Cardiac sarcoid is an infiltrative, granulomatous disease of the myocardium. It is more prevalent entity than once believed, especially subclinical disease. It affects heart mechanics causing ventricular failure, and disrupts the cardiac electrical system leading to third degree heart block, malignant ventricular arrhythmias, and sudden cardiac death. This makes early diagnosis and treatment of this devastating disease essential. Based on reviewed literature this paper proposes step‐wise diagnostic and therapeutic algorithms for patients with suspected cardiac sarcoidoisis who do or do not have prior history of systemic sarcoidosis. Clin. Cardiol. 2012 DOI: 10.1002/clc.21982The authors have no funding, financial relationships, or conflicts of interest to disclose.Special thanks to Dr. Maziar Zafari for his help with the editing process.

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PurposeThe burden of cancer is rising in low- and middle-income countries, yet cancer treatment requires resources that are often not available in these settings. Although management of chronic myeloid leukemia (CML) has been described in low- and middle-income countries, few programs involve patients treated in rural settings. We describe characteristics and early outcomes of patients treated for CML at rural district hospitals in Rwanda.MethodsWe conducted a retrospective review of patients with confirmed BCR-ABL–positive CML who were enrolled between July 1, 2009 and June 30, 2014. Types of data included patient demographics, diagnostic work up, treatment, clinical examination, laboratory testing, and death.ResultsForty-three patients were included, with a maximum follow-up of 58 months. Of 31 patients who were imatinib-naïve at enrollment, 54.8% were men and the median age at diagnosis was 36.9 years (interquartile range: 29-42 years). Approximately two-thirds of patients (67.7%) were on the national public insurance scheme. The imatinib dose was reduced for 16 patients and discontinued for five. Thirty-two of the 43 patients continued to have normal blood counts at last follow-up. Four patients have died and four are lost to follow-up.ConclusionOur experience indicates that CML can be effectively managed in a resource-constrained rural setting, despite limited availability of on-site diagnostic resources or specialty oncology personnel. The importance of model public-private partnerships as a strategy to bring high-cost, life-saving treatment to people who do not have the ability to pay is also highlighted.

Moderate alcohol intake is beneficial to the heart and cardiovascular system. A J- or U-shaped response has been shown in the majority of studies examining alcohol's effect on cardiovascular mortality and downstream cardio-metabolic effects, with heavy alcohol intake associated with worse outcomes. These effects apply to individuals with and without underlying coronary artery disease. However, care must be taken in defining "moderate" intake between the sexes. Males appear to have a wider therapeutic window and can afford 2 to 3 drinks per day whereas women should limit intake to 1 to 2 drinks per day (a "drink" being classified as 10 to 14 grams of alcohol). More than half of alcohol's cardioprotective effects can be attributed to its effect on lipoproteins, specifically an increase in high-density lipoprotein. Interestingly, the risk of cardiovascular mortality in former heavy drinkers has been shown to ultimately approach the risk seen in lifelong abstainers.

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Background: Societal guidelines have set prerequisites regarding procedures conducted in the EP lab. Despite metrics for management of EP cases, no clear guidelines exist for use of hemodynamic drugs to support complex ablations, particularly in setting of structural heart disease. Objectives: We sought to understand the variety and range of vasoactive medication use in patients undergoing PVC/VT ablation. Methods: Patients undergoing PVC or VT ablation, from January 2015 to December 2016, at our institution were analyzed. Demographics, echocardiography, and procedural details, including vasoactive medication use, were analyzed. Results: Sequential patients undergoing PVC or VT ablation (70 in each arm) were studied. Those undergoing PVC ablation (56 +/- 14 years, 30% female) had an average EF of 58% in comparison to 44% (p<0.01 for EF difference) in VT ablation patients (60 +/- 13 years, 20% female); more VT patients (62%) were under general anesthesia. Pressors were administered in 86% of cases with the significant majority (63%) consisting of alpha-agonists (phenylephrine, ephedrine, epinephrine). Importantly, 48% of cases required continuous drip initiation (Figure). Regardless of case type or abnormal EF, drip initiation with or administration of multiple bolus doses of alpha-agonists was much more frequent compared to inotropes (Figure). In a subset of patients with EF ≤ 35%, 96% received vasoactive medications with 73% receiving a continuous drip or multiple bolus doses of phenylephrine. Conclusions: Vasoactive medication use during ventricular EP cases is common. Regardless of baseline EF, a propensity for use of alpha-agonists exists that may affect the treatment of patients with abnormal LV function. More studies are needed to assess the impact of pressor use on patient safety and procedural endpoints in the EP lab. Figure:

Background: Risk factors leading to heart block (HB) and need for permanent pacemaker (PPM) implantation post-TAVR using latest generation heart valves have been described. Yet, little is known regarding pacing burden following PPM implantation among such patients. Objective: We sought to determine follow-up RV pacing burden among those undergoing PPM for HB following TAVR. Methods: From July 2016 to July 2017, we reviewed procedural and 3-month follow-up data (including PPM interrogation data) from all patients undergoing implantation of Edwards Sapien 3® and Medtronic Evolut-R® valves at our institution and requiring implantation of a PPM due to HB secondary to the TAVR procedure. Results: Of 132 included patients who underwent TAVR with new generation valves, 25 (19%) required post-TAVR PPM implantation. Of 25 patients, 18 had available follow-up pacemaker data [Table]. Pacing burden post-PPM implantation of 29mm valves was significantly greater compared to non-29mm valves (40.2% vs. 5.4%, p = 0.02). Those with baseline conduction system disease (RBBB or LBBB) had greater pacing burdens, in particular when 29mm Evolut-R® self-expanding valves were deployed (n=3, RV pacing burden 63.3%). Extension of programmed AV delays produced significant reduction in RV pacing burden. Conclusion: In those undergoing TAVR with latest generation valves complicated by HB requiring PPM use, implantation of larger-sized valves (29 mm Evolut-R® in the present series), as well as baseline RBBB or LBBB results in increased follow-up RV pacing burden. This may be mitigated by adjustment of pacing parameters. Further work investigating long-term pacing burden and its consequences is needed to provide additional insight. Table: Demographics, baseline ECG characteristics, procedural characteristics, pacing mode, pacing parameters and follow-up RV pacing burden.