Leadless cardiac pacing in resource limited settings: A Groote Schuur hospital experience with the Micra leadless pacemaker

Background: Cardiac pacemakers improve survival and quality of life in patients with atrioventricular (AV) block. However, conventional pacemakers carry a small risk of both acute and chronic lead and pacemaker generator complications. Leadless pacemakers negate these risks by not having a pacing lead and a subcutaneous generator. We report our Groote Schuur Hospital experience with the Medtronic Micra transcatheter pacing system (TPS).Methods: We report a consecutive case series of patients that received the Micra leadless pacemaker. The Micra transcatheter pacemaker, a single chamber ventricular pacemaker, is inserted using a TPS via the femoral vein into the right ventricle. Implantation data were obtained, and medical records were reviewed for the 6 weeks and 1-year follow-up visits.Results: A total of 5 patients were implanted with a Micra leadless pacemaker from 11 March 2015 - 2 November 2016. Four patients were male and 1 female, with an average age of 64 years. Four patients received the pacemaker for a second- or third-degree AV block and 1 patient received the pacemaker for unexplained syncope and right bundle branch block. The Micra leadless pacemaker was successfully implanted in all patients with no acute implantationrelated complications. One-year follow-up was available for 4 patients with good pacing thresholds, sensitivity and impedance. One patient demised after 9 months post Micra implantation due to unrelated causes (acute myeloid leukaemia).Conclusion: The Micra leadless pacing system is safe and effective and shows good short-term results in a real-world, resource-limited setting. This form of pacing offers a viable option for patients who require pacing for AV block, especially in patients with vascular access problems or who are at high risk of lead or pacemaker generator complications

Case Report: A young woman with weakness of the legs

A previously well 22-year-old woman presented with progressive weakness of her legs and urinary incontinence over 7 days. Clinically she was healthy, with no skin rashes. On neurological examination she had profound bilateral weakness of the lower limbs, hypertonia, hyperreflexia, a positive Babinski sign and a T6 sensory level. Tests for syphilis and HIV and screening for auto-immune conditions were negative. Magnetic resonance imaging of the brain and spinal cord revealed extensive cord swelling between the craniocervical junction and T11, a high signal in the right optic nerve and a normal brain. Aquaporin 4 antibodies (neuromyelitis optica immunoglobulin G (NMO-IgG)) were positive with a titre of 1:1 000. These findings confirmed a diagnosis of NMO or Devic’s disease

Digoxin therapy in the modern management of cardiovascular disease: An unusual but serious complication

A 67-year-old woman presented to the Emergency Unit, Groote Schuur Hospital, Cape Town, South Africa, with a 1-week history of poor appetite, vomiting and fatigue. Her background history was notable for infundibular pulmonary stenosis resection, pulmonary embolism and atrial flutter. Two days before, she complained to her general practitioner of recent-onset, recurrent syncope and worsening gastrointestinal upset. Her medical treatment included warfarin 5 mg daily, enalapril 5 mg twice daily, furosemide 40 mg twice daily, atenolol 50 mg twice daily, amiodarone 200 mg daily and digoxin 0.125 mg daily. The digoxin was added to her therapy 8 months earlier to optimise rate control.

Chronic lung disease and a history of tuberculosis posttuberculosis lung disease: Clinical features and inhospital outcomes in a resourcelimited setting with a high HIV burden

Background. Many patients with previous pulmonary tuberculosis (PTB) continue to experience respiratory symptoms long after completion of tuberculosis (TB) therapy, often resulting in numerous hospital visits and admissions.Objectives. To describe the profile of patients with chronic lung disease (CLD) with or without a history of PTB, and their in-hospital outcomes.Methods. We conducted a retrospective review of patients with CLD admitted with respiratory symptoms to Dora Nginza Hospital, Port Elizabeth, South Africa, from 1 April 2016 to 31 October 2016. These patients were divided into two groups: CLD with a history of PTB (CLD-TB) and CLD without a history of PTB. Patients with current culture-positive TB were excluded. Baseline characteristics and clinical outcomes (duration of hospitalisation and in-hospital mortality) were compared between the two groups.Results. During the study period, a total of 4 884 patients were admitted and 242 patients received a diagnosis of CLD. In the CLD patient group, 173 had CLD-TB and 69 had no history of PTB. Patients with CLD-TB presented with respiratory symptoms a median of 41 months (interquartile range (IQR) 101) after completion of TB therapy. CLD-TB patients were predominantly male (59.5%), and compared with patients with no history of PTB were more likely to be HIV-positive (49.7% v. 8.7%; p=0.001) and had had more frequent hospital admissions before the current admission (median 2.0 (IQR 2.0) v. 0; p=0.001) and longer hospital stays (median 5 days (IQR 7) v. 2 (4); p=0.002). However, there was no statistically significant difference in in-hospital mortality between the two groups (17.3% v. 10.1%; p=0.165).Conclusions. In patients with CLD, a history of PTB is associated with numerous hospital admissions and longer hospital stays but not with increased in-hospital mortality. TB therefore continues to be a public health burden long after cure of active disease.Â

Chronic lung disease and a history of tuberculosis (post-tuberculosis lung disease): Clinical features and in-hospital outcomes in a resource-limited setting with a high HIV burden

