Pulmonary artery injury in left atrial appendage closure device implantation: a systematic review of a potentially fatal complication

Background

Pulmonary artery (PA) injury is a rarely reported complication following percutaneous left atrial appendage closure (LAAC). This study aims to systematically review all reported cases of PA injury associated with LAAC.

Methods

PubMed/Medline, SCOPUS, EMBASE, Google Scholar and the MAUDE databases were searched to find studies reporting PA injury during or after LAAC with the Amplatzer Amulet (AA), Amplatzer Cardiac Plug (ACP) or Watchman device through October 2019. Categorical data were reported in terms of numbers and/or percentages (%).

Results

We found 13 cases (mean age 71.4 yrs) with reported PA injury associated with LAAC. Of these, 9 were case reports, 3 were reported in observational studies, and 1 was in the MAUDE database. Most cases (n=8) were reported in Europe followed by Australia (n=2) and Asia (n=2). The indication for device implantation in all patients was a high bleeding risk with anticoagulation for atrial fibrillation. Five cases were reported with the ACP (1/5 patients died), 5 with AA (2/5 patients died), and 3 with the Watchman (1/2 patients died). Acute and late presentations following implantation were reported for all three devices. 69.2% of cases (9/13) occurred acutely (during or within 24 hours of intervention). Of these, 3/9 occurred during device implantation. 2/4 of the delayed cases occurred >2 weeks following implantation. The mortality rate for acute and delayed cases was 22% (2/9 patients) and 50% (2/4 patients), respectively. A majority of the cases were attributable to barb/strut/hook injury of the PA. PA injury was associated with a mortality rate of approximately 31%. All surviving patients were managed with surgical intervention.

Conclusion

PA injury is an infrequently reported complication following LAAC and is associated with high mortality. Cases can present acutely (intra-procedurally or within 24 hours) or delayed (>24 hours post-implantation). A majority of cases are due to direct injury of the PA by the struts/hooks/barbs of the device. Practitioners should be cognizant of this life-threatening complication, which requires a high index of suspicion for diagnosis and can occur weeks after device implantation.

Funding Acknowledgement

Type of funding source: None

P549CIED infection risk score validation using US health claims data

Funding Acknowledgements

This work was supported by Medtronic

Background/Introduction: The increasing number of cardiac implantable electronic device (CIED) infections has led to increased interest in the identification of patients who may benefit from additional infection prevention measures.

Purpose

The purpose of this evaluation was to validate the predictive value of the Prevention of Arrhythmia Device Infection Trial (PADIT) risk score to identify patients at increased risk of CIED infection using a U.S. health claims data set.

Methods

A retrospective analysis using the Optum® Clinformatics® claims database was conducted to create a dataset of index procedures which either did or did not result in an infection.  The study population included both commercial and Medicare Advantage patients aged ≥18 years with at least one record of a CIED procedure between January 2011 and September 2014.  Major CIED infections, defined as an infection associated with system removal, invasive procedure without system removal, or death attributable to infection, were identified through diagnosis and procedure codes.  The dataset was randomized (stratified by PADIT score, which included prior procedures, age, depressed renal function, immunocompromised, and procedure type) into a Development Dataset (60%) and a Validation dataset (40%).  A frailty model allowing multiple procedures per patient was fit using the Development Dataset, with PADIT score as the only predictor, excluding patients with prior infection. Prior CIED infection, which was not available in the original PADIT data, was examined for additional predictive value.

Results

The data extraction resulted in a dataset of 53,554 index procedures among 51,583 patients, with 30,950 patients randomized to the Development Dataset.  The distribution of procedures was pacemakers (52%), ICD (20%), CRT (12%), and Revision/Upgrade (16%), while prior procedures were none (62%), 1 (37%), and 2 (1%). Among patients with no history of prior CIED infection, the frailty model showed that a 1 unit increase in the PADIT score predicts higher infection risk (20%) in the U.S. claims data set (Table 1). Prior CIED infection was associated with strong additional predictive value (HR 4.77, p < 0.0001) after adjusting for PADIT score.

Conclusion

In the largest external validation of a CIED risk score, the PADIT risk score predicts increased CIED infection risk, identifying higher risk patients that can benefit from targeted interventions to reduce the risk of CIED infection. Prior CIED infection brings additional predictive value to the PADIT score.

