Improved survival in patients with atrial fibrillation and heart failure undergoing catheter ablation compared to medical treatment: A systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy. METHODS AND RESULTS: A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all-cause mortality. Secondary endpoints included atrial-arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF). Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow-up duration was 32.9 ± 14.5 months. All-cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95% confidence interval [CI] 0.51-0.83, p = .0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all-cause mortality was observed with CA. Rates of all-atrial arrhythmia recurrence were significantly lower in the CA group (39.9% vs. 69.6%, RR: 0.55, 95% CI: 0.40-0.76, p = .0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ± 7.6%) as compared to conventional treatment (+3.3 ± 8%) (mean difference 6.2, 95% CI: 3.6-8.8, p < .00001). CONCLUSION: CA for AF in patients with HF decreases all-cause mortality, improves all-atrial arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients. Nonetheless, the benefit of CA in patients with severely reduced ejection fraction and New York Heart Association class IV HF has not been clearly elucidated.

Focal impulse and rotor modulation guided ablation versus pulmonary vein isolation for atrial fibrillation: A meta-analysis of head-to-head comparative studies.

INTRODUCTION: Empirical pulmonary vein isolation (PVI) remains the cornerstone for catheter ablation of atrial fibrillation (AF). Various ablation strategies and modalities are continually tested with the aim of improving ablation outcomes. Although focal impulse and rotor modulation (FIRM)-guided ablation is currently used as an adjunct to PVI, evidence supporting this strategy is conflicting. We sought to examine whether the utilization of FIRM-guided ablation with or without PVI is associated with a decrease in all-atrial arrhythmia recurrence as compared to PVI alone. METHODS: A systematic review of PubMed, Cochrane, and Embase was performed for head-to-head study designs comparing outcomes of patients who underwent FIRM-guided ablation with or without PVI to those who underwent PVI alone. The primary efficacy endpoint was all-atrial arrhythmia recurrence. The secondary endpoints were complications rates and procedural characteristics. RESULTS: Overall, six studies comprising 674 patients undergoing either FIRM-guided ablation ± PVI versus PVI were included (mean age 63.4 ± 9.2, male 74%, 9% paroxysmal AF, 91% nonparoxysmal AF). After a mean follow-up of 18.8 months, FIRM-guided ablation with or without PVI was not associated with improvement in all-atrial arrhythmia recurrence rate compared to PVI alone (43.4% vs. 45.9%, risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.77-1.47; p = .70). No statistically significant difference was noted in complication rates between the two groups (RR: 1.66; 95% CI: 0.08-34.54; p = .74). CONCLUSION: In this meta-analysis of head-to-head comparison studies, FIRM-guided ablation with or without PVI did not provide any benefit in improving all-atrial arrhythmia recurrence at follow-up when compared to PVI alone.

Efficacy and safety of left atrial appendage electrical isolation during catheter ablation of atrial fibrillation: an updated meta-analysis.

AIMS: Left atrial appendage electrical isolation (LAAEI) has been shown to improve freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal atrial fibrillation (AF). The aim of this study is to investigate the long-term efficacy and safety outcomes of LAAEI in patients with non-paroxysmal AF undergoing catheter ablation. METHODS AND RESULTS: A systematic review of Medline, Cochrane, and Embase was performed for clinical studies evaluating the benefit of LAAEI in non-paroxysmal AF. Nine studies with a total of 2336 patients were included (mean age: 65 ± 9 years, 63% male). All studies included patients with persistent AF, long-standing persistent AF, or both. At a mean follow-up of 40.5 months, patients who underwent LAAEI had significantly higher freedom from all-atrial arrhythmia recurrence than patients who underwent standard ablation alone [69.3% vs. 46.4%; risk ratio (RR) 0.54; 95% confidence interval (CI) 0.42-0.69; P < 0.0001]. A 46% relative risk reduction and 22.9% absolute risk reduction in atrial-arrhythmia recurrence was noted with LAAEI. Rates of cerebral thromboembolism were not significantly different between the two groups (LAAEI 3% vs. standard ablation 1.6%, respectively; RR 1.76; 95% CI 0.61-5.04; P = 0.29). Furthermore, there was no significant difference in the acute procedural complication rates between the two groups (LAAEI 4% vs. standard ablation 3%, respectively; RR 1.29; 95% CI 0.83-2.02; P = 0.26). CONCLUSION: At long-term follow-up, LAAEI led to a significantly higher improvement in freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal AF, when compared to standard ablation alone. Importantly, this benefit was achieved without an increased risk of acute procedural complications or cerebral thromboembolic events.

Cavotricuspid isthmus line in patients undergoing catheter ablation of atrial fibrillation with or without history of typical atrial flutter: A meta-analysis.

BACKGROUND: Pulmonary vein isolation (PVI) is the mainstay of catheter ablation (CA) for paroxysmal atrial fibrillation (AF). However, for persistent and long-standing persistent AF, there are no established strategies to improve the success rate of CA. Despite studies indicating that prophylactic cavotricuspid isthmus (CTI) ablation provides no or limited incremental benefit in patients with AF, it is still routinely performed worldwide. OBJECTIVE: We sought to examine whether CTI ablation for AF is associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone in patients with and without typical atrial flutter (AFL). METHODS: A systematic review of PubMed, Cochrane, and Embase was performed for clinical studies including AF patients, reporting outcomes of CTI + PVI versus PVI alone. The primary efficacy endpoint was recurrence of all-atrial arrhythmias. RESULTS: Five studies comprising 1400 patients undergoing CTI + PVI versus PVI alone were included; 1110 patients had AF without AFL, and 290 patients had coexistent AF and AFL. After a mean follow-up of 14.4 ± 4.8 months, CTI + PVI was not associated with improvement in recurrence of all-atrial arrhythmias when compared with PVI alone (risk ratio [RR]: 1.29; 95% confidence interval [CI]: 0.93-1.79;p = .13). In the subgroup analysis, there were no differences between both groups in patients with AF without AFL (RR: 1.55; 95% CI: 0.96-2.48; p = .07), and in patients with AF and AFL (RR: 0.91; 95% CI: 0.6-1.39; p = .68). CONCLUSION: In AF patients, irrespective of the presence of typical AFL, additional CTI ablation is not associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone.

Incidental Discovery of Klippel-Feil Syndrome: Beyond the Expected Clinical Triad.

Klippel-Feil syndrome (KFS) is a rare congenital disorder characterized by the fusion of cervical vertebrae, limiting neck mobility, and often presenting with clinical manifestations such as neck pain, stiffness, and neurological deficits. While the classical presentation of KFS includes a "clinical triad" comprising a shortened neck, a low posterior hairline, and limited cervical motion, not all patients exhibit all three features. This case report presents an 81-year-old male with the complete KFS triad and underscores the diagnostic challenges and management strategies associated with this condition. Despite the rarity of KFS, understanding it is crucial for clinicians due to its profound implications on patient management and quality of life. This case emphasizes the importance of clinical suspicion in Internal Medicine, showcasing how an isolated presentation may often be a manifestation of an underlying congenital condition.

Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation.

BACKGROUND: Subcutaneous implantable cardioverter-defibrillator (S-ICD) is an effective alternative to transvenous implantable cardioverter-defibrillator. General anesthesia (GA) is considered the standard sedation approach because of the pain caused by the manipulation of subcutaneous tissue with S-ICD implantation. However, GA carries several limitations, including additional risk of adverse events, prolonged in-room times, and increased costs. OBJECTIVE: The purpose of this study was to define the effectiveness and safety of tumescent local anesthesia (TLA) in comparison to GA in patients undergoing S-ICD implantation. METHODS: We performed a prospective, nonrandomized, controlled, multicenter study of patients referred for S-ICD implantation between 2019 and 2020. Patients were allocated to either TLA or GA on the basis of patient's preferences and/or anesthesia service availability. TLA was prepared using lidocaine, epinephrine, sodium bicarbonate, and sodium chloride. All patients provided written informed consent, and the institutional review board at each site provided approval for the study. RESULTS: Sixty patients underwent successful S-ICD implantation from July 2019 to November 2020. Thirty patients (50%) received TLA, and the rest GA. There were no differences between groups with regard to baseline characteristics. In-room and procedural times were significantly shorter with TLA (107.6 minutes vs 186 minutes; P < .0001 and 53.2 minutes vs 153.7 minutes; P < .0001, respectively). Pain was reported less frequently by patients who received TLA. The use of opioids was significantly reduced in patients who received TLA (23% vs 62%; P = .002). CONCLUSION: TLA is an effective and safe alternative to GA in S-ICD implantation. The use of TLA is associated with shorter in-room and procedural times, less postprocedural pain, and reduced usage of opioids and acetaminophen for analgesia.

Comparison Between Anatomical and Functional Imaging Modalities for Evaluation of Chest Pain in the Emergency Department.

Evaluation of chest pain in the emergency department (ED) frequently employs a noninvasive strategy, including coronary computed tomography angiography (CCTA), stress echocardiography (SE), or myocardial perfusion imaging (MPI). We sought to report the real-world experience of utilizing CCTA compared with SE and MPI at an urban hospital ED. We conducted a retrospective cohort study of consecutively enrolled patients presenting with chest pain who had normal or nondiagnostic electrocardiogram (ECG), negative initial troponin-T, at least intermediate risk based on modified Diamond-Forrester criteria, and who underwent CCTA, SE, or MPI based on their individual test eligibility criteria. The primary outcome was ED discharge time. Secondary outcomes included test utilization and 30-days rehospitalization rates. The 2,143 patients who were included (mean age was 56 ± 12 years; 55% women) utilization rate (test performed/eligible) was lower for CCTA (n = 354/1,329) and MPI (n = 530/1,435) compared with SE (n = 1,259/1,650), p <0.001. Mean ED discharge times for both CCTA and SE were 12.5 ± 7.4 versus 16 ± 7.3 hours for MPI (p <0.0001). Patients with SE and CCTA were less likely to undergo coronary angiography (29%, 25%, vs 52% for MPI). There was a 1% cardiac-related 30-days rehospitalization rate in the CCTA group versus 1% in SE and 3% in the MPI group (p <0.01). In conclusion, CCTA and SE were associated with faster ED discharge and lower frequency of diagnostic coronary angiography. Notwithstanding its clinical utility, CCTA was underutilized at our large urban ED setting.

T-wave inversion as a manifestation of COVID-19 infection: a case series.

PURPOSE: Cardiac involvement with COVID-19 infection has become evident by elevated troponin, cardiac arrhythmias, ST segment elevation, myocarditis, fulminant heart failure, and sudden cardiac death. We aimed to describe the association of COVID-19 and T-wave inversion (TWI) in a large case series. METHODS: We conducted an observational, retrospective study of confirmed COVID-19 cases with at least one electrocardiogram (ECG) in a large hospital in New York City (March 23, 2020-April 23, 2020). Patients with new TWI or pseudonormalization were further analyzed. Mortality and the need for invasive mechanical ventilation were the main outcomes. RESULTS: A total of 3225 patients were screened; 195 (6%) were selected for further analysis: 181 with TWI and 14 with T-wave pseudonormalization. Mean age was 66 ± 7 years; 51% were male. TWI were more commonly noted in the lateral (71%), followed by anterior (64%), inferior (57%), and septal (26%) leads. A total of 44 patients (23%) had elevated troponin. A total of 50 patients died (26%). Mortality rates of 35%, and 52% were observed in patients with diffuse TWI, and elevated troponin, respectively. Mortality rate of 80% was observed in patients with both elevated troponin and diffuse TWI. Additionally, 30% of the entire cohort and 58% of patients with elevated troponin required invasive mechanical ventilation. CONCLUSION: Our study demonstrates that new TWI is a relatively common finding in COVID-19 patients. Importantly, our findings suggest that new TWI or T-wave pseudonormalization, particularly with elevated troponin, was associated with higher rates of mechanical ventilation and in-hospital mortality.