Incidence of premature battery depletion in subcutaneous cardioverter-defibrillator patients: insights from a multicenter registry.

BACKGROUND: The subcutaneous ICD established its role in the prevention of sudden cardiac death in recent years. The occurrence of premature battery depletion in a large subset of potentially affected devices has been a cause of concern. The incidence of premature battery depletion has not been studied systematically beyond manufacturer-reported data. METHODS: Retrospective data and the most recent follow-up data on S-ICD devices from fourteen centers in Europe, the US, and Canada was studied. The incidence of generator removal or failure was reported to investigate the incidence of premature S-ICD battery depletion, defined as battery failure within 60 months or less. RESULTS: Data from 1054 devices was analyzed. Premature battery depletion occurred in 3.5% of potentially affected devices over an observation period of 49 months. CONCLUSIONS: The incidence of premature battery depletion of S-ICD potentially affected by a battery advisory was around 3.5% after 4 years in this study. Premature depletion occurred exclusively in devices under advisory. This is in line with the most recently published reports from the manufacturer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04767516 .

Midodrine in end-stage heart failure.

It is estimated that 5% of patients with heart failure (HF) will progress to end-stage disease refractory to medical therapy and might require prolonged hospitalisation with inotropic support. We present the case of a patient with end-stage HF who was admitted with cardiogenic shock. During his hospitalisation, he required prolonged intravenous vasopressor therapy due to refractory hypotension. He did not qualify for heart transplantation or left ventricular-assist device strategies. Midodrine was started as a last resort attempt to wean off vasopressors. After 5 days of therapy, the patient was weaned entirely off vasopressors and was discharged home for hospice care. By the time of discharge, he was tolerating low-dose carvedilol along with midodrine. We propose midodrine as a reasonable alternative for patients with end-stage HF with reduced ejection fraction and refractory hypotension, who are dependent on intravenous vasoactive drugs and are not candidates for advanced HF therapies.

Insight on the Genetics of Atrial Fibrillation in Puerto Rican Hispanics.

Non-Hispanic whites present with higher atrial fibrillation (AF) prevalence than other racial minorities living in the mainland USA. In two hospital-based studies, Puerto Rican Hispanics had a lower prevalence of atrial fibrillation of 2.5% than non-Hispanic Whites with 5.7%. This data is particularly controversial because Hispanics possess a higher prevalence of traditional risk factors for developing AF yet have a lower AF prevalence. This phenomenon is known as the atrial fibrillation paradox. Despite recent advancements in understanding AF, its pathogenesis remains unclear. In this study, we compared a genetic dataset of Puerto Rican Hispanics to 111 SNP known to be associated with AF in a large European cohort and determine if they are associated with AF susceptibility in our cohort. To achieve this aim, we performed a secondary analysis of existing data using the following two studies: (1) The Pharmacogenetics of Warfarin in Puerto Ricans study and the (2) A Genomic Approach for Clopidogrel in Caribbean Hispanics, and assess for the presence of European SNPs associated with AF from the genome-wide association study of 1 million people identifies 111 loci for atrial fibrillation. We used data from 555 cardiovascular Puerto Rican Hispanic patients, consisting of 486 control and 69 cases. We found that the following SNPs showed significant association with AF in PHR: rs2834618, rs6462079, rs7508, rs2040862, and rs10458660. Some of these SNPs are proteins involved in lysosomal activities responsible for breaking ceramides to sphingosines and collagen deposition around atrial cardiomyocytes. Furthermore, we performed a machine learning analysis and determined that Native American admixture and heart failure were strongly predictive of AF in PHR. For the first time, this study provides some genetic insight into AF's mechanisms in a Puerto Rican Hispanic cohort.

Use of Sublingual Nitrates for Management of Limb Ischemia Secondary to Inadvertent Intra-Arterial Buprenorphine/Naloxone (Suboxone®) Film Injection.

Multiple case reports have signaled a rise in buprenorphine abuse in the US, particularly among inmates. We present the case of limb ischemia secondary to accidental intra-arterial buprenorphine/naloxone film injection successfully treated with sublingual nitroglycerin. A 39-year-old man with history of intravenous drug use presented sudden severe left hand pain since three days prior to evaluation. Pain was preceded by self-injection of dissolved buprenorphine/naloxone sublingual film onto the affected arm. An arteriogram suggested severe vasoconstriction in the absence of frank thrombosis. Patient was initially treated with continuous heparin infusion and nifedipine. Forty-eight hours later, due to poor response, sublingual nitroglycerin was added to therapy. Digits regained color, sensation, and pain resolved within 15 minutes of administration of sublingual nitroglycerin. The presence of acute limb ischemia caused by prolonged vasospasm is a very rare complication. A normal angiogram should raise suspicion regarding vasospasm as the mechanism of ischemia, and prompt nitroglycerin therapy.

