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עמוד בית
Fri, 31.05.24

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April 2024
Dante Antonelli MD, Vladimir Poletaev MD, Vidal Essebag MD, Alexander Feldman MD

Inappropriate implantable cardiac defibrillator (ICD) shock due to electromagnetic interference (EMI) induced by electrocautery is a well-known theoretical association but is rarely reported [1]. We report a case of EMI induced by electrocautery causing inappropriate ICD shock, underlining that, with the use of monopolar cautery, not only the location of the surgery but also electrodispersive pad (EDP) placement may be important to avoid EMI.

March 2024
Amir Aker MD, Ina Volis MD, Walid Saliba MD MPH, Ibrahim Naoum MD, Barak Zafrir MD

Background: Ischemic stroke is associated with increased risk of morbidity and mortality in future vascular events.

Objectives: To investigate whether CHA2DS2-VASc scores aid in risk stratification of middle-aged patients without atrial fibrillation (AF) experiencing ischemic stroke.

Methods: We analyzed data of 2628 patients, aged 40–65 years with no known AF who presented with acute ischemic stroke between January 2020 and February 2022. We explored the association between CHA2DS2-VASc scores categorized by subgroups (score 2–3, 4–5, or 6–7) with major adverse cardiac and cerebrovascular events (MACCE) including recurrent stroke, myocardial infarction, coronary revascularization, or all-cause death during a median follow-up of 19.9 months.

Results: Mean age was 57 years (30% women); half were defined as low socioeconomic status. Co-morbidities included hypertension, diabetes, obesity, and smoking in 40–60% of the patients. The incidence rate of MACCE per 100 person-years was 6.7, 12.2, and 21.2 in those with score 2–3, 4–5, and 6–7, respectively. In a multivariate cox regression model, compared to patients with score 2–3 (reference group), those with score 4–5 and 6–7 had an adjusted hazard ratio (95% confidence interval [95%CI]) for MACCE of 1.74 (95%CI 1.41–2.14) and 2.87 (95%CI 2.10–3.93), respectively. The discriminative capacity of CHA2DS2-VASc score for overall MACCE was modest (area under curve 0.63; 95%CI 0.60–0.66), although better for myocardial infarction 0.69 (95% CI 0.61–0.77).

Conclusions: CHA2DS2-VASc score may predict future MACCE in middle-aged patients with ischemic stroke and no history of AF.

November 2023
Anat Milman MD PhD, Bernard Belhassen MD, Eyal Nof MD, Israel Barbash MD, Amit Segev MD, Roy Beinart MD

A 42-year-old healthy man collapsed suddenly in the street while walking. The patient received 2 minutes of basic life support until an automatic external defibrillator was brought and detected ventricular fibrillation (VF), which was successfully terminated by a single shock. The patient regained consciousness and was transferred to the hospital.

The patient’s physical examination was normal with no neurologic deficit. Blood pressure was 147/102 mmHg. Brain computed tomography showed normal findings. The first troponin I measurement within 1 hour of the event was in the normal range (19.6 ng/L, normal < 20 ng/L) and rose to 99.9 ng/L after 3 hours.

June 2023
Mustafa Gabarin MD, Yoav Arnson MD, Yoram Neuman MD, Ziad Arow MD, Abid Assali MD, David Pereg MD

Background: Direct oral anticoagulants (DOACs) are the treatment of choice for patients with non-valvular atrial fibrillation; however, bleeding risk remains significant. We reported a single-center experience with 11 patients who presented with hemorrhagic cardiac tamponade while treated with DOACs.

Objectives: To evaluate the characteristics and clinical outcomes of patients under DOACs with cardiac tamponade.

Methods: We retrospectively identified 11 patients treated with DOACs admitted with pericardial tamponade in our cardiology unit during 2018–2021.

