Low voltage area guided substrate modification in nonparoxysmal atrial fibrillation: A systematic review and meta-analysis.

BACKGROUND: Low voltage areas (LVAs) on left atrial (LA) bipolar voltage mapping correlate with areas of fibrosis. LVAs guided substrate modification was hypothesized to improve the success rate of atrial fibrillation (AF) ablation particularly in nonparoxysmal AF population. However, randomized controlled trials (RCTs) and observational studies yielded mixed results. METHODS: The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to August 2022. Relevant studies comparing LVA guided substrate modification (LVA ablation) versus conventional AF ablation (non LVA ablation) in patients with nonparoxysmal AF were identified and a meta-analysis was performed (Graphical Abstract image). The efficacy endpoints of interest were recurrence of AF and the need for repeat ablation at 1-year. The safety endpoint of interest was adverse events for both groups. Procedure related endpoints included total procedure time and fluoroscopy time. RESULTS: A total of 11 studies with 1597 patients were included. A significant reduction in AF recurrence at 1-year was observed in LVA ablation versus non LVA ablation group (risk ratio [RR] 0.63 (27% vs. 36%),95% confidence interval [CI] 0.48-0.62, p < .001]. Also, redo ablation was significantly lower in LVA ablation group (RR 0.52[18% vs. 26.7%], 95% CI 0.38-0.69, p < .00133). No difference was found in the overall adverse event (RR 0.7 [4.3% vs. 5.4%], 95% CI 0.36-1.35, p = .29). CONCLUSION: LVA guided substrate modification provides significant reduction in recurrence of all atrial arrhythmias at 1-year compared with non LVA approaches in persistent and longstanding persistent AF population without increase in adverse events.

Adverse clinical outcomes in patients undergoing both PCI and TAVR: Analysis from a pooled multi-center registry.

BACKGROUND: There is a paucity of data regarding the optimum timing of PCI in relation to TAVR. OBJECTIVE: We compared the major adverse cardiovascular and cerebrovascular events (MACCE) rates among patients who underwent percutaneous coronary intervention (PCI) before transcatheter aortic valve replacement (TAVR) with those who received PCI with/after TAVR. METHODS: In this multicenter study, we pooled all consecutive patients who underwent TAVR at three high volume centers. RESULTS: Among 3,982 patients who underwent TAVR, 327 (8%) patients underwent PCI within 1 year before TAVR, 38 (1%) had PCI the same day as TAVR and 15 (0.5%) had PCI within 2 months after TAVR. Overall, among patients who received both PCI and TAVR (n = 380), history of previous CABG (HR:0.501; p = .001), higher BMI at TAVR (HR:0.970; p = .038), and statin therapy after TAVR (HR:0.660, p = .037) were independently associated with lower MACCE while warfarin therapy after TAVR was associated with a higher risk of MACCE (HR:1.779, p = .017). Patients who received PCI within 1 year before TAVR had similar baseline demographics, STS scores, clinical risk factors when compared to patients receiving PCI with/after TAVR. Both groups were similar in PCI (Syntax Score, ACC/AHA lesion class) and TAVR (valve types, access) related variables. There were no significant differences in terms of MACCE (log rank p = .550), all-cause mortality (log rank p = .433), strokes (log rank p = .153), and repeat PCI (log rank p = .054) in patients who underwent PCI with/after TAVR when compared to patients who received PCI before TAVR. CONCLUSION: Among patients who underwent both PCI and TAVR, history of CABG, higher BMI, and statin therapy had lower, while those discharged on warfarin, had higher adverse event rates. Adverse events rates were similar regardless of timing of PCI.

Impact of COVID-19 infection on baseline autonomic symptoms in patients with preexisting postural tachycardia syndrome and orthostatic intolerance: A retrospective study.

