Outcomes in congenital and childhood complete atrioventricular block: A meta-analysis.

BACKGROUND: The long-term outcomes of patients with congenital and childhood complete atrioventricular block (CCAVB/CAVB) after pacemaker implantation are unclear. METHODS: We performed a meta-analysis of all the studies of CCAVB. A systematic search of PubMed and CENTRAL databases from January 1, 1967 to January 31, 2020 was performed. The quality of studies included was critically appraised using the Newcastle-Ottawa scale, and outcome data were analyzed using the restricted maximum likelihood function. RESULTS: Twenty-nine studies were eligible for analysis, with a total of 1553 patients. The all-cause-mortality was 5.7% (95% confidence interval [CI]: 2.5%-9.9%), while pacing-induced cardiomyopathy (PICM) was seen in 3.8% (95% CI: 1.2-7.2). Diagnosis at birth (effect size [ES] [95%CI]: -2.23 [-0.36 to -0.10]; p < .001), presence of congenital heart disease (ES [95%CI]: -0.67 [0.41-0.93]; p < .001), younger age at pacemaker implantation (ES [95%CI]: -0.01 [-0.02 to -0.001]; p = .02), and duration of pacing (ES [95%CI]: -0.03 [-0.05 to -0.003]; p = .03), were associated with an higher mortality on binominal logistic regression. None of the parameters were significant on multivariate analysis. CONCLUSION: Pooled proportional mortality in patients with CCAVB and CAVB is 5.7% with an infrequent incidence of PICM (3.8%) in the paced patients with AVB suggesting that pacing in these patients is an effective management strategy with a low incidence of long-term side effects. Registry and randomized data can throw additional light regarding the natural history and appropriate management strategy in these patients.

Impact of intracardiac echocardiography on readmission morbidity and mortality following atrial fibrillation ablation.

INTRODUCTION: The use of intracardiac echocardiography (ICE) is beneficial during the ablation of atrial fibrillation (AF). Evidence is conflicting regarding the clinical impact of using ICE on arrhythmia recurrence and mortality. METHODS: Patients undergoing catheter ablation of AF during 2010-2017 were identified using the International Classification of Diseases-9th and 10th Revision-Clinical Modification (ICD-9-CM and ICD-10-CM) from the Nationwide Readmissions Database. Propensity matching was used to generate a control group. Patient demographics, Charlson comorbidity indexes, time from discharge to readmission, and the reason of readmission were extracted. RESULTS: From 2010 to 2017, 51 129 patients were included in the analysis out of which ICE was used in 8005 (15.7%) patients. The in-hospital mortality at readmission was significantly higher in the patients without ICE use (2.9% vs. 1.7%, p = .02). The length of stay (LOS) at readmission was significantly higher in non-ICE arm (median [interquartile range, IQR]: 3 [2-6] vs. 2 [3-5] days, p < .0001) with similar healthcare-associated cost (HAC) in both the groups (median [IQR]: US$7507.3 [4057.8-15 474.2] vs. 7339.4 [4024.8-15 191.6], p = .43). Freedom from readmission was 12% higher (hazard ratio [HR] [95% confidence interval, CI]: 0.88 [0.83-0.94], p < .0001) with the use of ICE at 90-day follow-up, which was driven by 24% reduction in heart failure (HF) at follow-up (HR [95% CI]: 0.76 [0.60-0.96], p = .02). CONCLUSIONS: ICE use during AF ablation procedure reduces readmissions at 90 days by 12%, driven by a 24% decrease in HF-related admissions. The non-ICE arm showed a significantly higher LOS which offsets marginally higher HAC in the ICE arm.

A case report of lead dysfunction presenting as high ventricular premature complex burden.

Pacemaker-troubleshooting is an important step in the evaluation of a patient with syncope post-pacemaker-implantation. The basic functions of sensing, pacing and impedance may remain spuriously normal in the case of lead-microfracture or insulation break. We report a case in which the lead dysfunction was diagnosed based on multiple episodes of premature ventricular beats.

Safety and Efficacy of Ibutilide for Acute Pharmacological Cardioversion of Rheumatic Atrial Fibrillation.

INTRODUCTION: Ibutilide is indicated for acute cardioversion of nonvalvular atrial fibrillation (AF). However, its efficacy and safety in the pharmacological cardioversion of rheumatic AF are unknown. METHODS: Patients with mild-to-moderate rheumatic mitral valve (MV) disease with symptomatic, paroxysmal, or persistent AF were included in the analysis. Intravenous ibutilide was administered at doses tailored to body weight (0.5-2.0 mg) for over 10 min. The primary end point was efficacy, assessed as the rate of conversion of AF to sinus rhythm. The secondary end point was safety, including arrhythmic events and death within 24 h of drug initiation. RESULTS: From June 2016 to October 2018, 165 patients (94 with mitral stenosis, 23 with mitral regurgitation, 11 with mixed MV disease, and 37 with MV replacement) received ibutilide (mean dose 0.90 ± 0.54 mg). Ibutilide successfully converted AF to sinus rhythm in 127/165 (76.9%) patients, with a conversion time of 7.9 ± 4.1 min. The QTc increased from 419.9 ± 15.8 to 487.5 ± 34 ms after ibutilide administration (p < 0.001). The mean change in QTc after ibutilide administration (∆QTc) was 72.01 ± 36.03. There were no deaths, but 3 patients (1.8%) developed torsades de pointes (TdP) requiring defibrillation 55 ± 37 min after infusion. CONCLUSION: Ibutilide cardioverted 77% of rheumatic AF to sinus rhythm, indicating its potential as a clinically useful option for pharmacological cardioversion of rheumatic AF. TdP is a potentially serious adverse event that requires careful monitoring.

MRI in patients with cardiac implantable electronic devices: A comprehensive review.

Magnetic resonance imaging (MRI) has become a commonly used non-ionizing radiation dependent imaging modality which has an excellent spatial resolution with the capability to provide physiological information. Cardiac implantable electronic devices (CIEDs) are used in modern cardiology with a frequency of 1:50 over 75 years of age and nearly one in three people in this population required MRI during their lifetime. Changes in the CIED structure, electronics, and algorithms paired with changes in the protocol design of MRI have created a relatively safe environment for performing MRI in patients with CIED. Despite their documentation in literature and a guideline document from a professional society, significant skepticism exists in doing MRI in patients with CIEDs. We intend to give an overview of interactions between MRI and CIEDs, including the evidence available in this regard and conclude with the suggestion of a protocol for safely carrying out an MRI in patients with CIEDs.

Changing QRS duration and morphology with A-paced and A-sensed rhythm in postcardiac resynchronization therapy (CRT) patients.

Meticulous interpretation of the ECGs of patients with cardiac resynchronization defibrillator therapy (CRT-D) device is important to ensure optimal synchronization of both the chambers. We present the ECGs of such a patient who was noted to have different morphologies of the biventricular-paced QRS depending in atrial-sensed (A-sensed) or atrial-paced (A-paced) rhythm.

Sonographic Appearance of Testicular Adrenal Rest Tumour in a Patient with Congenital Adrenal Hyperplasia.

BACKGROUND: Testicular adrenal rest tumours (TARTs) are benign testicular masses that are found in inadequately treated patients with congenital adrenal hyperplasia (CAH). Recognizing this association and identifying characteristic ultrasound features of TARTs is important so as to avoid misdiagnosing them as malignancies, which can lead to unnecessary interventions. CASE REPORT: We describe a case of a 9-year-old boy, with a diagnosis of CAH and precocious puberty, who was referred to our department for an ultrasound evaluation of the abdomen and scrotum. On ultrasound, there were well-defined, heterogeneous, predominantly hypoechoic, round-to-oval masses in both testes. Taking into account the presence of CAH and a typical sonographic appearance of bilateral testicular masses, a diagnosis of testicular adrenal rest tumour was made; biopsy was deferred and hormonal treatment was modified. CONCLUSIONS: Prompt diagnosis of testicular adrenal rest tumours is essential, as it only indicates inadequate hormonal control. Moreover, it can prevent unnecessary biopsies and orchidectomies, and can maintain fertility. TARTs have a typical imaging appearance that every radiologist must be aware of.