Spontaneous Fungal Peritonitis: A Rare Complication of Heart Failure.

This report presents a case of spontaneous fungal peritonitis (SFP) in a patient with cardiogenic ascites. Physicians need to be aware of this life-threatening condition because early suspicion of SFP can improve survival.

Acute ST-elevation myocardial infarction in a young patient with antiphospholipid syndrome.

Acute coronary syndrome rarely occurs in young individuals and is seldomly associated with antiphospholipid syndrome. We report the case of a 26-year-old Hispanic man who presented with acute ST-elevation myocardial infarction and was treated with urgent percutaneous transluminal coronary angioplasty. He experienced stent thrombosis within 48 h of intervention and subsequently developed a left apical thrombus. Hypercoagulable state studies were obtained at admission and 12 weeks after the event establishing the diagnosis of antiphospholipid syndrome.

Implantation of a completely right sided subcutaneous cardioverter-defibrillator in a patient with situs inversus dextrocardia.

Dextrocardia is a congenital anomaly where the heart is abnormally located in the right hemithorax. In these patients, the implementation of transvenous implantable cardioverter-defibrillator (TV-ICD) can be technically challenging and pose a higher risk of complications than the general population. We present the case of a male patient that was successfully submitted to right-sided implantation of subcutaneous ICD (S-ICD) as an alternative to transvenous ICD (TV-ICD) for primary prevention of sudden cardiac death. This option is not only feasible but may potentially be ideal for these patients, as it circumvents challenges and potential complications of TV-ICD insertion.

Predicting performance on the United States Medical Licensing Examination Step 1 and Step 2 Clinical Knowledge using results from previous examinations.

BACKGROUND: Finding early specific indicators of failure in the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) could be used to develop early interventions that could solve deficiencies and help at-risk students to ultimately attain a passing score. This study was aimed at determining if the National Board of Medical Examiners (NBME) Comprehensive Basic Science Examination (CBSE) could predict a passing score during the USMLE Step 1. We also assessed if the NBME Medicine Clinical Science Subject Examination (CSSE) or the USMLE Step 1 could predict passing scores during the USMLE Step 2 CK. METHODS: Gender and scores from 724 students who took the USMLE Step 1 were linked and analyzed with the scores of the NBME CBSE, the NBME Medicine CSSE, and the USMLE Step 2 CK using IBM-SPSS. RESULTS: There were significant correlations between the scores from NBME CBSE and USMLE Step 1 (r=0.73, P≤0.001), between the scores from the NBME Medicine CSSE and the USMLE Step 2 CK (r=0.572, P≤0.001), and between the scores from the USMLE Step 1 and Step 2 CK (r=0.698, P≤0.001). Students with scores <66 in the NBME CBSE were less likely to approve the USMLE Step 1 on their first attempt (P≤0.00001). There was a significant correlation (r=0.684, P≤0.0001) between a score of ≥208 in the USMLE Step 1 and passing the Step 2 CK on the first attempt. CONCLUSION: A score <66 in the NBME CBSE might indicate failure during the USMLE Step 1 first take. Similarly, a score <208 in the USMLE Step 1 might predict failure in the USMLE Step 2 CK.

Non-Invasive Therapy of Peripheral Arterial Disease.

Peripheral arterial disease (PAD) is a significant cause of morbidity and mortality worldwide. Lifestyle changes, like the cessation of the use of tobacco as well as a modification of dietary and exercise habits, can be the most cost-effective interventions in patients with PAD. Smocking cessation is the most important intervention, since it increases survival in these patients. Antiplatelet therapy is an essential component in the treatment of peripheral arterial disease (PAD) of the lower extremities. In addition to delaying arterial obstructive progression, these agents are most usefull in reducing adverse cardiovascular events such as non-fatal myocardial infarction (MI), stroke and vascular death. Mainstay of treatment continues to be aspirin monotherapy (75-325mg daily). Current treatment for lower extremity PAD is directed towards the relief of symptoms and improvement in QoL. The two agents which have consistently been found to be most efficient in achieving these goals are cilostazol and naftidrofuryl oxalate. Naftidrofuryl oxalate may emerge as the most efficient and cost-effective treatment for symptom relief.

Implantable cardioverter-defibrillators for primary prevention of sudden cardiac death in patients with left ventricular systolic dysfunction: 14 years after MADIT.

