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Kramer CM, DiMarco JP, Kolm P, Ho CY, Desai MY, Kwong RY, Dolman SF, Desvigne-Nickens P, Geller N, Kim DY, Maron MS, Appelbaum E, Jerosch-Herold M, Friedrich MG, Schulz-Menger J, Piechnik SK, Mahmod M, Jacoby D, White J, Chiribiri A, Helms A, Choudhury L, Michels M, Bradlow W, Salerno M, Dawson DK, Weinsaft JW, Berry C, Nagueh SF, Buccarelli-Ducci C, Owens A, Casadei B, Watkins H, Weintraub WS, Neubauer S. Predictors of Major Atrial Fibrillation Endpoints in the National Heart, Lung, and Blood Institute HCMR. JACC Clin Electrophysiol 2021; 7:1376-1386. [PMID: 34217663 PMCID: PMC8605982 DOI: 10.1016/j.jacep.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVES This study sought to identify predictors of major clinically important atrial fibrillation endpoints in hypertrophic cardiomyopathy. BACKGROUND Atrial fibrillation (AF) is a common morbidity associated with hypertrophic cardiomyopathy (HCM). The HCMR (Hypertrophic Cardiomyopathy Registry) trial is a prospective natural history study of 2,755 patients with HCM with comprehensive phenotyping. METHODS All patients received yearly telephone follow-up. Major AF endpoints were defined as requiring electrical cardioversion, catheter ablation, hospitalization for >24 h, or clinical decisions to accept permanent AF. Penalized regression via elastic-net methodology identified the most important predictors of major AF endpoints from 46 variables. This was applied to 10 datasets, and the variables were ranked. Predictors that appeared in all 10 sets were then used in a Cox model for competing risks and analyzed as time to first event. RESULTS Data from 2,631 (95.5%) patients were available for analysis after exclusions. A total of 127 major AF endpoints events occurred in 96 patients over 33.3 ± 12.4 months. In the final model, age, body mass index (BMI), left atrial (LA) volume index, LA contractile percent (active contraction), moderate or severe mitral regurgitation (MR), and history of arrhythmia the most important. BMI, LA volume index, and LA contractile percent were age-dependent. Obesity was a stronger risk factor in younger patients. Increased LA volume, reduced LA contractile percent, and moderate or severe MR put middle-aged and older adult patients at increased risk. CONCLUSIONS The major predictors of major AF endpoints in HCM include older age, high BMI, moderate or severe MR, history of arrhythmia, increased LA volume, and reduced LA contractile percent. Prospective testing of a risk score based on these parameters may be warranted.
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Affiliation(s)
| | - John P DiMarco
- University of Virginia Health System, Charlottesville, Virginia, USA
| | - Paul Kolm
- MedStar Health Research Institute, Washington, DC, USA
| | - Carolyn Y Ho
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | | | - Nancy Geller
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Dong-Yun Kim
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | | | | | | | | | - Jeanette Schulz-Menger
- Charité Experimental Clinical Research Center and Helios Clinics Berlin-Buch, Berlin, Germany
| | | | | | | | - James White
- University of Calgary, Calgary, Alberta, Canada
| | | | - Adam Helms
- University of Michigan, Anne Arbor, Michigan, USA
| | | | | | | | - Michael Salerno
- University of Virginia Health System, Charlottesville, Virginia, USA
| | | | | | - Colin Berry
- University of Glasgow, Glasgow, United Kingdom
| | | | | | - Anjali Owens
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Neubauer S, Kolm P, Ho CY, Kwong RY, Desai MY, Dolman SF, Appelbaum E, Desvigne-Nickens P, DiMarco JP, Friedrich MG, Geller N, Harper AR, Jarolim P, Jerosch-Herold M, Kim DY, Maron MS, Schulz-Menger J, Piechnik SK, Thomson K, Zhang C, Watkins H, Weintraub WS, Kramer CM. Distinct Subgroups in Hypertrophic Cardiomyopathy in the NHLBI HCM Registry. J Am Coll Cardiol 2020; 74:2333-2345. [PMID: 31699273 DOI: 10.1016/j.jacc.2019.08.1057] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/19/2019] [Accepted: 08/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The HCMR (Hypertrophic Cardiomyopathy Registry) is a National Heart, Lung, and Blood Institute-funded, prospective registry of 2,755 patients with hypertrophic cardiomyopathy (HCM) recruited from 44 sites in 6 countries. OBJECTIVES The authors sought to improve risk prediction in HCM by incorporating cardiac magnetic resonance (CMR), genetic, and biomarker data. METHODS Demographic and echocardiographic data were collected. Patients underwent CMR including cine imaging, late gadolinium enhancement imaging (LGE) (replacement fibrosis), and T1 mapping for measurement of extracellular volume as a measure of interstitial fibrosis. Blood was drawn for the biomarkers N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (cTnT), and genetic analysis. RESULTS A total of 2,755 patients were studied. Mean age was 49 ± 11 years, 71% were male, and 17% non-white. Mean ESC (European Society of Cardiology) risk score was 2.48 ± 0.56. Eighteen percent had a resting left ventricular outflow tract (LVOT) gradient ≥30 mm Hg. Thirty-six percent had a sarcomere mutation identified, and 50% had any LGE. Sarcomere mutation-positive patients were more likely to have reverse septal curvature morphology, LGE, and no significant resting LVOT obstruction. Those that were sarcomere mutation negative were more likely to have isolated basal septal hypertrophy, less LGE, and more LVOT obstruction. Interstitial fibrosis was present in segments both with and without LGE. Serum NT-proBNP and cTnT levels correlated with increasing LGE and extracellular volume in a graded fashion. CONCLUSIONS The HCMR population has characteristics of low-risk HCM. Ninety-three percent had no or only mild functional limitation. Baseline data separated patients broadly into 2 categories. One group was sarcomere mutation positive and more likely had reverse septal curvature morphology, more fibrosis, but less resting obstruction, whereas the other was sarcomere mutation negative and more likely had isolated basal septal hypertrophy with obstruction, but less fibrosis. Further follow-up will allow better understanding of these subgroups and development of an improved risk prediction model incorporating all these markers.
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Affiliation(s)
- Stefan Neubauer
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Paul Kolm
- MedStar Heart and Vascular Institute, Washington, DC
| | - Carolyn Y Ho
- Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Milind Y Desai
- Cardiovascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Evan Appelbaum
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - John P DiMarco
- Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia
| | - Matthias G Friedrich
- Departments of Medicine and Diagnostic Radiology, McGill University, Montreal, Quebec, Canada
| | - Nancy Geller
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Andrew R Harper
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Petr Jarolim
- Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Jerosch-Herold
- Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dong-Yun Kim
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Martin S Maron
- Division of Cardiology, Tufts New England Medical Center, Boston, Massachusetts
| | - Jeanette Schulz-Menger
- Cardiology Department, Charite' Experimental Clinical Research Center and Helios Clinics Berlin-Buch, Berlin, Germany
| | - Stefan K Piechnik
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Kate Thomson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Cheng Zhang
- MedStar Heart and Vascular Institute, Washington, DC
| | - Hugh Watkins
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Christopher M Kramer
- Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia.
