Endo-epicardial ablation vs endocardial ablation for the management of ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy: A systematic review and meta-analysis.

BACKGROUND: The pathologic process of ARVC (arrhythmogenic right ventricular cardiomyopathy) typically originates in the epicardium or subepicardial layers with progression toward endocardium. However, in the most recent ARVC international task force consensus statement, epicardial ventricular tachycardia (VT) ablation is recommended as a Class I indication only in patients with at least one failed endocardial VT ablation attempt. OBJECTIVE: The aim of this meta-analysis is to assess the outcomes of ARVC patients undergoing combined endo-epicardial VT ablation, as compared to endocardial ablation alone. METHODS: A systematic review of PubMed, Embase, and Cochrane was performed for studies reporting clinical outcomes of endo-epicardial VT ablation vs endocardial-only VT ablation in patients with ARVC. Fixed-Effect model was used if I2 < 25 and the Random-Effects Model was used if I2 ≥ 25%. RESULTS: Nine studies consisting of 452 patients were included (mean age 42.3 ± 5.7 years; 70% male). After a mean follow-up of 48.1 ± 21.5 months, endo-epicardial ablation was associated with 42% relative risk reduction in VA recurrence as opposed to endocardial ablation alone (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.45-0.75; P < .0001). No significant differences were noted between endo-epicardial and endocardial VT ablation groups in terms of all-cause mortality (RR, 1.19; 95% CI, 0.03-47.08; P = .93) and acute procedural complications (RR, 5.39; 95% CI, 0.60-48.74; P = .13). CONCLUSIONS: Our findings suggest that in patients with ARVC, endo-epicardial VT ablation is associated with a significant reduction in VA recurrence as opposed to endocardial ablation alone, without a significant difference in all-cause mortality or acute procedural complications.

Oral anticoagulation after catheter ablation of atrial fibrillation and the associated risk of thromboembolic events and intracranial hemorrhage: A systematic review and meta-analysis.

AIMS: We sought to examine whether continuing oral anticoagulation (OAC) after catheter ablation (CA) for atrial fibrillation (AF) is associated with improved outcomes. OAC reduces morbidity and mortality in patients with AF. However, the continuation of OAC following the blanking period of CA is controversial due to conflicting published data. METHODS: A systematic review of Medline, Cochrane, and Embase was performed for studies comparing patients who were continued on OAC (ON-OAC) vs those in which OAC was discontinued (OFF-OAC). CHA2 DS2 VASc score had to be available for the classification of patients into high- or low-risk cohorts (CHA2 DS2 VASc ≥ 2 and ≤ 1, respectively). The primary efficacy outcome was thromboembolic events (TE). Intracranial hemorrhage (ICH) was the primary safety outcome. RESULTS: Five studies comprising 3956 patients were included (mean age, 61.1 ± 2.9 years; 72.4% male, CHA2 DS2 VASc ≤ 1 50.1%; CHA2 DS2 VASc ≥ 2 49.9%). After a mean follow-up of 39.6 ± 11.7 months, OAC-continuation was associated with a significant decrease in risk of TE in the high-risk cohort (CHA2 DS2 VASc ≥ 2) (risk ratio [RR] 0.41, 95% confidence interval [CI] 0.21-0.82, P = .01) with a RR reduction of 59%. ICH was significantly higher in the ON-OAC group (RR, 5.78; 95% CI, 1.33-25.08; P = .02). No significant benefit was observed in the low-risk cohort ON-OAC after the blanking period. CONCLUSION: Continuation of OAC after CA of AF with CHA2 DS2 VASc ≥ 2 is associated with a significant decreased TE risk and a favorable net clinical benefit in spite of ICH being significantly increased in the ON-OAC group. Continued OAC offers no benefit with CHA2 DS2 VASC ≤ 1.

Safety of catheter ablation for atrial fibrillation in the octogenarian population.

