In-hospital Outcomes and Post Discharge Mortality in Patients with Acute Coronary Syndrome and Atrial Fibrillation.

BACKGROUND: It is unclear whether advances in management of acute coronary syndromes (ACS) and introduction of novel oral anticoagulants (NOAC) have changed outcomes in patients with ACS with concomitant atrial fibrillation (AF) . OBJECTIVE: Examine the incidence of AF in patients admitted for ACS and evaluate its association with adverse outcomes given the recent advances in management of both diseases. METHODS: Natural language processing search algorithms identified AF in patients admitted with ACS across 13 Northwell Health Hospitals from 2015 to 2021. Hierarchical generalized linear mixed modeling was used to assess the association between AF and in-hospital mortality, bleeding, and stroke outcomes; marginal Cox regression modeling was used to assess the association between AF and post-discharge mortality. RESULTS: Of 12,315 patients admitted for ACS, 3,018 (24.5%) had AF with 1,609 (53.3%) newly diagnosed. AF patients more commonly received anticoagulation with an oral anticoagulant (80.4% vs 12.3%) or heparin (61.9% vs 56.9%), had lengthier intensive care unit stay (72 vs 49 hours), and underwent fewer percutaneous coronary interventions (31.9% vs 53.1%). In-hospital bleeding, stroke and mortality were higher in the AF group (15.3% vs 5.0%, 7.4% vs 2.4%, 6.9% vs 2.1% respectively). AF was an independent risk factor for all in-hospital outcomes (ORs: 2.5, 2.7 and 2.0 for bleeding, stroke, and mortality, respectively) as well as post-discharge mortality ( HRs: 1.3 95% CI: 1.2-1.5). CONCLUSION: AF is present in 25% of ACS patients and increases risk of in-hospital and post discharge adverse outcomes. Additional data is required to direct optimal management.

Site-specific effects of dobutamine on cardiac conduction and refractoriness.

BACKGROUND: Isoproterenol, a non-specific beta agonist, is commonly used during electrophysiology studies (EPS). However, with the significant increase in the price of isoproterenol in 2015 and the increasing number of catheter ablations performed, the cost implications cannot be ignored. Dobutamine is a less expensive synthetic compound developed from isoproterenol with a similar mechanism to enhance cardiac conduction and shorten refractoriness, thus making it a feasible substitute with a lower cost. However, the use of dobutamine for EPS has not been well-reported in the literature. OBJECTIVE: To determine the site-specific effects of various doses of dobutamine on cardiac conduction and refractoriness and assess its safety during EPS. METHODS: From February 2020 to October 2020, 40 non-consecutive patients scheduled for elective EPS, supraventricular tachycardia, atrial fibrillation, and premature ventricular contraction ablations at a single center were consented and prospectively enrolled to assess the effect of dobutamine on the cardiac conduction system. At the end of each ablation procedure, measures of cardiac conduction and refractoriness were recorded at baseline and with incremental doses of dobutamine at 5, 10, 15, and 20 mcg/kg/min. For the primary analysis, the change per dose of dobutamine from baseline to each dosing level of dobutamine received by the patients, comparing atrioventricular node block cycle length (AVNBCL), ventricular atrial block cycle length (VABCL) and sinus cycle length (SCL), was tested using mixed-effect regression. For the secondary analysis, dobutamine dose level was tested for association with relative changes from baseline of each electrophysiologic parameter (SCL, AVNBCL, VABCL, atrioventricular node effective refractory period (AVNERP), AH, QRS, QT, QTc, atrial effective refractory period (AERP), ventricular effective refractory period (VERP), using mixed-effect regression. Changes in systolic and diastolic blood pressures were also assessed. The Holm-Bonferroni method was used to adjust for multiple testing. RESULTS: For the primary analysis there was no statistically significant change of AVNBCL and VABCL relative to SCL from baseline to each dose level of dobutamine. The SCL, AVNBCL, VABCL, AVNERP, AERP, VERP and the AH, and QT intervals all demonstrated a statistically significant decrease from baseline to at least one dose level with incremental dobutamine dosing. Two patients (5%) developed hypotension during the study and one patient (2.5%) received a vasopressor. Two patients (5%) had induced arrhythmias but otherwise no major adverse events were noted. CONCLUSION: In this study, there was no statistically significant change of AVNBCL and VABCL relative to SCL from baseline to any dose level of dobutamine. As expected, the AH and QT intervals, and the VABCL, VERP, AERP and AVNERP all significantly decreased from baseline to at least one dose level with an escalation in dobutamine dose. Dobutamine was well-tolerated and safe to use during EPS.

