Mode and Characteristics of Arrhythmia Initiation in Idiopathic Ventricular Fibrillation: A THESIS Substudy.

BACKGROUND: There is limited information on the mode of arrhythmia initiation in idiopathic ventricular fibrillation (IVF). A non-pause-dependent mechanism has been suggested to be the rule. OBJECTIVES: The aim of this study was to assess the mode and characteristics of initiation of polymorphic ventricular tachycardia (PVT) in patients with short or long-coupled PVT/IVF included in THESIS (THerapy Efficacy in Short or long-coupled idiopathic ventricular fibrillation: an International Survey), a multicenter study involving 287 IVF patients treated with drugs or radiofrequency ablation. METHODS: We reviewed the initiation of 410 episodes of ≥1 PVT triplet in 180 patients (58.3% females; age 39.6 ± 13.6 years) with IVF. The incidence of pause-dependency arrhythmia initiation (prolongation by >20 ms of the preceding cycle length) was assessed. RESULTS: Most arrhythmias (n = 295; 72%) occurred during baseline supraventricular rhythm without ambient premature ventricular complexes (PVCs), whereas 106 (25.9%) occurred during baseline rhythm including PVCs. Nine (2.2%) arrhythmias occurred during atrial/ventricular pacing and were excluded from further analysis. Mode of PVT initiation was pause-dependent in 45 (15.6%) and 64 (60.4%) of instances in the first and second settings, respectively, for a total of 109 of 401 (27.2%). More than one type of pause-dependent and/or non-pause-dependent initiation (mean: 2.6) occurred in 94.4% of patients with ≥4 events. Coupling intervals of initiating PVCs were <350 ms, 350-500 ms, and >500 ms in 76.6%, 20.72%, and 2.7% of arrhythmia initiations, respectively. CONCLUSIONS: Pause-dependent initiation occurred in more than a quarter of arrhythmic episodes in IVF patients. PVCs having long (between 350 and 500 ms) and very long (>500 ms) coupling intervals were observed at the initiation of nearly a quarter of PVT episodes.

Meta-Analysis of Genome-Wide Association Studies Reveals Genetic Mechanisms of Supraventricular Arrhythmias.

BACKGROUND: Substantial data support a heritable basis for supraventricular tachycardias, but the genetic determinants and molecular mechanisms of these arrhythmias are poorly understood. We sought to identify genetic loci associated with atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular accessory pathways or atrioventricular reciprocating tachycardia (AVAPs/AVRT). METHODS: We performed multiancestry meta-analyses of genome-wide association studies to identify genetic loci for AVNRT (4 studies) and AVAP/AVRT (7 studies). We assessed evidence supporting the potential causal effects of candidate genes by analyzing relations between associated variants and cardiac gene expression, performing transcriptome-wide analyses, and examining prior genome-wide association studies. RESULTS: Analyses comprised 2384 AVNRT cases and 106 489 referents, and 2811 AVAP/AVRT cases and 1,483 093 referents. We identified 2 significant loci for AVNRT, which implicate NKX2-5 and TTN as disease susceptibility genes. A transcriptome-wide association analysis supported an association between reduced predicted cardiac expression of NKX2-5 and AVNRT. We identified 3 significant loci for AVAP/AVRT, which implicate SCN5A, SCN10A, and TTN/CCDC141. Variant associations at several loci have been previously reported for cardiac phenotypes, including atrial fibrillation, stroke, Brugada syndrome, and electrocardiographic intervals. CONCLUSIONS: Our findings highlight gene regions associated with ion channel function (AVAP/AVRT), as well as cardiac development and the sarcomere (AVAP/AVRT and AVNRT) as important potential effectors of supraventricular tachycardia susceptibility.

Management of Inherited Arrhythmia Syndromes: A HiRO Consensus Handbook on Process of Care.

