Longitudinal QTc stability and impact of baseline cardiac rhythm on discharge dose in dofetilide-treated patients.

INTRODUCTION: Dofetilide suppresses atrial fibrillation (AF) in a dose-dependent fashion. The protective effect of AF against QTc prolongation induced torsades de pointe and transient post-cardioversion QTc prolongation may result in dofetilide under-dosing during initiation. Thus, the optimal timing of cardioversion for AF patients undergoing dofetilide initiation to optimize discharge dose remains unknown as does the longitudinal stability of QTc . The purpose of this study was to evaluate the impact of baseline rhythm on dofetilide dosing during initiation and assess the longitudinal stability of QTc-all (Bazzett, Fridericia, Framingham, and Hodges) over time. METHODS: Medical records of patients who underwent preplanned dofetilide loading at a tertiary care center between January 2016 and 2019 were reviewed. RESULTS: A total of 198 patients (66 ± 10 years, 32% female, CHADS2 -Vasc 3 [2-4]) presented for dofetilide loading in either AF (59%) or sinus rhythm (SR) (41%). Neither presenting rhythm, nor spontaneous conversion to SR impacted discharge dose. The cumulative dofetilide dose before cardioversion moderately correlated (r = .36; p = .0001) with discharge dose. Postcardioversion QTc-all prolongation (p < .0001) prompted discharge dose reduction (890 ± 224 mcg vs. 552 ± 199 mcg; p < .0001) in 30% patients. QTc-all in SR prolonged significantly during loading (p < .0001). All patients displayed QTc-all reduction (p < .0001) from discharge to short-term (46 [34-65] days) that continued at long-term (360 [296-414] days) follow-ups. The extent of QTc-all reduction over time moderately correlated with discharge QTc-all (r = .54-0.65; p < .0001). CONCLUSION: Dofetilide initiation before cardioversion is equivalent to initiation during SR. Significant QTc reduction proportional to discharge QTc is seen over time in all dofetilide-treated patients. QTc returns to preloading baseline during follow-up in patients initiated in SR.

Diastolic Dysfunction and Health Status Outcomes After Transcatheter Aortic Valve Replacement.

Background: Baseline left ventricular diastolic dysfunction (LVDD) is associated with poor health status in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), but health status improvement after TAVR appears similar across all grades of LVDD. Here, we aim to examine the relationship between changes in LVDD severity and health status outcomes following TAVR. Methods: Patients who underwent TAVR and had evaluable LVDD at both baseline and 1 year in the PARTNER (Placement of Aortic Transcatheter Valves) 2 SAPIEN 3 registries and PARTNER 3 trial were analyzed. LVDD grade was evaluated using echocardiography core lab data and an adapted definition of American Society of Echocardiography guidelines. Health status was assessed using the Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS) score. The association between ΔLVDD severity and ΔKCCQ-OS was examined using linear regression models adjusted for baseline KCCQ-OS. Results: Of 1100 patients, 724 (65.8%), 283 (25.7%), and 93 (8.5%) had grade 0/1, 2, and 3 LVDD at baseline, respectively. At 1 year, LVDD severity was unchanged in 790 (71.8%) patients, improved in 189 (17.2%), and worsened in 121 (11.0%). Among 376 patients with baseline grade 2 or 3 LVDD, 50.3% had improvement in LVDD. In the overall cohort, KCCQ-OS score improved by 21.9 points at 1 year. There was a statistically significant association between change in LVDD severity (improved, unchanged, and worsened) and ΔKCCQ-OS at 1 year (p = 0.007). Conclusions: Change in LVDD grade was associated with change in health status 1 year following TAVR.

Out-of-hospital cardiac arrest survival when CPR is initiated by first responders.

