Surgical versus catheter ablation in atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Atrial fibrillation (AF) is the most common cardiac arrhythmia with a high stroke and mortality rate. The video-assisted thoracoscopic radiofrequency pulmonary vein ablation is a treatment option for patients who fail catheter ablation. Randomized data comparing surgical versus catheter ablation are limited. We performed a meta-analysis of randomized control trials to explore the outcome efficacy between surgical and catheter radiofrequency pulmonary vein ablation in patients with AF. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2020. Included studies were published randomized control trials that compared video-assisted thoracoscopic and catheter radiofrequency pulmonary vein ablation. Data from each study were combined using the fixed-effects, generic inverse variance method of DerSimonian, and Laird to calculate odds ratios and 95% confidence intervals. RESULTS: Six studies from November 2013 to 2020 were included in this meta-analysis involving 511 AF patients (79% paroxysmal) with 263 catheter ablation (mean age 56 ± 3 years) and 248 surgical ablations (mean age 52 ± 4 years). Catheter ablation was associated with increased atrial arrhythmias recurrence when compared to surgical ablation (pooled relative risk = 1.85, 95% confidence interval: 1.44-2.39, p < .001, I2 = 0.0%) but associated with less total major adverse events (pooled relative risk = 0.29, 95% confidence interval: 0.16-0.53, p < .001, I2 = 0.0%). In subgroup analysis, catheter ablation was associated with increased AF recurrence in refractory paroxysmal AF when compared to surgical ablation (pooled relative risk = 2.47, 95% confidence interval: 1.31-4.65, p = .005, I2 = 0.0%) but not in persistent AF (relative risk = 1.09, 95% confidence interval: 0.60-2.0, p = .773). CONCLUSION: Catheter ablation was associated with higher atrial arrhythmia recurrence when compared with surgical ablation. However, our study suggests that the benefit of surgical ablation in patients with persistent AF is unclear. More studies and alternative ablation strategies investigation in persistent AF are warranted.

Atypical atrial flutter: review of mechanisms, advances in mapping and ablation outcomes.

PURPOSE OF REVIEW: Atrial flutter (AFL) is the second most prevalent arrhythmia after atrial fibrillation (AF). It is a macro-reentrant tachycardia that is either cavotricuspid isthmus dependent (typical) or independent (atypical). This review aims at highlighting mechanism, diagnosis and treatment of atypical AFL and the recent developments in electroanatomic mapping. RECENT FINDINGS: Incidence of left AFL is at an exponential rise presently with increase in AF ablation rates. The mechanism of left AFL is most often peri-mitral, roof-dependent or within pulmonary veins in preablated, in contrast to posterior or anterior wall low voltage areas in ablation naïve patients. Linear lesions, compared to pulmonary vein isolation alone, have higher incidence of atypical right or left AFL. Catheter ablation for atypical AFL is associated with lower rates of thromboembolic events, transfusions, and length of stay compared to typical AFL. SUMMARY: Advances in mapping have allowed rapid simultaneous acquisition of automatically annotated points in the atria and identification of details of macro-reentrant circuits, including zones of conduction block, scar, and slow conduction.

Does the Age of Sudden Cardiac Death in Family Members Matter in Brugada Syndrome?

Background Brugada syndrome is an inherited cardiac channelopathy associated with major arrhythmic events (MAEs). The presence of a positive family history of sudden cardiac death (SCD) as a risk predictor of MAE remains controversial. We aimed to examine the association between family history of SCD and MAEs stratified by age of SCD with a systematic review and meta-analysis. Methods and Results We searched the databases of MEDLINE and EMBASE from January 1992 to January 2020. Data from each study were combined using the random-effects model. Fitted metaregression was performed to evaluate the association between the age of SCD in families and the risk of MAE. Twenty-two studies from 2004 to 2019 were included in this meta-analysis involving 3386 patients with Brugada syndrome. The overall family history of SCD was not associated with increased risk of MAE in Brugada syndrome (pooled odds ratio [OR], 1.11; 95% CI, 0.82-1.51; P=0.489, I2=45.0%). However, a history of SCD in family members of age younger than 40 years of age did increase the risk of MAE by ≈2-fold (pooled OR, 2.03; 95% CI, 1.11-3.73; P=0.022, I2=0.0%). When stratified by the age of cut point at 50, 45, 40, and 35 years old, a history of SCD in younger family member was significantly associated with a higher risk of MAE (pooled OR, 0.49, 1.30, 1.51, and 2.97, respectively; P=0.046). Conclusions A history of SCD among family members of age younger than 40 years was associated with a higher risk of MAE.

A case of irreversible bradycardia after rituximab therapy for diffuse large B-cell lymphoma.

This is a case of a middle-aged woman with underlying cardiac conduction system with episodes of AV Wenckebach, who subsequently developed significant AV conduction system abnormalities after receiving one standard dose of Rituximab infusion for diffuse large B-cell lymphoma. Rituximab, being a monoclonal antibody against CD-20 antigen, is effective in treatment of B-cell lymphoma but may also cause bradyarrythmias likely due to the calcium ion channel property of CD-20 antigen.

"Acing" the Hidden Spade: Review of Diagnosis, Follow-up, Prognosis, and Various Associations of Apical Variant Hypertrophic Cardiomyopathy.

Apical variant hypertrophic cardiomyopathy (AHCM) is a known entity since its first introduction by Sakamoto and Yamaguchi. However, unlike classical hypertrophic cardiomyopathy (HCM), it is less explored in terms of its associated diagnosis and long-term outcomes. Through this case presentation, we aim to have an in-depth review to help physicians identify and better understand several aspects of AHCM. Given the increased availability and utilization of high precision cardiac imaging modalities, apical septal hypertrophic cardiomyopathy will increasingly be recognized as a distinct, clinically significant variant of classical HCM. Contrast echocardiogram is the most effective and diagnostic study when performed in the right setting with high suspicion on clinical examination findings and typical electrocardiogram (EKG) findings. Cardiac magnetic resonance imaging (MRI) has equal diagnostic yield as a contrast echocardiogram. It is associated with a wide spectrum of presentation ranging from asymptomatic course with incidental findings on imaging to rarely being associated with ventricular arrhythmia. The question of utility of implantable defibrillators in individuals, particularly without any underlying arrhythmias, remains unexplained and needs further evidence-based guidance.

Ineffective Antibiotic Prophylaxis: An Unusual Presentation of Infective Endocarditis with Insights into the Appropriateness of Prophylaxis.

The practice of antibiotic prophylaxis for the prevention of infective endocarditis (IE) has undergone a major paradigm shift over the past few decades. From the earlier practice of antibiotic prophylaxis for all patients undergoing dental procedures, since 2006, the American College of Cardiology/American Heart Association (ACC/AHA) guidelines have now narrowed down the indications to use it only in patients at high risk for IE. A true concern for antibiotic resistance remains eminent when used without appropriate indications. Through this case presentation of IE and the associated preceding use of antibiotics, we take this opportunity to explain the appropriateness of prophylaxis in patients from different risk groups. We also shed some light on alternative, effective, and, yet, harmless measures for the prevention of IE in patients at low risk.

Hypoglycemia-associated In-stent Thrombosis: Are We Doing Too Much?

Diabetes mellitus is one of the most common modifiable risk factors for coronary artery disease, and its prevalence is rising globally. Persistent hyperglycemia has a well-established cardiovascular risk, and its treatment plays an important role in the prevention of future cardiovascular events. While we improved microvascular complications such as retinopathy, nephropathy, and neuropathy by stringent blood glucose control, the cardiovascular morbidity and mortality in diabetics remain high. Hypoglycemia, on the other hand, is an important side effect of pharmaceutical blood glucose control, especially those who are treated with insulin. Here, we report the case of a 38-year-old man with type 1 diabetes presenting twice with acute ST-elevation myocardial infarction, both in the setting of documented hypoglycemia. There are reported cases of acute cardiovascular events or silent myocardial ischemia associated with hypoglycemia, and we wish to raise awareness for clinicians who treat this special population of patients.

Pulmonary Embolism Secondary to Testosterone-Enhancing Herbal Supplement Use.

Decreased testosterone levels in men are often a normal sign of aging. Testosterone replacement therapy (TRT) is a well-established option for those with symptomatic hypogonadism related to low testosterone levels. Conversely, designer herbal supplements in the context of testosterone supplementation are poorly studied, yet remain popular among aging men who seek the well-known, often enhancing, effects of testosterone that involve muscle mass and sexual function/drive. In 2014, the Food and Drug Administration (FDA) issued a warning about the significant risk of venous clots secondary to testosterone product use. Testosterone-induced polycythemia is one of the proposed mechanisms for this increased clotting propensity. Increased thromboxane A2 receptor density on platelets and increased platelet aggregation have also been linked to testosterone treatment in men. Fenugreek extract is a common active ingredient in commercially available herbal supplements that are often marketed as testosterone enhancers. It is thought that certain fenugreek compounds inhibit aromatase and 5-alpha-reductase activity, leading to diminished testosterone breakdown. However, the efficacy and safety profile of this agent in its use for boosting testosterone levels are unclear. In this case report, we present a patient with new-onset, bilateral pulmonary embolism possibly associated with the daily use of fenugreek-containing testosterone supplements.