Use of a pocket compression device for the prevention and treatment of pocket hematoma after pacemaker and defibrillator implantation (STOP-HEMATOMA-I).

BACKGROUND: Pocket hematoma is a recognized complication after placement of cardiac implantable electronic devices and is associated with increased device infection, length of hospitalization, and morbidity especially with uninterrupted antiplatelet agents and anticoagulants. We assessed the use of a post-surgical vest to decrease the incidence of pocket hematoma in patients undergoing device implantation with uninterrupted antiplatelet and anticoagulants. METHODS: In this observational study, a vest was used by 20 consecutive patients who were compared to 20 age-, gender-, procedure-matched patients who received standard care. All patients were continued on antiplatelet and anticoagulants in the perioperative period. The pocket was assessed at post procedure day 0, 2, and 7, respectively. RESULTS: There were no significant differences in the baseline characteristics between both groups. Baseline mean international normalized ratio (INR) was significantly higher in the vest group when compared with the control group (2.7 ± 0.4 vs. 2.2 ± 0.3 = <0.001). The incidence of pocket hematoma was significantly lower in the vest group than the control group (0 vs 30%, p = 0.02) at the end of 7 days. Control group had a total of six hematomas with one patient requiring evacuation and blood transfusion. The vest group had three hematomas on day 2 that resolved by day 7. CONCLUSIONS: The risk of moderate or large pocket hematoma is significantly reduced with the use of this vest in high-risk patients undergoing implantable devices on uninterrupted antiplatelet and anticoagulants.

Elevated brain natriuretic peptide level in patients undergoing atrial fibrillation ablation: is it a predictor of failed ablation or a mere function of atrial rhythm and rate at a point in time?

BACKGROUND: Pre- and postablation atrial fibrillation (AF) brain natriuretic peptide (BNP) levels were shown to predict increased recurrence of AF following ablation. OBJECTIVE: Our objective was to assess whether elevated BNP levels merely represent the presence of AF at the time of measurement or indeed the true recurrence of AF. METHODS AND RESULTS: In a prospective study of 88 patients undergoing AF ablation, BNP levels were measured immediately before, after, 24 h, and 4-6 months postablation. BNP levels were stratified by presenting rhythm and ventricular rate at the time of measurement. Median BNP level preablation was higher in patients presenting in AF compared to sinus rhythm (SR) (54(44-79) pg/ml vs. 30(18-47) pg/ml, p < 0.001). Postablation restoration of SR in patients presenting in AF reduced median BNP levels from 54(44-79) pg/ml to 40(37-51) pg/ml, (p < 0.001). However, no change was noted in patients who presented in and maintained SR throughout the procedure (30(18-47) pg/ml to 27(16-40) pg/ml, p = 0.270). At 4-6 months, BNP measured in patients in SR was not significantly different from postablation BNP (35(22-53) pg/ml vs. 38(20-52) pg/ml, p = 0.656), although 35% of them had AF recurrence in 1-year follow-up. Median BNP level measured in five patients while in atrial arrhythmia was elevated compared to postablation BNP (464(421-464) pg/ml to 37(36-37) pg/ml, p = 0.043). BNP levels and ventricular rates are positively correlated at all times pre- and postablation. CONCLUSIONS: BNP level rises acutely during AF and with rapid ventricular rates. BNP level seems to be a function of atrial rhythm and ventricular rate rather than short- or long-term predictor of AF ablation success.

Atrial fibrillation ablation in patients with gastroesophageal reflux disease or irritable bowel syndrome-the heart to gut connection!

PURPOSE: An association between atrial fibrillation (AF) and gastroesophageal reflux disease (GERD) and/or irritable bowel syndrome (IBS) is increasingly being identified; yet the role of radiofrequency catheter ablation (RFA) of AF has not been systematically evaluated in these patient populations. METHODS: We performed a prospective matched case-control study of AF patients with GERD and/or IBS who underwent RFA for AF in two centers in North America. AF patients with GERD and/or IBS (gastrointestinal [GI] group) were matched by age, gender, and type of AF at each of the centers with an equal number of AF patients without GERD or IBS (non-GI group). RESULTS: Sixty patients were included in the study with 30 in each group. Mean age of the population was 45 years with 14 (47 %) males and 21 (87 %) patients with paroxysmal AF in each group. More patients in the GI group had identifiable GI triggers for AF episodes. During RFA, more patients in the GI group had a "vagal response" compared to non-GI group (60 vs 13 %; p < 0.001). Left atrial scar as identified by electroanatomical mapping was more common in patients in the non-GI group compared to the GI group (57 vs 27 %; p = 0.018). At 1-year follow-up, 56 (93 %) of the patients were free from AF with no difference between both groups. CONCLUSIONS: Majority of AF patients with GERD and/or IBS have triggered AF and a positive vagal response during RFA. RFA is equally effective in this patient population when compared to those without GERD or IBS.

Radiofrequency ablation of atrial fibrillation in patients with mitral or aortic mechanical prosthetic valves: a feasibility, safety, and efficacy study.

BACKGROUND: Patients with prosthetic valves have a high prevalence of atrial fibrillation (AF). We report a multicenter experience of performing pulmonary vein antral isolation (PVAI) in this challenging, high-risk cohort of patients. OBJECTIVE: The purpose of this study was to assess the feasibility, safety, and efficacy of radiofrequency (RF) ablation for sinus rhythm restoration in AF patients with mitral or aortic mechanical prosthetic valves. METHODS: A total of 50 patients with prosthetic valves (group I) who underwent RF ablation for AF between January 1, 2007, and April 30, 2009, were identified prospectively at four tertiary care centers. A matched group of 50 patients (group II) acted as controls. RESULTS: Total procedural time (199.4 ± 49 minutes vs 166.6 ± 27.5 minutes, P <.001) and fluoroscopy time (60 ± 17 minutes vs 53.8 ± 6.8 minutes, P <.01) were prolonged, with a higher incidence of atrial flutter at 3 months in group I (18% vs 6%, P = .1) compared to group II. At 12 months, 80% of patients in the valve group were in sinus rhythm after an average of 1.3 procedures, and 82% of controls were in sinus rhythm after an average 1.2 procedures (P = .9). There was a trend toward a higher nonfatal complication rate in the valve group than in the control group (8% vs 4%, P = .1). CONCLUSION: In patients with prosthetic valves, RF ablation for AF is feasible, safe, and efficacious, with a trend toward a higher nonfatal complication rate and an increased rate of postablation atrial flutter.

Is antero-posterior position superior to antero-lateral position for placement of electrodes for external cardioversion of atrial fibrillation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the antero-posterior position is superior to the antero-lateral position for the placement of electrodes for cardioversion of atrial fibrillation. Altogether 167 papers were found using the reported search, of which 5 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is no clinical difference between the two positions although if one position fails to convert the patient, the alternative position may still achieve success.

Is clopidogrel beneficial following coronary bypass surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether clopidogrel is superior to aspirin in preventing adverse events post coronary arterial bypass grafting. Altogether 220 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that if aspirin is not tolerated, clopidogrel is an acceptable alternative, but there is no strong evidence that clopidogrel is superior to aspirin postcoronary surgery.

Is an early invasive approach superior to a conservative strategy in patients with acute coronary syndrome?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether an early invasive approach (involving early coronary angiography followed by revascularisation if suitable) is superior to a conservative approach (with revascularisation only in patients with failed medical therapy) in patients with acute coronary syndrome. Altogether 282 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that in patients diagnosed with acute coronary syndrome, an early invasive approach is clearly superior to a conservative approach.

Can cardiac troponins be used to diagnose a perioperative myocardial infarction post cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether Troponin I or T can effectively diagnose a perioperative myocardial infarction after cardiac surgery. Altogether 191 papers were found using the reported search, of which 17 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that Troponin I and T can both be used to indicate myocardial damage, with the level correlating well with the level of injury. However until issues such as a 'gold standard' for peri-operative MI are addressed, one single cut-off point cannot be recommended for either test.

Is addition of anti-platelet therapy to warfarin beneficial to patients with prosthetic heart valves?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether addition of anti-platelet therapy to warfarin reduced the incidence of thromboembolic complications in patients with prosthetic heart valves. Altogether 253 papers were found using the reported search, of which 11 papers represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that low dose aspirin (80-100 mg daily) in addition to warfarin in patients with prosthetic heart valves reduces all cause long term mortality (NNT=19), with significant reductions in thromboembolism but an increase in bleeding.

What is the optimal anticoagulation management of patients post-cardiac surgery who go into atrial fibrillation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether anticoagulation is indicated for patients in atrial fibrillation (AF) following coronary artery bypass grafting. Altogether 166 papers were found using the reported search, of which 10 presented the best evidence to answer the clinical question. In addition the American Heart Association guidelines for management of atrial fibrillation were reviewed. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that patients post-cardiac surgery require warfarinisation while in atrial fibrillation with an INR of 2-3, and full anticoagulation should be commenced within 48 h of the onset of AF as their risk of stroke is doubled by the onset of AF.