Electrographic flow mapping of persistent atrial fibrillation: intra- and inter-procedure reproducibility in the absence of 'ground truth'.

AIMS: Validating mapping systems that identify atrial fibrillation (AF) sources (focal/rotational activity) is confounded by the absence of ground truth. A key concern of prior mapping technologies is spatiotemporal instability, manifesting as poor map reproducibility. Electrographic flow (EGF) employs a novel algorithm that visualizes atrial electrical wavefront propagation to identify putative AF sources. We analysed both intra- (3 min) and inter- (>3 months) procedure EGF map reproducibility. METHODS AND RESULTS: In 23 persistent AF patients, after pulmonary vein isolation (PVI), EGF maps were generated from 3 serial 1 min recordings using a 64-electrode basket mapping catheter (triplets) at right and left atrial locations. Source prevalence from map triplets was compared between recordings. Per protocol, 12 patients returned for 3-month remapping (1 non-inducible): index procedure post-PVI EGF maps were compared with initial EGF remapping at 3-month redo. Intra-procedure reproducibility: analysing 224 map triplets (111 right atrium, 113 left atrium) revealed a high degree of map consistency with minimal min-to-min shifts: 97 triplets (43%), exact match of leading sources on all 3 maps; 95 triplets (42%), leading source within 1 electrode space on 2 of 3 maps; and 32 triplets (14%), chaotic leading source pattern. Average deviation in source prevalence over 60 s was low (6.4%). Inter-procedure reproducibility: spatiotemporal stability of EGF mapping >3 months was seen in 16 of 18 (89%) sources mapped in 12 patients with (re)inducible AF. CONCLUSION: Electrographic flow mapping generates reproducible intra- and inter-procedural maps, providing rationale for randomized clinical trials targeting these putative AF sources.

Outcome of high-power short-duration radiofrequency ablation in combination with half-normal saline irrigation for the treatment of atrial fibrillation.

BACKGROUND: Data regarding the use of high-power short-duration (HPSD) radiofrequency (RF) in combination with half-normal saline irrigation for catheter irrigation are limited. OBJECTIVES: This study investigated the safety and efficacy of using HPSD RF ablation in combination with half-normal saline irrigation for the treatment of AF. METHODS: One hundred consecutive patients with AF underwent RF ablation using HPSD combined with half-normal saline for catheter irrigation. In addition, the following ablation strategies were used: 1 mm tags for the display of ablation lesions on the mapping system, high-frequency jet ventilation (HFJV), low contact force, pacing after ablation to verify areas of noncapture, atrial/ventricular pacing at 500 to 700 ms to aid in catheter stability, use of two skin electrodes to reduce impedance, and postablation adenosine infusion. Power was started at 40 to 45 W and was modulated manually based on impedance changes. RESULTS: The average age of patients was 65.2 years and 70% were male. Forty seven percent had paroxysmal AF and the average CHA2 DS2 -VASc score was 2.1 ± 1.6. The average power and lesion duration were 38.1 ± 3.3 W and 8.1 ± 2.3 s, respectively. During a median follow-up period of 321 ± 139 days, 89% of the patients remained free from any atrial arrhythmias after a single RF ablation procedure. No procedure-related death, stroke, pericardial effusion, or atrioesophageal fistula occurred during follow-up. CONCLUSIONS: Catheter ablation using HPSD RF lesions in combination with half-normal saline irrigation and is safe and effective, and results in high rate of freedom from AF.

Pulsed Field Ablation: a New Paradigm for Catheter Ablation of Arrhythmias.

PURPOSE OF REVIEW: Current ablation approach for arrhythmias relies upon the use of radiofrequency (RF) and cryoablation catheters. Although there have been significant advances both in catheter design and in energy delivery approaches, limitations such as suboptimal efficacy and safety remain. Pulsed field ablation (PFA) has emerged as a novel approach to ablation that is distinct from RF and cryoablation by virtue of selective ablation of myocardial tissue. Preclinical and clinical reports have demonstrated lesion durability with an excellent safety profile. These findings need to be confirmed in prospective randomized trials that are currently ongoing. In this review, we describe efficacy and safety outcomes from both pre-clinical and clinical studies that have been performed so far and briefly discuss ongoing clinical trials and future investigations. RECENT FINDINGS: Data from pre-clinical and clinical research have shown PFA as a promising tool for ablation of cardiac arrhythmias. In addition to safety regarding mitigating the risk to surrounding structures such as the phrenic nerve, esophagus, PFA also offers an effective method for ablation. In this review, we summarize the currently published pre-clinical and clinical data evaluating the safety and efficacy of PFA for cardiac arrhythmias.

