P2884Complications of cardiac implantable electronic device intervention in patients with left ventricular assist devices

Background

There are limited data on management of cardiac implantable electronic devices (CIED) in patients with left ventricular assist devices (LVADs). These patients may be at elevated risk of complications after undergoing CIED procedures.

Purpose

In order to better understand these risks, we set out to describe and quantify the complications associated with CIED procedures among patients with LVADs.

Methods

We retrospectively evaluated all patients with LVADs at our institution (n=235) from August 2007 to November 2017 who had any subsequent CIED procedure (initial implant, generator exchange, lead revision or extraction). We identified device-related complications at 30 days and one year from the time of the CIED procedure. Complications were defined as death, stroke, cardiac perforation, pericardial effusion, pneumothorax, lead dislodgment, infection, and any hematoma requiring a direct physician encounter.

Results

Forty-eight CIED interventions were performed on 42 patients after LVAD implant. Mean age was 49.4±15.1 years and 64% were male. Mean duration of LVAD therapy prior to procedure was 396 days. All patients were on warfarin therapy (mean INR 2.33±0.68); in 83% of procedures patients were on at least one anti-platelet agent. All interventions involved placement or revision of an ICD system. Fourteen procedures (29%) were initial implants and 34 (71%) were secondary procedures (19 generator exchanges, 13 lead revisions ± generator exchange and 2 extractions). Seven procedures (14.5%) were complicated by pocket hematoma; all of these were in secondary procedures. Patients with hematomas trended toward higher INR (2.51±0.26 vs 2.31±0.72); this was not statistically significant. Two patients with hematoma developed CIED infection, resulting in a total infection rate of 4.2%. Of those, one developed systemic infection requiring extraction of the system and the other developed a pocket infection managed with pocket washout and prolonged antibiotics. All complications occurred within 30 days of the procedure (Figure 1).

Figure 1. Complication free survival

Conclusion

In this single center study, CIED procedures on patients with preexisting LVAD was associated with a low rate of complications requiring intervention.

Acknowledgement/Funding

Emory University

P1019Validation of a risk score to predict the need for pacemaker implantation after transcatheter aortic valve replacement

Background

New conduction abnormalities necessitating pacemaker implantation (PMI) is a common occurrence after TAVR. There is an increased rate of PMI in the those receiving the most contemporary implanted valve, the Edwards Sapien-3 (S3), compared to prior generation balloon expandable valves. We previously described predictors of PMI in a large cohort. Herein we sought to validate these predictors of PMI in a subsequent validation cohort.

Methods

We evaluated all patients undergoing first time elective TAVR with S3 at our institution (n=326). We developed a risk score based on a predictive model we have previously described. Patients received one point for each of the following: history of syncope, oversizing of the valve >16%, baseline right bundle branch block morphology, and two points for a QRS duration >115 ms. We performed regression analysis of the risk score and need for PMI. We also evaluated the performance of the risk score using ROC analysis.

Results

Thirty patients (8%) of the total cohort had need for PMI after S3 implantation. Those with PMI had a higher rate of pre-existing infra-nodal conduction system disease – including QRS duration >115ms (57% vs. 20%, p<0.001) and right bundle branch block (RBBB) morphology (47% vs. 10%, p<0.001) - as well as more frequent valve oversizing >15.7% (47% vs. 23%, p<0.01). There was no significant difference in a history of syncope (10% vs. 8%, p=0.72) between groups. The PMI risk score had an area under the curve of 0.753 on ROC analysis. The PMI risk score was significantly associated with PMI (OR 2.37; 95% CI [1.64–3.34], p<0.001).

Rate of PMI Stratified by Risk Score

Conclusions

The PMI risk score was strongly predictive of the need for PMI after implantation of the S3 valve in a large validation cohort. The PMI risk score performed well in sensitivity analysis. This PMI risk score represents a simple tool to help further risk stratify patients being considered for TAVR.

