Evidence for concealed fasciculo-ventricular connections as revealed by His bundle pacing.

BACKGROUND: It is almost 100 years ago since Mahaim described the so-called paraspecific connections between the ventricular conduction axis and the crest of the muscular ventricular septum, believing such pathways to be ubiquitous. These pathways, however, have yet to be considered as potential pathways for septal activation during His bundle pacing. MATERIALS: So as to explore the hypothesis that specialised septal pathways might provide the substrate for septal activation during His bundle pacing, we compared the findings from 22 serially sectioned histological datasets and 34 different individuals undergoing His bundle pacing. RESULTS: We found histologically specialised pathways connecting the branching component of the atrioventricular conduction axis with the crest of the muscular ventricular septum in almost four-fifths of the histological datasets. In 32 of 34 patients undergoing His bundle pacing, the QRS complex closely resembled published images of known conduction through fasciculo-ventricular pathways. In only two patients was a delta wave not seen at any pacing voltages. Capture of these connections varied according to pacing voltage, a finding which correlated with the distance of the pathways from the site of penetration of the ventricular conduction axis. Ventricular activation times remained normal in the presence of the delta wave at higher pacing voltage but were prolonged at lower voltages. CONCLUSIONS: Our histologic findings confirm fasciculo-ventricular connections, initially described by Mahaim as being paraspecific, are likely ubiquitous. Analysis of 12-lead electrocardiograms leads us to conclude that fasciculo-ventricular pathways, concealed during sinus rhythm, become manifest with His bundle pacing.

Left atrial appendage closure using WATCHMAN device in chronic kidney disease and end-stage renal disease patients.

BACKGROUND: Chronic kidney disease (CKD) and end-stage renal disease are considered independent risk factors for developing atrial fibrillation (AF). Percutaneous occlusion of left atrial appendage (LAAC) using WATCHMAN device is a widely accepted alternative to anticoagulation therapy to prevent ischemic stroke in AF in patients who are not candidates for anticoagulation. There is limited data regarding the utilization and periprocedural safety of this intervention in patients with CKD/ESRD. METHODS: We retrospectively reviewed all hospitalizations from 2016 to 2017 with (ICD-10) procedure diagnosis code of LAA closure using WATCHMAN procedure with and without a secondary diagnosis of CKD/ESRD in acute-care hospitals across the United States using the national inpatient sample. Demographic variables (gender, race, income, hospital characteristics, medical comorbidities) were collected and compared. The primary outcomes were inpatient mortality, hospital length, and cost of stay. RESULTS: There were over 71 million discharges included in the combined 2016 and 2017 NIS database. Sixteen thousand five hundred five hospitalizations were for adult patients with a procedure code for LAA closure via watchman procedure. Of 16,505 patients, 3245 (19.66%) had CKD and ESRD. There was no statistically significant difference in mortality, length, and cost of stay in patients with and without CKD/ESRD. There were no statistically significant differences in periprocedural cerebrovascular accidents in both groups. CONCLUSION: Patients with and without ESRD/CKD who undergo LAA occlusion with Watchman have similar procedure related, in-hospital mortality, and complications.

Systemic Sclerosis Is Associated With Increased Inpatient Mortality in Patients Admitted for Acute Coronary Syndrome: Analysis of the National Inpatient Sample.

