Initial Clinical Impressions of the Critical Care of COVID-19 Patients in Seattle, New York City, and Chicago.

Since the first recognition of a cluster of novel respiratory viral infections in China in late December 2019, intensivists in the United States have watched with growing concern as infections with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus-now named coronavirus disease of 2019 (COVID-19)-have spread to hospitals in the United States. Because COVID-19 is extremely transmissible and can progress to a severe form of respiratory failure, the potential to overwhelm available critical care resources is high and critical care management of COVID-19 patients has been thrust into the spotlight. COVID-19 arrived in the United States in January and, as anticipated, has dramatically increased the usage of critical care resources. Three of the hardest-hit cities have been Seattle, New York City, and Chicago with a combined total of over 14,000 cases as of March 23, 2020.In this special article, we describe initial clinical impressions of critical care of COVID-19 in these areas, with attention to clinical presentation, laboratory values, organ system effects, treatment strategies, and resource management. We highlight clinical observations that align with or differ from already published reports. These impressions represent only the early empiric experience of the authors and are not intended to serve as recommendations or guidelines for practice, but rather as a starting point for intensivists preparing to address COVID-19 when it arrives in their community.

Efficacy and safety of remote magnetic catheter navigation vs. manual steerable sheath-guided ablation for catheter ablation of atrial fibrillation: a case-control study.

AIMS: Data comparing remote magnetic catheter navigation (RMN) to manual catheter navigation (MCN) using steerable sheath for ablation of atrial fibrillation (AF) is lacking. The aim of the present case-control study was to seek AF recurrence data after AF ablation using RMN in comparison to MCN using steerable sheath in patients with either paroxysmal or persistent AF. METHODS AND RESULTS: This study comprised 140 patients with AF (50% paroxysmal). Seventy were ablated utilizing RMN and 70 with MCN. Primary endpoint was defined as the time to first recurrence after index procedure. After 28.8 ± 18.9 months of follow-up, more patients in the MCN group using steerable sheath remained free of recurrence compared with RMN group [(59.1 vs. 40%, respectively, P = 0.031), in patients with persistent AF P = 0.057, while in patients with paroxysmal AF, P = 0.18]. Index procedure time (223.6 ± 44.2 vs. 170.8 ± 51.8 min, P < 0.001) and radiofrequency application time (75.4 ± 20.9 vs. 56.6 ± 24.9 min, P < 0.001) were longer in the RMN group; however, the respective total fluoroscopy time (13.7 ± 7.8 vs. 36.6 ± 12.7 min, P < 0.001) was significantly shorter. In multivariable Cox-regression analysis, RMN was the only factor independently associated with shorter time to first recurrence during follow-up (P = 0.048). Complication rate did not differ significantly between groups (P = 0.056), although the incidence of significant pericardial effusion was higher in the MCN group (3 cases vs. 0 in RMN group). CONCLUSION: Although in patients with persistent AF, the recurrence rate is higher in RMN group, the outcome is comparable between RMN and MCN groups in patients with paroxysmal AF. A multicentre prospective randomized study is warranted to clarify this issue.

Catheter ablation of atrial fibrillation using remote magnetic catheter navigation: a case-control study.

AIMS: To compare the acute and the 6 month outcome of catheter ablation of atrial fibrillation (AF) using irrigated tip magnetic catheter and remote magnetic cathter navigation (RMN) with manual catheter navigation (MCN) in patients with paroxysmal and persistent AF. METHODS AND RESULTS: In this retrospective analysis 356 patients (235 male, mean age: 57.9 ± 10.9 years) with AF (70.5%, paroxysmal) who underwent catheter ablation between August 2007 and May 2008 using either RMN (n = 70, 46 male, mean age: 57.9 ± 10.1 years, 50% paroxysmal) or MCN (n = 286, 189 male, mean age: 58.0 ± 13.9 years, 75.5% paroxysmal) were included. All patients completed an intensive follow-up strategy. Complete pulmonary vein isolation was achieved in 87.6 and 99.6% of patients in RMN and MCN groups, respectively (P < 0.05). The procedure, fluoroscopy, and radiofrequency application times were 223 ± 44 vs. 166 ± 52 min (P < 0.0001), 13.7 ± 7.8 vs. 34.5 ± 15.1 min (P < 0.0001), and 75.4 ± 20.9 vs. 53.2 ± 21.4 min (P < 0.0001) in RMN and MCN groups, respectively. Seven (10.0%) and 28 (9.8%) patients in RMN and MCN groups received antiarrhythmic medications during the follow-up (P = 0.96). All the patients completed the 6 month follow-up. Freedom from AF at 6 months was achieved in 57.8 and 66.4% of the patients in RMN and MCN groups, respectively (P = 0.196). In patients without previous AF catheter ablation procedure the freedom from AF at 6 months were 68.2 and 60.5% in the MCN and RMN groups, respectively (P = 0.36). CONCLUSION: Catheter ablation using irrigated tip magnetic catheter and RMN is an effective and safe method for catheter ablation of AF. Compared to manual catheter navigation, the procedure and radiofrequency application times were longer and fluoroscopy time was shorter in the RMN group compared with the MCN group.

Six-month follow-up of isthmus-dependent right atrial flutter ablation using a remote magnetic catheter navigation system: a case-control study.

OBJECTIVE: The objective of this study was to compare results between the magnetic navigation system (MNS) and conventional catheter ablation of cavo-tricuspid isthmus (CTI)-dependent right atrial flutter (AFL) in a case control study. BACKGROUND: A remote MNS has been used for ablation of various arrhythmias including CTI-dependent AFL but comparative results between MNS and conventional ablation are not available. METHODS: Between May and September 2007, a total of 51 consecutive patients (45 men, mean age 65.4 +/- 9.4 years) had undergone catheter ablation for CTI-dependent AFL. The catheter ablation (70 degrees C, 70 W, 90 s) was performed with either an 8-mm-tip magnetic catheter using MNS (case group, n = 26, 23 men, mean age 64.6 +/- 9.6 y) or a conventional 8-mm catheter (case group, n = 25, 22 men, mean age 65.4 +/- 9.1 y). Acute procedural success was defined as complete bidirectional isthmus block and success at six months was defined as absence of AFL during the six months follow-up. RESULTS: With respect to baseline characteristics there were no differences between the two groups. The procedure time in MNS and conventional group was [median (range)] 53 (30-130) min and 45 (30-100) min, respectively (P = 0.12). Acute success was achieved by MNS and conventional ablation in 25/26 (96.2%) and 25/25 (100%) of patients, respectively (P = 0.53). During the six months of follow-up 4 patients, 2 in each group, experienced recurrence (P = 0.90). No major complication occurred during the procedure. Charring on the catheter tip occurred in 5 patients (19.2%) in MNS and none of the patients in the control group (P <0.05). CONCLUSION: This case-control study demonstrated the acute and mid-term efficacy and safety of catheter ablation by MNS for CTI-dependent AFL, similar to rates achieved by conventional radiofrequency catheter ablation.

Ablation of atrial fibrillation: patient selection, techniques, and the results.

Atrial fibrillation (AF) is a common arrhythmia, affecting an estimated 2 million people in the United States and its prevalence increases with age, reaching 10% in those > or = 80 years. AF confers a four- to fivefold increased risk of stroke compared to the general population and has been associated with a doubling of all-cause mortality. During the past decade, limited success rates of drug treatment stimulated an exploration of interventional treatment options for AF. As our knowledge on initiating triggers and perpetuating substrate of AF expanded, different potentially curative catheter ablation techniques have been developed. In this article we review the current patient selection criteria, methods, and the results of the catheter ablation of atrial fibrillation.