Clinical Significance of Supraventricular Tachycardia During Pregnancy in Healthy Women

BACKGROUND

Supraventricular tachycardias (SVT) are the most frequently encountered arrhythmias in pregnancy with unclear clinical significance.

OBJECTIVES

This study sought to report the prevalence, describe the management, and explore the association between SVT and adverse obstetric outcomes.

METHODS

Cohort study of primiparous and multiparous women without history of Cesarean section (CS), and with structurally normal hearts admitted in labor. The study group consisted of women with at least 1 SVT episode during pregnancy, and the control group was randomly selected in a 4:1 ratio.

RESULTS

Of 141,769 women meeting the inclusion criteria, SVT diagnosis was confirmed in 122. A total of 76 (age 33.2 ± 4.8 years) had at least 1 symptomatic and documented episode during pregnancy. In women with a known SVT diagnosis before pregnancy, medical therapy was not associated with a lower risk of SVT recurrence (OR: 1.07; 95% CI: 0.41-2.80). However, catheter ablation before pregnancy was associated with significantly lower risk of SVT recurrence (OR: 0.09; 95% CI: 0.04-0.23). Women with SVT during pregnancy had higher incidence of CS (39.5% vs 27.0%; P = 0.03), and preterm labor (PTL) (30.3% vs 8.6%; P < 0.001). Adjusting for age and parity, SVT during pregnancy was an independent predictor of CS (OR: 1.80; 95% CI: 1.03-3.10), particularly planned CS (OR: 2.89; 95% CI: 1.06-7.89) and PTL (OR: 4.37; 95% CI: 2.30-8.31).

CONCLUSIONS

SVT during pregnancy is associated with increased risk for CS and PTL in healthy women. History of SVT should be sought as early as preconception counseling, and a multidisciplinary approach is warranted for both prevention and management of SVT occurrence.

Pulmonary vein narrowing after pulsed field versus thermal ablation

AIMS

When it occurs, pulmonary vein (PV) stenosis after atrial fibrillation (AF) ablation is associated with significant morbidity. Even mild-to-moderate PV narrowing may have long-term implications. Unlike thermal ablation energies, such as radiofrequency (RF) or cryothermy, pulsed field ablation (PFA) is a non-thermal modality associated with less fibrotic proliferation. Herein, we compared the effects of PFA vs. thermal ablation on PV narrowing after AF ablation.

METHODS AND RESULTS

ADVENT was a multi-centre, randomized, single-blind study comparing PFA (pentaspline catheter) with thermal ablation-force-sensing RF or cryoballoon (CB)-to treat drug-refractory paroxysmal AF. Pulmonary vein diameter and aggregate cross-sectional area were obtained by baseline and 3-month imaging. The pre-specified, formally tested, secondary safety endpoint compared a measure of PV narrowing between PFA vs. thermal groups, with superiority defined by posterior probability > 0.975. Among subjects randomized to PFA (n = 305) or thermal ablation (n = 302), 259 PFA and 255 thermal ablation (137 RF and 118 CB) subjects had complete baseline and 3-month PV imaging. No subject had significant (≥70%) PV stenosis. Change in aggregate PV cross-sectional area was less with PFA (-0.9%) than thermal ablation (-12%, posterior probability > 0.999)-primarily driven by the RF sub-cohort (-19.5%) vs. CB sub-cohort (-3.3%). Almost half of all PFA PV diameters did not decrease, but the majority (80%) of RF PVs decreased, regardless of PV anatomic location.

CONCLUSION

In this first randomized comparison of PFA vs. thermal ablation, PFA resulted in less PV narrowing-thereby underscoring the qualitatively differential and favourable impact of PFA on PV tissue.

Anatomically Based Ablation of Left Ventricular Summit Premature Ventricular Complexes Guided by Intracardiac Echocardiography

