Takotsubo Cardiomyopathy: A Long Term Follow-up Shows Benefit with Risk Factor Reduction

Only sparse data was available on long-term of Takotusbo Cardiomyopathy (TC). Previous studies suggested prognosis is not necessarily benign. We report the long-term follow-up of 12 TC patients actively managed with risk factor reduction. Retrospective analysis of all patients diagnosed with TC at our hospital between 1998 and 2010. We identified 12 patients with TC among 1651 cases of emergent left heart catheterization over 12 years. Mean follow-up time was 8.3 ± 3.6 years. All were female, 87% had hypertension, 25% had history of Coronary Artery Disease (CAD), 67% had hyperlipidemia, 44% had some preceding emotional trauma, and 44% had some physical/physiological stress. Previous studies have shown that over 50% of TC patients experience future cardiac events, and 10% have a recurrence of TC. Patients were prescribed therapeutic lifestyle changes (TLC) and guideline directed medical therapy (GDMT) for aggressive risk factor reduction. TLC included diet, exercise, and cardiac rehabilitation. GDMT often included aspirin, beta-blockers, ACE-inhibitors, and statins. Follow-up echocardiograms showed recovery and maintenance of the ejection fraction. There was no cardiac mortality and no recurrences of TC. Aggressive risk factor reduction with TLC and GDMT may be effective in improving the long term outcomes of patients with TC

Non-pharmacologic approach to prevent embolization in patients with atrial fibrillation in whom anticoagulation is contraindicated

Ischemic stroke is the most common complication of atrial fibrillation (AF). Anticoagulation therapy reduces the risk of systemic embolization in almost all patients with AF irrespective of the type of AF (paroxysmal, persistent or permanent). But, all patients are not suitable candidates for systemic anticoagulation mainly due to the risk of bleeding. Left atrial appendage closure (LAAC) devices have been found to be very effective non-pharmacologic alternative therapy for such patients. There are various types of LAAC devices but United States Food and Drug Administration (USFDA) have approved only Watchman device. Initially, bigger medical centers in the US had started the insertion of Watchman device but with improving procedural techniques and exciting outcomes, even the community-based hospitals have started to embrace this therapy. We have presented the first three cases of Watchman device placement performed in our hospital and discussed about the indications for placement of LAAC devices .We have also reviewed their efficacy individually

Reducing radiation exposure in an electrophysiology lab with introduction of newer fluoroscopic technology

The use of fluoroscopic devices exposes patients and operators to harmful effects of ionizing radiation in an electrophysiology (EP) lab. We sought to know if the newer fluoroscopic technology (Allura Clarity) installed in a hybrid EP helps to reduce prescribed radiation dose. We performed radiation dose analysis of 90 patients who underwent various procedures in the EP lab at a community teaching hospital after the introduction of newer fluoroscopic technology in June of 2016.Watchman device insertion, radiofrequency ablation procedures, permanent pacemaker (PPM)/implantable cardioverter defibrillator (ICD) placement and battery changes were included in the study to compare radiation exposure during different procedures performed commonly in an EP lab. In all cases of watchman device placement, radiofrequency ablation procedures, PPM/ICD placement and battery changes, there was a statistically significant difference (<0.05) in radiation dose exposure. Significant reduction in radiation exposure during various procedures performed in an EP lab was achieved with aid of newer fluoroscopic technology and better image detection technology

Response to Ponamgi et al. Comments on Khalighi et al. Takotsubo Cardiomyopathy: A Long Term Follow-up Shows Benefit with Risk Factor Reduction. J. Cardiovasc. Dev. Dis., 2015, 2, 273–281.

We appreciate the thorough response given by Ponagmi et al. [1], who rightly point out that the pathophysiology and modifiable risk factors of Takotsubo Cardiomyopathy (TC) have yet to be unequivocally established. [...

Elevated troponin and left bundle branch block in the setting of suspected septicemia and demand ischemia: to treat or not to treat

Elevated troponin and atypical chest pain in the setting of septicemia and Type II Non ST elevation myocardial infarction is frequently encountered. These cases are not necessarily scheduled for emergent cardiac catheterization. High index of clinical suspicion and continuous in-patient cardiac monitoring with serial trending of cardiac enzymes are important in such cases. Subsequent sudden development of electrocardiogram changes requires prompt investigation with emergent coronary catheterization. These types of cases may be missed especially in females who present with atypical chest pain and in patients with Left bundle branch block

A Case of Late Implantable Cardiac Device Infection with Aspergillus in an Immunocompetent Host.