INTRODUCTION: Catheter ablation (CA) has been shown to be an effective treatment for atrial fibrillation (AF). The complication rates and outcomes among octogenarians remain poorly studied. We aimed to compare trends, morbidity, and mortality associated with CA for AF among octogenarians versus those less than 80 years old. METHODS: Using weighted sampling from the National Inpatient Sample database, we identified patients with a primary diagnosis of AF and a primary procedure of CA (2004-2013). Our primary outcome was mortality. Secondary outcomes included incidence of major and minor complications. RESULTS: Among 86,119 patients who underwent CA for AF, 3,482 were 80 years old or older. Complications were significantly more frequent in octogenarians; [16.2% (564 of 3,482) versus 9.8% (8,092 of 82,637), P < 0.001]. Of note, there was no significant difference for the composite of major complications; [3.6% (124 of 3482) in octogenarians versus 2.8% (2286 of 82637), P = 0.20]. The total mortality rate was not significant in a multivariate regression analysis (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.35-2.64; P = .94). The presence of chronic renal failure (OR, 4.19; 95% CI, 2.75-6.36; P < 0.001), anemia (OR, 1.75; 95% CI, 1.03-2.97; P = .04), and chronic pulmonary disease (OR, 1.75; 95% CI, 1.11-2.62; P = .015) were predictors of major complications in octogenarians. CONCLUSION: Catheter ablation for AF in octogenarians does not confer a higher mortality risk than in those less than 80 years old. The procedure is associated with a higher rate of overall complications but there was no difference in terms of major complications or death. The presence of anemia, CKD or pulmonary disease were predictors of major complications in octogenarians.

Uninterrupted direct oral anticoagulants vs. uninterrupted vitamin K antagonists during catheter ablation of non-valvular atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials.

Aims: To assess the incremental benefit of uninterrupted direct oral anticoagulants (DOACs) vs. uninterrupted vitamin K antagonists (VKA) for catheter ablation (CA) of non-valvular atrial fibrillation (NVAF) on three primary outcomes: major bleeding, thrombo-embolic events, and minor bleeding. A secondary outcome was post-procedural silent cerebral infarction (SCI) as detected by brain magnetic resonance imaging. Methods and results: A systematic review of Medline, Cochrane, and Embase was done to find all randomized controlled trials (RCTs) in which uninterrupted DOACs were compared against uninterrupted VKA for CA of NVAF. A fixed-effect model was used, with the exception of the analysis regarding major bleeding events (I2 > 25), for which a random effects model was used. The benefit of uninterrupted DOACs over VKA was analysed from four RCTs that enrolled a total of 1716 patients (male: 71.2%) with NVAF. Of these, 1100 patients (64.1%) had paroxysmal atrial fibrillation. No significant benefit was seen in major bleeding events [risk ratio (RR) 0.54, 95% confidence interval (95% CI) 0.29-1.00; P = 0.05]. No significant differences were found in minor bleeding events (RR 1.11, 95% CI 0.82-1.52; P = 0.50), thrombo-embolic events (RR 0.74, 95% CI 0.26-2.11; P = 0.57), or post-procedural SCI (RR 1.06, 95% CI 0.74-1.53; P = 0.74). Conclusion: An uninterrupted DOACs strategy for CA of NVAF appears to be as safe as uninterrupted VKA without a significantly increased risk of minor or major bleeding events. There was a trend favouring DOACs in terms of major bleeding. Given their ease of use, fewer drug interactions and a similar security and effectiveness profile, DOACs should be considered first line therapy in patients undergoing CA for NVAF.

Effect of Hydroxychloroquine on QTc in Patients Diagnosed with COVID-19: A Systematic Review and Meta-Analysis.

BACKGROUND: Hydroxychloroquine or chloroquine with or without the concomitant use of azithromycin have been widely used to treat patients with SARS-CoV-2 infection, based on early in vitro studies, despite their potential to prolong the QTc interval of patients. OBJECTIVE: This is a systematic review and metanalysis designed to assess the effect of hydroxychloroquine with or without the addition of azithromycin on the QTc of hospitalized patients with COVID-19. MATERIALS AND METHODS: PubMed, Scopus, Cochrane and MedRxiv databases were reviewed. A random effect model meta-analysis was used, and I-square was used to assess the heterogeneity. The prespecified endpoints were ΔQTc, QTc prolongation > 500 ms and ΔQTc > 60 ms. RESULTS: A total of 18 studies and 7179 patients met the inclusion criteria and were included in this systematic review and meta-analysis. The use of hydroxychloroquine with or without the addition of azithromycin was associated with increased QTc when used as part of the management of patients with SARS-CoV-2 infection. The combination therapy with hydroxychloroquine plus azithromycin was also associated with statistically significant increases in QTc. Moreover, the use of hydroxychloroquine alone, azithromycin alone, or the combination of the two was associated with increased numbers of patients that developed QTc prolongation > 500 ms. CONCLUSION: This systematic review and metanalysis revealed that the use of hydroxychloroquine alone or in conjunction with azithromycin was linked to an increase in the QTc interval of hospitalized patients with SARS-CoV-2 infection that received these agents.

Imaging Integration to Localize and Protect the Left Coronary Artery in Patients Undergoing LAAEI.

