Optimal Surgical Approach to Left Atrioesophageal Fistula After Catheter Radiofrequency Ablation.

Atrioesophageal fistula formation is a rare but formidable complication after catheter radiofrequency ablation for atrial fibrillation. We present 4 patients who underwent urgent primary intracardiac repair of the left atrium via sternotomy with central cardiopulmonary bypass and early aortic cross-clamp, followed by repair of the esophagus. We believe that this approach represents the safest strategy for addressing this morbid and often fatal complication.

COVID-19 and cardiac arrhythmias.

BACKGROUND: Early studies suggest that coronavirus disease 2019 (COVID-19) is associated with a high incidence of cardiac arrhythmias. Severe acute respiratory syndrome coronavirus 2 infection may cause injury to cardiac myocytes and increase arrhythmia risk. OBJECTIVES: The purpose of this study was to evaluate the risk of cardiac arrest and arrhythmias including incident atrial fibrillation (AF), bradyarrhythmias, and nonsustained ventricular tachycardia (NSVT) in a large urban population hospitalized for COVID-19. We also evaluated correlations between the presence of these arrhythmias and mortality. METHODS: We reviewed the characteristics of all patients with COVID-19 admitted to our center over a 9-week period. Throughout hospitalization, we evaluated the incidence of cardiac arrests, arrhythmias, and inpatient mortality. We also used logistic regression to evaluate age, sex, race, body mass index, prevalent cardiovascular disease, diabetes, hypertension, chronic kidney disease, and intensive care unit (ICU) status as potential risk factors for each arrhythmia. RESULTS: Among 700 patients (mean age 50 ± 18 years; 45% men; 71% African American; 11% received ICU care), there were 9 cardiac arrests, 25 incident AF events, 9 clinically significant bradyarrhythmias, and 10 NSVTs. All cardiac arrests occurred in patients admitted to the ICU. In addition, admission to the ICU was associated with incident AF (odds ratio [OR] 4.68; 95% confidence interval [CI] 1.66-13.18) and NSVT (OR 8.92; 95% CI 1.73-46.06) after multivariable adjustment. Also, age and incident AF (OR 1.05; 95% CI 1.02-1.09) and prevalent heart failure and bradyarrhythmias (OR 9.75; 95% CI 1.95-48.65) were independently associated. Only cardiac arrests were associated with acute in-hospital mortality. CONCLUSION: Cardiac arrests and arrhythmias are likely the consequence of systemic illness and not solely the direct effects of COVID-19 infection.

Spiral wave classification using normalized compression distance: Towards atrial tissue spatiotemporal electrophysiological behavior characterization.

Analysis of electrical activation patterns such as re-entries during atrial fibrillation (Afib) is crucial in understanding arrhythmic mechanisms and assessment of diagnostic measures. Spiral waves are a phenomena that provide intuitive basis for re-entries occurring in cardiac tissue. Distinct spiral wave behaviors such as stable spiral waves, meandering spiral waves, and spiral wave break-up may have distinct electrogram manifestations on a mapping catheter. Hence, it is desirable to have an automated classification of spiral wave behavior based on catheter recordings for a qualitative characterization of spatiotemporal electrophysiological activity on atrial tissue. In this study, we propose a method for classification of spatiotemporal characteristics of simulated atrial activation patterns in terms of distinct spiral wave behaviors during Afib using two different techniques: normalized compressed distance (NCD) and normalized FFT (NFFTD). We use a phenomenological model for cardiac electrical propagation to produce various simulated spiral wave behaviors on a 2D grid and labeled them as stable, meandering, or breakup. By mimicking commonly used catheter types, a star shaped and a circular shaped both of which do the local readings from atrial wall, monopolar and bipolar intracardiac electrograms are simulated. Virtual catheters are positioned at different locations on the grid. The classification performance for different catheter locations, types and for monopolar or bipolar readings were also compared. We observed that the performance for each case differed slightly. However, we found that NCD performance is superior to NFFTD. Through the simulation study, we showed the theoretical validation of the proposed method. Our findings suggest that a qualitative wavefront activation pattern can be assessed during Afib without the need for highly invasive mapping techniques such as multisite simultaneous electrogram recordings.

Centrifugal gradients of rate and organization in human atrial fibrillation.