Inherited arrhythmia syndromes are rare genetic conditions that predispose seemingly healthy individuals to sudden cardiac arrest and death. The Hearts in Rhythm Organization is a multidisciplinary Canadian network of clinicians, researchers, patients, and families that aims to improve care for patients and families with inherited cardiac conditions, focused on those that confer predisposition to arrhythmia and sudden cardiac arrest and/or death. The field is rapidly evolving as research discoveries increase. A streamlined, practical guide for providers to diagnose and follow pediatric and adult patients with inherited cardiac conditions represents a useful tool to improve health system utilization, clinical management, and research related to these conditions. This review provides consensus care pathways for 7 conditions, including the 4 most common inherited cardiac conditions that confer predisposition to arrhythmia, with scenarios to guide investigation, diagnosis, risk stratification, and management. These conditions include Brugada syndrome, long QT syndrome, arrhythmogenic right ventricular cardiomyopathy and related arrhythmogenic cardiomyopathies, and catecholaminergic polymorphic ventricular tachycardia. In addition, an approach to investigating and managing sudden cardiac arrest, sudden unexpected death, and first-degree family members of affected individuals is provided. Referral to specialized cardiogenetic clinics should be considered in most cases. The intention of this review is to offer a framework for the process of care that is useful for both experts and nonexperts, and related allied disciplines such as hospital management, diagnostic services, coroners, and pathologists, in order to provide high-quality, multidisciplinary, standardized care.

Les syndromes d'arythmie héréditaires sont des troubles génétiques rares qui prédisposent des personnes en apparence en bonne santé à un arrêt cardiaque soudain et à la mort. L'organisation Hearts in Rhythm Organization est un réseau multidisciplinaire canadien qui regroupe des cliniciens, des chercheurs ainsi que des patients et leurs proches dans le but d'améliorer les soins prodigués aux patients atteints de maladies cardiaques héréditaires et à leur famille, en particulier dans le cas des maladies qui entraînent une prédisposition à l'arythmie et à un arrêt cardiaque soudain et/ou à la mort. Puisque ce champ de recherche évolue rapidement, la mise au point d'un guide pratique et simple à l'intention des professionnels de la santé pour le diagnostic et le suivi des patients enfants et adultes présentant une maladie cardiaque héréditaire serait donc un outil intéressant pour améliorer l'utilisation du système de santé et la prise en charge clinique de ces maladies tout en orientant la recherche à ce propos. La présente synthèse expose les trajectoires de soins faisant l'objet d'un consensus pour sept maladies, dont les quatre maladies cardiaques héréditaires les plus courantes qui prédisposent à l'arythmie. Elle présente aussi des scénarios pour orienter les examens, le diagnostic, la stratification du risque et la prise en charge des patients. Ces maladies sont le syndrome de Brugada, le syndrome du QT long, la cardiomyopathie arythmogénique du ventricule droit et les cardiomyopathies arythmogènes associées, et la tachycardie ventriculaire polymorphe catécholaminergique. En outre, une approche pour la prise en charge de l'arrêt cardiaque soudain, de mort subite inattendue et des membres de la famille immédiate de la personne touchée est proposée. L'orientation vers des cliniques spécialisées en cardiogénétique doit être envisagée dans la plupart des cas. L'objectif est d'établir un cadre de soins qui soit utile pour les experts et les non-experts ainsi que pour les professionnels des domaines connexes, par exemple le personnel de l'administration hospitalière et des services diagnostiques, les coroners et les pathologistes, en vue d'offrir des soins multidisciplinaires normalisés de grande qualité.

Advancing Commotio cordis Safety Standards Using the Total Human Models for Safety (THUMS).

Commotio cordis is one of the leading causes of sudden cardiac death in youth baseball. Currently, there are chest protector regulations regarding the prevention of Commotio cordis in baseball and lacrosse; however, they are not fully optimized. For the advancement of Commotio cordis safety, it is vital to include various age groups and a variety of impact angles in the testing process. This study employed finite element models and simulated Commotio cordis-inducing baseball collisions for different velocities, impact angles, and age groups. Commotio cordis risk response was characterized in terms of left ventricular strain and pressure, chest band and rib deformation, and force from impact. Normalized rib and chest band deformation when correlated with left ventricular strain resulted in R2 = 0.72, and R2 = 0.76, while left ventricular pressure resulted in R2 = 0.77, R2 = 0.68 across all velocities and impact angles in the child models. By contrast, the resultant reaction force risk metric as used by the National Operating Committee on Standards for Athletic Equipment (NOCSAE) demonstrated a correlation of R2 = 0.20 in the child models to ventricular strain, while illustrating a correlation to pressure of R2 = 0.74. When exploring future revisions to Commotio cordis safety requirements, the inclusion of deformation-related risk metrics at the level of the left ventricle should be considered.