BACKGROUND: Postural orthostatic tachycardia syndrome (POTS) and dysautonomia following a SARS-CoV-2 infection have been recently reported. The underlying mechanism of dysautonomia is not well understood. The impact of this viral illness on the underlying autonomic symptoms has not been studied in patients with a pre-existing POTS diagnosis. Our study aims to report the impact of a COVID-19 infection on patients with preexisting POTS, both during the acute phase of the disease and post-recovery. METHODS: Institutional Review Board (IRB) approval was obtained to access charts of the study subjects. All patients with known POTS disease who acquired COVID-19 infection between April 2020 and May 2021 were included. The end point of the study was worsening POTS related symptoms including orthostatic dizziness, palpitation, fatigue and syncope/ presyncope post COVID-19 infection that required escalation of therapy. Basic demographics, details of POTS diagnosis, medications, Additional information regarding COVID 19 infection, duration of illness, need for hospitalization, worsening of POTS symptoms, need for ED visits, the type of persisting symptoms and vaccination status were obtained from the retrospective chart review. RESULTS: A total of 41 patients were studied. The alpha-variant was the most common causing SARS-CoV-2 infection. 27% (11 patients) of them had tested positive for COVID- 19 infection more than once. About 38 (92.7%) of them reported having worsening of their baseline POTS symptoms during the active infection phase. About 28 patients (68%) experienced worsening of their dysautonomia symptoms for at least 1-6 months post infection. Nearly 30 patients (73.2%) required additional therapy for their symptom control and improvement. CONCLUSIONS: Patients with pre-existing POTS, most experienced a worsening of their baseline autonomic symptoms after suffering the COVID-19 infection which required additional pharmacotherapy for their symptom improvement.

Prevalence of Heart Failure With Preserved Ejection Fraction in Patients Undergoing Atrial Fibrillation Ablation Based on Resting and Post-Tachycardia Pacing Left Atrial Pressure.

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are frequent co-morbid conditions. In patients with symptomatic AF and preserved left ventricular ejection fraction the clinical diagnosis of HFpEF may be difficult, as history, examination, and echocardiography are not sensitive or specific. This study sought to assess the prevalence of HFpEF in patients undergoing AF ablation utilizing resting and post-tachycardia pacing left atrial pressure (LAP) measurements. This retrospective cohort study consisted of consecutive patients with symptomatic AF and preserved left ventricular ejection fraction who had invasive hemodynamic assessment (IHA) of LAP under resting and post-tachycardia pacing conditions while undergoing AF ablation from 2020 to 2022 at a tertiary care academic medical center. Elevated LAP was defined as ≥15 mm Hg at rest and ≥15 mm Hg post-tachycardia pacing. Patients were stratified into 3 groups: (1) normal resting and post-tachycardia pacing LAP (control group), (2) elevated resting LAP (apparent HFpEF), (3) normal resting but elevated post-tachycardia pacing LAP (occult HFpEF). A total of 78 patients were included with age 64.6 ± 9.1 years, 28 (36%) female, body mass index 33.3 ± 6.5 kg/m2, 5 (6%) paroxysmal and 73 (94%) persistent AF, and CHA2DS2-VASc 3.0 ± 1.5. IHA categorized 31 (40%), 32 (41%), and 15 patients (19%) into groups 1, 2, and 3 respectively. Notably, while only 9 patients (12%) were diagnosed with HFpEF based on clinical evaluation, 47 patients (60%) were diagnosed by IHA. IHA in patients undergoing AF ablation suggests a high prevalence of clinically undiagnosed HFpEF through a novel methodology measuring resting and post-tachycardia pacing LAP.

Short-term Outcomes of Hypertensive Crises in Patients with Orthostatic Hypotension.

Supine hypertension-orthostatic hypotension disease poses a management challenge to clinicians. Data on short term outcomes of patients with orthostatic hypotension (OH) who are hospitalized with hypertensive (HTN) crises is lacking. The Nationwide Readmission Database 2016-2019 was queried for all hospitalizations of HTN crises. Hospitalizations were stratified according to whether OH was present or not. We employed propensity score to match hospitalizations for patients with OH to those without, at 1:1 ratio. Outcomes evaluated were 30-days readmission with HTN crises or falls, as well as hospital outcomes of in-hospital mortality, acute kidney injury, acute congestive heart failure, acute coronary syndrome, type 2 myocardial infarction, aortic dissection, stroke, length of stay (LOS), discharge to nursing home and hospitalization costs. We included a total of 9451 hospitalization (4735 in the OH group vs 4716 in the control group). OH group was more likely to be readmitted with falls (Odds ratio [OR]:3.27, P < 0.01) but not with HTN crises (P = 0.05). Both groups had similar likelihood of developing acute kidney injury (P = 0.08), stroke/transient ischemic attack (P = 0.52), and aortic dissection (P = 0.66). Alternatively, OH group were less likely to develop acute heart failure (OR:0.54, P < 0.01) or acute coronary syndrome (OR:0.39, P < 0.01) in the setting of HTN crises than non-OH group. OH group were more likely to have longer LOS and have higher hospitalization costs. Patients with OH who are admitted with HTN crises tend to have similar or lower HTN-related complications to non-OH group while having higher likelihood of readmission with falls, LOS and hospitalization costs. Further studies are needed to confirm such findings.

