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Case Presentation: An 86 year old man underwent PCI of distal LAD for severe single vessel coronary artery disease identified after a high risk pharmacologic nuclear stress test (evaluation of exertional fatigue prior to abdominal aortic aneurysm surgical repair). ECHO was consistent with preserved LVEF (60-65%), moderate concentric LVH and mild left atrial enlargement. Less than a week after PCI, he presented to the emergency department for NYHA III dyspnea and fatigue. The patient was not taking any negative chronotropic medications. CT angiography of the chest excluded pulmonary edema, pneumonia and pulmonary embolism; repeat limited ECHO was unchanged. EKG showed first degree AV block (PR 400ms, figure 1). Severely prolonged PR interval with otherwise-unexplained exertional symptoms raised suspicion for pseudo-pacemaker syndrome. In the absence of an alternative cause of declining exertional tolerance, a dual chamber pacemaker with short programmed AV delay (<200ms) was implanted. The patient reported resolution of exertional fatigue and dyspnea on one-month followup. Discussion: Pseudo-pacemaker syndrome is a rare, infrequently reported, complication of first degree AV block with severely prolonged PR>300ms. P-wave at the end of the preceding T-wave suggests AV dyssynchrony (arrowhead, figure 1). Left atrial contraction against a closed mitral valve led to loss of atrial contribution to cardiac output, and elevated left atrial pressure. These changes, accentuated by physiologic increase in heart rate on exertion, most likely caused symptoms in this patient. It is interesting that AV dyssynchrony in pacemaker syndrome is caused by the pacemaker (VVI pacing) whereas the AV dyssynchrony in pseudo-pacemaker syndrome from severely prolonged PR interval is treated with a pacemaker. In the appropriate clinical picture, it is an indication for dual-chamber pacemaker implantation for first degree AV block without bradycardia or pauses.

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PAM and pneumococcal meningitis remain virtually indistinguishable; however, these predictive features should be validated in a prospective study and may lead to a viable algorithm for early management of these patients.

Background: Acute kidney injury (AKI) complicating cardiogenic shock is associated with increased mortality. We hypothesize that renal replacement therapy (RRT) improves survival in cardiogenic shock supported by Impella-CP (Abiomed, Danvers, MA) complicated by AKI. Methods: A retrospective chart review identified 34 patients on Impella-CP for cardiogenic shock between January 2015 and December 2017. AKI was defined as an increase in serum creatinine≥0.3 mg/dL from baseline. Three groups were analyzed: AKI plus RRT, AKI minus RRT, and no AKI. Pre-existing dialysis patients were excluded. The only indication for RRT was AKI not responding to diuretics. Thirty-day mortality was analyzed. Results: There were 13 patients with no AKI, 9 with AKI plus RRT groups, and 12 with AKI minus RRT. Thirty-day mortality was similar between no AKI and AKI plus RRT groups [30.8% (4/13) vs.22.2% (2/9), p=0.48; relative risk [RR] 2.25 (95% confidence interval [CI] 0.22-22.1)]. Thirty-day mortality was higher in AKI minus RRT group compared to the no AKI group [75.0% (9/12) vs. 30.8% (4/13); p=0.03; RR 6.75 (95% CI 1.16-39.2)]. Conclusion: In cardiogenic shock patients on Impella-CP, AKI minus RRT is associated with a higher 30-day mortality compared to patients without AKI and/or patients with AKI plus RRT. Short-term mortality may improve in cardiogenic shock patients with AKI who are treated with RRT.