Incidence of Atrioventricular Block After Valve Replacement in Carcinoid Heart Disease.

BACKGROUND: Carcinoid heart disease (CaHD) is a rare condition that has a high impact on the morbidity and mortality of its patients. Once heart failure symptoms develop in the patient with CaHD, cardiac valve surgery is often the only effective treatment. Although atrioventricular block (AVB) is a known postoperative complication of the valve surgery, the incidence of AVB in this population has not been well described. METHODS: Comprehensive records were collected retrospectively on consecutive patients with CaHD who underwent a valve surgery at a tertiary medical center from January 2001 to December 2015. We excluded patients with pre-existing permanent pacemaker (PPM). RESULTS: Nineteen consecutive patients were included in this study and 18 of them underwent at least dual valve (tricuspid and pulmonary valve) replacement surgery. Our 30-day post-surgical mortality was 0%. During the 6-month observation period following the surgery, 31.5% (n = 6) required PPM implantation due to complete AVB. There was no statistical difference in baseline characteristics and electrocardiographic and echocardiographic parameters between the patients who did or did not require PPM placement. CONCLUSIONS: Our study revealed that almost one-third of CaHD patients who underwent a valve replacement surgery developed AVB requiring PPM implantation. Due to high incidence of PPM requirement, we believe that prophylactic placement of an epicardial lead during the valve surgery can be helpful in these patients to reduce serious complication from placement of pacemaker lead on a later date through a prosthetic valve.

Cost conscious care: preoperative evaluation by a cardiologist prior to low-risk procedures.

Background: Preoperative testing before low-risk procedures remains overutilised. Few studies have looked at factors leading to increased testing. We hypothesised that consultation to a cardiologist prior to a low-risk procedure leads to increased cardiac testing. Methods and results: 907 consecutive patients who underwent inpatient endoscopy/colonoscopy at a single academic centre were identified. Of those patients, 79 patients (8.7%) received preoperative consultation from a board certified cardiologist. 158 control patients who did not receive consultation from a cardiologist were matched by age and gender. Clinical and financial data were obtained from chart review and hospital billing. Logistic and linear regression models were constructed to compare the groups. Patients evaluated by a cardiologist were more likely to receive preoperative testing than patients who did not undergo evaluation with a cardiologist (OR 47.5, (95% CI 6.49 to 347.65). Specifically, patients seen by a cardiologist received more echocardiograms (60.8% vs 22.2%, p<0.0001) and 12-lead electrocardiograms (98.7% vs 54.4%, p<0.0001). There was a higher rate of ischaemic evaluations in the group evaluated by a cardiologist, but those differences did not achieve statistical significance. Testing led to longer length of stay (4.35 vs 3.46 days, p=0.0032) in the cohort evaluated by a cardiologist driven primarily by delay to procedure of 0.76 days (3.14 vs 2.38 days, p=0.001). Estimated costs resulting from the longer length of stay and increased testing was $10 624 per patient. There were zero major adverse cardiac events in either group. Conclusion: Preoperative consultation to a cardiologist before a low-risk procedure is associated with more preoperative testing. This preoperative testing increases length of stay and cost without affecting outcomes.

Society of Cardiovascular Anesthesiologists/European Association of Cardiothoracic Anaesthetists Practice Advisory for the Management of Perioperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery.

Postoperative atrial fibrillation (poAF) is the most common adverse event after cardiac surgery and is associated with increased morbidity, mortality, and hospital and intensive care unit length of stay. Despite progressive improvements in overall cardiac surgical operative mortality and postoperative morbidity, the incidence of poAF has remained unchanged at 30%-50%. A number of evidence-based recommendations regarding the perioperative management of atrial fibrillation (AF) have been released from leading cardiovascular societies in recent years; however, it is unknown how closely these guidelines are being followed by medical practitioners. In addition, many of these society recommendations are based on patient stratification into "normal" and "elevated" risk groups for AF, but criteria for that stratification have not been clearly defined. In an effort to improve the perioperative management of AF, the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee developed a multidisciplinary Atrial Fibrillation Working Group that created a summary of current best practice based on a distillation of recent guidelines from professional societies involved in the care of cardiac surgical patients. An evidence-based set of survey questions was then generated to describe the current practice of perioperative AF management. Through collaboration with the European Association of Cardiothoracic Anaesthetists (EACTA), that survey was distributed to the combined memberships of both the SCA and EACTA, yielding 641 responses and resulting in the most comprehensive understanding to date of perioperative AF management in North America, Europe, and beyond. The survey data demonstrated the broad range of therapies utilized for the prevention and treatment of poAF, as well as a spectrum of adherence to published guidelines. With the goal of improving adherence, a graphical advisory tool was created with an easily accessible format that could be utilized for bedside management. Finally, given that no evidence-based threshold currently exists to differentiate patients at normal risk to develop poAF from those at elevated risk, the SCA/EACTA AF working group created a list of poAF risk factors using expert opinion and based on published risk score models for poAF. This approach allows stratification of patients into risk groups and facilitates adherence to the evidence-based recommendations summarized in the graphical advisory tool. It is our hope that these new additions to the clinical toolkit for the management of perioperative AF will improve the evidence-based care and outcomes of cardiac surgical patients worldwide.