Roof-dependent Atrial Flutter Changed into Single-loop Biatrial Flutter During Ablation.

A single-loop biatrial flutter is an uncommon form of atypical atrial flutter, and it can occur with septal or anterior line ablation in the left atrium (LA). We report a case with a roof-dependent atrial flutter that changed into a single-loop biatrial flutter during roof-line ablation. The activation entered the right atrium (RA) at the septum/fossa ovalis and coronary sinus ostium, exited the RA likely via the Bachmann's bundle and/or septopulmonary bundle, and entered the LA posterior to the roof line. The biatrial flutter was terminated with linear ablation between the right and left inferior pulmonary veins. RA mapping and biatrial flutter should be considered if roof-dependent atrial flutter slowed down during the roof-line ablation without termination.

Temporal Changes and Clinical Implications of Delayed Peridevice Leak Following Left Atrial Appendage Closure.

OBJECTIVES: The aim of this study was to assess temporal changes and clinical implications of peridevice leak (PDL) after left atrial appendage closure. BACKGROUND: Endocardial left atrial appendage closure devices are alternatives to long-term oral anticoagulation (OAC) for patients with atrial fibrillation. PDL >5 mm may prohibit discontinuation of OAC. METHODS: Patients included in the study had: 1) successful Watchman device implantation without immediate PDL; 2) new PDL identified at 45 to 90 days using transesophageal echocardiography; 3) eligibility for OAC; and 4) 1 follow-up transesophageal echocardiographic study for PDL surveillance. Relevant clinical and imaging data were collected by chart review. The combined primary outcome included failure to stop OAC after 45 to 90 days, transient ischemic attack or stroke, device-related thrombi, and need for PDL closure. RESULTS: Relevant data were reviewed for 1,039 successful Watchman device implantations. One hundred eight patients (10.5%) met the inclusion criteria. The average PDL at 45 to 90 days was 3.2 ± 1.6 mm. On the basis of a median PDL of 3 mm, patients were separated into ≤3 mm (n = 73) and >3 mm (n = 35) groups. In the ≤3 mm group, PDL regressed significantly (2.2 ± 0.8 mm vs 1.6 ± 1.4 mm; P = 0.002) after 275 ± 125 days. In the >3 mm group, there was no significant change in PDL (4.9 ± 1.4 mm vs 4.0 ± 3.0 mm; P = 0.12) after 208 ± 137 days. The primary outcome occurred more frequently (69% vs 34%; P = 0.002) in the >3 mm group. The incidence of transient ischemic attack or stroke in patients with PDL was significantly higher compared with patients without PDL, irrespective of PDL size. CONCLUSIONS: New PDL detected by transesophageal echocardiography at 45 to 90 days occurred in a significant percentage of patients and was associated with worse clinical outcomes. PDL ≤3 mm tended to regress over time.

Obstructive Sleep Apnea and Cardiovascular Disease.

Obstructive sleep apnea (OSA) presents as repetitive interruptions of ventilation >10 seconds during sleep as a result of upper airway obstruction resulting in increased respiratory effort. Intermittent hypoxia causes physiologic changes resulting in increased catecholamine production, increased total peripheral resistance, tachycardia, and increased venous return, leading to increased cardiac output, hypertension, tachyarrhythmias, left ventricular hypertrophy, and heart failure. OSA causes an abnormal dip on 24-hour ambulatory blood pressure monitoring. Definitive diagnosis is made by polysomnography. Continuous positive airway pressure (CPAP) remains the first-line treatment. Effective treatment using CPAP reduces blood pressure and is indispensable for proper management of atrial fibrillation.

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

BACKGROUND: Catheter ablation is considered the first-line treatment of symptomatic atrioventricular nodal reentrant tachycardia (AVNRT). It has been associated with a risk of heart block (HB) requiring a pacemaker. This study aims to determine potential clinical predictors of complete heart block as a result AVNRT ablation. METHODS: Consecutive patients undergoing catheter ablation for AVNRT from January 2001 to June 2019 at two tertiary hospitals were included. We defined ablation-related HB as the unscheduled implantation of pacemaker within a month of the index procedure. Use of electroanatomic mapping (EAM), operator experience, inpatient status, age, sex, fluoroscopy time, baseline PR interval, and baseline HV interval was included in univariate and multivariate models to predict HB post ablation. RESULTS: In 1708 patients (56.4 ± 17.0 years, 61% females), acute procedural success was 97.1%. The overall incidence of HB was 1.3%. Multivariate analysis showed that age more than 70 (odds ratio [OR] 7.907, p ≤ .001, confidence interval [CI] 2.759-22.666), baseline PR ≥ 190 ms (OR 2.867, p = .026, CI 1.135-7.239) and no use of EAM (OR 0.306, p = .037, CI 0.101-0.032) were independent predictors of HB. CONCLUSION: Although the incidence of HB post AVNRT ablation is generally low, patients can be further stratified using three simple predictors.

Proarrhythmic Manifestations of Neuromuscular Dystrophinopathies.

Muscular dystrophy has been an elusive term ever since it was first described in the 19th century. Introduced in 1891 by Wilhelm Heinrich Erb, muscular dystrophy has been classified as part of a larger group of genetically determined, progressive degenerative neuromuscular disorders termed "dystrophinopathies." Cardiac arrhythmias may occur during the neurologic course of the disease. Although descriptions of the dystrophinopathies have been reported in the literature, few articles address the use of antiarrhythmic pharmacotherapy in patients with muscular dystrophy. We discuss the pathophysiology of the most common dystrophinopathies, their proarrhythmic sequelae, and the therapeutic use of antiarrhythmic agents in the clinical setting.

Electrocardiographic localization of ventricular arrhythmias successfully ablated from the distal great cardiac vein.

BACKGROUND: Idiopathic ventricular arrhythmias (IVAs) from the left ventricular (LV) summit may be successfully ablated from the distal great cardiac vein (dGCV). Using a 12-lead electrocardiogram (ECG) to localize IVAs that can be ablated from the dGCV is valuable for ablation planning. OBJECTIVE: To determine if a "w" wave, a notch in the Q wave in lead I, and other ECG features can identify IVAs that can be successfully ablated from the dGCV. METHODS: We reviewed outflow tract premature ventricular contraction (PVC) ablations performed at two centers between September 2010 and June 2018. Successful PVC ablations, in which the PVCs were mapped from the right ventricular outflow tract, coronary cusps, commissures, endocardial LV, and the coronary venous system including the dGCV were included. ECG characteristics were compared between patients with successful ablations in the dGCV and non-dGCV sites. RESULTS: Of the 120 patients (age 56.8 ± 13.8 years, 45% female) that met the inclusion criteria, the dGCV was the successful ablation site in 18 patients (15%). Multivariate analysis with binary logistic regression showed that a "w" in lead I in combination with an early precordial pattern break and a maximum deflection index (MDI) ≥ 0.5 had sensitivity and specificity for a successful ablation in the dGCV of 94.4% and 96.1%, respectively. CONCLUSION: Combining a "w" wave in lead I with an early precordial pattern break and an MDI ≥ 0.5 is highly sensitive and specific for identifying the dGCV as a successful ablation site for PVCs.

Effect of Chloroquine, Hydroxychloroquine, and Azithromycin on the Corrected QT Interval in Patients With SARS-CoV-2 Infection.

BACKGROUND: The novel SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) is responsible for the global coronavirus disease 2019 pandemic. Small studies have shown a potential benefit of chloroquine/hydroxychloroquine±azithromycin for the treatment of coronavirus disease 2019. Use of these medications alone, or in combination, can lead to a prolongation of the QT interval, possibly increasing the risk of Torsade de pointes and sudden cardiac death. METHODS: Hospitalized patients treated with chloroquine/hydroxychloroquine±azithromycin from March 1 to the 23 at 3 hospitals within the Northwell Health system were included in this prospective, observational study. Serial assessments of the QT interval were performed. The primary outcome was QT prolongation resulting in Torsade de pointes. Secondary outcomes included QT prolongation, the need to prematurely discontinue any of the medications due to QT prolongation, and arrhythmogenic death. RESULTS: Two hundred one patients were treated for coronavirus disease 2019 with chloroquine/hydroxychloroquine. Ten patients (5.0%) received chloroquine, 191 (95.0%) received hydroxychloroquine, and 119 (59.2%) also received azithromycin. The primary outcome of torsade de pointes was not observed in the entire population. Baseline corrected QT interval intervals did not differ between patients treated with chloroquine/hydroxychloroquine (monotherapy group) versus those treated with combination group (chloroquine/hydroxychloroquine and azithromycin; 440.6±24.9 versus 439.9±24.7 ms, P=0.834). The maximum corrected QT interval during treatment was significantly longer in the combination group versus the monotherapy group (470.4±45.0 ms versus 453.3±37.0 ms, P=0.004). Seven patients (3.5%) required discontinuation of these medications due to corrected QT interval prolongation. No arrhythmogenic deaths were reported. CONCLUSIONS: In the largest reported cohort of coronavirus disease 2019 patients to date treated with chloroquine/hydroxychloroquine±azithromycin, no instances of Torsade de pointes, or arrhythmogenic death were reported. Although use of these medications resulted in QT prolongation, clinicians seldomly needed to discontinue therapy. Further study of the need for QT interval monitoring is needed before final recommendations can be made.

