Safety of left atrial appendage closure in heart failure patients.

INTRODUCTION: Left atrial appendage closure (LAAC) is an intervention aimed at stroke prevention in nonvalvular atrial fibrillation (AF). There is a three-fold increased risk of stroke in patients with concomitant presence of AF and heart failure (HF). While anticoagulation is effective, only 60% receive it. We aimed at studying the safety of LAAC in HF patients using a national all-payer database. METHODS: We queried the National Inpatient Sample for the year 2016-2018 for WATCHMAN device insertion using ICD 10 procedure codes. We divided the study population into HF and non-HF groups. Outcomes were compared using appropriate statistical tests, p< .05 was considered significant. RESULTS: 34 385 LAAC procedures were identified of which 8530 (24.8%) were done in patients with HF. The mean (SD) age of the study population was 76 (7.9) years and 42% were female. There was no difference in mean age between HF and non-HF groups. Our findings indicate that there is no difference in inpatient mortality and cardiac complications between the HF and non-HF groups. However, noncardiac complications including acute kidney injury and respiratory failure were higher in the HF group. CONCLUSION: LAAC appears to be a safe procedure in patients with HF. The study is limited by a short follow up period and long-term follow-up is required before definitive conclusions can be made.

Use of Serratus Anterior Plane and Transversus Thoracis Plane Blocks for Subcutaneous Implantable Cardioverter-Defibrillator (S-ICD) Implantation Decreases Intraoperative Opioid Requirements.

OBJECTIVES: The present study investigated whether regional anesthetic techniques, especially truncal blocks, can provide adjunct anesthesia without the additional risk of general anesthesia and neuraxial techniques for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation. DESIGN: Single-center, prospective, randomized study. SETTING: Holding area and operating room at a single-center tertiary care hospital. PARTICIPANTS: The study comprised 22 American Society of Anesthesiologists (ASA) physical status 3 or 4 patients with severe cardiac disease undergoing S-ICD implantation. INTERVENTIONS: Patients received either a combination of serratus anterior plane block and transversus thoracis plane block or surgical infiltration of local anesthetics. MEASUREMENTS AND MAIN RESULTS: Perioperative analgesic medication in the fascial plane block group versus the surgical wound infiltration group, visual analog pain scale score (0-10), intraoperative vital signs, total procedure time, and length of stay in the intensive care unit were measured. Total intraoperative fentanyl requirements (µg) were significantly less in the truncal block group versus the surgical infiltration group (45 [25-50] v 90 [50-100]; p = 0.026), and no patients had any adverse sequelae related to the study. Median intraoperative propofol use in the surgical infiltration group was 66.48 (47.30-73.73) µg/kg/min, and 65.95 (51.86-104.86) µg/kg/min for the truncal block group. This difference between the groups was not statistically significant (p = 0.293). CONCLUSIONS: The performance of both the serratus anterior plane block and transversus thoracis plane blocks for S-ICD implantation are appropriate and may have the benefit of decreasing intraoperative opioid requirements.

Catheter ablation of atrial arrhythmias in cardiac sarcoidosis.

BACKGROUND: We previously reported on the incidence and clinical implications of supraventricular arrhythmia in patients with cardiac sarcoidosis (CS). The role of catheter ablation for the management of atrial arrhythmia (AA) in this patient population is unknown. METHODS AND RESULTS: One hundred consecutive patients with CS were monitored for the incidence of supraventricular arrhythmias. Those with persistent symptoms despite optimal medical therapy proceeded to catheter ablation. Following ablation, all patients were followed serially with Holter monitoring or device interrogation. Thirty-two (32%) patients had symptomatic supraventricular arrhythmias. Nine (28%) patients had symptomatic AA requiring catheter ablation for clinical indications. Mean age was 55 ± 11.6 years. Five (56%) patients had atrial fibrillation (AF), of whom 2 also had cavotricuspid isthmus ablation. Four patients had isolated atrial flutter: 2 patients with left atrial flutter, and 2 patients with cavotricuspid flutter. All other arrhythmias were ablated in the left atrium. Mean duration of follow-up was 1.8 ± 1.9 years. One patient with atypical atrial flutter, and one patient with AF have had recurrence; the remaining patients remain in sinus rhythm. CONCLUSIONS: Our study suggests that AA in CS is frequently left atrial in origin. Catheter ablation appears to be effective and safe for the maintenance of sinus rhythm in patients with CS.

