A strategy of rapid cardioversion minimizes the significance of early recurrent atrial tachyarrhythmias after ablation for atrial fibrillation.

BACKGROUND: The significance of early recurrent atrial tachyarrhythmias after atrial fibrillation (AF) ablation is unclear. Atrial remodeling driven by these tachyarrhythmias can result in electrical, contractile, and structural changes that may impair long-term therapy success. Aggressive attempts to restore sinus rhythm in the temporal period of healing after ablation might improve outcomes. METHODS: A total of 1,759 AF ablations were performed at Intermountain Medical Center or LDS Hospital. A total of 455 of those were among patients requiring repeat ablations. Patients were instructed to take their pulse daily and, if greater than 100 bpm or irregular, present the following business day fasting to the clinic for evaluation and cardioversion if AF or atrial flutter (AFL) were present. RESULTS: Of the ablations performed, a total of 515 (29%, age: 65.6 ± 11.2 years, male: 57.9%) developed AF/AFL that required cardioverison. The majority of these arrhythmias first occurred in the initial 90 days (63.7%) postablation. During this period, 62.8% were on an antiarrhythmic drug (AAD). Only 25.1% were using an AAD at 3 months. The majority of ablations (75.6%) who experienced AF/AFL within the first 90 days after ablation were in sinus rhythm with no AAD at 1 year. Further, 48% of those with the first recurrence from 90 to 180 days were in sinus rhythm with no AAD at 1 year. CONCLUSIONS: The time at which the first recurrence of AF/AFL occurs impacts long-term outcomes. An aggressive strategy of rapid cardioversion postablation reduces the significance of recurrent AF/AFL during the first 6 months.

The prevalence and cost of the faint and fall problem in the state of Utah.

BACKGROUND: Understanding the frequency and economic impact of faint and fall is a prerequisite for the creation of cost-effective diagnostic approaches. METHODS: We evaluated the total number of patients presenting with faint or fall to the University of Utah Health Care System between November 1, 2008, and October 31, 2009. Using these data, we estimated the prevalence and total cost of the faint and fall problem in the state of Utah. RESULTS: A total of 1,936 and 6,043 patients presented with faint and fall resulting in a total number of visits equal to 2,701 and 8,163, respectively. The yearly prevalence of faints was 9.5 patients (13.2 visits) per 1,000 inhabitants and the yearly prevalence of falls was 29.8 patients (40.2 visits) per 1,000 inhabitants. The prevalence of faints and falls progressively increased with age, reaching the values of 40 and 115 per 1,000 inhabitants in subjects aged >80 years. In both patient populations, two-thirds of visits were outpatient evaluations. While the cardiovascular service was involved in the outpatient evaluation of faint visits in 24% of the cases, <1% of outpatient fall visits resulted in a cardiovascular consultation. The average payments received per faint and fall patient evaluations were $2,517 and $3,200, respectively, resulting in an estimated yearly cost equal to $90,901,958 and $351,959,040, respectively. CONCLUSION: This study highlights the magnitude of the faint and fall problem in the state of Utah. Our results provide all stakeholders with a frame of reference for the creation of cost-effective diagnostic approaches.

Evaluation of patients with "faint" in an American teaching hospital: a dire need for a standardized approach.

BACKGROUND: Fainting is a major healthcare problem with significant morbidity, mortality, and healthcare cost. We sought to assess the appropriateness of current clinical practice when compared to a guideline-based algorithm. METHODS: The records of 100 consecutive patients who presented with faint and were referred to the University of Utah for further evaluation by specialists were reviewed. We analyzed the clinical characteristics, tests performed, diagnosis made, and number of admissions. In addition, we applied a guideline-based algorithm to assess the appropriateness of these evaluations. RESULTS: The mean age was 49 ± 21 years with 57% being female. One-third presented with their first event. Structural heart disease was present in 22% of the cases. Twelve (36%) of 32 admissions were inappropriate. There was an underutilization of orthostatic testing, carotid sinus massage, and implantable loop recorder and overutilization of imaging studies and neurologic consultation. Specifically, active standing and tilt-table testing were performed in only 24% and 7% of the cases, respectively, none of the patients had carotid sinus massage despite 26% of them being ≥65 years old, and only 3% of the patients received an implantable loop recorder. With the current practice, a final diagnosis was made in 45 cases with 17 (38%) of the 45 final diagnoses not being sufficiently supported by the completeness of the evaluation. CONCLUSION: With the current practice at a major university hospital, the cause of faint was unexplained in a high number of cases. Our findings highlight the need for a standardized approach to patients presenting with faint.

Transcatheter Aortic Valve Replacement in Dextrocardia With Situs Inversus.