Society of Cardiovascular Anesthesiologists/European Association of Cardiothoracic Anaesthetists Practice Advisory for the Management of Perioperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery.

Postoperative atrial fibrillation (poAF) is the most common adverse event after cardiac surgery and is associated with increased morbidity, mortality, and increased hospital and intensive care unit length of stay. Despite progressive improvements in overall cardiac surgical operative mortality and postoperative morbidity, the incidence of poAF has remained unchanged at 30% to 50%. A number of evidence-based recommendations regarding the perioperative management of atrial fibrillation (AF) have been released from leading cardiovascular societies in recent years; however, it is unknown how closely these guidelines are being followed by medical practitioners. In addition, many of these society recommendations are based on patient stratification into "normal" and "elevated" risk groups for AF, but criteria for that stratification have not been defined clearly. In an effort to improve the perioperative management of AF, the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee developed a multidisciplinary Atrial Fibrillation Working Group that created a summary of current best practices based on distillation of recent guidelines from professional societies involved in the care of cardiac surgical patients. An evidence-based set of survey questions then was generated to describe the current practice of perioperative AF management. Through a collaboration with the European Association of Cardiothoracic Anaesthetists (EACTA), that survey was distributed to the combined memberships of both the SCA and the EACTA, yielding 641 responses and resulting in the most comprehensive understanding to date of perioperative AF management in North America and Europe and beyond. The survey data demonstrated the broad range of therapies used for prevention and treatment of poAF, as well as a spectrum of adherence to published guidelines. With the goal of improving adherence, a graphical advisory tool was created with an easily accessible format that could be used for bedside management. Finally, given that no evidence-based threshold currently exists to differentiate patients at normal risk of developing poAF from those at elevated risk, the SCA/EACTA AF working group created a list of poAF risk factors using expert opinion, based on published risk score models for poAF. This allows stratification of patients into risk groups and facilitates adherence to the evidence-based recommendations summarized in the graphical advisory tool. It is the working group's hope that these new additions to the clinical toolkit for management of perioperative AF will improve the evidence-based care and outcomes of cardiac surgical patients worldwide.

Echocardiography fails to detect left ventricular noncompaction in a cohort of patients with noncompaction on cardiac magnetic resonance imaging.

BACKGROUND: Left ventricular noncompaction (LVNC) is a rare disorder characterized by increased left ventricular trabeculation, deep intertrabecular recesses, and a thin compacted myocardial layer with associated clinical sequelae. Cardiac imaging with echocardiogram and cardiac magnetic resonance (CMRI) can detect variable myocardial morphology including excessive trabeculations. Multiple CMRI and echocardiographic criteria have been offered that attempt to identify LVNC morphology. The aim of this study was to assess the utility of echocardiogram in identifying LVNC in a cohort of patients with LVNC detected on CMRI. HYPOTHESIS: Echocardiography fails to identify LVNC morphology in a large proportion of patients with LVNC/hypertrabeculation detected on CMRI. METHODS: There were 1060 CMRI studies collected from 2009 to 2015 at 2 institutions. The patients included in this study (n = 37) met the criteria for LVNC on CMRI and had complete CMRI and echocardiogram images Clinical and imaging data were retrospectively reviewed. RESULTS: Of the 37 patients with LVNC on CMRI, only 10 patients (27%) had LVNC identified on echocardiogram (P < 0.0001, 95% confidence interval: 25.7%-66.2%). Echocardiography and CMRI were also significantly different in terms of identification of distribution of LVNC. Although 21 of 37 patients (57%) had evidence of LVNC in either the anterior or lateral walls on CMRI, there were 0 patients with LVNC detected in the anterior or lateral walls on echocardiogram (P = 0.019). CONCLUSIONS: Echocardiogram fails to detect LVNC morphology/hypertrabeculation in a significant number of a cohort of patients with LVNC on CMRI. LVNC may be missed if echocardiogram is the only imaging modality performed in a cardiac evaluation.

