P-wave axis is associated with all-cause mortality in diabetes: The ACCORD trial.

Abnormal P-wave axis (PWA) has emerged as a novel marker of risk for both cardiovascular disease (CVD) and all-cause mortality (ACM) in the general population, though this relationship has not been adequately explored among those with type 2 diabetes (DM2). We aimed to explore the association between abnormal PWA and ACM among a large, well-phenotyped group of participants with DM2 from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. This analysis included 8899 ACCORD participants with available PWA data on baseline electrocardiogram. Cox proportional hazards models were used to examine the association between PWA and ACM in models adjusted for demographics, ACCORD trial treatment assignment, and potential confounders. PWA was modeled as either normal (0° -75°) or abnormal (<0° or >75°). Over 44,000 person-years of follow up, there were 609 deaths. Participants with abnormal PWA had increased risk of ACM (HR 1.61, 95% CI 1.25-2.08). After multivariable adjustment, the association remained significant (HR 1.33, 95% CI 1.03-1.72). This relationship was similar in subgroups stratified by age, race, sex, and history of CVD. Among ACCORD trial participants, abnormal PWA was associated with an increased risk of mortality. Abnormal PWA may have added value beyond traditional risk factors in prediction models.

Outcomes of an expedited same-day discharge protocol following cardiac implantable electronic device (CIED) implantation.

BACKGROUND: With increasing constraints on healthcare resources, greater attention is being focused on improved resource utilization. Prior studies have demonstrated safety of same-day discharge following CIED implantation but are limited by vague protocols with long observation periods. In this study, we evaluate the safety of an expedited 2 hour same-day discharge protocol following CIED implantation. METHODS: Patients undergoing CIED implantation at three centers between 2015 and 2021 were included. Procedural, demographic, and adverse event data were abstracted from the electronic health record. Patients were divided into same-day discharge (SDD) and delayed discharge (DD) cohorts. The primary outcome was complications including lead malfunction requiring revision, pneumothorax, hemothorax, lead dislodgement, lead perforation with tamponade, and mortality within 30 days of procedure. Outcomes were compared between the two cohorts using the χ2 test. RESULTS: A total of 4543 CIED implantation procedures were included with 1557 patients (34%) in the SDD cohort. SDD patients were comparatively younger, were more likely to be male, and had fewer comorbidities than DD patients. Among SDD patients, the mean time to post-operative chest X-ray was 2.6 h. SDD had lower rates of complications (1.3% vs 2.1%, p = 0.0487) and acute care utilization post-discharge (9.6% vs 14.0%, p < 0.0001). There was no difference in the 90-day infection rate between the cohorts. CONCLUSIONS: An expedited 2 hour same-day discharge protocol is safe and effective with low rates of complications, infection, and post-operative acute care utilization.

Comparison of Bolus Dosing of Methohexital and Propofol in Elective Direct Current Cardioversion.

Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; P=0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; P=0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; P=0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; P=0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; P<0.001) and less hypoxemia (0.0% versus 15.2%; P=0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; P=0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; P=0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196.

Sinus node sparing novel hybrid approach for treatment of inappropriate sinus tachycardia/postural sinus tachycardia: multicenter experience.

BACKGROUND: The ideal treatment of inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS) still needs to be defined. Medical treatments yield suboptimal results. Endocardial catheter ablation of the sinus node (SN) may risk phrenic nerve damage and open-heart surgery may be accompanied by unjustified invasive risks. METHODS: We describe our first multicenter experience of 255 consecutive patients (235 females, 25.94 ± 3.84 years) having undergone a novel SN sparing hybrid thoracoscopic ablation for drug-resistant IST (n = 204, 80%) or POTS (n = 51, 20%). As previously described, the SN was identified with 3D mapping. Surgery was performed through three 5-mm ports from the right side. A minimally invasive approach with a bipolar radiofrequency clamp was used to ablate targeted areas while sparing the SN region. The targeted areas included isolation of the superior and the inferior caval veins, and a crista terminalis line was made. All lines were interconnected. RESULTS: Normal sinus rhythm (SR) was restored in all patients at the end of the procedure. All patients discontinued medication during the follow-up. After a blanking period of 6 months, all patients presented stable SR. At a mean of 4.07 ± 1.8 years, normal SN reduction and chronotropic response to exercise were present. In the 51 patients initially diagnosed with POTS, no syncope occurred. During follow-up, pericarditis was the most common complication (121 patients: 47%), with complete resolution in all cases. Pneumothorax was observed in 5 patients (1.9%), only 3 (1.1%) required surgical drainage. Five patients (1.9%) required a dual-chamber pacemaker due to sinus arrest > 5 s. CONCLUSIONS: Preliminary results of this multicenter experience with a novel SN sparing hybrid ablation of IST/POTS, using surgical thoracoscopic video-assisted epicardial ablation combined with simultaneous endocardial 3D mapping may prove to be an efficient and safe therapeutic option in patients with symptomatic drug-resistant IST and POTS. Importantly, in our study, all patients had a complete resolution of the symptoms and restored normal SN activity.