Comparison between TightRail rotating dilator sheath and GlideLight laser sheath for transvenous lead extraction.

BACKGROUND: There are limited data on the comparative analyses of TightRail rotating dilator sheath (Philips) and laser sheath for lead extraction. OBJECTIVE: To evaluate the effectiveness and safety of the TightRail sheath as a primary or secondary tool for transvenous lead extraction (TLE). METHODS: Retrospective cohort analysis of 202 consecutive patients who underwent TLE using either TightRail sheath and/or GlideLight laser sheath (Philips) in our hospital. The study population was divided into three groups: Group A underwent TLE with laser sheath only (N = 157), Group B with TightRail sheath only (N = 22), and Group C with both sheaths (N = 23). RESULTS: During this period, 375 leads in 202 patients were extracted, including 297 leads extracted by laser sheath alone, 45 leads by TightRail sheath alone, and 33 by both TightRail sheath and laser sheaths. The most common indications included device infection (44.6%) and lead-related complications (44.1%). The median age of leads was 8.9 years. TightRail sheath (Group B) achieved similar efficacy as a primary extraction tool compared with laser sheath (Group A), with complete procedure success rate of 93.3% (vs. 96.6%, P = .263) and clinical success rate of 100.0% (vs. 98.1%, P = .513). Among 32 leads in which Tightrail was used after laser had failed (Group C), the complete procedure success rate was 75.8%. No significant difference in procedural adverse events was observed. CONCLUSION: Our single-center experience confirms that the TightRail system is an effective first-line and second-line method for TLE. Further investigation is required to guide the selection of mechanical and laser sheaths in lead extraction cases.

Should Primary Prevention ICDs Still Be Placed in Patients with Non-ischemic Cardiomyopathy? A Review of the Evidence.

PURPOSE OF REVIEW: Recent evidence has suggested that implantable defibrillator (ICD) in non-ischemic cardiomyopathy (NICM) may not offer mortality benefit in the presence of guideline-directed medical therapy (GDMT) and cardiac resynchronization therapy (CRT). RECENT FINDINGS: Despite significant benefits of GDMT and CRT, current evidence is derived from ICD trials that rely predominantly on reduced left ventricular ejection fraction alone (LVEF). The majority of patients with sudden cardiac death (SCD) have LVEF > 30% indicating that LVEF by itself is an inadequate predictor of SCD. The Danish study to assess the efficacy of ICD in patients with non-ischemic systolic heart failure on mortality (DANISH) highlights the importance of better risk stratifying NICM patients for ICD implantation. Assessment of life expectancy, comorbidities, presence of advanced heart failure, etiology of NICM, and the presence of myocardial fibrosis can help risk stratify ICD beyond LVEF. Genetics and biomarkers can be of further assistance in risk stratification.

Impact of treatment crossovers on clinical outcomes in the rate and rhythm control strategies for atrial fibrillation: Insights from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial.

We investigated the rates and reasons for crossover to alternative treatment strategies and its impact on mortality in patients who were enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. Over a mean follow-up period of 3.5 years, 842 patients underwent crossover to the alternative treatment arms in AFFIRM. The rate of crossover from rhythm to rate control (594/2,033, 29.2%) was more frequent than the rate of crossover from rate to rhythm control (248/2,027, 12.2%, P < 0.0001). The leading reasons for crossover from rhythm to rate control were failure to achieve or maintain sinus rhythm (272/594, 45.8%) and intolerable adverse effects (122/594, 20.5%). In comparison, the major reasons for crossover from rate to rhythm control were failure to control atrial fibrillation symptoms (159/248, 64.1%) and intolerable adverse effects (9/248, 3.6%). This difference in crossover pattern was statistically significant (P < 0.0001). There was a significantly decreased risk of all-cause mortality (adjusted HR: 0.61, 95% CI: 0.48-0.78, P < 0.0001) and cardiac mortality (adjusted hazard ratio [HR]: 0.61, 95% confidence interval [CI]: 0.43-0.88, P = 0.008) in the subgroup of patients who crossed over from rhythm to rate control as compared to those who continued in rhythm control. There was a nonsignificant trend toward decreased all-cause (adjusted HR: 0.76, 95% CI: 0.53-1.10, P = 0.14) and cardiac mortality (adjusted HR: 0.70, 95% CI: 0.42-1.18, P = 0.18) in patients who crossed over from rate to rhythm control as compared to those who continued rate control.