Early psychosis treatment in an integrated model within an adult mental health service

OBJECTIVE

To compare the treatment of patients with early psychosis, 2 years after the introduction of an integrated model of enhanced management within a public adult mental health service, with an historic cohort from the same service.

METHOD

Variables examined in the 2001 cohort were compared with 2008 patients. Computer database review and a file audit were conducted for all patients with early psychosis across the first 2 years of the program.

RESULTS

Compared to the historic cohort, patients in the current cohort were 24% less likely to have been admitted (P=0.004). There were statistically significant reductions in involuntary status and use of a locked unit. Rates of police involvement in admission and use of seclusion were also reduced, though this trend was not significant. Average length of stay was reduced. Median duration of untreated psychosis was 3 months in both 2001 and 2008 cohorts.

CONCLUSIONS

The introduction of an integrated model of management within an area mental health service for patients with early psychosis contributed to significant reductions in admissions, involuntary status and use of a locked ward. The data suggests that enhanced treatment of early psychosis patients can be offered within generic services.

A reading list for Bill Gates--and you. A conversation with literary critic Harold Bloom. Interview by Diane L. Coutu

In today's technology-driven world, who has time to pick up a 400-page novel? Most executives don't--they have urgent e-mails to answer, training seminars to attend, meetings to lead, and trade publications to scan. But according to Harold Bloom, one of America's most influential scholars, they should make time in their hectic schedules to read great works. In a wide-ranging conversation with HBR senior editor Diane Coutu, Bloom discusses the importance of literature: every individual--regardless of profession--needs to stretch his or her mind and reflect now and again on the human condition. "By reading great imaginative literature, you can prepare yourself for surprise and even get a kind of strength that welcomes and exploits the unexpected," he says. Because there are so many great works and there is so little time, Bloom presents a reading list for busy executives. Shakespeare's King Lear can teach businesspeople about change. Ralph Waldo Emerson's essays capture the ethos of the American spirit--individualism and inventiveness. Bloom says Sigmund Freud's conceptions "form the only Western mythology that contemporary intellectuals have in common." And people will never fully understand some aspects of themselves until they read Miguel de Cervantes's Don Quixote. In short, Bloom believes the humanities have much to offer businesspeople: great books broaden their awareness and their range of sensibility, he says. But reading literature will not make businesspeople more moral, he cautions. Bloom also discusses other topics such as how to read well, the state of popular fiction, the role of irony, and the subject of change.

Compartment syndrome of the forearm as the initial symptom of systemic Vibrio vulnificus infection

Sepsis, cellulitis, and necrotizing fasciitis rarely have been described as causes of compartment syndrome. We report a case in which forearm compartment syndrome presented as the initial symptom of systemic infection. Vibrio vulnificus, the etiologic pathogen of the compartment syndrome, was isolated from wound and blood cultures. The patient was treated with systemic antibiotic treatment and multiple forearm fasciotomies. The infectious process progressed rapidly, however and due to underlying liver insufficiency, the patient died of hepatorenal syndrome. This case illustrates the nature of V. vulnificus infections, which are characterized by shellfish transmission, predilection for soft tissue seeding, and a fulminant course in the compromised host.

Closed reduction of coronal fractures of the capitellum

Closed reductions of displaced coronal fractures of the capitellum were successfully obtained for nine patients. The method involves spontaneous reduction by allowing the elbow to fully extend under anesthesia and then gradually flexing the elbow while distracting the elbow joint. Distraction allows the radial head to capture the capitellar fragment in the joint rather than push it proximally. The elbow is immobilized at 90 degrees for 3 weeks. Gentle active motion is then started. Closed reduction is often or usually obtained, but open reduction and internal fixation are performed in those cases in which a closed reduction cannot be obtained.

