HHV-6 Myocarditis Progressing to Ventricular Standstill Requiring Cardiac Transplant.

Human herpesvirus-6 (HHV-6) is an increasingly recognized cause of myocarditis. We present the case of a 46-year-old woman who presented with fulminant HHV-6 myocarditis requiring heart transplantation. (Level of Difficulty: Advanced.).

Increased incidence of electrical abnormalities in a pacemaker lead family.

INTRODUCTION: Several recent studies have raised concern about noise detections on Tendril pacemaker leads, which may represent insulation failure or algorithm-driven overreporting of physiologic signals. METHODS: We identified all pacemaker leads actively followed at Albany Medical Center, of which 1111 leads (262 Abbott Tendril, 576 Medtronic CapSure, 30 Fineline, 195 Ingevity, 48 Dextrus) in 703 patients were included in this observational study. Electrical abnormalities, comprising low-impedance measurements <200 Ω and repeated noise detections, were catalogued, as was initial management and subsequent need for surgical intervention. RESULTS: During 54 months median follow-up (interquartile range 24-105), 63 leads (5.7%) demonstrated electrical abnormalities, including low impedances in 21 and noise in 59. Tendril leads manifested abnormalities most frequently (n = 50; 19.1%) compared with CapSure (n = 9; 1.6%), Fineline (n = 0), Ingevity (n = 0), and Dextrus (n = 4; 8.3%) leads. The risk of abnormalities was significantly higher in Tendril leads (HR 9.6, 95% CI 5.2-17.6; p < .001). Low impedances were measured on 19 Tendril leads, a significantly higher risk than on other leads (HR 23.8, 95% CI 5.5-102.1; p < .001). Although observation and reprogramming sensitivity were the initial management strategy for 45 and 7 leads, respectively, 18 ultimately required surgical intervention, including 15 Tendrils. No electrical abnormalities were observed in 12 non-Tendril leads attached to Abbott devices compared with 48 of 252 Tendrils attached to Abbott devices (log-rank p = .035). CONCLUSION: Tendril leads demonstrate significantly higher risk of repeated low impedances and noise compared to other manufacturers' models, raising concern that these findings reflect early insulation failure. Increased scrutiny is warranted.

Baseline diastolic pressure gradient and pressure reduction in chronic heart failure patients implanted with the CardioMEMS™ HF sensor.

AIMS: Remote haemodynamic monitoring (RHM) decreases hospitalization rates in patients with chronic heart failure (HF). Many patients with chronic HF develop pulmonary hypertension (PH) secondary to left heart disease with some acquiring combined pre-capillary and post-capillary PH (Cpc-PH). The efficacy of RHM in achieving pulmonary pressure reductions in patients with Cpc-PH vs. isolated post-capillary PH (Ipc-PH) is unknown. The purpose of this study is to evaluate whether a higher baseline diastolic pressure gradient (DPGbaseline ) measured at the time of CardioMEMS™ HF sensor implantation is associated with lower reductions in pulmonary artery diastolic pressures (PADP). METHODS AND RESULTS: This was a retrospective analysis of 32 patients meeting clinical indications for CardioMEMS™ implantation. DPGbaseline categorized patients as Cpc-PH (DPG ≥ 7 mmHg) or Ipc-PH (DPG < 7 mmHg). Minimum achievable PADP (PADPmin ) and ∆PADP (PADPbaseline  - PADPmin ) were determined. Pearson's correlation analysis and comparison of mean pressure changes were assessed. Median age was 69 years, and median left ventricular ejection fraction (LVEF) was 25%. Eight patients (25%) had a LVEF ≥40%. Twenty-five patients (78%) met criteria for Ipc-PH and seven (22%) for Cpc-PH. Neither PADPmin (ρ = 0.27; P = 0.13) nor ΔPADP (ρ = 0.07; P = 0.72) was correlated with DPGbaseline . A trend towards higher ΔPADP was seen in Cpc-PH vs. Ipc-PH patients (15.2 vs. 9.88 mmHg; P = 0.12). There was a moderate positive correlation between baseline PADP and ΔPADP [ρ = 0.55 (0.26-0.76); P < 0.001]. CONCLUSIONS: Decreased PADP reduction was not seen in Cpc-PH vs. Ipc-PH patients. Higher PADPbaseline was associated with greater ΔPADP. Larger studies are needed to elaborate our findings.

Cardiogenic Shock: Recent Developments and Significant Knowledge Gaps.

PURPOSE OF REVIEW: Patients with cardiogenic shock (CS) continue to have high rates of morbidity and mortality. We aimed to describe current principles in the management of CS including coronary revascularization, medical management, mechanical circulatory support, and supportive care. RECENT FINDINGS: Revascularization is still recommended, but trials have not found a benefit in the revascularization of nonculprit artery lesions. New mechanical circulatory support options are available, but optimal use remains uncertain. Overall improvement in outcomes appears to have plateaued. There remain substantial knowledge gaps about the management of CS. The ideal timing and selection criteria for mechanical support remain under-developed. There has been little systematic study to inform medical management or supportive care of this patient population. A more expansive research focus is necessary to improve the care of CS.