BACKGROUND: In most patients with out-of-hospital cardiac arrest (OHCA), cardiopulmonary resuscitation (CPR) is initiated by first responders (non-transporting firefighters or police) or emergency medical service (EMS) personnel. Whether survival outcomes differ when CPR is initiated by first responders vs. EMS is unclear. METHODS: Within the CARES registry, we identified 162,896 adult patients with a non-traumatic OHCA in whom CPR was initiated by first responders or EMS during 2013-2021. Using multivariable hierarchical logistic regression to adjust for demographics, cardiac arrest characteristics and time to first CPR, we compared rates of survival to hospital admission and to discharge in patients with CPR initiated by first responders and EMS. RESULTS: CPR was initiated by first responders in 70,889 (43.5%) and by EMS in 92,007 (56.5%) patients. Time to first CPR was shorter when first responders initiated CPR (median: 8.0 [5.0-13.0] vs. 10.0 minutes [IQR: 6.0-14.0]; standardized difference 16.1%). The likelihood of survival to hospital admission was similar when CPR was initiated by first responders (27.1% [first responders] vs. 26.8% [EMS]; adjusted OR: 0.98 [0.96, 1.01], P = 0.15) whereas survival rates to discharge were higher with CPR initiated by first responders (9.4% [first responders] vs. 7.7% [EMS]; adjusted OR: 1.17 [1.02, 1.21], P < 0.001). After adjustment for time to first CPR, rates of survival to discharge were similar between the first responder and EMS groups (adjusted OR: 1.04 [1.00-1.08]; P = 0.07). CONCLUSIONS: CPR initiated by first responders for OHCA is associated with higher overall survival rates and higher survival was largely mediated by earlier response times.

Health Status Outcomes in Older Adults Undergoing Chronic Total Occlusion Percutaneous Coronary Intervention.

Background Although chronic total occlusions (CTOs) are common in older adults, they are less likely to be offered CTO percutaneous coronary intervention for angina relief than younger adults. The health status impact of CTO percutaneous coronary intervention in adults aged ≥75 years has not been studied. We sought to compare technical success rates and angina-related health status outcomes at 12 months between adults aged ≥75 and <75 years in the OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion) registry. Methods and Results Angina-related health status was assessed with the Seattle Angina Questionnaire (score range 0-100, higher scores denote less angina). Technical success rates were compared using hierarchical modified Poisson regression, and 12-month health status was compared using hierarchical multivariable linear regression between adults aged ≥75 and <75 years. Among 1000 participants, 19.8% were ≥75 years with a mean age of 79.5±4.1 years. Age ≥75 years was associated with a lower likelihood of technical success (adjusted risk ratio=0.92 [95% CI, 0.86-0.99; P=0.02]) and numerically higher rates of in-hospital major adverse cardiovascular events (9.1% versus 5.9%, P=0.10). There was no difference in Seattle Angina Questionnaire Summary Score at 12 months between adults aged ≥75 and <75 years (adjusted difference=0.9 [95% CI, -1.4 to 3.1; P=0.44]). Conclusions Despite modestly lower success rates and higher complication rates, adults aged ≥75 years experienced angina-related health status benefits after CTO-percutaneous coronary intervention that were similar in magnitude to adults aged <75 years. CTO percutaneous coronary intervention should not be withheld based on age alone in otherwise appropriate candidates.

An Analysis of Telehealth in the Outpatient Management of Atrial Fibrillation During the COVID-19 Pandemic.

The COVID-19 pandemic accelerated adaption of a telehealth care model. We studied the impact of telehealth on the management of atrial fibrillation (AF) by electrophysiology providers in a large, multisite clinic. Clinical outcomes, quality metrics, and indicators of clinical activity for patients with AF during the 10-week period of March 22, 2020 to May 30, 2020 were compared with those from the 10-week period of March 24, 2019 to June 1, 2019. There were 1946 unique patient visits for AF (1,040 in 2020 and 906 in 2019). During 120 days after each encounter, there was no difference in hospital admissions (11.7% vs 13.5%, p = 0.25) or emergency department visits (10.4% vs 12.5%, p = 0.15) in 2020 compared with 2019. There was a total of 31 deaths within 120 days, with similar rates in 2020 and 2019 (1.8% vs 1.3%, p = 0.38). There was no significant difference in quality metrics. The following clinical activities occurred less frequently in 2020 than in 2019: offering escalation of rhythm control (16.3% vs 23.3%, p <0.001), ambulatory monitoring (29.7% vs 51.7%, p <0.001), and electrocardiogram review for patients on antiarrhythmic drug therapy (22.1% vs 90.2%, p <0.001). Discussions about risk factor modification were more frequent in 2020 compared with 2019 (87.9% vs 74.8%, p <0.001). In conclusion, the use of telehealth in the outpatient management of AF was associated with similar clinical outcomes and quality metrics but differences in clinical activity compared with traditional ambulatory encounters. Longer-term outcomes warrant further investigation.