OBJECTIVE: This study aims to compare the outcomes of patients primarily admitted for acute coronary syndrome (ACS) with and without systemic sclerosis (SSc). The primary outcome was odds of inpatient mortality. Hospital length of stay, total hospital charges, rates of cardiovascular procedures, and treatments were secondary outcomes of interest. METHODS: Data were abstracted from the National Inpatient Sample (NIS) 2016 and 2017 Database. The NIS was searched for hospitalizations for adult patients with ACS (ST-segment elevation myocardial infarction [STEMI], non-ST-segment elevation myocardial infarction [NSTEMI], and unstable angina) as principal diagnosis with and without SSc as secondary diagnosis using International Classification of Diseases, Tenth Revision codes. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders. RESULTS: There were more than 71 million discharges included in the combined 2016 and 2017 NIS database. There were 1,319,464 hospitalizations for adult patients with a principal International Classification of Diseases, Tenth Revision code for ACS. There were 1155 (0.09%) of these hospitalizations that had SSc. The adjusted odds ratios for inpatient mortality for ACS, STEMI, and NSTEMI hospitalizations with coexisting SSc compared with those without SSc were 2.02 (95% confidence interval [CI], 1.19-3.43; p = 0.009), 2.47 (95% CI, 1.05-5.79; p = 0.038), and 2.19 (95% CI, 1.14-4.23; p = 0.019), respectively. CONCLUSIONS: Acute coronary syndrome hospitalizations with SSc have increased inpatient mortality compared with those without SSc. ST-segment elevation myocardial infarction and NSTEMI hospitalizations with SSc have increased inpatient mortality compared with STEMI and NSTEMI hospitalizations without SSc, respectively. Acute coronary syndrome hospitalizations with SSc have similar hospital length of stay, total hospital charges, rates of revascularization strategies (percutaneous coronary intervention, coronary artery bypass surgery, and thrombolytics), and other interventions (such as percutaneous external assist device and intra-aortic balloon pump) compared with those without SSc.

Thirty-Day Hospital Readmissions for Acute Gout in the United States: Analysis of the Nationwide Readmission Database.

BACKGROUND/OBJECTIVE: The aims of this study were to describe the rates and characteristics of nonelective 30-day readmission among adult patients hospitalized for acute gout and to assess predictors of readmission. METHODS: We analyzed the 2017 Nationwide Readmission Database. Gout hospitalizations were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification code. Hospitalizations for adult patients were included. We excluded planned or elective readmissions. We utilized χ2 tests to compare baseline characteristics between readmissions and index hospitalizations. We used multivariate Cox regression to identify independent predictors of readmissions. RESULTS: A total of 11,727 index adult hospitalizations with acute gout listed as the principal diagnosis were discharged alive and included. One thousand five hundred ninety-four (13.6%) readmissions occurred within 30 days. Acute gout was the most common reason for readmission. Readmissions had higher inpatient mortality (2.4% vs 0.1%, p < 0.0001), greater mean age (68.1 vs 67.0 years, p = 0.021), and longer hospital length of stay (5.9 vs 3.8 days, p < 0.0001) compared with index hospitalizations. Charlson Comorbidity Index scores of ≥2 (score 2: adjusted hazards ratio [AHR], 1.67; p = 0.001; score ≥3: AHR, 2.08; p < 0.0001), APR-DRG (All Patients Refined Diagnosis Related Groups) severity levels ≥2 (level 2: AHR, 1.43; p = 0.044; level 3: AHR, 1.83; p = 0.002; level 4: AHR, 2.38; p = 0.002), admission to metropolitan hospital (AHR, 1.83; p = 0.012), atrial fibrillation (AHR, 1.31; p = 0.004), and anemia (AHR, 1.30; p = 0.001) were significantly associated with 30-day readmissions. CONCLUSIONS: Acute gout readmissions were associated with worse outcomes compared with index hospitalizations. Charlson Comorbidity Index scores ≥2, APR-DRG severity levels ≥2, admission to metropolitan hospital, atrial fibrillation, and anemia were significant predictors of readmission.

In-hospital outcomes of transcatheter mitral valve repair in patients with and without end stage renal disease: A national propensity match study.