Sudden cardiac death (SCD) is the most common cause of death among patients with heart failure and left ventricular systolic dysfunction. Implantable cardioverter-defibrillators (ICDs) have been shown to be the single most effective therapy for primary prevention of SCD in patients with heart failure. The superiority of this therapy was clearly established for patients with ischemic cardiomyopathy by large clinical trials, such as the Multicenter Automatic Defibrillator Implantation Trial (MADIT), Multicenter Unsustained Tachycardia Trial (MUSTT), and MADIT-II studies. On the other hand, there was much debate on whether these results could be extrapolated for patients with non-ischemic cardiomyopathy until the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) demonstrated a significant benefit of this therapy. Given the high costs of this therapy and the limited resources allocated to health care multiple studies have attempted to identify patients at higher risk of suffering SCD, who in theory will benefit the most out of this therapy. However, these studies have not established a reliable way to predict which patients will receive a direct survival benefit from ICD therapy. Until we are capable of further defining which patients will derive the absolute highest benefit from an ICD, we must rely on the information available from published trials and adhere to current clinical practice guidelines regarding this pressing issue.

A peripheral artery disease screening study in Puerto Rico.

UNLABELLED: Peripheral artery disease (PAD) of the lower extremities is frequently underdiagnosed and undertreated. The results of screening for PAD in adults attending outpatient clinics at different sites in Puerto Rico from 2007 to 2010 are presented. METHODS: A total of 33 outpatients screening clinics were conducted at different sites throughout the Island. Following the ACC/AHA Guideline recommendations, asymptomatic patients who qualified were screened for PAD using the ankle-brachial index (ABI). An ABI < 0.9 was considered positive for PAD. We estimated the prevalence of PAD in the study population and used logistic regression models to assess factors associated with a positive screening test for PAD. RESULTS: A total of 933 patients were screened for PAD. Out of the 933 patients, the ABI was < 0.9 in 390 (41.8%) of them. Bivariate analysis showed a significant difference in PAD screening results by gender (P = 0.004) and history of arterial hypertension (P = 0.004). Regarding clinical characteristics, leg edema 44.7% (P = 0.001), intermittent claudication 40.3% (P = 0.002), distal extremity coldness 29.0% (P = 0.012), and weak lower extremity pulses 67.5% (P < 0.001) were more prevalent on patients with an ABI < 0.9. In the multivariate analysis, male gender (OR = 1.92, 95% CI: 1.18, 3.11) and arterial hypertension (OR = 2.16, 95% CI: 1.28, 3.65) were significantly associated with PAD after adjusting for specific confounders. CONCLUSIONS: Arterial hypertension, cigarette smoking, diabetes mellitus, and dyslipidemia are known key factors in development of PAD. Practicing physicians must be aware of the importance of an early diagnosis of PAD, particularly in the asymptomatic patient, so as to institute preventive and management measures.

Update in atrial fibrillation.

Atrial fibrillation (AF) is a common cardiac arrhythmia associated with major morbidity and mortality. Atrial enlargement, remodeling, and fibrosis are key to initiation and perpetuation of AF. Therapy for AF is directed at symptom control via rate or rhythm control, as well as prevention of thromboembolic events. In the recent past multiple alternatives, including pharmacological and non-pharmacological, have emerged as possible therapies for AF. In this review, we intend to summarize the most important advances in AF therapy in recent years.

Spontaneous coronary artery dissection: a rare etiology of ST elevation myocardial infarction.

Spontaneous coronary artery dissection (SCAD) is an extremely rare etiology of acute myocardial infarction, most commonly seen in pre-menopausal women with no risk factors for atherosclerotic coronary artery disease (CAD). We present the case of a 41-year-old woman with no history of systemic illness who presented severe, oppressive retrosternal pain with ST-segment elevations in leads I, AVL, V1 through V6 in the absence of risk factors for CAD. Emergency percutaneous coronary intervention (PCI) revealed an aneurysmatic dilatation of the left main coronary artery with complete dissection of the left anterior descending artery and the ramus branch, causing distal occlusion of the affected vessels. The patient was submitted for emergency Coronary Artery Bypass Graft (CABG) surgery. This is thought to be caused by hormonal changes that cause weakness of the vasa vasorum and promote hemorrhage into the media.

Giant cardiac myxoma in an asymptomatic 57-year-old woman: a case report.

