Atrial Fibrillation Complicating Acute Myocardial Infarction: Prevalence, Impact, and Management Considerations.

PURPOSE OF REVIEW: Atrial fibrillation (AF) and myocardial infarction (MI) often coexist, and this overlapping nature leads to heightened morbidity and increases the need for comprehensive risk management strategies. The precise trajectory and implications of atrial fibrillation complicating myocardial infarction remain subjects of debate, with divergent reports presenting varying accounts. This review seeks to provide an in-depth exploration of the existing literature to cover the predictors, implication, and available management of new onset atrial fibrillation (NOAF) complicating acute myocardial infarction (AMI). RECENT FINDINGS: Clinical risk factors, laboratory markers, echocardiographic findings, and angiographic data can be used to assess patients at risk of developing NOAF post-AMI. The diagnosis of NOAF post MI has been associated with overall worse short- and long-term prognosis with increased risk for mortality, cardiogenic shock, stroke, and bleeding, along with reduced rates of coronary angiography and percutaneous coronary intervention, and higher risk of future recurrence of AF and ischemic stroke. Despite the paucity of preventative treatment, the optimal management of acute coronary syndrome and the use of guideline directed therapy do decrease the risk of development of atrial fibrillation post myocardial infarction.

Proposal of high-risk adenoma detection rate as an impactful, complementary quality indicator of colonoscopy.

BACKGROUND AND AIMS: Adenoma detection rate (ADR), a validated quality indicator (QI) of colonoscopy, does not take into account risk stratification of adenomas. Low-risk adenomas are not associated with a significantly increased risk of future colorectal cancer (CRC). On the other hand, high-risk adenomas (HRA) are associated with up to six fold higher risk of future CRC. Therefore, HRA detection rate (HR-ADR) as a QI in addition to ADR may further enhance the efficacy of screening colonoscopy. Our aim was to calculate ADR and HR-ADR in a large cohort of average risk screening colonoscopy patients and propose HR-ADR which correlates with current threshold ADR. METHODS: This is a retrospective chart review of all colonoscopies performed in patients aged ≥ 50 years at our institution between 2012 and 2014. Average risk patients who had complete colonoscopy with good, excellent and adequate bowel preparation were included. Overall and gender-specific ADR and HR-ADR were calculated. HR-ADR was defined as proportion of colonoscopies with HRA. RESULTS: Among 4158 colonoscopies included, ADR was 26.4 ± 10.9% overall, 32.7 ± 14.5% in men, and 22.1 ± 12.6% in women. HR-ADR was 8.0 ± 5.7% overall, 10.2 ± 8.6% in men, and 6.1 ± 6% in women. There was only moderate correlation between ADR and HR-ADR [r = 0.57 (0.40-0.70)]. HR-ADR corresponding with minimum threshold ADR of 30% in men and 20% in women were calculated to be 7% in men and 4% in women. CONCLUSIONS: HR-ADR correlates only moderately with ADR. Based on the current threshold ADRs, we propose a benchmark HR-ADR of 7% in men and 4% in women as complementary QI to ADR.

Epidemiology of fatal ruptured aortic aneurysms in the United States (1999-2016).

OBJECTIVE: Ruptured aortic aneurysms (rAAs) are associated with high mortality. The purpose of this study was to describe the trends of deaths due to rAA in the United States. METHODS: A retrospective review of the national death certificate data from the U.S. National Vital Statistics System was done to identify deaths due to rAAs in the United States between 1999 and 2016. Patients aged 15 years or older with rAA as the underlying cause of death as defined by International Classification of Diseases, Tenth Revision codes I71.1 (ruptured thoracic aortic aneurysm [rTAA]), I71.3 (ruptured abdominal aortic aneurysm [rAAA]), I71.5 (ruptured thoracoabdominal aortic aneurysm), and I71.8 (rAA of unspecified site) were included and standardized to U.S. Census data. RESULTS: A total of 104,458 deaths due to rAAs occurred during the study period. The overall age-adjusted incidence of fatal rAA was 23.3 per 1 million (rAAA, 15.1; rTAA, 3.1; thoracoabdominal, 0.4; and unspecified site, 4.8). The annual incidence of rAA decreased by 68% from 40.0 (1999) to 12.8 (2016) per 1 million (rTAA by -67% from 5.5 to 1.8 and rAAA by -70% from 26.3 to 7.89 per 1 million; P < .001 for all comparisons). These trends were consistent across age groups, sexes, and races. There was a significant seasonal variation in rAA mortality, with higher deaths in winter months compared with summer months. The incidence of rAA is highest in Midwest states (27.1 per 1 million), followed by Northeast (23.8 per 1 million) and West (14 per 1 million) states, and lowest in Southern states (13.6 per 1 million). Only 57% of rAAA deaths occurred in men ≥65 years. CONCLUSIONS: The incidence of fatal rAA, rTAA, and rAAA drastically decreased in the United States between 1999 and 2016, a trend that was consistent across age groups, sexes, and races. A significant percentage of fatal rAAAs occurred in patients who are not eligible for the current screening program.