Association between Heat Shock Protein-60 and Development of Atrial Fibrillation: Results from the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: During atrial fibrillation (AF), a high rate of myocyte activation causes cellular stress and initiates the process of atrial remodeling, which further promotes persistence of AF. Although heat shock proteins (HSPs) have been shown to prevent atrial remodeling and suppress the occurrence of AF in cellular and animal experimental models, increased levels of HSP-60 have been observed in patients with postoperative AF, likely reflecting a response to cellular stress. To better understand the role of HSP-60 in relation to AF, we examined the association of HSP-60 levels in relation to the future development of AF in the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS: MESA is a cohort study that recruited 6,814 participants aged 45-84 years and free of known cardiovascular disease at baseline (2000-2002) from six field centers. We investigated 983 participants, selected at random from the total cohort, who had HSP-60 measured and were free of AF at baseline. We tested the association of HSP-60 levels with the incidence of AF using multivariate Cox models after adjustment for demographics, clinical characteristics, and biomarkers. RESULTS: During an average of 10.6 years of follow-up, 77 participants developed AF. We did not observe a significant association between the log-transformed HSP-60 levels and development of AF on either unadjusted or multivariate analysis (adjusted hazard ratio: 1.02 per unit difference on natural log scale, 95% confidence interval: 0.77-1.34 ln (ng/mL). CONCLUSION: Contrary to the findings from the preclinical studies, which demonstrated an important role of HSP-60 in the pathogenesis of AF, we did not observe a significant association between HSP-60 and occurrence of AF.

Incidence and Predictors of Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has emerged as an alternative treatment for patients with symptomatic aortic stenosis who are at high risk for surgical aortic valve replacement. The development of conduction abnormalities is a major complication in the postprocedural period of TAVR. OBJECTIVES: The objective of this study was to investigate the development of postprocedural conduction abnormalities and the requirement of permanent pacemaker (PPM) implantation in patients undergoing TAVR. METHODS: Data from 137 consecutive patients who underwent TAVR (Edwards SAPIEN valve, Edwards Lifesciences, Irvine, CA, USA) between June 2008 and October 2012 were reviewed. Patients with prior history of PPM (n = 27) were excluded. The role of various predictors for pacemaker implantation after TAVR, including the valve index (calculated as [valve size/left ventricular outflow tract diameter] × 100) was investigated. RESULTS: A total of 31/110 (28.2%) patients required implantation of a PPM after TAVR. The median time to implantation of a PPM was 5 days after the procedure. The development of postprocedural complete heart block was the most common indication for implantation of a PPM (16/31; 51.6%). On multivariate analysis, the presence of preexisting right bundle branch block (RBBB) was found to be a strong predictor of PPM implantation after TAVR (adjusted odds ratio: 4.87; 95% confidence interval: 1.29-18.46, P = 0.020). Using the receiver operated curve analysis, a cut-off value of valve index of 128 was found to be a strong predictor for PPM implantation with a sensitivity of 73% and specificity of 61% (c statistic = 0.68). CONCLUSIONS: This study identified the presence of prior RBBB and a valve index of 128 as important risk factors for PPM implantation after TAVR. A larger implanted valve size relative to left ventricular outflow tract diameter leads to a greater compression of the intrinsic conduction system, increasing the need for pacemaker placement.

Impact of catheter ablation on P-wave parameters on 12-lead electrocardiogram in patients with atrial fibrillation.

BACKGROUND: Catheter ablation has emerged as a widely used treatment modality for atrial fibrillation (AF). P-wave abnormalities have been described in the patients with AF, and catheter ablation may potentially further impact P-wave parameters due to ablation of atrial tissue. METHODS: We reviewed data on P-wave parameters (P-wave duration, amplitude and P-wave duration and amplitude product) in leads V1 and aVF and changes in the P-terminal force (Ptf; product of duration and amplitude of terminal part of P-wave) in lead V1 from 12-lead electrocardiograms obtained prior to and after CA of a total of 46 (28 paroxysmal and 18 persistent) AF patients. RESULTS: The median age of patients in our study was 63 (range: 30-77) years. We noticed a significant reduction in the P-wave duration (from 87.39±28.62ms at baseline to 72.09±24.59ms; p=0.0072) and the product of P-wave duration and amplitude in lead V1 (12.16±5.54mVms at baseline to 8.30±5.78mVms, p=0.0015) after CA. There was also a significant decrease in P-wave duration (from 92.57±19.67ms at baseline to 76.48±16.32ms after CA, p=0.0001) and P-wave duration and amplitude product in lead aVF (12.61±4.05mVms at baseline to 9.77±3.86mVms after CA, p=0.0001). CA also led to a significant decrease in Ptf (from 4.56±1.88 at baseline to 2.85±1.42mVms, p<0.0001). CONCLUSION: Radiofrequency catheter ablation of AF leads to modification of P-wave parameters with substantial diminution in both the amplitude and duration of the P-wave in leads V1 and aVF. This likely represents reduction in electrically active atrial tissue after ablation, and may serve as a marker for the extent of ablated atrial tissue.

A Novel ECG-Based Deep Learning Algorithm to Predict Cardiomyopathy in Patients With Premature Ventricular Complexes.

BACKGROUND: Premature ventricular complexes (PVCs) are prevalent and, although often benign, they may lead to PVC-induced cardiomyopathy. We created a deep-learning algorithm to predict left ventricular ejection fraction (LVEF) reduction in patients with PVCs from a 12-lead electrocardiogram (ECG). OBJECTIVES: This study aims to assess a deep-learning model to predict cardiomyopathy among patients with PVCs. METHODS: We used electronic medical records from 5 hospitals and identified ECGs from adults with documented PVCs. Internal training and testing were performed at one hospital. External validation was performed with the others. The primary outcome was first diagnosis of LVEF ≤40% within 6 months. The dataset included 383,514 ECGs, of which 14,241 remained for analysis. We analyzed area under the receiver operating curves and explainability plots for representative patients, algorithm prediction, PVC burden, and demographics in a multivariable Cox model to assess independent predictors for cardiomyopathy. RESULTS: Among the 14,241-patient cohort (age 67.6 ± 14.8 years; female 43.8%; White 29.5%, Black 8.6%, Hispanic 6.5%, Asian 2.2%), 22.9% experienced reductions in LVEF to ≤40% within 6 months. The model predicted reductions in LVEF to ≤40% with area under the receiver operating curve of 0.79 (95% CI: 0.77-0.81). The gradient weighted class activation map explainability framework highlighted the sinus rhythm QRS complex-ST segment. In patients who underwent successful PVC ablation there was a post-ablation improvement in LVEF with resolution of cardiomyopathy in most (89%) patients. CONCLUSIONS: Deep-learning on the 12-lead ECG alone can accurately predict new-onset cardiomyopathy in patients with PVCs independent of PVC burden. Model prediction performed well across sex and race, relying on the QRS complex/ST-segment in sinus rhythm, not PVC morphology.

Interatrial Block Association With Adverse Cardiovascular Outcomes in Patients Without a History of Atrial Fibrillation.

BACKGROUND: Interatrial block (IAB) is associated with thromboembolism and atrial arrhythmias. However, prior studies included small patient cohorts so it remains unclear whether IAB predicts adverse outcomes particularly in context of atrial fibrillation (AF)/atrial flutter (AFL). OBJECTIVES: This study sought to determine whether IAB portends increased stroke risk in a large cohort in the presence or absence of AFAF/AFL. METHODS: We performed a 5-center retrospective analysis of 4,837,989 electrocardiograms (ECGs) from 1,228,291 patients. IAB was defined as P-wave duration ≥120 ms in leads II, III, or aVF. Measurements were extracted as .XML files. After excluding patients with prior AF/AFL, 1,825,958 ECGs from 458,994 patients remained. Outcomes were analyzed using restricted mean survival time analysis and restricted mean time lost. RESULTS: There were 86,317 patients with IAB and 355,032 patients without IAB. IAB prevalence in the cohort was 19.6% and was most common in Black (26.1%), White (20.9%), and Hispanic (18.5%) patients and least prevalent in Native Americans (9.2%). IAB was independently associated with increased stroke probability (restricted mean time lost ratio coefficient [RMTLRC]: 1.43; 95% CI: 1.35-1.51; tau = 1,895), mortality (RMTLRC: 1.14; 95% CI: 1.07-1.21; tau = 1,924), heart failure (RMTLRC: 1.94; 95% CI: 1.83-2.04; tau = 1,921), systemic thromboembolism (RMTLRC: 1.62; 95% CI: 1.53-1.71; tau = 1,897), and incident AF/AFL (RMTLRC: 1.16; 95% CI: 1.10-1.22; tau = 1,888). IAB was not associated with stroke in patients with pre-existing AF/AFL. CONCLUSIONS: IAB is independently associated with stroke in patients with no history of AF/AFL even after adjustment for incident AF/AFL and CHA2DS2-VASc score. Patients are at increased risk of stroke even when AF/AFL is not identified.

Speckle echocardiographic left atrial strain and stiffness index as predictors of maintenance of sinus rhythm after cardioversion for atrial fibrillation: a prospective study.

BACKGROUND: Echocardiographic left atrial (LA) strain parameters have been associated with atrial fibrillation (AF) in prior studies. Our goal was to determine if strain measures [peak systolic longitudinal strain (LAS) and stiffness index (LASt)] changed after cardioversion (CV); and their relation to AF recurrence. METHODS AND RESULTS: 46 participants with persistent AF and 41 age-matched participants with no AF were recruited. LAS and LASt were measured before and immediately after CV using 2D speckle tracking imaging (2DSI). Maintenance of sinus rhythm was assessed over a 6-month follow up. Mean LAS was lower, and mean LASt higher, in participants with AF before CV as compared to control group (11.9±1.0 vs 35.7±1.7, p<0.01 and 1.31±0.17 vs 0.23±0.01, p<0.01, respectively). There was an increase in the mean LAS immediately after CV (11.9±1.0 vs 15.9±1.3, p<0.01), whereas mean LASt did not change significantly after CV (p=0.62). Although neither LAS nor LASt were independently associated with AF recurrence during the follow-up period, change in LAS after cardioversion (post-CV LAS-pre-CV LAS) was significantly higher among individuals who remained in sinus rhythm when compared to individuals with recurrent AF (3.6±1.1 vs 0.4±0.8, p=0.02). CONCLUSIONS: LAS and LASt differed between participants with and without AF, irrespective of the rhythm at the time of echocardiographic assessment. Baseline LAS and LASt were not associated with AF recurrence. However, change in LAS after CV may be a useful predictor of recurrent arrhythmia.

The Care of Patients With Atrial Fibrillation and Heart Failure.

Atrial fibrillation (AF) and heart failure (HF) are the 2 emerging epidemics in global cardiovascular disease. AF remains the most common cardiac arrhythmia, affecting over 33 million adults worldwide, and continues to increase in prevalence as the populations of many nations age. The prevalence of HF also surges, now afflicting 37 million adults globally. Interestingly, these 2 disease processes share many of the same risk factors and stem from many of the same pathophysiologic derangements, with AF occurring in over half of all patients with HF and HF occurring in over one third of all patients with AF. Furthermore, exacerbation of one of these ailments often drives decompensation or compromises therapy of the other, and it has been widely reported that coexistence of AF in patients with HF portends a poorer prognosis. As a result, many clinicians now routinely face the problem of AF in the patient with HF. In this review, we highlight the fundamental pathologic forces embedded in the relationship between AF and HF and then proceed to a discussion on the management of these complex patients with a detailed exploration of the clinical data.

Impact of Racial and Gender Variations in Patients With Out-of-hospital Cardiac Arrest: A Nation-Wide Study.

The overall incidence of Out-of-hospital Cardiac Arrest (OHCA) is decreasing worldwide due to emergency responses, but there are gender and racial differences in the incidence of OHCA, which remain under investigation. Our aim was to identify the incidence, gender, and racial disparities in patients admitted with OHCA. The National Inpatient Sample Database is one of the largest all-payer inpatient database. It was queried to identify patients 18 years or older who were hospitalized with the principal diagnosis of OHCA. There was a total of 85,988 patients who were discharged with a diagnosis classified as OHCA using the ICD-9 code for a period of 2 years. The mean age of the patients who had presented to the hospital with OHCA was 64.3 (±18.5 years). Overall, a greater number of males suffered from OHCA were compared with female population of (48,635 vs 37,366; P < 0.0001). The incidence of OHCA was higher among Caucasians as compared with African Americans (54,812, 63.8% vs 13,787, 16%; P < 0.0001). In-hospital deaths after OHCA were 43,024 (50%). But African Americans had higher mortality than Caucasians after hospitalization for OHCA (adjusted odds ratio, 1.23; 95% confidence interval, 1.18-1.26; P < 0.01). We observed significant differences in gender and racial factors in the patients who were admitted to the hospital with a diagnosis of OHCA based on an analysis of the national inpatient database.

Percutaneous Extraction of a Migrated WATCHMAN™ Device After Seven Months.

Rarely, a left atrial appendage closure device may chronically migrate to an unfavorable position postoperatively, requiring removal. We present the details of a case in which a WATCHMAN™ device (Boston Scientific, Natick, MA, USA) implanted seven months prior was found to have migrated with protrusion 0.91 cm outside the left atrial appendage together with a 90º tilt and peridevice leakage. Adopting a femoral arterial retrograde approach, a 27-mm WATCHMAN™ device was temporarily positioned in the ascending aorta for cerebroembolic protection, never released from the connecting wire. Extraction of the original WATCHMAN™ device was performed using an endoscopic grasping tool, with subsequent device re-implantation of a new device and removal of the temporarily positioned device in the ascending aorta.

Arrhythmias and device therapies in patients with cancer therapy-induced cardiomyopathy.

Our knowledge of associated cardiotoxicities from novel therapeutics in oncology continues to expand. These include arrhythmias from cancer-therapy induced cardiomyopathy resulting from both direct and indirect effects on cardiomyocytes and other mechanisms that can adversely impact cardiovascular outcomes and overall mortality. In this review, we focus on both the arrhythmias of various classes of oncologic agents as well as the use of cardiac implantable electronic devices (cardioverter-defibrillators, permanent pacemakers, and cardiac resynchronization therapy) in cardio-oncology patients.

Identification of a High-risk Subgroup With Malignant Mitral Valve Prolapse Who Are Predisposed to Sudden Cardiac Death: A Review.

Mitral valve prolapse (MVP) affects approximately 170 million people worldwide; however, phenotypically, there is a wide variety of heterogeneity. In particular subsets, the incidence of sudden cardiac death is calculated to be 998 per 100,000 person-years, which is significantly increased when compared with the general population of MVP patients. Individuals with high-risk features have been identified as young females with bileaflet MVP and electrocardiogram findings of frequent complex ectopy, ST-T wave changes, and inferior T wave inversions. Supplemental imaging modalities in this subgroup demonstrate redundant leaflets and chordae on 2-dimensional transthoracic echocardiography along with varying severity of mitral annular disjunction. Detailed morphologic assessment by 3-dimensional echocardiography provides a quantitative assessment of annular disjunction along with left ventricular longitudinal and basal circumferential strain patterns. Late gadolinium enhancement on cardiac magnetic resonance imaging identifies diffuse and isolated left ventricle fibrosis involving the fascicles and papillary muscles, which has been visualized in isolation during autopsy. Findings of this review propose that sudden cardiac death as a result of malignant arrhythmias arises from automaticity, complex ectopy, and reentry at the level of the fascicles and papillary muscles. The repetitive mechanical stress provides a nidus for the development of both micro- and macrofibrosis easily identified by late gadolinium enhancement on cardiac magnetic resonance imaging. Escalation to electrophysiology studies and early intervention could provide new targeted lifesaving therapies.

Left Atrial Appendage Anatomy: Implications for Endocardial Catheter-based Device Closure.

This clinical review focuses on both current devices approved by the United States Food and Drug Administration and investigational devices available for left atrial appendage (LAA) closure. Specifically, the article describes the anatomical considerations that are particularly relevant from a procedural standpoint. In addition, we have also focused on the technical aspects of the procedure.

Stress-Induced Cardiomyopathy Secondary to COVID-19.

A 67-year-old female with prior medical history of HTN and asthma presented with acute-onset dyspnea and nausea for 4 days prior to admission. Upon initial encounter in the emergency room, she was found to have findings of abnormal pulmonary infiltrates and consequent workup revealed COVID-19. During further hospital course, the patient developed abnormal EKG and echocardiographic findings consistent with stress-induced cardiomyopathy.

Atrial Fibrillation in Hypertrophic Cardiomyopathy: Evidence-based Review About Mechanism, Complications and Management.

Hypertrophic cardiomyopathy (HCM) is 1 of the most frequent genetic cardiovascular diseases affecting 1 out of every 500 individuals in general population. Atrial Fibrillation incidences were 3.8% per 100 patients per year and overall prevalence among HCM patients are 27.09%. Higher risk of death noted in HCM patients with atrial fibrillation. Stroke and other thrombo embolic risks are increased in such patients. Medical management using mainly betablockers or amiodarone produced variable results and high rate of recurrence. Catheter ablation reduced symptom burden and complications despite moderate recurrence. Patients with multiple repeated procedures found to have better success rate and outcomes. The complications are not high leading to increased feasibility of the procedure. More research using latest techniques in catheter ablation need to be studied.