The Storm Before the Calm: Ablation of Premature Ventricular Complex Trigger for Incessant Ventricular Fibrillation.

Ventricular tachycardia storm is associated with high mortality rates and is often refractory to treatment. Historically, few options for treatment have existed in cases when antiarrhythmic drugs fail. We report the case of a patient with incessant ventricular fibrillation (VF) in the postinfarction period that was triggered by premature ventricular contractions (PVCs) that persisted despite normal electrolytes, exclusion of ongoing ischemia, infusions of antiarrhythmic drugs, general anesthesia, full circulatory support with extracorporeal membranous oxygenation, and cardiac sympathetic denervation. Given that the VF appeared to be triggered consistently by a unifocal, short-coupled PVC (consistent with Purkinje fiber-mediated VF), we performed catheter ablation, after which point, the patient experienced no further PVCs or ventricular arrhythmia. This case serves as a reminder of three key teaching points. First, not all VF is created equal, with some cases being chiefly the result of a vulnerable substrate and others being best accounted for by frequent triggers. Second, examining the available electrocardiographic data and appropriately interpreting them can guide the selection of therapies up to and including catheter ablation for treatment-refractory VF. Third, full circulatory support greatly facilitates successful electroanatomic mapping and catheter ablation of unstable ventricular arrhythmias.

Safety and feasibility of peri-device leakage closure after LAAO: an international, multicentre collaborative study.

BACKGROUND: Residual peri-device leakage (PDL) is frequent after left atrial appendage occlusion (LAAO). Little is known about management strategies, procedural aspects and outcomes of interventional PDL closure. AIMS: The aim of this study was to assess the safety and feasibility of PDL closure after LAAO. METHODS: Fifteen centres contributed data on baseline characteristics, in-hospital and follow-up outcomes of patients who underwent PDL closure after LAAO. Outcomes of interest included acute success and complication rates and long-term efficacy of the procedure. RESULTS: A total of 95 patients were included and a cumulative number of 104 leaks were closed. The majority of PDLs were detected within 90 days (range 41-231). Detachable coils were the most frequent approach (42.3%), followed by the use of the AMPLATZER Vascular Plug II (29.8%) and the AMPLATZER Duct Occluder II (17.3%). Technical success was 100% with 94.2% of devices placed successfully within the first attempt. There were no major complications requiring surgical or transcatheter interventions. During follow-up (96 days [range 49-526]), persistent leaks were found in 18 patients (18.9%), yielding a functional success rate of 82.7%, although PDLs were significantly reduced in size (pre-leak sizemax: 6.1±3.6 mm vs post-leak sizemax: 2.5±1.3 mm, p<0.001). None of the patients had a leak >5 mm. Major adverse events during follow-up occurred in 5 patients (2 ischaemic strokes, 2 intracranial haemorrhages, and 1 major gastrointestinal bleeding). CONCLUSIONS: Several interventional techniques have become available to achieve PDL closure. They are associated with high technical and functional success and low complication rates.

Effect of Intensive Blood Pressure Lowering on Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis.

The effect of intensive versus standard blood pressure (BP) lowering on the risk of atrial fibrillation (AF) is uncertain. Intensive BP lowering is associated with a lower risk of AF among patients with hypertension. We searched PubMed, EMBASE, and CENTRAL (inception to June 5, 2020) for randomized controlled trials evaluating the effect of intensive versus standard (target systolic BP < 140 mmHg) BP lowering on incident AF. We assessed heterogeneity using the I2 statistic then used fixed-effects meta-analysis models to report pooled treatment effects and 95% confidence intervals. We also tested for publication bias by three funnel plot-based methods. The quality of each study was assessed with the Cochrane Risk of Bias tool. We assessed 16 candidate studies for eligibility from 2,312 published articles, but only three randomized clinical trials were eligible for inclusion and included a combined 12,219 participants with hypertension: Cardio-Sis (Studio Italiano Sugli Effetti Cardiovascolari del Controllo della Pressione Arteriosa Sistolica), ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial), and SPRINT (Systolic Blood Pressure Intervention Trial). The target systolic BP in the intensive BP arm was <120 mmHg for participants in SPRINT and ACCORD-BP, but <130 mmHg for participants in Cardio-Sis. Participants randomized to intensive BP lowering had significantly lower risk of incident AF compared with those randomized to standard BP lowering (AF incidence 2.2% vs. 3.0%, respectively; pooled hazard ratio (95% confidence interval): 0.74 (0.59 - 0.93)). Intensive BP lowering is associated with a significantly lower risk of incident AF in patients with hypertension. These findings add to the current evidence supporting the benefits of intensive BP control.

Association of P-Wave Axis With Incident Atrial Fibrillation in Diabetes Mellitus (from the ACCORD Trial).

Abnormal P-wave axis may reflect preclinical atrial dysfunction and has been associated with an increased risk of incident atrial fibrillation (AF) in the general population. Patients with diabetes mellitus (DM) have a higher prevalence of AF, but the association of abnormal P-wave axis and the risk of incident AF in those with diabetes has not been previously explored. For this analysis, we included 8,965 eligible participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. P-wave axis was automatically measured on study electrocardiogram and visually confirmed, with the normal range being between 0° and 75°. At baseline, 8% of the study population had an abnormal P-wave axis. During 43,856 person-years of follow-up, there were 145 cases of incident AF. Using multivariable-adjusted Cox proportional hazards models, participants with abnormal P-wave axis had an increased risk of incident AF (hazard ratio 2.65, 95% confidence interval 1.76 to 3.99, p < 0.0001). Findings were similar in prespecified subgroups, without evidence of effect modification. Both left- and right-axis deviation of the P-wave were associated with incident AF. Our results suggest that abnormal P-wave axis is associated with incident AF in those with DM and that this relation is conserved in prespecified subgroups. There may be utility in considering P-wave axis values from routine ECGs in these patients.

AngioVac Debulking in Endocarditis Patients with Large, Device-related Vegetations.

As the number and complexity of cardiovascular implantable electronic devices has increased, so too has the incidence of device-related infections. Such a rise requires that the focus be directed toward developing universal standards for infected lead removal. To date, no consensus currently exists regarding the optimal management of patients with large vegetations (diameter > 2 cm). In these individuals, medical therapy is universally ineffective and they are often too ill for surgical extraction; furthermore, transvenous lead extraction (TLE) carries with it a risk of large septic pulmonary emboli. We present a series of five cases in which the AngioVac thrombectomy system (AngioDynamics Inc., Latham, NY, USA) was used as an adjunct to TLE. Debridement of infected leads prior to percutaneous lead extraction was accomplished as either a bridge to or as concomitant therapy with laser lead removal at our institution. This study included three males and two females with an average age of 52 years. The sizes of vegetations removed from leads ranged from 1.5 cm to 3.9 cm in the largest dimension and the average diameter was 2.65 cm ± 1.1 cm. The vegetations were successfully debulked in all five patients. This suggests that TLE performed with assistance from the AngioVac system (AngioDynamics Inc., Latham, NY, USA) is a safe and effective alternative to open surgical lead removal in patients with large lead vegetations.

Ventricular tachycardia associated with radiation-induced cardiac sarcoma.

Cardiac tumors can lead to distinct electrocardiographic changes and ventricular arrhythmias. Benign and malignant cardiac tumors have been associated with ventricular tachycardia. When possible, benign tumors should be resected when ventricular arrhythmias are intractable. Chemotherapy can shrink malignant tumors and eliminate arrhythmias. We report the case of a 52-year-old woman with breast sarcoma whom we diagnosed with myocardial metastasis after she presented with palpitations. The initial electrocardiogram revealed sinus rhythm with new right bundle branch block and ST-segment elevation in the anterior precordial leads. During telemetry, hemodynamically stable, sustained ventricular tachycardia with right ventricular localization was detected. Images showed a myocardial mass in the right ventricular free wall. Amiodarone suppressed the arrhythmia. To our knowledge, this is the first report of ventricular tachycardia associated with radiation-induced undifferentiated sarcoma. We discuss the distinct electrocardiographic changes and ventricular arrhythmias that can be associated with cardiac tumors, and we review the relevant medical literature.

Comparison of predictors of heart failure-related hospitalization or death in patients with versus without preserved left ventricular ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) is recognized as a major cause of cardiovascular morbidity and mortality. An ability to identify patients with HFpEF who are at increased risk for adverse outcomes can facilitate their more careful management. We studied the patients having heart failure (HF) using data from the Heart Failure Adherence and Retention Trial (HART). HART enrolled 902 patients in the New York Heart Association (NYHA) class II or III who had been recently hospitalized for HF to study the impact of self-management counseling on the primary outcome of death or HF hospitalization. In HART, 208 patients had HFpEF and 692 had HF with reduced ejection fraction (HFrEF) and were followed for a median of 1,080 days. Two final multivariate models were developed. In patients having HFpEF, predictors of primary outcome were male gender (odds ratio [OR] 3.45, p = 0.004), NYHA class III (OR 3.05, p = 0.008), distance covered on a 6-minute walk test (6-MWT) of <620 feet (OR 2.81, p = 0.013), and <80% adherence to prescribed medications (OR 2.61, p = 0.018). In patients having HFrEF, the predictors were being on diuretics (OR 3.06, p = 0.001), having ≥3 co-morbidities (OR 2.11, p = 0.0001), distance covered on a 6-MWT of <620 feet (OR 1.94, p = 0.001), NYHA class III (OR 1.90, p = 0.001), and age >65 years (OR 1.63, p = 0.01). In conclusion, indicators of functional status (6-MWT and NYHA class) were common to both patients with HFpEF and those with HFrEF, whereas gender and adherence to prescribed therapy were unique to patients having HFpEF in predicting death or HF hospitalization.