Safety and feasibility of pulmonary vein isolation utilizing pulsed field ablation in patients with symptomatic atrial fibrillation and implanted Watchman devices.

BACKGROUND: Pulsed field ablation (PFA) is a novel method of non-thermal cardiac ablation for atrial fibrillation (AF). Its use on patients with pre-existing Watchman devices has not been studied. METHODS: Pulmonary vein isolation (PVI) utilizing PFA was performed in 7 patients with symptomatic AF and implanted Watchman devices. All cases were conducted at a single academic center. RESULTS: Successful PVI in patients with Watchman devices implanted at a median time of 534 days prior to the index ablation procedure (IQR 365 days) was achieved in all cases. No major adverse events (intraprocedural CVA, post-procedural CVA, major or minor bleeding events, device embolization, or cardiac tamponade) were observed. In 6 of 7 patients, a low-dose direct oral anticoagulant (DOAC) strategy was implemented post-PFA. CONCLUSION: We present the first reported case series of PFA in patients with AF and implanted Watchman devices. This study highlights the safety and feasibility of the FARAPULSE PFA system in this patient population.

Hospital outcomes of patients receiving catheter ablation of atrial fibrillation, left atrial appendage closure, or both.

BACKGROUND: Catheter ablation (CA) and left atrial appendage closure (LAAC) require transseptal access; combining both in a single procedure may have advantages. However, the safety of this approach has not been extensively studied. The objective of this study was to compare in hospital outcomes among patients receiving CA, LAAC, and combination of both treatments on the same day. METHODS: We conducted a retrospective cohort analysis of the National Inpatient Sample database. The primary outcome was the presence of major adverse cardiovascular and cerebrovascular events (MACCE) during index hospitalization. Secondary outcomes included stroke, pericardial effusion, pericardiocentesis, and bleeding. RESULTS: A total of 69,285 hospitalizations with AF were included in the analysis, of which 71.7% received LAAC, 27.8% received CA, and 0.5% received combination of both treatments on the same day. MACEE (OR, 1.63; 95% CI, 0.39-6.70), stroke (OR, 2.98; 95% CI, 0.55-16.01), pericardial effusion (OR, 0.33; 95% CI, 0.07-1.41), pericardiocentesis (OR, 1.00; 95% CI, 0.25-3.86), and bleeding (OR, 3.25; 95% CI, 0.87-12.07) did not differ significantly between CA and combination treatment. Similarly, MACCE (OR, 1.11; 95% CI, 0.28-4.41), stroke (OR, 1.03; 95% CI, 0.24-4.35), pericardial effusion (OR, 0.45; 95% CI, 0.11-1.90), pericardiocentesis (OR, 0.63; 95% CI, 0.14-2.83), and bleeding (OR, 2.04; 95% CI, 0.65-6.39) did not differ significantly between LAAC and combination treatment. CONCLUSIONS: The combined approach is infrequently used in clinical practice (< 1%). However, major life-threatening adverse events did not differ between CA and LAAC when performed in isolation or combined in a single procedural stage on the same day.

Transcatheter Closure of Persistent Left Superior Vena Cava Draining to Pulmonary Vein: A Rare Entity.

We describe a patient with recurrent embolic strokes who was found to have a persistent left superior vena cava draining into a pulmonary vein. Transcatheter placement of a vascular plug resulted in successful occlusion of the superior vena cava. Repeat bubble study on follow-up imaging was negative for a right-to-left shunt. (Level of Difficulty: Advanced.).