Rates and risk of arrhythmias in cancer survivors with chemotherapy-induced cardiomyopathy compared with patients with other cardiomyopathies.

Objectives: There is little information about arrhythmia burden in cancer survivors with chemotherapy-induced cardiomyopathy (CIC). We hypothesise that the rates and risk of arrhythmias will be similar in CIC when compared with other non-ischaemic cardiomyopathy (NICMO) aetiologies. Methods: We retrospectively identified nine patients with CIC and an implantable defibrillator and 18 age and sex-matched control patients (nine patients with NICMO and nine patients with ischaemic cardiomyopathy (ICMO)). Rates and odds of arrhythmias were calculated by type of cardiomyopathy, adjusting for days since implantable cardioverter defibrillator implantation, history of atrial fibrillation and length of follow-up using logistic regression analysis. Results: Compared with patients with NICMO, rates and adjusted odds were similar for patients with CIC for atrial arrhythmias (44.4% vs 33.3%; adjusted OR=1.89; 95% CI0.17 to 21.03; P=0.61), non-sustained ventricular tachycardia (NSVT) (44.4% vs 33.3%; OR=2.10; 95% CI 0.21 to 20.56; P=0.53), and the combined outcome of NSVT, sustained ventricular tachycardia and/or ventricular fibrillation (44.4% vs 44.4%; OR=2.70; 95% CI 0.25 to 29.48; P=0.42). Conversely, compared with patients with NICMO, patients with ICMO demonstrated higher rates and adjusted odds of the combined outcome (88.9% vs 44.4%; OR=28.60; 95% CI 1.26 to 648.2; P=0.04) and NSVT (77.8% vs 33.3%; OR=8.95; 95% CI 0.90 to 88.94; P=0.06). Conclusions: While tentative based on sample size, rates of arrhythmias in patients with CIC appear to be similar to those experienced by patients with other forms of NICMO.

Gender-Specific Differences for Risk of Disability and Death in Atrial Fibrillation-Related Stroke.

In the latest American Heart Association/American College of Cardiology/Heart Rhythm Society atrial fibrillation (AF) guidelines, CHA2DS2-VASc replaced the CHADS2 stroke risk assessment to determine prophylactic anticoagulation, reflecting female gender's association with stroke incidence in AF. However, little investigation has been pursued of potential risk factors associated with worsened stroke severity. In this study, we examined patients with AF with ischemic stroke patient characteristics associated with increased stroke severity. Using the Get With The Guidelines-Stroke database, we retrospectively identified 221 consecutive patients with AF diagnosed with acute ischemic stroke and performed in depth chart review, evaluating demographics, labs, and co-morbidities. We analyzed the modified Rankin Scale (mRS) at discharge as a surrogate for stroke severity, defining severe stroke as fatal (mRS of 6) or disabling (mRS 4 to 5), requiring max assistance with ambulation or activities of daily living. Female gender, advanced age, and decreased body surface area were associated with disabling or fatal stroke (68.3% of patients with mRS 4 to 6 vs 50% with mRS 0 to 3, 78.4 vs 71.1 year, and 1.83 vs 1.92, respectively). Using a backward elimination approach revealed a logistic regression model with statistically significant odds ratios (ORs) for female gender (OR 1.99) and age (OR 1.04), and borderline significant for a history of coronary artery disease (OR 1.89). In conclusion, female gender is associated in the AF population with a twofold risk of severe disabling or fatal ischemic stroke, a finding that persists after controlling for potential confounders. This finding highlights the potential benefit from appropriate anticoagulation use for stroke prophylaxis in the AF population.

Maternal arrhythmia: a case report and review of the literature.