Allele specific-PCR and melting curve analysis showed relatively high frequency of β-casein gene A1 allele in Iranian Holstein, Simmental and native cows

There are two allelic forms of A1 and A2 of β-casein gene in dairy cattle. Proteolytic digestion of bovine β-casein A1 type produces bioactive peptide of β-casomorphin-7 known as milk devil. β-casomorphin-7 causes many diseases, including type 1 diabetes, cardiovascular disease syndrome, sudden death and madness. The aim of the present study was to determine the different allelic forms of β-casein gene in Iranian Holstein, Simmental and native cattle in order to identify A1 and A2 variants. The blood samples were collected randomly and DNA was extracted using modified salting out method. An 854 bp fragment including part of exon 7 and part of intron 6 of β-casein gene was amplified by allele specific polymerase chain reaction (AS-PCR). Also, the accuracy of AS-PCR genotyping has been confirmed by melting temperature curve analysis using Real-time PCR machinery. The comparison of observed allele and genotype frequency among the studied breeds was performed using the Fisher exact and Chi-squared test, respectively by SAS program. Obtained results showed the A1 allele frequencies of 50, 51.57, 54.5, 49.4 and 46.6% in Holstein, Simmental, Sistani, Taleshi and Mazandarani cattle populations, respectively. The chi-square test was shown that no any populations were in Hardy-Weinberg equilibrium for studied marker locus. Comparison and analysis of the test results for allelic frequency showed no any significant differences between breeds (P&gt;0.05). The frequency of observed genotypes only differs significantly between Holstein and Taleshi breeds but no any statistically significant differences were found for other breeds (P&gt;0.05). A relatively high frequency of β-casein A1 allele was observed in Iranian native cattle. Therefore, determine the genotypes and preference alleles A2 in these native and commercial cattle is recommended.

Ultrasound assisted preparation of water in oil emulsions and their application in arsenic (V) removal from water in an emulsion liquid membrane process

Water in oil emulsions are prepared by using an ultra-sonication device and used in an emulsion liquid membrane process in order to recover arsenic (V) ions from an aqueous medium. The aim of this work is the investigation of the effect of emulsifier concentration and composition, and also sonication time on the emulsion droplet size and the extraction efficiency in order to obtain stable emulsions with small droplets that favor the extraction. Results show that ultrasonic waves reduce internal droplet size which enhances the extraction of arsenic. In addition, internal droplet size is decreased initially and then increased by increasing Span 80 concentration. On the other hand, by increasing Span 80 concentration, extraction amount is increased and then decreased. Furthermore, emulsifier blends provide more stability for the emulsion. Increasing concentration of Tween 20 as a hydrophilic emulsifier up to an optimum concentration decreases internal droplet size and increases extraction amount. By increasing sonication time up to 4 min, the internal droplet size is decreased and the extraction amount is increased. If sonication time is increased further, the internal droplet size is increased and the extraction amount is decreased.

Sol–Gel Synthesis of Alumina–Titania Nanostructure Membrane: Preparation and Characterization

In the present paper, the preparation and characterization of porous alumina–titania nanostructure membrane is described. The membrane layers consisted of an α-alumina membrane support, which was dip-coated with a composite alumina–titania top layer prepared in a sol–gel process. Thermogravimetric analysis showed that drying progress of the membrane layer is completed at about 560 °C. Scanning electron microscopy analysis displayed a smooth and defect-free layer of alumina–titania membrane after calcination at 600 °C. X-ray diffraction analysis showed the formation of gamma and orthorhombic alumina, brookite titania, and aluminium titanate (Al2TiO5) after the calcination step. Transmission electron microscopy analysis showed that the alumina–titania composite particle size was almost below 40 nm. The Brunauer–Emmet–Teller (BET) surface area, average pore size, and thickness of the membrane top layer were determined to be 292 m2/g, 2.2 nm, and 4 μm, respectively.

Rapid detection of Salmonella dublin by PCR amplification of the SopE gene and its cloning

This study is directed towards the method of amplifying and cloning the SopE gene, that encodes Salmonella outer protein E. Strains used in this study were S. dublin collected from Kermanshah province. Genomic DNA was extracted by the general boiling method. Using the specific primers, a part of SopE gene was multiplied. The PCR product was inserted into the cloning vector (pTZ57R/T). Furthermore, E. coli DH5alpha bacteria were transformed to amplify the recombinant plasmid. Recombinant clones were identified by blue/white selection. Recombinant plasmids were purified by alkaline lysis procedure. Moreover, identity of the SopE/pTZ57R/T product was confirmed by restriction enzyme digestion assay and sequencing. Finally, the cloned gene was compared with that published by the NCBI Genbank (L78932). The results showed that the obtained sequence differed in four nucleotides which resulted in two amino acid differences. The cloned SopE was submitted to the NCBI Genbank (EU399750).

