Anthony Aizer

Mupirocin Prophylaxis to Prevent Staphylococcus aureus Infection in Patients Undergoing Dialysis: A Meta-analysis

A systematic review of the English-language literature was performed to determine the overall benefit of mupirocin therapy in reducing the rate of Staphylococcus aureus infection among patients undergoing hemodialysis (HD) or peritoneal dialysis (PD). Included studies met the following criteria: they were randomized clinical trials or cohort studies; cohorts consisted of adults (age, > or =18 years) requiring HD or PD; mupirocin therapy was administered to the treatment group, and placebo or no therapy was administered to the control group; and the primary outcome of interest was the difference in the number of S. aureus infections among mupirocin-treated and -untreated patients. Ten studies described in 9 articles were analyzed. A total of 2445 patients were included in the analysis. Use of mupirocin reduced the rate of S. aureus infections by 68% (95% confidence interval [CI], 57%-76%) among all patients undergoing dialysis; risk reductions were 80% (95% CI, 65%-89%) among patients undergoing HD and 63% (95% CI, 50%-73%) among patients undergoing PD. When data were stratified by type of infection, S. aureus bacteremia was found to be reduced by 78% among patients undergoing HD, and peritonitis and exit-site infections were found to be reduced by 66% and 62%, respectively, among patients undergoing PD. Mupirocin prophylaxis substantially reduces the rate of S. aureus infection in the dialysis population. Optimal regimens that minimize the emergence of mupirocin resistance need to be explored.

Standardization and validation of an automated algorithm to identify fractionation as a guide for atrial fibrillation ablation

BACKGROUND Atrial fibrillation catheter ablation is frequently guided by identification of fractionated electrograms, which are thought to be critical for maintenance of the arrhythmia. Objective automated means for identifying fractionation independent of physician interpretation have not been standardized or validated. OBJECTIVE The purpose of this study was to standardize and validate an automated algorithm to rapidly identify fractionated electrograms for high-density atrial fibrillation fractionation mapping. METHODS Left and right atrial fractionation maps were generated by EnSite NavX 6.0 software, using standardized ablation catheters in eight patients with atrial fibrillation. Two blinded electrophysiologists interpreted all electrograms as either fractionated or not fractionated. A stepwise approach was used to optimize automated settings to accurately identify fractionation. High-density fractionation maps were generated with a 20-pole mapping catheter in eight other patients. Two blinded electrophysiologists interpreted all electrograms as near field or far field. The algorithm was refined to optimize settings to exclude far-field signals and retain near-field signals. The sampling segment length was adjusted to optimize recording time to ensure reproducibility. RESULTS Using 1,514 points, the automated software achieved sensitivity of 0.75 and specificity of 0.80 for identification of fractionated electrograms. Using 725 points collected via multipole catheters with optimal automated settings, 94% of near-field fractionated electrograms were accurately identified. A 6-second sampling length was needed for reproducible fractionation measurements. CONCLUSION Standardized settings of EnSite NavX 6.0 software with 6-second data collection per point can rapidly and accurately generate high-density fractionation maps independent of physician electrogram interpretation. This may allow for an automated, standardized approach to atrial fibrillation fractionated ablation.

Meta-analysis to assess the appropriate endpoint for slow pathway ablation of atrioventricular nodal reentrant tachycardia.

Background:  There are little data on the appropriate endpoint for slow pathway ablation that balances acceptable procedural times, recurrence rates, and complication rates. This study compared recurrence rates of three commonly utilized endpoints of slow pathway ablation for atrioventricular nodal reentrant tachycardia (AVNRT).

