T ranscatheter aortic valve implantation (TAVI) has become the treatment of choice for patients with aortic stenosis who are considered to be nonoperable and a good alternative for those at high surgical risk.1 However, the occurrence of some periprocedural complications remains a concern. The need for permanent pacemaker implantation (PPI) after the procedure is one of the most frequent complications associated with TAVI, with an overall incidence of ≈15% (≈25% and 7% after TAVI with self-expandable valves [SEVs] and balloon-expandable valves [BEVs], respectively). 1 Clinical Perspective on p 1243Strong evidence supports the potential negative impact of right ventricular apical pacing, which has been associated with an increased rate of the combined end point of mortality and rehospitalization for heart failure in patients with left ventricular dysfunction, 2-4 ventricular tachyarrhythmias, 5,6 and pacing-induced cardiomyopathy in patients without overt structural heart disease. 7 However, evidence for the clinical impact of PPI after TAVI remains scarce and based on small Background-Very few data exist on the clinical impact of permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation. The objective of this study was to assess the impact of PPI after transcatheter aortic valve implantation on late outcomes in a large cohort of patients. =0.121). Conclusions-The need for PPI was a frequent complication of transcatheter aortic valve implantation, but it was not associated with any increase in overall or cardiovascular death or rehospitalization for heart failure after a mean follow-up of ≈2 years. Indeed, 30-day PPI was a protective factor for the occurrence of unexpected (sudden or unknown) death.

Background-We aimed to determine the incidence, predictors, clinical characteristics, management, and outcomes of infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). Methods and Results-This multicenter registry included 53 patients (mean age, 79±8 years; men, 57%) who suffered IE after TAVI of 7944 patients after a mean follow-up of 1.1±1.2 years (incidence, 0.67%, 0.50% within the first year after TAVI). Mean time from TAVI was 6 months (interquartile range, 1-14 months). Orotracheal intubation (hazard ratio, 3.87; 95% confidence interval, 1.55-9.64; P=0.004) and the self-expandable CoreValve system (hazard ratio, 3.12; 95% confidence interval, 1.37-7.14; P=0.007) were associated with IE (multivariate analysis including 3067 patients with individual data).The most frequent causal microorganisms were coagulase-negative staphylococci (24%), followed by Staphylococcus aureus (21%) and enterococci (21%). Vegetations were present in 77% of patients (transcatheter valve leaflets, 39%; stent frame, 17%; mitral valve, 21%). At least 1 complication of IE occurred in 87% of patients (heart failure in 68%). However, only 11% of patients underwent valve intervention (valve explantation and valve-in-valve procedure in 4 and 2 patients, respectively). The mortality rate in hospital was 47.2% and increased to 66% at the 1-year follow-up. IE complications such as heart failure (P=0.037) and septic shock (P=0.002) were associated with increased in-hospital mortality. Conclusions-The incidence of IE at 1 year after TAVI was 0.50%, and the risk increased with the use of orotracheal intubation and a self-expandable valve system. Staphylococci and enterococci were the most common agents. Although most patients presented at least 1 complication of IE, valve intervention was performed in a minority of patients, and nearly half of the patients died during the hospitalization period. Clinical Perspective on p 1574Transcatheter aortic valve implantation (TAVI) represents a paradigm shift in the treatment of aortic stenosis in patients considered at high or prohibitive surgical risk. 5 The reported rates of early IE after TAVI have varied from 0.1% to 3.03%, [6][7][8] with no differences compared with surgical aortic valve replacement, as shown in the prospective randomized Placement of Aortic Transcatheter Valves (PARTNER) trial. 6 However, data on the clinical characteristics, causes, treatment, and clinical outcomes of IE after TAVI are scarce and limited to case reports and small series, which indeed may suffer from publication bias.9 Such information is crucial to improve both the diagnosis and management of this entity in the context of TAVI. The particular features of TAVI candidates and the specific design of transcatheter valve prostheses, including a much higher amount of metal (stent frame) around the valve leaflets compared with surgical valves, may indeed alter the outcome and management of IE. The objectives of this multicenter registry were thus to evaluate the incidence, predictors, and cl...

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Inflammation, the primary response of innate immunity, is essential to initiate the calcification process underlying calcific aortic valve disease (CAVD), the most prevalent valvulopathy in Western countries. The pathogenesis of CAVD is multifactorial and includes inflammation, hemodynamic factors, fibrosis, and active calcification. In the development of CAVD, both innate and adaptive immune responses are activated, and accumulating evidences show the central role of inflammation in the initiation and propagation phases of the disease, being the function of Toll-like receptors (TLR) particularly relevant. These receptors act as sentinels of the innate immune system by recognizing pattern molecules from both pathogens and host-derived molecules released after tissue damage. TLR mediate inflammation via NF-κB routes within and beyond the immune system, and play a crucial role in the control of infection and the maintenance of tissue homeostasis. This review outlines the current notions about the association between TLR signaling and the ensuing development of inflammation and fibrocalcific remodeling in the pathogenesis of CAVD. Recent data provide new insights into the inflammatory and osteogenic responses underlying the disease and further support the hypothesis that inflammation plays a mechanistic role in the initiation and progression of CAVD. These findings make TLR signaling a potential target for therapeutic intervention in CAVD.

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Young children who accidentally ingested drugs and, less frequently, domestic products accounted for most cases of intoxication who presented at the pediatric emergency department.

Introduction Evidence implicates vitamin D deficiency in poorer outcomes and increased susceptibility to hospital-acquired infections (HAIs). This study examined the association between serum vitamin D levels and HAIs in a population of hepatobiliary surgery patients. Methods Participants in this prospective analytical observational study were patients who underwent hepatobiliary surgery in a tertiary hospital in Aragon, Spain, between February 2018 and March 2019. Vitamin D concentrations were measured at admission and all nosocomial infections during hospitalization and after discharge were recorded. Results The mean 25-hydroxyvitamin D concentration of the study population (n = 301) was 38.56 nmol/L, which corresponds to vitamin D deficiency. Higher vitamin D concentrations were associated with a decreased likelihood of developing a HAI in general (p = 0.014), and in particularly surgical site infection (p = 0.026). The risk of HAI decreased by 34% with each 26.2-nmol/L increase in serum vitamin D levels. Conclusions Vitamin D levels may constitute a modifiable risk factor for postoperative nosocomial infections in hepatobiliary surgery patients.