OBJECTIVES: To study trends of utilization, outcomes, and cost of care in patients undergoing undergoing transcatheter mitral valve repair (TMVr) with end-stage renal disease (ESRD). BACKGROUND: Renal disease has been known to be a predictor of poor outcome in patients with mitral valve disease. Outcome data for patients with ESRD undergoing TMVr remains limited. Therefore, our study aims to investigate trends of utilization, outcomes, and cost of care among patients with ESRD undergoing TMVr. METHODS: We analyzed NIS data from January 2010 to December 2017 using the ICD-9-CM codes ICD-10-CM to identify patients who underwent TMVr. Baseline characteristics were compared using a Pearson 𝜒2 test for categorical variables and independent samples t-test for continuous variables. Propensity matched analysis was done for adjusted analysis to compare outcomes between TMVr with and without ESRD. Markov chain Monte Carlo was used to account for missing values. RESULTS: A total of 15,260 patients (weighted sample) undergoing TMVr were identified between 2010 and 2017. Of these, 638 patients had ESRD compared to 14,631 patients who did not have ESRD. Adjusted in-hospital mortality was lower in non-ESRD group (3.9 vs. <1.8%). Similarly, ESRD patients were more likely to have non-home discharges (85.6 vs. 74.9%). ESRD patients also had a longer mean length of stay (7.9 vs. 13.5 days) and higher mean cost of stay ($306,300 vs. $271,503). CONCLUSION: ESRD is associated with higher mortality, complications, and resource utilization compared to non-ESRD patients. It is important to include this data in shared decision-making process and patient selection.

Predictors of outcomes in hospitalized patients undergoing pacemaker insertion: Analysis from the national inpatient database (2016-2017).

BACKGROUND: Pacemaker implantation in the U.S. is rising due to an aging population. The aim of this analysis was to identify risk factors associated with increased mortality and complications in hospitalized patients requiring pacemaker implantation. METHODS: We performed a retrospective analysis using the National Inpatient Sample database, identifying hospitalized patients who underwent pacemaker implantation using International Classification of Disease, Tenth Revision, Clinical Modification codes. Independent predictors of inpatient mortality were identified using multivariate logistic regression analysis. RESULTS: There were 242,980 hospitalizations with pacemaker implantation during 2016 and 2017. The most frequently encountered indications for hospitalizations involving pacemaker insertion included sick sinus syndrome (SSS) (27.60%), complete atrioventricular (AV) block (21.57%), and second-degree AV block (7.83%). Chronic liver disease was associated with the highest adjusted odds of inpatient mortality (aOR = 5.76, 95% CI: 4.46 to 7.44, p < .001). Comorbid anemia had the highest statistically significant adjusted odds ratio (aOR) for predictors of post-procedural cardiac complications (aOR = 3.17, 95% CI: 2.81 to 3.58, p < .001). Mortality in hospitalized patients needing pacemaker implantation was 1.05%. About 3.36% of hospitalizations developed post procedural circulatory complications (PPCC), 2.45% developed sepsis, and 1.84% developed mechanical complications of cardiac electronic devices. CONCLUSIONS: We identified several predictors of inpatient mortality in hospitalized patients undergoing pacemaker implantation, including chronic liver disease, protein-calorie malnutrition, chronic heart failure, anemia, and history of malignancy. Anemia, chronic liver disease, and congestive heart failure were independent predictors of adverse outcomes in such patients.

Effect of His bundle pacing on right bundle branch block located distal to site of pacing.

BACKGROUND: It is generally accepted that bundle branch block (BBB) may be corrected simply by selective His bundle pacing (S-HBP) distal to site of block. However, clinical HBP is often non-selective (NS), the site of block unknown and moving the HB lead is not always an option. Thus, while correction of right (R) BBB in NS-HBP has been reported, its mechanism is unknown. METHODS: Threshold testing was done during His bundle pacing in 39 patients with RBBB. We compared NS-HBP and S-HBP and analyzed the role of pacing voltage and capture threshold of the parallel pathway, in partially or completely correcting RBBB. RESULTS: During NS-HBP, higher pacing voltage completely corrected RBBB in 22/35 patients as compared to 5/18 patients at lower voltage. Remaining patients showed incomplete correction of RBBB. NS-HBP group with lower capture threshold of 1.3 ± 0.5 V completely resolved RBBB in 9/14 vs 3/11 patients in NS-S HBP group with higher capture threshold of 2.4 ± 0.8 V. QRS activation time in NSHBP was 91 ± 8 ms (baseline 97 ± 7 ms p = ns). S-HBP resolved RBBB in only 1/21 patients. CONCLUSIONS: 1.) Lack of correction with S-HBP suggests that RBBB was distal to site of HBP and yet was corrected with NS-HBP. 2.) Voltage dependent correction of RBBB in NS-HBP suggests that conduction via a specialized parallel pathway maintains normal ventricular activation time. 3.) Correction of RBBB in all patients with NS-HBP, suggests that conduction block was either bypassed or right ventricular free wall pre-excited by conduction via parallel pathway.

