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To determine the frequency and predictors of pericardial effusion following epicardial sheath removal.Pericardial effusion can occur following cardiac surgical or interventional procedures including percutaneous epicardial access (EpiAcc), which is increasingly used as part of electrophysiology ablation procedures.A retrospective analysis of the Mayo Clinic comprehensive electronic medical record was performed from all patients who underwent planned EpiAcc as part of an electrophysiology ablation procedure between January 1, 2004 and June 30, 2013.Of 144 patients (mean age 51.3 ± 15.5 years, 68% male) who underwent planned EpiAcc as part of an electrophysiology ablation (95.8% pericardial access success rate), seven (4.9%) developed a postoperative pericardial effusion requiring repeat EpiAcc. Inferior access was utilized in 74 (51.4%) patients. Patients with pericardial effusion tended to be younger (41.1 years vs 51.8 years, P = 0.08) and were more likely to have undergone inferior approach access (85.7% vs 49.6%, P = 0.06) than those who did not develop postoperative pericardial effusion. Seventy-one percent of patients with postoperative pericardial effusion versus 32.1% of patients without postoperative pericardial effusion had a preprocedure ejection fraction ≥55% (P = 0.03). There were no procedural-related deaths, and no difference in mortality between groups.Postoperative pericardial effusion requiring repeat access/drainage was relatively infrequent, occurring in 4.9% of patients shortly after epicardial procedures. While the majority occur early and therefore require close observation, some patients may present in a delayed manner.

Percutaneous epicardial access for ablative therapies is an increasingly common technique utilized for refractory ventricular arrhythmias. There are, however few known data on obesity and complication rates associated with this procedure.We retrospectively reviewed the charts of subjects undergoing epicardial access at Mayo Clinic between January 2004 and June 2013. Baseline clinical and echocardiographic data were collected for each subject, who was then classified into body mass index (BMI) categories as underweight, normal weight, overweight, and obese based on a BMI of18.5, 18.5-24.99, 25-29.99, and ≥30, respectively. Events and complications were recorded, and procedural and clinical success rates were determined. There was no statistically significant difference in access approach, procedural or clinical outcomes, or complications among the BMI categories. Note that 95.1%, 91.7%, and 93.1% derived procedural success among the normal weight, overweight, and obese categories, respectively (P value = 0.81). Similarly, there was no difference in clinical outcomes with success rates of 68.3%, 66.7%, and 75.9% between the respective groups (P value = 0.54). At 5 years, there was a trend toward increased mortality among obese individuals (28.8%) compared to normal weight (8.8%) and overweight (9.8%) patients (P value = 0.139).Percutaneous epicardial access, mapping, and ablation can be performed in obese individuals with similar outcomes to those of lower weight category. Obesity should not preclude the use of percutaneous epicardial access when clinically indicated.

The short-term safety of and blood pressure changes after withdrawing hypertension treatment in older adults in preparation for clinical trials have not been well established.Participants were enrolled in a clinical trial and antihypertensive medications were tapered over 3 weeks (week 1: reduction by 25%-50%; week 2: 50%-75%, week 3: off). Blood pressure was measured at the initial visit and after stopping all antihypertensive therapy (personnel) and twice a day during the taper phase (provided monitor). Trend analyses and linear models were used to assess changes in blood pressure.All participants (n = 53, mean age = 71 years, total of 1158 readings) successfully tapered their medications with no symptoms. Only 2% of the readings exceeded 180/100 mm Hg, but none were consecutive. Blood pressure gradually increased with an overall increase of 12/6 mm Hg, 95% confidence interval (4/1, 21/11). The daily increase in blood pressure was 0.2 mm Hg (standard error = 0.1) in both the systolic and diastolic blood pressure. Increases in systolic and diastolic blood pressure were comparable for all antihypertensive classes (P.05 for all).Short-term (3-4 weeks) withdrawal of antihypertensive therapy in older adults with hypertension is safe and is associated with mild increases in blood pressure.

The association between diastolic dysfunction (DD) severity and clinical outcomes in patients hospitalized for acute heart failure (AHF) with and without diabetes remains undefined. Our objective is to compare the clinical characteristics, echocardiographic characteristics, and clinical outcomes of

The large dark cluster in the left corner looks all but conquered by the infiltrating cells gone awry. The bright flower-shaped blossom amid the speckles like a winter snowstorm signals a massive battle about to commence between two giant forces. Yet to understand the true meaning of what lies ahead requires a lower magnification: the ability to synthesize information obtained from each section of the field in order to make a decision. With a confident swipe and a loud click, he makes his move. “Your turn,” he says. With its origins in China over 2,000 years ago, Go, or weiqi, is a two-player game in which black and white stones are placed on the vacant intersections of a 19 × 19 board. Alternating turns placing pieces on the board, each player attempts to surround as much territory as possible while simultaneously preventing the opponent from doing the same. Indeed, directly translated, the two Chinese characters representing weiqi means the game of encircling. When one player's stones are …

