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Background Left atrial appendage closure (LAAC) during cardiac surgery in atrial fibrillation (AF) patients has been investigated in multiple studies with variable safety and efficacy results. Methods A comprehensive review was performed of all studies comparing LAAC and placebo arm during cardiac surgery in AF patients. A random-effect model was used to calculate risk ratios, mean differences, and 95% confidence intervals. Results Five randomized controlled trials and 22 observational studies were included with a total of 540,111 patients. The LAAC group had significantly decreased postoperative stroke/embolic events as compared to the no LAAC group with all cardiac surgeries (3.74% vs 4.88%, p = 0.0002), isolated valvular surgery (1.95% vs 4.48%, p = 0.002). However, CABG insignificantly favored the LAAC group for stroke/embolic events (6.72% vs 8.30%, p = 0.07). There was no difference between both groups in all-cause mortality in the perioperative period (p = 0.42), but was significantly lower in the LAAC arm after two years (14.1% vs 18.3%, p = 0.02). There was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time between both groups (p = 0.53 and p = 0.45). The bypass and the cross-clamp time were longer in the LAAC group (4 and 9 min, respectively). Conclusion In AF patients, LAAC during cardiac surgery had a decreased risk of stroke and long-term all-cause mortality. Additionally, there was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time.

Distal radial artery access (DRA) is recommended as the preferred approach over the traditional proximal radial artery access (TRA) for coronary procedures; however, there are limited randomized controlled trials (RCTs) that compared the 2. We conducted an updated meta-analysis of all RCTs from inception to July 26, 2021, that compared DRA versus TRA in patients who underwent coronary procedures. The statistical analysis was performed using a random effect model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). A total of 5 RCTs were included with a total of 1,005 patients. A pooled analysis of the data showed that the rate of successful cannulation was similar between the 2 arms (RR 0.85, 95% CI 0.68 to 1.07, p = 0.16, I2 = 94%). The rate of radial artery spasm significantly favored the DRA arm as compared with TRA (RR 0.51, 95% CI 0.34 to 0.75, p = 0.0007, I2 = 0%). Significantly more patients from the DRA arm required alternative arterial access. Moreover, the DRA group had an insignificantly decreased rates of radial artery occlusion (RR 0.24, 95% CI 0.05 to 1.20, p = 0.08, I2 = 46%) and early discharge after transradial stenting of coronary arteries access-site hematomas (RR 0.52, 95% CI 0.18 to 1.149, p = 0.22, I2 = 0%). The mean time for hemostasis was significantly shorter in the DRA arm (mean difference −6.64, 95% CI −10.37 to −2.90, p = 0.0005, I2 = 88%). In conclusion, DRA should be considered as a viable, effective, and safe arterial access method for patients who underwent coronary procedures.

A 61-year-old woman with no significant previous medical history presented to an urgent care facility with generalised rash, flushing and abdominal pain after eating mahi-mahi. She was diagnosed with an allergic reaction and discharged home. Later she experienced severe acute abdominal pain and multiple episodes of vomiting, which prompted her to go to the hospital. On admission, the patient had an elevated white count, lipase, amylase and C reactive protein with normal liver enzymes and bilirubin. Imaging showed acute pancreatitis that was suspected to be secondary to scombroid poisoning. This was confirmed by elevated immunoglobulin E and histamine levels. The acute pancreatitis was treated with pain management and supportive treatment. Scombroid poisoning is a well-recognised disease, however, acute pancreatitis secondary to this is rare as only two cases have been reported in the literature, one with codfish and the second an unknown type of fish.

Pasteurella (P.) canis bacteremia is rare with only five reported cases in the literature, which was likely correlated with a state of immunosuppression. A 59-year-old male with a history of right lower extremity (RLE) squamous cell carcinoma (SCC) and non-alcoholic cirrhosis presented for a two week duration of RLE pain, swelling, erythema, and open wounds. The patient admitted that his dog has regularly licked his wounds in the past week. Laboratory investigations and imaging confirmed cellulitis and P. canis bacteremia. Additionally, punch skin biopsies showed his SCC is well differentiated and invasive. The patient was started on empirical intravenous antibiotics. Once deemed medically stable and asymptomatic, the patient was discharged from the hospital on culture directed oral antibiotics. He was also educated on wound care and wound hygiene with his dog. It is important for the general practitioner to know that P. canis bacteremia is possible, although rare. Additionally, it is useful to know that patients without animal bites and immunosuppression are at risk of bacteremia. Finally, with the appropriate antibiotics, P. canis bacteremia can have a favorable prognosis.

