Background Pulmonary vein isolation (PVI) for atrial fibrillation (AF) is associated with a transient increased risk of thromboembolic and hemorrhagic events. We hypothesized that dabigatran can be safely used as an alternative to continuous warfarin for the peri-procedural anticoagulation in PVI. Methods and Results 999 consecutive patients undergoing PVI were included; 376 patients were on dabigatran (150 mg) and 623 were on warfarin with therapeutic INR. Dabigatran was held 1 to 2 doses prior to PVI and restarted at the conclusion of the procedure or as soon as patients were transferred to the nursing floor. Propensity score matching was applied to generate a cohort of 344 patients in each group with balanced baseline data. Total hemorrhagic and thromboembolic complications were similar in both groups, before (3.2% vs 3.9%; p = 0.59), and after (3.2% vs 4.1%; p = 0.53) matching. Major hemorrhage occurred in 1.1% vs 1.6% (p = 0.48) before, and 1.2% vs 1.5% (p = 0.74) after matching in the dabigatran vs warfarin group respectively. A single thromboembolic event occurred in each of the dabigatran and warfarin groups. Despite higher doses of intra-procedural heparin, the mean ACT was significantly lower in patients who held dabigatran for 1 or 2 doses than those on warfarin. Conclusions Our study found no evidence to suggest a higher risk of thromboembolic or hemorrhagic complications with use of dabigatran for peri-procedural anticoagulation in patients undergoing PVI compared to uninterrupted warfarin therapy.
Background Vascular complications are a known risk of catheter-based pulmonary vein antral isolation (PVAI). Procedure-related thromboembolic events necessitate full-dose anticoagulation, which worsens outcomes in the event of vascular access injury. Objective Real-time ultrasound allows direct visualization of vascular structures. We hypothesized that ultrasound use with venipuncture reduces vascular complications associated with PVAI. Methods Retrospective analysis of all adverse events occurring with PVAI was performed during two periods: 2005– 2006 when ultrasound was not used and 2008–2010 when ultrasound was routinely employed. All patients received full-dose IV heparin during PVAI. In the no ultrasound cohort, only 14 % underwent PVAI without stopping warfarin, while 91 % of patients in the ultrasound cohort were on continued warfarin. Only patients deemed at high risk for thromboembolism with a periprocedural international normalized ratio (INR) less than 2 were bridged with subcutaneous low-molecular-weight heparin. Results Ultrasound reduced total vascular complications (1.7 vs. 0.5 %, p<0.01) and decreased the incidence of major vascular complications by sevenfold. Warfarin with INR≥1.2 on the day of PVAI was associated with more vascular complications (4.3 vs. 1.2 %, p<0.01). Ultrasound guidance overcame the risk associated with warfarin therapy. Vascular complications in anticoagulated patients with INR≥1.2 using ultrasound guidance were two- and ninefold lower than those in patients not using ultrasound with an INR<1.2 (0.5 vs. 1.2 %, p<0.05) and INR≥1.2 (0.5 vs. 4.3 %, p<0.01), respectively. Conclusion Ultrasound-guided venipuncture improves the safety profile of PVAI, reducing vascular complications in patients on warfarin to levels below those with no ultra-sound and off warfarin.
Amiodarone is increasingly prescribed for patients with ventricular and supraventricular tachyarrhythmias. Many adverse effects have been reported due to this drug and include injury to the liver, thyroid, cornea, skin, and neuromuscular system. Pulmonary toxicity is one of the more serious side effects of this anti-arrhythmic drug and is potentially fatal. Since the first case of amiodarone-induced pneumonitis was described in the early 1980s, amiodarone pneumonitis has been recognized as a distinctive and not uncommon form of drug-induced lung injury. On the other hand, amiodarone-induced pulmonary toxicity resulting in alveolar hemorrhage is rare. The authors report a patient with amiodarone-induced alveolar hemorrhage and review the literature.
With increasing rates of device implantation, there is an increased recognition of device infection. We conducted a retrospective observational study in a tertiary care center in Lebanon, with data collected from medical records of patients presenting with cardiac implantable electronic device (CIED) infection from 2000 to 2017 with the purpose of identifying etiologies, risk factors and other parameters, and comparing them to available data from the rest of the world. We identified a total of 22 CIED infections. The most common microbial etiologies, including involvement in polymicrobial infection, were coagulase-negative staphylococci (45.5%) and Staphylococcus aureus (22.7%). Rare cases of Brucella melitensis , Sphingomonas paucimobilis , and Kytococcus schroeteri device infection were seen. Heart failure was seen in 77.3% of patients, hypertension in 68.2%, and chronic kidney disease in 50%. Skin changes were the most common presenting symptoms (86.4%). Antibiotics were given to all patients and all had their devices removed, with 36.4% undergoing new device implantation. This is the first study of CIED infections in Lebanon and the Middle East. Local epidemiology and occupational exposure must be considered while contemplating the microbial etiology of infection. Close monitoring after device implantation is important in preventing device infection that carries high risk of morbidity and mortality.
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