The Zwolle experience with left bundle branch area pacing using stylet-driven active fixation leads

AIMS

Left bundle branch area pacing (LBBAP) is a novel physiological pacing modality and is regarded as a viable alternative to His bundle pacing. LBBAP has mostly been performed with the lumen-less permanent pacing lead (SelectSecure™ Model 3830, Medtronic, Inc.) with a fixed helix. The aim of this study was to compare the non-stylet driven lumen-less lead (LLL) (Medtronic 3830) with a standard stylet-driven active fixation lead (SDL) (Tendril™ STS Model 2088TC-38, Abbott Laboratories) in terms of lead parameters, procedural success and complication rates.

METHODS

Patients receiving a LBBA pacemaker in the Isala Hospital, The Netherlands, were prospectively enrolled. The majority received a standard right ventricular (RV) lead as backup, the implanter chose between LLL and SDL for the LBBAP lead.

RESULTS

The study included 94 patients with a mean follow-up of 30 weeks. 30/31 LLL procedures were successful, compared with 62/63 in the SDL group. Including the participants that lost LBBAP during follow-up resulted in success rates of 90.3% for LLL versus 96.8% for SDL, P = 0.199. Mean number of deployments was significantly lower in the SDL group compared with the LLL group (2 ± 2.3 versus 4 ± 3.4, P = 0.005), implantation and procedural times were comparable. Pacing thresholds were low and remained low in both groups (at last follow-up 0.8 ± 0.30 V for LLL versus 0.6 ± 0.20 V for SDL). Complication rates did not differ significantly between both groups, P = 0.805.

CONCLUSION

LBBAP using SDL is feasible and has comparable success rates with lower number of deployments of the active fixation screw.

A de novo mosaic mutation in SPAST with two novel alternative alleles and chromosomal copy number variant in a boy with spastic paraplegia and autism spectrum disorder

Here we report a 12 year old male with an extreme presentation of spastic paraplegia along with autism and dysmorphisms. Whole exome sequencing identified a predicted pathogenic pair of missense variants in SPAST at the same chromosomal location, each with a different alternative allele, while a chromosome microarray identified a 1.73 Mb paternally inherited copy gain of 1q21.1q21.2 resulting in a blended phenotype of both Spastic paraplegia 4 and 1q21.1 microduplication syndrome. We believe that the extreme phenotype observed is likely caused by the presence of cells which contain only mutant SPAST, but that the viability of the patient is possible due mosaicism of mutant alleles observed in different proportions across tissues.

Association of apical rocking with super-response to cardiac resynchronisation therapy

Background

Super-responders to cardiac resynchronisation therapy (CRT) show an exceptional improvement in left ventricular ejection fraction (LVEF). Previous studies showed that apical rocking was independently associated with echocardiographic response to CRT. However, little is known about the association between apical rocking and super-response to CRT.

Objectives

To determine the independent association of LV apical rocking with super-response to CRT in a large cohort.

Methods

A cohort of 297 consecutive heart failure patients treated with primary indication for CRT-D were included in an observational registry. Apical rocking was defined as motion of the left ventricular (LV) apical myocardium perpendicular to the LV long axis. ‘Super-response’ was defined by the top quartile of LVEF response based on change from baseline to follow-up echocardiogram. Best-subset regression analysis identified predictors of LVEF super-response to CRT.

Results

Apical rocking was present in 45 % of patients. Super-responders had an absolute mean LVEF increase of 27 % (LVEF 22.0 % ± 5.7 at baseline and 49.0 % ± 7.5 at follow-up). Apical rocking was significantly more common in super-responders compared with non-super-responders (76 and 34 %, P < 0.001). In univariate analysis, female gender (OR 2.39, 95 % CI 1.38–4.11), lower LVEF at baseline (OR 0.91 95 % CI 0.87–0.95), non-ischaemic aetiology (OR 4.15, 95 % CI 2.33–7.39) and apical rocking (OR 6.19, 95 % CI 3.40–11.25) were associated with super-response. In multivariate analysis, apical rocking was still strongly associated with super-response (OR 5.82, 95 % CI 2.68–12.61). Super-responders showed an excellent clinical prognosis with a very low incidence of heart failure admission, cardiac mortality and appropriate ICD therapy.

Conclusion

Apical rocking is independently associated with super-response to CRT.

Electronic supplementary material

The online version of this article (doi:10.1007/s12471-015-0768-4) contains supplementary material, which is available to authorized users.