Background Transcatheter aortic valve replacement (TAVR) is now indicated in patients with symptomatic aortic stenosis and low, moderate, and high surgical risk. There are multiple types of valves available in TAVR. SAPIEN 3, and Evolut R are two of the most commonly used valves. Methods We conducted a systematic review and meta-analysis of all studies that compared SAPIEN 3 vs Evolut R in patients undergoing TAVR. The primary endpoint of this meta-analysis was 30-day mortality. Secondary outcomes included major of life-threatening bleeding, risk of stroke, need of permanent pacemaker implantation, and risk of moderate to severe paravalvular regurgitation (PVR). Results We included a total of 9 studies. One study was a randomized clinical trial, five were prospective observational studies and three were retrospective. 30-day mortality rate was similar between SAPIEN 3 and Evolut R (odds ratio (OR) 1.19; 95% confidence interval (CI) 0.72 to 1.93; p = 0.47). The risk of major or life-threatening bleeding (OR of 0.83, 95% CI 0.50 to 1.39; p = 0.48), and the risk of stroke (OR of 0.82, 95% CI 0.38 to 1.78; p = 0.62) were also similar between the two types of valves. Compared to SAPIEN 3, Evolut R was associated with statistically significant risk of permanent pacemaker implantation (OR of 1.40, 95% CI 1.15 to 1.70; p = 0.0007), and moderate to severe PVR (OR of 2.56, 95% CI 1.14 to 5.74; p = 0.02). Conclusions At 30 day follow up, both Evolut R and SAPIEN 3 shared similar risks of 30-day mortality, major or life-threatening bleeding, and stroke; however greater odds of pacemaker placement implantation and moderate to severe PVR were associated with Evolut R.

This case report illustrates the rare occurrence of an implantable port becoming infected, forming septic pulmonary emboli (SPE), and eventually a secondary spontaneous pneumothorax (SSP). A 43-year-old male presented to the emergency department for a five-day duration of fevers, generalized malaise, difficulty in breathing, non-productive cough, and left chest pain. Past history revealed right carotid body paraganglioma that required resection, adjuvant chemotherapy via a port in the left subclavian vein, and radiation. The cancer was in remission for one year prior to this admission and the port had not been used in six months, but had not been removed. Chest computed tomography demonstrated bilateral pleural cavitations and parenchymal ground-glass opacities. Blood cultures and subsequent sensitivities grew methicillin sensitive Staphylococcus aureus (MSSA). We initiated empiric broad spectrum coverage and later switched to cefazolin. A left shoulder ultrasound illustrated a subclavian vein thrombus, so the port was removed. Culture of the catheter tip also grew MSSA. Four days later the patient developed acute dyspnea. Repeat imaging showed a new right-sided spontaneous hydropneumothorax with loculated pleural effusions along with progression of the bilateral opacities and cavitations. Therefore, chest tubes were placed with pleural fluid cultures growing MSSA. Additionally, video-assisted thoracoscopic surgery with decortication was performed. The patient was discharged home on six weeks of intravenous cefazolin via a peripherally inserted central catheter (PICC). This case demonstrates that the physicians should be aware of the lethal complications of a port and should attempt to remove them once they are no longer required.

Legionella lung abscess (LLA) is known to develop from pneumonia and Legionnaires’ disease in immunocompromised patients and aspiration. Literature review showed reports of aspiration pneumonia in immunocompetent patients; however, no such was found between LLA and immunocompetency. A 53-year-old male with history of depression and paraumbilical hernia presented for chest pain, which was right sided, started acutely, constant, radiated to the back, and exaggerated with taking deep breaths. The patient denied all other symptoms. Social history was only pertinent for being an active 35 pack-year smoker. The patient was recently admitted one month ago for viral meningitis from Echovirus. On physical exam, the patient was vitally stable, had absent breath sounds in the right middle lobe, and was significantly tender at the right anterior chest. Labs revealed elevated sedimentation rate and C-reactive protein. Imaging demonstrated a right middle lobe lung abscess. Throughout the hospital course, Legionella pneumophila serogroup 1 (LPS1) was found to be positive on urine antigen, sputum polymerase chain reaction, and sputum cultures. The patient was switched to intravenous levofloxacin and ampicillin-sulbactam. Upon symptomatic resolution, the patient was discharged home with recommendations for a follow-up chest computed tomography and diagnostic bronchoscopy. We hypothesize that smoking causes neutrophilic stasis within the lung and the development of the LLA. Treatment includes intravenous long term antibiotics and possibly drainage.