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Kramer C, DiMarco JP, Kolm P, Ho C, Kwong RY, Desai MY, Desvigne-Nickens P, Dolman S, Appelbaum E, Friedrich M, Geller N, Jerosch-Herold M, Kim DY, Maron M, Schulz-Menger J, Piechnik S, Zhang C, Watkins H, Weintraub WS, Neubauer S. PREDICTORS OF CLINICALLY SIGNIFICANT ATRIAL FIBRILLATION IN THE NHLBI HYPERTROPHIC CARDIOMYOPATHY REGISTRY (HCMR). J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31303-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Porterfield C, DiMarco JP, Mason PK. Effectiveness of implantation of a subcutaneous implantable cardioverter-defibrillator in a patient with complete heart block and a pacemaker. Am J Cardiol 2015; 115:276-8. [PMID: 25465940 DOI: 10.1016/j.amjcard.2014.10.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 10/21/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
Abstract
The subcutaneous implantable cardioverter-defibrillator (S-ICD) represents an important alternative to traditional ICD therapy. The major limitation of this technology is the inability to provide pacing. Here, we present a case of a patient with complete heart block and a pacemaker who underwent placement of an S-ICD. Special considerations had to be taken with regards to evaluation and implantation of the S-ICD because of the pacemaker. In conclusion, implantation of an S-ICD can be done in patients with pacemaker effectively with appropriate electrocardiographic screening, device testing, and programming.
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Hussain S, Moorman L, Moorman JR, DiMarco JP, Malhotra R, Darby A, Bilchick K, Mangrum JM, Ferguson JD, Mason PK. Cost of a recall of a single-center experience managing the Riata defibrillator lead. Am J Cardiol 2015; 115:206-8. [PMID: 25479754 DOI: 10.1016/j.amjcard.2014.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 10/23/2014] [Accepted: 10/23/2014] [Indexed: 11/26/2022]
Abstract
Riata and Riata ST defibrillator leads (St. Jude Medical, Sylmar, California) were recalled in 2011 due to increased risk of insulation failure leading to externalized cables. Fluoroscopic screening can identify insulation failure, although the relation between mechanical failure and electrical failure is unclear. At the time of the recall, the University of Virginia developed a screening program, including fluoroscopic evaluation, education sessions, device interrogation, and remote monitoring for patients with this defibrillator lead. The aim of this study was to review the outcomes of the screening program, including costs, which were absorbed by our institution. Costs were calculated using Medicare reimbursement estimates. Forty-eight patients participated in the screening program. At initial screening, 31% were found to have evidence of insulation failure but electrical function was normal in all leads. The cost of this program was $35,358.72. The cost per diagnosis of mechanical lead failure was $2,357.25. During 2 years of follow-up, 1 patient experienced Riata lead electrical failure without fluoroscopic evidence of insulation failure. Patients were more likely to have a lead revision if there was evidence of insulation failure. Lead revisions occurred at the time of generator change in 88% of patients with insulation failure but in only 14% of patients with a fluoroscopically normal lead (p = 0.04). The cost of recall-related defibrillator lead revisions was $81,704.55. In conclusion, our Riata screening program added expense without clear benefit to patients. In fact, patients may have been put at more risk by undergoing defibrillator lead revisions based solely on the results of the fluoroscopic screening.
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Affiliation(s)
- Sarah Hussain
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Liza Moorman
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - J Randall Moorman
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - John P DiMarco
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Rohit Malhotra
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Andrew Darby
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Kenneth Bilchick
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - J Michael Mangrum
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - John D Ferguson
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Pamela K Mason
- Division of Cardiology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia.
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DiMarco JP, O’Connor P, Cohen JA, Reder AT, Zhang-Auberson L, Tang D, Collins W, Kappos L. First-dose effects of fingolimod: Pooled safety data from three phase 3 studies. Mult Scler Relat Disord 2014; 3:629-38. [DOI: 10.1016/j.msard.2014.05.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 05/23/2014] [Accepted: 05/27/2014] [Indexed: 11/26/2022]
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Malhotra R, Bilchick KC, DiMarco JP. Usefulness of pharmacologic conversion of atrial fibrillation during dofetilide loading without the need for electrical cardioversion to predict durable response to therapy. Am J Cardiol 2014; 113:475-9. [PMID: 24321897 PMCID: PMC3932309 DOI: 10.1016/j.amjcard.2013.10.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/05/2013] [Accepted: 10/05/2013] [Indexed: 10/26/2022]
Abstract
Conversion of persistent atrial fibrillation (AF) to sinus rhythm is frequently seen during the 3-day in-hospital loading period required during dofetilide initiation, but it is not known whether pharmacologic conversion (PC) without the need for electrical cardioversion (EC) is a predictor of long-term maintenance of sinus rhythm during continued therapy with dofetilide. We sought to test the hypothesis that PC predicts durable maintenance of sinus rhythm and determine additional predictors of long-term maintenance of sinus rhythm on dofetilide. We retrospectively reviewed all elective inpatient admissions for dofetilide loading from 2003 to 2011 at the University of Virginia. A multivariate Cox proportional hazards model was used to assess predictors of maintenance of sinus rhythm after in-hospital dofetilide loading. In all, 101 patients with a current duration of AF lasting for a median of 1.86 months (interquartile range 0.47 to 6.03) were included in the analysis. Forty-seven patients were in the PC group, whereas 54 patients were in the EC group. Patients in the PC group remained longer in sinus rhythm compared with the patients in the EC group (log-rank p = 0.032). The seventy-fifth percentile for the current episode duration in the PC group was 5.77 months, indicating that even long-standing persistent AF frequently converted pharmacologically. Hypertension and a longer duration of the current AF episode were also predictors of recurrence in the multivariate model. In conclusion, PC during in-hospital dofetilide loading is an important predictor of durable response even in long-standing persistent patients, which has important public health implications for choice of therapy.
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Affiliation(s)
- Rohit Malhotra
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia.
| | - Kenneth C Bilchick
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - John P DiMarco
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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Fogel RI, Epstein AE, Mark Estes N, Lindsay BD, DiMarco JP, Kremers MS, Kapa S, Brindis RG, Russo AM. The Disconnect Between the Guidelines, the Appropriate Use Criteria, and Reimbursement Coverage Decisions. J Am Coll Cardiol 2014; 63:12-4. [DOI: 10.1016/j.jacc.2013.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 07/06/2013] [Accepted: 07/08/2013] [Indexed: 11/17/2022]
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Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NAM, Ferguson TB, Hammill SC, Karasik PE, Link MS, Marine JE, Schoenfeld MH, Shanker AJ, Silka MJ, Stevenson LW, Stevenson WG, Varosy PD, Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Creager MA, DeMets D, Ettinger SM, Guyton RA, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2013; 144:e127-45. [PMID: 23140976 DOI: 10.1016/j.jtcvs.2012.08.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation 2012; 127:e283-352. [PMID: 23255456 DOI: 10.1161/cir.0b013e318276ce9b] [Citation(s) in RCA: 411] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NAM, Ferguson TB, Hammill SC, Karasik PE, Link MS, Marine JE, Schoenfeld MH, Shanker AJ, Silka MJ, Stevenson LW, Stevenson WG, Varosy PD. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2012; 61:e6-75. [PMID: 23265327 DOI: 10.1016/j.jacc.2012.11.007] [Citation(s) in RCA: 552] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abdelhadi RH, Saba SF, Ellis CR, Mason PK, Kramer DB, Friedman PA, Gura MT, DiMarco JP, Mugglin AS, Reynolds MR, Bazaz RR, Retel LK, Hayes DL, Hauser RG. Independent multicenter study of Riata and Riata ST implantable cardioverter-defibrillator leads. Heart Rhythm 2012; 10:361-5. [PMID: 23128017 DOI: 10.1016/j.hrthm.2012.10.045] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Riata and Riata ST leads (St Jude Medical, Sylmar, CA) are prone to failure. There are no independent multicenter reports regarding Riata or Riata ST lead performance. OBJECTIVE To conduct a retrospective multicenter study of Riata and Riata ST leads that were implanted and followed at 7 centers. METHODS The study included adults who received St Jude Medical Riata or Riata ST leads. Data for Quattro Secure leads were obtained from an earlier study. RESULTS From 2002 to 2010, 1081 patients received a Riata (n = 774) or Riata ST (n = 307) lead. Follow-up was longer for Riata than Riata ST leads (4.2 ± 2.4 years vs 3.3 ± 1.7 years; P<.0001). During the study, 67 leads failed (6.2%), including 62 of 774 Riata (8.0%) and 5 of 307 Riata ST (1.6%) leads. Forty-seven of 67 lead failures (70.1%) were caused by electrical malfunction, and 20 lead failures (29.9%) were due to externalized conductors (ECs) that were electrically intact. Of 110 leads examined fluoroscopically, ECs were found in 26 of 81 Riata (32%) and 1 of 29 Riata ST (3.4%) leads. Of 26 Riata leads with ECs, 7 (27%) were malfunctioning. Riata leads had lower overall and malfunction free survival compared to Quattro leads (P<.0001), while Riata ST lead survival was not different (P = .422). CONCLUSIONS The survival of Riata (but not Riata ST) leads was lower than Quattro leads; however, Riata ST leads had significantly shorter follow-up than Riata leads. ECs were common in Riata leads, and more than a quarter of Riata leads that had ECs were malfunctioning. Our observations suggest that systematic fluoroscopic examination of patients with Riata leads is appropriate.
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Affiliation(s)
- Raed H Abdelhadi
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota 55407, USA.
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Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NAM, Ferguson TB, Hammill SC, Karasik PE, Link MS, Marine JE, Schoenfeld MH, Shanker AJ, Silka MJ, Stevenson LW, Stevenson WG, Varosy PD, Ellenbogen KA, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hayes DL, Page RL, Stevenson LW, Sweeney MO. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. [corrected]. Circulation 2012; 126:1784-800. [PMID: 22965336 DOI: 10.1161/cir.0b013e3182618569] [Citation(s) in RCA: 239] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Mason PK, Lake DE, DiMarco JP, Ferguson JD, Mangrum JM, Bilchick K, Moorman LP, Moorman JR. Impact of the CHA2DS2-VASc score on anticoagulation recommendations for atrial fibrillation. Am J Med 2012; 125:603.e1-6. [PMID: 22502952 PMCID: PMC4555351 DOI: 10.1016/j.amjmed.2011.09.030] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 09/19/2011] [Accepted: 09/24/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke (CHADS(2)) score is used to predict the need for oral anticoagulation for stroke prophylaxis in patients with atrial fibrillation. The Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category (CHA(2)DS(2)-VASc) schema has been proposed as an improvement. Our objective is to determine how adoption of the CHA(2)DS(2)-VASc score alters anticoagulation recommendations. METHODS Between 2004 and 2008, 1664 patients were seen at the University of Virginia Atrial Fibrillation Center. We calculated the CHADS(2) and CHA(2)DS(2)-VASc scores for each patient. The 2006 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines for atrial fibrillation management were used to determine anticoagulation recommendations based on the CHADS(2) score, and the 2010 European Society of Cardiology guidelines were used to determine anticoagulation recommendations based on the CHA(2)DS(2)-VASc score. RESULTS The average age was 62±13 years, and 34% were women. Average CHADS(2) and CHA(2)DS(2)-VASc scores were 1.1±1.1 and 1.8±1.5, respectively (P<.0001). The CHADS(2) score classified 33% as requiring oral anticoagulation. The CHA(2)DS(2)-VASc score classified 53% as requiring oral anticoagulation. For women, 31% had a CHADS(2) score ≥ 2, but 81% had a CHA(2)DS(2)-VASc score ≥ 2 (P = .0001). Also, 32% of women with a CHADS(2) score of zero had a CHA(2)DS(2)-VASc score ≥ 2. For men, 25% had a CHADS(2) score ≥ 2, but 39% had a CHA(2)DS(2)-VASc score ≥ 2 (P<.0001). CONCLUSION Compared with the CHADS(2) score, the CHA(2)DS(2)-VASc score more clearly defines anticoagulation recommendations. Many patients, particularly older women, are redistributed from the low- to high-risk categories.
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Affiliation(s)
- Pamela K Mason
- University of Virginia Health System, Charlottesville, VA 22908, USA.
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Bunch TJ, Darby A, May HT, Ragosta M, Lim DS, Taylor AM, DiMarco JP, Ailawadi G, Revenaugh JR, Weiss JP, Mahapatra S. Efficacy and safety of ventricular tachycardia ablation with mechanical circulatory support compared with substrate-based ablation techniques. Europace 2011; 14:709-14. [PMID: 22080473 DOI: 10.1093/europace/eur347] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Catheter ablation of ventricular tachycardia (VT) can be limited by haemodynamic instability. In these cases, substrate-based ablation is typically performed. An alternative is to perform activation and entrainment mapping during VT supported by a percutaneous left ventricular assist device (pVAD). We sought to compare the complication and success rates of pVAD-assisted VT ablation with scar-based techniques. METHODS AND RESULTS Thirteen consecutive patients with haemodynamically unstable VT underwent pVAD-assisted ablation (pVAD group) and were retrospectively compared with 18-matched patients undergoing a substrate-based VT ablation (non-pVAD group). There was no significant difference in age or ejection fraction between the groups although pVAD patients tended to have more shocks in the preceding months. Procedure times were longer for the pVAD group. The number of monomorphic VTs induced was greater in the pVAD group (3.2 vs. 1.6, P= 0.04); however, after ablation, there was no difference in inducibility between the pVAD and non-pVAD group (10 of 13 vs. 12 of 18; 77 vs. 67%, P = 0.69). There was no difference in acute complications including stroke or death. At 9 ± 3 months, 1-year freedom from implantable cardioverter-defibrillator (ICD) shocks/therapies for sustained VT were similar (P= 0.96). In multivariable analysis, the absence of atrial fibrillation (hazard ratio=0.15, P= 0.04) was associated with a lower incidence of ICD shocks. CONCLUSIONS In high-risk patients, pVAD-assisted VT ablation guided by activation and entrainment mapping is a feasible alternative to substrate mapping and allows outcomes comparable to substrate mapping.
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Affiliation(s)
- T Jared Bunch
- Intermountain Medical Center, Salt Lake City, UT, USA
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Estes NAM, Sacco RL, Al-Khatib SM, Ellinor PT, Bezanson J, Alonso A, Antzelevitch C, Brockman RG, Chen PS, Chugh SS, Curtis AB, DiMarco JP, Ellenbogen KA, Epstein AE, Ezekowitz MD, Fayad P, Gage BF, Go AS, Hlatky MA, Hylek EM, Jerosch-Herold M, Konstam MA, Lee R, Packer DL, Po SS, Prystowsky EN, Redline S, Rosenberg Y, Van Wagoner DR, Wood KA, Yue L, Benjamin EJ. American Heart Association atrial fibrillation research summit: a conference report from the American Heart Association. Circulation 2011; 124:363-72. [PMID: 21709057 DOI: 10.1161/cir.0b013e318224b037] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Irvine JN, LaPar DJ, Mahapatra S, DiMarco JP, Ailawadi G. Treatment of a malpositioned transcutaneous ventricular pacing lead in the left ventricle via direct aortic puncture. Europace 2011; 13:1207-8. [PMID: 21421571 DOI: 10.1093/europace/eur048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An 81-year-old woman with progressive cough was hospitalized 2 weeks following transcutaneous pacemaker implantation. Imaging revealed an absent brachiocephalic vein and aberrant course of a ventricular lead into the aorta with implantation into the left ventricle. We describe the unusual anatomic course, diagnosis, and surgical extraction of a malpositioned pacer lead.
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Affiliation(s)
- James N Irvine
- Division of Thoracic & Cardiovascular Surgery, Department of Surgery, PO Box 800679, University of Virginia, Charlottesville, VA 22908, USA
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Mason PK, Moorman L, Lake DE, Mangrum JM, DiMarco JP, Ferguson JD, Mahapatra S, Bilchick KC, Wiggins D, Mounsey JP, Moorman JR. Gender and Racial Characteristics of Patients Referred to a Tertiary Atrial Fibrillation Center. J Atr Fibrillation 2010. [DOI: 10.4022/jafib.v2i3.591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Mason PK, Moorman L, Lake DE, Mangrum JM, DiMarco JP, Ferguson JD, Mahapatra S, Bilchick KC, Wiggins D, Mounsey JP, Moorman JR. Gender and Racial Characteristics of Patients Referred to a Tertiary Atrial Fibrillation Center. J Atr Fibrillation 2010; 3:301. [PMID: 28496679 DOI: 10.4022/jafib.301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 11/19/2010] [Accepted: 11/24/2010] [Indexed: 11/10/2022]
Abstract
Atrial Fibrillation Centers (AFCs) are becoming increasingly common and are often developed at institutions to provide comprehensive evaluation and management for patients with atrial fibrillation (AF) including catheter and surgical ablation. Studies have shown that women and racial minority patients are less likely to be offered aggressive or invasive therapies. The University of Virginia (UVA) AFC was opened in 2004. We analyzed data collected during initial visits to our AFC from 2004-2008 to determine the gender and racial characteristics of a tertiary AFC population. Multivariable regression analysis was used to compare clinical characteristics. There were a total of 1664 consecutive initial patient visits. Cardiologists referred 61% and primary care physicians referred 37% of patients. Twice as many men were referred as women (570 vs. 1094; P<0.0001). Women were older (68.0±11.9 vs. 62.4±13.0 years; P<0.0001) and more symptomatic with palpitations (80% vs. 73%; P=0.008), but otherwise were not substantially different from men. Our referring physicians treated the majority of both men and women with anticoagulant and rate-controlling medications. African American patients accounted for 2.8% of AFC initial visits. In contrast, they accounted for 7.4% of patients seen for a primary diagnosis of AF at all other UVA outpatient clinics (P<0.0001). In conclusion, the demographics of a tertiary AFC are different than those of the general population. Women and racial minority patients are underrepresented, and the women have few comorbidities and symptoms than the known epidemiology would lead us to expect.
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Bilchick KC, Kamath S, DiMarco JP, Stukenborg GJ. Bundle-branch block morphology and other predictors of outcome after cardiac resynchronization therapy in Medicare patients. Circulation 2010; 122:2022-30. [PMID: 21041691 DOI: 10.1161/circulationaha.110.956011] [Citation(s) in RCA: 199] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Clinical trials of cardiac resynchronization therapy (CRT) have enrolled a select group of patients, with few patients in subgroups such as right bundle-branch block (RBBB). Analysis of population-based outcomes provides a method to identify real-world predictors of CRT outcomes. METHODS AND RESULTS Medicare Implantable Cardioverter-Defibrillator Registry (2005 to 2006) data were merged with patient outcomes data. Cox proportional-hazards models assessed death and death/heart failure hospitalization outcomes in patients with CRT and an implantable cardioverter-defibrillator (CRT-D). The 14 946 registry patients with CRT-D (median follow-up, 40 months) had 1-year, 3-year, and overall mortality rates of 12%, 32%, and 37%, respectively. New York Heart Association class IV heart failure status (1-year hazard ratio [HR], 2.23; 3-year HR, 1.98; P<0.001) and age ≥ 80 years (1-year HR, 1.74; 3-year HR, 1.75; P<0.001) were associated with increased mortality both early and late after CRT-D. RBBB (1-year HR, 1.44; 3-year HR, 1.37; P<0.001) and ischemic cardiomyopathy (1-year HR, 1.39; 3-year HR, 1.44; P<0.001) were the next strongest adjusted predictors of both early and late mortality. RBBB and ischemic cardiomyopathy together had twice the adjusted hazard for death (HR, 1.99; P<0.001) as left BBB and nonischemic cardiomyopathy. QRS duration of at least 150 ms predicted more favorable outcomes in left BBB but had no impact in RBBB. A secondary analysis showed lower hazards for CRT-D compared with standard implantable cardioverter-defibrillators in left BBB compared with RBBB. CONCLUSIONS In Medicare patients, RBBB, ischemic cardiomyopathy, New York Heart Association class IV status, and advanced age were powerful adjusted predictors of poor outcome after CRT-D. Real-world mortality rates 3 to 4 years after CRT-D appear higher than previously recognized.
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Affiliation(s)
- Kenneth C Bilchick
- Departments of Medicine, University of Virginia Health System, PO Box 800158, Charlottesville, VA 22901, USA.
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Wazni O, Epstein LM, Carrillo RG, Love C, Adler SW, Riggio DW, Karim SS, Bashir J, Greenspon AJ, DiMarco JP, Cooper JM, Onufer JR, Ellenbogen KA, Kutalek SP, Dentry-Mabry S, Ervin CM, Wilkoff BL. Lead extraction in the contemporary setting: the LExICon study: an observational retrospective study of consecutive laser lead extractions. J Am Coll Cardiol 2010; 55:579-86. [PMID: 20152562 DOI: 10.1016/j.jacc.2009.08.070] [Citation(s) in RCA: 417] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Revised: 07/13/2009] [Accepted: 08/03/2009] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This study sought to examine the safety and efficacy of laser-assisted lead extraction and the indications, outcomes, and risk factors in a large series of consecutive patients. BACKGROUND The need for lead extraction has been increasing in direct relationship to the increased numbers of cardiovascular implantable electronic devices. METHODS Consecutive patients undergoing transvenous laser-assisted lead extraction at 13 centers were included. RESULTS Between January 2004 and December 2007, 1,449 consecutive patients underwent laser-assisted lead extraction of 2,405 leads (20 to 270 procedures/site). Median implantation duration was 82.1 months (0.4 to 356.8 months). Leads were completely removed 96.5% of the time, with a 97.7% clinical success rate whereby clinical goals associated with the indication for lead removal were achieved. Failure to achieve clinical success was associated with body mass index <25 kg/m(2) and low extraction volume centers. Procedural failure was higher in leads implanted for >10 years and when performed in low volume centers. Major adverse events in 20 patients were directly related to the procedure (1.4%) including 4 deaths (0.28%). Major adverse effects were associated with patients with a body mass index <25 kg/m(2). Overall all-cause in-hospital mortality was 1.86%; 4.3% when associated with endocarditis, 7.9% when associated with endocarditis and diabetes, and 12.4% when associated with endocarditis and creatinine > or =2.0. Indicators of all-cause in-hospital mortality were pocket infections, device-related endocarditis, diabetes, and creatinine > or =2.0. CONCLUSIONS Lead extraction employing laser sheaths is highly successful with a low procedural complication rate. Total mortality is substantially increased with pocket infections or device-related endocarditis, particularly in the setting of diabetes, renal insufficiency, or body mass index <25 kg/m(2). Centers with smaller case volumes tended to have a lower rate of successful extraction.
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Affiliation(s)
- Oussama Wazni
- Department of Cardiovascular Disease, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Ferguson JD, Helms A, Mangrum JM, Mahapatra S, Mason P, Bilchick K, McDaniel G, Wiggins D, DiMarco JP. Catheter ablation of atrial fibrillation without fluoroscopy using intracardiac echocardiography and electroanatomic mapping. Circ Arrhythm Electrophysiol 2010; 2:611-9. [PMID: 20009075 DOI: 10.1161/circep.109.872093] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Catheter ablation of atrial fibrillation is currently guided by x-ray fluoroscopy. The associated radiation risk to patients and medical staff may be significant. We report an atrial fibrillation ablation technique using intracardiac echocardiography (ICE) and electroanatomic mapping without fluoroscopy. METHODS AND RESULTS Twenty-one patients with atrial fibrillation (age, 42 to 73 years; 14 male; 14 paroxysmal, 7 persistent; body mass index, 26 to 38) underwent ablation. A decapolar catheter was advanced through the left subclavian vein until stable coronary sinus electrograms appeared on all electrodes. Two 9F sheaths were advanced transfemorally over a guide wire to the right atrium. A rotational ICE catheter was advanced through a deflectable sheath. Double transseptal puncture was performed with ICE guidance and facilitated by electrocautery. A 3D MRI left atrial image was registered to the ostia of the pulmonary veins using ICE. Catheter ablation was performed using ICE and electroanatomic mapping navigation. In 19 cases, no fluoroscopy was used and the staff did not wear protective lead. In 2 cases, 2 to 16 minutes of fluoroscopy was used to assist transseptal puncture. Median procedure time was 208 (188 to 221) minutes; coronary sinus cannulation took 5 (2 to 26) minutes; double transseptal took 26 (17 to 40) minutes; left atrial ablation time was 103 (90 to 127) minutes. All patients underwent circumferential pulmonary vein ablation and 8 patients underwent additional left atrial ablation. There were no procedure-related complications. CONCLUSIONS Catheter ablation of atrial fibrillation without fluoroscopy is feasible and merits further attention. This technique may be especially helpful in preventing x-ray exposure in children, pregnant women, and obese patients undergoing left atrial ablation.
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Affiliation(s)
- John D Ferguson
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, VA 22908, USA.
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Affiliation(s)
- Pamela K Mason
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
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Helms AS, West JJ, Patel A, Lipinski MJ, Mangrum JM, Mounsey JP, DiMarco JP, Ferguson JD. Relation of left atrial volume from three-dimensional computed tomography to atrial fibrillation recurrence following ablation. Am J Cardiol 2009; 103:989-93. [PMID: 19327428 DOI: 10.1016/j.amjcard.2008.12.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 12/01/2008] [Accepted: 12/01/2008] [Indexed: 10/21/2022]
Abstract
The effect of left atrial (LA) structural remodeling and dilatation on the outcome of ablation of atrial fibrillation (AF) remains unknown. We correlated potential prognostic markers of AF ablation, including LA volume from computed tomography, with AF recurrence after ablation. We studied 73 consecutive patients (52 with paroxysmal AF, 21 with persistent AF) undergoing AF ablation. LA volume was calculated by axial slice summation from 3-dimensional computed tomography. Follow-up was through 12 months, with success of ablation determined by electrocardiography and lack of symptoms (unless symptoms proved not AF by Holter monitor). Overall procedure success was 66% (including 15% repeat ablations, 12% on antiarrhythmics). Pulmonary vein isolation was performed, with additional linear ablation in 44 (60%). Mean LA volume (95% confidence interval) for those with recurrent AF was 119 ml (104 to 135) versus 98 ml (90 to 106) for no recurrence (p = 0.01, rank-sum test). Wide variation in LA volume occurred in the 2 groups, but, of the 15% of patients with very large LA volumes (>135 ml), 82% had recurrent AF. A cutpoint of 135 ml yields 36% sensitivity and 96% specificity for recurrence. In multivariable regression analysis, only LA volume and number of cardiovascular co-morbidities were associated with more recurrence (p = 0.02 and p = 0.03, respectively). In conclusion, LA volume varies greatly in those with and without successful AF ablations, mean LA volume is significantly larger in those with recurrence, and patients with LA volumes >135 ml are very likely to develop recurrent AF.
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Affiliation(s)
- John P. DiMarco
- From the Cardiac Electrophysiology Laboratory; Cardiovascular Division; University of Virginia Health System, Charlottesville, Va
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Abstract
Over the last 15 years, a series of well-designed randomized clinical trials has clearly demonstrated that implantable cardioverter-defibrillator (ICD) therapy reduces mortality in select high-risk populations. Despite the widespread acceptance of ICD therapy, many questions related to its optimal use remain. This article discusses several key issues now confronting clinicians.
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Affiliation(s)
- Pamela K Mason
- Department of Internal Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Abstract
The post-myocardial infarction (MI) patient with left ventricular dysfunction (LVD) is at risk for ventricular arrhythmias resulting in sudden cardiac death. In high-risk post-MI patients with a depressed left ventricular ejection fraction, prophylactic implantable cardioverter defibrillators (ICDs) may significantly improve survival. These benefits are in addition to those of optimal pharmacologic therapy, and ICD therapy should be considered the standard of care in these patients. Recent device trials have demonstrated the benefits of prophylactic ICD placement in patients who have been selected based on post-MI left ventricular systolic dysfunction alone. In addition, cardiac resynchronization therapy can improve the quality of life beyond that achievable with drug therapy alone and should be considered in patients with symptomatic heart failure with QRS prolongation. Further risk stratification studies of post-MI LVD patients will allow ICD therapy to be applied in a more cost-effective manner.
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Affiliation(s)
- Alan H Kadish
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Helms A, West JJ, Patel A, Mounsey JP, DiMarco JP, Mangrum JM, Ferguson JD. Real-time rotational ICE imaging of the relationship of the ablation catheter tip and the esophagus during atrial fibrillation ablation. J Cardiovasc Electrophysiol 2008; 20:130-7. [PMID: 18775048 DOI: 10.1111/j.1540-8167.2008.01277.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Atrioesophageal fistula is a rare complication of atrial fibrillation (AF) ablation that should be avoided. We investigated whether rotational intracardiac echocardiography (ICE) can help to minimize ablation close to the esophagus. METHODS AND RESULTS We studied 41 patients referred for catheter ablation of refractory AF. A rotational ICE catheter was inserted into the (LA) to determine the location of the esophagus. The esophagus was identified to be either adjacent to the pulmonary vein (PV) ostium or to a cuff 2 cm outside the ostium. Circumferential ablation was performed at the PV ostium, with the exact ablation location determined by ICE. The relationship of the catheter tip to the esophagus was imaged during energy delivery, allowing interruption when respiration moved the tip closer to the esophagus. Out of 41 patients, the esophagus was seen near left-sided PVs in 32 and near right-sided PVs in three patients. The median distance from LA endocardium to esophagus was 2.2 mm (range, 1.4-6 mm). In 21 of 35 patients with a closely related esophagus, ablation over the esophagus was avoided by ablating either lateral or medial to the esophagus. In 14 patients, the esophagus could not be avoided, and risk was minimized by limiting lesion size. Significant movement (>10 mm) of the esophagus during the procedure occurred in 3/41 cases. CONCLUSION Rotational ICE can accurately determine the distance of ablation sites from the esophagus. Real-time imaging of the relationship of the ablation catheter tip to the esophagus may reduce the incidence of esophageal injury.
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Affiliation(s)
- Adam Helms
- University of Virginia Health System, Charlottesville, Virginia 22908, USA
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 51:e1-62. [PMID: 18498951 DOI: 10.1016/j.jacc.2008.02.032] [Citation(s) in RCA: 1090] [Impact Index Per Article: 68.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: Executive Summary. Circulation 2008. [DOI: 10.1161/circualtionaha.108.189741] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008. [PMID: 18483207 DOI: 10.1161/circulationaha.108.189742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350-408. [PMID: 18483207 DOI: 10.1161/circualtionaha.108.189742] [Citation(s) in RCA: 935] [Impact Index Per Article: 58.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Naccarelli GV, Conti JB, DiMarco JP, Tracy CM. Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing, and Arrhythmia Management. J Am Coll Cardiol 2008; 51:374-80. [PMID: 18206755 DOI: 10.1016/j.jacc.2007.11.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Fisher JD, Buxton AE, Lee KL, Packer DL, Echt DS, Denes P, Lehmann MH, DiMarco JP, Roy D, Hafley GE. Designation and distribution of events in the Multicenter UnSustained Tachycardia Trial (MUSTT). Am J Cardiol 2007; 100:76-83. [PMID: 17599445 PMCID: PMC4733349 DOI: 10.1016/j.amjcard.2007.02.055] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Revised: 02/06/2007] [Accepted: 02/06/2007] [Indexed: 10/23/2022]
Abstract
Patients with coronary artery disease, depressed left ventricular ejection fraction, and nonsustained ventricular tachycardia (VT) have a high mortality rate due to arrhythmic (arrhythmic death/cardiac arrest) and other cardiac causes. The Multicenter UnSustained Tachycardia Trial (MUSTT) investigated whether electrophysiologic study (EPS) was helpful in choosing drug or defibrillator therapy in patients induced into sustained VT. The events committee attempted to categorize follow-up events in patients in MUSTT and to present a detailed breakdown of events. A derivative of the Hinkle-Thaler classification was used, incorporating lessons from other multicenter studies. The committee was blinded to results of EPS and implantable cardioverter-defibrillator (ICD) or other antiarrhythmic therapy status of patients. The primary end point was cardiac arrest or death from arrhythmia. Secondary end points were death from all causes, cardiac causes, and spontaneous sustained VT. Classifications were death and cardiac arrest. Each was similarly divided as arrhythmic with 14 subcategories, e.g., unwitnessed or related to EPS and nonarrhythmic with 10 subcategories, e.g., ischemia. Terminal VF in progressive heart failure was considered nonarrhythmic. Events were reviewed by 2 members. Disagreements were resolved by the 2 members or, if needed, by the full committee. Of the 2,202 patients in MUSTT, there were 902 deaths. Sustained VT requiring cardioversion occurred in 182 patients. An additional 94 patients had resuscitated cardiac arrests. Events occurred in 1,027 patients, and all were reviewed. The 3 leading events were deaths that were classed as sudden/unwitnessed (23% of 902), due to progressive heart failure (22%), or due to noncardiovascular causes (18%). Arrhythmic deaths or cardiac arrests were highest in inducible patients randomized to no antiarrhythmic therapy; next were inducible patients receiving an ICD; and lowest were in patients who were noninducible. In conclusion, the classification system provided a detailed breakdown of events in consistent categories, showing utility for event analysis and interpretation and development of therapeutic strategies. The classifications assigned by the committee were used in all MUSTT outcomes reports, thus affecting all reported outcomes and overall interpretations of the MUSTT.
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Affiliation(s)
- John D Fisher
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA.
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Buxton AE, Calkins H, Callans DJ, DiMarco JP, Fisher JD, Greene HL, Haines DE, Hayes DL, Heidenreich PA, Miller JM, Poppas A, Prystowsky EN, Schoenfeld MH, Zimetbaum PJ, Heidenreich PA, Goff DC, Grover FL, Malenka DJ, Peterson ED, Radford MJ, Redberg RF. ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology). J Am Coll Cardiol 2007; 48:2360-96. [PMID: 17161282 DOI: 10.1016/j.jacc.2006.09.020] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Mangrum JM, Ferguson JD, DiMarco JP. Acute and Chronic Pharmacologic Management of Supraventricular Tachycardias. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50029-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Abraham WT, Abrams J, Aklog L, Albert MA, Antman EM, Anyanwu A, Arora R, Bakris GL, Bates ER, Bermudez EA, Cabell CH, Calhoun DA, Califf RM, Callans DJ, Chrysant G, Cohn JN, Colucci WS, Couper GS, Dangas GD, Danik JS, Davidson MH, DiMarco JP, Drexler H, Dzau VJ, Ellis SG, Falk RH, Falkner B, Fang JC, Ferguson JD, Forbess LW, Fox KA, Freedman J, Frisch DR, Frishman WH, Froelicher VF, Gaasch WH, Gehr TW, Giugliano RP, Givertz MM, Gordon BR, Gulliver GA, Hoit BD, Hsue PY, Hudgins LC, Jacobson JT, Kadish AH, Karha J, Katakam R, Khosla N, Krousel-Wood M, Kupersmith J, Kushner FG, Landzberg MJ, Lincoff AM, Maisel WH, Mangrum JM, Martucci G, Materson BJ, Mathier MA, McManus K, Meadows J, Melo LG, Mullany CJ, Mullen M, Muni NI, Murali S, Myers JN, Napolitano C, Nattel S, Newby DE, Nishizaka MK, Ooi OC, Oparil S, Peterson GE, Priori SG, Reimold SC, Rihal CS, Sacks FM, Saltman AE, Schroeder J, Schwartz GL, Shirazi F, Sica DA, Stevenson LW, Stone NJ, Sweitzer NK, Townsend RR, Umans JG, Velazquez EJ, Ward CA, Washam JB, Waters DD, Weber MA, Whelton PK, Wiviott SD, Wollert KC, Woosley RL, Young WF, Zimetbaum P, Zuckerman BD. Contributors. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50003-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Buxton AE, Calkins H, Callans DJ, DiMarco JP, Fisher JD, Greene HL, Haines DE, Hayes DL, Heidenreich PA, Miller JM, Poppas A, Prystowsky EN, Schoenfeld MH, Zimetbaum PJ, Goff DC, Grover FL, Malenka DJ, Peterson ED, Radford MJ, Redberg RF. ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology). Circulation 2006; 114:2534-70. [PMID: 17130345 DOI: 10.1161/circulationaha.106.180199] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tracy CM, Akhtar M, DiMarco JP, Packer DL, Weitz HH, Creager MA, Holmes DR, Merli G, Rodgers GP. American College of Cardiology/American Heart Association 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion. Circulation 2006; 114:1654-68. [PMID: 16987946 DOI: 10.1161/circulationaha.106.178893] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tracy CM, Akhtar M, DiMarco JP, Packer DL, Weitz HH, Creager MA, Holmes DR, Merli G, Rodgers GP, Tracy CM, Weitz HH. American College of Cardiology/American Heart Association 2006 Update of the Clinical Competence Statement on Invasive ElectrophysiologyStudies,CatheterAblation,andCardioversion. J Am Coll Cardiol 2006; 48:1503-17. [PMID: 17010821 DOI: 10.1016/j.jacc.2006.06.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
This case report describes the diagnosis of Chagas myocarditis in a patient from Honduras who presented with syncope. The discussion summarizes the pathophysiology of cardiac Chagas disease. Acute, latent, and chronic Chagas myocarditis are described. The role of CMR in diagnosing Chagas myocarditis is discussed.
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Affiliation(s)
- Rajan A G Patel
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
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Prudente LA, Reigle J, Bourguignon C, Haines DE, DiMarco JP. Psychological indices and phantom shocks in patients with ICD. J Interv Card Electrophysiol 2006; 15:185-90. [PMID: 17019638 DOI: 10.1007/s10840-006-9010-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Accepted: 05/02/2006] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Some patients with ICDs experience the sensation of a shock in the absence of true therapy (phantom shock). We hypothesize that phantom shocks may be a manifestation of anxiety, depression or PTSD. METHODS AND RESULTS All patients over 18 years old with an ICD were eligible to enroll in the study. The first 75 subjects who agreed to participate were enrolled and divided into three groups: ICD patients with phantom shocks (n = 19); ICD patients who had actual shocks (n = 28) and ICD patients who had no shocks (n = 28). During a clinic visit a demographic questionnaire and three psychological rating scales were administered: the Spielberger State-Trait Anxiety Inventory (STAI); the Center for Epidemiologic Studies Depression Scale (CES-D) and the Posttraumatic Stress Checklist (PCL-C). No significant differences between groups were found in gender, race, age, history of MI or cardiac surgery status. Data analysis of the psychological indices using one-way ANOVA showed that the group with phantom shocks had more depression (CES-D p = 0.011) and more anxiety (STAI p = 0.010) than the other groups. Multiple comparisons of group means showed a greater percentage of clinically depressed patients in the phantom shock group than in the other groups. CONCLUSION Patients with phantom shocks are more likely to be clinically depressed and have higher levels of anxiety than other ICD patients, regardless of history of actual shocks.
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Affiliation(s)
- Liza A Prudente
- Electrophysiology, University of Virginia Health System, Box 801461, Charlottesville, VA 22908, USA.
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Naccarelli GV, Conti JB, DiMarco JP, Tracy CM. Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing, and Arrhythmia Management. J Am Coll Cardiol 2006; 47:904-10. [PMID: 16487872 DOI: 10.1016/j.jacc.2005.12.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hummel JP, Lindner JR, Belcik JT, Ferguson JD, Mangrum JM, Bergin JD, Haines DE, Lake DE, DiMarco JP, Mounsey JP. Extent of myocardial viability predicts response to biventricular pacing in ischemic cardiomyopathy. Heart Rhythm 2005; 2:1211-7. [PMID: 16253911 DOI: 10.1016/j.hrthm.2005.07.027] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Accepted: 07/27/2005] [Indexed: 01/30/2023]
Abstract
BACKGROUND The clinical response to biventricular pacing is unpredictable, especially in patients with ischemic cardiomyopathy. OBJECTIVES The purpose of this study was to prospectively examine the relationship between the extent of myocardial viability and the response to cardiac resynchronization therapy. METHODS Twenty-one patients with ischemic left ventricular (LV) dysfunction (left ventricular ejection fraction [LVEF] 21 +/- 5%), New York Heart Association (NYHA) functional class III-IV, and QRS >120 ms received biventricular devices. Myocardial viability was assessed by myocardial contrast echocardiography, and a perfusion score index (PSI) was calculated from summed segmental perfusion scores. LV performance was assessed by echocardiography on the day after implantation and at 6 months. RESULTS PSI was closely correlated with acute improvement in LVEF (P = .003, r = 0.65), stroke volume (P = .02, r = 0.54), and end-systolic volume (P = .05, r = -0.49). PSI also correlated with early diastolic LV relaxation (E', P < .05, r = 0.50) and global myocardial performance or Tei index (P = .003, r = 0.63). By multiple linear regression analysis, PSI provided incremental predictive value to the degree of dyssynchrony, measured by tissue Doppler imaging, for predicting improvement in LVEF. At 6 months, PSI remained positively correlated with improvement in ventricular performance and with reduction in LV end-diastolic dimension (P = .003, r = -0.68). PSI also influenced the clinical variables of NYHA class, 6-minute walk distance, quality-of-life score, and number of hospitalizations for heart failure. CONCLUSION In patients with ischemic cardiomyopathy, the extent of myocardial viability predicts acute and long-term improvement in LV performance, exercise tolerance, and reduction in LV end-diastolic dimension with biventricular pacing.
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Affiliation(s)
- James P Hummel
- Cardiovascular Division, University of Virginia School of Medicine, Charlottesville, VA 22908, USA.
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McCotter CJ, Angle JF, Prudente LA, Mounsey JP, Ferguson JD, DiMarco JP, Hummel JP, Mangrum JM. Placement of Transvenous Pacemaker and ICD Leads Across Total Chronic Occlusions. Pacing and Clinical Electrophysiology 2005; 28:921-5. [PMID: 16176530 DOI: 10.1111/j.1540-8159.2005.00203.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To establish a method of implantation for device leads across total venous occlusions. BACKGROUND Indications for pacemaker and implantable cardiac defibrillator implantation continue to expand. Chronic venous occlusions are increasingly encountered with lead placement. Some degree of obstruction can be as high as 13% before device implantation and 50% after transvenous device implantation. We report an approach of venoplasty/dilatation of chronic total occlusions to allow lead placement. METHODS From January 1, 2002 through December 16, 2004, 1,356 systems (initial and upgrade) were implanted at the University of Virginia. At the time of device implant, seven patients were noted to have chronic venous occlusions and alternative access was precluded. Four of the seven patients had an existing system; the other three received initial implantations. Subsequently, these seven patients had a 5 Fr catheter placed in the basilic/axillary/subclavian vein and a venogram was obtained to demonstrate the area of chronic occlusion. A guide wire was advanced across the lesion for initial recanalization. Dilatation or venoplasty was performed at the occluded site. A guide wire was retained across the lesion and the patient underwent lead implantation. RESULTS In all seven patients, recanalization was achieved and leads were successfully placed. There were no complications or damage to the vessels or existing leads. CONCLUSIONS Venoplasty or dilatation of chronic total venous occlusion is a safe and effective technique, which allows for placement of transvenous leads.
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Affiliation(s)
- Craig J McCotter
- Department of Radiology, Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA 22908-0158, USA
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DiMarco JP, Flaker G, Waldo AL, Corley SD, Greene HL, Safford RE, Rosenfeld LE, Mitrani G, Nemeth M. Factors affecting bleeding risk during anticoagulant therapy in patients with atrial fibrillation: observations from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Am Heart J 2005; 149:650-6. [PMID: 15990748 DOI: 10.1016/j.ahj.2004.11.015] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Stroke and systemic thromboembolism are serious problems for patients with atrial fibrillation (AF), but their incidence can be substantially reduced by appropriate anticoagulation. Bleeding is the major complication of anticoagulant treatment, and the relative risks for bleeding vs stroke must be considered when starting anticoagulation. METHODS The AFFIRM trial included patients with AF and at least one risk factor for stroke, randomly assigning them to either a rate-control or rhythm-control strategy. All patients were initially treated with warfarin. The incidence of protocol-defined major and minor bleeding was documented during follow-up. Variables associated with bleeding were determined using a Cox proportional hazards model, using baseline and time-dependent covariates. RESULTS The 4060 patients in the AFFIRM trial were followed for an average of 3.5 years. Major bleeding occurred in 260 patients, an annual incidence of approximately 2% per year, with no significant difference between the rate-control and rhythm-control groups. Increased age, heart failure, hepatic or renal disease, diabetes, first AF episode, warfarin use, and aspirin use were significantly associated with major bleeding. Minor bleeding was common in both treatment arms, with 738 patients reporting this problem in one or more visits. CONCLUSIONS Bleeding is a significant problem that complicates management of patients with AF. Risk factors for bleeding can be identified, and knowledge of these risk factors can be used to plan therapy.
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Affiliation(s)
- John P DiMarco
- Cardiovascular Division, University of Virginia Health System, Charlottesville, Va 22908, USA.
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47
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Curtis AB, Gersh BJ, Corley SD, DiMarco JP, Domanski MJ, Geller N, Greene HL, Kellen JC, Mickel M, Nelson JD, Rosenberg Y, Schron E, Shemanski L, Waldo AL, Wyse DG. Clinical factors that influence response to treatment strategies in atrial fibrillation: the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Am Heart J 2005; 149:645-9. [PMID: 15990747 DOI: 10.1016/j.ahj.2004.09.038] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The AFFIRM Study was a randomized multicenter comparison of 2 treatment strategies, rate-control versus rhythm-control, in high-risk patients with atrial fibrillation (AF). The primary outcome of the trial showed no overall difference in survival between strategies. However, there may be important patient subgroups for which there are identifiable differences in outcome with 1 of the 2 strategies. METHODS AND RESULTS Subgroups that were prespecified for analysis from the main AFFIRM Study were age, sex, coronary artery disease (CAD), hypertension, congestive heart failure (CHF), left ventricular ejection fraction (LVEF), rhythm at randomization, first episode of AF, and duration of the qualifying episode of AF. Baseline characteristics were analyzed for each subgroup. Adjusted hazard ratios for each subgroup and for each stratum were generated using Cox models, and these models were used to determine whether treatment strategy affected overall survival differentially by subgroup. Adjusted survival was worse for patients > or =65 years and for patients with a history of CHF, CAD, or an abnormal LVEF. In the adjusted analyses, the effect of treatment strategy was similar within all of the prespecified subgroups. When each subgroup stratum was analyzed separately, patients > or =65 years and patients without a history of CHF had significantly better outcome with rate-control therapy (each P < .01). CONCLUSIONS Overall, treatment effect for rate control versus rhythm control was the same within each subgroup. However, certain selected patient categories may have better survival with one particular strategy for management of AF.
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Affiliation(s)
- Anne B Curtis
- University of Florida, Box 100277, 1600 SW Archer Rd, Gainesville, FL 32610, USA.
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Corley SD, Epstein AE, DiMarco JP, Domanski MJ, Geller N, Greene HL, Josephson RA, Kellen JC, Klein RC, Krahn AD, Mickel M, Mitchell LB, Nelson JD, Rosenberg Y, Schron E, Shemanski L, Waldo AL, Wyse DG. Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation 2004; 109:1509-13. [PMID: 15007003 DOI: 10.1161/01.cir.0000121736.16643.11] [Citation(s) in RCA: 807] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The AFFIRM Study showed that treatment of patients with atrial fibrillation and a high risk for stroke or death with a rhythm-control strategy offered no survival advantage over a rate-control strategy in an intention-to-treat analysis. This article reports an "on-treatment" analysis of the relationship of survival to cardiac rhythm and treatment as they changed over time. METHODS AND RESULTS Modeling techniques were used to determine the relationships among survival, baseline clinical variables, and time-dependent variables. The following baseline variables were significantly associated with an increased risk of death: increasing age, coronary artery disease, congestive heart failure, diabetes, stroke or transient ischemic attack, smoking, left ventricular dysfunction, and mitral regurgitation. Among the time-dependent variables, the presence of sinus rhythm (SR) was associated with a lower risk of death, as was warfarin use. Antiarrhythmic drugs (AADs) were associated with increased mortality only after adjustment for the presence of SR. Consistent with the original intention-to-treat analysis, AADs were no longer associated with mortality when SR was removed from the model. CONCLUSIONS Warfarin use improves survival. SR is either an important determinant of survival or a marker for other factors associated with survival that were not recorded, determined, or included in the survival model. Currently available AADs are not associated with improved survival, which suggests that any beneficial antiarrhythmic effects of AADs are offset by their adverse effects. If an effective method for maintaining SR with fewer adverse effects were available, it might be beneficial.
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Affiliation(s)
- John P DiMarco
- Electrophysiology Laboratory, Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville 22908-0158, USA.
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Mason PK, Wood MA, Reese DB, Lobban JH, Mitchell MA, DiMarco JP. Usefulness of implantable loop recorders in office-based practice for evaluation of syncope in patients with and without structural heart disease. Am J Cardiol 2003; 92:1127-9. [PMID: 14583373 DOI: 10.1016/j.amjcard.2003.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early use of an implantable loop recorder for evaluating unexplained syncope in an office-based electrophysiology practice is an effective approach in patients with and without structural heart disease. Documentation of rhythm with an implantable loop recorder at the time of symptoms is possible in approximately 50% and 80% of patients in both groups after 1 and 2 years of follow-up, respectively.
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Affiliation(s)
- Pamela K Mason
- University of Virginia Health System, Charlottesville 22908-0158, USA
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