Increased inpatient mortality in patients hospitalized for atrial fibrillation and atrial flutter with concomitant amyloidosis: Insight from National Inpatient Sample (NIS) 2016-2017.

PURPOSE: Using National Inpatient Database (NIS), comparison of clinical outcomes for patients primarily admitted for atrial fibrillation/flutter with and without a secondary diagnosis of amyloidosis was done. Inpatient mortality was the primary outcome and hospital length of stay (LOS), mean total hospital charges, odds of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block, cardiogenic shock and cardiac arrest were secondary outcomes. METHODS: NIS database of 2016, 2017 was used for only adult hospitalizations with atrial fibrillation/flutter as principal diagnosis with and without amyloidosis as secondary diagnosis using ICD-10 codes. Multivariate logistic with linear regression analysis was used to adjust for confounders. RESULTS: 932,054 hospitalizations were for adult patients with a principal discharge diagnosis of atrial fibrillation/flutter. 830 (0.09%) of these hospitalizations had amyloidosis. Atrial fibrillation/flutter hospitalizations with co-existing amyloidosis have higher inpatient mortality (4.22% vs 0.88%, AOR: 3.92, 95% CI 1.81-8.51, p = 0.001) and likelihood of having a secondary discharge diagnosis of cardiac arrest (2.40% vs 0.51%, AOR: 4.80, 95% CI 1.89-12.20, p = 0.001) compared to those without amyloidosis. CONCLUSIONS: Hospitalizations of atrial fibrillation/flutter with co-existing amyloidosis have higher inpatient mortality and odds of having a secondary discharge diagnosis of cardiac arrest compared to those without amyloidosis. However, LOS, total hospital charges, likelihood of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block and cardiogenic shock were similar between both groups.

Voltage dependent conduction abnormalities in His bundle pacing in patients without His Purkinje system disease.

BACKGROUND: During His bundle (HB) pacing, the active fixation of HB lead may cause disruption of the enclosed conduction fibers and cause conduction delay. His Purkinje conduction delays have been shown to revert to normal with higher voltage pacing. OBJECTIVE: To determine if conduction delays seen with penetrative HB pacing are voltage dependent and can resolve with higher stimulus voltage. METHODS: In 17 patients undergoing HBP, the effect of voltage on a composite His Purkinje system-ventricular activation time (hVAT) as well as electrocardiographic (ECG) evidence of conduction delay, was systematically evaluated. RESULTS: There was highly significant prolongation of hVAT indicative of conduction delay in 13/17 patients. ECG changes of rightward delay were also seen in 9/13 patients. Both types of delays we manifest at lower voltages and we uniquely resolved by higher stimulation voltage. A pre-excitation like abnormality was also seen in 15/17 patients. This conduction abnormality was manifest at higher voltage without prolongation of hVAT. In 6/15 patients the pre-excitation like abnormality ceased at lower voltage. CONCLUSION: HB pacing is associated with evidence of significant conduction delay noted at low voltage, which resolves with higher stimulation voltage. The more common pre-excitation like abnormality appears to occur at high voltage and, in of itself, does not appear to prolong hVAT.

Trends in the Use and Complications of Cardiac Resynchronization Therapy Device Implantation in Chronic Kidney Disease Patients.

Large-scale multi-hospital data on cardiac resynchronization therapy (CRT) device implantation in patients with chronic kidney disease (CKD) are currently lacking. The purpose of this study was to examine the incidence of CRT device implantation in patients hospitalized with CKD and the impact of CRT device implantation on hospital complications and outcomes. We analyzed the Nationwide Inpatient Sample from 2008-2014 to identify yearly trends in CRT device implantation during CKD hospitalizations. We compared CRT biventricular pacemakers (CRT-Ps) and CRT defibrillators (CRT-Ds). We also obtained rates of comorbidities and complications associated with CRT device implantations. From 2008-2014, the proportion of hospitalized patients with a concurrent diagnosis of CKD receiving CRT-P devices consistently went up from 2008 to 2014 (from 12.3% to 23.8%, P < .0001) compared to the number of hospitalized patients with a concurrent diagnosis of CKD receiving CRT-D devices, which showed a consistent downward trend (from 87.7% to 76.2%, P < .0001). During CKD hospitalizations, most CRT device implantations were performed in patients aged 65-84 years (68.6%) and in men (74.3%). The most common complication of CRT device implantation during hospitalizations involving CKD was hemorrhage or hematoma (2.7%). Patients hospitalized with CKD who developed any complication associated with CRT device implantation had 3.35-fold increased odds of mortality compared to those without complications (odds ratio, 3.35; 95% confidence interval, 2.18-5.16; P < .0001). In summary, this study shows that CRT-P implantations became more common in CKD patients, while the rate of CRT-D implantations decreased over time. Hemorrhage or hematoma was the most common complication (2.7%), and the mortality risk was increased by 3.35 times in patients who developed periprocedural complications.

Sodium-glucose cotransporter-2 inhibitors improve liver enzymes in patients with co-existing non-alcoholic fatty liver disease: a systematic review and meta-analysis.

Introduction: Non-alcoholic fatty liver disease (NAFLD) is characterized by hepatic steatosis, inflammation, and fibrosis. While sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been established to improve glycaemic control in type-2 diabetes mellitus (T2DM), evidence of the beneficial effects in diabetics with coexisting NAFLD has yet to be quantitatively summarized. Material and methods: We searched the PubMed, Medline, CINAHL, and Cochrane databases and ClinicalTrial.gov from database inception to July 2020. We included randomized controlled trials assessing the impact of SGLT2 inhibitors on liver enzymes among patients with NAFLD. Our primary outcome included liver inflammation as measured using liver transaminase. Secondary outcomes included drug efficacy on hepatic steatosis and body mass index. Risk differences were calculated using a random model. Results: A total of 10,555 patients were included in this meta-analysis (SGLT2 inhibitor group: n = 7125; control group: n = 3430). The treatment duration ranged from 8 to 52 weeks. Patients with T2DM, who were treated with SGLT2 inhibitor had decrease in ALT (SMD = -0.22, 95% CI: -0.27 to -0.20) and AST levels (SMD = -0.20, 95% CI: -0.31 to -0.08). The SGLT-2 inhibitor did not cause statistically significant weight loss (SMD = -0.21, 95% CI: -0.47 to 0.06), fibrosis regression utilizing FIB-4 score (SMD = -0.12, 95% CI: -0.41 to 0.18), and hepatic steatosis by using MRI-PDFF (SMD = -0.31, 95% CI: -0.68 to 0.07), as compared to controls. Conclusions: The SGLT2 inhibitor treatment may improve liver function, as demonstrated in the statistically significant reduction in transaminase levels. There were also notable trends in improved liver fibrosis and steatosis across the study periods.

Gender, Racial, Ethnic, and Socioeconomic Disparities in Palliative Care Encounters in Ischemic Stroke Admissions.

BACKGROUND: There is a scarcity of data on disparities in palliative care encounters in ischemic stroke patients. We have sought to answer these questions using the national inpatient database (NIS) data between 2002 and 2017. We aim to study gender, racial, regional, and socioeconomic disparities in palliative care encounters in ischemic stroke patients. METHODS: We have analyzed the NIS data from January 2002 to December 2017 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and ICD-10-CM codes. Linear regression was used for trend analysis and multiple logistic regression was used for adjusted analysis. RESULTS: A total of 9,542,169 discharge encounters with a diagnosis of ischemic stroke were recorded from 2002 to 2017. Out of these 412,394 (4.3%) had a palliative care (PC) encounter. The median age for patients with a PC encounter was 81 (Interquartile range [IQR 79-88]). PC encounters have shown a rapid increase over the years (from 0.5% in 2002 to 8.3% in 2017, p < 0.01). Adjusted multivariate analysis showed that African Americans (OR, 0.726 [95%CI, 0.716-0.736], p < 0.01), and Hispanics (OR, 0.738 [95%CI, 0.725-0.751]) were less likely to have a PC encounters. Females (OR, 1.18 7 [95% CI, 1.177-1.197], p < 0.01) were more likely to have PC encounters. Patients with better socio-economic status (OR, 1.034 [95%CI, 1.011-1.034], p < 0.01), having private insurance (OR, 1.562 [95%CI, 1.542-1.583], p < 0.01) and being in urban centers (OR, 1.815 [95%CI, 1.788-1.843], p < 0.01) were more likely to receive a PC encounter. CONCLUSIONS: Significant racial, ethnic and socioeconomic disparities exist in PC encounters in ischemic stroke patients. The underlying reasons for this need to be explored further.

Outcomes of hospitalizations with acute respiratory distress syndrome with and without atrial fibrillation - Analyses from the National Inpatient Sample (2004-2014).

BACKGROUND: Acute respiratory distress syndrome (ARDS) is associated with high mortality. Atrial fibrillation (AF) is a common arrhythmia seen in critically ill patients. The impact of AF on the outcomes in patients with ARDS is less understood. In this analysis we attempt to evaluate the association of concurrent AF and various clinical outcomes in patients with ARDS. METHODS: We conducted a retrospective analysis of adult discharges from the National Inpatient Sample (NIS) between 2004 and 2014. International Classification of Disease codes were used to identify those with ARDS and AF. RESULTS: We found 1,200,737 hospitalizations with ARDS, out of which 238,455 had concomitant diagnosis of AF. Hospitalizations with AF had higher prevalence of comorbidities including chronic pulmonary disease, diabetes mellitus, hypertension, obesity, congestive heart failure and renal failure. On adjusted analysis, AF was associated with increased odds of acute myocardial infarction, cardiogenic shock, pressor use, acute kidney injury, permanent pacemaker implantation, cardiac arrest, mechanical circulatory support use and higher length of stay and inflation-adjusted cost in hospitalizations with ARDS. However, there was no significant difference in adjusted all-cause mortality in ARDS with and without AF (25.42% vs 20.23%, p=0.53). CONCLUSIONS: AF is associated with worse clinical outcomes, higher length of stay and cost in ARDS hospitalizations as compared to those without AF.

Trends in Characteristics and Outcomes in Primary Heart Failure Hospitalizations Among Older Population in the United States, 2004 to 2018.

BACKGROUND: Heart failure (HF) accounts for a significant proportion of morbidity, mortality, and health care costs among older adults in the United States. We evaluated trends in clinical outcomes and the economic burden of HF hospitalizations in older patients (≥80 years). METHODS: This analysis included data from the National Inpatient Sample between January 2004 and December 2018. We examined the trends of clinical characteristics, inpatient mortality, and health care cost utilization in older US adults for HF hospitalizations. RESULTS: We identified 6 034 951 weighted HF hospitalizations for older adults (3527 per 100 000 person-years). After an initial decline in HF hospitalizations per 100 000 older US older adults from 4211 in 2004 to 3089 in 2014, there was increase to 3388 in 2018 (P trend <0.001 for both). There was an overall increase in cardiometabolic and chronic comorbidities during the study period. Overall, inpatient mortality was 4.7%; the adjusted inpatient mortality decreased from 6.1% in 2004 to 3.6% in 2018 (P trend <0.001). There was a decrease in adjusted mean length of stay (from 6.0 days in 2004 to 4.7 days in 2018) and adjusted inflation-adjusted care costs (from $11 865 in 2004 to $9677 in 2018) during the study period (P trend <0.001 for both). In comparison with younger adults (<80 years), older adults had higher inpatient mortality (4.7% versus 2.2%) but lower inflation-adjusted care costs ($10 587 versus $14 088). CONCLUSIONS: This 15-year national data suggests that despite a higher comorbidity burden and the recent increase in hospitalizations for HF in older patients, there has been an encouraging trend towards lower inpatient mortality, health care cost, and hospital length of stay among older adults in the United States.

Trends in Characteristics and Outcomes of Peripartum Cardiomyopathy Hospitalizations in the United States Between 2004 and 2018.

Data are limited on contemporary temporal trends in maternal characteristics and outcomes in hospitalized patients with peripartum cardiomyopathy (PC). We used the National Inpatient Sample database from January 1, 2004, to December 31, 2018, to identify PC hospitalizations in women aged 15 to 54 years. Weighted survey data were used to derive national estimates for the United States population and examine trends. Between 2004 and 2018, there was a total of 23,420 weighted hospitalizations for PC in women aged 15 to 54 years. The mean (standard error) age of this hospitalized PC population was 30.3 (0.1) years, with 44.6% White, 39.3% Black, 9.0% Hispanics, and 7.1% "Other" racial/ethnic groups. There was a nonsignificant increase in the PC hospitalization per 100,000 live births from 33.6 in 2004 to 42.4 in 2018 (p-trend = 0.06) over the study period, driven by a statistically significant increase in the younger women age group 15 to 35 years (p-trend = 0.04). The PC hospitalizations per 100,000 live births for women aged 36 to 54 years were more than double that observed in women aged 15 to 35 years (77.6 vs 33.5). PC hospitalizations were more than threefold greater in Black versus White women (103.5 vs 32.0 per 100,000 live births). Overall, inpatient mortality was 0.8%; the adjusted inpatient mortality showed a nonsignificant overall decrease from 1.1% in 2004 to 0.5% in 2018 (p-trend = 0.15). The overall mean length of stay was 4.6 days; the adjusted mean length of stay decreased from 5.8 days in 2004 to 4.6 days in 2018 (p-trend <0.01). In conclusion, there has been a nonsignificant increase in hospitalizations for PC, driven by an increasing rate of hospitalizations in younger women. The older maternal age group and Black patients had a higher proportional hospitalization as compared with the younger age group and White patients. There was a nonsignificant decrease in inpatient mortality.

Effect of Nonselective His Bundle Pacing on Delayed Myocardial Activation in Left-axis Deviation and Left Bundle Branch Block.

It has been suggested that nonselective His bundle pacing (NS-HBP) corrects terminal conduction delay in right bundle branch block by early excitation of the right ventricular free wall. A similar analysis of NS-HBP, in patients with left bundle branch block (LBBB) and left-axis deviation (LAD) has not been done. Therefore, we compared the baseline QRS parameters in LAD and LBBB during NS-HBP and selective HBP (S-HBP). In LAD patients (n = 16), NS-HBP normalized the QRS axis from -35° ± 10° to 30° ± 34° (p < 0.01) and increased the lead 1 voltage (L1V) from 0.55 ± 0.3 mV to 0.88 ± 0.2 mV (p < 0.001) without increasing the peak lateral wall activation time (PLWAT) (p = not significant). In 23 of 41 LBBB patients, NS-HBP decreased the prolonged PLWAT by 73 ms (p < 0.0001), resolved the mid-QRS notch, normalized the QRS axis, and increased the L1V from 0.5 ± 0.3 mV to 1.15 ± 0.3 mV (p < 0.0001). In the remaining 18 LBBB patients, NS-HBP did not resolve the mid-QRS notch; however, the peak septal activation time decreased by 45 ms (p < 0.0001), PLWAT decreased by 53 ms (p < 0.0001), L1V increased from 0.5 ± 0.3 mV to 0.87 ± 0.4 mV (p < 0.0001), and the QRS axis normalized. All patients who developed S-HBP at lower pacing showed uncorrected LBBB (n = 6) or LAD (n = 7). In conclusion, NS-HBP, which causes myocardial activation in advance of simultaneously initiated S-HBP, results in a paced QRS complex with a normal axis and shorter activation times and restores the L1V in patients with LAD and LBBB. In some patients, a mid-QRS notch was seen with NS-HBP, which suggests fusion with S-HBP, which conducts without LBBB correction. A higher L1V in association with a shorter PLWAT and a normal QRS axis suggests that a more organized degree of left ventricular activation occurs with NS-HBP as compared to LBBB.

A Case of Biatrial-dependent Tachycardia.

We present an interesting case of atrial flutter in a patient with previous pulmonary vein isolation. The entirety of the atrial flutter cycle length was mapped to the left atrium; however, an atrial flutter could not be terminated from the left side. Subsequently, the right atrium was mapped and an area of earliest activation was noted in the junction between the superior vena cava and right atrium. Ablation performed in this area terminated the flutter. We believe that both the left atrium and the portion of the right atrium indicated were part of the circuit and herein discuss the likely mechanism of the biatrial dependence of this tachycardia.

How to Achieve Near Zero Fluoroscopy During Radiofrequency Ablation of Atrial Fibrillation: A Strategy Used at Two Centers.

Radiofrequency ablation for atrial fibrillation is currently the most effective rhythm control strategy. These procedures, although safe, pose a risk for potential exposure to radiation and can be time consuming. Radiation exposure during ablation can increase the risk of serious complications in both patients as well as physicians. The overall procedure time also increases with use of fluoroscopy. Advances in mapping technology, such as electroanatomic mapping, use of contact force technology, intracardiac echocardiography and use of versatile sheaths and catheters has vastly enhanced our ability to both shorten the procedure duration and minimize or even eliminate radiation exposure. Use of near zero fluoroscopy technique is increasingly gaining acceptance in electrophysiology centers. At this point, there is no uniform technique and various centers use individual techniques based on their expertise and availability of various tools. There is need for a uniform technique that is workflow friendly and widely accepted. There is a learning curve associated with this technique and efforts should be made to incorporate zero fluoroscopic technique for ablation as an essential part of electrophysiology training programs. In this paper, we present the strategy being practiced at two centers, that involves a series of steps, to either decrease or eliminate the use of fluoroscopy during atrial fibrillation ablation.

Hyperkalemia: Major but still understudied complication among heart transplant recipients.

Hyperkalemia is a recognized and potentially life-threatening complication of heart transplantation. In the complex biosystem created by transplantation, recipients are susceptible to multiple mechanisms for hyperkalemia which are discussed in detail in this manuscript. Hyperkalemia in heart transplantation could occur pre-transplant, during the transplant period, or post-transplant. Pre-transplant causes of hyperkalemia include hypothermia, donor heart preservation solutions, conventional cardioplegia, normokalemic cardioplegia, continuous warm reperfusion technique, and ex-vivo heart perfusion. Intra-transplant causes of hyperkalemia include anesthetic medications used during the procedure, heparinization, blood transfusions, and a low output state. Finally, post-transplant causes of hyperkalemia include hemostasis and drug-induced hyperkalemia. Hyperkalemia has been studied in kidney and liver transplant recipients, but there is limited data on the incidence, causes, management, and prevention in heart transplant recipients. Hyperkalemia is associated with an increased risk of hospital mortality and readmission in these patients. This review describes the current literature pertaining to the causes, pathophysiology, and treatment of hyperkalemia in patients undergoing heart transplantation and focuses primarily on post-heart transplantation.