The combination of coronary sinus ostial atresia/abnormalities and a small persistent left superior vena cava-Opportunity for left ventricular lead implantation and unrecognized source of thromboembolic stroke.

BACKGROUND: Coronary sinus (CS) ostial atresia/abnormalities prevent access to the CS from the right atrium (RA) for left ventricular (LV) lead implantation. Some patients with CS ostial abnormalities also have a small persistent left superior vena cava (sPLSVC). OBJECTIVE: The purpose of this study was to describe CS ostial abnormalities and sPLSVC as an opportunity for LV lead implantation and unrecognized source of stroke. METHODS: Twenty patients with CS ostial abnormalities and sPLSVC were identified. Clinical information, imaging methods, LV lead implantation techniques, and complications were summarized. RESULTS: Forty percent had at least 1 previously unsuccessful LV lead placement. In 70%, sPLSVC was identified by catheter manipulation and contrast injection in the left brachiocephalic vein, and in 30% by levophase CS venography. In 30%, sPLSVC was associated with drainage from the CS into the left atrium (LA). When associated with CS ostial abnormalities, the sPLSVC diameter averaged 5.6 ± 3 mm. sPLSVC was used for successful LV lead implantation in 90% of cases. In 80%, the LV lead was implanted down sPLSVC, and in 20%, sPLSVC was used to access the CS from the RA. Presumably because of unrecognized drainage from the CS to the LA, 1 patient had a stroke during implantation via sPLSVC. CONCLUSION: When CS ostial abnormalities prevent access to the CS from the RA, sPLSVC can be used to successfully implant LV leads. In some, the CS partially drains into the LA and stroke can occur spontaneously or during lead intervention. It is important to distinguish sPLSVC associated with CS ostial abnormalities from isolated PLSVC.

Minimally invasive thoracoscopic surgery is an effective approach for treating inappropriate sinus tachycardia.

INTRODUCTION: Inappropriate sinus tachycardia (IST) is characterized by increased heart rate out of proportion to normal physiologic demand. IST ablation is challenging for the electrophysiology community due to the epicardial location of the sinus node and the risk of phrenic nerve (PN) injury during catheter ablation. In this study, we investigated the safety and efficacy of a minimally invasive thoracoscopic surgery for elimination of IST. METHODS: Patients with IST who failed medical therapy or endocardial ablation underwent minimally invasive thoracoscopic epicardial ablation. Epicardial activation mapping was performed to identify the earliest activation site and any possible migration of earliest activation along the lateral right atrium. The PN in each patient was protected by a pericardial retraction suture. RESULTS: From 1 January 2000 to 15 June 2018, 10 patients (eight females and two males) underwent minimally invasive thoracoscopic IST ablation. Mean age of the patients was 36.7 ± 12.5 years. Mean baseline sinus rate was 113.8 ± 21.8 beats per minute. After surgery, the mean heart rate significantly decreased to 79.8 ± 8.2 at postoperative day 1 and to 75.8 ± 8.1 at day 30 (both P < .001). No in-hospital death, stroke, or PN injury occurred. One patient required reintubation, one patient developed postoperative pericarditis, and another patient had a pulmonary embolus. Median follow-up was 6 months (range, 1-50). Freedom from reintervention was 88% at 6 months. CONCLUSION: Minimally invasive thoracoscopic ablation for IST is a safe and effective approach that preserves the phrenic nerve. Due to the possibility of IST activation site migration, continued follow-up after surgery is required.

Electronic consults for improving specialty care access for veterans.

OBJECTIVES: We adopted e-consults within an active referral management (ARM) process for our Veterans Health Administration (VHA) outpatient cardiology clinic to reduce clinic wait times. STUDY DESIGN: Prospective multiphase cohort study. METHODS: Our ARM process consisted of reviewing all incoming consult requests for our outpatient clinic and triaging the requests to either an e-consult or a clinic visit. The primary outcome was wait time for an appointment in our clinic. RESULTS: Median wait time prior to the ARM process was 24 days. After implementation of the ARM process, wait times decreased to 13 days (46% reduction). Approximately 60% of incoming consults could be triaged into e-consults, predominantly by managing stable diseases or minor symptoms. CONCLUSIONS: E-consults and ARM of clinical referrals were effective at reducing wait times for our outpatient VHA cardiology clinic. The majority of clinical referrals could be handled through an e-consult and did not require an in-person clinic visit.

Meta-Analysis Comparing Catheter-Guided Ablation Versus Conventional Medical Therapy for Patients With Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction.

The prognostic benefit of catheter ablation (CA) for atrial fibrillation in the setting of heart failure (HF) with reduced ejection fraction (EF) is unclear. A systematic search of medical literature was limited to randomized controlled trials. The primary outcome was all-cause mortality, and secondary outcomes were HF hospitalizations, stroke, left ventricular EF improvement, change in 6-minute walk test, and change in Minnesota living with HF questionnaire (Δ MLHFQ). Random effects risk ratios (RR) were calculated for categorical outcomes and standardized mean differences (SMD) for continuous ones, using Der-Simonian and Liard model. A total of 775 ambulatory patients from 6 trials were included. The mean EF was 31% with a mean New York Heart Association classification class 2.5. At a mean follow-up of 26 months, CA was associated with lower incidences of all-cause mortality (RR 0.50, 95% confidence intervals [CI] 0.34 to 0.74, I2 = 0%, p <0.0001), and HF hospitalizations (RR 0.58, 95% CI 0.41 to 0.81, p = 0.002, I2 = 0%), with similar incidences of stroke. Left ventricular EF improvement (SMD = 2.58, 95% CI 0.88 to 4.27), and change in Minnesota living with heart failure HF questionnaire (SMD = -0.40, 95% CI -0.65 to -0.14) were also in favor of CA, with no difference noted in change in 6-minute walk test. The incidence of all reported procedural complications (including major and minor) was 7.3%. In conclusion, CA of atrial fibrillation appears to be associated with improved survival and HF hospitalizations compared with medical therapy, with evidence of low ablation-related complications.

Iatrogenic Ventricular Fibrillation after Direct-Current Cardioversion of Preexcited Atrial Fibrillation Caused by Inadvertent T-Wave Synchronization.

Direct-current cardioversion is an important means of managing arrhythmias. During treatment, carefully synchronizing energy delivery to the QRS complex is necessary to avoid ventricular fibrillation caused by a shock during the vulnerable period of ventricular repolarization, that is, a shock on the T wave. The presence of an accessory pathway and ventricular preexcitation can lead to difficulty in distinguishing the QRS complex from the T wave because of bizarre, wide, irregular QRS complexes and prominent repolarization. We present the cases of 2 patients who had iatrogenic ventricular fibrillation from inappropriate T-wave synchronization during direct-current cardioversion of preexcited atrial fibrillation. Our experience shows that rapidly recognizing the iatrogenic cause of VF and immediate treatment with unsynchronized defibrillation can prevent adverse clinical outcomes.

In-Hospital Cerebrovascular Outcomes of Patients With Atrial Fibrillation and Cancer (from the National Inpatient Sample Database).

Limited data are available regarding the impact of cancer on cerebrovascular accidents in patients with atrial fibrillation (AF). We queried the Nationwide Inpatient Survey Database to identify patients who have diagnostic code for AF. We performed a 1:1 propensity matching based on the CHA2DS2VASc score and other risk factors between patients with AF who had lung, breast, colon, and esophageal cancer, and those who did not (control). The final cohort included a total of 31,604 patients. The primary outcome of in-hospital cerebrovascular accidents (CVA) was lower in the cancer group than in the control group (4% vs 7%, p < 0.001), but with only a weak association (ф = -0.067). In-hospital mortality was higher in the cancer group than in the control group (18% vs 11%, p < 0.001; ф = -0.099). A subgroup analysis according to cancer type showed similar results with a weak association with lower CVA in breast cancer (4% vs 7%; ф = -0.066, p < 0.001), lung cancer (4% vs 6%; ф = -0.062, p < 0.001), colon cancer (4% vs 6%; ф = -0.062, p < 0.001), and esophageal cancer (3% vs 7%; ф = -0.095, p < 0.001) compared with the control groups. A weak association with higher in-hospital mortality was demonstrated in lung cancer (20% vs 11%; ф = -0.127, p < 0.001), colon cancer (16% vs 11%; ф = -0.076, p < 0.001), and esophageal cancer (20% vs 12%; ф = -0.111, p < 0.001) compared with the control groups, but no significant difference between breast cancer and control groups in mortality (11% vs 11%; ф = -0.002, p = 0.888). In conclusion, in patients with AF, cancer diagnosis may not add a predictive role for in-hospital CVA beyond the CHADS2VASc score.

Atrial Fibrillation Ablation Increases Inflammation-Chemokine Modulation Suppresses Activation of Leukocytes Isolated after Ablation.

AIMS: Atrial fibrillation (AF) ablation is associated with increased circulating markers of inflammation. Innate immune or inflammation pathways up-regulate mononuclear cell responses and may increase the risk for recurrent arrhythmia. Chemokines and serine protease coagulation pathways both activate innate immune responses. Here, we measured inflammatory markers in peripheral blood samples from patients after cryoballoon and/or radiofrequency pulmonary vein isolation and assessed the capacity for the inhibition of chemokine and serine protease pathways to block cell activation. METHODS: Markers of inflammation were measured in 55 patients immediately before and one day after AF ablation. Peripheral blood mononuclear cells (PBMCs) isolated from 19 patients were further tested for responsiveness to two anti-inflammatory proteins ex vivo using fluorescence assays and RT-qPCR analysis of gene expression. RESULTS: White blood cells (WBC), C-reactive protein, fibrinogen and troponin T levels were significantly elevated after ablation. PBMCs isolated from the circulating blood had increased activation with Phorbol 12-myristate 13-acetate. Cell activation, as measured by membrane fluidity, was blunted after treatment with a broad-spectrum chemokine modulating protein, M-T7, which interferes with chemokine/glycosaminoglycan (GAG) interactions, but not by Serp-1, a serine protease inhibitor (serpin) that targets both thrombotic and thrombolytic pathway proteases. Differential gene expression changes in the apoptotic pathway were identified with M-T7 and Serp-1. CONCLUSIONS: Patients undergoing AF ablation have significantly increased inflammatory markers. Inhibition of chemokine signaling, but not serine proteases, reduced the activation of monocytes isolated from patients, in vitro. Targeting chemokines have the potential to reduce post-ablation activation of circulating leukocytes.

Impact of a Pharmacy-Cardiology Collaborative Practice on Dofetilide Safety Monitoring.

BACKGROUND: Limited studies have been published examining dofetilide's postmarketing use and its recommended monitoring. OBJECTIVE: To evaluate the impact of a collaborative pharmacy-cardiology antiarrhythmic drug (AAD) monitoring program on dofetilide monitoring. METHODS: This retrospective cohort study was performed to assess if a novel monitoring program improved compliance with dofetilide-specific monitoring parameters based on the Food and Drug Administration's Risk Evaluation and Mitigation Strategy. RESULTS: A total of 30 patients were included in the analysis. The monitoring parameters evaluated included electrocardiogram, serum potassium, serum magnesium, and kidney function. The primary outcome evaluated was the composite of these dofetilide monitoring parameters obtained in each cohort. In the standard cohort, 245 of 352 (69.6%) monitoring parameters were completed versus 134 of 136 (98.5%) in the intervention group ( P < 0.05). CONCLUSION: A collaborative pharmacy-cardiology AAD monitoring program was associated with a significant improvement in dofetilide monitoring. This improvement could potentially translate into enhanced patient safety outcomes, such as prevention of adverse drug reactions and decreased hospitalizations.

Postgraduate Education in Quality Improvement Methods: Initial Results of the Fellows' Applied Quality Training (FAQT) Curriculum.

OBJECTIVE: Training in quality improvement (QI) is a pillar of the next accreditation system of the Accreditation Committee on Graduate Medical Education and a growing expectation of physicians for maintenance of certification. Despite this, many postgraduate medical trainees are not receiving training in QI methods. We created the Fellows Applied Quality Training (FAQT) curriculum for cardiology fellows using both didactic and applied components with the goal of increasing confidence to participate in future QI projects. METHODS AND RESULTS: Fellows completed didactic training from the Institute for Healthcare Improvement's Open School and then designed and completed a project to improve quality of care or patient safety. Self-assessments were completed by the fellows before, during, and after the first year of the curriculum. The primary outcome for our curriculum was the median score reported by the fellows regarding their self-confidence to complete QI activities. Self-assessments were completed by 23 fellows. The majority of fellows (15 of 23, 65.2%) reported no prior formal QI training. Median score on baseline self-assessment was 3.0 (range, 1.85-4), which was significantly increased to 3.27 (range, 2.23-4; P = 0.004) on the final assessment. The distribution of scores reported by the fellows indicates that 30% were slightly confident at conducting QI activities on their own, which was reduced to 5% after completing the FAQT curriculum. An interim assessment was conducted after the fellows completed didactic training only; median scores were not different from the baseline (mean, 3.0; P = 0.51). CONCLUSION: After completion of the FAQT, cardiology fellows reported higher self-confidence to complete QI activities. The increase in self-confidence seemed to be limited to the applied component of the curriculum, with no significant change after the didactic component.