UNLABELLED: Pregnant patients with maternal arrhythmias can be challenging and difficult to treat. Medication choices may be limited in patients who are pregnant. Pregnancy carries with it a unique and complex physiology, coupled with fetal concerns. We describe a pregnant patient with an arrhythmia to illustrate treatment thought process and options. We also present a comprehensive review of the literature in regard to treatment of maternal arrhythmias and their potential adverse fetal and maternal outcomes. These treatments include antiarrhythmic medications, electrical cardioversion, and radiofrequency ablation. Antepartum and intrapartum monitoring will also be addressed along with delivery planning and postpartum considerations. The most important aspect in treating these patients is the use of a multidisciplinary approach. The decision of what therapy to use must be addressed on a case-by-case basis with special attention to the patient's individual issues and concerns. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians, emergency room physicians LEARNING OBJECTIVES: After completion of this educational activity, the obstetrician/gynecologist should be better able to assess and council patients on the risks and complications of maternal arrhythmias in pregnancy. Evaluate the current treatment options available for health care providers caring for pregnant patients with maternal arrhythmia, and manage the antepartum course, labor, and delivery in these patients.

Prevalence and predictors of warfarin use in patients with atrial fibrillation at low or intermediate risk and relation to thromboembolic events.

BACKGROUND: According to the American College of Cardiology/American Heart Association/European Society of Cardiology guidelines, the choice of aspirin or warfarin to prevent thromboembolic events (TEs) in patients with nonrheumatic atrial fibrillation (AF) should be based on the CHADS(2) score. The purpose of this study was to determine the predictors of warfarin use in patients with AF at low (CHADS(2) =0) or intermediate (CHADS(2) =1) risk for TEs. HYPOTHESIS: Warfarin use is low in intermediate- and low-risk patients. METHODS: Clinical characteristics of 3086 consecutive patients (mean age, 70 ± 13 years) with nonrheumatic AF from an academic multispecialty practice were determined between 2006 and 2008 through individual chart review. Patients were identified based on an inpatient or outpatient encounter, in which a billing diagnosis code of AF or atrial flutter (AFl) was recorded. The decision for anticoagulation was at the discretion of the primary care physician or cardiologist. No intervention to guide anticoagulant therapy was made. RESULTS: Warfarin was prescribed in 180/497 low-risk patients (36%), and in 646/938 intermediate-risk patients (69%). Among high-risk patients (CHADS(2) ≥2), warfarin was used in 792/968 patients (82%) with a CHADS(2) = 2, in 343/410 patients (84%) with a CHADS(2) =3, and in 225/273 patients (82%) with a CHADS(2) ≥4. On multivariate analysis, independent predictors of warfarin use in low-risk patients were nonparoxysmal AF (odds ratio [OR]: 5.02, P<0.0001) and age between 65 and 74 years (OR: 2.21, P<0.0001). Among intermediate-risk patients, congestive heart failure (OR: 7.34, P<0.0001), nonparoxysmal AF (OR: 4.04, P<0.0001), coronary artery disease (OR: 2.53, P<0.0001), age between 65 and 74 years (OR: 1.68, P = 0.002), and female gender (OR: 1.69, P = 0.002) were independent predictors of warfarin use. Lack of warfarin use (OR: 4.9, P<0.001) and female gender (OR: 2.0, P = 0.03) were associated with a higher risk of TEs in intermediate-risk patients. None of the CHADS(2) parameters was predictive of TEs. Warfarin was not associated with reduction in TEs in low-risk patients. Warfarin use did not have a significant effect on bleeding. CONCLUSIONS: Although either aspirin or warfarin is recommended to prevent TEs in patients with AF at intermediate risk for TEs, warfarin is preferred in the majority of patients in general practice. Lack of warfarin use is associated with a higher risk of TEs in intermediate-risk patients with AF. The adoption of new oral anticoagulants that have lower risk of major hemorrhage than warfarin for low- or intermediate-risk AF patients remains to be determined.

Patient and physician determinants of implantable cardioverter defibrillator use in the heart failure population.