Background. Many patients with previous pulmonary tuberculosis (PTB) continue to experience respiratory symptoms long after completion of tuberculosis (TB) therapy, often resulting in numerous hospital visits and admissions.Objectives. To describe the profile of patients with chronic lung disease (CLD) with or without a history of PTB, and their in-hospital outcomes.Methods. We conducted a retrospective review of patients with CLD admitted with respiratory symptoms to Dora Nginza Hospital, Port Elizabeth, South Africa, from 1 April 2016 to 31 October 2016. These patients were divided into two groups: CLD with a history of PTB (CLD-TB) and CLD without a history of PTB. Patients with current culture-positive TB were excluded. Baseline characteristics and clinical outcomes (duration of hospitalisation and in-hospital mortality) were compared between the two groups.Results. During the study period, a total of 4 884 patients were admitted and 242 patients received a diagnosis of CLD. In the CLD patient group, 173 had CLD-TB and 69 had no history of PTB. Patients with CLD-TB presented with respiratory symptoms a median of 41 months (interquartile range (IQR) 101) after completion of TB therapy. CLD-TB patients were predominantly male (59.5%), and compared with patients with no history of PTB were more likely to be HIV-positive (49.7% v. 8.7%; p=0.001) and had had more frequent hospital admissions before the current admission (median 2.0 (IQR 2.0) v. 0; p=0.001) and longer hospital stays (median 5 days (IQR 7) v. 2 (4); p=0.002). However, there was no statistically significant difference in in-hospital mortality between the two groups (17.3% v. 10.1%; p=0.165).Conclusions. In patients with CLD, a history of PTB is associated with numerous hospital admissions and longer hospital stays but not with increased in-hospital mortality. TB therefore continues to be a public health burden long after cure of active disease.

HIV-positive patients in the intensive care unit: A retrospective audit

Background. The indications for and outcomes of intensive care unit (ICU) admission of HIV-positive patients in resource-poor settings such as sub-Saharan Africa are unknown. Objective. To identify indications for ICU admission and determine factors associated with high ICU and hospital mortality in HIV-positive patients. Methods. We reviewed case records of HIV-positive patients admitted to the medical and surgical ICUs at Groote Schuur Hospital, Cape Town, South Africa, from 1 January 2012 to 31 December 2012. Results. Seventy-seven HIV-positive patients were admitted to an ICU, of whom two were aged 13 (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.1 - 1.7; p=0.015), receipt of renal replacement therapy (RRT) (OR 2.2, 95% CI 1.2 - 4.1; p=0.018) and receipt of inotropes (OR 2.3, 95% CI 1.6 - 3.4; p<0.001). Predictors of hospital mortality were severe sepsis on admission (OR 2.8, 95% CI 0.9 - 9.1; p=0.07), receipt of RRT (OR 1.9, 95% CI 1.0 - 3.6; p=0.056) and receipt of inotropic support (OR 2.0, 95% CI 1.4 - 3.2; p<0.001). Use of highly active antiretroviral therapy (HAART), CD4 count, detectable HIV viral load and diagnosis at ICU admission did not predict ICU or hospital mortality. Conclusions. Respiratory illnesses remain the main indication for ICU in HIV-positive patients. HIV infection is often diagnosed late, with patients presenting with life-threatening illnesses. Severity of illness as indicated by a high APACHE ΙΙ score, multiple organ dysfunction requiring inotropic support and RRT, rather than receipt of HAART, CD4 count and diagnosis at ICU admission, are predictors of ICU and hospital mortality

Profile, presentation and outcomes of prosthetic valve endocarditis in a South African tertiary hospital: Insights from the Groote Schuur Hospital Infective Endocarditis Registry

Background. Prosthetic valve infective endocarditis (PVE) is associated with high morbidity and mortality. The prevalence of PVE in South African retrospective studies ranges between 13% and 17%.Objectives. To define the clinical profile and outcomes of patients with PVE, and compare them with those of native valve endocarditis (NVE) patients.Methods. We performed a prospective observational study of patients presenting or referred to Groote Schuur Hospital, Cape Town, with definite or possible infective endocarditis (IE) based on the 2015 European Society of Cardiology IE diagnostic criteria. Consenting adult patients who met the inclusion criteria were enrolled into the Groote Schuur Hospital Infective Endocarditis Registry, which was approved by the University of Cape Town Human Research Ethics Committee. This study is an analysis of the patients enrolled between 1 January 2017 and 31 December 2019.Results. During the study period, a total of 135 patients received a diagnosis of possible or definite IE (PVE n=18, NVE n=117). PVE therefore accounted for 13.3% of the overall IE cohort. PVE patients had a mean (standard deviation) age of 39.1 (14.6) years, and 56.6% were male. PVE occurred within 1 year of valve surgery in 50.0% of cases. Duke’s modified diagnostic criteria for definite IE were met in 94.4% of the PVE cohort. Isolated aortic valve PVE was present in 33.3%, and a combination of aortic and mitral valve PVE in 66.6%. Tissue prosthetic valves were affected in 61.1% of cases. Of the PVE cases, 55.6% were healthcare associated. On transthoracic echocardiography, vegetations (61.1%), prosthetic valve regurgitation (44.4%) and abscesses (22.2%) were discovered. Staphylococcus and Streptococcus species accounted for 38.8% and 22.2% of PVE cases, respectively, and 27.8% of cases were blood culture negative. Valve surgery was performed in 38.7% of the PVE patients, and 55.6% of the patients died during the index hospitalisation. Secondary analysis indicated that the PVE patients were sicker than those with NVE, with a higher frequency of septic shock and atrioventricular block (22.2% v. 7%; p=0.02 and 27.8% v. 12%; p=0.04, respectively). In addition, in-hospital mortality was higher in PVE patients than NVE patients (55.6% v. 31.6%; p=0.04).Conclusions. PVE was uncommon, mainly affecting tissue prosthetic valves and prosthetic valves in the aortic position. Patients with PVE were sicker than those with NVE and had high in-hospital mortality