Concomitant leadless pacemaker implantation and lead extraction during an active infection.

INTRODUCTION: The need for transvenous lead extractions due to cardiac implantable electronic device (CIED)-related infections continues to rise. Current guidelines recommend complete device removal in the setting of an active infection, which can be challenging in pacemaker-dependent patients. METHODS: We retrospectively reviewed all leadless pacemaker implants between January 2018 and November 2019 and identified a subset of patients who had undergone a concomitant CIED extraction in the setting of an active infection. Baseline characteristics, procedural details, and clinical follow-ups were recorded. RESULTS: Seventeen patients received a leadless pacemaker during the same procedure as the CIED extraction. There were no procedural complications. All patients were being treated for an active CIED infection at the time of the procedure. Fourteen patients (82.4%) were completely pacemaker-dependent and four patients (23.5%) had positive blood cultures at the time of the leadless pacemaker implantation. During a median follow-up of 143 days (interquartile range: 57, 181 days), there were no recurrent infections. CONCLUSION: Simultaneous leadless pacemaker implantation and CIED extraction are safe and feasible in the setting of an active infection. This strategy may be particularly useful in patients that are pacemaker-dependent.

Cardiac involvement in the muscular dystrophies.

Cardiac disease is a common clinical manifestation present in a variety of neuromuscular disorders, most notably the muscular dystrophies. Heart disease may produce the presenting or predominant symptoms in these disorders but more often not does not result in clinical features at the time of initial presentation. Cardiac involvement in the muscular dystrophies results from pathologic changes in the myocardium and the cardiac conduction system, leading to cardiomyopathy and/or rhythm disturbances including supraventricular arrhythmias, life-threatening ventricular arrhythmias, and sudden cardiac death. This Review covers the spectrum of cardiac dysfunction in these inherited muscle disorders and proposes practical recommendations for monitoring and management. Muscle Nerve 57: 707-715, 2018.

Left ventricular geometry predicts ventricular tachyarrhythmia in patients with left ventricular systolic dysfunction: a comprehensive cardiovascular magnetic resonance study.

BACKGROUND: Most patients with implantable cardioverter-defibrillator (ICD) implantation fail to utilize the device resulting in increasing societal costs and patient exposure to device morbidity. We sought to determine whether volumetric cardiovascular magnetic resonance (CMR) left ventricular (LV) spherical remodeling predicts future ventricular arrhythmias in primary ICD patients with reduced LV ejection fraction (EF). METHODS: Sixty-eight consecutive patients with transthoracic echocardiographic LVEF <35% referred for CMR prior to ICD implantation for primary prevention of sudden death were identified. Sphericity index was measured as the ratio of LV end-diastolic volume (from cine short axis stack) to the volume of a sphere with a LV end-diastolic 4-chamber length diameter. RESULTS: During a median follow-up of 55 months (interquartile range; 28-88), 15 patients (22%) received appropriate ICD therapy. Multivariable Cox's proportional hazard modeling identified increased CMR-derived sphericity index as the strongest independent predictor of appropriate ICD therapy (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.02 to 1.16; p = 0.007). In addition, dichotomized volumetric CMR-derived sphericity index ≥0.57 carried a 4-fold hazard risk for appropriate ICD therapy, controlling for age and LVEF (HR, 4.49; 95% CI, 1.53 to 13.21; p = 0.006). When sphericity index, LVEF and mass index were used in combination, important incremental prognostic information was achieved (net reclassification improvement, 0.42; 95% CI, 0.06 to 0.77). CONCLUSIONS: The combined assessment of LV geometry, mass index and systolic function may provide incremental prognostic information regarding ventricular arrhythmia requiring appropriate ICD therapy in primary prevention patients with reduced LVEF.

Geometric comparison of the mitral and tricuspid valve annulus: Insights from three dimensional transesophageal echocardiography.

AIM: To apply real time three-dimensional transesophageal echocardiography (RT3D TEE) for quantitative and qualitative assessment of the mitral valve annulus (MVA) and tricuspid valve annulus (TVA) in the same patient. METHODS: Our retrospective cohort study examined the MVA and TVA in 49 patients by RT3D TEE. MVA and TVA shape were examined by TEE. The MVA and TVA volume data set images were acquired in the mid esophageal 4-chamber view. The MVA and TVA were acquired separately, with optimization of each for the highest frame rate and image quality. The 3D shape of the annuli was reconstructed using the Philips® Q lab, MVQ ver. 6.0 MVA model software. The end-systolic frame was used. The parameters measured and compared were annular area, circumference, high-low distances (height), anterolateral-posterolateral (ALPM), and anteroposterior (AP) axes. RESULTS: A total of 49 patients (mean age 61 ± 14 years, 45% males) were studied. The ALPM and the AP axes of the MVA and TVA are not significantly different. The ALPM axis of the MVA was 37.9 ± 6.4 mm and 38.0 ± 5.6 mm for the TVA (P = 0.70). The AP axis of the MVA was 34.8 ± 5.7 mm and 34.9 ± 6.2 mm for the TVA (P = 0.90). The MVA and the TVA had similar circumference and area. The circumference of the MVA was 127.9 ± 16.8 mm and 125.92 ± 16.12 mm for the TVA (P = 0.23). The area of the MVA was 1103.7 ± 307.8 mm2 and 1131.7 ± 302.0 mm2 for the TVA (P = 0.41). The MVA and TVA are similar oval structures, but with significantly different heights. The ALPM/AP ratio for the MVA was 1.08 ± 0.33 and 1.09 ± 0.28 for the TVA (P < 0.001). The height for the MVA and TVA was 9.23 ± 2.11 mm and 4.37 ± 1.48 mm, respectively (P < 0.0001). CONCLUSION: RT3D TEE plays an unprecedented role in the management of valvular heart disease. The specific and exclusive shape of the MVA and TVA was revealed in our study of patients studied. Moreover, the intricate codependence of the MVA and the TVA depends on their distinctive shapes. This realization seen from our study will allow us to better understand the role valvular disease plays in disease states such as hypertrophic cardiomyopathy and pulmonary hypertension.

Neuromuscular Disorders and the Role of the Clinical Electrophysiologist.

Cardiac involvement is common and may be the presenting or predominant manifestation in a variety of neuromuscular disorders, most notably the inherited muscle disorders, or muscular dystrophies. Cardiac manifestations of the neuromuscular disorders result from pathological involvement of the myocardium and the cardiac conduction system, with resulting cardiomyopathy or rhythm disturbances including supraventricular arrhythmias, life-threatening ventricular arrhythmias, and sudden cardiac death. Many of these neuromuscular disorders are rare and may be unrecognized by even experienced specialists in internal and cardiovascular medicine. Furthermore, the initial cardiac manifestations in these patients are often asymptomatic. The goal of this investigation is to review the scope of cardiac conduction defects and rhythm disturbances in these disorders and to propose some practical recommendations for arrhythmia monitoring and management of these patients.

Management of hypertension in patients with coronary artery disease.

Hypertension is the most prevalent and significant modifiable risk factor in individuals with concomitant coronary artery disease. The number of individuals with hypertension is substantially increasing every year. It has been shown in several studies that it is imperative to effectively control blood pressure in order to reduce the risk of adverse cardiovascular events. There are many classes of medications that can help control blood pressure in individuals with hypertension and coronary artery disease. The management of blood pressure in this high-risk population continues to be a challenge, especially as more people survive myocardial infarctions and the prevalence of disease such as diabetes mellitus increases as the population continues to age. In this article, we will review the different therapeutic antihypertensive agents recommended by the different societies on hypertension including the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, and the challenges faced in special cases of resistant hypertension.