Response to letter to editor, re-predictors of morbidity and in-hospital mortality following procedure-related cardiac tamponade.

We had included only the patients with cardiac tamponade, excluded those coded for pericardial effusion. The feasibility of comparison of the databases of two regions needs to be evaluated. There are some inherent limitations for the studies carried out from the National In-patient Samples (NIS) database.

Characteristics and Outcomes of Hospitalized Patients with Heart Failure and Sarcoidosis: A Propensity-Matched Analysis of the Nationwide Readmissions Database 2010-2019.

BACKGROUND: Sarcoidosis is associated with a poor prognosis. There is a lack of data examining the outcomes and readmission rates of sarcoidosis patients with heart failure (SwHF) and without heart failure (SwoHF). We aimed to compare the impact of non-ischemic heart failure on outcomes and readmissions in these two groups. METHODS: The US Nationwide Readmission Database was queried from 2010 to 2019 for SwHF and SwoHF patients identified using the International Classification of Diseases, 9th and 10th Editions. Those with ischemic heart disease were excluded, and both cohorts were propensity matched for age, gender, and Charlson Comorbidity Index (CCI). Clinical characteristics, length of stay, adjusted healthcare-associated costs, 90-day readmission and mortality were analyzed. RESULTS: We identified 97,961 hospitalized patients (median age 63 years, 37.9% male) with a diagnosis of sarcoidosis (35.9% SwHF vs 64.1% SwoHF). On index admission, heart failure patients had higher prevalences of atrioventricular block (3.3% vs 1.4%, P < .0001), ventricular tachycardia (6.5% vs 1.3%, P < .0001), ventricular fibrillation (0.4% vs 0.1%, P < .0001) and atrial fibrillation (22.1% vs 7.5%, P < .0001). SwHF patients were more likely to be readmitted (hazard ratio 1.28, P < .0001), had higher length of hospital stay (5 vs 4 days, P < .0001), adjusted healthcare-associated costs ($9,667.0 vs $9,087.1, P < .0001) and mortality rates on readmission (5.1% vs 3.8%, P < .0001). Predictors of mortality included heart failure, increasing age, male sex, higher CCI, and liver disease. CONCLUSION: SwHF is associated with higher rates of arrhythmia at index admission, as well as greater hospital cost, readmission and mortality rates compared to those without heart failure.

Predictors of morbidity and in-hospital mortality following procedure-related cardiac tamponade.

Background: Cardiac tamponade (CT) can be a complication following invasive cardiac procedures. We assessed CT following common cardiac electrophysiology (EP) procedures to facilitate risk prediction of associated morbidity and in-hospital mortality. Methods: Patients who underwent various EP procedures in the cardiac catheterization lab (ablations and device implantations) were identified using the International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification (ICD-9-CM and ICD-10-CM, respectively) from the Nationwide Inpatient Sample (NIS) database. Patient demographics, presence of comorbidities, CT-related events, and in-hospital death were also abstracted from the NIS database. Results: The frequency of CT-related events in patients with EP intervention from 2010 to 2017 ranged from 3.4% to 7.0%. In-hospital mortality related to CT-related events was found to be 2.2%. Increasing age was the only predictor of higher mortality in atrial fibrillation (AF) ablation and cardiac resynchronization therapy (CRT) groups (OR [95% CI]: AF ablation = 11.15 [1.70-73.34], p = .01; CRT = 1.41 [1.05-1.90], p = .02). Conclusions: In the real-world setting, CT-related events in EP procedures were found to be 3.4%-7.0% with in-hospital mortality of 2.2%. Older patients undergoing AF ablation were found to have higher mortality.

Impact of Cardiac Implantable Electronic Devices on Cost and Length of Stay in Patients With Surgical Aortic Valve Replacement and Transcutaneous Aortic Valve Implantation.

Surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in aortic stenosis are associated with arrhythmic complications that can require cardiac implantable electronic device (CIED) implantation, but impact on healthcare-associated cost (HAC) and length of stay (LOS) are unknown. This study aimed to assess differences among SAVR/TAVI patients with CIED implantation on HAC and LOS. Patients hospitalized for SAVR or TAVI between 2011 and 2017 on the National Inpatient Sample database were identified and stratified according to presence/type of CIED implantation. During this period, 95,262 patients were identified; 6,435 (6.8%) patients received CIED (median [interquartile range] age: 74.0 [66.0 to 82.0] years). The median adjusted HAC was $44,271 and LOS was 6 days. CIED implantation was associated with longer LOS and higher adjusted HAC in patients with SAVR and TAVI (p <0.0001). Patients with in-hospital death and complications because of SAVR or TAVI had longer preceding in-hospital days of admission. Male patients admitted to small hospitals and the West region had the highest HAC. In conclusion, CIED implantation for arrhythmias results in higher HAC and longer LOS in patients with aortic stenosis for both SAVR and TAVI.

Meta-analysis comparing outcomes of high-power short-duration and low-power long-duration radiofrequency ablation for atrial fibrillation.

OBJECTIVE: High power short duration (HPSD) ablation strategy is proposed to be more effective than low power long duration (LPLD) for radiofrequency ablation of atrial fibrillation. Although small trials abound, data from a large cohort are lacking. This meta-analysis compares all the existing studies comparing these two approaches to evaluate perceived advantages of one over the other. METHODS: A systematic search of PubMed, EMBASE, and Cochrane databases identified studies comparing HPSD to LPLD ablation. All the analyses used the random-effects model. RESULTS: Ablation settings varied widely across 20 studies comprising 2,136 patients who underwent HPSD and 1,753 patients who underwent LPLD. The pooled incidence of atrial arrhythmia recurrence after HPSD ablation was 20% [95% confidence interval (CI): 0.16-0.25; I2=88%]. Atrial arrhythmia recurrences were significantly less frequent with HPSD ablation (incidence risk ratio=0.66; 95% CI: 0.49-0.88; I2=72%; p=0.004). Procedural, fluoroscopy, and ablation times were significantly shorter with HPSD ablation. First-pass pulmonary vein isolations (PVIs) were significantly more [odds ratio (OR)=2.94; 95% CI: 1.50-5.77; I2=89%; p=0.002), and acute pulmonary vein reconnections (PVRs) were significantly lesser (OR=0.41; 95% CI: 0.28-0.62; I2=62%; p<0.001) in the HPSD group. Although radiofrequency energy was significantly higher, esophageal thermal injuries (ETI) were lower with HPSD ablation. Acute complications, including steam-pops, were rare and statistically similar in both the groups. CONCLUSION: HPSD ablation enables faster first-pass PVI with fewer PVRs, similar ETI rates, rare collateral damage, and lower recurrence of atrial arrhythmia in the long term than LPLD. Randomized controlled studies with a larger cohort are indicated both to confirm the benefit of HPSD ablation and standardize the ablation protocol.

Incidence and Predictors of Implantable Cardioverter-defibrillator Therapies After Generator Replacement-A Pooled Analysis of 31,640 Patients' Data.