Results: The mean age was 84 ± 4 years; 7 males. Atrial fibrillation was the indication for anticoagulation in all cases. DOACs included apixaban (8 patients), dabigatran (2 patients), and rivaroxaban (1 patient). Urgent pericardiocentesis via a subxiphoid approach under echocardiography guidance was successfully performed in 10 patients. One patient was treated with urgent surgical drainage with a pericardial window. Reversal of anticoagulation using prothrombin complex concentrate and idarucizumab was given before the procedure to 6 patients treated with apixaban and one patient treated with dabigatran. One patient, initially treated with urgent pericardiocentesis, underwent pericardial window surgery due to re-accumulation of blood in the pericardium. The pericardial fluid analysis demonstrated hemopericardium. Cytology tests were negative for malignant cells in all cases. Discharge diagnoses regarding the cause of hemopericardium included pericarditis (3 patients) and idiopathic (8 patients). Medical therapy included non-steroidal anti-inflammatory drugs (1 patient), colchicine (3 patients), and steroids (3 patients). No patient died during hospitalization.

Conclusions: Hemorrhagic cardiac tamponade is a rare complication of DOACs. We found good short-term prognosis following pericardiocentesis.

Dante Antonelli MD, Vladimir Poletaev MD, Alexander Feldman MD

Inappropriate shocks are a serious and still unresolved problem associated with implantable cardioverter defibrillators (ICDs) that have been associated with increased mortality and impairment of quality of life [1] despite advances in device safety. We report a case of electromagnetic interference (EMI) while showering that resulted in an inappropriate ICD discharge.

March 2023
Batya Wizman MD, Moti Haim MD, Ido Peles, Roi Westreich MD, Amjad Abu-Salman MD, Gal Tsaban MD MPH, Natalie Yasoor, Orit Barrett MD, Yuval Konstantino MD

Background: Existing cardiac disease contributes to poor outcome in patients with coronavirus disease 2019 (COVID-19). Little information exists regarding COVID-19 infection in patients with a cardiac implantable electronic device (CIED).

Objectives: To assess the association between CIEDs and severity of COVID-19 infection.

Methods: We performed a retrospective analysis including 13,000 patients > 18 years old with COVID-19 infection between January and December 2020. Patients with COVID-19 who had a permanent pacemaker or defibrillator were matched 1:4 based on age and sex followed by univariate and multivariate analyses. Baseline characteristics and clinical outcomes were assessed.

Results: Forty patients with CIED and 160 patients without CIED were included in the current analysis. Mean age was 72.6 ± 13 years, and approximately 50% were females. Majority of the patients in the study arm had a pacemaker (63%), whereas only 15 patients (37%) had a defibrillator. Patients with COVID-19 and CIED presented more often with atrial fibrillation, coronary artery disease, heart failure, hypertension, diabetes, and chronic kidney disease. They were more likely to be hospitalized in the intensive care unit (ICU) and required more ventilatory support (35% vs. 18.3%). Thirty-day mortality (22.5% vs. 13.8%) and 1-year mortality (25% vs. 15%) were higher among patients with COVID-19 and CIED.

Conclusions: Patients with COVID-19 and CIED had a significantly higher prevalence of co-morbidities that were associated with increased mortality. Although,CIED by itself was not found as an independent risk factor for morbidity and mortality, it may serve as a warning for severe illness with COVID-19.

December 2022
Ze'ev Itsekson Hayosh MD, Eiman Abu Bandora MD, Natalia Shelestovich MD, Maya Nulman MD, Mati Bakon MD, Gal Yaniv MD, Boris Khaitovitch MD, Shmuel Balan MD, Alexandra Gerasimova MD, Tali Drori MD, Stefan Mausbach MD, Yvonne Schwammenthal MD, Arnon Afek MD, Joab Chapman MD, Efrat Shavit Stein MD, David Orion MD

Endovascularly retrieved clots may be a potential resource for diagnosing stroke etiology. This method may influence secondary prevention treatment. We measure thrombin activity eluted by serially washing clots. We concluded that an assay measuring the change in thrombin in clots retrieved during acute stroke endovascular thrombectomy procedures may serve as a diagnostic marker of the origin of the clot. The suggested mechanism for these differences may be the clot location before its retrieval, with high blood flow causing thrombin washout in atherosclerotic clots, in contrast to atrium appendage low blood flow retaining high thrombin levels.

November 2022
Yehonatan Sherf MD MPH, Dekel Avital MD, Shahar Geva Robinson MD, Natan Arotsker MD, Liat Waldman Radinsky MD, Efrat Chen Hendel MD MPH, Dana Braiman MD, Ahab Hayadri MD, Dikla Akselrod MD, Tal Schlaeffer-Yosef MD, Yasmeen Abu Fraiha MD, Ronen Toledano MD, Nimrod Maimon MD MHA

Background: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Previous studies showed that rhythm and rate control strategies are associated with similar rates of mortality and serious morbidity. Beta blockers (BB) and calcium channel blockers (CCB) are commonly used and the selection between these two medications depends on personal preference.

Objectives: To compare real-time capability of BB and CCB for the treatment of rapid AF and to estimate their efficacy in reducing hospitalization duration.

Methods: We conducted a retrospective cohort study of 306 patients hospitalized at Soroka Hospital during a 5-year period with new onset AF who were treated by a rate control strategy.

Results: A significant difference between the two groups regarding the time (in hours) until reaching a target heart rate below 100 beats/min was observed. BB were found to decrease the heart rate after 5 hours (range 4–14) vs. 8 hours (range 4–18) for CCB (P = 0.009). Patients diagnosed with new-onset AF exhibited shorter duration of hospitalization after therapy with BB compared to CCB (median 72 vs. 96 hours, P = 0.012) in the subgroup of patients discharged with persistent AF. There was no significant difference between CCB and BB regarding the duration of hospitalization (P = 0.4) in the total patient population.

Conclusions: BB therapy is more potent for rapid reduction of the heart rate compared to CCB and demonstrated better efficiency in shortening the duration of hospitalization in a subgroup of patients. This finding should be reevaluated in subsequent research.

July 2022
Magdi Zoubi MD, Ashraf Hejly MD, Howard Amital MD MHA, and Naim Mahroum MD
March 2022
Lior Fortis MD, Ella Yahud MD, Ziv Sevilya PhD, Roman Nevzorov MD MPH, Olga Perelshtein Brezinov MD, Michael Rahkovich MD, Eli I Lev MD, and Avishag Laish-Farkash MD PhD

Background: The CHA2DS2-VASc score has been shown to predict systemic thromboembolism and mortality in certain groups in sinus rhythm (SR), similar to its predictive value with atrial fibrillation (AF).

Objectives: To compare factors of inflammation, thrombosis, platelet reactivity, and turnover in patients with high versus low CHA2DS2-VASc score in SR.

Methods: We enrolled consecutive patients in SR and no history of AF. Blood samples were collected for neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), immature platelet fraction (IPF%) and count (IPC), CD40 ligand, soluble P-selectin (sP-selectin) and E-selectin. IPF was measured by autoanalyzer and the other factors by ELISA.

Results: The study comprised 108 patients (age 58 ± 18 years, 63 women (58%), 28 (26%) with diabetes), In addition, 52 had high CHA2DS2-VASc score (³ 2 for male and ³ 3 for female) and 56 had low score. Patients with low scores were younger, with fewer co-morbidities, and smaller left atrial size. sP-selectin was higher in the high CHA2DS2-VASc group (45, interquartile ratio [IQR] 36–49) vs. 37 (IQR 28–46) ng/ml, P = 0.041]. Inflammatory markers were also elevated, CRP 3.1 mg/L (IQR 1.7–9.3) vs. 1.6 (IQR 0.78–5.4), P < 0.001; NLR 2.7 (IQR 2.1–3.8) vs. 2.1 (IQR 1.6–2.5), P = 0.001, respectively. There was no difference in E-selectin, CD40 ligand, IPC, or IPF% between the groups.

Conclusions: Patients in SR with high CHA2DS2-VASc score have higher inflammatory markers and sP-selectin. These findings may explain the higher rate of adverse cardiovascular events associated with elevated CHA2DS2-VASc score.

Lian Bannon MD, Omer Shlezinger MD, Alexandra Nathan MD, Yan Topilsky MD, Ilan Merdler MD MHA, and Eihab Ghantous MD
Sebastian Szmit MD PhD, Jarosław Kępski MD, and Michał Wilk MD

Atrial fibrillation is becoming an increasingly important problem in cardio-oncology. Specific risk factors for atrial fibrillation occurrence include type of cancer disease and anticancer drugs. Anticoagulation is often abandoned. The CHA2DS2-VASc and CHA2DS2 scores may be important not only in predicting stroke but also in mortality. The role of new direct oral anticoagulants is growing, but they need to be used in a personalized approach depending on the risk of unbeneficial interactions with cancer treatment and the risk of bleeding.

February 2022
Erez Marcusohn MD, Maria Postnikov MD, Ofer Kobo MD, Yaron Hellman MD, Diab Mutlak MD, Danny Epstein MD, Yoram Agmon MD, Lior Gepstein MD PHD, and Robert Zukermann MD

Background: The diagnosis of atrial fibrillation (AFIB) related cardiomyopathy relies on ruling out other causes for heart failure and on recovery of left ventricular (LV) function following return to sinus rhythm (SR). The pathophysiology underlying this pathology is multifactorial and not as completely known as the factors associated with functional recovery following the restoration of SR.

Objectives: To identify clinical and echocardiographic factors associated with LV systolic function improvement following electrical cardioversion (CV) or after catheter ablation in patients with reduced ejection fraction (EF) related to AFIB and normal LV function at baseline.

Methods: The study included patients with preserved EF at baseline while in SR whose LVEF had reduced while in AFIB and improved LVEF following CV. We compared patients who had improved LVEF to normal baseline to those who did not.

Results: Eighty-six patients with AFIB had evidence of reduced LV systolic function and improved EF following return to SR. Fifty-five (64%) returned their EF to baseline. Patients with a history of ischemic heart disease (IHD), worse LV function, and larger LV size during AFIB were less likely to return to normal LV function. Multivariant analysis revealed that younger patients with slower ventricular response, a history of IHD, larger LV size, and more significant deterioration of LVEF during AFIB were less likely to recover their EF to baseline values.

Conclusions: Patients with worse LV function and larger left ventricle during AFIB are less likely to return their baseline LV function following the restoration of sinus rhythm.

January 2022
Gergana Marincheva MD, Tal Levi MD, Olga Perelshtein Brezinov MD, Andrei Valdman MD, Michael Rahkovich MD, Yonatan Kogan MD, and Avishag Laish-Farkash MD PhD

Background: Endocardial leads of permanent pacemakers (PPM) and implantable defibrillators (ICD) across the tricuspid valve (TV) can lead to tricuspid regurgitation (TR) or can worsen existing TR with subsequent severe morbidity and mortality.

Objectives: To evaluate prospectively the efficacy of intraprocedural 2-dimentional-transthoracic echocardiography (2DTTE) in reducing/preventing lead-associated TR.

Methods: We conducted a prospective randomized controlled study comparing echocardiographic results in patients undergoing de-novo PPM/ICD implantation with intraprocedural echo-guided right ventricular (RV) lead placement (Group 1, n=56) versus non-echo guided implantation (Group 2, n=55). Lead position was changed if TR grade was more than baseline in Group 1. Cohort patients underwent 2DTTE at baseline and 3 and/or 6 months after implantation. Excluded were patients with baseline TR > moderate or baseline ≥ moderate RV dysfunction.

Results: The study comprised 111 patients (74.14 ± 11 years of age, 58.6% male, 19% ICD, 42% active leads). In 98 patients there was at least one follow-up echo. Two patients from Group 1 (3.6%) needed intraprocedural RV electrode repositioning. Four patients (3.5%, 2 from each group, all dual chamber PPM, 3 atrial fibrillation, 2 RV pacing > 40%, none with intraprocedural reposition) had TR deterioration during 6 months follow-up. One patient from Group 2 with baseline mild-moderate aortic regurgitation (AR) had worsening TR and AR within 3 months and underwent aortic valve replacement and TV repair.

Conclusions: The rate of mechanically induced lead-associated TR is low; thus, a routine intraprocedural 2DTTE does not have a significant role in reducing/preventing it

Tzlil Mordechay-Heyn MD, Haggi Mazeh MD, Yair Elitzur MD, and Auryan Szalat MD
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