Erector Spinae Plane Block Decreases Narcotic Requirements in Patients Undergoing Subcutaneous Implantable Cardioverter-defibrillator Placement Under Sedation.

Providing adequate analgesia perioperatively during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation can be a challenge. The objective of our study was to assess the efficacy and safety of the erector spinae plane (ESP) block technique in providing analgesia and minimizing the risk of opioid use in high-risk patient populations. We enrolled consecutive patients >18 years of age undergoing S-ICD implantation from February 2020 to February 2022 at our center prospectively. Patients were randomly assigned to receive the ESP block or traditional wound infiltration. A total of 24 patients were enrolled, including 13 patients randomized to ESP block and 11 patients as controls who received only wound infiltration. The primary outcome assessed was the overall use of perioperative analgesic medications in the ESP block group versus the surgical wound infiltration group. A significant reduction in intraoperative fentanyl use was observed [median ([interquartile range]) in the ESP block group (0 [0-50] µg) compared to the wound infiltration block group (75 [50-100] µg) (P = .001). The overall postoperative day (POD) 0 fentanyl use was also significantly decreased (75 [50-100] µg) in the ESP block group compared to the surgical wound infiltration group (100 [87.5-150] µg) (P = .049). There was also a trend of decreased POD 0 oxycodone-acetaminophen use. Finally, the number of days to discharge was less in the ESP block group. These results indicate that ESP block is an innovative, safe, and effective technique that decreases intraoperative and postoperative opioid consumption and may be a useful adjunct pain-management technique in these high-risk patients. Larger studies are needed to further validate its use.

Efficacy and safety of implantable cardiac defibrillators for treatment of ventricular arrhythmias in patients with cardiac sarcoidosis.

AIMS: Implantable cardiac defibrillator (ICD) implantation is a class IIA recommendation for patients with cardiac sarcoidosis (CS). However, little is known about the efficacy and safety of ICDs in this population. The goal of this multicentre retrospective data review was to evaluate the efficacy and safety of ICDs in patients with CS. METHODS AND RESULTS: Electrophysiologists at academic medical centres were asked to identify consecutive patients with CS and an ICD. Clinical information, ICD therapy history, and device complications were collected for each patient. Data were collected on 235 patients from 13 institutions, 64.7% male with mean age 55.6 ± 11.1. Over a mean follow-up of 4.2 ± 4.0 years, 85 of 234 (36.2%) patients received an appropriate ICD therapy (shocks and/or anti-tachycardia pacing) and 67 of 226 (29.7%) received an appropriate shock. Fifty-seven of 235 patients (24.3%) received a total of 222 inappropriate shocks. Forty-six adverse events occurred in 41 of 235 patients (17.4%). Patients who received appropriate ICD therapies were more likely to be male (73.8 vs. 59.6%, P = 0.0330), have a history of syncope (40.5 vs. 22.5%, P = 0.0044), lower left ventricular ejection fraction (38.1 ± 15.2 vs. 48.8 ± 14.7%, P ≤ 0.0001), ventricular pacing on baseline electrocardiogram (16.1 vs. 2.1%, P = 0.0002), and a secondary prevention indication (60.7 vs. 24.5%, P < 0.0001) compared with those who did not receive appropriate ICD therapies. CONCLUSION: Patients with CS and ICDs are at high risk for ventricular arrhythmias. This population also has high rates of inappropriate shocks and device complications.

A Rare Case of Blue-Gray Discoloration Induced by Low-Dose Amiodarone.

Amiodarone is increasingly used in cardiology due to convenient dosing, low frequency of pro-arrhythmic effects, and good short term tolerance without significant hypotension. However, chronic use is associated with multisystem toxic side effects. We describe a rare case of amiodarone induced blue-gray skin discoloration.