BACKGROUND: With the increasing use of cardiac implantable electronic devices (CIED), there has been an associated increase in rate of complications. Infection accounts for about 1% of these, of which only a handful were reported secondary to Aspergillus fumigatus. All of these were seen in chronically-ill patients with several co-morbid conditions within a few years of implantation. None have been reported in an otherwise immunocompetent patient at 7 years after CIED implantation. CASE REPORT: A 67-year-old woman with symptomatic sick sinus syndrome required a pacemaker 15 years ago with subsequent revision 7 years prior due to battery depletion. She now presented with a left pectoral non-tender mass that developed over several weeks. She denied history of recent fever, trauma, or infection. An elective pacemaker revision and pocket exploration led to the drainage of 150 cc of serosanguineous discharge from the pocket. She received peri-procedural prophylaxis with Vancomycin, but later, wound cultures grew Aspergillus fumigatus. She underwent complete removal of the pacemaker system along with a 6-week course of voriconazole and is doing well. CONCLUSIONS: Even though Staphylococcus aureus causes most CIED infections, there should be a suspicion for fungal organisms, especially in culture-negative infections, in immunocompromised states like diabetes mellitus or with minimal improvement on antibiotics. If not treated appropriately, aspergillosis may have catastrophic outcomes, including endocarditis, often leading to death. Appropriate treatment should include immediate initiation of antifungals and removal of the CIED. It is still unclear why an immunocompetent patient developed aspergillosis, but appropriate management helped avoid a grave outcome

Application of ICD guidelines and indications in a community-based academic hospital: a case series-based discussion.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) are indeed beneficial in selected patients as evidenced by multiple large randomized controlled trials (RCTs) since 1980. A systematic method for stratification of patients and hospital-wide criteria/guidelines to ascertain appropriate device implantation became necessary. METHODS: Major ICD/CRT (cardiac resynchronization therapy) clinical studies and relevant guidelines were reviewed, and an institution-wide inclusion and exclusion criteria for ICD/CRT was formulated. A retrospective analysis of selected cases was performed to discuss the criteria and special clinical situations. RESULTS: We have translated the evolving ICD/CRT studies into a standard of care at our hospital by formulating a standard, practical, and update-to-date ICD inclusion and exclusion criteria. Thirteen cases were selected to represent major indications and contraindications of ICDs in our practice. These cases cover indications of ICD for secondary prevention of sudden cardiac death (SCD), primary prevention of SCD in patients with CHF resulted from either ischemic or non-ischemic cardiomyopathy, as well as for infiltrative cardiomyopathy and inherited conditions. We discussed the application of CRT in patients with CHF associated with prolonged QRS duration. We then covered the potential benefits of ICD with/without CRT in certain special populations of patients that have not been adequately evaluated by currently available RCTs; these include alcoholic, elderly, female, and ESRD/HD patients. Finally, we addressed risks, complications and contraindications of ICD, as well as application of an external wearable defibrillator in AMI, or status post-CABG patient during the mandatory waiting period for an ICD. CONCLUSIONS: Establishment of the ICD/CRT criteria represents a practical translation of emerging CRTs and helps to standardize patient care in our hospital. It also improves cost-effectiveness as well as appropriate utilization of institute and device resources

Development of New Deep Venous Thrombosis While on Apixaban

The efficacy of novel oral anticoagulants (NOACs) in preventing deep venous thrombosis (DVT) has been established in large multicenter trials. Predictable pharmacokinetics, avoidance of routine laboratory monitoring, and lesser drug interactions have made NOACs safer and more tolerable treatment option in comparison to warfarin. However, cases of treatment failure mainly due to interindividual variation in plasma drug levels can be seen rarely. In this report we describe a case of acute DVT of right lower extremity in a patient who was on apixaban for prevention of venous thromboembolism (VTE) due to underlying nonvalvular atrial fibrillation (NVAF)

Reducing Radiation Exposure in an Electrophysiology Lab with Introduction of Newer Fluoroscopic Technology.

The use of fluoroscopic devices exposes patients and operators to harmful effects of ionizing radiation in an electrophysiology (EP) lab. We sought to know if the newer fluoroscopic technology (Allura Clarity) installed in a hybrid EP helps to reduce prescribed radiation dose. We performed radiation dose analysis of 90 patients who underwent various procedures in the EP lab at a community teaching hospital after the introduction of newer fluoroscopic technology in June of 2016. Watchman device insertion, radiofrequency ablation procedures, permanent pacemaker (PPM)/implantable cardioverter defibrillator (ICD) placement and battery changes were included in the study to compare radiation exposure during different procedures performed commonly in an EP lab. In all cases of watchman device placement, radiofrequency ablation procedures, PPM/ICD placement and battery changes, there was a statistically significant difference