Background Infection is a serious complication of cardiovascular implantable electronic device (CIED) implantation. Kidney failure is as an independent risk factor for CIED infection and associated mortality. The presence of multiple comorbid conditions may contribute to varied clinical presentations and poor outcomes in hemodialysis (HD)–dependent patients with cardiac device infection. Study Design Case series. Setting & Participants CIED infections in HD patients (n=17) and non-HD patients (n=398) at Mayo Clinic in Rochester, MN, between 1991 and 2008. Outcomes Surgical management and death. Measurements Clinical presentations, microbial organisms. Results Of the 415 patients admitted with CIED infection, 17 (4%) were receiving long-term HD therapy. Among those on HD, mean age was 72±15 (SD) years, 59% were female, and 53% had a central venous catheter for dialysis access. All 17 patients receiving HD therapy presented with CIED-associated bloodstream infection and 41% of these had infected vegetations on CIED leads or cardiac valves. A majority (82%) were managed with complete device removal and almost half (43%) received a replacement device once bloodstream infection cleared. Device infection was associated with significant short-term mortality in HD patients and 90-day survival was only 76% in this group of patients. Limitations Smaller sample size, majority white cohort, observational study. Conclusions CIED infection in patients receiving HD therapy is usually associated with bloodstream infection and is frequently complicated with device-related endocarditis. Despite complete device removal in the majority of HD patients with infection, mortality remains high.

IntroductionGastroparesis is a common motility disorder that is characterized by delayed gastric emptying in the absence of mechanical obstruction. Diabetes, along with other neuromuscular and infiltrating disorders, can predispose individuals to an increased risk of developing gastroparesis. Gastroparesis can be easily diagnosed through gastric emptying studies but is usually difficult to successfully treat. Therapy usually begins with pro-kinetic and anti-emetic agents.Case presentationOur patient was an 87-year-old African-American woman who was a nursing home resident, with a history of diabetes mellitus type 2 and subarachnoid hemorrhage leading to aphasia, hemiplegia, seizures and dysphagia requiring percutaneous gastric feeds. While at the nursing home, she had recurrent aspiration pneumonia and large tube-feed residuals consistent with a diagnosis of underlying gastroparesis. Her management included metoclopramide and reduced tube-feeding rates, which improved her symptoms. However, within months the aspiration and increased residuals returned. After trials of different medication therapies without success, she started mirtazapine and her residual volume and aspirations decreased with a dose of 15mg nightly.ConclusionIn patients with gastroparesis recalcitrant to first line therapies such as metoclopramide, off-label use of mirtazapine may provide adequate non-invasive management of gastroparetic symptoms.

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Influenza causes cardiac and pulmonary complications that can lead to death. Its effect on the conduction system, first described a century ago, has long been thought to be fairly benign. We report 2 cases of high-grade atrioventricular block associated with acute influenza infection. Both patients—a 50-year-old woman with no history of cardiac disease or conduction abnormalities and a 20-year-old man with a history of complex congenital heart disease and conduction abnormalities—received a permanent pacemaker. In the first case, pacemaker interrogation at 4 months revealed persistent atrioventricular block. In the second case, pacemaker interrogation at 3 months suggested resolution. Whether such influenza-associated changes are transient or permanent remains unknown. We recommend keeping a careful watch on influenza patients with cardiac rhythm abnormalities and monitoring them closely to see if the problem resolves.