Primary cardiac neoplasms are rare and left atrial myxomas represent the most common form of primary cardiac masses. We present the case of a 57-year-old woman with Diabetes Mellitus and arterial hypertension who was incidentally found to have a giant myxoma in the left atrium. She was asymptomatic but given the high risk of embolization and sudden cardiac death, surgical removal of the tumor was performed. A 6.0 x 5.0 x 4.5 cm mass was recovered, confirmed to be a benign cardiac myxoma on microscopic examination. Symptoms associated with cardiac masses will depend upon tumor location and size, usually related to flow obstruction and embolization. An inflammatory response due to secretion of cytokines may also be observed. In this case, the patient had no symptoms despite the size of the tumor that occupied virtually 90% of the left atrial volume.

Analysis of heart failure management at the Heart Failure and Transplantation Clinics of the Cardiovascular Center of Puerto Rico and the Caribbean.

BACKGROUND: Disease management programs (DMP) have been shown to be effective in management of patients with heart failure (HF). OBJECTIVE: To describe the experience at the Heart Failure and Transplantation Clinic of the Cardiovascular Center of Puerto Rico and the Caribbean (HFTC-CCPRC) implementing a model of DMP to a Hispanic population afflicted by HF. METHODS: A retrospective study was performed. Medical records from patients referred to the HFTC-CCPRC from 1999 to 2005 were selected for review. Information regarding drug regimen, New York Heart Association (NYHA) functional class, left ventricular ejection fraction (LVEF) determinations by echocardiography or scintigraphic ventriculography, left ventricular dimensions measurements, maximal oxygen consumption (MVO2 max) determination, hospitalizations, and death cases were obtained from the initial evaluation and at 3, 6, and 12 months post-intervention at the HFTC-CCPRC. RESULTS: A total of 633 records were screened, from which 244 had complete information for analysis. After 12 months of treatment at the HFTC-CCPRC, NYHA functional class had decreased from 2.70 + 0.59 to 2.13 +/- 0.53 (p < 0.01). LVEF had also increased from 21.0 +/- 8.2% to 39.9 +/- 14.6% (p < 0.01). Hospitalization rate was reduced from 62.7% within the year prior to initial evaluation to 7.2% at the end of the 12-month period (p < 0.01). CONCLUSIONS: In our patient population, we found significant improvement in several parameters, including NYHA functional class, LVEF, and hospitalization rate after intervention at the HFTC-CCPRC. These findings are most likely related to improved guideline adherence, and are consistent with published data regarding the value of DMP's.

Benign cardiac neoplasms: the experience at the Cardiovascular Center of Puerto Rico and the Caribbean.

INTRODUCTION: Neoplasms of the heart are extremely rare and difficult to diagnose. In this study, we intend to describe the experience at the Cardiovascular Center of Puerto Rico and the Caribbean (CCPRC) dealing with benign cardiac neoplasms. METHODS: A retrospective review of the archival material at our institution was conducted using the 2007 ICD-9-CM code 212.7. A total of 77 cases with a diagnosis of Benign Heart Neoplasm were found from 1992 to 2008 but only those with an official pathologic report (n = 43) were considered. The clinical charts provided data related to age, sex, presenting symptoms, non-invasive and invasive characteristics, surgical procedures, and pathological findings. Data was compared using paired and unpaired Student's t-test, x2, and Fisher's Exact Test when appropriate. For interpretation of results, a p-value < 0.05 was considered significant. RESULTS: The mean age for diagnosis was 51.49 years. The most common presenting symptom by which these patients sought medical attention was congestive heart failure (35%), followed by chest pain (18%) and neurologic symptoms (14%). The most common location of the mass was the left atrium (81%) and overall, the most common heart neoplasm in this study was myxoma (83.7%). The rate of surgical complications was 30% (n = 13), with the cross clamp time and bypass time found to be the only factors influencing length of stay. Mortality rate was 7% (n = 3). CONCLUSIONS: This study of a total of 43 pathologically confirmed benign cardiac neoplasms admitted to the Cardiovascular Center of Puerto Rico and the Caribbean from 1992 to 2008 validates the fact that heart neoplasms represent a fairly rare diagnosis. It is also consistent with previously published series that establish myxoma as the most common of these benign neoplasms. The main clinical findings as well as the results of surgery were presented.

Ventricular non-compaction cardiomyopathy.

Non-compaction of the left ventricle is an extremely rare cardiomyopathy resulting from a defective morphogenesis of the endomyocardium. It results in an architecturally aberrant ventricular wall consisting of two layers: a compacted layer and a loose interwoven meshwork with prominent trabeculae and deep intertrabecular recesses that communicate with the left ventricular cavity. This report describes the case of a 25-year-old man with dilated cardiomyopathy, due to non-compaction of the left ventricle, presenting with a transient ischemic attack.