Recent studies report surprisingly low rates of implantable cardioverter defibrillator (ICD) placement for primary prevention against sudden cardiac death among patients with heart failure and left ventricular systolic dysfunction. Reasons for the low rates of utilization are not well understood. The authors examined ICD implantation rates at a university-based tertiary care center and used multivariable analysis to identify independent factors associated with ICD utilization. The ICD implantation rate for 850 eligible patients was 70%. Forty-seven (18%) patients refused implantation; women were twice as likely to refuse compared to men (8% vs 4%, P=.013). Race was not associated with utilization. On multivariable analysis, independent predictors of implantation included having a heart failure specialist (odds ratio [OR], 8.13; P<.001) or general cardiologist (OR, 2.23; P=.13) managing care, age range 70 to 79 (OR, 0.55; P<.001) or 80 and older (OR, 0.26; P<.001), female sex (OR, 0.49; P<.001), QRS interval (OR, 1.016; P<.001), diastolic blood pressure (OR, 0.979; P=.011), cerebrovascular disease (OR, 0.44; P=.007), and dementia (OR, 0.13; P=.002). Our registry of patients with cardiomyopathy and heart failure reveals that high rates of utilization are possible. Factors closely associated with ICD utilization include type of physician coordinating care, age, and comorbidities.

Inadvertent electrical isolation of the left atrial appendage during catheter ablation of persistent atrial fibrillation.

BACKGROUND: Left atrial appendage (LAA) isolation is rare and may be associated with impaired transport function and thromboembolism. OBJECTIVE: The purpose of this study was to determine the mechanisms of inadvertent isolation of the LAA during atrial fibrillation (AF) ablation. METHODS: This study consisted of 11 patients (ejection fraction 0.43 +/- 0.18, left atrial diameter 51 +/- 8 mm) with persistent AF who had LAA conduction block during a procedure for AF (n = 8) or atrial tachycardia (AT) (n = 3). RESULTS: LAA conduction block occurred during ablation at the Bachmann bundle region in 6 patients, mitral isthmus in 3, LAA base in 2, and coronary sinus in 1. The mean distance from the ablation site to the LAA base was 5.0 +/- 1.9 cm. LAA isolation was transient in all 6 patients in whom LAA conduction was monitored and was permanent in the 4 patients in whom conduction was not monitored during energy delivery. The remaining patient was noted to have LAA isolation during a redo procedure before any ablation. Nine of (82%) the 11 patients have remained arrhythmia-free without antiarrhythmic drugs at mean follow-up of 6 +/- 7 months, and all have continued taking warfarin. CONCLUSION: Electrical isolation of the LAA may occur during ablation of persistent AF and AT even when the ablation site is remote from the LAA. This likely is due to disruption of the Bachmann bundle and its leftward extension, which courses along the anterior left atrium and bifurcates to surround the LAA. Monitoring of LAA conduction during ablation of persistent AF or AT is important in avoiding permanent LAA isolation.

Atrial tachycardia after circumferential pulmonary vein ablation of atrial fibrillation: mechanistic insights, results of catheter ablation, and risk factors for recurrence.

OBJECTIVES: The aim of this study was to determine the mechanism of atrial tachycardia (AT) that occurs after ablation of atrial fibrillation (AF). BACKGROUND: Patients who undergo catheter ablation of AF may develop AT during follow-up. METHODS: Seventy-eight patients underwent an ablation procedure for AT after circumferential pulmonary vein ablation (CPVA) for AF. The 3-dimensional maps from the AF and AT procedures were compared to determine whether AT arose from a prior ablation line. RESULTS: A total of 155 ATs were mapped, and the mechanism was re-entry in 137 (88%) and focal in 18 (12%). The most common left atrial (LA) ablation targets were the mitral isthmus, roof, and septum. The critical isthmus in 115 of the 120 LA re-entrant ATs (96%) traversed a prior ablation line, consistent with a gap-related mechanism. Catheter ablation was successful in 66 of the 78 patients (85%). After a mean follow-up of 13 +/- 10 months, 60 of the 78 patients (77%) were free of AT/AF without antiarrhythmic medications. Re-entrant septal AT was associated with recurrence (odds ratio 7.3; 95% confidence interval 1.5 to 36; p = 0.02), whereas PV isolation during the AT procedure was associated with a favorable outcome (odds ratio 0.17; 95% confidence interval 0.04 to 0.81; p = 0.03). CONCLUSIONS: Approximately 90% of ATs after CPVA are re-entrant, and nearly all are related to gaps in prior ablation lines. These findings suggest that the prevalence of these arrhythmias may be reduced by limiting the number of linear lesions, demonstration of linear block, and pulmonary vein disconnection during the initial AF procedure.