Transcatheter aortic valve replacement is a validated therapeutic option for severe symptomatic aortic stenosis. Dextrocardia with total situs inversus is a rare heart condition (1 in 12,000). We present an interesting case of transcatheter aortic valve replacement with a CoreValve Evolut R (Medtronic, Minneapolis, Minnesota) through a transfemoral approach in a patient with dextrocardia and situs inversus. (Level of Difficulty: Intermediate.).

High prevalence of right ventricular dysfunction in ICD patients with shocks: a potential new predictor in risk stratification.

BACKGROUND: Despite identifying several risk factors for sudden cardiac death, our ability to predict arrhythmic events in patients with an implantable cardioverter defibrillator (ICD) remains poor. The purpose of this study was to determine if patients who received appropriate ICD shocks had a higher degree of right ventricular (RV) dysfunction at baseline when compared to patients who did not receive ICD shocks. METHODS: We conducted a 1:2 case-control, retrospective study comparing RV end-diastolic and end-systolic areas (RV ED and RV ES areas, respectively), fractional RV area change, and RV wall thickness in 19 consecutive patients who received appropriate ICD shocks (shock group) with another group of 38 patients who did not receive ICD shocks (no-shock group). RESULTS: There was no significant difference in the RV end-diastolic areas between the groups. However, patients who experienced ICD shocks had a higher RV end-systolic area and a lower RV fractional area change when compared to patients without ICD shocks, 16.3 ± 4.9 cm(2) and 27.7 ± 9.0% in the shock group versus 14.2 ± 4.4 cm(2) and 35.8 ± 10.3% in the no-shock group; (p = 0.08 and 0.004, respectively). Furthermore, the RV wall thickness was greater in patients with ICD shocks when compared to patients without ICD shocks, 0.49 ± 0.05 cm and 0.44 ± 0.04 cm, respectively (p = 0.001). Utilizing a logistic regression analysis and after controlling for variables with univariate significance (p < 0.1), RV wall thickness independently predicted ICD shocks (OR 13.9 mm(-1) change of RV thickness, p = 0.004). CONCLUSION: Our findings suggest that some measurements of RV function might prove to be useful in predicting future arrhythmic events. Additional prospective studies are needed to test this hypothesis.

Underevaluation of cardiovascular risk factors in patients with nonaccidental falls.

BACKGROUND: The incidence of adult patients with falls seeking medical assistance in the Salt Lake City area, Utah, is 28,000 per million adult inhabitants. OBJECTIVE: We sought to evaluate the prevalence of cardiovascular risk assessment and cardiovascular abnormalities in patients presenting with nonaccidental falls at the University of Utah hospital and its affiliated clinics. METHODS: We conducted a search of all patients in the University of Utah patient database as well as 9 affiliated primary care and family practice clinics in Utah who were evaluated for a "fall" during October 2009. We analyzed the records of 338 patients who had a fall within the previous 3 months. Nonaccidental falls were defined as falls unrelated to a contact incident or "slip or trip." RESULTS: Nonaccidental falls occurred in 81 (24%) patients, 39 of these being ≥65 years old. Cardiovascular risk assessment and specifically orthostatic testing were evaluated in 40% and 3% of the patients, respectively. In patients ≥65 years old, the prevalence of cardiovascular risk assessment, orthostatic testing, and carotid sinus massage were equally low at 56%, 5%, and 0%, respectively. Cardiovascular abnormalities were present in 17 (21%) patients, with 9 of them being referred for cardiac evaluation. CONCLUSION: Our results highlight the inconsistent assessment of potential cardiovascular risk factors in patients with nonaccidental falls, supporting the adoption of a standardized approach in these patients.

Atrial Fibrillation in Hypertrophic Obstructive Cardiomyopathy - Antiarrhythmics, Ablation and More!

Hypertrophic cardiomyopathy (HCM) is a genetic disease of the cardiac sarcomere with an autosomal dominant pattern of inheritance. Patients with HCM are at high risk of developing atrial fibrillation (AF) particularly in the setting of advanced diastolic dysfunction and left atrial enlargement. AF is a marker of increased mortality and morbidity and results in a significant reduction in quality of life. Antiarrhythmic medications improve symptoms and reduce AF recurrence, but few are safe and there exists little data to guide their long-term use in HCM. Non-pharmacologic approaches have emerged and have equal or greater efficacy than pharmacologic approaches. Although these approaches are promising, the long-term impact on atrial function needs to be carefully studied as it may impact quality of life in patients that age in the setting of a progressive diastolic disease disorder. Nonetheless, with the significant impact of AF in HCM, rhythm control strategies are often required. The understanding of rhythm control strategies in HCM, an often rapidly progressive diastolic dysfunction disorder, may provide insight in how to treat the much more prevalent AF patient with hypertensive cardiomyopathy. Regardless of treatment strategy (rhythm or rate control) patients are a moderate to high risk of thromboembolism and until data are available to suggest otherwise require long-term warfarin anticoagulation.