Quality of Life Outcomes After Transcatheter Aortic Valve Replacement in Nonagenarians.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) is an increasingly prevalent treatment in patients who are intermediate or high risk for surgical intervention. In nonagenarian patients undergoing TAVR, symptomatic relief and quality of life (QoL) outcomes have not been well established. This study explores these outcomes in this patient population that has been underrepresented in landmark clinical trials. METHODS: All patients who underwent TAVR between January 1, 2015 and December 31, 2018 at Delray Medical Center were included. The 12-item Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS) score was used to assess QoL prior to and 30 days following TAVR in two patient groups: the nonagenarian group (patients ≥90 years old) and the younger group (patients <90 years old). KCCQ-OS scores were compared between these two groups. Frailty assessment included grip strength, gait speed, and activities of daily living. Unadjusted and adjusted analyses (baseline KCCQ-OS score, frailty, and Society of Thoracic Surgery perioperative risk of mortality [STS-PROM] score) were performed to assess the impact of age on QoL outcomes in both groups. RESULTS: Of the total 223 patients included in this study, a total of 46 (20.6%) were nonagenarians and 118 (52.7%) were men. KCCQ-OS scores were lower at baseline and 30-day follow-up in nonagenarians compared with the younger group (P=.70). Age was a significant predictor of 30- day KCCQ-OS in unadjusted and adjusted analyses (adjusted for baseline KCCQ-OS, frailty, and STS-PROM score). Nonagenarians had an average 6.45 points lower 30-day KCCQ-OS scores than the younger patients in adjusted analysis. However, there was a significant clinical improvement in the 30-day KCCQ-OS score in both groups (P<.001). CONCLUSIONS: Our data suggest that with appropriate patient selection, a significant clinical improvement may be expected with TAVR in nonagenarians.

Contrast-Induced Acute Kidney Injury: Review and Practical Update.

Contrast-induced acute kidney injury (CI-AKI) is an important consideration in patients undergoing cardiac catheterization. There has been a continuous strive to decrease morbidity and improve procedural safety. This review will address the pathophysiology, predictors, and clinical management of CI-AKI with a concise overview of the pathophysiology and a suggested association with left atrial appendage closure. Minimizing contrast administration and intravenous fluid hydration are the cornerstones of an effective preventive strategy. A few adjunctive pharmacotherapies hold promise, but there are no consensus recommendations on prophylactic therapies.

Accuracy of Commonly-Used Imaging Modalities in Assessing Left Atrial Appendage for Interventional Closure: Review Article.

Periprocedural imaging assessment for percutaneous Left Atrial Appendage (LAA) transcatheter occlusion can be obtained by utilizing different imaging modalities including fluoroscopy, magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound imaging. Given the complex and variable morphology of the left atrial appendage, it is crucial to obtain the most accurate LAA dimensions to prevent intra-procedural device changes, recapture maneuvers, and prolonged procedure time. We therefore sought to examine the accuracy of the most commonly utilized imaging modalities in LAA occlusion. Institutional Review Board (IRB) approval was waived as we only reviewed published data. By utilizing PUBMED which is an integrated online website to list the published literature based on its relevance, we retrieved thirty-two articles on the accuracy of most commonly used imaging modalities for pre-procedural assessment of the left atrial appendage morphology, namely, two-dimensional transesophageal echocardiography, three-dimensional transesophageal echocardiography, computed tomography, and three-dimensional printing. There is strong evidence that real-time three-dimensional transesophageal echocardiography is more accurate than two-dimensional transesophageal echocardiography. Three-dimensional computed tomography has recently emerged as an imaging modality and it showed exceptional accuracy when merged with three-dimensional printing technology. However, real time three-dimensional transesophageal echocardiography may be considered the preferred imaging modality as it can provide accurate measurements without requiring radiation exposure or contrast administration. We will present the most common imaging modality used for LAA assessment and will provide an algorithmic approach including preprocedural, periprocedural, intraprocedural, and postprocedural.

Endoscopic Management of an Intramural Sinus Leak After Per- Oral Endoscopic Myotomy.

Per-oral endoscopic myotomy (POEM) was developed less than a decade ago for the treatment of achalasia. Its minimally invasive approach and the favorable short-term outcome have led to rapid adoption of the technique throughout the world. As with any new technique, there will be adverse events, and it is important that effective treatments for these adverse events be discussed. We present a case of successful endoscopic management of an intramural sinus leak after a POEM procedure using tandem fully covered esophageal stents.