Incident atrial fibrillation in patients undergoing bariatric surgery: a systematic review and meta-analysis.

BACKGROUND: There are controversial data regarding the relationship between bariatric surgery and atrial fibrillation (AF). This meta-analysis was performed to evaluate (i) the incidence and (ii) the risk of AF in patients following bariatric surgery. AIMS: To explore the incidence and risk factors of AF in patients after bariatric surgery. METHODS: A literature search was conducted utilising MEDLINE, EMBASE and Cochrane Database from inception through March 2019. We included studies that evaluated the (i) incidence and (ii) risk of AF in patients after bariatric surgery. Pooled incidence and odds ratios (OR) with 95% confidence interval (CI) were calculated using random effects meta-analysis. RESULTS: Seven cohort studies consisting of 7681 patients undergoing bariatric surgery were enrolled in this systematic review. The prevalence of AF in patients undergoing bariatric surgery ranged between 0% and 4.6%. Overall, the pooled estimated incidence of AF following bariatric surgery was 5.3% (95% CI: 1.9-13.8) at a median follow-up time of 7.9 years (interquartile range (IQR) 4.1-15.0 years). Compared to controls, the pooled OR of AF among patients undergoing bariatric surgery was 0.42 (95% CI: 0.22-0.83) at a median follow-up time of 7.9 years (IQR 7.2-19.0 years). Egger regression test demonstrated no significant publication bias in our meta-analysis of AF incidence following bariatric surgery. CONCLUSION: The overall estimated incidence of AF following bariatric surgery was 5.3%. Our study demonstrates a significant beneficial association between bariatric surgery and AF, with a 0.42-fold decreased risk of AF. Future large-scale studies are needed to confirm the potential benefits of bariatric surgery on risk of AF.

Radiofrequency ablation of atrial fibrillation: A 14 years' experience at a tertiary care center in Thailand.

BACKGROUND: The result of atrial fibrillation (AF) ablation varies across centers. Most data are derived from the Western world, while data from Southeast Asian countries are lacking. We aimed to investigate the outcomes of AF ablation in Thailand. METHOD: We performed a retrospective analysis of patients who underwent AF ablation in a tertiary care center, between the years 2006-2020. Details of AF ablation, including pulmonary vein isolation (PVI), and complex fractionated atrial electrogram (CFAE) ablation, were classified. The success rate of AF ablation is determined by freedom from AF beyond 3 months blanking period. Combined success rate of AF ablation was reported along with the success rate of each technique (PVI, CFAE, and combine PVI plus CFAE). RESULT: We identified a total of 171 patients who underwent the first AF ablation. Ninety-four (55%) patients went through PVI, 55 (32%) patients for CFAE ablation, and 22 (13%) patients for PVI plus CFAE ablation. Overall freedom from AF was 73% at 12 months, 66% at 24 months, and 55% at 36 months. The success rate of PVI was 79% at 12 months, 74% at 24 months, and 59% at 36 months. The success rate of CFAE ablation was 63% at 12 months, 51% at 24 months, and 47% at 36 months. CONCLUSION: Catheter ablation of AF is proven safe and effective in Thai population.

Cannabis and adverse cardiovascular events: A systematic review and meta-analysis of observational studies.

Background: Cannabis is the most used illicit drug in the world. Global trends of decriminalization and legalization of cannabis lead to various forms of cannabis use and bring great concerns over adverse events, particularly in the cardiovascular (CV) system. To date, the association between cannabis and adverse CV events is still controversial. Purpose: We aim to conduct a systematic review and meta-analysis to assess the adverse CV events from cannabis use. Patients and methods: A systematic search for publications describing the adverse CV events of cannabis use, including acute myocardial infarction (MI) and stroke, was performed via PubMed, Scopus, and Cochrane Library databases. Data on effect estimates in individual studies were extracted and combined via random-effects meta-analysis using the DerSimonian and Laird method, a generic inverse-variance strategy. Results: Twenty studies with a total of 183,410,651 patients were included. The proportion of males was 23.7%. The median age and follow-up time were 42.4 years old (IQR: 37.4, 50.0) and 6.2 years (IQR: 1.7, 27.7), respectively. The prevalence of cannabis use was 1.9%. Cannabis use was not significantly associated with acute MI (pooled odds ratio (OR): 1.29; 95%CI: 0.80, 2.08), stroke (pooled OR 1.35; 95%CI: 0.74, 2.47), and adverse CV events (pooled OR: 1.47; 95%CI: 0.98, 2.20). Conclusion: The risk of adverse CV events including acute MI and stroke does not exhibit a significant increase with cannabis exposure. However, caution should be exercised when interpreting the findings due to the heterogeneity of the studies.

T-Peak to T-End Interval for Prediction of Positive Response to Ajmaline Challenge Test in Suspected Brugada Syndrome Patients.

BACKGROUND: Brugada syndrome (BrS) is diagnosed in patients with ST-segment elevation with coved-type morphology in the right precordial leads, occurring spontaneously or after provocative drugs. Due to electrocardiographic (ECG) inconsistency, provocative drugs, such as sodium-channel blockers, are useful for unmasking BrS. Ajmaline is superior to flecainide and procainamide to provoke BrS. Prolonged T-peak to T-end (TpTe) is associated with an increased risk of ventricular arrhythmia and sudden cardiac death in Brugada syndrome patients. OBJECTIVE: This study aimed to investigate the predictive value of T-peak to T-end interval and corrected T-peak to T-end interval for predicting the positive response of the ajmaline challenge test in suspected Brugada syndrome patients. METHODS: Patients who underwent the ajmaline test in our center were enrolled. Clinical characteristics and electrocardiographic parameters were analyzed, including TpTe, corrected TpTe, QT, corrected QT(QTc) interval, and S-wave duration, compared with the result of the ajmaline challenge test. RESULTS: The study found that TpTe and corrected TpTe interval in suspected BrS patients were not significantly associated with a positive response to the ajmaline challenge test. CONCLUSIONS: The T-peak to T-end interval and corrected T-peak to T-end interval could not predict the positive response of the ajmaline challenge test in suspected Brugada syndrome patients.

Concomitant myocarditis and painless thyroiditis after AstraZeneca coronavirus disease 2019 vaccination: a case report.

BACKGROUND: Incidence of myocarditis following messenger RNA coronavirus disease 2019 vaccination has been widely described, but this clinical scenario after adenoviral vector coronavirus disease 2019 vaccination has only been rarely reported. In addition, a few case reports of thyroiditis after adenoviral vector coronavirus disease 2019 vaccination have been published. CASE PRESENTATION: A 55-year-old Thai woman presented with palpitation without neck pain 14 days after receiving AstraZeneca coronavirus disease 2019 vaccination. Electrocardiography revealed sinus tachycardia. Her blood tests showed elevation of cardiac troponin and free triiodothyronine with suppressed serum thyroid stimulating hormone, reflecting a hyperthyroid status. Evidence of myocardial inflammation and necrosis from cardiac magnetic resonance imaging supported the diagnosis of recent myocarditis. Laboratory results and imaging findings were consistent with thyroiditis. After 3 weeks of symptomatic treatment, her symptom and blood tests had returned to normal. CONCLUSIONS: This case demonstrates that the adenoviral vector coronavirus disease 2019 vaccine could possibly cause myocarditis and painless thyroiditis. Clinicians should have a high index of suspicion and promptly evaluate these conditions, despite minimal symptoms.

Benefit of Atrial Overdrive Pacing in Patients with Sleep Apnea: A Meta-Analysis.

BACKGROUND: Sleep apnea is one of the most common conditions around the world. This disorder can significantly impact cardiovascular morbidity and mortality. Atrial overdrive pacing (AOP) is a treatment modality that can potentially decrease respiratory events. There is currently a lack of evidence to confirm the benefits of AOP. We aimed to assess the impact of AOP in patients with obstructive sleep apnea (OSA), central sleep apnea (CSA), and mixed type. METHODS: A literature search for studies that reported the impact on apnea-hypopnea index (AHI) by cardiac implantable electronic devices with different pacing modes was conducted using MEDLINE, Embase, and Cochrane Database from inception through July 2020. Pooled standard mean difference with 95%CI was calculated using a random-effects model. RESULTS: Fifteen studies, including thirteen randomized studies and two observational studies containing 440 patients, were identified. The standard mean difference in apnea-hypopnea index of atrial overdrive pacing demonstrated less duration of apnea/hypopnea in patients with atrial overdrive pacing (AOP) (SMD -0.29, 95%CI: -0.48, -0.10, I2 = 57%). Additional analysis was performed to assess the effect of atrial overdrive pacing in patients with or without severe sleep apnea syndrome (mean AHI < 30 defined as non-severe). There was no statistically significant difference in standardized mean in AHI in both subgroups between AOP and control groups (SMD -0.25, severe sleep apnea syndrome SMD -0.03, I2 = 0.00%). CONCLUSIONS: AOP was associated with a statistically significant reduction in AHI, but the magnitude of reduction was small. AOP may potentially be used as an adjunctive treatment with other modalities in treating patients with sleep apnea.

Structurally Abnormal Myocardium Underlies Ventricular Fibrillation Storms in a Patient Diagnosed With the Early Repolarization Pattern.

OBJECTIVES: The aim of this study was to investigate the mechanism underlying QRS-slurring in a patient with the early repolarization pattern in the electrocardiogram (ECG) and ventricular fibrillation (VF) storms. BACKGROUND: The early repolarization pattern refers to abnormal ending of the QRS complex in subjects with structurally normal hearts and has been associated with VF. METHODS: We studied a patient with slurring of the QRS complex in leads II, III, and aVF of the ECG and recurrent episodes of VF. Echocardiographic and imaging studies did not reveal any abnormalities. Endocardial mapping was normal but subxyphoidal epicardial access was not possible. Open chest epicardial mapping was performed. RESULTS: Mapping showed that the inferior right ventricular free wall activated the latest with local J-waves in unipolar electrograms. The last moment of epicardial activation concurred with QRS-slurring in the ECG whereas the J-waves in the local unipolar electrograms occurred in the ST-segment of the ECG. Myocardial biopsies obtained from the late activated tissue showed severe fibrofatty alterations in the inferior right ventricular wall where fractionation and local J-waves were present. After ablation, the early repolarization pattern in the ECG disappeared and arrhythmias have been absent since (follow-up 18 months). CONCLUSIONS: In this patient, the electrocardiographic early repolarization pattern was caused by late activation due to structurally abnormal myocardium. The late activated areas were marked by J-waves in local electrograms. Ablation of these regions prevented arrhythmia recurrence and normalized the ECG.

Hypertension Subtypes among Thai Hypertensives: An Analysis of Telehealth-Assisted Instrument in Home Blood Pressure Monitoring Nationwide Pilot Project.

BACKGROUND: White-coat hypertension (HT), masked HT, HT with white-coat effect, and masked uncontrolled HT are well-recognized problems of over- and undertreatment of high blood pressure in real-life practice. However, little is known about the true prevalence in Thailand. OBJECTIVES: To examine the prevalence and characteristics of each HT subtype defined by mean home blood pressure (HBP) and clinic blood pressure (CBP) using telemonitoring technology in Thai hypertensives. METHODS: A multicenter, observational study included adult hypertensives who had been diagnosed for at least 3 months based on CBP without the adoption of HBP monitoring. All patients were instructed to manually measure their HBP twice a day for the duration of at least one week using the same validated automated, oscillometric telemonitoring devices (Uright model TD-3128, TaiDoc Corporation, Taiwan). The HBP, CBP, and baseline demographic data were recorded on the web-based system. HT subtypes were classified according to the treatment status, CBP (≥or <140/90 mmHg), and mean HBP (≥or <135/85 mmHg) into the following eight subtypes: in nonmedicated hypertensives, there are four subtypes that are normotension, white-coat HT, masked HT, and sustained HT; in treated hypertensives, there are four subtypes that are well-controlled HT, HT with white-coat effect, masked uncontrolled HT, and sustained HT. RESULTS: Of the 1,184 patients (mean age 58 ± 12.7 years, 59% women) from 46 hospitals, 1,040 (87.8%) were taking antihypertensive agents. The majority of them were enrolled from primary care hospitals (81%). In the nonmedicated group, the prevalence of white-coat and masked HT was 25.7% and 7.0%, respectively. Among the treated patients, the HT with white-coat effect was found in 23.3% while 46.7% had uncontrolled HBP (a combination of the masked uncontrolled HT (9.6%) and sustained HT (37.1%)). In the medicated older subgroup (n = 487), uncontrolled HBP was more prevalent in male than in female (53.6% vs. 42.4%, p=0.013). CONCLUSIONS: This is the first nationwide study in Thailand to examine the prevalence of HT subtypes. Almost one-fourth had white-coat HT or HT with white-coat effect. Approximately half of the treated patients especially in the older males had uncontrolled HBP requiring more intensive interventions. These results emphasize the role of HBP monitoring for appropriate HT diagnosis and management. The cost-effectiveness of utilizing THAI HBPM in routine practice needs to be examined in the future study.

Common and rare susceptibility genetic variants predisposing to Brugada syndrome in Thailand.

BACKGROUND: Mutations in SCN5A are rarely found in Thai patients with Brugada syndrome (BrS). Recent evidence suggested that common genetic variations may underlie BrS in a complex inheritance model. OBJECTIVE: The purpose of this study was to find common and rare/low-frequency genetic variants predisposing to BrS in persons in Thailand. METHODS: We conducted a genome-wide association study (GWAS) to explore the association of common variants in 154 Thai BrS cases and 432 controls. We sequenced SCN5A in 131 cases and 205 controls. Variants were classified according to current guidelines, and case-control association testing was performed for rare and low-frequency variants. RESULTS: Two loci were significantly associated with BrS. The first was near SCN5A/SCN10A (lead marker rs10428132; odds ratio [OR] 2.4; P = 3 × 10-10). Conditional analysis identified a novel independent signal in the same locus (rs6767797; OR 2.3; P = 2.7 × 10-10). The second locus was near HEY2 (lead marker rs3734634; OR 2.5; P = 7 × 10-9). Rare (minor allele frequency [MAF] <0.0001) coding variants in SCN5A were found in 8 of the 131 cases (6.1% in cases vs 2.0% in controls; P = .046; OR 3.3; 95% confident interval [CI] 1.0-11.1), but an enrichment of low-frequency (MAF<0.001 and >0.0001) variants also was observed in cases, with 1 variant (SCN5A: p.Arg965Cys) detected in 4.6% of Thai BrS patients vs 0.5% in controls (P = 0.015; OR 9.8; 95% CI 1.2-82.3). CONCLUSION: The genetic basis of BrS in Thailand includes a wide spectrum of variant frequencies and effect sizes. As previously shown in European and Japanese populations, common variants near SCN5A and HEY2 are associated with BrS in the Thai population, confirming the transethnic transferability of these 2 major BrS loci.

Incidence of atrial fibrillation in pregnancy and clinical significance: A meta-analysis.

PURPOSE: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, and is associated with increased morbidity and mortality. However, the incidence and maternal/fetal outcomes of AF in pregnancy remain unclear. This study's aims were to investigate the pooled incidence of AF in pregnant women and to assess maternal/fetal outcomes of AF in pregnancy. MATERIAL AND METHODS: A literature search for studies that reported incidence of AF in pregnancy, was conducted using MEDLINE, EMBASE and Cochrane Database from inception through May 2018. Pooled incidence with 95%CI were calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42018095955). RESULTS: We identified 7 cohort studies including 301,638 pregnancies. The pooled estimated incidence of AF in pregnancy among women with no known heart disease, and those with structural heart disease was 0.3% (95%CI: 0.01%-40.6%) and 2.2% (95%CI: 0.96%-5.01%), respectively. Among women with known AF, the pooled estimated incidence of recurrent AF in pregnancy was 39.2% (95%CI: 16.9%-67.2%). The pooled estimated incidence of pre-eclampsia and congestive heart failure among pregnant patients with AF was 4.1% (95%CI: 2.1%-7.8%) and 9.6% (95%CI: 5.7%-15.9%), respectively. The pooled estimated incidence of fetal events including premature birth, small for gestational age, respiratory distress syndrome, intraventricular hemorrhage, death was 26.6% (95%CI: 20.4%-34.0%). CONCLUSION: The overall estimated incidence of AF and recurrent AF during pregnancy is as high as 2.2% and 39.2%, respectively. AF during pregnancy may result in poor maternal and fetal outcomes.

Efficacy and safety of anticoagulation for atrial fibrillation in patients with cirrhosis: A systematic review and meta-analysis.

OBJECTIVE: The atrial fibrillation-related stroke is clearly prevented by anticoagulation treatment, however, management of anticoagulation for AF in patients with cirrhosis represents a challenge due to bleeding concerns. To address this issue, a systematic review and meta-analysis of the literature was performed. METHODS: A literature search for studies reporting the incidence of AF in patients with cirrhosis was conducted using MEDLINE, EMBASE and Cochrane Database, from inception through July 2018. RESULTS: 7 cohort studies including 19,798 patients with AF and cirrhosis were identified. The use of anticoagulation (%) among included studies ranged from 8.3% to 53.9%. Anticoagulation use for AF in patients with cirrhosis was significantly associated with a reduced risk of stroke, with a pooled HR of 0.58 (95%CI: 0.35-0.96). When compared with no anticoagulation, the use of anticoagulation was not significantly associated with a higher risk of bleeding, with a pooled HR of 1.45 (95%CI: 0.96-2.17). Compared to warfarin, the use of direct oral anticoagulants (DOACs) was associated with a lower risk of bleeding among AF patients with cirrhosis. CONCLUSION: Our study demonstrates that anticoagulation use for AF in patients with cirrhosis is associated with a reduced risk of stroke, without increasing significantly the risk of bleeding, when compared to those without anticoagulation.

Feasibility, safety, and mid-term efficacy of cardiac resynchronization therapy in patients with severe heart failure and ventricular conduction delay: Chulalongkorn experience.

BACKGROUND: Heart failure is a major and growing public health problem in developed and developing countries. Despite major advances in medical therapy, morbidity and mortality remain high. Cardiac resynchronization therapy (CRT) has been proposed as an adjunctive therapy in patients with drug-refractory heart failure and ventricular conduction delay. Short and long-term studies have demonstrated the clinical benefits of CRT. OBJECTIVE: The present study was designed to assess the feasibility, safety, and mid-term efficacy of CRT in patients with severe heart failure and ventricular conduction delay in the institute. MATERIAL AND METHOD: Ten patients with severe heart failure in New York Heart Association (NYHA) functional class III or IV with left ventricular ejection fraction (LVEF) < 35%, QRS duration >120 ms with left bundle branch block morphology received CRT At baseline, and 6 months after implantation, the following parameters were evaluated: NYHA class, QRS duration, LVEF N-terminal pro-brain natriuretic peptide (NT-pro BNP) level, 6-minute walking distance, SF-36 quality-of-life (QOL) score, and number of heart failure visit. RESULTS: All clinical parameters improved significantly at 6 months. NYHA class decreased from 3.5 +/- 0.5 to 2.4 +/- 0.7 (p < 0.01). QRS duration decreased from 145 +/- 22 ms to 126 + 6 ms (p < 0.01). LVEF increasedfrom 21 +/- 6% to 31 +/- 12% (p < 0.01). NT-pro BNP level decreased from 2503 +/- 1953 pg/ml to 767 +/- 342 pg/ml (p < 0.01). The 6-minute walking distance increased from 153 +/- 122 m to 278 +/- 128 m (p < 0.01). QOL score improved from 66 +/- 14 to 98 +/- 25 (p < 0. 01). The number of heart failure visits was reduced from 3.8 +/- 3.7 per year to 0.5 +/- 0.8 visit per year (p < 0.01). Seventy percent of patients were free of heart failure visit for one year after implantation. One patient had sudden cardiac death eleven months after implantation. There was no procedure-related mortality. One patient had left ventricular lead dislodgement 3 months after implantation. CONCLUSION: In the present study, CRT was safe and effective in improving heart failure symptom, functional status, LV function, and quality of life. CRT also reduced heart failure hospitalization in the presented severe heart failure and ventricular conduction delay patients.

Intrauterine therapy for fetal supraventricular tachycardia in a twin pregnancy.

A case of a twin pregnancy in which one fetus developed hydrops secondary to supraventricular tachycardia was detected at 21 weeks' gestation. Transplacental digoxin therapy successfully converted the supraventricular tachycardia to a normal sinus rhythm without evidence of maternal or fetal side-effects. The pregnancy proceeded to term and elective cesarean section was carried out at 37 weeks' gestation.