Baseline Characteristics and Predictive Factors of Intravenous Immunoglobulin Response in Drug and Device Refractory Gastroparesis Symptoms.

INTRODUCTION: Intravenous immunoglobulin (IVIG) has been shown in a small pilot series to be helpful for some patients with gastroparesis that is refractory to drugs, devices, and surgical therapies. Many but not all patients have serologic neuromuscular markers. We hypothesize that those patients with serologic markers and/or longer duration of therapy would have better responses to IVIG. MATERIALS AND METHODS: We studied 47 patients with a diagnosis of gastroparesis and gastroparesis-like syndrome that had all failed previous therapies including available and investigational drugs, devices, and/or pyloric therapies. Patients had a standardized 12-week course of IVIG, dosed as 400 mg/kg per week intravenously. Symptom assessment was done with Food and Drug Administration (FDA) compliant traditional patient-reported outcomes. Success to IVIG was defined as 20% or greater reduction in average symptom scores from baseline to the latest evaluation. RESULTS: Fourteen patients (30%) had a response, and 33 (70%) had no response per our definition. Patients responding had a higher glutamic acid decarboxylase 65 positivity (64% vs. 30%, P =0.049, missing=3) and longer duration of therapy (>12 wk/continuous: 86% vs. 48%, P =0.09). CONCLUSIONS: In this moderately sized open-label series of refractory patients with gastroparesis symptoms treated with IVIG, 30% of patients responded. While serologic markers and extended therapies show a trend to greater response, neither was statistically significant, except for glutamic acid decarboxylase 65 which showed a higher positivity rate in responders. We conclude that a clinical trial of IVIG may be warranted in severely refractory patients with gastroparesis symptoms.

Drooping After Scoping: A Rare Case of Peripheral Facial Nerve Palsy After RoutineEsophagogastroduodenoscopy.

Peripheral facial nerve palsy is a prevalent type of mononeuropathy that can have a variety of etiologies. Facial nerve damage because of esophagogastroduodenoscopy, however, is exceedingly rare and has only been reported in 1 patient. We report the first case in the United States of a patient who developed left-sided facial nerve palsy after a routine esophagogastroduodenoscopy, with little meaningful recovery of nerve function. We hope to bring awareness to gastroenterologists of this rare complication with potential long-term detrimental effects that can be avoided with the adjustment of equipment and patient position before the procedure.

Mechanisms and management of gastrointestinal symptoms in postural orthostatic tachycardia syndrome.

Postural orthostatic tachycardia syndrome (POTS) is a disorder of orthostatic intolerance associated with many GI manifestations that can be broadly classified into two different categories: those present all the time (non-positional) and those that occur with orthostatic position change. There are also many conditions that can co-exist with POTS such as mast cell activation syndrome and the hypermobile form of Ehlers-Danlos syndrome (hEDS) that are also oftentimes associated with GI symptoms. In the current issue of Neurogastroenterology and Motility, Tai et al. explored the relationship between functional GI disorders among hEDS patients with and without concomitant POTS and showed that the hEDS-POTS cohort was more likely to have more than one GI organ involved compared to the cohort with hEDS alone, and certain GI symptoms were also more common in the hEDS-POTS cohort. In this review article, we will briefly review the literature surrounding putative mechanisms responsible for GI symptoms in POTS with an emphasis on the contributory role of concomitant hEDS and then discuss management strategies for GI symptoms in POTS.

Perioperative predictors of permanent pacing and long-term dependence following tricuspid valve surgery: a multicentre analysis.

AIMS: Permanent pacemaker placement (PPM) is often required after valvular surgery and is especially common following tricuspid valve surgery [tricuspid valve repair or replacement (TVR)]. Literature suggests that surgical intervention for isolated tricuspid valve disease is becoming more prevalent. Predictors of PPM dependency following TVR are currently unknown and would be clinically useful from a prognostication standpoint. METHODS AND RESULTS: We conducted a multicentre, retrospective study to assess perioperative factors of TVR that predispose to PPM placement and long-term PPM dependency from 2008 to 2014. Regression analysis was used to determine independent predictors of PPM implantation. A total of 237 patients (age 66 ± 15 years, 29% male) were studied, and the incidence of PPM placement following TVR was 27% (65/237). No significant differences were observed between those who received PPM and those who did not in age (P = 0.092), gender (P = 0.359), and co-morbidities. Regression analysis identified cross-clamp time >60 min (OR 4.1, 95% CI 1.3-12.9, P = 0.015) and concomitant mitral valve surgery (OR 3.8, 95% CI 1.2-12.2, P = 0.026) as independent risk factors for PPM following TVR. Long-term PPM dependency data were only available in 28 patients who received PPM with 14 of these patients developing long-term dependence. The only statistically significant difference noted was an increased frequency of coronary artery disease in the long-term dependent group vs. the non-dependent group (64% vs. 14%, P = 0.018). CONCLUSION: Cross-clamp time >60 min and concomitant mitral valve surgery were independent predictors of PPM implantation following TVR. Long-term PPM dependency is more prevalent after TVR than other types of valvular surgery.

Atrial Tachycardias After Surgical Atrial Fibrillation Ablation: Clinical Characteristics, Electrophysiological Mechanisms, and Ablation Outcomes From a Large, Multicenter Study.

OBJECTIVES: The clinical characteristics, electrophysiological mechanisms, and ablation outcomes of post-surgical atrial fibrillation ablation (SAFA) atrial tachycardias (ATs) have not been studied in a large, multicenter cohort. BACKGROUND: ATs are often seen following SAFA. METHODS: Analysis was performed on 137 patients (age, 62 ± 10 years; 74% male) who underwent catheter ablation for symptomatic post-SAFA AT from 2004 to 2013 at 3 high-volume institutions in the United States. RESULTS: A total of 137 patients had 149 ATs that were mapped; 103 (69%) had a left atrial (LA) origin and 46 (31%) had a right atrial origin. Of the 149, a total of 44 (30%) had a focal mechanism, with 29 (66%) having an LA origin, with 53% localized to LA posterior wall. Of the 105 re-entrant ATs, 74 (71%) were of LA origin. The predominant circuits were cavotricuspid isthmus (n = 25), perimitral (n = 19), LA roof (n = 17), left pulmonary veins (n = 13), right pulmonary vein/LA septum (n = 12), and LA appendage (n = 7). A total of 93% of patients had ≥1 pulmonary vein reconnection requiring reisolation. Catheter ablation resulted in termination and noninducibility of 97% of right atrial and 93% of LA ATs. Over a 12-month follow-up, 80% of patients were free of any AT or AF. CONCLUSIONS: In this large multicenter cohort of post-SAFA ATs, most were of LA origin, with macro-re-entry being the most common arrhythmia mechanism. Wide variability in location of AT circuits was seen in both right atrial and LA and likely reflects underlying arrhythmogenic substrate and differences in modified SAFA techniques. Catheter ablation was highly successful in eliminating the culprit AT with favorable long-term outcomes.