INTRODUCTION: Animal studies show that atrial fibrillation (AF) may emanate from sites of high rate and regularity, with fibrillatory conduction to adjacent areas. We used simultaneous mapping to find evidence for potential drivers in human AF defined as sites with higher rate and regularity than surrounding tissue. MATERIALS AND METHODS: In 24 patients (age 61+/-10 years; 12 persistent), we recorded AF simultaneously from 32 left atrial bipolar basket electrodes in addition to pulmonary veins (PV), coronary sinus, and right atrial electrodes. We measured AF cycle length (CL) by Fourier transform and electrogram regularity at each electrode, referenced to patient-specific atrial anatomy. RESULTS: We analyzed 10,298 electrode-periods. Evidence for potential AF drivers was found in 11 patients (five persistent). In persistent AF, these sites lay at the coronary sinus and left atrial roof but not PVs, while in paroxysmal AF six of nine sites lay at PVs (P<0.05). During ablation, a subset of patients experienced AF CL prolongation or termination with a focal lesion; in each case this lesion mapped to potential driver sites on blinded analysis. Conversely, sequential mapping failed to reveal these sites, possibly due to fluctuations in dominant frequency at driver locations in the context of migratory AF. CONCLUSIONS: Simultaneous multisite recordings in human AF reveal evidence for drivers that lie near PVs in paroxysmal but not persistent AF, and were sites where ablation slowed or terminated AF in a subset of patients. The future work should determine if real-time ablation of AF-maintaining regions defined in this fashion eliminates AF.

Electrocardiographic measurements of regional atrial fibrillation cycle length.

BACKGROUND: Differences in atrial fibrillation (AF) cycle length (CL) between the left (LA) and right (RA) atrium and coronary sinus (CS) may help separate paroxysmal from persistent AF and identify patients most likely to respond to pulmonary vein isolation, but has not been measured noninvasively. METHODS AND RESULTS: We developed methods to estimate regional intraatrial AF CL from the surface electrocardiogram (ECG) in 20 patients with persistent AF and 10 patients with paroxysmal AF prior to ablation. Intraatrial AF CL was measured near the LA appendage, mid-CS, and lateral RA. In simultaneous filtered ECG, AF CL was estimated using autocorrelation. The mean of ECG-derived AF CL in leads V5, I, and aVL was used to estimate LA CL; leads aVF, II, and III for CS CL; and V1, V2, and aVR for RA CL. ECG CL estimates for the LA, CS, and RA had R(2) > 0.91 versus measured CL (all P < 0.001). Though magnitudes of left-versus-right AF CL gradients were small in this series, the ECG predicted the direction of gradients in 62% of measurements (P < 0.05). When the gradient was >10 ms, the direction was accurately predicted in eight of 11 patients. The accuracy of AF CL estimates was not adversely affected by AF type or LA dilatation (< or =40 or >40 mm). The ECG-estimated AF-CL showed high 5-minute temporal stability (P < 0.001 each chamber). CONCLUSIONS: Left and right atrial AF CL, and their gradients, can be accurately determined from the ECG using autocorrelation analysis. This approach may be a helpful guide prior to ablation procedures.

The effect of transvenous pacemaker and implantable cardioverter defibrillator lead placement on tricuspid valve function: an observational study.

This study assessed the effect of transtricuspid placement of permanent pacemaker (PPM) and implantable cardioverter defibrillator (ICD) leads on tricuspid regurgitation (TR) in 248 patients with echocardiograms before and after placement. Some 21.2% of patients with baseline mild TR or less developed abnormal TR (3.4% mild-moderate, 12.8% moderate, 1.1% moderate-severe, 3.9% severe) after implant. TR worsened by 1 grade or more after implant in 24.2% (20.7% of PPMs vs. 32.4% of ICDs; P < .05). TR worsening was more common with ICDs than PPMs in patients with baseline mild TR or less. After lead implantation, abnormal TR developed in 21.2% and severe TR developed in 3.9% of patients with initially normal TR. TR worsened by at least 1 grade in 24.2%. Patients with ICDs had a higher rate of TR worsening compared with patients with PPMs (32.4% vs. 20.1%; P < .05).

Changes in heart rate variability are correlated to hemodynamic improvement with chronic CARVEDILOL therapy in heart failure.

BACKGROUND: Reduced heart rate variability (HRV) has been shown to predict mortality in heart failure (CHF). The relationship between improved cardiac function and improvement in HRV has not been previously studied. METHODS AND RESULTS: This was substudy of a randomized, placebo-controlled, double-blinded trial of carvedilol of four months duration. Analysis of HRV was performed on 24-hour Holter monitors obtained at baseline and completion of study. All subjects had symptomatic CHF and an left ventricular ejection fraction (LVEF) <0.35. Study medication was titrated over 1 month to 50 mg/day (< or =75 kg) or 100 mg/day (<75 kg). A total of 17 subjects were randomized to carvedilol and 12 to placebo. Treatment with carvedilol was associated with significant increases in total frequency power, very low frequency power, high frequency power, SDNN, the root-mean square of difference of successive RRs, and pNN50. Change in time and frequency domain measures of HRV had a positive correlation with change in LVEF and negative correlation with change in coronary sinus norepinephrine levels. CONCLUSION: Carvedilol therapy in patients with CHF significantly increased HRV. Change in HRV correlates to improved hemodynamics. This suggests that carvedilol therapy partially normalizes autonomic modulation of heart rate in patients with CHF.