To the Editor: With the widespread use of blood pressure medications, it has become extremely difficult to assess the effects of elevated blood pressure on physiological and pathological phenomena without the confounding effects of antihypertensives. In both observational studies and randomized clinical trials, attempts to account for the antihypertensive effects have ranged from overly simplified dichotomous measures (either on or not on treatment) to tedious formulas that, in most instances, cannot be calculated in the population studied. Here, we propose a novel yet simple measurement index that not only takes into consideration whether an individual is on treatment but also accounts for the number and doses of each antihypertensive medication taken. We are suggesting that this measure maybe superior to the dichotomous measure and can be used to prospectively assess changes in blood pressure treatment. The developed measure was used in an ongoing trial, the Antihypertensive and Vascular, Endothelial, …

R heumatological disorders are not frequently considered in the differential diagnosis of patients with delirium and fever. Nonetheless, there are case reports of elderly patients who have developed delirium secondary to calcium pyrophosphate deposition disease (CPPD). In such cases, patients with delirium and CPPD underwent extensive evaluations which revealed no causes for delirium other than CPPD, and they experienced dramatic improvements in their mental status when treated with corticosteroids, nonsteroidal anti-inflammatory drugs, and colchicine. A proposed mechanism of delirium in CPPD is activation of inflammatory mediators and cytokines such as interleukin 1 (IL-1), which have been shown to result in numerous central nervous system effects. Although delirium secondary to CPPD has been well described, we could find only a single report in the French literature of an elderly woman who presented with a febrile encephalopathy that was attributed to polyarticular gout. To our knowledge, we present the first report in the English literature of a patient with delirium secondary to acute polyarticular gout.

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy or apical ballooning syndrome, is a condition of stress-induced apical hypokinesis in the setting of a preserved basal segment. It has become increasingly recognized and described. While it can mimic the presentation of an acute myocardial infarction, it is a transient phenomenon, and ventricular systolic function typically recovers completely. We review the relevant literature over the past 2 decades regarding the pathophysiology, diagnosis, epidemiology, management, and prognosis of this condition. Keywords: apical ballooning syndrome, takotsubo cardiomyopathy, stress-induced cardio-myopathy, myocardial infarction, heart failure Introduction Takotsubo cardiomyopathy (TTC), also known as stress-induced cardiomyopathy or apical ballooning syndrome (ABS), is a condition most frequently characterized by dysfunction of the apical and mid-portions of the myocardium, with a relatively preserved or hyperkinetic base.

The association between aortic stenosis and gastrointenstinal bleeding due to acquired von Willebrand syndrome (AVWS) has been well established. We report a patient with AVWS from underlying severe endocarditis-associated aortic regurgitation and pre-existing mitral regurgitation. Cardiovascular disease-related AVWS occurs from a selective loss of the largest multimers of von Willebrand factor from high shear forces, and desmopressin leads to transient clinical improvement.

We thank Dr. Pressler and colleagues for their interest in our paper [(1)][1]. The progression of pre-clinical diastolic dysfunction (PDD) to symptomatic heart failure with preserved ejection fraction (HFpEF) is dependent on a variety of comorbid conditions, including pulmonary, renal, and

Objective To determine the risks of acute kidney injury development and long-term clinical outcomes of patients with hypertensive crisis. Patients and Methods This was a population study of Olmsted County residents with hypertensive crisis between January 1, 2000, and December 31, 2008, with follow-up until June 30, 2016. Results The results demonstrated that those with underlying chronic kidney disease upon admission for hypertensive crisis, defined as a systolic blood pressure above 180 mm Hg or diastolic blood pressure above 120 mm Hg, were more likely to develop acute kidney injury during hospitalization (odds ratio, 6.04; 95% CI, 1-26; P=.02). Hospitalization length of stay was increased when patients developed acute kidney injury during hypertensive crisis hospitalization (7.6±9 vs 3.4±4 days; P=.04). Furthermore, those who developed acute kidney injury had increased cardiac rehospitalization frequency over 10 years (87% vs 46%; P=.009). These results suggest that those with poor renal reserve are more likely to have further acute kidney damage in the setting of hypertensive crisis, likely due to decreased renal perfusion and neurohormonal dysregulation. Conclusion In patients hospitalized for hypertensive crisis, chronic renal insufficiency was a risk factor associated with acute kidney injury development during hospitalization. Those who developed acute kidney injury had longer hospitalizations with increased rehospitalization frequency. Future studies are warranted to further investigate whether the preservation of renal function will improve clinical outcomes in hospitalized patients with hypertensive crisis.