Persistent and Recurrent Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes.

BACKGROUND: Scarce data exist on the evolution of device-related thrombus (DRT) after left atrial appendage closure (LAAC). OBJECTIVES: This study sought to assess the incidence, predictors, and clinical impact of persistent and recurrent DRT in LAAC recipients. METHODS: Data were obtained from an international multicenter registry including 237 patients diagnosed with DRT after LAAC. Of these, 214 patients with a subsequent imaging examination after the initial diagnosis of DRT were included. Unfavorable evolution of DRT was defined as either persisting or recurrent DRT. RESULTS: DRT resolved in 153 (71.5%) cases and persisted in 61 (28.5%) cases. Larger DRT size (OR per 1-mm increase: 1.08; 95% CI: 1.02-1.15; P = 0.009) and female (OR: 2.44; 95% CI: 1.12-5.26; P = 0.02) were independently associated with persistent DRT. After DRT resolution, 82 (53.6%) of 153 patients had repeated device imaging, with 14 (17.1%) cases diagnosed with recurrent DRT. Overall, 75 (35.0%) patients had unfavorable evolution of DRT, and the sole predictor was average thrombus size at initial diagnosis (OR per 1-mm increase: 1.09; 95% CI: 1.03-1.16; P = 0.003), with an optimal cutoff size of 7 mm (OR: 2.51; 95% CI: 1.39-4.52; P = 0.002). Unfavorable evolution of DRT was associated with a higher rate of thromboembolic events compared with resolved DRT (26.7% vs 15.1%; HR: 2.13; 95% CI: 1.15-3.94; P = 0.02). CONCLUSIONS: About one-third of DRT events had an unfavorable evolution (either persisting or recurring), with a larger initial thrombus size (particularly >7 mm) portending an increased risk. Unfavorable evolution of DRT was associated with a 2-fold higher risk of thromboembolic events compared with resolved DRT.

Outcomes of pediatric patients with COVID-19 and in-hospital cardiopulmonary resuscitation.

BACKGROUND: Early studies found low survival rates for adults with COVID-19 infection and in-hospital cardiac arrest (IHCA). We evaluated the association of COVID-19 infection on survival outcomes in pediatric patients undergoing cardiopulmonary resuscitation (CPR). METHODS: Within Get-With-The-Guidelines®-Resuscitation, we identified pediatric patients who underwent CPR for an IHCA or bradycardia with poor perfusion between March and December, 2020. We compared survival outcomes (survival to discharge and return of spontaneous circulation for ≥20 minutes [ROSC]) between patients with suspected/confirmed COVID-19 infection and non-COVID-19 patients using multivariable hierarchical regression, with hospital site as a random effect and patient and cardiac arrest variables with a significant (p < 0.05) bivariate association as fixed effects. RESULTS: Overall, 1328 pediatric in-hospital CPR events were identified (590 IHCA, 738 bradycardia with poor perfusion), of which 46 (32 IHCA, 14 bradycardia) had suspected/confirmed COVID-19 infection. Rates of survival to discharge were similar between those with and without COVID-19 infection (39.1% vs. 44.9%; adjusted RR, 1.14 [95% CI: 0.55-2.36]), and these estimates were similar for those with IHCA and bradycardia with poor perfusion (adjusted RRs of 1.03 and 1.05; interaction p = 0.96). Rates of ROSC were also similar between pediatric patients with and without COVID-19 overall (67.4% vs. 76.9%; adjusted RR, 0.87 [0.43, 1.77]), and for the subgroups with IHCA or bradycardia requiring CPR (adjusted RRs of 0.95 and 0.86, interaction p = 0.26). CONCLUSIONS: In a large multicenter national registry of CPR events, COVID-19 infection was not associated with lower rates of ROSC or survival to hospital discharge in pediatric patients undergoing CPR.