The Effect of Exposure of Guinea Pig to Cigarette Smoke and their Sensitization in Tracheal Responsiveness to Histamine and Histamine Receptor (H(1)) Blockade by Chlorpheniramine

Airway responsiveness to histamine and histamine H(1) receptor blockade by chlorpheniramine (CR-1) on guinea pig trachea were examined. Chronic obstructive pulmonary disease (COPD) and asthma were induced in guinea pigs by exposing them to cigarette smoke for 3 months and by sensitization with injection and inhalation of ovalbumin (OA). The responses of tracheal chains of COPD (n=8), COPD+asthma (n=6) and control animals (n=8) to histamine (EC(50) H) and (CR-1) were measured. The in vitro histamine responses of COPD and COPD+asthmatic guinea pigs in tracheal chains were significantly higher than those of control animals (p<0.001 and p<0.01, respectively). The CR-1 blockade was also significantly greater in trachea of COPD and COPD+asthma compared to that of controls (p<0.01 and p<0.05, respectively). There were significant correlations between EC(50) H and (CR-1) (r=-0.542, p<0.01). The hematocrit in COPD and COPD+asthma groups was also significantly higher than in controls (p<0.001 for both groups). The contractility of tracheal chains to histamine in COPD+asthma animals was significantly greater than those of control and COPD groups (p<0.05 for both cases). The differences in contractility between COPD and COPD+asthmatic groups, however, suggests different basic mechanisms for AHR in COPD and asthma.

Naltrexone, an opioid receptor antagonist, attenuates liver fibrosis in bile duct ligated rats

AIM

The aim of this study was to investigate the hypothesis that the opioid system is involved in the development of hepatic fibrosis.

METHODS

The effect of naltrexone (an opioid receptor antagonist) on hepatic fibrosis in bile duct ligated (BDL) or sham rats was assessed by histology and hepatic hydroxyproline levels. Liver matrix metalloproteinase 2 (MMP-2) was measured by zymography, and alpha smooth muscle actin (alpha-SMA) and CD45 (leucocyte common antigen) by immunohistochemistry. The redox state of the liver was assessed by hepatic glutathione (GSH)/oxidised glutathione (GSSG) and S-nitrosothiol levels. Subtypes of opioid receptors in cultured hepatic stellate cells (HSCs) were characterised by reverse transcriptase-polymerase chain reaction, and the effects of selective delta opioid receptor agonists on cellular proliferation, tissue inhibitor of metalloproteinase 1 (TIMP-1), and procollagen I expression in HSCs determined.

RESULTS

Naltrexone markedly attenuated the development of hepatic fibrosis as well as MMP-2 activity (p<0.01), and decreased the number of activated HSCs in BDL rats (p<0.05). The development of biliary cirrhosis altered the redox state with a decreased hepatic GSH/GSSG ratio and increased concentrations of hepatic S-nitrosothiols, which were partially or completely normalised by treatment with naltrexone, respectively. Activated rat HSCs exhibited expression of delta1 receptors, with increased procollagen I expression, and increased TIMP-1 expression in response to delta(1) and delta(2) agonists, respectively.

CONCLUSIONS

This is the first study to demonstrate that administration of an opioid antagonist prevents the development of hepatic fibrosis in cirrhosis. Opioids can influence liver fibrogenesis directly via the effect on HSCs and regulation of the redox sensitive mechanisms in the liver.

Relaxant effects of Rosa damascena on guinea pig tracheal chains and its possible mechanism(s)

Several therapeutic effects including hypnotic, antispasmodic, treatment of abdominal and chest pain and strengthening the heart have been described for the flowers of Rosa damascena. Therefore in the present study, the relaxant effects of ethanolic extract and essential oils of Rosa damascena on tracheal chains of guinea pigs were examined. The relaxant effects of four cumulative concentrations of ethanolic extract (0.25, 0.5, 0.75, and 1.0g%) and essential oils (0.25, 0.5, 0.75, and 1.0vol.%) in comparison with saline as negative control and four cumulative concentrations of theophylline (0.25, 0.5, 0.75, and 1.0mM) were examined by their relaxant effects on precontracted tracheal chains of guinea pig by 60mM KCl (group 1, n=5) and 10microM methacholine in two different conditions including: non-incubated tissues (group 2, n=8) and incubated tissues with 1microM propranolol and 1microM chlorpheniramine (group 3, n=5). In group 1 experiments two final concentrations of essential oil and theophylline and only final concentration of ethanolic extract showed relaxant effects compared to that of saline (p<0.01-0.001). In group 2 three higher concentrations of ethanolic extract and theophylline and all concentrations of essential oil showed concentration dependent relaxant effects compared to that of saline (p<0.05-0.001). In addition, the effect of 0.25 and 0.5g% of essential oils in group 2 was significantly higher than those of theophylline and ethanolic extract (p<0.01 for all cases). However, in group 3 experiments the extract and essential oil of Rosa damascena did not show any significant relaxant effect. There were significant correlations between the relaxant effects and concentrations for ethanolic extract and essential oil and theophylline in groups 1 and 2. These results showed a potent relaxant effect of Rosa damascena on tracheal chains of guinea pigs that was comparable to that of theophylline at concentrations used.

Relaxant effect ofThymus vulgaris on guinea-pig tracheal chains and its possible mechanism(s)

Thymus vulgaris for the treatment of respiratory diseases is indicated widely, and relaxant effects on smooth muscle have been shown previously. In the present study, the relaxant effects of macerated and aqueous extracts of Thymus vulgaris on tracheal chains of guinea-pigs were examined using cumulative concentrations of macerated and aqueous extracts in comparison with saline (as the negative control) and theophylline (as the positive control). The relaxant effects of four cumulative concentrations of macerated and aqueous extracts (0.25, 0.5, 0.75 and 1.0 g %) in comparison with saline (as the negative control) and four cumulative concentrations of theophylline (0.25, 0.5, 0.75 and 1.0 mm; as the positive control) were examined for their relaxant effects on precontracted tracheal chains of guinea-pig by 60 mm KCl and 10 microm methacholine in two different conditions: non-incubated tissues and incubated tissues with 1 microm propranolol and 1 microm chlorphenamine. There were significant correlations between the relaxant effects and the concentrations for both extracts and theophylline in all experimental groups (p < 0.01 to p < 0.001). These results demonstrated a potent relaxant effect of Thymus vulgaris on guinea-pig tracheal chains that was comparable to theophylline at the concentrations used.

Antitussive effect of Carum copticum in guinea pigs

Several therapeutic effects including anti-asthma and dyspnea have been described for the seeds of Carum copticum In previous studies the relaxant and anticholinergic (functional antagonism) effects, histamine (H(1)) inhibitory effect of Carum copticum have been demonstrated on guinea pig tracheal chains. In the present study the antitussive effect of this plant was evaluated. The antitussive effects of aerosols of two different concentrations of aqueous and macerated extracts and carvacrol, codeine, and saline were tested by counting the number of coughs produced due to aerosol of citric acid 10 min after exposing animals to aerosols of different solutions (for carvacrol n=5 and for other solutions n=6). The results showed significant reduction of cough number obtained in the presence of both concentrations of aqueous and macerated extracts and codeine (p<0.001 for extracts and p<0.01 for codeine). The cough number obtained in the presence of higher concentration of aqueous and macerated extracts was significantly less than those of lower concentrations (p<0.05 for both extracts). In addition the cough number obtained in the presence of both concentrations of aqueous and macerated extracts was significantly lower than that of codeine (p<0.05 to 0.001). However, carvacrol did not show any antitussive effect. These results indicated an antitussive effect of Carum copticum which was even greater than that of codeine at concentrations used. In addition the antitussive effect of Carum copticum was not due to its main constituent, carvacrol.

Pre-emptive analgesia with local anaesthetic for herniorrhaphy

There is little evidence that local anaesthetics produce pre-emptive analgesia and one reason may be the short duration of action of the drugs studied. We examined the pre-emptive analgesic effect of a bupivacaine field block on postoperative pain in 40 patients following herniorrhaphy in a double-blind, randomised trial. Patients received the block either after induction but before surgery, or after surgery but before the end of anaesthesia. There was no difference in pain scores or analgesic consumption up to 7 days after surgery between the two groups. We have demonstrated that bupivacaine does not appear to provide significant pre-emptive analgesia following a field block for herniorrhaphy. This study does not support the hypothesis that pre-emptive analgesia with local anaesthetic depends upon the duration of action of the drug.

Effect of meloxicam on postoperative pain after abdominal hysterectomy

We studied 36 patients, allocated randomly to receive meloxicam 15 mg rectally (n = 18) or placebo suppository (n = 18) before total abdominal hysterectomy in a double-blind study. Visual analogue scores for pain at rest (P < 0.005), on movement (P < 0.05) and on coughing (P < 0.05) were significantly decreased in the meloxicam group during the first 24 h after surgery. Mean 24-h PCA morphine requirements were 33.2 (SD 16.9) mg and 38.2 (20.8) mg in the meloxicam and placebo groups, respectively (ns). There was no difference in the incidence of nausea, vomiting or sedation between groups.