Sudden death after open gastric bypass surgery

Purpose: Gastric bypass surgery has become a relatively low-risk bariatric surgical intervention in a high-risk patient population (Nguyen et al., Arch Surg, 141:445-449, 2006; Buchwald et al. JAMA, 13:1724-1737, 2004). Surgical interventions in patients suffering from morbid obesity are typically associated with excess morbidity (Parikh et al., Am Surg, 73:959-962, 2007). Though overall mortality after bariatric surgery is <1% is low (Mason et al., Obes Surg, 17:9-14, 2007), some surgical complications such as anastomotic leaks, staple line disruption and bowel obstruction may still impact on postoperative outcome (Parikh et al., Am Surg, 73:959-962, 2007; Mason et al., Obes Surg, 17:9-14, 2007). Early symptoms are often missed, as clinical presentation may be discreet, inexistent or falsely attributed to obesity. Methods: This case report refers to a patient in whom discomfort and agitation associated with a rise in temperature heralded a fulminant septic shock syndrome precipitating his death. Literature on early complications and management after gastric bypass is reviewed. Conclusion: A high level of suspicion should be present in the case of an unexpected postoperative deterioration of the patient's general condition. Time to treat may be very short (Mason et al., Obes Surg, 17:9-14, 2007). Computed tomography is mandatory to rule out pulmonary embolism and bypass obstructio

Cardiac resynchronization therapy in the presence of total atrioventricular block reduces long-lasting atrial fibrillation episodes

BACKGROUND There is an ongoing debate on how cardiac resynchronization therapy (CRT) in the presence of total AV block affects atrial fibrillation (AF) episodes and symptoms in patients with AF. METHODS Seventy-five patients with symptomatic, drug and ablation refractory AF received, irrespective of their left ventricular ejection fraction (EF), either a CRT device and underwent subsequent atrioventricular node (AVN) ablation or already had a total AV block and underwent CRT upgrade. Long-lasting AF episodes (>48 h), left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), left atrial diameter (LAD), NTproBNP levels, EHRA score, and NYHA class had been monitored on the follow-up. RESULTS The number of patients experiencing long-lasting AF episodes (>48 h) and symptoms decreased significantly within 24 months after CRT implantation in the presence of total AV block (p < .001) from 57 (76%) to 25 (33.3%). Mean LAD decreased from 52 mm (IQR 48.0-56.0) to 48 mm (IQR 42.0-52.0, p < .001) and LVEDD from 54 mm (IQR 49.0-58.0) to 51 mm (IQR 46.5-54.0, p < .001). CONCLUSION A combination of total AVN block and biventricular pacing markedly reduces long-lasting AF episodes, symptoms, left atrial diameter, and left ventricular end-diastolic diameter

The Quest for New Approaches in Myocarditis and Inflammatory Cardiomyopathy

Myocarditis is a diverse group of heart-specific immune processes classified by clinical and histopathological manifestations. Up to 40% of dilated cardiomyopathy is associated with inflammation or viral infection. Recent experimental studies revealed complex regulatory roles for several microribonucleic acids and T-cell and macrophage subtypes. Although the prevalence of myocarditis remained stable between 1990 and 2013 at about 22 per 100,000 people, overall mortality from cardiomyopathy and myocarditis has decreased since 2005. The diagnostic and prognostic value of cardiac magnetic resonance has increased with new, higher-sensitivity sequences. Positron emission tomography has emerged as a useful tool for diagnosis of cardiac sarcoidosis. The sensitivity of endomyocardial biopsy may be increased, especially in suspected sarcoidosis, by the use of electrogram guidance to target regions of abnormal signal. Investigational treatments on the basis of mechanistic advances are entering clinical trials. Revised management recommendations regarding athletic participation after acute myocarditis have heightened the importance of early diagnosis. (C) 2016 by the American College of Cardiology Foundation.Peer reviewe

Medical therapy with flecainide and propafenone in atrial fibrillation: Long-term clinical experience in the tertiary care setting

BACKGROUND: Flecainide and propafenone are Class Ic antiarrhythmic drugs that block the cardiac fast inwards Na+ current and are used for rhythm control in patients with atrial fibrillation (AF). However, data on long-term clinical efficacy and safety of these drugs in a real-world setting are scarce. METHODS: Patients with AF who received chronic flecainide or propafenone therapy were retrospectively studied from the database of a tertiary care center. The primary outcome of the study was clinical efficacy of Class Ic antiarrhythmics, which was assessed based on the improvement of arrhythmia-related symptoms at the time of last follow-up. RESULTS: Among the 361 patients (261 males, 72.3%) with a mean age of 56 ± 12 years, 287 (79.5%) were using long-term flecainide, and 74 (20.5%) patients propafenone. The majority of the patients had paroxysmal AF (n = 331, 91.7%) and had an atrioventricular-nodal blocking co-medication (n = 287, 79.5%). A total of 117 (32%) patients discontinued therapy after a median of 210 days (interquartile range 62-855 days). Clinical efficacy was observed in 188 patients (52%). The most common reason for therapy discontinuation was adverse drug effects, particularly proarrhythmic effects (48% for flecainide and 33% for propafenone). Patients who did not clinically benefit from Class Ic antiarrhythmics more often underwent pulmonary vein isolation (p = 0.02). CONCLUSIONS: Long-term therapy with Class Ic antiarrhythmics showed clinical efficacy in approximately half of the patients with paroxysmal or persistent AF. However, these drugs were also associated with a relatively high rate of adverse events, and in particular proarrhythmic effects, which often resulted in therapy discontinuation rendering appropriate patient selection and therapy surveillance essential