BACKGROUND Antiarrhythmic drugs (AADs) and catheter ablation are first line treatments of paroxysmal atrial fibrillation (PAF), however there exists a paucity of data regarding the potential benefit of different catheter ablation technologies versus AADs as an early rhythm strategy. OBJECTIVE To assess the safety and efficacy of cryoablation versus radiofrequency ablation vs AADs as a first line therapy of PAF. METHODS MEDLINE, Embase, Scopus and CENTRAL were searched to retrieve randomized clinical trials (RCTs) comparing cryoablation, radiofrequency ablation (RFA) or AADs to one another as first line therapies for AF. The primary outcome was overall freedom from arrhythmia recurrence [AF, atrial flutter (AFL), atrial tachycardia)]. Secondary outcomes included freedom from symptomatic arrhythmia recurrence, hospitalization, and serious adverse events. A random-effects Bayesian network meta-analysis was used to calculate odds ratios (OR) and 95% credible intervals (CrI). RESULTS Six RCTs (N = 1,212) met the inclusion criteria (605 AADs, 365 Cryoablation, and 245 RFA). Compared with AADs, overall recurrence was reduced with RFA (OR: 0.31; 95% CrI: 0.10 to 0.71) and cryoablation (OR: 0.39; 95% CrI: 0.16 to 1.00). Comparing ablation (cryoablation and RFA) with AADs in respect to freedom from symptomatic AF recurrence, neither cryoablation (OR: 0.35; 95% CrI: 0.06 to 1.96) nor RFA (OR: 0.34; 95% CrI: 0.07 to 1.27) resulted in statistically significant reductions individually compared to AADs, though pooled ablation with both technologies showed lower odds of arrhythmia recurrence (OR: 0.35; 95% CrI: 0.13 to 0.79). In terms of serious adverse events rates, neither cryoablation (OR: 0.77; 95% CrI: 0.44 to 1.39) nor RFA (OR: 1.45; 95% CrI: 0.67 to 3.23) were significantly different to AADs. RFA resulted in a statistically significant reduction in hospitalizations compared to AAD (OR: 0.08; 95% CrI: 0.01 to 0.99), whereas cryoablation did not (OR: 0.77; 95% CrI: 0.44 to 1.39). The surface under the cumulative ranking curve (SUCRA) showed RFA to be the most effective treatment at reducing overall rates of recurrence, symptomatic recurrence and hospitalizations; whereas cryoablation was most likely to reduce serious adverse events. CONCLUSION Cryoablation and RFA are both effective and safe first line therapies for AF compared to AADs, with RFA being the most effective at reducing recurrences. This article is protected by copyright. All rights reserved.

Background: In 2011, the European Society of Cardiology (ESC) has recommended the 0/1-hour algorithm with high-sensitivity cardiac troponin assays to diagnose acute myocardial infarction. However, there is no defined difference between high-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity cardiac troponin I (hs-cTnI). Methods: We conducted the first meta-analysis of randomized controlled trials and observation studies from inception to 13 August 2021 that evaluated the 0/1-hour algorithm with hs-cTnT or hs-cTnI. The statistical analysis was performed using R version 3.6.3 with packages “metaprop” and “metafor”. We constructed two-by-two tables, pooled studies by a random-effects model using proportion, and calculated sensitivity, NPV, specificity, and PPV with 95% confidence intervals (CI). Results: Two RCTs and 15 observational studies were included with total of 17,883 patients and a median weighted follow-up period of 267 days. For hs-cTnT-Roche, the rates of pooled sensitivity was 98% (95% CI 94-99, I2 =87%), NPV was 99% (95% CI 98-100%, I2 =88%), specificity was 93% (95% CI 90-96%, I2 =98%), and PPV was 61% (95% CI 44-75%, I2 =98%). On the other hand, hs-cTnI-Pooled had a sensitivity of 99% (95% CI 97-99%, I2 =48%), NPV of 100% (95% CI 100-100%, I2 =41%), specificity of 95% (95% CI 94-97%, I2 =95%), PPV of 68% (95% CI 63-73%, I2 =71%) Conclusion: Assays of hs-cTnI-Pooled have higher values of sensitivity, NPV, specificity, and PPV when compared to hs-cTnT-Roche.

This meta-analysis was conducted to compare clinical outcomes of valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) versus redo-surgical aortic valve replacement (Redo-SAVR) in failed bioprosthetic aortic valves. We conducted a comprehensive review of previous publications of all relevant studies through August 2020. Twelve observational studies were included with a total of 8,430 patients, and a median-weighted follow-up period of 1.74 years. A pooled analysis of the data showed no significant difference in all-cause mortality (OR 1.15; 95% CI 0.93 to 1.43; p = 0.21), cardiovascular mortality, myocardial infarction, permanent pacemaker implantation, and the rate of moderate to severe paravalvular leakage between ViV-TAVI and Redo-SAVR groups. The rate of major bleeding (OR 0.36; 95% CI 0.16 to 0.83, p = 0.02), procedural mortality (OR 0.41; 95% CI 0.18 to 0.96, p = 0.04), 30-day mortality (OR 0.58; 95% CI 0.45 to 0.74, p0.0001), and the rate of stroke (OR 0.65; 95% CI 0.52 to 0.81, p = 0.0001) were significantly lower in the ViV- TAVI arm when compared with Redo-SAVR arm. The mean transvalvular pressure gradient was significantly higher post-implantation in the ViV-TAVI group when compared with the Redo-SAVR arm (Mean difference 3.92; 95% CI 1.97 to 5.88, p0.0001). In conclusion, compared with Redo-SAVR, ViV-TAVI is associated with a similar risk of all-cause mortality, cardiovascular mortality, myocardial infarction, permanent pacemaker implantation, and the rate of moderate to severe paravalvular leakage. However, the rate of major bleeding, stroke, procedural mortality and 30-day mortality were significantly lower in the ViV-TAVI group when compared with Redo-SAVR.