Cosmic radiation induced software electrical resets in ICDs during air travel

C T c r . ntroduction osmic radiation is a well-known cause of single-event psets (SEU) on disruption to electrical circuits in electronic evices. It most commonly occurs and is reported for deices such as laptop computers, cell phones, and personal igital assistants. We report 3 patients with implantable ardioverter-defibrillators (ICDs) who experienced SEUs uring air travel that may be attributed to exposure to osmic radiation while on commercial airline flights. These ases highlight the significant impact of SEUs on ICDs and atient clinical outcomes and the need for further recogniion and study of this problem. Cosmic radiation was discovered by the Nobel Laureate ictor Hess in 1912. While studying radioactivity, he disovered the source of radioactive particles showering down hrough the earth’s atmosphere as cosmic radiation. Cosmic adiation originates from the sun, other stars, and catalysms in outer space, some having occurred millions of ears ago, and is made up of protons, electrons, and neurons. At sea level, cosmic radiation contributes 13% of the atural background radiation. There are 4 predominant factors contributing to cosmic adiation. (1) Altitude: the earth’s atmosphere shields osmic radiation. At higher altitude the shield decreases, herefore the density of cosmic radiation increases. At flying ltitude, cosmic radiation is 100 times greater than at sea evel (Figure 1). (2) Latitude: the earth’s magnetic field eflects cosmic radiation. Shielding cosmic rays is greatest t the equator and decreases at the outer poles. Cosmic adiation at either the north or the south pole is twice as reat as at the equator. (3) Solar activity: the sun’s activity ycles every 11 years, with periods of high and low activity. uring a quiet solar year (2007), large amounts of cosmic adiation shower down through the atmosphere. (4) Solar roton events: these are large, explosive ejections of harged particles. This increased ejection of solar energy

The role of multimodality imaging in percutaneous left atrial appendage suture ligation with the LARIAT device.

Atrial fibrillation (AF), the most common cardiac arrhythmia, is a significant cause of embolic stroke. Although systemic anticoagulation is the primary strategy for preventing the thromboembolic complications of AF, anticoagulants carry major bleeding risks, and many patients have contraindications to their use. Because thromboembolism typically arises from a clot in the left atrial appendage (LAA), local therapeutic alternatives to systemic anticoagulation involving surgical or percutaneous exclusion of the LAA have been developed. Surgical exclusion of the LAA is typically performed only as an adjunct to other cardiac surgeries, thus limiting the number of eligible patients. Furthermore, surgical exclusion of the LAA is frequently incomplete, and thromboembolism may still occur. Percutaneous LAA exclusion includes two approaches: transseptal delivery of an occlusion device to the LAA and epicardial suture ligation of the LAA, the LARIAT procedure. In the LARIAT procedure, a pretied snare is placed around the epicardial surface of the LAA orifice via pericardial access. Proper snare placement is achieved with epicardial and endocardial magnet-tipped guidewires. The endocardial wire is advanced transvenously to the LAA apex after transseptal puncture. The epicardial wire, introduced into the pericardial space, achieves end-to-end union with the endocardial wire at the LAA apex. The snare is then placed over the LAA, tightened, and sutured. On the basis of early clinical experience, the LARIAT procedure has a high success rate of LAA exclusion with low risk for complications. The authors describe the indispensable role of real-time transesophageal echocardiography in the guidance of LAA epicardial suture ligation with the LARIAT device.

Percutaneous treatment of the superior vena cava syndrome via an excimer laser sheath in a patient with a single chamber atrial pacemaker

A 21-year-old woman presented with a pacemaker-associated superior vena cava (SVC) syndrome refractory to medical therapy. In the past, treatment of this condition has involved surgical exploration which is invasive. With the evolution of percutaneous techniques, treatment has included venoplasty and stenting over the pacemaker lead. There is limited experience with a more advanced percutaneous technique in which the lead is extracted by an excimer laser sheath. The extraction is immediately followed by venoplasty and stenting at the site of stenosis with subsequent implantation of a new permanent pacemaker at the previously occluded access site. The patient underwent this procedure which proved to be safe, minimally invasive, and an efficient method of treating SVC syndrome secondary to a single chamber atrial pacemaker.

Right‐Sided Implantation and Subpectoral Position are Predisposing Factors for Fracture of a 6.6 French ICD Lead

Background: The Medtronic Sprint Fidelis (Medtronic Inc., Minneapolis, MN, USA) lead family is associated with an unacceptable incidence of premature lead failure. There are limited data on risk factors for lead fracture. We hypothesized that factors leading to potential increased forces on the lead related to device implantation or technique may be associated with premature lead failure.

Isoproterenol infusion increases level of consciousness during catheter ablation of atrial fibrillation.

IntroductionThe objective of this study was to determine the effects of isoproterenol infusion on level of consciousness during ablation using total intravenous anesthesia.Methods and resultsSeven patients undergoing total intravenous anesthesia for atrial fibrillation ablation were monitored for level of consciousness using bispectral EEG levels (BIS). Isoproterenol infusion was performed after the ablation during anesthesia. BIS levels prior to, during, and post-isoproterenol infusion were recorded and correlated to isoproterenol infusion doses. In all patients, BIS levels significantly increased during isoproterenol infusion (median BIS prior to infusion, 46; during infusion, 64 (p < 0.02)). With a subsequent increase in anesthetic medication, BIS levels could again be reduced.ConclusionIsoproterenol infusion alters consciousness level during total intravenous anesthesia for atrial fibrillation ablation. BIS monitoring is a novel way to modulate anesthesia during ablation to potentially optimize patient comfort and ablation success.