Effective monitoring of pollution by toxic trace elements in waters, sediment and biota of the Derwent River Estuary, Tasmania, through long-term retention of analytical facilities

This study considers the effectiveness of the monitoring of toxic trace elements in various media from a polluted river estuary over a period of 15 years, using the same analytical techniques, facilities and, in some cases, the same operators. It shows that reliable comparisons can be made for monitoring waters, sediment and biota from the Derwent River Estuary between 1975 data and that from 1990. Rigorous studies were undertaken before and during 1975 to ensure that reliable data was achieved at that time. Such studies are reviewed and included the evaluation of digestion techniques for a range of heavy metals, specific attention to the reliability of mercury determination in sediments between laboratories, a comparison of direct calibration and standard addition techniques for metals in seawater, recoveries of an organomercury compound from fish, and sources of error arising from sample preparation of biota for subsequent metal analysis. Comparative results for standard reference materials in both 1975 and 1990 show good agreement and are considered reliable except for lead at low concentrations. The long-term retention of the analytical facilities permits a direct comparison of data from 2 monitoring programmes over the space of 15 years.

Patient satisfaction within an emergency department: the impact of a hospital volunteer program

During the past decade, the proliferation of managed care plans and the reduction of governmental reimbursement has seriously eroded hospital revenues. As a result, hospitals are managing with less resources yet confronting more complex patient problems, particularly in the Emergency Department of the hospital. Since the Emergency Department is frequently the major interface between the hospital and the community, it is essential that patients have a positive experience while obtaining care. This study explores the impact of a hospital-based volunteer program upon patient satisfaction within an Emergency Department and the implications for hospital administrators.

[Transference, taboo and truth]

The author re-examines the development of the concept of transference in Freud's work. He gives special attention to Totem and Taboo published in 1912-13. He notes that Freud's totally unsupported hypotheses within this model become illuminating and intelligible if "totem" is translated as "psychoanalyst" and "taboo" as "transference (neurosis)".

The use of contracts in the inpatient treatment of the borderline personality disorder

This paper reviews and describes the clinical, administrative, and psychodynamic aspects of the use of contracts. The particular focus is on how the characteristic difficulties which borderline personality disorder patients encounter on inpatient services are helped by contracting. The use of contracts facilitates the therapeutic alliance, and aids in the avoidance of excessive regression and acting out. The improved stabilization of the patient permits a more constructive use of transference and countertransference, and facilitates a clearer examination of Axis I diagnosis and the use of medication. The contracting process can be a useful addition to the inpatient treatment of borderline personality disorder patients.

Fractures of the capitellum

Forty intact cadaver elbows were studied to determine the contribution of the capitellum to elbow stability. With the elbow at 10 degrees of flexion, valgus motion of the elbow after capitellum excision demonstrated a minimal increase. Although some increase in valgus motion did occur after capitellum excision and radial head resection it was not until the ulnar collateral ligament was released that a severe valgus deformity was produced. In addition, isolated capitellum excisions occurring with release of the medial collateral ligament produced severe valgus motion, demonstrating the importance of medial structures to elbow stability. The cadaver study suggests excision of the capitellum in the otherwise intact elbow has little effect on valgus motion. Over the past 15 years, 17 patients with fractures of the capitellum were treated. Followup at greater than 1 year utilizing various treatment modalities is reported. Although closed reduction gave the best result, acceptable results were also obtained by open reduction and internal fixation and excision. Our clinical findings corroborated the cadaver findings in that valgus instability of the elbow only occurred when fracture of the capitellum was associated with medial ligament injuries.

Thermodynamic properties of the binary molten salt systems, PbBr2-KBr, PbBr2-RbBr and PbBr2-CsBr, by measurement of the electromotive forces of galvanic cells

The electromotive forces of galvanic cells for the formation of PbBr2 in the molten binary salt systems, PbBr2-KBr, PbBr2,-RbBr and PbBr2-CsBr, have been measured. Activities, activity coefficients and partial molar free energies have been calculated for each component of the three systems. Integral free energies of mixing have also been calculated. Various models of mixing of molten salts have been applied to the results. The systems contain complex ions, probably mixtures of PbBr42-, PbBr64- with some PbBr3-.