Outcomes of Coronary Artery Bypass Grafting in Patients With Previous Mediastinal Radiation.

Studies have shown that patients with radiation therapy-associated coronary artery disease tend to have worse outcomes with percutaneous revascularization. Previous irradiation has been linked with future internal mammary artery graft disease. Studies investigating the outcomes of coronary artery bypass surgery (CABG) among patients with previous radiation are limited. The Nationwide Readmission Database for the years 2016 to 2019 was queried for hospitalizations with CABG and history of mediastinal radiation. Complex samples multivariable logistic and linear regression models were used to determine the association between the history of mediastinal radiation and in-hospital mortality, 90 days all-cause unplanned readmission rates, and acute coronary syndrome readmission rates. A total of 533,702 hospitalizations (2,070 in the irradiation history group and 531,632 in the control group) were included in this analysis. Patients with radiation therapy history were less likely to have traditional coronary artery disease risk factors and more likely to have associated valvular disease. Patients with a history of irradiation had similar in-hospital mortality and 90-day readmission risk at the expense of higher hospitalizations costs (ß coefficient: $2,764; p = 0.005). They had a higher likelihood of readmission with acute coronary syndrome within 90 days (adjusted odds ratio 1.67, p = 0.02). In a conclusion, a history of mediastinal irradiation is not associated with increased rates of short-term mortality or increased all-cause readmission risk after CABG. However, it may be associated with increased acute coronary syndrome readmission rates.

Role of Adjunctive Cryoballoon Left Atrial Posterior Wall Isolation in Non-paroxysmal Atrial Fibrillation: A Meta-analysis.

Progressive remodeling of left atrial posterior wall (LAPW) plays an important role in the pathology of persistent/ long-standing persistent atrial fibrillation. The role of pulmonary veins isolation (PVI) and adjunctive LAPW isolation using cryothermal energy in non-paroxysmal atrial fibrillation is yet to be established. The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to April 2022. Relevant randomized trials and observational studies comparing de novo cryoballoon PVI only versus PVI+LAPWI in patients with non paroxysmal AF were identified and a meta-analysis was performed using the random effect model. The efficacy endpoints of interest were recurrence of AF, recurrence of non-AF and all atrial arrhythmias at 1-year post ablation. The safety endpoint of interest was all adverse events between the two groups. A total of 6 studies (3 prospective trials and 3 observational studies) with 1037 patients were included. A significant reduction in AF recurrence at 1-year was observed in PVI+LAPWI group (OR 0.36 (17% vs 39%), 95% CI 0.26-0.49, P < 0.001). Also, lower incidence of overall atrial arrhythmias was found in PVI+LAPWI (OR 0.37 (23% vs 47%),95% CI 0.28-0.49, P < 0.001). For safety endpoints, the overall adverse event rate was low without the significant difference between the groups (OR: 0.86, (3% vs 3.5%) 95% CI 0.36-2.07, P = 0.74). Cryoballoon LAPWI plus PVI provides a significant reduction in recurrence of all atrial arrhythmias and AF at 1-year compared with PVI alone in non paroxysmal AF population without increase in adverse events rate.

Dirty Jobs: Macrophages at the Heart of Cardiovascular Disease.

Cardiovascular disease (CVD) is one of the greatest public health concerns and is the leading cause of morbidity and mortality in the United States and worldwide. CVD is a broad yet complex term referring to numerous heart and vascular conditions, all with varying pathologies. Macrophages are one of the key factors in the development of these conditions. Macrophages play diverse roles in the maintenance of cardiovascular homeostasis, and an imbalance of these mechanisms contributes to the development of CVD. In the current review, we provide an in-depth analysis of the diversity of macrophages, their roles in maintaining tissue homeostasis within the heart and vasculature, and the mechanisms through which imbalances in homeostasis may lead to CVD. Through this review, we aim to highlight the potential importance of macrophages in the identification of preventative, diagnostic, and therapeutic strategies for patients with CVD.