Among primary prevention implantable cardioverter-defibrillator (ICD) recipients, 75% do not experience any appropriate ICD therapies during their lifetime, and nearly 25% have improvements in their left ventricular ejection fraction (LVEF) during the lifespan of their first generator. The practice guidelines concerning this subgroup's clinical need for generator replacement (GR) remain unclear. We conducted a proportional meta-analysis to determine the incidence and predictors of ICD therapies after GR and compared this to the immediate and long-term complications. A systematic review of existing literature on ICD GR was performed. Selected studies were critically appraised using the Newcastle-Ottawa scale. Outcomes data were analyzed by random-effects modeling using R (R Foundation for Statistical Computing, Vienna, Austria), and covariate analyses were conducted using the restricted maximum likelihood function. A total of 31,640 patients across 20 studies were included in the meta-analysis with a median (range) follow-up of 2.9 (1.2-8.1) years. The incidences of total therapies, appropriate shocks, and anti-tachycardia pacing post-GR were approximately 8, 4, and 5 per 100 patient-years, respectively, corresponding to 22%, 12%, and 12% of patients of the total cohort, with a high level of heterogeneity across the studies. Greater anti-arrhythmic drug use and previous shocks were associated with ICD therapies post-GR. The all-cause mortality was approximately 6 per 100 patient-years, corresponding to 17% of the cohort. Diabetes mellitus, atrial fibrillation, ischemic cardiomyopathy, and the use of digoxin were predictors of all-cause mortality in the univariate analysis; however, none of these were found to be significant predictors in the multivariate analysis. The incidences of inappropriate shocks and other procedural complications were 2 and 2 per 100 patient-years, respectively, which corresponded to 6% and 4% of the entire cohort. Patients undergoing ICD GR continue to require therapy in a significant proportion of cases without any correlation with an improvement in LVEF. Further prospective studies are necessary to risk-stratify ICD patients undergoing GR.

Frequency of Arrhythmias and Postural Orthostatic Tachycardia Syndrome in Patients With Marfan Syndrome: A Nationwide Inpatient Study.

Background Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder affecting multiple systems, particularly the cardiovascular system. The leading causes of death in MFS are aortopathies and valvular disease. We wanted to identify the frequency of arrhythmia and postural orthostatic tachycardia syndrome, length of hospital stay, health care-associated costs (HAC), and in-hospital mortality in patients with MFS. Methods and Results The National Inpatient Sample database from 2005 to 2014 was queried using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for MFS and arrhythmias. Patients were classified into subgroups: supraventricular tachycardia, ventricular tachycardia (VT), atrial fibrillation, atrial flutter, and without any type of arrhythmia. Data about length of stay, HAC, and in-hospital mortality were also abstracted from National Inpatient Sample database. Adjusted HAC was calculated as multiplying HAC and cost-to-charge ratio; 12 079 MFS hospitalizations were identified; 1893 patients (15.7%) had an arrhythmia; and 4.9% of the patients had postural orthostatic tachycardia syndrome. Median values of length of stay and adjusted HAC in VT group were the highest among the groups (VT: 6 days, $18 975.8; supraventricular tachycardia: 4 days, $11 906.6; atrial flutter: 4 days, $11 274.5; atrial fibrillation: 5 days, $10431.4; without any type of arrhythmia: 4 days, $8336.6; both P=0.0001). VT group had highest in-patient mortality (VT: 5.3%, atrial fibrillation: 4.1%, without any type of arrhythmia: 2.1%, atrial flutter: 1.7%, supraventricular tachycardia: 0%; P<0.0001) even after adjustment for potential confounders (without any type of arrhythmia versus VT; odds ratio [95% CI]: 3.18 [1.62-6.24], P=0.001). Conclusions Arrhythmias and postural orthostatic tachycardia syndrome in MFS were high and associated with increased length of stay, HAC, and in-hospital mortality especially in patients with VT.

Impact of Atrial Fibrillation on Outcomes of Aortic Valve Implantation.

