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    • br Materials and methods A retrospective questionnaire surve

    2019-07-01


    Materials and methods A retrospective questionnaire survey was conducted among 299 JHRS institutions from December 2012 to January 2013. Patients with persistent AF who underwent TEE for elective ECV were included. LA thrombus incidence, risk factors for thrombus formation as indicated by the CHADS2 score, history of gastrointestinal bleeding, Dabi dosage (110mg b.i.d or 150mg b.i.d), treatment duration before ECV (<3 weeks, 3–6 weeks, ≥6 weeks) and after ECV (<4 weeks, ≥4 weeks), and co-administration of amiodarone or verapamil were examined. Patients with LA thrombus underwent repeated TEE to determine LA thrombus fate and the possibility of thrombus resolution. Furthermore, embolic as well as hemorrhagic complications occurring in patients without LA thrombus were evaluated within 1 month of ECV while on Dabi. Comparisons between patients with and without LA thrombus were made using a Student t-test for age and a chi-square test for other variables.
    Results
    Discussion
    Conclusions LA thrombus developed in 4% of patients with AF who underwent ECV while receiving Dabi. Older patients with higher CHADS2 score who were receiving a lower Dabi dosage or shorter treatment duration were more likely to develop LA thrombus, which resolved with a prolonged or increased dosage. A higher Dabi dosage may be preferred to a lower dosage if acceptable before ECV, but further prospective randomized studies are needed to confirm these findings. Considering the limitation of ascertaining Dabi therapy adherence, performing a TEE in all patients receiving Dabi before ECV may be recommended.
    Institutional Review Board information entered in the system
    Conflict of interest
    Acknowledgments
    Introduction Bradyarrhythmia is usually a temporary complication of cervical spinal cord injury. In such cases, although the initial treatment involves pharmacological therapy and/or temporary cardiac pacing [1], for long-term refractory severe bradyarrhythmia, permanent cardiac pacemaker kainic acid may be considered [2]. We report a challenging case of cervical spinal cord injury, complicated by right-sided infective endocarditis after placement of a temporary pacing catheter in the right ventricle for severe bradyarrhythmia that led to cardiac arrest.
    Case report A 57-year-old man was transferred to our hospital for treatment of cervical spinal cord injury (Fig. 1A). He underwent spinal fusion surgery on day 3 of hospitalization. The patient was quadriplegic, ventilator dependent and had lost complete sensation from the neck down. Cardiac pauses lasting for 3–5s appeared on day 11 of hospitalization and cardiac arrest occurred suddenly on day 22 (Fig. 1B). Return of spontaneous circulation was achieved after chest compressions. A temporary pacing catheter was inserted into the right ventricle, and intravenous dopamine and oral theophylline were administered. The patient developed a fever on day 27; repeated blood cultures obtained on day 31 were both positive for methicillin-resistant Staphylococcus aureus. Echocardiography on day 33 showed a vegetation in the right ventricle (Fig. 2), confirming a diagnosis of right-sided infective endocarditis. The pacing catheter was removed immediately, and daptomycin was administered. Repeated blood cultures on day 36 were negative. Because of intractable diarrhea, daptomycin treatment was discontinued, and treatment with linezolid was initiated and continued until day 85. Dopamine infusion was discontinued on day 44, and intravenous isoproterenol treatment was initiated; on day 84, oral isoproterenol was replaced with intravenous isoproterenol. As no relapse of infective endocarditis or severe episode of bradyarrhythmia was noted after day 23, the patient was transferred to another hospital for rehabilitation 104 days after admission.
    Discussion This case describes right-sided infective endocarditis during temporary cardiac pacing for severe bradyarrhythmia resulting in cardiac arrest. Several mechanisms involving immunodeficiency in acute injury of central nervous system, including spinal cord injury, have been proposed [3]. However, this condition successfully resolved after the pacing catheter was removed and pharmacological therapy was administered without recurrences of bradyarrhythmia or infection. Bradyarrhythmia can be explained by the occurrences of unopposed vagal reflex due to damage of the sympathetic trunk, which attenuates excitatory inputs from the sympathetic motor center in the medulla to the intact sympathetic preganglionic neurons innervating the heart [1,2,4]. Cardiac arrest occurred in 16% of severe cervical spinal cord injuries (Frankel classification grade; A/B) versus in 0% of less severe cervical spinal cord injuries (C/D) [1]. Bradyarrhythmia persisted but spontaneously resolved within 6 weeks [1]; this may be associated with histologically observed atrophic changes in sympathetic preganglionic neurons in the acute phase of spinal cord injury that recover in the chronic phase [3]. Therefore, most cases of bradyarrhythmia due to cervical spinal cord injury can be treated with pharmacological therapy; however, temporary pacing may be necessary for the acute management of severe bradyarrhythmia as in this case.