Drug-Eluting Stents Versus Bare-Metal Stents in Large Coronary Artery Revascularization: Systematic Review and Meta-Analysis.

OBJECTIVES: We aim to determine if drug eluting stents (DES) are better than bare-metal stents (BMS) in large coronary artery (diameter ≥ 3 mm) percutaneous coronary intervention (PCI). BACKGROUND: DES have become the standard of care for PCI in coronary artery disease (CAD). However, the superiority of DES over BMS in large vessel CAD is not clear and previous studies have shown conflicting results. METHODS: Randomized controlled trials (RCTs) comparing outcomes of PCI with BMS and DES for large vessel CAD were identified from the year 2000 to August 2019. The outcomes were studied individually and included all-cause mortality, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis. Aggregated odds ratio and 95% CI were calculated using a random-effects model. RESULTS: Eight RCTs were included (4 with data for first-generation DES, 3 with data for second-generation DES, and 1 with data for both first- and second-generation DES). Compared to BMS, second generation DES had a significantly lower rate of all-cause mortality (2.4% vs. 3.9%, OR 0.74, 95% CI 0.56-0.98, P 0.04), TLR (3.5% vs. 8.6% OR 0.38 95% CI 0.28-0.53, P < 0.001), and MI (2.1% vs. 2.9% OR 0.73 95% CI 0.53-1.0, P 0.05). The difference in all-cause mortality was not seen with first-generation DES. CONCLUSION: Newer DES are associated with a lower mortality, TLR, and MI and thus should be preferred over BMS for large coronary artery PCI.

Outcomes and Resource Utilization of Atrial Fibrillation Hospitalizations With Type 2 Myocardial Infarction.

Scarce data exist on the prognostic impact of type 2 myocardial infarction (MI) in patients with AF. The Nationwide Readmission Database 2018 was queried for primary AF hospitalizations with and without type 2 MI. Complex samples multivariable logistic and linear regression models were used to determine the association between type 2 MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions). Of 382,896 weighted primary AF hospitalizations included in this study, 7,375 (1.9%) had type 2 MI. AF with type 2 MI is associated with significantly higher in-hospital mortality (adjusted OR [aOR] 1.76; 95% CI 1.30 to 2.38), LOS (adjusted parameter estimate [aPE] 0.48; 95% CI 0.35 to 0.62), hospital costs (aPE 1307.75; 95% CI 986.05 to 1647.44), discharges to nursing facility (aOR 1.38; 95% CI 1.24 to 1.54), and 30-day all-cause readmissions (adjusted hazard ratio 1.17; 95% CI 1.07 to 1.27) compared to AF without type 2 MI. Heart failure, chronic kidney disease, neurologic disorders, and age (per year) were identified as independent predictors of mortality among AF patients with type 2 MI. In conclusion, type 2 MI in the setting of AF hospitalization is associated with high in-hospital mortality and increased resource utilization.

Effect of High-Density Lipoprotein Cholesterol Levels on Overall Survival and Major Adverse Cardiovascular and Cerebrovascular Events.

Several studies designed to augment high density lipoprotein (HDL) levels have so far been unsuccessful in reducing rates of major adverse cardiovascular and cerebrovascular events (MACCE). In this study, we report the effect of HDL-C levels on overall survival outcomes and rates of MACCE following percutaneous coronary intervention (PCI). We reviewed patients who underwent PCI at the Cleveland Clinic from 2005 to 2017 and followed them through the end of 2018. Restricted cubic splines incorporated into Cox proportional hazard regression models were used to assess the outcomes. The HDL-C level associated with the lowest mortality was used as a reference value.15,633 patients underwent PCI during the study period, of which 70% were male, 81% were white, and 73% were on statins. The mean age at the time of procedure was 65.8 ± 11.8 years. After adjusting for demographics, co-morbidities, lipid profile, statin use, and date of procedure, our model demonstrated a U-shaped association between HDL-C and overall mortality, with HDL-C levels of 30-50 mg/dl associated with the most favorable outcomes, and HDL-C levels < 30 mg/dl or > 50 mg/dl associated with worse outcomes. A sensitivity analysis in men yielded a similar U-shaped association. In conclusion, our study shows that both low and high levels of HDL-C are associated with worse overall survival, with no effect on rates of MACCE in PCI patients. Further studies are required to understand the mechanism of this association between elevated HDL-C levels with increased overall mortality in patients with atherosclerotic cardiovascular disease (ASCVD).