Hemodynamically Tolerated Ventricular Tachycardia With Mildly Impaired Ejection Fraction: Do These Patients Have VT/VF Recurrence and ICD Therapies?

BACKGROUND: Patients with hemodynamically tolerated ventricular tachycardia (VT) and minimally reduced left ventricular ejection fraction (LVEF) remain a group that presents a prognostic and therapeutic dilemma. METHODS: We studied patients from our implanted cardioverter-defibrillator (ICD) database who received ICDs for hemodynamically tolerated VT and mildly reduced LVEF (36%-49%) at time of implant between May 2015 and December 2019. Time to appropriate ICD therapy was assessed. Clinical features associated with recurrent VT/ventricular fibrillation (VF) with ICD therapies were explored using binary logistic regression. RESULTS: Among 2037 ICDs placed between May 2015 and December 2019, 64 subjects met the inclusion criteria. The mean age of the study group was 68 ± 12 years, and 58 (90.6%) subjects were male. Average ejection fraction was 40% ± 4.4 (range 36%-49%). Twenty-two (34%) subjects received antitachycardia pacing (ATP) for VT at 229 ± 265 days after ICD placement. Fifteen (23%) subjects received appropriate ICD shocks 305 ± 321 days after implant. The rate of recurrent VT/VF among the 37 patients with ICD therapy was 195 ± 39 beats per minute (bpm). This was significantly more rapid than initial presenting VT rates before ICD placement (183 ± 27 bpm) (P = 0.048). Multivariate analysis showed no factors independently associated with recurrent VT/VF. CONCLUSIONS: Patients with mildly impaired LV function and hemodynamically tolerated VT receive appropriate ICD therapies over the 3 years following implant. This patient group warrants further investigation, as their recurrent VT/VF rates can be much more rapid, and 23% go on to receive appropriate ICD shocks.

Biomarkers as predictors of recurrence of atrial fibrillation post ablation: an updated and expanded systematic review and meta-analysis.

BACKGROUND: A high proportion of patients undergoing catheter ablation (CA) for atrial fibrillation (AF) experience recurrence of arrhythmia. This meta-analysis aims to identify pre-ablation serum biomarker(s) associated with arrhythmia recurrence to improve patient selection before CA. METHODS: A systematic approach following PRISMA reporting guidelines was utilised in libraries (Pubmed/Medline, Embase, Web of Science, Scopus) and supplemented by scanning through bibliographies of articles. Biomarker levels were compared using a random-effects model and presented as odds ratio (OR). Heterogeneity was examined by meta-regression and subgroup analysis. RESULTS: In total, 73 studies were identified after inclusion and exclusion criteria were applied. Nine out of 22 biomarkers showed association with recurrence of AF after CA. High levels of N-Terminal-pro-B-type-Natriuretic Peptide [OR (95% CI), 3.11 (1.80-5.36)], B-type Natriuretic Peptide [BNP, 2.91 (1.74-4.88)], high-sensitivity C-Reactive Protein [2.04 (1.28-3.23)], Carboxy-terminal telopeptide of collagen type I [1.89 (1.16-3.08)] and Interleukin-6 [1.83 (1.18-2.84)] were strongly associated with identifying patients with AF recurrence. Meta-regression highlighted that AF type had a significant impact on BNP levels (heterogeneity R2 = 55%). Subgroup analysis showed that high BNP levels were more strongly associated with AF recurrence in paroxysmal AF (PAF) cohorts compared to the addition of non-PAF patients. Egger's test ruled out the presence of publication bias from small-study effects. CONCLUSION: Ranking biomarkers based on the strength of association with outcome provides each biomarker relative capacity to predict AF recurrence. This will provide randomised controlled trials, a guide to choosing a priori tool for identifying patients likely to revert to AF, which are required to substantiate these findings.

Developing commotio cordis injury metrics for baseball safety: unravelling the connection between chest force and rib deformation to left ventricle strain and pressure.

Commotio cordis is a sudden death mechanism that occurs when the heart is impacted during the repolarization phase of the cardiac cycle. This study aimed to investigate commotio cordis injury metrics by correlating chest force and rib deformation to left ventricle strain and pressure. We simulated 128 chest impacts using a simulation matrix which included two initial velocities, 16 impact locations spread across the transverse and sagittal plane, and four baseball stiffness levels. Results showed that an initial velocity of 17.88 m/s and an impact location over the left ventricle was the most damaging setting across all possible settings, causing the most considerable left ventricle strain and pressure increases. The impact force metric did not correlate with left ventricle strain and pressure, while rib deformations located over the left ventricle were strongly correlated to left ventricle strain and pressure. These results lead us to the recommendation of exploring new injury metrics such as the rib deformations we have highlighted for future commotio cordis safety regulations.

Identifying Vulnerable Impact Locations to Reduce the Occurrence of Deadly Commotio Cordis Events in Children's Baseball: A Computational Approach.

Commotio cordis is the second leading cause of sudden cardiac death in young athletes. Currently available chest protectors on the market are ineffective in preventing cases of commotio cordis in young athletes who play baseball. This study focused on using contour maps to identify specific baseball impact locations to the chest that may result in instances of commotio cordis to children during baseball games. By identifying these vulnerable locations, we may design and develop chest protectors that can provide maximum protection to prevent commotio cordis in young athletes. Simulation cases were run using the validated CHARM-10 chest model, a detailed finite element model representing an average 10-year-old child's chest. A baseball model was developed in company with the chest model, and then used to impact the chest at different locations. A 7 × 8 impact location matrix was designed with 56 unique baseball impact simulations. Left ventricle strain and pressure, reaction force between the baseball and chest, and rib deformations were analyzed. Left ventricle strain was highest from baseball impacts directly over the left ventricle (0.34) as well as impacts slightly lateral and superior to the cardiac silhouette (0.34). Left ventricle pressure was highest with impacts directly over the left ventricle (82.94 kPa). We have identified the most dangerous impact locations resulting in high left ventricle strain and pressure. This novel study provided evidence of where to emphasize protective materials for establishing effective chest protectors that will minimize instances of commotio cordis in young athletes.

Ictal syncope or isolated syncope? A case report highlighting the overlap.

BACKGROUND: Ictal bradyarrhythmia is a rare condition defined by temporal lobe epilepsy resulting in bradycardia or asystole and can result in syncope. This needs to be differentiated from isolated syncope in patients with seizure disorder, as treatment strategies differ. CASE SUMMARY: A 50-year-old female with well-controlled temporal epilepsy and a 20-year seizure-free period presented to her neurologist with abrupt onset of sudden drop attacks thought to be ictal events with potential underlying ictal bradyarrhythmia and was initially treated with escalation of anticonvulsant therapy. However, her workup was consistent with a diagnosis of cardiac syncope. She subsequently underwent successful insertion of a pacemaker, with no recurrence of her presenting episodes at a 13-month follow-up. DISCUSSION: Ictal syncope and isolated syncope may share a common terminal pathway and may have similar presenting symptoms. In patients with known seizure disorder, loss of consciousness may be attributable to epileptic events, ictal syncope, or isolated syncope-which can be difficult to differentiate. This case highlights the ambiguous nature of such episodes and the importance of simultaneous electroencephalogram/electrocardiogram monitoring, as this can have implications on treatment.

A case report of inappropriate inhibition of ventricular pacing due to a unique pacemaker electrogram storage feature.

BACKGROUND: Modern permanent pacemakers (PPMs) have individual features designed to identify cardiac rhythm abnormalities and improve their performance. Inappropriate pacing inhibition may be an undesired outcome from these features and cause symptoms in patients who require frequent pacing, leading to dizziness, and syncope. Inappropriate inhibition can be difficult to identify in circumstances that are intermittent and difficult to reproduce. CASE SUMMARY: A 57-year-old female underwent a mitral valve replacement (MVR) for severe mitral stenosis. One month following MVR, she presented with symptomatic third-degree atrioventricular block, and a dual-chamber PPM (Advisa™, Medtronic, Minneapolis, USA) was implanted and programmed DDD 50-130 b.p.m. At the 3-month follow-up, she reported frequent episodes of lightheadedness. She was found to have intermittent ventricular pacing inhibition on a 48-h Holter monitor due to an internal function of the Advisa™ series of PPMs that attempts to store an electrogram (EGM) every 1 h and 30 s. During the EGM storage, an amplified signal from the storage capacitor can result in oversensing by the ventricular channel and inappropriate pacing inhibition. DISCUSSION: To rectify the issue, the ventricular lead sensitivity value was increased from 0.9 mV to 1.2 mV. No instances of inappropriate ventricular pacing inhibition were noted on follow-up. To our knowledge, this is a rare case of inappropriate ventricular pacing inhibition caused by a combination of PPM self-adjusting sensitivity algorithm and oversensing every 1 h and 30 s from an amplified storage capacitor. Physicians should be aware of this possible complication and differentiate it from device or lead malfunction.

Safety of Lead Repair Compared to Lead Revision for Visible Lead Insulation Defects in Patients With Cardiac Implantable Electronic Devices.

BACKGROUND: Cardiac implantable electronic devices deliver life-sustaining therapy and may be prone to hardware degeneration over time. Functioning transvenous endocardial leads with visible insulation breaks are amenable to lead revision (LRV) or lead repair (LRP), with medical adhesive. The latter is a less invasive and more cost-effective strategy. However, data are sparse on the overall safety of such an approach. METHODS: This is a retrospective cohort study of patients with lead insulation defects managed by either LRV or LRP with medical adhesive. The data analyzed were from January 2010 to January 2021. All-cause mortality, and both early and late complications, was ascertained for all cases. RESULTS: A total of 57 cases were identified, with a mean age (standard deviation) of 75 (±11.8) years; 18 (31.6%) were women. A total of 35 patients (62.5%) underwent LRV for an insulation defect, and 21 (37.5%) underwent LRP. There was no statistical difference in the rate of early and late complications between the 2 groups over a mean follow-up period of 1.15 (±0.78) years [3 (8%)] LRV vs 1 (5%) LRP, P = 0.88). One death was identified in each group, unrelated to either the device or a device-related procedure. There was no association between device type and the likelihood of LRP vs LRV as an attempted strategy (χ2 = 2.25, P = 0.53). CONCLUSIONS: The results of this study suggest that the use of a lead-repair strategy, with silicone adhesive glue and an anchoring sleeve, is not associated with an increased rate of early or late complications, compared with lead revision in the management of visible lead insulation defects with stable lead function.

INTRODUCTION: Les dispositifs cardiaques électroniques implantables offrent un traitement essentiel au maintien de la vie, mais peuvent subir une détérioration de leur matériel au fil du temps. Le fonctionnement des sondes endocavitaires transveineuses ayant des ruptures visibles de l'isolant se prête à la révision de sonde (RVS) ou à la réparation de sonde (RPS) au moyen d'un adhésif médical. Cette dernière stratégie est moins invasive et plus efficiente. Toutefois, les données sur l'innocuité générale d'une telle approche sont rares. MÉTHODES: Il s'agit d'une étude de cohorte rétrospective de patients dont les sondes montrent des défaillances de l'isolant prises en charge par RVS ou par RPS au moyen d'un adhésif médical. Les données analysées s'échelonnaient de janvier 2010 à janvier 2021. La mortalité toutes causes confondues ainsi que les complications précoces et tardives étaient établies pour tous les cas. RÉSULTATS: Nous avons trouvé un total de 57 cas, dont l'âge moyen (écart type) était de 75 (± 11,8) ans; 18 (31,6 %) étaient des femmes. Au total, 35 patients (62,5 %) avaient subi une RVS en raison d'une défaillance de l'isolant, et 21 (37,5 %) avaient subi une RPS. Il n'y avait aucune différence statistique dans le taux de complications précoces et tardives entre les deux groupes durant une période moyenne de suivi 1,15 (± 0,78) an [3 (8 %)] RVS vs un (5 %) RPS, P = 0,88. Dans chaque groupe, nous avons noté 1 décès non associé au dispositif ou à une intervention liée au dispositif. Il n'y avait aucune association entre le type de dispositif et la probabilité de tentative d'une stratégie de RPS vs d'une stratégie de RVS (χ2 = 2,25, P = 0,53). CONCLUSIONS: Les résultats de cette étude montrent que l'utilisation d'une stratégie de RPS au moyen d'un adhésif de silicone et d'une douille d'ancrage n'est pas associée à un taux plus élevé de complications précoces ou tardives que la RVS dans la prise en charge des défaillances visibles de l'isolant de la sonde lors de fonctionnement stable de la sonde.

Double chamber cross-talk, the ultimate double-cross.

Cross-talk is a well-described phenomenon in a dual-chamber cardiovascular implantable electronic device. Far-field ventricular events are more commonly sensed in the atrial channel, the reverse is uncommon, and seeing both at the same time has never been reported. We present a case of double cross-talk in a dual-chamber Medtronic ® implantable cardioverter-defibrillator. In this report, we decipher an unusual device response to the cross-talk and describe the programming changes required to resolve it.

A case report of capillary leak syndrome with recurrent pericardial and pleural effusions.

BACKGROUND: Capillary leak syndrome (CLS) is a rare connective tissue disease, triggered by the leak of serous fluid into the interstitial spaces, characterized by a hallmark of oedema and effusions in confined spaces. The limiting factor in CLS management appears to be its diagnosis rather than treatment, which is usually to contain the disease progression rather than a cure. CASE SUMMARY: We report a case of a 51-year-old woman with recurrent life-threatening presentations of pericardial effusions, pleural effusions, and generalized swelling of face and extremities. The only notable past medical history was of Type 1 diabetes. Numerous investigations did not lead to specific disease accounting for pericardial effusions and pleural effusions. Eventually, the diagnosis of CLS was made based on hypovolaemic shock, hypoalbuminaemia, and haemoconcentration without the presence of albuminuria. She was managed with steroids to reduce system inflammation and later with immunoglobulins and tumour necrosis factor to contain the disease process. Since her diagnosis and subsequent appropriate management, she has not had further admissions with cardiac tamponade 16 months of follow-up. DISCUSSION: The diagnosis of CLS is difficult to make unless there is a high degree of suspicion and until other causes have been ruled out. It remains a challenging condition to manage as the treatment options are limited and patients recurrently present with emergencies until the correct diagnosis is made and the optimal treatment is provided.

Delivery of cardiac resynchronization therapy via the left inferior phrenic vein: a case report.

BACKGROUND: The successful implantation of cardiac resynchronization therapy (CRT) may be prevented by anatomical variations that preclude the delivery of clinically effective left ventricular (LV) pacing from within the coronary sinus (CS) or its tributaries. Failure of lead delivery, suboptimal LV capture thresholds, or intractable phrenic nerve capture with accompanying diaphragmatic twitch is often encountered. Commonly employed alternative approaches to LV lead delivery, including epicardial, trans-septal, or transapical pacing are associated with significant morbidity. CASE SUMMARY: A 74-year-old man with ischaemic heart disease, prior mitral valve repair, long-standing atrial fibrillation, and severe symptomatic LV systolic dysfunction, underwent single chamber pacemaker upgrade to a CRT defibrillator. It was found not to be possible to place a CS lead during the procedure. Biventricular pacing was accomplished by the delivery of a pacing lead through the left inferior phrenic vein (LIPV). Satisfactory LV capture thresholds were obtained with the avoidance of clinically significant diaphragmatic stimulation. Following implantation, a marked clinical response to treatment was observed with improvement in both heart failure symptoms and LV ejection fraction. DISCUSSION: The LIPV is known to drain into the inferior vena cava in around one-third of examined subjects. In these individuals, LV lead delivery through the LIPV may provide an alternate route for the delivery of resynchronization therapy. This approach to the implantation of CRT may be considered when pacing via the CS or its branches are not achievable.

Pulsatile sterile abscess in the left breast following transapical transcatheter aortic valve implantation: a case report.

BACKGROUND: Over the last decade, transcatheter treatment of degenerative aortic valve stenosis has been established as an alternative to surgical aortic valve replacement. Late complications of transcatheter treatment of aortic stenosis (AS) are infrequent. CASE SUMMARY: We report an 87-year-old woman treated successfully with 23 mm Sapien 3 transapical transcatheter aortic valve implantation for severe AS. She presented 4 months later with a pulsatile mass in the left breast. After exclusion of other diagnoses, the mass was attributed to a sterile abscess communicating with the pericardial cavity due to post-operative chest infection and pleural effusion. Multimodality imaging helped to define the anatomy of the abscess and the mechanism of the pulsation. DISCUSSION: This is the first report of a pulsatile sterile abscess occurring as a complication of transapical aortic valve implantation. Multimodality imaging confirmed that the pulsation was due to extension of the abscess into the pericardial cavity, excluded direct communication with the left ventricle, and facilitated successful non-surgical management.

Mediastinal monophasic synovial sarcoma with pericardial extension causing hemodynamic instability.

A 46-year-old man presented with mass on chest x-ray along with a 6-month history of weight loss, dyspnea and cough. He was hypotensive and an echocardiogram showed large extra-cardiac mass compressing the right ventricular outflow tract resulting in features of cardiac tamponade. Chest computed tomography revealed a mediastinal mass invading the pericardium adjacent to right ventricular outflow tract. Biopsy of the mass confirmed primary monophasic synovial sarcoma. Chemotherapy and radiotherapy along with anti-inflammatories were given as surgery was too high risk due to the location of the tumour and pericardial involvement. Patient responded briefly to the treatment with improvement in hemodynamic parameters but over next weeks he became less responsive to treatment with increasing size. He died 2 months after treatment commenced.

Biodegradable PBAT/PLA Blend with Bioactive MCPA-PHBV Conjugate Suppresses Weed Growth.

The herbicide 2-methyl-4-chlorophenoxyacetic acid (MCPA) conjugated with poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBV) was prepared via a melt transesterification route. The resultant bioactive oligomer was then mixed with a blend of polylactide (PLA) and poly(butylene adipate-co-terephthalate) (PBAT) with different loadings to manufacture films to be used as a bioactive, biodegradable mulch to deliver the herbicide to target broadleaf weed species. The biological targeting of the MCPA-PHBV conjugate in the mulch film was investigated under glasshouse conditions using faba bean (Vicia faba) as a selective (nontarget) model crop species having broadleaf morphology. The presence of the MCPA-PHBV conjugate in the biodegradable PBTA/PLA blend was shown to completely suppress the growth of broadleaf weed species while displaying only a mild effect on the growth of the model crop. The degradation of the mulch film under glasshouse conditions was quite slow. The release of the MCPA-PHBV during this process was detected using NMR, GPC, EDS, and DSC analyses, indicating that the majority of the MCPA diffused out after MCPA-PHBV conjugate bond scission. These data provide a strong "proof of concept" and show that this biodegradable, bioactive film is a good candidate for future field applications and may be of wide agricultural applicability.

Percutaneous Device Closure of Paravalvular Leak: Combined Experience From the United Kingdom and Ireland.

BACKGROUND: Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery. METHODS: All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up. RESULTS: Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004-2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure (P<0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 (P<0.001) after a median follow-up of 110 (7-452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) (P<0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P=0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P=0.037), New York Heart Association class (HR, 2.00; P=0.015) at follow-up and baseline creatinine (HR, 8.19; P=0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P=0.002). CONCLUSION: Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery.