Clinical Protocol for Selecting Intracardiac or Transesophageal Echocardiography-Guided Left Atrial Appendage Occlusion.

Intracardiac echocardiography (ICE) has emerged as an alternative to transesophageal echo (TEE) to guide left atrial appendage occlusion (LAAO). We established a protocol to select patients appropriate for ICE guidance. Patients who underwent LAAO with the Watchman or Watchman FLX device (Boston Scientific, Marlborough, Massachusetts) from January 2018 to March 2022 at a large United States center were included. The novel protocol prospectively selected TEE or ICE guidance beginning in January 2020; previous LAAO procedures were retrospectively included. ICE was selected for patients with uninterrupted anticoagulation and appropriate LAA anatomy, renal function, and moderate sedation tolerance. In-hospital outcomes with successful implantation without conversion to TEE guidance, no peridevice leak, and no procedural complications were compared. Composite 1-year outcome included freedom from peridevice leak, device-related thrombus, stroke, and all-cause mortality. A total of 234 patients were included; the mean age was 76.1 ± 8.3 years old, and 42.3% were female. ICE guidance was used for 63 procedures; TEE guidance was used for 171 procedures. For the composite outcome, ICE-guided LAAO was superior to TEE-guided LAAO (risk difference 0.102, 96.8% vs 86.5%, 95% confidence interval 0.003 to 0.203, p = 0.029). In comparison to the TEE-guided group, ICE-guided procedures were shorter (89.1 ± 26.3 vs 99.8 ± 30.0 min, p = 0.0087) with less general anesthesia (26.6% vs 98.8%, p <0.0001). One-year composite adverse outcomes did not differ significantly (80.7% vs 88.9%, p = 0.17). In conclusion, the protocol to select appropriate patients for ICE versus TEE guidance for LAAO is safe and effective. Larger studies are indicated to validate this approach to improve outcomes, shorten procedures, and avoid general anesthesia.

Quantifying Risk Factors for Atrial Fibrillation: Retrospective Review of a Large Electronic Patient Database.

BACKGROUND: Despite the numerous comorbidities associated with atrial fibrillation (AF), the relative risk has been varying and not well-documented. AIM: To quantify the risk of diseases associated with AF. METHODS: Population-based retrospective analysis in IBM Explorys (1999-2019), an electronic database with over 63 million patients in the United States. Odds ratios were calculated between AF and other diseases. AF patients were also stratified by age, gender, and race to assess trends of AF in different demographic groups. RESULTS: 1,812,620 patients had AF in the database. Congestive heart failure had the highest association with AF (OR 42.95). Cardiomyopathy, coronary artery disease, hypertension, and myocardial infarction all had odds greater than 15. Anemia of chronic disease and chronic kidney disease had odds greater than 18, the highest for chronic inflammatory conditions. Other conditions commonly associated with AF were found to have odds less than 8, including hyperthyroidism, alcohol use, and sleep apnea. Helicobacter pylori infection had the lowest odds at 1.98. CONCLUSIONS: Epidemiologic information could be integrated with current clinical algorithms to more rapidly identify patients at risk of AF.

Clinician dashboard views and improvement in preventative health outcome measures: a retrospective analysis.

BACKGROUND: Measuring and reporting outcome data is fundamental for health care systems to drive improvement. Our electronic health record built a dashboard that allows each primary care provider (PCP) to view real-time population health quality data of their patient panel and use that information to identify care gaps. We hypothesized that the number of dashboard views would be positively associated with clinical quality improvement. METHODS: We performed a retrospective analysis of change in quality scores compared to number of dashboard views for each PCP over a five-month period (2017-18). Using the manager dashboard, we recorded the number of views for each provider. The quality scores analyzed were: colorectal cancer (CRC) screening rates and diabetic patients with an A1c greater than 9% or no A1c in the past year. RESULTS: Data from 120 PCPs were included. The number of dashboard views by each PCP ranged from 0 to 222. Thirty-one PCPs (25.8%) did not view their dashboard. We found no significant correlation between views and change in quality scores (correlation coefficient = 0.06, 95% CI [- 0.13, 0.25] and - 0.05, 95% CI [- 0.25, 0.14] for CRC and diabetes, respectively). CONCLUSION: Clinical dashboards provide feedback to PCPs and are likely to become more available as healthcare systems continue to focus on improving population health. However, dashboards on their own may not be sufficient to impact clinical quality improvement. Dashboard viewership did not appear to impact clinician performance on quality metrics.

Recurrent Volvulus during Pregnancy: Case Report and Review of the Literature.

INTRODUCTION: Sigmoid colon volvulus (SV) represents the most common etiology of antepartum gastrointestinal obstruction, with repetitive antepartum episodes rarely reported. CASE PRESENTATION: A 25-year-old multiparous patient with history of SV at 26 weeks in her previous pregnancy presented with recurrent episodes of SV at 32 0/7, 32 4/7, 37 0/7, and 38 1/7 weeks successfully managed with colonoscopic decompression. Labor was successfully induced at 38 4/7 weeks, and she experienced two further episodes on postpartum days #1 and #32 also treated with colonoscopic decompression, followed by laparoscopic resection. CONCLUSION: Successful treatment of antepartum SV with colonoscopic decompression does not preclude recurrence later in gestation and in future pregnancies.