Organochlorine pesticide residues in animals of Tasmania, Australia-1975-77

Animals taken in Tasmania including duck (Anas superciliosa), eel (Anguilla australis), English perch (Perca fluviatilis), white-faced heron (Ardea pacifica), brown trout (Salmo trutta), European starling (Strunus vulgaris), cat (Felis cattus), cormorant (Phalacrocorax sp.), mutton bird (Puffinus tenuirostris), Tasmanian devil (Sarcophilus harrisii), rainbow trout (Salmo gairdnerii), Tasmanian raven (Corvus mellori), tench (Tinca tinca), and quail (Coturnix sp.) were sampled for p,p'-DDE, pp,p'-TDE, p,p'-DDT, lindane, dieldrin, and hexachlorobenzene. Pesticide residue levels exceeded 0.1 ppm in at least one animal from each area and in the majority of animals sampled from all areas. Pesticide sources could not be determined, partly because migratory species such as ducks, mutton birds, cormorants, and eels may have ingested pesticides outside of Tasmania.

A survey of blood lead levels in dogs and cats

The blood of 206 dogs and 26 cats was analyzed for lead by non-flame atomic absorption giving mean levels of 6.4 mug/100 ml for dogs and 5.2 mug/100 ml for cats. Statistical treatment of the results using a paired Students' t-test showed significant differences by age for dogs but not for cats. Urban dogs had significantly higher blood lead levels than country dogs (P less than 0.05) thus indicating that dogs can be regarded as useful environmental monitors for lead pollution.

Activity models in the Na+,Zn2+/Cl-,SO42- reciprocal fused salt system

The conformal ionic solution model has been applied to the charge asymmetrical, reciprocal fused salt system: Na+,Znz+/C1-,S042-. This model takes into account binary and ternary type interactions as well as the exchange equilibrium: ZnCl2 + Na2SO4 ↔ ZnSO4 + 2NaCl Calculated ZnCl2 activities are found to be in reasonable agreement with experimental values.

Activities of PbCl2 in the K+, Pb2+/Cl-,SO42- reciprocal molten salt system

Activities of PbCl2 in the molten system K2SO4+PbCl2 have been measured at 1012 K by a transpiration vapour pressure method. Values of PbCl2 activities are calculated from the conformal ionic solution model (CIS), the result being in reasonable agreement with experimentally measured values. Results obtained may therefore be summarized by the CIS equation APbCl2 = xpb(xcl)2exp[0.2405/T)(X?k)2{-3285-X?pb(11564+2032(3X?k-1))}] where Xi, X?t are ion fractions and equivalent ion fractions respectively.

Vapour pressures and activities in the reciprocal fused salt systems ZnCl2 + Na2SO4 and ZnSO4 + NaCl

Zinc chloride vapour pressures, activities and partial molar energies have been determined in the reciprocal fused salt system: Zn,Na/Cl,SO4 over the range 770-900 K. The transpiration vapour pressure of pure ZnCl2 was first redetermined for the range 720-900 K and found to follow the equation (in which P� is in mmHg): �������������� Log P�ZnCl2 = (-8247�17)/T-5.033 log T + 26.213 � 0.006 Activities of ZnC1, in the reciprocal system differed greatly from ideality, the degree of departure varying with both composition and temperature. In general, at relatively high ZnCl, concentrations, observed activities were greater than ideal and ZnCl2 partial molar enthalpies were positive; this behaviour is believed to be largely caused by the effect of partial covalent bonding in pure ZnCl2. At low ZnCl2 concentrations, activities were much less than ideal and ZnCl2 partial molar enthalpies were negative; this other effect is believed to be caused by the formation of complex ions within this system.

Densities and molar volumes for the molten salt systems ZnBr2 + KBr, CdI2 + NaI and CdI2 + CsI

Densities of binary mixtures of ZnBr2 + KBr, CdI2 + NaI and CdI2 + CsI, have been measured by an Archimedian method over a wide range of temperature. Results have been expressed in terms of simple linear equations in temperature. Molar volumes for the systems have excess values in the ZnBr2 + KBr and CdI2 + CsI systems but not to such an extent in the CdI2+NaI system. The excess molar volumes are related to the possible formation of complex ions in the systems concerned.

Mass spectrometric identification of cadmium(II) chlorobromide

Mass spectrometric studies above solid CdCl2 + CdBr2 mixtures in the temperature range 720-770 K have revealed the existence of "mixed halide" gaseous species of formula CdClBr. The heat of formation of CdClBr(g) from CdCl2(g) and CdBr2(g) has been found to be 0.4 � 1 kcal/mol. It is reasoned that the driving force for "mixed halide" formation is associated with a decrease in molecular symmetry.