Sex-Based Differences in Cardiac Arrhythmias, ICD Utilisation and Cardiac Resynchronisation Therapy

Many important differences in the presentation and clinical course of cardiac arrhythmias are present between men and women that should be accounted for in clinical practice. In this paper, we review published data on gender differences in cardiac excitable properties, supraventricular tachycardias, ventricular tachycardias, sudden cardiac death, and the utilisation of implantable defibrillators and cardiac resynchronisation therapy. Women have a higher heart rate at rest, and a longer QT interval than men. They further have a narrower QRS complex and lower QRS voltages on the 12-lead ECG with more often non-specific repolarisation abnormalities at rest. Supraventricular tachycardias, such as AV nodal reentrant tachycardia, are twice as frequent in women compared with men. Atrial fibrillation, however, has a 1.5-fold higher prevalence in men. The triggers for idiopathic right ventricular outflow tract tachycardia (VT) initiation are gender specific, i.e. hormonal changes play an important role in the occurrence of these VTs in women. There are clear-cut gender differences in acquired and congenital LQTS. Brugada syndrome affects men more commonly and severely than women. Sudden cardiac death is less prevalent in women at all ages and occurs 10 years later in women than in men. This may be related to the later onset of clinically manifest coronary heart disease in women. Among patients who receive ICDs and CRT devices, women appear to be under-represented, while they may benefit even more from these novel therapies.

Penetrating spinal injuries and their management

Penetrating spinal trauma due to missile/gunshot injuries has been well reported in the literature and has remained the domain of military warfare more often. Civic society's recent upsurge in gunshot injuries has created a dilemma for the treating neurosurgeon in many ways as their management has always involved certain debatable and controversial issues. Both conservative and surgical management of penetrating spinal injuries (PSI) have been practiced widely. The chief neurosurgical concern in these types of firearm injuries is the degree of damage sustained during the bullet traversing through the neural tissue and the after-effects of the same in long term. We had an interesting case of a penetrating bullet injury to cervical spine at C2 vertebral level. He was operated and the bullets were removed from posterior midline approach. Usually, the management of such cases differs from region to region depending on the preference of the surgeon but still certain common principles are followed world over. Thus, we realized the need to review the literature regarding spinal injuries with special emphasis on PSI and to study the recent guidelines for their treatment in light of our case.

Single-stage distraction correction for neglected dorsal fracture dislocations of the proximal interphalangeal joint: a report of eight cases

We present the outcome of treatment of eight chronic neglected dorsal fracture dislocations of the proximal interphalangeal joint treated with a single-stage ligamentous distraction using the Penning mini-external fixator and a closed reduction. The distraction correction and 2 to 3 mm over distraction was performed acutely at the time of operation in all eight cases at an average injury-to-surgery time of 6 weeks. Satisfactory results with an average range of motion of 79 degrees were obtained at an average follow-up of 20 months. This technique is simple, effective and offers the advantage of being minimally invasive. We recommend this single-stage distraction correction technique for the treatment of chronic neglected dorsal dislocations of the proximal interphalangeal joint, which are no more than 10 weeks-old.

Preliminary report on spiegelberg pre and post-operative monitoring of severe head-injured patients who received decompressive craniectomy

The monitoring of craniospinal compliance is uncommonly used clinically despite it's value. The Spiegelberg compliance monitor calculates intracranial compliance (C = deltaV/deltaP) from a moving average of small ICP perturbations (deltaP) resulting from a sequence of up to 200 pulses of added volume (deltaV = 0.1 ml, total V = 0.2 ml) made into a double lumen intraventricular balloon catheter. The objective of this study was thus to determine the effectiveness of the decompressive craniectomy done on the worst brain site with regard to compliance (Cl), pressure volume index (PVI), jugular oximetry (SjVo2), autoregulation abnormalties, brain tissue oxygen (TiO2) and cerebral blood flow (CBF). This is a prospective cohort study of 17 patients who were enrolled after consent and approval of the ethics committee between the beginning of the year 2001 and end of the year 2002. For pre and post assessment on compliance and PVI, all 12 patients who survived were reported to become normal after decompressive craniectomy. There is no significant association between pre and post craniectomy assessment in jugular oxymetry (p > 0.05), autoregulation (p > 0.05), intracranial brain oxymetry (p = 0.125) and cerebral blood flow (p = 0.375). Compliance and PVI improved dramatically in all alive patients who received decompressive craniectomy. Compliance and PVI monitoring may be crucial in improving the outcome of severe head injured patients after decompressive craniectomy.