Trends, Burden, and Impact of Arrhythmias on Cardiac Transplant Recipients: A 16-year Nationwide Study.

Orthotopic heart transplantation is the most effective long-term therapy for end-stage heart disease. Denervation with the loss of autonomic modulation, vasculopathy, utilization of immunosuppressant drugs, and allograft rejection may result in an increased prevalence of arrhythmias in transplanted hearts. We aim to describe the trends, distribution, and the clinical impact of arrhythmias in patients with transplanted hearts. We queried the National Inpatient Sample with administrative codes for cardiac transplant patients using procedure ICD-9-CM codes 37.5 and 33.6. Arrhythmias were extracted using validated ICD-9-CM codes. Statistical Analysis System (SAS) version 9.4 was used for analysis. There were a total of 30,020 hospitalizations of heart transplant recipients between 1999 and 2014 in the United States of which 1,6342 (54.4%) had an arrhythmia. The frequency of total arrhythmias increased from 53.6% (n=1,158) in 1999 to 67.3% (n=1,575) in 2014. Transplant patients with arrythmias was not associated with significantly higher inpatient mortality (7.72% vs 6.90%, P = 0.225). The most common arrythmia was atrial fibrillation ([AF]26.83%) followed by ventricular tachycardia (22.86%). Trends in mortality associated with arrhythmias following heart transplant has been decreasing from 12.3% in 1999 to 8.9% in 2014 (P = 0.04). Subgroup analysis of ventricular arrythmias (VA) following heart transplant were associated with increased mortality (8.61% vs 6.94%, P = 0.0229). Over half of patients develop 1 or more cardiac arrhythmia after heart transplant. There is an increasing secular trend in the frequency of arrhythmias post cardiac transplant with atrial fibrillation determined to be the most common arrhythmia.

Diagnosing a wide complex tachycardia using basic electrophysiologic properties of the cardiac conduction system.

65-year-old man with a history of coronary artery disease s/p percutaneous coronary intervention to the left anterior descending artery and atrial fibrillation s/p recent (<3 months) pulmonary vein isolation presented to the emergency department with symptoms of palpitations for 1 day after admittedly forgetting to take his medications found to be in a wide complex tachycardia. We discuss a stepwise approach using properties of the conduction system to diagnose the patient's tachycardia.

Trends, Prevalence, and Outcomes of Sudden Cardiac Arrest Post Cardiac Transplant: A Nationwide 16-Year Study.

Heart transplantation is the most effective long-term therapy for end-stage heart disease. There is limited data related to sudden cardiac arrest (SCA) in postheart transplant recipients. We aimed to describe the trends, and rate of SCA following heart transplantation and thereby identify clinical predictors as well as outcomes of SCA in patients post-transplant. We queried the National Inpatient Sample (NIS) with administrative codes for SCA and heart transplant. We assessed baseline differences between SCA and non-SCA admissions, with hazard ratios adjusted for age, gender, CCI, and race. Multivariable logistic regression models were generated to identify the independent predictors for SCA. There was a total of 30,020 hospitalizations of heart transplant recipients between 1999 and 2014 in the United States and among these 1,953 patients (6.5%) suffered SCA with an increasing trend of admissions for SCA. Among the patients who suffered from SCA, 18.83% died during the same hospitalization, 19.29% were discharged to a long-term facility, and 61.38% were discharged home. Multivariate analysis demonstrated that conduction system disorders (Hazard ratio [95% confidence interval]; 7.1 [4.5-11.1]), female gender (HR:1.2 [1.1-1.3]), diabetes (HR:1.4 [1.2-1.6]), and hypertension (HR:1.2 [1.1-1.4]) were the strongest predictors for SCA. SCA hospitalizations occur in 6.5% of patients post cardiac transplant and have been increasing from 1999 to 2014. Conduction block, graft rejection, female gender, hypertension, diabetes are independent predictors for SCA in heart transplant recipients.

Thromboembolic risk and anticoagulation strategies in patients undergoing catheter ablation for atrial fibrillation.

