Background:An atrial leadless pacemaker (Aveir AR [Abbott]) has recently become available, enabling atrial pacing and maintaining strict atrioventricular synchronization. Although the efficacy and safety of leadless pacemakers have already been reported, some cases present challenges during implantation due to anatomical variations. Case summary:A 66-year-old man visited our hospital complaining of dizziness. A 12-lead electrocardiogram exhibited junctional rhythm with a heart rate of 40 beats/min. A leadless pacemaker was implanted instead of a transvenous pacemaker because of daily oral steroid administration and the risk of a pocket infection.The Aveir AR delivery catheter was guided to the base of the right atrial appendage (RAA) using deflection manoeuvres. However, upon deflection release, the catheter tip slipped towards the superior vena cava because of the significantly small RAA. To avoid catheter tip slip, the catheter lever was turned clockwise to rotate the chevron marker one-quarter from its initial position while maintaining deflection. Mapping measurements obtained while maintaining catheter deflection were favourable. Even after releasing the deflection, the catheter tip position remained stable at the RAA base without slippage. Subsequently, the delivery catheter deflection was released, and the chevron marker 1 1/2 was rotated under fluoroscopy. The Aveir AR position and each final parameter were favourable. No adverse events, including cardiac tamponade and dislodgement, were recorded. Discussion:This case highlights the specific bailout technique using partial rotation while maintaining deflection for Aveir AR implantation in a markedly small RAA; however, it should not replace standard implantation technique.
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OBJECTIVES:To determine whether CT within 6 months after total arch replacement (TAR) with a frozen elephant trunk (FET) for chronic aortic dissection predicts mid-term outcomes and informs the timing of distal treatment. METHODS:We analysed 56 consecutive patients who underwent TAR with FET at 2 centres (2009-2022) and had evaluable 6-month postoperative CT. Early remodelling was defined as the change from baseline to 6 months in the maximal outer-to-outer diameter of the proximal descending thoracic aorta at Level A (Ishimaru zone 3, 20 mm distal to the left subclavian artery, measured on centreline-orthogonal reconstructions). Patients were classified as early positive remodelling (EPR; no increase or a decrease) or early negative remodelling (ENR; ≥1-mm increase). Prespecified outcomes were distal aortic reintervention, distal stent graft-induced new entry (dSINE), and overall survival. RESULTS:Mean follow-up was 5.4 years (standard deviation 3.7). Distal reintervention was required in 36/56 patients (64%). At 5 years, freedom from distal reintervention was higher with EPR than with ENR (44.6% vs 6.2%; P = .003). dSINE occurred in 26/56 patients (46.4%); 5-year dSINE-free survival was 65.1% (95% CI, 39.6-81.9) with EPR versus 18.2% (95% CI 5.9-35.2) with ENR (P = .008). Overall, 5-year survival for the cohort was 80.0% (95% CI 64.7-89.2). Among ENR patients, 5-year survival was 0% with conservative management versus 40.5% with distal intervention (P < .001); within EPR, 5-year survival was 65.9% with conservative management versus 85.7% with reintervention (P = .210). CONCLUSIONS:A 6-month CT provides simple, actionable risk stratification after TAR with FET for chronic aortic dissection. Absence of EPR identifies a high-risk subgroup (ENR) that warrants closer surveillance and timely distal intervention, optimizing follow-up intensity and treatment timing.
BACKGROUND:Social frailty, characterized by reduced social participation and support, is associated with adverse outcomes. Although patients with rheumatoid arthritis (RA) are at increased risk of social frailty, longitudinal changes remain unclear. This study investigated the reversibility of social frailty and associated factors in RA. METHODS:This longitudinal analysis was based on a multicenter observational cohort. Social frailty was assessed using the Social Frailty Index. Among the 605 patients with RA, 216 who were socially frail at baseline were enrolled. Improvement was defined as a reduction in score from ≥2 to ≤1 at 1-year follow-up. Multivariate logistic regression adjusted for age, sex, disease duration, disease activity, educational level, marital status, and Health Assessment Questionnaire Disability Index (HAQ-DI) was performed, and frequency of laughter was additionally included. RESULTS:Of the 216 patients, 87 (40.2%) improved after 1 year. Age and marital status were independently associated with improvement (OR [95% CI]: 0.99 [0.98-0.99] and 3.73 [1.97-7.05], respectively), whereas disease activity and educational level were not associated with improvement. Although frequency of laughter was significant in one model, this effect was not consistently demonstrated. HAQ-DI showed a trend but was not an independent factor. Component analysis showed higher improvement in social roles, daily conversation, and going out, whereas living alone showed minimal change. CONCLUSIONS:Among patients with baseline social frailty, social frailty in RA appears to be partially reversible. Marital status was independently associated with improvement, whereas disease activity was not.
We herein report four patients who were unable to receive idecabtagene vicleucel (ide-cel) due to disease progression, despite undergoing leukapheresis within specification. The median age of the patients was 70 (range, 68-77) years old. Two patients had nonsecretory subtypes at the diagnosis. The median number of prior therapy lines was 4.5 (range, 4-6), and 3 patients were penta-refractory. All patients were refractory to the latest treatment. The median time from apheresis to ide-cel cancellation was 44.5 (range: 24-71) days. Our findings suggest that the nonsecretory subtype and penta-refractoriness may increase the risk of treatment discontinuation. Early ide-cel application and improved bridging therapy are warranted to enhance treatment completion after leukapheresis.
