Heath Saltzman

Renal dysfunction in heart failure patients: what is the evidence?

Congestive heart failure (CHF) is an increasingly common medical condition and the fastest growing cardiovascular diagnosis in North America. Over one-third of patients with heart failure also have renal insufficiency. It has been shown that renal insufficiency confers worsened outcomes to patients with heart failure. However, a majority of the larger and therapy-defining heart failure medication and device trials exclude patients with advanced renal dysfunction. These studies also infrequently perform subgroup analyses based on the degree of renal dysfunction. The lack of information on heart failure patients who have renal insufficiency likely contributes to their being prescribed mortality and morbidity reducing medications and receiving diagnostic and therapeutic procedures at lower rates than heart failure patients with normal renal function. Inclusion of patients with renal insufficiency in heart failure studies and published guidelines for medication, device, and interventional therapies would likely improve patient outcomes.

Clinical Utility of Intravascular Ultrasound in the Assessment of Coronary Allograft Vasculopathy: A Review

Coronary artery vasculopathy (CAV) is one of the major factors that limit the long-term survival of heart transplant recipients. It is difficult to diagnose CAV, especially in the early stages. Traditional coronary angiography has been used for the diagnosis of CAV, but this method has limitations. Current literature suggests that intravascular ultrasound (IVUS) is a safe imaging technique that is beneficial for the early diagnosis of CAV; in comparison, IVUS with virtual histology (IVUS-VH) is an even more promising diagnostic utility. Despite its advantages, IVUS is currently not routinely utilized as the primary diagnostic modality for CAV in heart transplant recipients. In this review, we evaluate and summarize the clinical utility of IVUS in the early diagnosis of CAV, including its utility for assessing vessel remodeling, plaque composition, and prognostic value; morphometric analysis; and guiding therapy. After reviewing the relevant published literature, it is our recommendation that the use of IVUS be considered in all post-transplant CAV screening.

Arrhythmias and Heart Failure

Atrial fibrillation and ventricular tachyarrhythmias are frequently seen in patients with heart failure, and complicate the management of such patients. Both types of arrhythmia lead to increased morbidity and mortality, and often prove to be challenging issues to manage. The many randomized studies that have been performed in patients with these conditions and concomitant heart failure have helped in designing optimal treatment strategies.

Aggregatibacter aphrophilus pacemaker endocarditis: a case report

BackgroundAggregatibacter bacteria are a rare cause of endocarditis in adults. They are part of a group of organisms known as HACEK – Haemophilus, Aggregatibacter, Cardiobacter, Eikenella, and Kingella. Among these organisms, several Haemophilus species have been reclassified under the genus Aggregatibacter. Very few cases of Aggregatibacter endocarditis in patients with pacemaker devices have been reported.Case presentationWe present here what we believe to be the first case of Aggregatibacter aphrophilus pacemaker endocarditis. A 62-year-old African American male with a medical history significant for dual-chamber pacemaker placement in 1996 for complete heart block with subsequent lead manipulation in 2007, presented to his primary care doctor with fever, chills, night sweats, fatigue, and ten-pound weight loss over a four-month period. Physical examination revealed a new murmur and jugular venous distension which prompted initiation of antibiotics for suspicion of endocarditis. Both sets of initial blood cultures were positive for A. aphrophilus. Transesophageal echocardiogram revealed vegetations on the tricuspid valve and the right ventricular pacemaker lead (Figure 1). This case highlights the importance of identifying rare causes of endocarditis and recognizing that treatment may not differ from the standard treatment for typical presentations. The patient received intravenous ceftriaxone for his endocarditis for a total of six weeks. Upon device removal, temporary jugular venous pacing wires were placed. After two weeks of antibiotic treatment and no clinical deterioration, a new permanent pacemaker was placed and the patient was discharged home.ConclusionsThis is the first case of A. aphrophilus endocarditis in a patient with a permanent pacemaker. Our patient had no obvious risk factors other than poor dentition and a history of repeated pacemaker lead manipulation. This suggests that valvulopathies secondary to repeated lead manipulation can be clinically significant factors in morbidity and mortality in this patient population.

Device Management in Heart Failure

Purpose of ReviewMedical devices have become an integral part of comprehensive heart failure management. Not all heart failure patients, however, accrue benefit from every new device, and even with extensive practice guidelines, this remains an evolving field.Recent FindingsThe addition of implantable devices, like internal cardioverter defibrillators (ICDs), and novel pacing technologies, including cardiac resynchronization therapy (CRT), have helped to compliment goal-directed medical therapy and positively impact prognosis in multiple high-quality clinical trials. This review attempts to summarize the rapidly evolving literature with respect to existing device guidelines for routine implantable devices as well as some available and future technologies that are not yet a part of routine guidelines.SummaryICD, CRT, and other implantable devices continue to save lives, decrease hospitalizations, and evolve the management of patients with heart failure beyond the capabilities of optimal guideline-directed medical therapy alone.

INCREASED SHOCK IMPEDANCE IS ASSOCIATED WITH FAILED SUBCUTANEOUS IMPLANTABLE CARDIOVERTER DEFIBRILLATOR DEFIBRILLATION THRESHOLD TESTING

Background: The Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) is indicated for patients who have a standard indication for a transvenous implantable cardioverter defibrillator (T-ICD) without the need for cardiac pacing. While recent literature questions the utility of defibrillation

UTILITY OF INTRACARDIAC ECHOCARDIOGRAPHY IN SETTING OF CARDIAC DEVICE-RELATED ENDOCARDITIS AND LEAD EXTRACTION

Transesophageal echocardiography (TEE) is currently the gold standard for diagnosis of cardiac device- related endocarditis (CDE) with a sensitivity of 94-96%. Intracardiac echocardiography (ICE) is routinely used during lead extraction procedures for early identification of procedural complications