Clinical Course of Sarcoidosis in World Trade Center-Exposed Firefighters

Background Sarcoidosis is believed to represent a genetically primed, abnormal immune response to an antigen exposure or inflammatory trigger, with both genetic and environmental factors playing a role in disease onset and phenotypic expression. In a population of firefighters with post‐World Trade Center (WTC) 9/11/2001 (9/11) sarcoidosis, we have a unique opportunity to describe the clinical course of incident sarcoidosis during the 15 years postexposure and, on average, 8 years following diagnosis. Methods Among the WTC‐exposed cohort, 74 firefighters with post‐9/11 sarcoidosis were identified through medical records review. A total of 59 were enrolled in follow‐up studies. For each participant, the World Association of Sarcoidosis and Other Granulomatous Diseases organ assessment tool was used to categorize the sarcoidosis involvement of each organ system at time of diagnosis and at follow‐up. Results The incidence of sarcoidosis post‐9/11 was 25 per 100,000. Radiographic resolution of intrathoracic involvement occurred in 24 (45%) subjects. Lung function for nearly all subjects was within normal limits. Extrathoracic involvement increased, most prominently joints (15%) and cardiac (16%) involvement. There was no evidence of calcium dysmetabolism. Few subjects had ocular (5%) or skin (2%) involvement, and none had beryllium sensitization. Most (76%) subjects did not receive any treatment. Conclusions Extrathoracic disease was more prevalent in WTC‐related sarcoidosis than reported for patients with sarcoidosis without WTC exposure or for other exposure‐related granulomatous diseases (beryllium disease and hypersensitivity pneumonitis). Cardiac involvement would have been missed if evaluation stopped after ECG, 48‐h recordings, and echocardiogram. Our results also support the need for advanced cardiac screening in asymptomatic patients with strenuous, stressful, public safety occupations, given the potential fatality of a missed diagnosis.

Left Atrial Appendage Occlusion/Exclusion: Procedural Image Guidance with Transesophageal Echocardiography

&NA; Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. In this article, the authors describe the crucial role of two‐ and three‐dimensional transesophageal echocardiography in the pre‐ and postprocedural assessment and intraprocedural guidance of percutaneous left atrial appendage (LAA) occlusion procedures. Although recent advances have been made in the field of systemic anticoagulation with the novel oral anticoagulants, these medications come with a significant risk for bleeding and are contraindicated in many patients. Because thromboembolism in atrial fibrillation typically arises from thrombi originating in the LAA, surgical and percutaneous LAA exclusion/occlusion techniques have been devised as alternatives to systemic anticoagulation. Currently, surgical LAA exclusion is typically performed as an adjunct to other cardiac surgical procedures, which limits the number of eligible patients. Recently, several percutaneously delivered devices for LAA exclusion from the systemic circulation have been developed, some of which have been shown in clinical trials to reduce the risk for thromboembolism. These devices use an either purely endocardial LAA occlusion approach, such as the Watchman and Amulet procedures, or both an endocardial and a pericardial (epicardial) approach, such as the Lariat procedure. In the Watchman and Amulet procedures, a transseptally delivered structure composed of nitinol is placed in the LAA orifice, thereby excluding the LAA from the systemic circulation. In the Lariat procedure, a magnet link is created between a transseptally delivered endocardial wire and epicardially delivered pericardial wire, followed by epicardial suture ligation of the LAA. HighlightsThe LAA is the most common site of thrombus formation in nonvalvular atrial fibrillation.In nonvalvular atrial fibrillation, percutaneous LAA occlusion/exclusion is an alternative method of thromboembolism prevention for patients who are either ineligible for or too high risk to receive systemic anticoagulation therapy.2D/3D transesophageal echocardiography has a critical role in all percutaneous LAA occlusion/exclusion procedures, including screening for eligibility, device sizing, intraprocedural guidance, and postprocedural follow up.The most commonly used percutaneous LAA occlusion/exclusion devices worldwide include the Watchman, Amulet, and Lariat.