Recurrent acute coronary syndrome in a patient with right coronary artery ectasia: a case report

BACKGROUND

Coronary artery ectasia is characterized by an abnormal dilatation of the coronary arteries. Coronary artery ectasia is observed in 3-8% of patients undergoing coronary angiography and sometimes leads to acute coronary syndrome regardless of the presence or absence of coronary stenosis or atrial fibrillation.

CASE PRESENTATION

A 61-year-old Indonesian man presented with typical angina that began 1 week before admission and had worsened 3 hours prior to admission. Accompanying symptoms included dyspnea, nausea, and sweating. He was hemodynamically stable and had a history of tobacco smoking and dyslipidemia. An electrocardiogram showed ST-segment depression and T inversion. Laboratory results showed an international normalized ratio of 1.28. Dual antiplatelet therapy was administered along with fondaparinux, and symptoms were alleviated. Coronary angiography showed an ectatic and turbulent mid-distal right coronary artery and slow flow at the first presentation. There was a patent stent in the proximal-mid left anterior descending coronary artery. This patient had previously presented with recurrent acute coronary syndrome and received two coronary stents for the stenotic vessels.

DISCUSSION

He had right coronary artery ectasia and experienced recurrent acute coronary syndrome. He received dual antiplatelet therapy along with warfarin after stenting of his left anterior descending coronary artery. However, he presented with unstable angina pectoris 7 months before the latest admission and at the latest admission despite a patent stent and no other significant obstructive lesion. The unstable angina pectoris might have been caused by slow flow, microvascular angina caused by small thrombi and/or vasospasm, or epicardial thrombosis at the ectatic coronary artery that dissolved after anticoagulation therapy prior to coronary angiography. Anticoagulant therapy may have a greater benefit than antiplatelet therapy in this patient due to the turbulence and stasis of blood in the ectatic vessel, although coexisting coronary conditions mandated antiplatelet therapy. His international normalized ratio was suboptimal and needed to be improved.

CONCLUSION

Coronary ectasia may play a role in recurrent acute coronary syndrome, and administration of an anticoagulant to prevent acute coronary syndrome in this patient was in accordance with the varying hemodynamic property of coronary artery ectasia.

Is Anticoagulant Necessary in Patients with Coronary Artery Ectasia Presenting with Acute Coronary Syndrome? A Systematic Review of Case Reports

Coronary artery ectasia is found in 3 to 8% of patient's undergoing angiography and may sometimes induce acute myocardial infarction. Some articles reported a recurrence of acute coronary syndrome (ACS) in the presence of coronary artery ectasia (CAE). Our study aims to summarize the latest evidence on whether the use of anticoagulant in addition to SAPT/DAPT (single antiplatelet/dual antiplatelet) treating ACS with CAE patients is necessary. Since the trials concerning our objectives were scarce, we pooled case reports/series. We performed a comprehensive search on case reports/series on coronary artery ectasia that presented with acute coronary syndrome published until March 2019. We collected 13 cases from 11 reports. Out of 13 patients, 5 (38.5%) took DAPT only without anticoagulant and 8 (61.5%) took anticoagulant ± DAPT. Three out of five (60%) who took DAPT only, experienced recurrences at 1st and 2nd months' follow-up. The other two (40%) was uneventful at a mean of two months' follow-up. Eight patients who took anticoagulant were uneventful for a mean of 8.4 months. Those who took anticoagulant were at lower risk of experiencing ACS recurrence ( p  = 0.035). Two of the patients who experienced recurrence became 6 and 12 months free after optimal anticoagulation. The author of this study proposed that anticoagulant must be considered should SAPT/DAPT failed to provide adequate protection to the recurrence of ACS, especially in CAE patients who did not have other obvious stenotic lesions. However, the evidence is weak since this study only pooled case reports/series.

Serum Galectin-3 level and recurrence of atrial fibrillation post-ablation - Systematic review and meta-analysis

BACKGROUND

Serum galectin-3, a circulating biomarker of fibrosis, has been associated with atrial remodelling. Recent studies investigating serum galectin-3 and AF recurrence post-ablation have shown mixed results. We aimed to analyze the latest evidence on the association between serum galectin-3 and AF recurrence after catheter ablation.

METHODS

We performed a comprehensive search on topics that assesses serum galectin-3 and AF recurrence post-ablation up until August 2019.

RESULTS

There were 597 patients from seven studies. The mean difference of serum galectin-3 was similar in both AF recurrence and non AF recurrence group (mean difference 0.78 ng/mL [-0.56, 2.13]; p = 0.25; I2: 69%. Upon removal of a study in sensitivity analysis, the serum galectin-3 became higher in AF recurrence group (mean difference 1.41 ng/mL [0.47, 2.34], p = 0.003; I2: 17%). Serum galectin-3 was associated with a higher risk for AF recurrence (HR 1.25 [1.01, 1.55]; p = 0.04; I2: 76%). Upon removal of a study in sensitivity analysis, HR became 1.45 [1.07, 1.96], p = 0.02; I2: 47%. Meta-analysis of adjusted HR demonstrated that high serum galectin-3 independently predicts AF recurrence (HR 1.15 [1.02, 1.29], p < 0.02; I2: 57%, p = 0.10) CONCLUSION: Serum galectin-3 is associated with an increased risk of AF recurrence post-ablation. Further studies are required, especially emphasis on the cut-off point should be given, before integrating it in routine risk stratification for AF ablation.

Association between PR Interval, First-degree atrioventricular block and major arrhythmic events in patients with Brugada syndrome - Systematic review and meta-analysis

BACKGROUND

Risk stratification in patients with asymptomatic Brugada Syndrome is challenging, and despite recent advances, there is no clear evidence. The first-degree atrioventricular block was hypothesized to be a predictor of arrhythmic events. Measurement of the PR interval and diagnosing atrioventricular block from surface ECG is easy, noninvasive, and cost-effective. We aimed to assess the latest evidence on PR interval or first-degree atrioventricular block and major arrhythmic events related to Brugada Syndrome.

METHODS

We performed a comprehensive search in PubMed for "atrioventricular block" OR "PR interval" and "Brugada syndrome." We included studies that have a component of PR interval and/or first-degree atrioventricular block and major arrhythmic events related to Brugada Syndrome including syncope/VT/VF/appropriate ICD shocks/ICD implantation.

RESULTS

We included 1526 subjects from 7 studies. Pooled mean difference of PR interval in 4 studies showed a significant difference [MD 10.77 ms (2.97-18.57) P = 0.007, moderate-high heterogeneity I2 = 53% P = 0.08]. On sensitivity analysis by removing a study, it became MD 6.50 ms [1.97-11.03], P = 0.005, heterogeneity I2 = 0% P = 0.52. Indicating that PR interval was prolonged by small margin. Pooled analysis of the association between a first-degree atrioventricular block and major arrhythmic events was significant [OR 3.33 (2.02-5.50) P < 0.001, low heterogeneity I2 = 0% P = 0.57].

CONCLUSION

First-degree AV block is associated with more frequent major arrhythmic events in Brugada syndrome patients. PR interval seemed to be prolonged but is yet to be determined whether the PR interval association is still significant if it did not cross the first-degree AVB threshold.

Efficacy and safety of catheter ablation for atrial fibrillation in congenital heart disease - A systematic review and meta-analysis

BACKGROUND

Prevalence of atrial fibrillation (AF) in patients with congenital heart disease (CHD) is on the rise. Anti-arrhythmic drugs are usually the first line of treatment in CHD, however, it is often ineffective and poorly tolerated. We aimed to perform a systematic review to assess the efficacy and safety of catheter ablation for AF in CHD.

METHODS

We performed a comprehensive search on catheter ablation for atrial fibrillation in congenital heart disease up until July 2019 through several electronic databases.

RESULTS

Ablation of AF in patients with CHD had a modest 12 months AF freedom ranging from 32.8% to 63%, which can be increased by subsequent/repeat ablation. The complexity of CHD appears to have a significant effect on a study but not in others. Catheter ablation in ASD and persistent left superior vena cava had a high success rate. Overall, catheter ablation is safe whichever the type of CHD is.

CONCLUSION

Catheter ablation for AF in CHD had modest efficacy that can be increased by subsequent/repeat ablation and it also has an excellent safety profile. Ablation in complex CHD could also have similar efficacy, however, it is preferably done by experts in a high volume tertiary center.

Efficacy and safety of renal denervation in addition to pulmonary vein isolation for atrial fibrillation and hypertension-Systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

This systematic review and meta-analysis aimed to assess the latest evidence on the use of renal denervation (RDN) + pulmonary vein isolation (PVI) compared to PVI alone for treating atrial fibrillation (AF) with hypertension.

METHODS

A systematic literature search from several electronic databases was performed up until January 2020. The primary outcome was AF recurrence defined as AF/atrial flutter (AFL)/atrial tachycardia (AT) ≥30 seconds at 12-month follow-up and the secondary outcome was procedure-related complications.

RESULTS

There were 568 subjects from five studies. AF recurrence was 90/280 (32.1%) in the RDN + PVI group and 142/274 (51.8%) in the PVI group. RDN + PVI was associated with a lower incidence of AF recurrence (RR 0.62 [0.51, 076], P < .001; I 2: 0%). Pooled analysis of HR showed that RDN + PVI was associated with reduced AF recurrence (HR 0.51 [0.38, 0.70], P < .001; I 2: 0%). Complications were 7/241 (2.9%) in the RDN + PVI group and 8/237 (3.4%) in the PVI group. The rate of complications between the groups was similar (RR 0.87 [0.33, 2.29], P = .77; I 2: 0%). In the subgroup analysis of paroxysmal AF, RDN + PVI was shown to reduce AF recurrence (RR 0.64 [0.49, 0.82], P < .001; I 2: 0% and HR 0.56 [0.38, 0.82], P = .003; I 2: 0%) compared to PVI alone. RDN + PVI has a moderate certainty of evidence in the reducing AF recurrence with an absolute reduction of 197 fewer per 1000 (from 254 fewer to 124 fewer).

CONCLUSION

RDN in addition to PVI, is associated with reduced 12-month AF recurrence and similar procedure-related complications compared to PVI alone.

The efficacy and safety of oral paracetamol versus oral ibuprofen for patent ductus arteriosus closure in preterm neonates - A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to synthesize the latest evidence on the efficacy and safety of oral acetaminophen compared to oral ibuprofen for patent ductus arteriosus (PDA) in preterm infants.

METHODS

We performed a systematic literature search on topics that assesses the use of oral paracetamol compared to oral ibuprofen in preterm neonates diagnosed with PDA from PubMed, EuropePMC, Cochrane Central Database, ScienceDirect, ProQuest, ClinicalTrials.gov, and hand-sampling from potential articles.

RESULTS

There were 1547 subjects from 10 selected studies. Primary closure rate was similar in both groups. Subgroup analysis on studies enrolling neonates with ≤30 weeks gestational age showed that ibuprofen was superior (OR 0.52 [0.31, 0.90], I2: 0%). On the other hand, paracetamol was superior neonates with ≤34 weeks gestational age (OR 1.73 [1.01, 2.94], I2: 30%). Reopening rate, surgical closure rate, mortality, intraventricular hemorrhage, and necrotizing enterocolitis were similar in both groups. Rate of renal dysfunction (OR 0.27 [0.10, 0.77], I2: 0%) and gastrointestinal bleeding (OR 0.31 [0.11, 0.88], I2: 0%) were lower in paracetamol group. Subgroup analysis of randomized controlled studies (RCTs) showed similar results. Meta-regression analysis showed that the primary closure rate was not influenced by gestational age, birth weight, and gender. GRADE demonstrates a low level of certainty for primary closure and mortality. Renal dysfunction and gastrointestinal bleeding havea moderate level of certainty.

CONCLUSION

There was no significant difference between the efficacy of oral paracetamol and oral ibuprofen. However, the rate of renal dysfunction and gastrointestinal bleeding were higher in oral ibuprofen.

Clinical significance of bendopnea in heart failure-Systematic review and meta-analysis

BACKGROUND

Bendopnea is a symptom mediated by increased ventricular filling pressure during bending forward. Presence of bendopnea in patients can be easily evaluated without additional maneuver in several countries whose norms, habits, culture, and occupation relates to a higher frequency of bending forward. This information may prove valuable in routine clinical practice. We aimed to analyze the latest evidence on bendopnea in order to further define the clinical significance of this symptom.

METHODS

We performed a comprehensive search on bendopnea in heart failure from inception up until January 2019 through PubMed, EuropePMC, EBSCOhost, Cochrane Central Database, and ClinicalTrials.gov.

RESULTS

There were 283 patients (31.76%) who have bendopnea, and a total of 891 patients from six studies were included. Bendopnea was associated with the presence of dyspnea [odds ratio (OR) 69.70 (17.35-280.07); <0.001], orthopnea [OR 3.02 (2.02-4.52); <0.001], paroxysmal nocturnal dyspnea [OR 2.76 (1.76-4.32); <0.001], and abdominal fullness [OR 7.50 (4.15-13.58); <0.001]. Association with elevated jugular venous pressure was shown in two studies. New York Heart Association (NYHA) functional class IV was more prevalent in patients with bendopnea [OR 7.58 (4.35-13.22); <0.001]. Bendopnea was also associated with increased mortality [OR 2.21 (1.34-3.66); 0.002].

CONCLUSION

Bendopnea is associated with the presence of several signs and symptoms. This study also showed that bendopnea is one of the signs and symptoms of advanced heart failure associated with increased mortality. However, owing to the limited number of studies, further investigation is needed before drawing a definite conclusion.

Fragmented QRS is associated with intraventricular dyssynchrony and independently predicts nonresponse to cardiac resynchronization therapy-Systematic review and meta-analysis

BACKGROUND

Fragmented QRS (fQRS) is postulated to be associated with ventricular dyssynchrony and might be able to predict a nonresponse to cardiac resynchronization therapy (CRT) implantation. In this systematic review and meta-analysis, we aim to assess whether fQRS can be a marker of intraventricular dyssynchronies in patients with ischemic and nonischemic cardiomyopathy and whether it is an independent predictor of nonresponse in patients receiving CRT.

METHODS

We performed a comprehensive search on topics that assesses fQRS and its association with intraventricular dyssynchrony and nonresponse to CRT up until September 2019.

RESULTS

Fragmented QRS is associated with intraventricular dyssynchrony (OR 10.34 [3.39, 31.54], p < .001; I2 : 80% with sensitivity 76.8%, specificity 77%, LR+ 3.3, and LR- 0.3). Subgroup analysis showed that fQRS is associated with intraventricular dyssynchrony in patients with narrow QRS complex (OR 20.92 [12.24, 35.73], p < .001; I2 : 0%) and nonischemic cardiomyopathy (OR of 19.97 [12.12, 32.92], p < .001; I2 : 0%). Fragmented QRS was also associated with a higher time-to-peak myocardial sustained systolic (Ts-SD) (OR 15.19 [12.58, 17.80], p < .001; I2 : 0% and positive Yu index (OR 15.61 [9.07, 26.86], p < .001; I2 : 0%). Fragmented QRS has a pooled adjusted OR of OR of 1.70 [1.35, 2.14], p < .001; I2 : 62% for association with a nonresponse to CRT. QRS duration is found to be higher in nonresponders group mean difference -8.54 [-13.38, -3.70], p < .001; I2 : 70%.

CONCLUSION

Fragmented QRS is associated with intraventricular dyssynchrony and is independently associated with nonresponse to cardiac resynchronization therapy.

Electrocardiographic early repolarization is associated with future ventricular arrhythmia after acute myocardial infarction-Systematic Review and Meta-Analysis

BACKGROUND

Early repolarization (ER) has been linked to ventricular arrhythmia (VA) and sudden cardiac death in patients without structural heart disease. We aimed to assess the latest evidence on whether ER is associated with future VA after acute myocardial infarction (AMI).

METHODS

We performed a comprehensive search on the topic that assesses ER and VA/adverse cardiovascular events in AMI. We included studies with sufficient details on ER and VA, we also performed a meta-analysis on their morphology.

RESULTS

A total of 3350 subjects from 9 studies were included. Five hundred and twenty-one (15.55%) had ER and 2829 (84.45%) did not. On meta-analysis, ER (+) in AMI was associated with VA with a pooled odds ratio (OR) of 3.58 (2.70-4.73), P < 0.001; heterogeneity I 2 34%. Subgroup analysis of patients with ST-segment elevation myocardial infarction (STEMI) showed an OR of 2.79 [1.98-3.93], P < 0.001; heterogeneity I 2 0%. Inferior location of ER (+) was associated with VA OR 3.98 [1.86-8.53], P = 0.008; I 2 67%. Notching had a 5.41 [3.52-8.32], P < 0.001; low heterogeneity I 2 0% of having VA. Pooled OR for J-point elevation was 4.72 [2.63-8.46], P < 0.001; I 2 25%. Horizontal ST-segment was associated with VA with an OR of 4.30 [1.89-975], P < 0.001; I 2 59%. Lateral location and slurred morphology were not associated with VA. Upon sensitivity analysis for inferior location and horizontal ST-segment, removal of a study reduces heterogeneity significantly.

CONCLUSION

Early repolarization especially those with the inferior location, notching morphology, an elevated J-point and horizontal ST-segment had a higher likelihood of VA in AMI including STEMI patients.

Markers of ventricular repolarization as an additional non-invasive electrocardiography parameters for predicting ventricular tachycardia/fibrillation in patients with Brugada Syndrome - A systematic review and meta-analysis

BACKGROUND

Controversies surrounded the management of asymptomatic Brugada syndrome. Prognostication using electrophysiology study (EPS) is disputable. Non-invasive parameters may be a valuable additional tool for risk stratification. We aim to evaluate the use markers of ventricular repolarization including Tpeak-to-Tend (TpTe), Tpe Dispersion, TpTe/QT ratio, and QTc interval as additional non-invasive electrocardiography parameters for predicting ventricular tachycardia/fibrillation in patients with Brugada syndrome.

METHODS

We performed a comprehensive search on TpTe, Tpe Dispersion, TpTe/QT ratio, and QTc interval as a predictor for ventricular tachycardia(VT)/fibrillation(VF)/aborted sudden cardiac death/appropriate ICD shock in patients with Brugada syndromes up until October 2018.

RESULTS

We included ten studies in the qualitative synthesis and eight studies in meta-analysis. There were a total of 2126 subjects from ten studies. We found that TpTe interval (mean difference 11.97 m s [5.02-18.91]; p < 0.001; I2 80% possibly on ≥80-100 m s and maximum QTc interval (mean difference 11.42 m s [5.90-16.93], p < 0.001; I2 28%) were the most potential ECG parameters to predict VT/VF/AT/SCD. Tpe dispersion and TpTe/QT ratio have a high heterogeneity. Upon sensitivity analysis, there is no single study found to markedly affect heterogeneity of Tpe dispersion and TpTe/QT ratio. Removal of a study reduced maximum QTc interval heterogeneity to 0%.

CONCLUSIONS

Measurement of TpTe interval, Tp-e dispersion, TpTe/QT ratio, and QTc interval on ECG emerge as a promising prognostication tool which needs further investigations with a more standardized method, outcome, and cut-off points. As for now, only maximum QTc interval has a reliable result with low heterogeneity sufficiently reliable for prognostication.

Evidence-Based Case Report: The Use of D-Dimer Assay to Exclude Left Atrial Thrombus in Patient with Atrial Fibrillation >48 Hours

INTRODUCTION

Patients with atrial fibrillation (AF) for >48 hours who are a candidate for cardioversion should have transesophageal echocardiography (TEE) performed to exclude left atrial thrombus (LAT) that may cause systemic thromboembolism upon conversion to sinus rhythm. However, TEE facilities were limited, especially in developing countries.

CASE ILLUSTRATION

A 50 years-old man presented with exertional dyspnea and palpitation for 72 hours prior to admission. Electrocardiography showed AF with a ventricular rate of 140x/minute. Cardioversion was decided to be the best approach. This patient has an AF >48 hours of onset, hence, LAT should be excluded by the use of TEE. Unfortunately, there was no TEE facility nearby.

DISCUSSION

Upon comprehensive search on the use of D-Dimer assay to exclude the LAT in AF patients, we found seven studies showed increased D-dimer level in those with left atrial thrombus. In 4 studies, AUC was > 0.70, sensitivity and specificity varied from 75.9% to 89% and 73.1% to 95% respectively. However, there is no single cut-off point, due to the heterogeneity of cut-off points.

CONCLUSION

D-dimer assay combined with other variables of atrial thrombus exclusion score is valuable in excluding LAT. Previously, weeks of anticoagulation is more advisable before attempting cardioversion in the absence of nearby TEE facilities. With current evidence, a low D-dimer and ATE score of 0 is safe for cardioversion.

Left atrial posterior wall isolation in addition to pulmonary vein isolation using a pentaspline catheter in pulsed-field ablation for atrial fibrillation: A systematic review and meta-analysis

BACKGROUND

Persistent atrial fibrillation (AF) may require extensive ablation strategies. Left atrial posterior wall isolation (LAPWI) might address potential substrates for recurrence during pulsed-field ablation (PFA).

OBJECTIVE

This meta-analysis aimed to investigate the feasibility and effectiveness of LAPWI in addition to pulmonary vein isolation (PVI) using a pentaspline catheter in PFA for AF.

METHODS

Comprehensive search was conducted using PubMed, SCOPUS, ScienceDirect, and EuropePMC for studies reporting LAPWI+PVI using a pentaspline catheter in PFA ablation for AF. The primary outcome was atrial tachyarrhythmia (ATa) recurrence, defined as AF/atrial flutter/atrial tachycardia after blanking period.

RESULTS

There were 882 patients from 7 studies. The success rate of LAPWI was 100% using mean/median of 16 to 20 added PFA applications with no reported acute left atrial posterior wall reconnection and esophageal complications. In mean follow-up of 240 ± 91 days, ATa recurrence was 21% (95% CI 13%-29%; I2 = 84.8%) in the LAPWI+PVI group. Meta-regression analysis showed that age, left ventricular ejection fraction, and repeat procedure did not significantly influence ATa recurrence (P > .05). Each 1-mm increase in left atrial diameter, increases the chance of ATa recurrence by 6% (R2 = 100%, P < .001, I2 = 0%). Meta-analysis showed no difference in terms of ATa recurrence among LAPWI+PVI patients compared with those without LAPWI (odds ratio 0.78, 95% confidence interval 0.50-1.21, P = .27; I2 = 0%, P = .86). Procedure time and fluoroscopy time did not significantly differ (P > .05).

CONCLUSION

LAPWI using a pentaspline catheter during PFA was feasible and did not prolong the procedure/fluoroscopy but did not reduce ATa recurrence. LAPWI may be considered during PFA, although the benefit is uncertain.

The impact of empirical superior vena cava isolation in addition to pulmonary vein isolation on outcomes in atrial fibrillation - Systematic review, meta-analysis, and meta-regression

BACKGROUND

Atrial tachyarrhythmia (ATa) recurrence remains high after pulmonary vein isolation (PVI), with the superior vena cava (SVC) being a common source of non-pulmonary vein foci.

OBJECTIVE

This meta-analysis aimed to synthesize the latest evidence and provide elaborate comparative analysis and meta-regression analysis regarding the empirical SVC isolation (eSVCi) versus no eSVCi in atrial fibrillation (AF) ablation.

METHODS

A systematic review was conducted on studies comparing eSVCi to no eSVCi (PVI-only or adjunctive SVC isolation). The primary outcome was ATa recurrence, defined as AF/atrial flutter/atrial tachycardia lasting over 30 s after a blanking period. Secondary outcomes included procedural duration, fluoroscopic duration, and complications.

RESULTS

Thirteen studies involving 2,176 patients were analyzed, with a mean follow-up of 18 ± 9.6 months. ATa recurrence was significantly lower with eSVCi (OR 0.54 [95 % CI: 0.41, 0.72], p < 0.001; I2 = 40.7 %). Subgroup analysis revealed eSVCi reduced ATa recurrence in observational studies but not in RCTs, and in initial ablations but not repeat procedures. eSVCi was beneficial in both PVI-only and adjunctive SVC isolation subgroups. Meta-regression showed the benefit of eSVCi was less in patients with non-paroxysmal AF (p = 0.044) and hypertension (p = 0.012). Procedural time, fluoroscopic time, and complications were similar between the two groups.

CONCLUSION

eSVCi potentially reduce ATa recurrence compared to no eSVCi, without increasing complications or prolonging procedural times.

Prevention of Contrast-induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention

Contrast-induced nephropathy (CIN) or contrast-induced acute kidney injury has varying definitions, but in general, increased serum creatinine level by ≥ 0.3 mg/dL (26.5 µmol/L) or 1.5x of baseline value or urine output <0.5 mL/kg/h within 1-7 days after contrast media (CM) administration can be considered as CIN. CIN is one of the most common complications and is associated with increased mortality in patients undergoing percutaneous coronary intervention (PCI). Thus, risk stratification for CIN should be made and preventive strategies should be employed in which the intensity of the approach must be tailored to patient's risk profile. In all patients, adequate hydration is required, nephrotoxic medications should be discontinued, and pre-procedural high-intensity statin is recommended. In patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, IV hydration should be started 12 hours pre-procedure up until 12-24 hours after the procedure. Remote ischemic preconditioning may be performed pre-procedurally. Radial first approach for vascular access is recommended. During the procedure, low or iso-osmolar CM should be used and its volume should be limited to eGFR x 3.7. In patients at high risk for CIN, additional contrast-sparing strategies may be applied, such as using a contrast reduction system, 5 Fr catheter with no sideholes, CM dilution, limiting test injection, confirming placement using guidewire, use of stent enhancing imaging technology, using metallic/software roadmap to guide PCI, use of IVUS or dextran-based OCT, and coronary aspiration. A more advanced hydration technique based on central venous pressure, left ventricular end-diastolic pressure, or using furosemide-matched hydration, might be considered.

Very-high-power Short-duration Ablation versus Conventional Ablation for Pulmonary Vein Isolation in Atrial Fibrillation: Systematic Review and Meta-analysis

The aim of this study was to compare the effectiveness and safety of very-high-power short-duration (VHPSD) ablation (70-90 W/4-7 s) with conventional ablation (30-40 W/>20 s, 50 W/7-11 s) for pulmonary vein isolation (PVI) in patients with AF. A total of 13 studies were included in this analysis (1,527 patients). AF recurrence occurred in 14% (95% CI [11-18%]) of the VHPSD group. VHPSD was associated with lower AF recurrence (OR 0.65; 95% CI [0.48-0.89]; p=0.006) compared with the conventional ablation group. Subgroup analysis showed that additional ablation beyond PVI had a similar rate of AF recurrence (16% versus 10%) compared with PVI alone. Procedure and ablation durations were significantly shorter in the VHPSD group with a mean differences of -14.4 minutes (p=0.017) and -14.1 minutes (p<0.001), respectively. Complications occurred in 6% (95% CI [3-9%]) of the VHPSD group, and the rate was similar between the two groups (OR 1.03; 95% CI [0.60-1.80]; p=0.498). VHPSD ablation resulted in less AF recurrence and a shorter procedure time. Additional ablation beyond PVI alone in VHPSD may not provide additional benefits.

Ethanol infusion into the vein of Marshall reduced atrial tachyarrhythmia recurrence during catheter ablation: A systematic review and meta-analysis

BACKGROUND

Ethanol infusion into the vein of Marshall (EIVoM) may increase mitral isthmus bidirectional block (MIBB) and cause local autonomic denervation that may improve outcome.

OBJECTIVE

This meta-analysis aimed to investigate whether the addition of EIVoM to atrial fibrillation (AF) ablation led to a better outcome.

METHODS

Systematic literature search was performed using PubMed, Scopus, ScienceDirect, and Europe PMC for studies that compared the addition of EIVoM during AF ablation with radiofrequency ablation. The primary outcome was atrial tachyarrhythmia (ATa) recurrence, defined as AF/atrial flutter/atrial tachycardia after the blanking period.

RESULTS

There were 2821 patients from 11 studies, and EIVoM was successful in 77% (95% confidence interval [CI] 62%-92%). ATa recurrence was 27% (95% CI 20%-34%) in the EIVoM group and 42% (95% CI 33%-51%) in ablation-only group. EIVoM reduced ATa recurrence (odds ratio [OR] 0.52; 95% CI 0.36-0.76; P < .001; I2 = 76.92). The rate of MIBB was 85% (95% CI 77%-94%) in the EIVoM group and 73% (95% CI 61%-85%) in the ablation-only group, which was significantly higher (OR 3.87; 95% CI 1.46-10.28; P < .001; I2 = 83.68). The mitral isthmus reconnection rate (OR 0.44; 95% CI 0.15-1.29; P = .14; I2 = 63.6) and repeat procedure rate (OR 0.76; 95% CI 0.53-1.08; P = .12; I2 = 48) were similar; however, a leave-one-out sensitivity analysis showed P < .05 for both. The benefits of EIVoM were not affected by age, left atrial diameter, and left ventricular ejection fraction (P > .05). Age (P = .029) and left atrial diameter (P = .042) were inversely associated with EIVoM benefits in terms of repeat ablation and mitral isthmus reconnection (age; P = .003).

CONCLUSION

The addition of EIVoM to ablation increased MIBB and reduced ATa recurrence.

Fragmented QRS and QRS Duration As a Marker of Myocardial Reperfusion Measured by Myocardial Blush Grade in Reperfusion Therapy: Systematic Review and Meta-Analysis

Myocardial blush grade (MBG) is an indicator of microvascular perfusion and patency and an independent predictor of cardiac outcomes. QRS duration and fragmented QRS (fQRS) before reperfusion and its changes after reperfusion are shown to be associated with MBG. We aimed to assess the latest evidence on the association between fQRS and QRS duration with MBG in reperfusion therapy. We performed a comprehensive search on the association between fQRS and QRS duration in successful/impaired reperfusion measured by MBG. There were a total of 1,311 patients from six studies. A shorter QRS duration immediately and at 60 minutes after reperfusion attempt was associated with successful reperfusion, with a mean difference (MD) of -10.62 ms ([-15.55, -5.70]; p  < 0.001; I 2  = 69%) and -15.66 ms ([-19.96, -11.37]; p  < 0.001; I 2  = 77%), respectively, and upon sensitivity analysis, with exclusion of a study, heterogeneity decreases to 33 and 0%. QRS narrowing immediately and 60 minutes after reperfusion attempt was correlated with reperfusion, with an MD of -10.72 ([-16.57, -4.88] ; p  < 0.001; I 2  = 97%) and -10.93 ([-14.00, -7.85]; p  < 0.001; I 2  = 97%), lesser in impaired reperfusion, respectively. QRS duration on admission was not associated with reperfusion outcome. Two studies reported that fQRS was associated with impaired perfusion, with an odds ratio of 9.88 ([5.62-17.38]; p  < 0.0001) and 4.74 ([2.45-9.20]; p  < 0.0001), respectively. A longer QRS duration immediately and at 60 minutes after reperfusion attempt was associated with impaired perfusion. QRS narrowing after reperfusion attempt was correlated with successful reperfusion. fQRS was also associated with a higher probability of impaired perfusion.