OBJECTIVES: This study sought to determine the distance between the anterior wall of the left atrial appendage (LAA) ostium to the left main coronary artery (LMCA) and the left circumflex artery (LCx) in patients undergoing left atrial appendage electrical isolation (LAAEI). BACKGROUND: LAAEI improves outcomes in nonparoxysmal atrial fibrillation ablation. There is a potential risk of damaging the LMCA and the LCx during LAAEI. METHODS: Patients undergoing LAAEI during the period between January 1, 2017 and October 31, 2018, were included in this study. Patients underwent cardiac computed tomography prior to ablation. The position of the LAA was analyzed. The closest distances between the LMCA, its bifurcation, LCx, and the anterior wall of the LAA ostium were measured. Additionally, imaging integration was performed to localize these vessels and catheter ablation was performed at least 5 mm away. RESULTS: A total of 74 patients (mean age: 68 ± 9.5 years; male 54%) who underwent LAAEI were included. The mean distance from the anterior wall of the LAA ostium to the LMCA was 7.88 ± 2.8 mm, to the LMCA bifurcation was 9.24 ± 4.40 mm, and to the LCx was 10.03 ± 4.56 mm. The LCx artery was found along the LAA ostium in 98% of the cases, whereas the LMCA was found in only 48.6%. No coronary damage or vasospasm was observed after performing LAAEI. CONCLUSIONS: A detailed imaging integration with cardiac computed tomography, electroanatomic mapping, and CARTOSOUND reconstructions to accurately define the anatomical relationship between the LMCA and LCx and the anterior edge of the LAA ostium should be performed prior to delivering radiofrequency energy during LAAEI. When the distance on cardiac computed tomography between the LAA ostium and left coronary arteries is >10 mm, intraprocedural localization of these vessels may be not necessary.

Mapping and localization of the left phrenic nerve during left atrial appendage electrical isolation to avoid inadvertent injury in patients undergoing catheter ablation of atrial fibrillation.

BACKGROUND: A significant role of the left atrial appendage (LAA) in the genesis of atrial fibrillation (AF) has been described. Left atrial appendage electrical isolation (LAAEI) confers substantial long-term clinical benefits. Nevertheless, the left phrenic nerve (LPN) is in the vicinity of the LAA and can be injured during radiofrequency ablation at the ostial level. OBJECTIVE: The purpose of this study was to describe our experience mapping the LPN, its anatomic relationships to the LAA and alternative approaches to isolate this structure when the LPN is located at the LAA ostium. METHODS: Patients undergoing LAAEI for nonparoxysmal AF were included in this study. We attempted to localize the LPN with high-output pacing (20 mA/2 ms). Cases were classified into 4 groups (distal, middle, proximal segment and unmappable) based on the position of the LPN in electroanatomic mapping in the posterior wall of the LAA. RESULTS: A total of 66 cases were included in this study. The LPN was mapped in the distal segment in 27 cases (40.9%); in the middle segment in 22 (33.3%); and at the proximal segment/ostium in 3 (4.5%); the LPN was unmappable in 14 cases (21.2%). In the 3 patients in whom the LPN was at the ostial level or crossing the ostium, segmental LAAEI was attempted in 2, with successful LAAEI achieved in 1 case. There was no LPN injury. CONCLUSION: LPN mapping is feasible and should be routinely performed to prevent LPN injury during LAAEI.

Significant Benefit of Uninterrupted DOACs Versus VKA During Catheter Ablation of Atrial Fibrillation.

OBJECTIVES: This study assessed the incremental benefit of uninterrupted direct oral anticoagulants (DOACs) versus uninterrupted vitamin K antagonists (VKAs) for catheter ablation (CA) of nonvalvular atrial fibrillation (NVAF) on 3 primary outcomes: major bleeding events (MBEs), minor bleeding events, and thromboembolic events (TEs). The secondary outcome was post-procedural silent cerebral infarction (SCI) as detected by brain cardiac magnetic resonance. BACKGROUND: As a class, evidence of the benefits of DOACs versus VKAs during CA of AF is scant. METHODS: A systematic review of Medline, Cochrane, and Embase was done to find all randomized controlled trials in which uninterrupted DOACs were compared against uninterrupted VKAs for CA of NVAF. A fixed-effect model was used, except when I2 was ≥25, in which case, a random effects model was used. RESULTS: The benefit of uninterrupted DOACs over VKAs was analyzed from 6 randomized control trials that enrolled a total of 2,256 patients (male: 72.7%) with NVAF, finding significant benefit in MBEs (relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.20 to 0.99; p = 0.05). No significant differences were found in minor bleeding events (RR: 1.12; 95% CI: 0.87 to 1.43; p = 0.39), TEs (RR: 0.75; 95% CI: 0.26 to 2.14; p = 0.59), or post-procedural SCI (RR: 1.09; 95% CI: 0.80 to 1.49; p = 0.58). CONCLUSIONS: An uninterrupted DOACs strategy for CA of AF appears to be safer than uninterrupted VKAs with a decreased rate of major bleeding events. There are no significant differences among the other outcomes. DOACs should be offered as a first-line therapy to patients undergoing CA of AF, due to their lower risk of major bleeding events, ease of use, and fewer interactions.

Combined Endocardial-Epicardial Versus Endocardial Catheter Ablation Alone for Ventricular Tachycardia in Structural Heart Disease: A Systematic Review and Meta-Analysis.

OBJECTIVES: This study sought to determine whether combined endocardial-epicardial (endo-epi) ablation was superior to endocardial only ablation in patients with scar-related ventricular tachycardia (VT). BACKGROUND: Limited single-center studies suggest that combined endo-epi ablation strategy may be superior to endocardial ablation (endo) alone in patients with nonischemic cardiomyopathy (NICM) and arrhythmogenic right ventricular cardiomyopathy (ARVC), and ischemic cardiomyopathy (ICM). METHODS: A systematic review of Medline, Cochrane, and Embase databases was performed for studies that reported outcomes comparing endo-epi with endo VT ablation alone. RESULTS: Seventeen studies consisting of 975 patients were included (mean 56 ± 10 years of age; 79% male; NICM in 36.6%; ICM in 32.8%; and ARVC in 30.6%). After a mean follow-up of 27 ± 21 months, endo-epi ablation was associated with a 35% reduction in risk of VT recurrence compared with endocardial ablation alone (risk ratio [RR]: 0.65; 95% confidence interval [CI]: 0.55 to 0.78; p < 0.001). Sensitivity analysis showed lower risk of VT recurrence in ICM (RR: 0.43; 95% CI: 0.28 to 0.67; p = 0.0002) and ARVC (RR: 0.59; 95% CI: 0.43 to 0.82; p = 0.0002), with a nonsignificant trend in NICM (RR: 0.87; 95% CI: 0.70 to 1.08; p = 0.20). Endo-epi, compared with endo ablation, was associated with reduced all-cause mortality (RR: 0.56; 95% CI: 0.32 to 0.97; p = 0.04). Acute procedural complications were higher with the endo-epi approach (RR: 2.62; 95% CI: 0.91 to 7.52; p = 0.07). CONCLUSIONS: This meta-analysis suggests that a combined endo-epi ablation is associated with a lower risk of VT recurrence and subsequent mortality than endo only VT ablation in patients with scar-related VT. Procedural complications, however, are higher with the endo-epi approach.

Chlamydia trachomatis en mujeres en etapa reproductiva con actividad sexual / Chlamydia trachomatis in women in reproductive stage with sexual activity

Objetivo: Determinar la prevalencia de Chlamydia trachomatis y sus factores condicionantes en mujeres en etapa reproductiva con actividad sexual. Materiales y métodos: Después de ser instruidas acerca del estudio, las pacientes acordaron su participación voluntaria y brindaron la información para el llenado de la ficha de recolección de datos. Se estimó un mínimo de 90 pacientes a incluir en el estudio que fueron seleccionadas por un muestreo por conveniencia. Se extrajo una muestra sanguínea y se utilizó el método de ELISA para determinar la presencia de anticuerpos IgG anti-Ch. trachomatis. Resultados: Se evidenció una prevalencia de infección del 10%. La frecuencia de infección se asoció a ser soltera, al cambio de pareja y la ausencia de leucorrea inespecífica. La edad, el grado de instrucción y la procedencia no tuvieron significancia estadística. Conclusiones: Se debe descartar el diagnóstico presuntivo de infección por Ch. trachomatis. Asimismo, su detección debería ser incluida dentro de los análisis requeridos por los consultorios de ginecología para lograr un diagnóstico que permita un tratamiento oportuno. (AU)

Objective: To determine the prevalence of Chlamydia trachomatis and its conditioning factors in reproductive stage women with sexual activity. Materials and methods: After being instructed about the study, the patients agreed to their voluntary participation and provided the information for filling out the data collection form. We estimated a minimum of 90 patients to be included in the study who were selected by a convenience sampling. A blood sample was taken and the ELISA method was used to determine the presence of anti-Ch trachomatis IgG antibodies. Results: An infection prevalence of 10% was evidenced. The frequency of infection was associated with being single, changing partners and the absence of nonspecific leucorrhoea. The age, the level of education and the origin did not have statistical significance. Conclusions: The presumptive diagnosis of Ch. trachomatis infection should be ruled out. Likewise, its detection should be included in the analyzes required by the gynecology offices to achieve a diagnosis that allows timely treatment. (AU)