[Establishment and analysis of a log to record scorpion stings in Morocco]

Within the framework of a strategy against scorpion stings, an information system was established to track the indicators of morbidity and mortality caused by scorpion stings. The study of these indicators was carried out based upon a national record of scorpion stings. During the year 2001, 15,571 cases of scorpion stings were reported, that translates into an incidence rate of 1.2%. The patients were poisoned in 11.6% of the cases. Most of the patients (79.3%) were only put under clinical surveillance and did not receive any symptomatic treatment. The death rate was 6.3% and death only occurred in children of less than 15 years old (2.1% of the cases). This study demonstrated an improvement in morbidity and mortality indicators in comparison to the data collected before this campaign, all of which verifies the positive impact of the strategy which was put into place. However, it is necessary to continue monitoring until Morocco can overcome this problem.

Persistence of two genotypes of Neisseria gonorrhoeae during transmission

Isolates of Neisseria gonorrhoeae were tested using a highly discriminatory typing method, opa typing, to examine the genetic diversity over a 2-year study period of isolates from all consecutive patients with gonorrhea attending the Genitourinary Medicine clinic in Sheffield, United Kingdom. Two opa genotypes were detected throughout the 2-year time period and comprised 41% of all strains tested. The persistence of two opa types was investigated further to determine the apparent genetic stability, by examining the ability of isolates to undergo intragenic and intergenic recombination and mutation in vitro. Intragenic recombination or mutation involving the opa genes of N. gonorrhoeae in the selected isolates was not detected, but intergenic recombination did occur. opa genes of N. gonorrhoeae in vivo appear to diversify primarily through intergenic recombination. Intergenic recombination in vivo would require the presence of a mixed gonococcal infection, in which an individual is concurrently colonized with more than one strain of N. gonorrhoeae. We propose that the level of diversity of opa genotypes in a population is linked to the degree of sexual mixing of individuals and the incidence of mixed infections of N. gonorrhoeae.

Laparoscopic fenestration and modified marsupialization of posttraumatic splenic cysts using a harmonic scalpel

In recent years, the advanced laparoscopic experience has revolutionized surgery and fostered the expansion of the indications for minimally invasive surgery in the diagnosis and treatment of all intra-abdominal pathology. Total splenectomy, which traditionally was the procedure of choice in the treatment of symptomatic nonparasitic splenic cysts, recently has been changed to a more conservative approach by many authors [1, 5, 9]. The conservative methods preserve immunologic function of the spleen and prevent the potentially fatal postsplenectomy sepsis complications [9]. We successfully performed laparoscopic fenestration and modified marsupialization of these cysts using a harmonic scalpel on two patients with symptomatic splenic psuedocysts.

Retrospective study of prion-protein accumulation in tonsil and appendix tissues

To identify individuals who could be at high risk of developing vCJD, a sensitive immunohistochemical technique was used to detect prion protein in a retrospective series of over 3000 tonsil and appendix specimens. No positives were detected but further studies are required to help reduce uncertainties about possible future numbers of vCJD cases in the UK.

Sexual histories, partnerships and networks associated with the transmission of gonorrhoea

We aimed to describe and compare sexual links among people with gonorrhoea, by studying patients in 2 UK departments of genitourinary medicine. Interviews were completed for 510 and 235 cases in London and Sheffield respectively. There was a greater proportion of cases in men, homosexual men, non-white and non-British people and fewer female sex workers in London. Total networks of 1738 people in London and 570 people in Sheffield were described. Large linked heterosexual networks identified in Sheffield were associated with local contact, including men with higher numbers of sexual partners. Condom use for vaginal sex was reported for 11% of heterosexual partnerships in Sheffield, and 27% in London, with little difference between regular and casual partners. It was more difficult to define networks in London due to a high proportion of relatively anonymous contacts. These difficulties suggest that research and interventions may profitably focus upon venues for meeting partners as well as partner notification.

Small-bowel perforation secondary to metastatic carcinoma of the breast

Perforation from a solitary metastatic lesion of the small bowel is rare. We report a case of acute perforation with no evidence of metastatic disease within the abdomen. Resection of the small bowel was performed.

Parathyroid cysts. Report of four cases and review of the literature

Though a rare lesion, a parathyroid cyst is of clinical significance because it mimics a thyroid cyst and can be associated with hyperparathyroidism. The cyst can be ectopic in location and therefore constitutes a differential diagnosis to a bronchial or thymic cyst. Four cases of parathyroid cyst are presented. Fine needle aspiration with parathyroid hormone assay is diagnostic. Surgical removal of the cyst is recommended.

Portal pyelophlebitis identified by CT scan in a patient with ischemic bowel

A 65-year-old male was found to have hepatic portal venous gas (HPVG) by computed tomogram secondary to ischemic bowel. Despite aggressive surgical and antibiotic treatment, the patient died within 12 hours. Portal pyelophlebitis, when identified by air in the portal venous system, is a grave indicator of ischemic bowel with a very high mortality rate, except in patients with inflammatory bowel disease.

