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Brucella suis infection in the United States is typically from feral swine exposure. We describe a case of B. suis cardiac implantable device infection in a man exposed to meat and blood from feral swine in Florida, USA. The infection was diagnosed using culture, molecular diagnostics, and whole-genome sequencing.

Aging results in loss of subcutaneous body fat as well as lean body mass. Elderly patients are also more likely to require cardiac implantable electronic devices (CIED) due to rising cardiovascular disease prevalence. A majority of the currently available devices require placement in a pocket created in the subcutaneous space between the subcutaneous fat tissue and the underlying chest wall muscle. Deficient subcutaneous fat tissue can result in device protrusion and even erosion through the skin. This can lead to significant morbidity and mortality especially when associated with device infection and need for device system extraction. This article reviews the scope of the problem and some of the strategies that can be employed to address the lack of subcutaneous soft tissue at the time of device implant.

Recent studies have shown conflicting data regarding left ventricular (LV) function in patients with neurocardiogenic syncope, with some investigators reporting a marked decrease in LV end-systolic wall stress and stress-corrected fractional shortening. We sought to determine the characteristics of resting LV deformation in patients with neurocardiogenic syncope by selective motion tracking of subendocardial and subepicardial regions using speckle tracking echocardiography. We assessed resting LV function in 82 patients undergoing head-up tilt-table (HUTT) testing. Patients were divided into 3 groups based on a positive HUTT test with associated co-morbid conditions (n = 30), no associated co-morbid conditions (n = 30), or negative HUTT results (n = 22). LV longitudinal, circumferential, and radial strains were obtained by speckle tracking echocardiography of subendocardial and subepicardial regions in each group and compared with resting LV deformation in 20 healthy control subjects. Compared with endocardial longitudinal strain in control subjects, that in patients with positive HUTT results was attenuated, irrespective of co-morbid conditions (p <0.05). Circumferential and radial strains did not differ among groups. On multivariate logistic regression analysis, endocardial longitudinal strain was an independent predictor (odds ratio, 1.16; p = 0.01) of positive HUTT test results. In conclusion, resting LV longitudinal strain is attenuated in patients with positive HUTT test results. Overall, these results may suggest that an increase in resting LV contractility is not a prerequisite for development of neurocardiogenic syncope.

Purpose of review There is apprehension and a general lack of familiarity with regard to using the ionic channel specific anti-arrhythmic agents among internists and even general cardiologists. Recent findings This may be related to their relative infrequent use, complicated mechanisms of actions, and real or perceived risks involved with their use. For example, the fact that coronary artery disease is listed as contraindication to the prescription of class IC agents, when so many patients are noted to have presence of non-obstructive disease on increasingly done CT scans, causes confusion and uncertainty about their use. Summary This review paper will attempt to lay out the general pharmacology of the commonly used anti-arrhythmic drugs and discuss their relevance and safe use in current clinical medicine.

Purpose of review There is apprehension and a general lack of familiarity with regards to using the “membrane-active” antiarrhythmic agents among internists and even general cardiologists. Recent findings This hesitancy regarding use of these agents may be related to their relative infrequent use, complicated mechanisms of actions, and real or perceived risks involved with their use. For example, the fact that dofetilide requires prescription only by certified electrophysiologists and hospitalization for initiation creates a mystique about its use. Summary This review paper will attempt to lay out the general pharmacology of the commonly used drugs and discuss their relevance and safe use in current clinical medicine.

Background In the era of an expanding use of transcatheter aortic valve replacement (TAVR), conduction disturbances and the requirement for permanent pacemaker (PPM) implantation remains a clinical concern. Hypothesis Using a single‐center experience, we sought to identify predictors of ventricular pacing burden after TAVR in patients who required PPM implantation. Methods We conducted a retrospective study of 359 consecutive patients with symptomatic severe aortic valve stenosis who underwent TAVR at our institution between September 2013 and July 2019. Thirty patients (8.4%) required a PPM within 30 days after TAVR. Pre and post‐TAVR electrocardiograms, pre‐TAVR echocardiograms and computed tomography (CT), TAVR procedural details and post‐TAVR device interrogation records at 1, 3, and 6 months were reviewed. Results Mean percentage of ventricular pacing (VP%) at 1, 3, and 6 months was 58%, 59%, and 56% respectively. Using univariate logistic regression analysis, patients who had low VP% < 5% at 6 months were more likely to have a prosthesis/echocardiography‐derived left ventricular outflow tract (LVOT) diameter ratio < 1.3 (OR 7.00, P‐value .048), prosthesis/CT‐derived aortic annulus diameter ratio < 1.02 (OR 7.11, P‐value .047), post‐TAVR new‐onset LBBB (OR 16.80, P‐value .019), time to PPM implantation greater than 2 days post‐TAVR (OR 9.38, P‐value .026) and pre‐TAVR use of a beta blocker (OR 9.40, P‐value .026). Conclusions In patients who required a PPM implantation post‐TAVR, a lower TAVR prosthesis/LVOT or aortic annulus diameter ratio, post‐TAVR new‐onset LBBB and later time of PPM implantation showed a trend toward predicting a low VP% at 6 months.