Coronary artery aneurysms: outcomes following medical, percutaneous interventional and surgical management.

BACKGROUND: Coronary artery aneurysms (CAAs) are increasingly diagnosed on coronary angiography; however, controversies persist regarding their optimal management. In the present study, we analysed the long-term outcomes of patients with CAAs following three different management strategies. METHODS: We performed a retrospective review of patient records with documented CAA diagnosis between 2000 and 2005. Patients were divided into three groups: medical management versus percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). We analysed the rate of major cardiovascular and cerebrovascular events (MACCEs) over a period of 10 years. RESULTS: We identified 458 patients with CAAs (mean age 78±10.5 years, 74.5% men) who received medical therapy (N=230) or underwent PCI (N=52) or CABG (N=176). The incidence of CAAs was 0.7% of the total catheterisation reports. The left anterior descending was the most common coronary artery involved (38%). The median follow-up time was 62 months. The total number of MACCE during follow-up was 155 (33.8%); 91 (39.6%) in the medical management group vs 46 (26.1%) in the CABG group vs 18 (34.6%) in the PCI group (p=0.02). Kaplan-Meier survival analysis showed that CABG was associated with better MACCE-free survival (p log-rank=0.03) than medical management. These results were confirmed on univariate Cox regression, but not multivariate regression (OR 0.773 (0.526 to 1.136); p=0.19). Both Kaplan-Meier survival and regression analyses showed that dual antiplatelet therapy (DAPT) and anticoagulation were not associated with significant improvement in MACCE rates. CONCLUSION: Our analysis showed similar long-term MACCE risks in patients with CAA undergoing medical, percutaneous and surgical management. Further, DAPT and anticoagulation were not associated with significant benefits in terms of MACCE rates. These results should be interpreted with caution considering the small size and potential for selection bias and should be confirmed in large, randomised trials.

Safety and Long-Term Patency of Endovascular Therapy for Infrarenal Aortic Disease: Single-Center Experience and Review of the Literature.

OBJECTIVES: Endovascular therapy (EVT) has emerged as an alternative to surgery for the treatment of symptomatic infrarenal aortic stenosis (IAS). However, long-term outcomes with EVT are unknown. METHODS: We performed a retrospective review of patients with IAS treated with the endovascular approach at the University of Toledo Medical Center, Toledo, Ohio. We compared our single-center study (SCS) with a review of published studies (ROS) regarding complications, patency rate (PR), and repeat intervention rate (RIR). Pearson's Chi-square or Fisher's exact test, and the Student's t-test or Mann-Whitney U-test, were used for categorical and continuous variables, respectively. For the ROS data, we used a pooled mean of means. RESULTS: A total of 25 patients from the SCS were compared with 698 patients from the ROS data. Mean age was 63 years vs 58 years, females comprised 48% vs 54%, Rutherford class 3 comprised 68% vs 69%, and mean follow-up duration was 67 months vs 44 months in SCS vs ROS, respectively. PR at 12 months was 96% vs 90%, while PR at maximum time-period was 92% vs 76% in SCS vs ROS, respectively. RIR in SCS was 4% at 12 months and 8% at the maximum time period (20.2 years). RIR in ROS was 24% at the maximum time period (10 years). The mortality rate was 0% in the SCS arm vs 3.4% in the ROS arm. CONCLUSION: EVT is highly effective and safe, and was associated with excellent patency rates at long-term follow-up.

Outcomes of patients with severe tricuspid regurgitation and congestive heart failure.

OBJECTIVES: A substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not. METHODS: Retrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes. RESULTS: Among a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p<0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71). CONCLUSION: Although corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients.