Carotid access for transcatheter aortic valve replacement: A meta-analysis.

OBJECTIVE: We sought to evaluate the feasibility and safety of carotid access transcatheter aortic valve replacement (TAVR) by performing a meta-analysis of published cases. BACKGROUND: Several case series and regional data have provided initial basis for carotid access TAVR in patients with prohibitive femoral approach. We performed this meta-analysis to provide further evidence of feasibility and safety of carotid TAVR. METHODS: We searched PubMed, EMBASE, CINAHL, and Cochrane CENTRAL for any study on carotid access TAVR involving ⩾5 patients since inception till March 1, 2020. Random-effects model was used to compute overall effects. The outcomes analyzed were all-cause mortality, Transient ischemic attack (TIA)/stroke, need for permanent pacemaker (PPM) implantation, pericardial tamponade, access site complications, major bleeding, and length of stay. RESULTS: There was a total of 17 retrospective studies (n = 2082) with a median follow-up of 1 month. Mean age of the patient was 80 years. Mean Euroscore and STS scores were 15 ± 6.2 and 7.9 ± 3.3, respectively. The procedural success rate was 99%. The rate of all-cause mortality was 6.7% (range 4.6-9.7%, p < .001, I2 = 67%). Incidence of TIA/stroke was 3.9% (range 3.1-4.8%, p < .001, I2 = 0%) and PPM implantation was 16.7% (range 12.5-21.9%, p < .001, I2 = 56%). Rate of pericardial tamponade, vascular complication, and major bleeding were 1.7, 2.5, and 7%, respectively. Average length of hospital stay was 7.7 days. CONCLUSION: Our results show that transcarotid approach is a feasible option in patients with prohibitive femoral access for TAVR.

Role of cardiac sympathetic denervation in ventricular tachycardia: A meta-analysis.

BACKGROUND: Cardiac sympathetic denervation (CSD) is being used in the management of refractory ventricular tachycardia (VT) and electrical storm. However, data on the role of CSD in the management of ventricular arrhythmia is limited. METHODS: We performed a meta-analysis of retrospective studies to calculate the pooled rate of freedom from VT and the standard mean difference of ICD shocks before and after CSD. RESULTS: 14 nonrandomized studies with a total of 311 patients with refractory VT or electrical storm were included. At a mean follow up of 15 ± 10.7 months, the pooled rate of freedom from VT (VT nonrecurrence rate) after CSD in all causes of arrhythmia was 60% (range 48.8% to 70%, I2   = 43%). When analysis was restricted to only arrhythmias caused by conditions other than catecholaminergic polymorphic ventricular tachycardia (CPVT) and long QT syndrome (LQTS), the pooled VT non-recurrence rate was 50% (range 41% to 58%, I2   = 5%). After CSD, mean total number of ICD shocks per person diminished by 3.01 (95% CI 1.09-4.94, P = .002, I2  = 96%) in overall analysis and by 0.97(95% CI 0.41-1.5, P = .001, I2  = 45%) when CPVT and LQTS were excluded. CONCLUSION: In patients with refractory VT or electrical storm, CSD is associated with pooled VT nonrecurrence rate of 60% at a mean follow-up of 15 ± 10.7 months. CSD was also associated with significantly lower mean number ICD shocks per person. Further studies are needed to validate this finding in a prospective setting.

Baseline thrombocytopenia in women with coronary heart disease increases incident acute coronary syndrome: insights from national inpatient database.

There are paucity of data on gender-based differences in the effect of thrombocytopenia and coronary heart disease (CHD) towards development of acute coronary syndrome (ACS). We used National Inpatient Sample (NIS) database of the United States to assess the gender-based differences in the association of thrombocytopenia with CHD and the impact of thrombocytopenia on mortality, length of stay and hospitalization costs on ACS subgroup of CHD. Our analysis found that thrombocytopenia was associated with increased odds of CHD on univariate (odds ratio [OR] 1.31 (95% CI 1.30-1.32) p < 0.001) and multivariate (OR 1.36 (95% CI 1.34-1.38) p < 0.001) analyses. Thrombocytopenic CHD patients had increased odds of developing ACS only in women (OR 1.15, 95% CI 1.12-1.17, p < 0.001). Thrombocytopenia was found to be associated with poor short-term outcome in ACS subgroup of CHD with higher in-hospital mortality (OR 1.64, CI 1.58 to 1.71, p < 0.001), length of stay (3.4 days, CI 3.30-3.52, p < 0.001), and cost of hospitalization ($55,652, CI 53,717-57,587, p < 0.001). Thrombocytopenic women with ACS have greater odds of mortality compared to men. Our study suggests that thrombocytopenia among women with CHD is associated with increased odds of developing ACS. Women with ACS have greater mortality compared to men. Thrombocytopenic ACS patients have worse in-hospital outcome compared to patients with normal platelet count. We demonstrated association only and is not possible to establish causality with our study.

Transseptal Puncture: Devices, Techniques, and Considerations for Specific Interventions.

PURPOSE OF REVIEW: Transseptal puncture is a routinely performed interventional cardiology procedure for an array of cardiac diseases. We aimed to review the current status of available devices and techniques of transseptal puncture with consideration to specific interventions. RECENT FINDINGS: Except for a few modifications, devices for transseptal puncture technique has not changed much compared to when it was first described almost 60 years ago. For difficult transseptal puncture, a few newer techniques such as radio frequency needle puncture system have been used but there is lack of robust clinical study. Advanced imaging, such as intracardiac echocardiography and transesophageal echocardiography, has been found to make transseptal puncture safer. A new transseptal approach that incorporates 3D non-fluoroscopic catheter tracking systems has shown promising results in two human studies. While various modifications in the transseptal technique tailored to the specific interventions have improved procedural safety, further improvement in existing devices focusing on distinct procedure might be needed in the future.

An update on the epidemiology, length of stay, and cost of Kawasaki disease hospitalisation in the United States.

BACKGROUND: Kawasaki disease is an acute vasculitis of childhood and is the leading cause of acquired heart disease in the developed countries. METHODS: Data from hospital discharge records were obtained from the National Kids Inpatient Database for years 2009 and 2012. Hospitalisations by months, hospital regions, timing of admission, insurance types, and ethnicity were analysed. Length of stay and total charges were also analysed. RESULTS: There were 10,486 cases of Kawasaki disease from 12,678,005 children hospitalisation. Kawasaki disease was more common between 0 and 5 years old, in male, and in Asian. The January-March quarter had the highest rate compared to the lowest in the July-September quarter (OR=1.62, p < 0.001). Admissions on the weekend had longer length of stay [4.1 days (95 % CI: 3.97-4.31)] as compared to admissions on a weekday [3.72 days (95 % CI: 3.64-3.80), p < 0.001]. Blacks had the longest length of stay and whites had the shortest [4.33 days (95 % CI: 4.12-4.54 days) versus 3.60 days (95 % CI: 3.48-3.72 days), p < 0.001]. Coronary artery aneurysm was identified in 2.7 % of all patients with Kawasaki disease. Children with coronary artery aneurysm were hospitalised longer and had higher hospital charge. Age, admission during weekend, and the presence of coronary artery aneurysm had significant effect on the length of stay. CONCLUSIONS: This report provides the most updated epidemiological information on Kawasaki disease hospitalisation. Age, admissions during weekend, and the presence of coronary artery aneurysm are significant contributors to the length of stay.

Efficacy and Safety of Proton Pump Inhibitors in the Long-Term Aspirin Users: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Long-term aspirin use in cardiovascular disease prevention may result in gastrointestinal bleeding. Although proton pump inhibitors (PPI) have been shown to reduce the risks of peptic ulcers and dyspeptic symptoms in long-term aspirin users in the randomized controlled trials, there are safety concerns about the long-term use of PPI. STUDY QUESTION: What is the safety and efficacy of PPI in patients using aspirin in long term for prevention of cardiovascular diseases and stroke? METHODS: We searched MEDLINE, EMBASE, CENTRAL, CINAHL, ProQuest, and relevant references from inception through February 2015, and used random-effects model for meta-analysis. RESULTS: A total of 10 publications from 9 studies (n = 6382) were included in the meta-analysis. Compared with control, PPI reduced the risks of peptic ulcers [risk ratio (RR): 0.19; 95% confidence interval: 0.13-0.26; P < 0.00001], gastric ulcers [0.24 (0.16-0.35); P < 0.00001], duodenal ulcers [0.12 (0.05-0.29); P < 0.00001], bleeding ulcers [0.22 (0.10-0.51); P = 0.0004], and erosive esophagitis [0.14 (0.07-0.28); P < 0.00001]. PPI increased the resolution of epigastric pain [1.13 (1.03-1.25); P = 0.01], heartburn [1.24 (1.18-1.31); P < 0.00001], and regurgitation [1.26 (1.13-1.40); P < 0.0001], but did not increase the risks of all-cause mortality [1.72 (0.61-4.87); P = 0.31], cardiovascular mortality [1.80 (0.59-5.44); P = 0.30], nonfatal myocardial infarction/ischemia [0.56 (0.22-1.41); P = 0.22], ischemic stroke/transient ischemic attack [1.09 (0.34-3.53); P = 0.89] and other adverse events. CONCLUSIONS: The PPI seems to be effective in preventing peptic ulcers and erosive esophagitis and in resolution of dyspeptic symptoms without increasing adverse events, cardiac risks or mortality in long-term aspirin users.

Anti-IL-17 therapy in treatment of rheumatoid arthritis: a systematic literature review and meta-analysis of randomized controlled trials.

IL-17 has a role in inflammation in RA, and its levels in joints correlate with disease severity. Multiple RCTs have been performed to study effects of anti-IL-17 agents. The objective of this study was to perform a systematic review and meta-analysis to analyze the efficacy and safety of anti-IL-17 agents in the management of RA. This work is based on a systematic review of studies retrieved by a sensitive search strategy in PubMed, EMBASE and Cochrane CENTRAL from inception through 9/7/15. Study selection criteria were the following: adult patients (age ≥ 18 years) with RAs, random selection of patients for anti-IL-17 therapy and treatment response compared to placebo. We performed systematic literature review per PRISMA guideline and two investigators independently selected seven randomized clinical trials (RCTs) for meta-analysis. We used random effect model calculating odds ratio (OR) and 95 % confidence interval (CI) to measure the efficacy with ACR20/50/70 responses and the safety with adverse events. Seven studies with total of 1226 patients including 905 in anti-IL-17 group and 321 in placebo were included in the meta-analysis. Anti-IL-17 was effective in achieving ACR20 and ACR50 compared to placebo (OR 2.47, 95 % CI 1.29-4.72, P = 0.006, I (2) 77 % and OR 2.94, 95 % CI 1.37-6.28, P = 0.005, I (2) 64 %, respectively). Data analysis for ACR70 showed a favorable trend toward anti-IL-17 (OR 2.62, 95 % CI 1-6.89, P = 0.05, I (2) 15 %). Subgroup analysis of ACR20 for individual anti-IL-17 agents showed that ixekizumab was more effective than placebo, while secukinumab showed a trend toward achieving the ACR20 response. However, brodalumab was not effective compared to placebo. Safety analysis did not show increased risk of any or serious adverse effects by anti-IL-17 compared to placebo (OR 1.23, 95 % CI 0.94-1.61, P = 0.13, I (2) = 0 % and OR 1.28, 95 % CI 0.57-2.88, P = 0.55, I (2) = 0 %, respectively). This meta-analysis concludes that anti-IL-17 is effective in the treatment of RA without increased risk of any or serious adverse effects; however, the results are limited by significant heterogeneity and small duration of studies.

Self-Measured Blood Pressure-Guided Pharmacotherapy: A Systematic Review and Meta-Analysis of United States-Based Telemedicine Trials.

BACKGROUND: The optimal approach to implementing telemedicine hypertension management in the United States is unknown. METHODS: We examined telemedicine hypertension management versus the effect of usual clinic-based care on blood pressure (BP) and patient/clinician-related heterogeneity in a systematic review/meta-analysis. We searched United States-based randomized trials from Medline, Embase, CENTRAL, CINAHL, PsycINFO, Compendex, Web of Science Core Collection, Scopus, and 2 trial registries. We used trial-level differences in BP and its control rate at ≥6 months using random-effects models. We examined heterogeneity in univariable metaregression and in prespecified subgroups (clinicians leading pharmacotherapy [physician/nonphysician], self-management support [pharmacist/nurse], White versus non-White patient predominant trials [>50% patients/trial], diabetes predominant trials [≥25% patients/trial], and White patient predominant but not diabetes predominant trials versus both non-White and diabetes patient predominant trials]. RESULTS: Thirteen, 11, and 7 trials were eligible for systolic and diastolic BP difference and BP control, respectively. Differences in systolic and diastolic BP and BP control rate were -7.3 mm Hg (95% CI, -9.4 to -5.2), -2.7 mm Hg (-4.0 to -1.5), and 10.1% (0.4%-19.9%), respectively, favoring telemedicine. Greater BP reduction occurred in trials where nonphysicians led pharmacotherapy, pharmacists provided self-management support, White patient predominant trials, and White patient predominant but not diabetes predominant trials, with no difference by diabetes predominant trials. CONCLUSIONS: Telemedicine hypertension management is more effective than clinic-based care in the United States, particularly when nonphysicians lead pharmacotherapy and pharmacists provide self-management support. Non-White patient predominant trials achieved less BP reduction. Equity-conscious, locally informed adaptation of telemedicine interventions is needed before wider implementation.

Heterogeneity of the Effect of Telemedicine Hypertension Management Approach on Blood Pressure: A Systematic Review and Meta-analysis of US-based Clinical Trials.

Background: Telemedicine management of hypertension (TM-HTN) uses home blood pressure (BP) to guide pharmacotherapy and telemedicine-based self-management support (SMS). Optimal approach to implementing TM-HTN in the US is unknown. Methods: We conducted a systematic review and a meta-analysis to examine the effect of TM-HTN vs. usual clinic-based care on BP and assessed heterogeneity by patient- and clinician-related factors. We searched US-based randomized clinical trials among adults from Medline, Embase, CENTRAL, CINAHL, PsycInfo, and Compendex, Web of Science Core Collection, Scopus, and two trial registries to 7/7/2023. Two authors extracted, and a third author confirmed data. We used trial-level differences in systolic BP (SBP), diastolic BP (DBP) and BP control rate at ≥6 months using random-effects models. We examined heterogeneity of effect in univariable meta-regression and in pre-specified subgroups [clinicians leading pharmacotherapy (physician vs. non-physician), SMS (pharmacist vs. nurse), White vs. non-White patient predominant trials (>50% patients/trial), diabetes predominant trials (≥25% patients/trial) and in trials that have majority of both non-White patients and patients with diabetes vs. White patient predominant but not diabetes predominant trials. Results: Thirteen, 11 and 7 trials were eligible for SBP, DBP and BP control, respectively. Differences in SBP, DBP and BP control rate were -7.3 mmHg (95% CI: - 9.4, -5.2), -2.7 mmHg (-4.0, -1.5) and 10.1% (0.4%, 19.9%), respectively, favoring TM-HTN. More BP reduction occurred in trials with non-physician vs. physician led pharmacotherapy (9.3/4.0 mmHg vs. 4.9/1.1 mmHg, P<0.01 for both SBP/DBP), pharmacist vs. nurses provided SMS (9.3/4.1 mmHg vs. 5.6/1.0 mmHg, P=0.01 for SBP, P<0.01 for DBP), and White vs. non-White patient predominant trials (9.3/4.0 mmHg vs. 4.4/1.1 mmHg, P<0.01 for both SBP/DBP), with no difference by diabetes predominant trials. Lower BP reduction occurred in both diabetes and non-White patient predominant trials vs. White patient predominant but not diabetes predominant trials (4.5/0.9 mmHg vs. 9.5/4.2 mmHg, P<0.01 for both SBP/DBP). Conclusions: TM-HTN is more effective than clinic-based care in the US, particularly when non-physician led pharmacotherapy and pharmacist provided SMS. Non-White patient predominant trials seemed to achieve lesser BP reduction. Equity conscious, locally informed adaptation of TM-HTN is needed before wider implementation. Clinical Perspective: What Is New?: In this systematic review and meta-analysis of US-based clinical trials, we found that telemedicine management of hypertension (TM-HTN) was more effective in reducing and controlling blood pressure (BP) compared with clinic based hypertension (HTN) care.The BP reduction was more evident when pharmacotherapy was led by non-physician compared with physicians and HTN self-management support was provided by clinical pharmacists compared with nurses,Non-White patient predominant trials achieved lesser BP reductions than White patient predominant trials.What Are the Clinical Implications?: Before wider implementation of TM-HTN intervention in the US, locally informed adaptation, such as optimizing the team-based HTN care approach, can provide more effective BP control.Without equity focused tailoring, TM-HTN intervention implemented as such can exacerbate inequities in BP control among non-White patients in the US.

Improving Outcomes in Cardiovascular Diseases: A Review on Vorapaxar.

Antiplatelet agents are the standard of practice in the management of atherosclerosis and acute coronary syndrome. In contrast to the available antiplatelet agents, vorapaxar represents a novel mechanism of action. It is an antagonist of the platelet protease-activated receptor-1 and inhibits thrombin-induced and thrombin receptor agonist peptide-induced platelet aggregation. The Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events-Thrombolysis in Myocardial Infarction 50 (TRA 2°P-TIMI 50) trial led to the approval of vorapaxar by the Food and Drug Administration and European Medicines Agency for the reduction of thrombotic cardiovascular events in patients with a history of myocardial infarction (MI) or peripheral arterial disease. TRA 2°P-TIMI 50 trial showed that the use of vorapaxar (2.5 mg once/daily) in addition to standard dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor was effective in the secondary prevention of recurrent thrombotic events among patients with previous atherothrombosis, particularly in patients with prior MI; at the expense of an increase in major bleeding. Another recently published Vorapaxar Therapy in Patients With Prior Myocardial Infarction Treated With Newer Generation P2Y12 Receptor Inhibitors Prasugrel and Ticagrelor (VORA-PRATIC) study showed that among post-MI patients treated with potent P2Y12 inhibitors (prasugrel or ticagrelor), vorapaxar reduced platelet-driven global thrombogenicity, an effect that persisted, albeit attenuated, in the absence of aspirin. The current review summarizes an up-to-date literature on pharmacokinetics, pharmacodynamics, and clinical efficacy of vorapaxar and proposes future directions of research.

Rotational Atherectomy in Acute Coronary Syndrome: A Meta-Analysis.

BACKGROUND: The use of rotational atherectomy (RA) in percutaneous coronary intervention (PCI) of acute coronary syndrome (ACS) is considered relatively contraindicated. There have been several observational studies showing RA use in ACS, however, no systemic studies have been undertaken. We sought to evaluate the feasibility and outcomes of RA PCI in ACS by performing a meta-analysis. METHODS: We searched PUBMED, EMBASE, CINAHL, and Cochrane Central Register of Clinical Trials for any studies that evaluated the role of RA PCI in ACS. The outcomes analyzed were all-cause mortality, cardiac mortality, short and long-term major adverse cardiac events (MACE), procedural complications and cardiac perforations. RESULTS: There was a total of 8 retrospective studies with a total population of 1237 with a median follow up of 23 months. The median age of the included patient was 73. Angiographic success rate was 97.4%. The rate of all-cause mortality and cardiac mortality were 5% (range 1-12%, p < 0.001, I2 = 92%) and 2% (range 0-5%, P = 0.03, I2 = 58%) respectively. In-hospital MACE and long-term MACE were 7% (range 3-13%, p < 0.001, I2 = 87%) and 29% (range 21-37%, p = 0.21, I2 = 34%) respectively. The incidence of total procedural complications was noted to be 7% (range 2-14%, p < 0.001, I2 = 90%). Rate of perforation was 1% (range 0-1%, p = 0.9, I2 = 0%). CONCLUSION: Our results show that RA PCI is feasible in ACS with comparable procedural complications and short-term MACE, but with a higher long-term MACE rate compared to RA PCI in routine cases.

Pacing therapies for sleep apnea and cardiovascular outcomes: A systematic review.

PURPOSE: Phrenic and hypoglossal nerve pacing therapies have shown benefit in sleep apnea. We sought to analyze the role of pacing therapies in sleep apnea and their impact on heart failure. METHODS: A comprehensive literature search in PubMed and Google Scholar from inception to August 5, 2019, was performed. A meta-analysis was performed using fixed effects model to calculate mean difference (MD) with 95% confidence interval (CI). RESULTS: Six studies were eligible and included 626 patients, of whom 334 were in the control arm and 393 were in the experimental arm. Phrenic nerve pacing (MD - 23.20 events/h, 95% CI - 27.96 to - 18.44, p < 0.00001) and hypoglossal nerve pacing (MD - 20.24 events/h, 95% CI - 23.22 to - 17.27, p < 0.00001) were associated with improvements in apnea-hypopnea index (AHI). Phrenic nerve pacing was associated with a trend towards improvements in left ventricular ejection fraction (MD 3.95%, 95% CI - 0.04 to 7.94, p = 0.05). Hypoglossal and phrenic nerve pacing were associated with improvements in the quality of life as assessed by improvements in Epworth sleepiness scale (MD 3.71 points, 95% CI 2.89 to 4.54, p < 0.00001). CONCLUSIONS: Our analysis suggests that phrenic and hypoglossal nerve pacing improves AHI and quality of life with a trend towards improvement in left ventricular ejection fraction, especially in central sleep apnea. Complications were high but future refinement in technology will likely improve clinical outcomes and minimize complications.

Evaluating the role of transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in left atrial appendage occlusion: a meta-analysis.

PURPOSE: Intracardiac echocardiography (ICE) is increasingly common among periprocedural imaging modalities used during complex cardiac procedures. We sought to perform a meta-analysis comparing transesophageal echocardiography (TEE) and ICE in endocardial left atrial appendage occlusion (LAAO). METHODS: We searched PubMed and Google Scholar regarding abstracts and manuscripts using keywords: atrial fibrillation, left atrial appendage occlusion, Watchman, Amplatzer Cardiac Plug, Amulet, intracardiac echocardiography, and transesophageal echocardiography from their inception to July 12, 2019. Data extraction was performed using standard form for the following: title, year of publication, sample size, comorbid conditions, LAAO device, type of pre-procedural imaging, intraprocedural imaging, and clinical outcomes including the following: acute procedural success, fluoroscopy, and total procedure time and complications. RESULTS: A total of 42 relevant studies were screened resulting in inclusion of 8 observational studies comparing TEE and ICE in endocardial LAAO. Outcomes assessed including procedural success (RR 1.00, 95% CI (0.97-1.03, p = 0.98)), complications (RR 0.77, 95% CI (0.52 to 1.15, p = 0.20)), fluoroscopy time (mean difference - 0.40, 95% CI (-3.12-2.32, p = 0.77)), and procedural time (mean difference - 8.02, 95% CI (-22.81 to 6.76, p = 0.29)) were found to be similar between both groups. CONCLUSIONS: While TEE is the gold standard for perioperative imaging with LAAO, ICE is a feasible and safe alternative that reduces exposure to general anesthesia and associated potential risks.

Diagnostic Utility of Smartwatch Technology for Atrial Fibrillation Detection - A Systematic Analysis.

BACKGROUND: Smartphone technologies have been recently developed to assess heart rate and rhythm, but their role in accurately detecting atrial fibrillation (AF) remains unknown. OBJECTIVE: We sought to perform a meta-analysis using prospective studies comparing Smartwatch technology with current monitoring standards for AF detection (ECG, Holter, Patch Monitor, ILR). METHODS: We performed a comprehensive literature search for prospective studies comparing Smartwatch technology simultaneously with current monitoring standards (ECG, Holter, and Patch monitor) for AF detection since inception to November 25th, 2019. The outcome studied was the accuracy of AF detection. Accuracy was determined with concomitant usage of ECG monitoring, Holter monitoring, loop recorder, or patch monitoring. RESULTS: A total of 9 observational studies were included comparing smartwatch technology, 3 using single-lead ECG monitoring, and six studies using photoplethysmography with routine AF monitoring strategies. A total of 1559 patients were enrolled (mean age 63.5 years, 39.5% had an AF history). The mean monitoring time was 75.6 days. Smartwatch was non-inferior to composite ECG monitoring strategies (OR 1.06, 95% CI 0.93 - 1.21, p=0.37), composite 12 lead ECG/Holter monitoring (OR 0.90, 95% CI 0.62 - 1.30, p=0.57) and patch monitoring (OR 1.28, 95% CI 0.84 - 1.94, p=0.24) for AF detection. The sensitivity and specificity for AF detection using a smartwatch was 95% and 94%, respectively. CONCLUSIONS: Smartwatch based single-lead ECG and photoplethysmography appear to be reasonable alternatives for AF monitoring.

Epicardial Interventions: Impact of Liposomal Bupivacaine on Postprocedural Management (The EPI-LIBRE Study).

BACKGROUND: Electrophysiological procedures such as epicardial ventricular tachycardia ablation and Lariat left atrial appendage ligation that involve the epicardial space are typically associated with significant postoperative pain due to mechanical irritation and associated inflammation. There is an unmet need for an effective pain management strategy in this group of patients. We studied how this impacts patient comfort and duration of hospitalization and other associated comorbidities related to pericardial access. METHODS: This is a multicenter retrospective study including 104 patients who underwent epicardial ventricular tachycardia ablation and Lariat left atrial appendage exclusion. We compared 53 patients who received postprocedural intrapericardial liposomal bupivacaine (LB)+oral colchicine (LB group) and 51 patients who received colchicine alone (non-LB group) between January 2015 and March 2018. RESULTS: LB was associated with significant lowering of median pain scale at 6 hours (1.0 [0-2.0] versus 8.0 [6.0-8.0], P<0.001), 12 hours (1.0 [1.0-2.0] versus 6.0 [5.0-6.0], P<0.001), and up to 48 hours postprocedure. Incidence of acute severe pericarditis delayed pericardial effusion and gastrointestinal adverse effects were similar in both groups. Median length of stay was significantly lower in LB group (2.0 versus 3.0; adjusted linear coefficient -1 [CI -1.3 to -0.6], P<0.001). Subgroup analysis demonstrated similar favorable outcomes in both Lariat and epicardial ventricular tachycardia ablation groups. CONCLUSIONS: Addition of intrapericardial postprocedural LB to oral colchicine in patients undergoing epicardial access during ventricular tachycardia ablation or Lariat procedure is associated with significantly decreased numeric pain score up to 48 hours compared with colchicine alone. It is also associated with significantly shorter length of hospital stay without an increase in the risk of adverse events.