The association between visceral obesity and cardiovascular risk has been well described. Some studies show a proportional relationship between the presence of visceral obesity and epicardial fat. Measuring the amount of epicardial adipose tissue (EAT) can be a novel parameter that is inexpensive and easy to obtain and may be helpful in cardiovascular risk stratification. However, the relationship between epicardial fat and cardiac function and that between epicardial fat and cardiac risk factors is less well described. To evaluate the association between echocardiographic epicardial fat and the morphologic and physiologic changes observed at echocardiography and to evaluate the association between epicardial fat and cardiac risk factors. A cross-sectional study of 97 echocardiographic studies (females, n = 42) was conducted. Two groups were identified: epicardial fat ≥ 5 mm (group I) and <5 mm (group II). Epicardial fat >5 mm was associated with LA enlargement, with lower ejection fraction, increased left ventricular mass, and abnormal diastolic function. On a multivariable regression analysis, all these parameters also correlated individually with EAT thickness independent of age. Hyperglycemia (DM), systolic hypertension, and lipid parameters for metabolic syndrome showed a trend for positive association, but this was not statistically significant. The association was not significant even for higher cutoff limits of EAT thickness. Epicardial fat >5 mm is associated with cardiac abnormalities on echocardiography. This is a sensitive assessment of body fat distribution, is easily available at echocardiography, and is simple to acquire at no added cost. Further studies looking at the appropriate cut-off thickness of EAT and the sites of measurement to be used are needed. Comparison of this simple and inexpensive measure with other measures of obesity, such as waist-hip ratio, body mass index, Dexa scan of visceral fat, and magnetic resonance imaging of visceral, are needed.

Objective The aim of this study is to evaluate the relationship between polarity of left ventricular (LV) pacing and the resultant regional, global, and transmural mechanical sequence of contraction. Background Cardiac resynchronization therapy (CRT) is widely utilized in patients with drug refractory congestive heart failure with systolic dysfunction (EF <35 %) and intraventricular conduction delay (QRS duration >120 ms). However, little is known about polarity of pacing stimulation and the resultant differences in LV mechanics. Methods The polarity of pacing was altered sequentially in 20 patients (73 ± 13, 16 males) with preexisting biventricular devices with potential choice of multiple vectors for pacing stimulation. Initial unipolar or extended bipolar configurations were switched to bipolar configuration or vice versa, and echocardiographic images were acquired for off-line analysis. Regional and global LV longitudinal and radial mechanics were assessed selectively from the subendocardial and subepicardial regions with 2D speckle-tracking echocardiography. Left ventricular capture by each vector configuration was confirmed by local lead capture and appropriate QRS alteration. Results Unipolar pacing resulted in increased dispersion of LV regional endocardial strains with a higher base-to-apex gradients of longitudinal shortening strains ( P  < 0.05). LV longitudinal shortening strain magnitude was higher at LV base with bipolar stimulation in comparison with unipolar stimulation (−10.5 ± 10.5 vs. −4.2 ± 6.3, P  = 0.02). Conclusion There is a difference in the mechanical activation sequence of the LV between unipolar vs. bipolar pacing stimulation. This may have important implications for CRT.

Pulmonary thromboembolic disease continues to be a challenge in terms of diagnosis and management. This is true for both the acute and chronic forms. Clinical presentation can be nonspecific and manifestations protean, hence a high index of clinical suspicion is warranted so that appropriate tests are performed to help clinch the diagnosis. Acute pulmonary embolus can result in death if untreated, and may progress to chronic thromboembolic pulmonary hypertension if not diagnosed or if it is undertreated. This extensive literature review provides an up-to-date evidence-based approach to the management of acute and chronic pulmonary thromboembolic disease.