Relationship between Surpoint Tag Index, a Radiofrequency Ablation lesion quality indicator, and Atrial wall thickness in Cavotricuspid isthmus Ablations exhibiting bidirectional block.

BACKGROUND: An RFA lesion quality indicator, Surpoint Tag Index® (TI) incorporates key factors: power, time, and contact force, impacting lesion quality. TI accurately estimates lesion depth in animal studies. However, the relationship between TI and in-vivo atrial wall thickness in patients exhibiting bidirectional block remains unknown. OBJECTIVE: To describe the relationship between atrial wall thickness and TI in CTI exhibiting bidirectional block. METHODS: Data from 492 RFA lesions from 25 patients undergoing PVI and CTI ablations in SR with point-by-point RF lesions (<45 W) utilizing a Thermocool Smarttouch® SF ablation catheter and CARTO-3 mapping were retrospectively analyzed. Operators were blinded to TI data and CTI thickness. CTI thickness was obtained using ICE images on Cartosound pre-ablation. Durable lesions were defined as part of a lesion set exhibiting bidirectional block of >30 min. RESULTS: In lesions exhibiting bidirectional block, the thinnest (1-2 mm; 5% lesions) and thickest (8-10 mm; 6% lesions) portions of the CTI correlated with the lowest (429 ± 75) and highest (516 ± 64) TI. The bulk of thickness (2-6 mm; 80%) correlated with a TI of 455 ± 72 (p = 0.001). There was a weak but positive correlation between TI and CTI thickness (r = 0.2; p ≤ 0.01). Examined in sectors, the anterior 1/3rd CTI was the thickest (4.8 ± 1.9 mm) but correlated with a similar TI value (479 ± 75 vs. 471 ± 70; p = 0.34) as the thinner middle 1/3rd (3.8 ± 1.7 mm; p ≤ 0.0001). CONCLUSION: A mean TI value of 455 correlates with bidirectional block across the bulk of CTI with lower and higher values needed for the thinner and thicker portions, respectively. Tissue composition, aside from wall thickness, influences TI values for the creation of the bidirectional block.

Comparison of the Safety of Left Atrial Appendage Occlusion in Patients Aged <75 Versus Those Aged ≥75 Years (from a Nationwide Cohort Sample).

The mean age in clinical trials of percutaneous left atrial appendage occlusion (LAAO) has been <75 years. We aimed to better understand the safety of LAAO in older patients. National Inpatient Sample and International Classification of Diseases, Tenth Revision codes were used to identify patients with atrial fibrillation who underwent LAAO during the years 2016-2018. Patients were grouped by age <75 and ≥75 years. Baseline characteristics; length of stay; cost; hospital mortality; and other adverse events, including hematoma, vascular complications, perforation/tamponade, and stroke/ transient ischemic attack, were compared for the 2 groups. A total of 6,877 patients were identified, of whom 4,160 (60.4%) were aged ≥75 years. Length of stay and hospitalization costs were similar for the 2 groups. There were 10 deaths in patients aged ≥75 years and 1 death in patients aged <75 years (p = 0.059). The incidence of perforation/tamponade was 1.3% in patients aged ≥75 years versus 0.6% for those <75 years (p = 0.008). This difference persisted on multivariate analysis (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.01 to 3.07). The risk of perforation/tamponade was also higher in female patients (OR 2.74, 95% CI 1.63 to 4.59). There was a trend toward higher combined procedure-related adverse events (OR 1.46, 95% CI 0.99 to 2.15) in patients ≥75 years. There was no difference in the individual components of hematoma, vascular complication, and stroke/transient ischemic attack between both groups. In conclusion, percutaneous LAAO was associated with a higher risk of perforation and tamponade in older patients, particularly women.

Lead Macrodislodgement of a Subcutaneous Implantable Cardioverter-Defibrillator Results in a Reel Problem.