Vapour phase composition and activities for the molten PbCl2 + NaCl system

Vapour pressures of molten PbCl2 + NaCl mixtures have been measured a.t 1071 K by a transpiration method. The vapours have also been investigated by mass spectrometry and the complex NaPbCl3 has been established. The enthalpy of formation of this complex from NaCl(g) and PbCl2(g) has been determined and the equilibrium constant for its formation has been estimated. Enthalpies of vaporization of NaCl and PbC12 and the enthalpy of dimerization of NaCl(g) agree with published results. The mass spectrometry results have enabled corrections to be made to measured activities of PbCl2 from the transpiration results, for errors due to the NaPbCl3 complexes. The activity values so determined are compared with those for other molten binary systems involving lead and alkali chlorides. The PbCl2 + NaCl system (like the other PbCl2 + alkali chloride systems except PbCl2 + LiCl) does not behave as regular solutions.

Mass spectrometry of the vapours over PbBr2+MBr mixtures (M = Na, K, Rb, Cs)

A mass spectrometric study of vapours above molten PbBr2+MBr mixtures has revealed the existence of vapour species of general formula MPbBr3 (M = Na, K, Rb, Cs). Second-law enthalpies of formation of these complexes were found to be in the range -39 to -44 kcal/mol; entropies of formation are estimated between -20 to -21 e.u. It is believed that these complex molecules have a bipyramidal structure.

Transpiration vapour pressures and activities in the molten salt systems ZnCl2 + NaCl and ZnCl2 + KCl

Vapour pressure measurements were made by a transpiration method for molten zinc chloride and molten mixtures of this salt with sodium and potassium chlorides, respectively. Activities of zinc chloride in the mixtures were calculated and from these values, those of the alkali chloride were calculated by Gibbs-Duhem integration. For this purpose a convenient computer method has been devised. Although the large deviations of activity and activity coefficients qualitatively support independent evidence that complex ions are formed in these systems, the results cannot quantitatively be explained using a calculation due to Braunstein in terms of interactions in the melt to form complex ions of a unique type, e.g. ZnCl3- or ZnCl42- etc. This indicates that the departure from ideal behaviour needs to be explained by a more detailed theory.

The electrical conductance of the molten salt systems PbCl2 + NaCl, PbCl2 + RbCl, and PbCl2 + CsCl

The specific conductances of molten mixtures of PbC12+MCl (M = Na, Rb, Cs) have been measured as functions of composition and temperatures from 800�C (or in some cases 850�C) to within a few degrees of the liquidus. The system PbCl2+CsCl exhibits a pronounced maximum of activation energy for conductance at 0.67 mole fraction CsCl. Equivalent conductances of the systems have been calculated and have been plotted against atomic ratio of Pb/Cl. An attempt has been made to explain the conductance results on the basis of the transport theory of Adam and Gibbs. The results are best explained by the presence in the PbCl2+RbCl and PbCl2+CsCl systems of complex ions of formula PbCl42-.

Viscosity and conductance micellar studies in molten pyridinium chloride

Viscosity and conductance measurements in cetyldimethylbenzylammonium chloride solutions in molten pyridinium chloride are in agreement with other studies that indicate that micellization commences at 0.06-0.07m at 155�. Effective molal volumes, bulk viscosities, and equivalent conductivities for this system and a comparison system (anilinium chloride as solute), have been calculated. The data suggest that around 0.12m the micelles are stabilized in a size distribution comprised mainly of asymmetric micelles. Molten pyridinium chloride behaves ultrasonically as an associated liquid. The densities and viscosities of 0.5M KCl sucrose solutions (25-40% sucrose) are also supplied as calibration data for electroviscometers in the range 2-5 cP.

Vapour phase composition and activities for the molten PbBr2+KBr system

Vapour pressures above molten PbBr2+KBr mixtures have been measured over a range of temperatures by a transpiration method. The vapours have been investigated also by mass spectrometry and the presence of the complex KPbBr3 has been established. The enthalpy and entropy of formation of this compound from PbBr2(g) and KBr(g) are similar to values obtained for the analogous chloride species. By combining the results of both methods, the true activities of lead bromide in the melt have been calculated as a function of composition, and the results have been interpreted to show that PbBr3 is the major complex ion present in the molten mixtures.