous agent. Often the syndrome is caused by a drug reaction involving drugs such as non-steroidal anti-inflammatory drugs, antibiotics, or opioids. There are a few reported cases in the literature regarding diclofenac-induced Kounis syndrome, and little is known about the management of this clinical entity. CASE REPORT: A case of Kounis syndrome with ST-elevation myocardial infarction secondary to intramuscular (i.m.) diclofenac in a patient with prior coronary artery bypass graft surgery is described in this report. Additionally, we discuss the pathophysiology, clinical presentation, and management of this rare clinical entity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As i.m. diclofenac is a commonly used drug in the emergency department, we urge emergency physicians to be aware of the existence of this potentially fatal diclofenac-related adverse drug effect. If Kounis syndrome is suspected, the emergency physician is advised to balance the benefit of epinephrine for the treatment of anaphylaxis with the small theoretical risk of increasing coronary vasospasm.