Lead macrodislodgement is a rare complication of cardiac implantable electronic devices associated with patient-related risk factors. This paper outlines a case of reel syndrome secondary to device manipulation 3 months after subcutaneous implantable cardioverter-defibrillator implantation and describes the challenges with lead macrodislodgement diagnosis, mechanisms, and management. (Level of Difficulty: Beginner.).

Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion.

BACKGROUND: Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited. OBJECTIVES: This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT. METHODS: Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT. RESULTS: A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180, 180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.57-3.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with ≥2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors. CONCLUSIONS: DRT after LAAO is associated with ischemic events. Patient- and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO.

COVID-19-associated meningoencephalitis treated with intravenous immunoglobulin.

A 40-year-old man presented with altered mental status after a recenthospitalisation for COVID-19 pneumonia. Cerebrospinal fluid (CSF) analysis showed lymphocytosis concerning for viral infection. The CSF PCR for SARS-CoV-2 was negative, yet this could not exclude COVID-19 meningoencephalitis. During hospitalisation, the patient's mentation deteriorated further requiring admission to the intensive care unit (ICU). Brain imaging and electroencephalogram (EEG) were unremarkable. He was, thus, treated with intravenous immunoglobulin (IVIg) for 5 days with clinical improvement back to baseline. This case illustrates the importance of considering COVID-19's impact on the central nervous system (CNS). Haematogenous, retrograde axonal transport, and the effects of cytokine storm are the main implicated mechanisms of CNS entry of SARS-CoV-2. While guidelines remain unclear, IVIg may be of potential benefit in the treatment of COVID-19-associated meningoencephalitis.

A Ghost Left Behind After Transvenous Lead Extraction: A Finding to be Feared.

BACKGROUND Following transvenous lead extraction (TLE) for infective endocarditis, a fibrinous remnant, or "ghost", that previously encapsulated the lead may remain. The main aim of this case report was to highlight the importance of identification of ghosts, their negative implications, and the importance of close monitoring. CASE REPORT A 72-year-old male with a history of heart failure with non-ischemic cardiomyopathy and remote cardiac resynchronization therapy defibrillator (CRT-D) placement as well as atrioventricular node ablation for atrial fibrillation presented following a mechanical fall. An initial evaluation revealed methicillin-resistant Staphylococcus aureus bacteremia; the suspected nidus was an indwelling chemotherapy port for non-Hodgkin's lymphoma. Echocardiography demonstrated vegetations on the aortic and mitral valves, and the right atrial device lead concerning for infective endocarditis. After TLE, a temporary transvenous wire was placed. Definitive pacing was then achieved by a Micra leadless pacemaker (LP). We opted with LP technology via the Micra device with plan for subcutaneous implantable cardioverter defibrillator (SICD) implantation to mitigate the risk of infection recurrence. After completion of 6 weeks of antibiotics, a pre-SICD transesophageal echocardiogram identified a 1.3 cm mobile echo-dense "ghost" in the right atrium. SICD was implanted as planned. Following expert consensus, no specific therapy was implemented when the ghost was identified. At 3 months, echocardiography revealed the absence of the ghost. At 1-year follow-up, no infection recurrence was noted. CONCLUSIONS The presence of ghosts after transvenous lead extraction is associated with poor outcome and infection recurrence thus requiring diligent monitoring and serial echocardiography as optimal management is yet to be defined.

A Spontaneous Isolated Superior Mesenteric Artery Dissection Associated with Cocaine Abuse: A Pathomechanistic Association.

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare potentially fatal disease. We present a case of cocaine-related SISMAD in a patient with abdominal pain. A 38-year-old African American male with hypertension and alcohol, cocaine, and tobacco abuse presented with abdominal pain and recent cocaine use. A CT angiogram revealed SISMAD; he was treated with conservative management. Cocaine and SISMAD share similar pathophysiologic mechanisms pertaining to vascular smooth muscle cell apoptosis and increased shear stress at fixed vascular positions. Our report emphasizes the need to consider cocaine abuse in SISMAD pathophysiology, risk stratification, and treatment algorithms in future studies.