Periprocedural thromboembolic and hemorrhagic events are complications of percutaneous radiofrequency catheter ablation (RFA) of atrial fibrillation (AF). The management of anticoagulation before and after RFA could play an important role in the prevention of these complications. The incidence of thromboembolic events varies from 1% to 5%, depending on the ablation and the anticoagulation strategy used in the periprocedural period. The scientific evidence behind the management of anticoagulation in patients with AF undergoing RFA is scarce and is mostly based on small studies and experts' consensus. It remains unclear whether catheter ablation for AF reduces the risk of stroke and obviates the need for anticoagulation after the procedure. Limited data are available regarding the risk of thromboembolism with and without warfarin after AF ablation. In this review we will review the most current evidence supporting the different strategies to reduce thromboembolic risk before, during, and after catheter ablation for AF.

Cybersecurity: The need for data and patient safety with cardiac implantable electronic devices.

Remote monitoring of cardiac implantable electronic devices (CIEDs) has become routine practice as a result of the advances in biomedical engineering, the advent of interconnectivity between the devices through the Internet, and the demonstrated improvement in patient outcomes, survival, and hospitalizations. However, this increased dependency on the Internet of Things comes with risks in the form of cybersecurity lapses and possible attacks. Although no cyberattack leading to patient harm has been reported to date, the threat is real and has been demonstrated in research laboratory scenarios and echoed in patient concerns. The CIED universe comprises a complex interplay of devices, connectivity protocols, and sensitive information flow between the devices and the central cloud server. Various manufacturers use proprietary software and black-box connectivity protocols that are susceptible to hacking. Here we discuss the fundamentals of the CIED ecosystem, the potential security vulnerabilities, a historical overview of such vulnerabilities reported in the literature, and recommendations for improving the security of the CIED ecosystem and patient safety.

Incidence and Predictors of Sudden Cardiac Arrest in Sarcoidosis: A Nationwide Analysis.

OBJECTIVES: This study sought to identify electrocardiographic (ECG) and clinical predictors of sudden cardiac arrest (SCA) in sarcoidosis. BACKGROUND: Sudden cardiac death (SCD) is the leading cause of death in cardiac sarcoidosis (CS) and may be the earliest manifestation of disease. Widespread or repeated advanced imaging is a challenging solution to this problem. ECG is an affordable and widely accessible modality that could help guide diagnostic approaches and risk stratification. METHODS: Data were obtained from the National Inpatient Sample (2005-2017) using International Classification of Diseases-9th Revision and -10th Revision-Clinical Modification. The primary outcome was to identify predictors of SCA, whereas predictors of SCA in young individuals and those with normal ventricular function served as secondary measures. Furthermore, temporal trends in sarcoidosis as well as SCA were also analyzed. Logistic regression analysis was used to calculate odds ratios, following which a multivariable regression was used to adjust for potential confounders. RESULTS: Electrocardiographic markers of AV node dysfunction or bundle branch block are associated with substantially increased risk of SCA in a limited proportion of patients (8.6%). This association is also observed among younger patients (<40 years) and those with normal ventricular function. CONCLUSIONS: ECG evidence of AV nodal dysfunction or distal conduction disease should raise suspicion for cardiac involvement in patients with sarcoidosis and are associated with increased risk of SCA. ECG markers could help identify patients who would benefit from advanced imaging. The sensitivity of ECGs is, however, limited and presence of a normal ECG does not reflect a low risk of SCA.

Does the use of intracardiac echocardiography during atrial fibrillation catheter ablation improve outcomes and cost? A nationwide 14-year analysis from 2001 to 2014.

BACKGROUND: Intracardiac echocardiography (ICE) use during catheter ablation of atrial fibrillation (AF) provides real-time information to guide transseptal access, for monitoring the ablation and recognition of pericardial bleed. We describe trends of ICE use, impact on complications, and its in-hospital outcomes. METHODS: The national in-patient sample database was queried from 2001 to 2014 for diagnosis of AF based on ICD-9-CM 427.31 with a catheter ablation procedure code (37.34) in the same hospitalization and its associated complications. ICE was identified using ICD-9-CM procedure code (37.28). Statistical Analysis System (SAS) was used for analysis. RESULTS: There was an estimated total 299,152 patients who underwent AF ablation from 2001 to 2014 of which ICE was used in 46,688 (15.6%) patients. The use of ICE significantly increased from 0.08% in 2001 to 15.7% in 2014. In-hospital mortality was significantly lower in patients in whom ICE was used (0.11% vs 0.54%, p < 0.0001). Complications were 52% lower in procedures using ICE vs without ICE (HR [95%CI]; 0.48 [0.44-0.51]). The rate of cardiac complications was also lower in ICE users (3.67% vs 4.51%; p = 0.025). The use of ICE during AF ablation resulted in significantly higher cost of hospitalization ($98,436 ± 597 vs $81,300 ± 310; p < 0.0001), but this was offset by a decreased length of hospital stay (2.1 ± 0.02 vs 4 ± 0.02 days; p < 0.0001). CONCLUSIONS: The use of ICE during AF ablation has increased over the years and is associated with lower in-hospital mortality and procedural complications, shorter LOS but an increased cost of hospitalization.

Arrhythmias in Cardiac Sarcoidosis Bench to Bedside: A Case-Based Review.

Cardiac sarcoidosis is a component of an often multiorgan granulomatous disease of still uncertain cause. It is being recognized with increasing frequency, mainly as the result of heightened awareness and new diagnostic tests, specifically cardiac magnetic resonance imaging and 18F-fluorodeoxyglucose positron emission tomography scans. The purpose of this case-based review is to highlight the potentially life-saving importance of making the early diagnosis of cardiac sarcoidosis using these new tools and to provide a framework for the optimal care of patients with this disease. We will review disease mechanisms as currently understood, associated arrhythmias including conduction abnormalities, and atrial and ventricular tachyarrhythmias, guideline-directed diagnostic criteria, screening of patients with extracardiac sarcoidosis, and the use of pacemakers and defibrillators in this setting. Treatment options, including those related to heart failure, and those which may help clarify disease mechanisms are included.

QTc interval screening in methadone treatment.

DESCRIPTION: An independent panel developed cardiac safety recommendations for physicians prescribing methadone. METHODS: Expert panel members reviewed and discussed the following sources regarding methadone: pertinent English-language literature identified from MEDLINE and EMBASE searches (1966 to June 2008), national substance abuse guidelines from the United States and other countries, information from regulatory authorities, and physician awareness of adverse cardiac effects. RECOMMENDATION 1 (DISCLOSURE): Clinicians should inform patients of arrhythmia risk when they prescribe methadone. RECOMMENDATION 2 (CLINICAL HISTORY): Clinicians should ask patients about any history of structural heart disease, arrhythmia, and syncope. RECOMMENDATION 3 (SCREENING): Obtain a pretreatment electrocardiogram for all patients to measure the QTc interval and a follow-up electrocardiogram within 30 days and annually. Additional electrocardiography is recommended if the methadone dosage exceeds 100 mg/d or if patients have unexplained syncope or seizures. RECOMMENDATION 4 (RISK STRATIFICATION): If the QTc interval is greater than 450 ms but less than 500 ms, discuss the potential risks and benefits with patients and monitor them more frequently. If the QTc interval exceeds 500 ms, consider discontinuing or reducing the methadone dose; eliminating contributing factors, such as drugs that promote hypokalemia; or using an alternative therapy. RECOMMENDATION 5 (DRUG INTERACTIONS): Clinicians should be aware of interactions between methadone and other drugs that possess QT interval-prolonging properties or slow the elimination of methadone.

Incessant palpitations in a young male.

27-year-old male with incessant palpitations and reduced ejection fraction presents for diagnostic electrophysiology study. ECG shows a long RP tachycardia. Permanent junctional reciprocating tachycardia is diagnosed on EP study with successful ablation of posteroseptal accessory pathway.

Trends, burden, and impact of arrhythmia on cardiac amyloid patients: A 16-year nationwide study from 1999 to 2014.

BACKGROUND: Patients with cardiac amyloidosis (CA) have increased mortality, which can be explained in part by an increased risk of arrhythmias. The burden of arrhythmias in CA, their predictors, and impact on in-hospital outcomes remains unclear. The role of implantable cardioverter-defibrillators (ICD) in this population is also uncertain. METHODS: We queried the National Inpatient Sample (NIS) using ICD-9-CM codes 277.39 and 425.7 to identify CA. Twelve common arrhythmias were extracted using appropriate, validated ICD-9-CM codes. ICD implantation was identified using procedure ICD-9 codes 37.94 to 37.98, 00.51 and 00.54. RESULTS: There were a total of 145,920 CA hospitalizations between 1999 and 2014 in the United States and 56,199 (38.5%) of them were associated with arrhythmias. The prevalence of arrhythmias remained relatively constant from 41.5% in 1999 to 40.2% in 2014. The most common arrhythmia was atrial fibrillation (25.4%). In-patient mortality was significantly higher in CA patients with arrhythmias (10.4% vs 6.5%, P < .001). ICD implantation was performed in 1,381 (0.94%) patients with CA and analysis revealed an incremental trend in implantation over the study period (0.48% in 1999 to 0.65% in 2014). In-hospital mortality was significantly lower in patients who underwent ICD implantation (3.7% vs 8%; P = .0078). CA patients with arrhythmias also had an increased cost of hospitalization and length of stay ($65,046 ± 1,079 vs $53,322 ± 687 and 8.3 ± 0.1 vs 7.4 ± 0.1 days, respectively; P < .0001). CONCLUSION: Cardiac arrhythmias are common in patients with CA and are associated with worse in-hospital outcomes, increased length of stay, and cost of hospitalization.

Trends of Acute Kidney Injury Requiring Dialysis Among Hospitalized Patients Undergoing Invasive Electrophysiology Procedures.

Electrophysiology (EP) procedures carry the risk of kidney injury due to contrast/hemodynamic fluctuations. We aim to evaluate the national epidemiology of acute kidney injury requiring dialysis (AKI-D) in patients undergoing EP procedures. Using the National Inpatient Sample, we included 2,747,605 adult hospitalizations undergoing invasive diagnostic EP procedures, ablation and implantable device placement from 2006 to 2014. We examined the temporal trend of AKI-D and outcomes associated with AKI-D. The rate of AKI-D increased significantly in both diagnostic/ablation group (8-21/10,000 hospitalizations from 2006 to 2014, P = 0.02) and implanted device group (19-44/10,000 hospitalizations from 2006 to 2014, P < 0.01), but it was explained by temporal changes in demographics and comorbidities. Cardiac resynchronization therapy and pacemaker placement had higher risk of AKI-D compared to implantable cardioverter-defibrillator placement (23 vs. 31 vs. 14/10,000 hospitalizations in cardiac resynchronization therapy, pacemaker placement, and implantable cardioverter-defibrillator group, respectively). Development of AKI-D was associated with significant increase in in-hospital mortality (adjusted odds ratio, 9.6 in diagnostic/ablation group, P < 0.01; adjusted odds ratio, 5.1 in device implantation group, P < 0.01) and with longer length of stay (22.5 vs. 4.5 days in diagnostic/ablation group, 21.1 vs. 5.7 days in implanted device group) and higher cost (282,775 vs. 94,076 USD in diagnostic/ablation group, 295,660 vs. 102,007 USD in implanted device group). The incidence of AKI-D after EP procedures increased over time but largely explained by the change of demographics and comorbidities. This increasing trend, however, was associated with significant increase in resource utilization and in-hospital mortality in these patients.

Fatal outcome in a pacemaker-dependent patient.

The recent advisory of Medtronic Sprint Fidelis leads has resulted in significant controversy over proper management of patients. The current manufacture's guidelines recommend programming specific device alerts with close follow-up and implantable cardioverter-defibrillator lead replacement in patients with evidence of breach in lead integrity. Recently, several studies have identified significant limitations in this method of surveillance. We report the case of a pacemaker-dependent patient with an ischemic cardiomyopathy, who presented with cardiac arrest and evidence of fracture of the pace/sense portion of a Sprint Fidelis lead during postmortem interrogation. Likely mechanisms leading to his ultimate demise are discussed.