Morgagni hernia: incidental repair during laparoscopic cholecystectomy

Anterior diaphragmatic hernias are a relatively rare finding. They can occur on either side of the body. We diagnosed and treated a Morgagni hernia during laparoscopic cholecystectomy.

Pattern of malignant bone tumour in northern areas of Pakistan

A review of 280 primary malignant bone tumours diagnosed during 1984-1988 is presented. These constituted 3.14% of all malignant tumours. Male to female ratio was 2.3:1. Majority of these patients presented with rapidly growing mass, pain and deformity. Histologically, osteosarcoma was the most frequent (36.4%) primary malignant tumour. Male to female ratio was 3.31:1. More than 49% of these cases were in their second decade of life. In females the greatest frequency was in 10-15 years and in males 16-20 years age groups. Femur was the most frequent site. Other common malignant bone tumours included chondrosarcoma (22.1%), plasma cell myeloma (15.0%) and Ewings's sarcoma (8.6%). Miscellaneous cases of fibrosarcoma, chrodoma, adamentinoma and ameloblastoma were also seen. This study outlines the frequency, symptomatology and histological pattern of various malignant bone tumours in northern areas of Pakistan.

Rectus sheath hematomas in hematological disorders

Rectus Sheath Hematomas are an uncommon cause of abdominal pain. There are many etiologies for this entity. The physician must be aware of this entity and include it in his differential when a patient presents with acute abdominal pain.

Micro-determination of fluoride by means of metallic sodium fusion and using fluoride-sensitive electrode

A simple and accurate method to determine the content of fluoride in non-volatile organofluoro compounds or in biological samples has been developed. The method includes the metallic sodium fusion followed by quantitative estimation of fluoride using fluoride-sensitive electrode.

Use of a totally implantable drug delivery system in a university-affiliated community hospital

We reviewed our experience at the Western Reserve Care System with totally implantable drug delivery systems (IDDS) in cancer patients with vascular access problems. Fifty-one ports were placed in 50 patients. Forty-nine of the IDDS were placed under local anesthesia. One patient developed a hemothorax during placement. Two catheters were removed because of infection. Two catheters found to be occluded responded to flushing with streptokinase. All catheters remained functional up to the time of treatment completion or of the patient's death. The low morbidity and high success rates of IDDS should encourage placement early in the course of chemotherapy.

Non-palpable breast lesions: out-patient needle localization and biopsy

One hundred and nine patients undergoing out-patient needle localization and biopsy of non-palpable breast lesions were studied. Six patients with carcinoma were detected, 5 of them qualifying as minimal carcinoma. Thirty five patients with proliferative fibrocystic breast disease in need of careful follow-up were identified. While the number of patients with carcinoma was low, the early stage of their disease justifies continued use of the procedure. Doing the procedure on an out-patient basis has been shown by others to provide a substantial reduction in cost. Our results suggest that the out-patient setting does not affect the morbidity or mortality of the procedure.

The immunohistochemical localization of pregnancy-specific beta 1-glycoprotein in postimplantation rat trophoblast

Pregnancy-specific beta 1-glycoprotein (SP1) was identified by peroxidase-antiperoxidase (PAP) immunohistochemistry in the placenta of inbred strains of rat between 10 and 21 days of gestation. SP1 was located predominantly in basal zone trophoblast and in intravascular trophoblast of decidual vessels, but it was absent from labyrinthine trophoblast. No perivascular cells were identified by SP1 staining, but occasional clusters of interstitial trophoblast stained for SP1. The results suggest that basal and labyrinthine trophoblast are functionally different.

Pregnancy-induced monoclonal antibody to a unique fetal antigen

An IgM monoclonal antibody was produced by fusing maternal splenic lymphocytes obtained on the day of delivery of the first litter in a WF X DA mating with P3-653 myeloma cells, and at the time when the lymphocytes were isolated there was no circulating antibody in the pregnant animal. The monoclonal antibody had the same specificity as the antibodies in the postpartum pregnancy serum: it reacted with a unique class I MHC antigen, designated the pregnancy-associated (Pa) antigen, which is not one of the currently known, haplo-type-specific class I antigens. The use of recombinant strains mapped the locus encoding the Pa antigen to the region of RT1.A and to the left of RT1.B.

Tuberculous brain abscess. Case report

The authors describe a case of tuberculous cerebral abscess of the frontal lobe that developed 1 year after an episode of acute miliary tuberculosis. The development of such a lesion indicates a persistence of infection and an immunological breakdown which may partly have been due to protein malnutrition.

Colitis cystica profunda

A localized type of colitis cystica profunda is described. Its clinical presentation, pathology, and treatment together with a short review of the literature are considered.