New or preexisting atrial fibrillation (AF) is frequent in patients undergoing aortic valve replacement. We evaluated whether the presence of AF during transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) impacts the length of stay, healthcare adjusted costs, and inpatient mortality. The median length of stay in the patients with AF increased by 33.3% as compared with those without AF undergoing TAVI and SAVR (5 [3 to 8] days vs 3 [2 to 6] days, p <0.0001 and 8 [6 to 12] days vs 6 [5 to 10] days, p <0.0001, respectively). AF increased the median value of adjusted healthcare associated costs of both TAVI ($46,754 [36,613 to 59,442] vs $49,960 [38,932 to 64,201], p <0.0001) and SAVR ($40,948 [31,762 to 55,854] vs $45,683 [35,154 to 63,026], p <0.0001). The presence of AF did not independently increase the in-hospital mortality. In conclusion, in patients undergoing SAVR or TAVI, AF significantly increased the length of stay and adjusted healthcare adjusted costs but did not independently increase the in-hospital mortality.

Atrial tachycardia misinterpreted as ventricular high-rate event in a patient with the sick sinus disease and a DDD pacemaker.

The device misinterpreted atrial high-rate episode (AHRE) as ventricular high-rate episode (VHRE), since consecutive atrial beats fell in the postventricular atrial blanking (PVAB) period. This resulted in the failure of auto mode switch (AMS). This was corrected by decreasing the PVAB and the patient was asymptomatic on follow-up.

Egg-shell calcification in Pick's disease (chronic constrictive pericarditis).

Egg-shell calcification is rare in cases with constrictive pericarditis. It leads to significant right heart failure and the only treatment is surgical excision of the pericardium. We present a case of a 22-year-old-male who was diagnosed to have severe pericardial calcification on the chest X-ray, which eventually led to a diagnosis of constrictive pericarditis and required an early surgical correction. This case shows that a common diagnostic test such as a chest X-ray does help to diagnose a severe systemic condition.

Loss of left ventricular component of biventricular pacing with low atrial rhythm, what is the mechanism?

Effective biventricular pacing is important to improve survival in patients with heart failure. We report a case of a patient with heart failure, who underwent cardiac resynchronization therapy, who had loss of biventricular pacing when in low atrial rhythm. We discuss the probable mechanism for the same.

A Network Meta-Analysis Comparing Osteoporotic Fracture among Different Direct Oral Anticoagulants and Vitamin K Antagonists in Patients with Atrial Fibrillation.

BACKGROUND: There are limited studies comparing the risk of osteoporosis and fractures between different direct oral anticoagulants (DOACs) and vitamin K antagonists (VKA) in non-valvular atrial fibrillation (AF). Using a network meta-analysis (NMA), we compared osteoporotic fractures among 5 different treatment arms, viz. dabigatran, rivaroxaban, apixaban, edoxaban, and VKA. METHODS: Ten studies, including 5 randomized control trials and 5 population-based studies, with a total of 321,844 patients (148,751 and 173,093 in the VKA and DOAC group, respectively) with a median follow-up of 2 years, were included. A Bayesian random-effects NMA model comparing fractures among the treatment arms was performed using MetInsight V3. Sensitivity analysis excluded studies with the highest residual deviances from the NMA model. RESULTS: The mean age of the patients was 70 years. The meta-analysis favored DOACs over VKA with significantly lower osteoporotic fracture (odds ratio [OR], 0.77; 95% credible interval [CrI], 0.70-0.86). The NMA demonstrated that fractures were significantly lower with apixaban compared with dabigatran (OR, 0.64; 95% CrI, 0.44-0.95); however, fractures were statistically similar between apixaban and rivaroxaban (OR, 0.84; 95% CrI, 0.58-1.24) and dabigatran and rivaroxaban (OR, 1.32; 95% CrI, 0.90-1.87). Based on the Bayesian model of NMA, the probability of osteoporotic fracture was highest with VKA and lowest with apixaban, followed by rivaroxaban, edoxaban, and dabigatran. CONCLUSIONS: The decision to prescribe anticoagulants in elderly patients with AF should be made not only based on thrombotic and bleeding risks but also on the risk of osteoporotic fracture; these factors should be considered and incorporated in contemporary cardiology practice.