Catheter ablation of premature ventricular contractions (PVCs) arising from the left ventricular summit (LVS) presents technical challenges due to the regional anatomy and frequent intramural site of origin (SOO). Intracardiac echocardiography (ICE) and the CARTOSOUND® (Biosense Webster, Diamond Bar, CA, USA) module allow the operator to directly reconstruct and visualize the dimensions and orientation of the LVS live and present it in relation to neighboring structures. We retrospectively reviewed consecutive cases between January 2021 and December 2022 of patients undergoing PVC ablation for a presumed LVS origin. The LVS was reconstructed by creating a three-dimensional representation of the left ventricular septum, using two-dimensional ICE sections. The earliest site in each chamber was tagged on the reconstructed LVS, and the presumed SOO was localized using a geometrical center point from all sites. Ablation was first delivered to the earliest site, except when the presence of coronary branches precluded radiofrequency delivery within the great cardiac vein. Of 20 patients (8 women, 62.4 ± 7.1 years old) with a presumed LVS origin, 12 had PVC recurrence within the monitoring period after the initial ablation for 192.5 ± 37.2 s at the earliest site. Among them, earliest activation was seen at the sinus of Valsalva (SoV), coronary venous system (CVS), and left ventricular endocardium (LVE) in four, six, and two patients, respectively. Using the reconstructed LVS, the anatomically closest site to the SOO was identified in the SoV, CVS, and LVE in four, two, and six cases, respectively. Throughout the study period (14.5 months; range, 9.3-19.7 months), 17 patients (85%) had complete elimination of PVCs as evaluated by 24-h event monitors at the 12-month visit. In 50% of cases, among patients in whom ablation at the earliest signal was unsuccessful, the site of successful ablation did not correlate with the second earliest signal or had no identifiable signal during initial activation mapping. The reconstructed LVS not only guided activation mapping but also identified sites proximal to the center point that had either a late activation signal, a low-amplitude signal, or no signal at all.

Pulsed Field or Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation

BACKGROUND

Catheter-based pulmonary vein isolation is an effective treatment for paroxysmal atrial fibrillation. Pulsed field ablation, which delivers microsecond high-voltage electrical fields, may limit damage to tissues outside the myocardium. The efficacy and safety of pulsed field ablation as compared with conventional thermal ablation are not known.

METHODS

In this randomized, single-blind, noninferiority trial, we assigned patients with drug-refractory paroxysmal atrial fibrillation in a 1:1 ratio to undergo pulsed field ablation or conventional radiofrequency or cryoballoon ablation. The primary efficacy end point was freedom from a composite of initial procedural failure, documented atrial tachyarrhythmia after a 3-month blanking period, antiarrhythmic drug use, cardioversion, or repeat ablation. The primary safety end point included acute and chronic device- and procedure-related serious adverse events.

RESULTS

A total of 305 patients were assigned to undergo pulsed field ablation, and 302 were assigned to undergo thermal ablation. At 1 year, the primary efficacy end point was met (i.e., no events occurred) in 204 patients (estimated probability, 73.3%) who underwent pulsed field ablation and 194 patients (estimated probability, 71.3%) who underwent thermal ablation (between-group difference, 2.0 percentage points; 95% Bayesian credible interval, -5.2 to 9.2; posterior probability of noninferiority, >0.999). Primary safety end-point events occurred in 6 patients (estimated incidence, 2.1%) who underwent pulsed field ablation and 4 patients (estimated incidence, 1.5%) who underwent thermal ablation (between-group difference, 0.6 percentage points; 95% Bayesian credible interval, -1.5 to 2.8; posterior probability of noninferiority, >0.999).

CONCLUSIONS

Among patients with paroxysmal atrial fibrillation receiving a catheter-based therapy, pulsed field ablation was noninferior to conventional thermal ablation with respect to freedom from a composite of initial procedural failure, documented atrial tachyarrhythmia after a 3-month blanking period, antiarrhythmic drug use, cardioversion, or repeat ablation and with respect to device- and procedure-related serious adverse events at 1 year. (Funded by Farapulse-Boston Scientific; ADVENT ClinicalTrials.gov number, NCT04612244.).

Leveraging electronic health record query to streamline adverse event reporting and protocol compliance

Electronic medical records are increasingly being leveraged to improve the efficiency and effectiveness of clinical trials. Reporting safety data and adhering to follow-up schedules are two challenges faced by study centers conducting a large number of clinical trials led by a single principal investigator. The Lenox Hill Electrophysiology Research Department collaborated with Northwell Health's informatics department to develop a live query accessing both inpatient and outpatient data. To demonstrate the efficacy of this approach we compared the compliance rate of adverse event reporting and patient follow-up visits between a clinical trial run using this approach and a clinical trial conducted prior to use. We compared the number of out of window visits, missed visits, missed assessments, subject drop out and number of late reported adverse events between both studies. The trial run using the described query method had a marked reduction in these categories. Leveraging available informatics resources have allowed for improved efficiency, accurate adverse even reporting and improved follow-up scheduling.

Delayed cardiac repolarisation as a predictor of in-hospital mortality in patients with COVID-19

OBJECTIVE

With the rapid influx of COVID-19 admissions during the first wave of the pandemic, there was an obvious need for an efficient and streamlined risk stratification tool to aid in triaging. To this date, no clinical prediction tool exists for patients presenting to the hospital with COVID-19 infection.

METHODS

This is a retrospective cohort study of patients admitted in one of 13 Northwell Health Hospitals, located in the wider New York Metropolitan area between 1 March 2020 and 27 April 2020. Inclusion criteria were a positive SARS-CoV-2 nasal swab, a 12-lead ECG within 48 hours, and a complete basic metabolic panel within 96 hours of presentation.

RESULTS

All-cause, in-hospital mortality was 27.1% among 7098 patients. Independent predictors of mortality included demographic characteristics (male gender, race and increased age), presenting vitals (oxygen saturation <92% and heart rate >120 bpm), metabolic panel values (serum lactate >2.0 mmol/L, sodium >145, mmol/L, blood urea nitrogen >40 mmol/L, aspartate aminotransferase >40 U/L, Creatinine >1.3 mg/dL and glycose >100 mg/L) and comorbidities (congestive heart failure, chronic obstructive pulmonary disease and coronary artery disease). In addition to those, our analysis showed that delayed cardiac repolarisation (QT corrected for heart rate (QTc) >500 ms) was independently associated with mortality (OR 1.41, 95% CI 1.05 to 1.90). Previously mentioned parameters were incorporated into a risk score that accurately predicted in-hospital mortality (AUC 0.78).

CONCLUSION

In the largest cohort of COVID-19 patients with complete ECG data on presentation, we found that in addition to demographics, presenting vitals, clinical history and basic metabolic panel values, QTc >500 ms is an independent risk factor for in-hospital mortality.

Clinical significance of unexplained persistent sinus tachycardia in women with structurally normal heart during the peripartum period

Background

Persistent sinus tachycardia (ST) is frequently encountered during pregnancy and peripartum period and its etiology often remains elusive. We sought to examine the possible association between unexplained persistent ST and obstetric outcomes.

Methods

A case control study was conducted using chart review of women admitted in labor to one of 7 hospitals of Northwell Health between January 2015 to June 2021. After excluding women with structurally abnormal hearts, we identified patients with persistent ST during the peripartum period, defined as a heart rate of more than 100 bpm for more than 48 h. A control group was created by randomly subsampling those who did not meet the inclusion criteria for sinus tachycardia. Obstetric outcomes were measured as mother’s length of stay (LOS), pre-term labor (PTL), admission to the neonatal ICU (NICU), and whether she received cesarean-section (CS).

Results

Seventy-eight patients with persistent ST were identified, out of 141,769 women admitted for labor throughout the Northwell Health system. 23 patients with ST attributable to infection or hypovolemia from anemia requiring transfusion and 55 with unclear etiology were identified. After adjusting for age and parity, pregnant mothers with ST were 2.35 times more likely to have a CS than those without (95% CI: 1.46–3.81, p = 0.0005) and had 1.38 times the LOS (1.21- 1.56, p < 0.0001). Among mothers with ST, those with unexplained ST were 2.14 times more likely to have a CS (1.22–3.75, p = 0.008).

Conclusion

Among pregnant patients, patients with ST have higher rates of CS.This association is unclear, however potential mechanisms include catecholamine surge, indolent infection, hormonal fluctuations, and medications. More studies are needed to explore the mechanism of ST in pregnant woman to determine the clinical significance and appropriate management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05012-3.

Prevalence and clinical significance of arrhythmias during labour in women with structurally normal hearts

Objectives

Examine the association between arrhythmias and adverse maternal outcomes in women with structurally normal hearts.

Methods

This was a case–control study of women admitted in labour to one of eight hospitals of Northwell Health from January 2015 to June 2021. After excluding women with structurally abnormal hearts, we identified women with an arrhythmic event and randomly subsampled the rest of the cohort to create a control group of 1025 patients. Multivariate analysis was performed to examine the association between arrhythmias and the incidence of caesarean section (CS), preterm labour (PTL), admission to the neonatal intensive care unit and longer length of stay (LOS).

Results

Of 1 41 769 women admitted in labour with a structurally normal heart, 137 had at least one arrhythmic event (0.097%). Supraventricular tachycardia (SVT), atrial fibrillation/flutter (AF) and frequent premature ventricular complexes or non-sustained ventricular tachycardia (VA) were present in 65 (0.046%), 22 (0.016%) and 46 (0.032%) women, respectively. Arrhythmia was previously diagnosed in 58.0% SVT cases but only in 9.7% AF and 8.1% VA cases. After adjusting for age, parity and comorbidities, the presence of any arrhythmia was an independent predictor of CS (OR 1.7 95% CI 1.2 to 2.5), PTL (OR 1.8, CI 1.1 to 3.0) and LOS (mean ratio 1.6, CI 1.4 to 1.8). This association was driven by presence of SVT and AF, whereas VAs were not associated with adverse outcomes.

Conclusions

Arrhythmias, specifically SVT and AF, during labour in women with structurally normal heart are independently associated with adverse obstetrical outcomes.

Autonomic Neuromodulation for Atrial Fibrillation Following Cardiac Surgery: JACC Review Topic of the Week

Autonomic neuromodulation therapies (ANMTs) (ie, ganglionated plexus ablation, epicardial injections for temporary neurotoxicity, low-level vagus nerve stimulation [LL-VNS], stellate ganglion block, baroreceptor stimulation, spinal cord stimulation, and renal nerve denervation) constitute an emerging therapeutic approach for arrhythmias. Very little is known about ANMTs' preventive potential for postoperative atrial fibrillation (POAF) after cardiac surgery. The purpose of this review is to summarize and critically appraise the currently available evidence. Herein, the authors conducted a systematic review of 922 articles that yielded 7 randomized controlled trials. In the meta-analysis, ANMTs reduced POAF incidence (OR: 0.37; 95% CI: 0.25 to 0.55) and burden (mean difference [MD]: -3.51 hours; 95% CI: -6.64 to -0.38 hours), length of stay (MD: -0.82 days; 95% CI: -1.59 to -0.04 days), and interleukin-6 (MD: -79.92 pg/mL; 95% CI: -151.12 to -8.33 pg/mL), mainly attributed to LL-VNS and epicardial injections. Moving forward, these findings establish a base for future larger and comparative trials with ANMTs, to optimize and expand their use.

Increased Inpatient Mortality for Cardiovascular Patients During the First Wave of the COVID-19 Epidemic in New York

Background

The acuity and magnitude of the first wave of the COVID‐19 epidemic in New York mandated a drastic change in healthcare access and delivery of care.

Methods and Results

We retrospectively studied patients admitted with an acute cardiovascular syndrome as their principal diagnosis to 13 hospitals across Northwell Health during March 11 through May 26, 2020 (first COVID‐19 epidemic wave) and the same period in 2019. Three thousand sixteen patients (242 COVID‐19 positive) were admitted for an acute cardiovascular syndrome during the first COVID‐19 wave compared with 9422 patients 1 year prior (decrease of 68.0%, P<0.001). During this time, patients with cardiovascular disease presented later to the hospital (360 versus 120 minutes for acute myocardial infarction), underwent fewer procedures (34.6% versus 45.6%, P<0.001), were less likely to be treated in an intensive care unit setting (8.7% versus 10.8%, P<0.001), and had a longer hospital stay (2.91 [1.71–6.05] versus 2.87 [1.82–4.95] days, P=0.033). Inpatient cardiovascular mortality during the first epidemic outbreak increased by 111.1% (3.8 versus 1.8, P<0.001) and was not related to COVID‐19‐related admissions, all cause in‐hospital mortality, or incidence of out‐of‐hospital cardiac deaths in New York. Admission during the first COVID‐19 surge along with age and positive COVID‐19 test independently predicted mortality for cardiovascular admissions (odds ratios, 1.30, 1.05, and 5.09, respectively, P<0.0001).

Conclusions

A lower rate and later presentation of patients with cardiovascular pathology, coupled with deviation from common clinical practice mandated by the first wave of the COVID‐19 pandemic, might have accounted for higher in‐hospital cardiovascular mortality during that period.

Clinical predictors of heart block during atrioventricular nodal reentrant tachycardia ablation: A multicenter 18-year experience

BACKGROUND

Catheter ablation is considered the first-line treatment of symptomatic atrioventricular nodal reentrant tachycardia (AVNRT). It has been associated with a risk of heart block (HB) requiring a pacemaker. This study aims to determine potential clinical predictors of complete heart block as a result AVNRT ablation.

METHODS

Consecutive patients undergoing catheter ablation for AVNRT from January 2001 to June 2019 at two tertiary hospitals were included. We defined ablation-related HB as the unscheduled implantation of pacemaker within a month of the index procedure. Use of electroanatomic mapping (EAM), operator experience, inpatient status, age, sex, fluoroscopy time, baseline PR interval, and baseline HV interval was included in univariate and multivariate models to predict HB post ablation.

RESULTS

In 1708 patients (56.4 ± 17.0 years, 61% females), acute procedural success was 97.1%. The overall incidence of HB was 1.3%. Multivariate analysis showed that age more than 70 (odds ratio [OR] 7.907, p ≤ .001, confidence interval [CI] 2.759-22.666), baseline PR ≥ 190 ms (OR 2.867, p = .026, CI 1.135-7.239) and no use of EAM (OR 0.306, p = .037, CI 0.101-0.032) were independent predictors of HB.

CONCLUSION

Although the incidence of HB post AVNRT ablation is generally low, patients can be further stratified using three simple predictors.

The Association of Structural Inequities and Race With Out-of-Hospital Sudden Death During the COVID-19 Pandemic

[Figure: see text].

Association between regional distributions of SARS-CoV-2 seroconversion and out-of-hospital sudden death during the first epidemic outbreak in New York

Background

Increased incidence of out-of-hospital sudden death (OHSD) has been reported during the coronavirus 2019 (COVID-19) pandemic. New York City (NYC) represents a unique opportunity to examine the epidemiologic association between the two given the variable regional distribution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in its highly diverse neighborhoods.

Objective

The purpose of this study was to examine the association between OHSD and SARS-CoV-2 epidemiologic burden during the first COVID-19 pandemic across the highly diverse neighborhoods of NYC.

Methods

The incidences of OHSD between March 20 and April 22, 2019, and between March 20 and April 22, 2020, as reported by the Fire Department of New York were obtained. As a surrogate for viral epidemiologic burden, we used percentage of positive SARS-CoV-2 antibody tests performed between March 3 and August 20, 2020. Data were reported separately for the 176 zip codes of NYC. Correlation analysis and regression analysis were performed between the 2 measures to examine association.

Results

Incidence of OHSD per 10,000 inhabitants and percentage of SARS-CoV-2 seroconversion were highly variable across NYC neighborhoods, varying from 0.0 to 22.9 and 12.4% to 50.9%, respectively. Correlation analysis showed a moderate positive correlation between neighborhood data on OHSD and percentage of positive antibody tests to SARS-CoV-2 (Spearman ρ 0.506; P <.001). Regression analysis showed that seroconversion to SARS-CoV-2 and OHSD in 2019 were independent predictors for OHSD during the first epidemic surge in NYC (R² = 0.645).

Conclusion

The association in geographic distribution between OHSD and SARS-CoV-2 epidemiologic burden suggests either a causality between the 2 syndromes or the presence of local determinants affecting both measures in a similar fashion.

Surface unipolar electrogram characteristics to predict site of origin of outflow tract arrhythmias using noninvasive mapping

BACKGROUND

Noninvasive electroanatomic mapping (NIEAM) demonstrate patterns of depolarization that are useful in identifying the chamber of origin (COO) in outflow tract ventricular arrhythmias (OTVA). However, its use in predicting exact site of origin (SOO) has not yet been validated.

METHODS

NIEAMs (CardioInsight, Medtronic) from 40 patients (age 62.5 ± 2.6) undergoing ablation for OTVA were reviewed for diagnostic accuracy in predicting the SOO. Earliest arrhythmia breakout and directionality of earliest instantaneous unipolar electrograms (uEGMs) on NIEAMs were evaluated subjectively by two observers for quality and amplitude. Sites with most negative earliest uEGMs on right and left ventricular outflow tracts, as well as epicardial surface were manually identified. Using NIEAM-based activation timing of the lateral mitral annulus and basal septum COO was identified for each OTVA. Predictions of SOO using NIEAMs was compared with true SOO from invasive study. NIEAMs SOO predictions were compared with subjective 12 lead electrocardiogram (ECG) review by two observers.

RESULTS

Review of arrhythmia breakout and signal directionality had poor diagnostic value in predicting SOO in OTVA (50.6% and 49.4%, 56.6% and 43.4%, respectively) and underperformed compared with ECG interpretation (59.1% and 80.5%). After excluding uEGMs with poor characteristics, the uEGM with most negative amplitude at the COO was predictive of the true SOO with 96.4% sensitivity and specificity.

CONCLUSION

We propose a stepwise approach when interpreting NIEAMs for OTVA where patterns of activation are evaluated first to determine the COO, followed by identification of the site with most negative amplitude instantaneous uEGM to determine SOO.

Safely Administering Potential QTc Prolonging Therapy Across a Large Health Care System in the COVID-19 Era

Supplemental Digital Content is available in the text.

Background:

The severe acute respiratory syndrome coronavirus 2 (SARs-CoV-2) has resulted in a global pandemic. Hydroxychloroquine±azithromycin have been widely used to treat coronavirus disease 2019 (COVID-19) despite a paucity of evidence regarding efficacy. The incidence of torsade de pointes remains unknown. Widespread use of these medications forced overwhelmed health care systems to search for ways to effectively monitor these patients while simultaneously trying to minimize health care provider exposure and use of personal protective equipment.

Methods:

Patients with COVID-19 positive who received hydroxychloroquine±azithromycin across 13 hospitals between March 1 and April 15 were included in this study. A comprehensive search of the electronic medical records was performed using a proprietary python script to identify any mention of QT prolongation, ventricular tachy-arrhythmias and cardiac arrest.

Results:

The primary outcome of torsade de pointes was observed in 1 (0.015%) out of 6476 hospitalized patients with COVID-19 receiving hydroxychloroquine±azithromycin. Sixty-seven (1.03%) had hydroxychloroquine±azithromycin held or discontinued due to an average QT prolongation of 60.5±40.5 ms from a baseline QTc of 473.7±35.9 ms to a peak QTc of 532.6±31.6 ms. Of these patients, hydroxychloroquine±azithromycin were discontinued in 58 patients (86.6%), while one or more doses of therapy were held in the remaining nine (13.4%). A simplified approach to monitoring for QT prolongation and arrythmia was implemented on April 5. There were no deaths related to the medications with the simplified monitoring approach and health care provider exposure was reduced.

Conclusions:

The risk of torsade de pointes is low in hospitalized patients with COVID-19 receiving hydroxychloroquine±azithromycin therapy.

Anatomic predictors of recurrence after cryoablation for atrial fibrillation: a computed tomography based composite score

BACKGROUND

Effective pulmonary vein isolation (PVI) with cryoablation depends on adequate occlusion of pulmonary veins (PV) by the cryoballoon and is therefore likely to be affected by PV and left atrial (LA) anatomical characteristics and variants. Thus, the objective of this study was to investigate the effect of LA and PV anatomy, evaluated by computed tomography (CT), on acute and long-term outcomes of cryoablation for atrial fibrillation (AF).

METHODS

Fifty-eight patients (64.72 + 9.44 years, 60.3% male) undergoing cryoablation for paroxysmal or early persistent AF were included. Pre-procedural CT images were analyzed to evaluate LA dimensions and PV anatomical characteristics. Predictors of recurrence were identified using regression analysis.

RESULTS

60.3% of patients had two PVs on each side with separate ostia, whereas 29.3% and 10.3% had right middle and left common PVs, respectively. The following anatomic characteristics were found to be independent predictors of recurrence: right superior PV ostial max:min diameter ratio > 1.32, left superior PV ostial max:min diameter ratio > 1.2, right superior PV antral circumference > 69.1 mm, right inferior PV antral circumference > 61.38 mm, right superior PV angle > 22.7°. Using these factors, LA diameter and right middle PV, a scoring model was created for prediction of "unfavorable" LA-PV anatomy (AUC = 0.867, p = 0.000009, score range = 0-7). Score of ≥ 4 predicted need for longer cryoenergy ablation (p = 0.039) and more frequent switch to radiofrequency energy (p = 0.066) to achieve PVI, and had a sensitivity of 83.3% and specificity of 82.5% to predict clinical recurrence.

CONCLUSION

CT-based scoring system is useful to identify "unfavorable" anatomy prior to cryo-PVI, which can result in procedural difficulty and poor outcomes.

Paroxysmal Atrial Fibrillation With Both Triggers and Rotational Drivers Within the Right Atrial Appendage

A 48-year-old woman with paroxysmal atrial fibrillation (AF) underwent an electrophysiology study after 2 previous failed ablations. Noninvasive mapping suggested AF initiation from the right atrial appendage (RAA) with rotational drivers of AF in the RAA. Invasive mapping confirmed these findings. The patient was successfully treated with cryoballoon RAA isolation. (Level of Difficulty: Intermediate.).

A standardized protocol to reliably visualize the left atrial appendage with intracardiac echocardiography: Importance of multiple imaging sites

BACKGROUND

Currently, there is no accepted protocol for left atrial appendage (LAA) imaging with intracardiac echocardiography (ICE).

OBJECTIVE

This study aimed to assess the utility of ICE to reliably visualize the entire cavity of the LAA and propose a specific procedural protocol to achieve the above objective.

METHODS

We created a three-dimensional reconstruction of the LAA, using two-dimensional ICE sections obtained from three different location (the right atrium [RA], right ventricle inflow [RVI], and right ventricular outflow [RVOT]). We then compared the three-dimensional LAA reconstruction by ICE with one obtained by cardiac computed tomography angiography (CCTA) for morphological and volume differences.

RESULTS

Three-dimensional reconstruction with ICE could reliably reproduce the LAA as visualized with CCTA but only when ICE sampling was performed from at least two catheter positions. There was no statistically significant difference between LAA volumes obtained with ICE and CCTA (P = 0.33). The contribution of each anatomical location to the total volume was 17% ± 16.6%, 74% ± 13.3%, and 33% ± 26% for RA, RVI, and RVOT, respectively.

CONCLUSION

In comparison with CCTA, the LAA can be reliably visualized in its entity by ICE, but only if multiple imaging positions (RA, RV inflow, and RVOT) are used.

New unipolar electrogram criteria to identify irreversibility of nonischemic left ventricular cardiomyopathy

OBJECTIVES

This study sought to assess the value of left ventricular (LV) endocardial unipolar electroanatomical mapping (EAM) in identifying irreversibility of LV systolic dysfunction in patients with left ventricular nonischemic cardiomyopathy (LVCM).

BACKGROUND

Identifying irreversibility of LVCM would be helpful but cannot be reliably accomplished by bipolar EAM or cardiac magnetic resonance identification of macroscopic scar.

METHODS

Detailed endocardial LV EAM was performed in 3 groups: 1) 24 patients with irreversible LVCM (I-LVCM) but with no or minimal macroscopic scar (<15% LV surface) evidenced on bipolar voltage EAM and/or cardiac magnetic resonance; 2) 14 patients with reversible ventricular premature depolarization-mediated LVCM (R-LVCM); and 3) 17 patients with structurally normal hearts. LV endocardial unipolar electrogram amplitude and area of unipolar amplitude abnormality were defined after excluding macroscopic scar.

RESULTS

Unipolar amplitude differed in the 3 groups: median of 7.6 (interquartile range [IQR]: 5.5 to 9.7) mV in I-LVCM group, 13.2 (IQR: 10.4 to 16.2) mV in R-LVCM group, and 16.3 (IQR: 13.6 to 19.8) mV in structurally normal hearts group (p < 0.001). Areas of unipolar abnormality represented a large proportion of total LV surface in I-LVCM, 64.7% (IQR: 47.5% to 75.9%) compared with R-LVCM, 5.2% (IQR: 0.0% to 19.1%) and structurally normal hearts, 0.1% (IQR: 0.0% to 0.9%), groups (p < 0.001). A unipolar abnormality area cutoff of 32% of total LV surface was 96% sensitive and 100% specific in identifying irreversible cardiomyopathy among patients with LV dysfunction (I-LVCM and R-LVCM), p < 0.001.

CONCLUSIONS

Detailed unipolar voltage mapping can identify irreversible myocardial dysfunction consistent with fibrosis, even in the absence of bipolar EAM or cardiac magnetic resonance abnormalities, and may serve as valuable prognostic tool in patients presenting with LVCM to facilitate clinical decision making.

Noninvasive programmed ventricular stimulation early after ventricular tachycardia ablation to predict risk of late recurrence

OBJECTIVES

The goal of this study was to evaluate the ability of noninvasive programmed stimulation (NIPS) after ventricular tachycardia (VT) ablation to identify patients at high risk of recurrence.

BACKGROUND

Optimal endpoints for VT ablation are not well defined.

METHODS

Of 200 consecutive patients with VT and structural heart disease undergoing ablation, 11 had clinical VT inducible at the end of ablation and 11 recurred spontaneously. Of the remaining 178 patients, 132 underwent NIPS through their implantable cardioverter-defibrillator 3.1 ± 2.1 days after ablation. At 2 drive cycle lengths, single, double, and triple right ventricular extrastimuli were delivered to refractoriness. Clinical VT was defined by comparison with 12-lead electrocardiograms and stored implantable cardioverter-defibrillator electrograms from spontaneous VT episodes. Patients were followed for 1 year.

RESULTS

Fifty-nine patients (44.7%) had no VT inducible at NIPS; 49 (37.1%) had inducible nonclinical VT only; and 24 (18.2%) had inducible clinical VT. Patients with inducible clinical VT at NIPS had markedly decreased 1-year VT-free survival compared to those in whom no VT was inducible (<30% vs. >80%; p = 0.001), including 33% recurring with VT storm. Patients with inducible nonclinical VT only, had intermediate 1-year VT-free survival (65%).

CONCLUSIONS

When patients with VT and structural heart disease have no VT or nonclinical VT only inducible at the end of ablation or their condition is too unstable to undergo final programmed stimulation, NIPS should be considered in the following days to further define risk of recurrence. If clinical VT is inducible at NIPS, repeat ablation may be considered because recurrence over the following year is high.

Presence of atrial fibrillation is independently associated with adverse outcomes in patients hospitalized with heart failure: an analysis of get with the guidelines-heart failure

BACKGROUND

It is unclear if the presence of atrial fibrillation (AF) on admission is associated with worse in-hospital outcomes in patients hospitalized with heart failure (HF). This study evaluated the clinical characteristics, management, length of stay, and mortality of HF patients with and without AF.

METHODS AND RESULTS

We studied 99 810 patients from 255 sites admitted with HF enrolled in Get With The Guidelines-Heart Failure between January 1, 2005, and December 31, 2010. Patients with AF on admission were compared with patients in sinus rhythm. A total of 31 355 (31.4%) HF patients presented with AF, of which 6701 (21.3%) were newly diagnosed. Patients in AF were older (77±12 versus 70±15, P<0.001) and were more likely to have history of stroke and valvular heart disease. AF patients had higher B-type natriuretic peptide levels and ejection fraction (42±17% versus 39±17%, P<0.001). AF patients were more likely to be hospitalized >4 days (48.8% versus 41.5%, P<0.001), discharged to a facility other than home (28.5% versus 19.7%, P<0.001), and had higher hospital mortality rate (4.0% versus 2.6%, P<0.001). AF, particularly newly diagnosed, was independently associated with adverse outcomes (adjusted odds ratios and 95% confidence intervals for mortality 1.17, 1.05-1.29, P=0.0029, and 1.29, 1.10-1.52, P=0.0023 for AF and newly diagnosed AF, respectively).

CONCLUSIONS

In patients hospitalized with HF, AF is present in one-third and is independently associated with adverse hospital outcomes and longer length of stay. Whether prompt restoration of sinus rhythm would improve outcomes in patients hospitalized with HF and new-onset or paroxysmal AF is unclear and requires further study.

Please treat me with metoclopramide

Severe peptic ulcer resulting in hypertrophic pyloric stenosis is a rare clinical problem nowadays. Symptoms include vomiting, nausea, early satiety, weight loss, epigastric pain especially after eating. The physical examination may not be helpful because the pyloric mass is difficult to palpate. We report a case of a 43-year-old man who presented to the emergency department complaining of vomiting. He asked for metoclopramide, refusing initially further investigation and gastrointestinal endoscopy. Finally, he agreed to undergo a barium meal examination, which showed severe pyloric stenosis. He underwent vagotomy and enteroanastomosis. The biopsy of the removed segment of the stomach did not show any malignant changes.

Tumor lysis syndrome

Tumor lysis syndrome (TLS) is an important metabolic disorder frequently encountered in the management of a variety of cancers including lymphoma, leukemia, and neuroblastoma. Delayed recognition can result in a variety of biochemical abnormalities resulting in life-threatening complications such as renal failure, arrhythmias, and seizures. Identification of high-risk patients and early recognition of the syndrome is crucial in the early institution of appropriate prophylaxis and treatment. Recent advances in the understanding of urate metabolism, development of new urate-lowering drugs, and the application of biomarkers, calculation methods, and prognostic models to identify high-risk patients will pave the way in improving the management of TLS. We included in this review the new information regarding the urate transporters URAT-1, organic anion transporter 1/3, and MRP4; the urate elimination pathway; a comparison of the old- (allopurinol, native uricase) and new- (febuxostat, Y-700, PEG-uricase, rasburicase) generation urate-lowering agents; and application of new biomarkers (cystatin-C, neutrophil gelatinase-associated lipocalin, kidney injury molecule 1), estimated glomerular filtration rate and calculation methods (modification of diet in renal disease and prognostic model (Penn Predictive Score of Tumor Lysis Syndrome) in the identification of high-risk patients, and alternative unexplored mechanisms (asymmetric dimethylarginine and adenosine) to explain renal injury related to TLS.

Ibutilide to expedite ED therapy for recent-onset atrial fibrillation flutter

OBJECTIVE

Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation (AF) and atrial flutter (AFl). Previous studies conducted outside the ED setting have demonstrated conversion rates of 60% to 80%. This response has been highest in patients with recent-onset AF-AFl. These observations and the 4-hour half-life of ibutilide suggest that it may be an excellent drug with which to treat AF-AFl in the ED. The purpose of the study was to examine the efficacy and safety of ibutilide in terminating AF-AFl in patients who present to the ED with symptoms of less than 3 days' duration, neither angina nor heart failure, and no comorbid conditions that require admission.

METHODS

Among 36 enrolled patients, the admission electrocardiogram demonstrated AF in 26 and AFl in 10. Ibutilide 1 mg was administered intravenously for 10 minutes. If sinus rhythm was not present 10 minutes after the infusion concluded, a second infusion of 1 mg was given. Successful conversion was defined as restoration of sinus rhythm within 1 hour after the last dose of ibutilide.

RESULTS

Sixteen (61.5%) of 26 patients with AF and 9 (90%) of 10 patients with AFl converted to sinus rhythm (overall conversion rate=69%). The mean time to arrhythmia termination was 19+/-9 minutes. The mean stay in the ED was 16.2 hours. No significant complications occurred.

CONCLUSION

We conclude that ibutilide is an excellent therapy option for restoring sinus rhythm in the ED. Its use may obviate the need for admission, avoid the risks and inconveniences of general anesthesia to perform electrical cardioversion, and reduce the ED length of stay in selected patients with recent-onset atrial arrhythmias.