Transesophageal Echocardiography-Guided Transseptal Left Atrial Access to Improve Safety in Patients Undergoing Pulmonary Vein Isolation

BACKGROUND: Endovascular pulmonary vein isolation (PVI) has become an important strategy for rhythm control in patients with symptomatic atrial fibrillation (AF). Transseptal access is a critical step of this procedure and can result in potentially life-threatening complications. This retrospective study evaluates the safety of standardized, transesophageal echocardiography (TEE)-guided transseptal access to the left atrium in consecutive patients who underwent PVI. METHODS: After the implementation of a standardized, TEE-guided procedure for transseptal access, the data of 404 consecutive PVI procedures using radiofrequency ablation and 3D-mapping were prospectively collected over 5 years. TEE-guided transseptal punctures were performed on 375 patients undergoing one to three PVIs. The patient cohort was retrospectively analyzed for major and minor complications, fluoroscopy time, fluoroscopy dose and ablation outcomes. RESULTS: No single complication related to transseptal access occurred, affirming the safety of the TEE-guided approach. Fluoroscopy time and fluoroscopy dose decreased significantly after 152 procedures. PVI-related minor complications occurred in 11 procedures (2.6%) and included 10 vascular-access-related complications (2.4%) and 1 TEE-related esophageal hematoma (0.2%), which healed spontaneously. CONCLUSION: Our single-center study shows that TEE guidance may allow safe transseptal access to the left atrium in patients undergoing PVI

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients

Objective: To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors. Design: Retrospective cohort study. Setting: Medical ICU of an academic tertiary care hospital. Patients: Atotal of 273 consecutive overdose admissions. Measurements and results: Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in apatient with alocalised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with ahigher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1-3) vs 1 (1-2), p = 0.025; and median 2 (1-7) vs 1 (1-3), p < 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7-0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7-11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 109/l 1.05; 95% CI 1.0-1.19; p = 0.049) were identified as independent risk factors. Conclusions: Clinically relevant aspiration pneumonitis is afrequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with ahigher incidence of cardiac arrest and increased ICU and total in-hospital sta

Nitric oxide synthase 2 is required for conversion of pro-fibrogenic inflammatory CD133+ progenitors into F4/80+ macrophages in experimental autoimmune myocarditis

Aims Experimental autoimmune myocarditis (EAM) model mirrors important mechanisms of inflammatory dilated cardiomyopathy (iDCM). In EAM, inflammatory CD133+ progenitors are a major cellular source of cardiac myofibroblasts in the post-inflammatory myocardium. We hypothesized that exogenous delivery of macrophage-colony-stimulating factor (M-CSF) can stimulate macrophage lineage differentiation of inflammatory progenitors and, therefore, prevent their naturally occurring myofibroblast fate in EAM. Methods and results EAM was induced in wild-type (BALB/c) and nitric oxide synthase 2-deficient (Nos2−/−) mice and CD133+ progenitors were isolated from inflamed hearts. In vitro, M-CSF converted inflammatory CD133+ progenitors into nitric oxide-producing F4/80+ macrophages and prevented transforming growth factor-β-mediated myofibroblast differentiation. Importantly, only a subset of heart-infiltrating CD133+ progenitors expresses macrophage-specific antigen F4/80 in EAM. These CD133+/F4/80hi cells show impaired myofibrogenic potential compared with CD133+/F4/80− cells. M-CSF treatment of wild-type mice with EAM at the peak of disease markedly increased CD133+/F4/80hi cells in the myocardium, and CD133+ progenitors isolated from M-CSF-treated mice failed to differentiate into myofibroblasts. In contrast, M-CSF was not effective in converting CD133+ progenitors from inflamed hearts of Nos2−/− mice into macrophages, and M-CSF treatment did not result in increased CD133+/F4/80hi cell population in hearts of Nos2−/− mice. Accordingly, M-CSF prevented post-inflammatory fibrosis and left ventricular dysfunction in wild-type but not in Nos2−/− mice. Conclusion Active and NOS2-dependent induction of macrophage lineage differentiation abrogates the myofibrogenic potential of heart-infiltrating CD133+ progenitors. Modulating the in vivo differentiation fate of specific progenitors might become a novel approach for the treatment of inflammatory heart disease