Catheter ablation versus medical therapy in atrial fibrillation: an umbrella review of meta-analyses of randomized clinical trials.

This umbrella review synthesizes data from 17 meta-analyses investigating the comparative outcomes of catheter ablation (CA) and medical treatment (MT) for atrial fibrillation (AF). Outcomes assessed were mortality, risk of hospitalization, AF recurrence, cardiovascular events, pulmonary vein stenosis, major bleeding, and changes in left ventricular ejection fraction (LVEF) and MLHFQ score. The findings indicate that CA significantly reduces overall mortality and cardiovascular hospitalization with high strength of evidence. The risk of AF recurrence was notably lower with CA, with moderate strength of evidence. Two associations reported an increased risk of pulmonary vein stenosis and major bleeding with CA, supported by high strength of evidence. Improved LVEF and a positive change in MLHFQ were also associated with CA. Among patients with AF and heart failure, CA appears superior to MT for reducing mortality, improving LVEF, and reducing cardiovascular rehospitalizations. In nonspecific populations, CA reduced mortality and improved LVEF but had higher complication rates. Our findings suggest that CA might offer significant benefits in managing AF, particularly in patients with heart failure. However, the risk of complications, including pulmonary vein stenosis and major bleeding, is notable. Further research in understudied populations may help refine these conclusions.

Predictors of pulmonary embolism in hospitalized patients with COVID-19.

BACKGROUND: High venous thromboembolism (VTE) rates have been described in critically ill patients with COVID-19. We hypothesized that specific clinical characteristics may help differentiate hypoxic COVID-19 patients with and without a diagnosed pulmonary embolism (PE). METHODS: We performed a retrospective observational case-control study of 158 consecutive patients hospitalized in one of four Mount Sinai Hospitals with COVID-19 between March 1 and May 8, 2020, who received a Chest CT Pulmonary Angiogram (CTA) to diagnose a PE. We analyzed demographic, clinical, laboratory, radiological, treatment characteristics, and outcomes in COVID-19 patients with and without PE. RESULTS: 92 patients were negative (CTA-), and 66 patients were positive for PE (CTA+). CTA + had a longer time from symptom onset to admission (7 days vs. 4 days, p = 0.05), higher admission biomarkers, notably D-dimer (6.87 vs. 1.59, p < 0.0001), troponin (0.015 vs. 0.01, p = 0.01), and peak D-dimer (9.26 vs. 3.8, p = 0.0008). Predictors of PE included time from symptom onset to admission (OR = 1.11, 95% CI 1.03-1.20, p = 0.008), and PESI score at the time of CTA (OR = 1.02, 95% CI 1.01-1.04, p = 0.008). Predictors of mortality included age (HR 1.13, 95% CI 1.04-1.22, p = 0.006), chronic anticoagulation (13.81, 95% CI 1.24-154, p = 0.03), and admission ferritin (1.001, 95% CI 1-1.001, p = 0.01). CONCLUSIONS: In 158 hospitalized COVID-19 patients with respiratory failure evaluated for suspected PE, 40.8% patients had a positive CTA. We identified clinical predictors of PE and mortality from PE, which may help with early identification and reduction of PE-related mortality in patients with COVID-19.

One year outcomes of atrial fibrillation ablation: Contemporary analysis of the United States Nationwide Readmission Database.

BACKGROUND: Data on long-term outcomes of catheter ablation (CA) for atrial fibrillation (AF) in outside of clinical trials settings are sparse. OBJECTIVE: We aimed to assess outcomes and readmissions at 1 year following admission for CA for AF. METHODS: Utilizing the Nationwide Readmissions Database (2016-2018), we identified patients with CA among all patients with a primary admission diagnosis of AF, and a control group by propensity score match adjusted for age, sex, comorbidities, CHA2DS2-VASc scores, and the hospital characteristics. The primary outcome was a composite of unplanned heart failure (HF), AF and stroke-related readmissions, and death at 1 year, and secondary outcomes were hospital outcomes and all-cause readmission rates. RESULTS: The study cohort consisted of 29,771 patients undergoing CA and 63,988 controls. Patients undergoing CA were younger with lower CHA2DS2-VASc scores and less comorbidities. Over a follow-up of 170 ±1.1 days, the primary outcome occurred in 5.2% in CA group and 6.0% of controls (hazard ratio [HR] and 95% confidence interval [CI]: 0.86 [0.76-0.94], p = .002). CA affected AF and stroke related readmission, but showed no effect on HF and mortality outcome. Male sex (HR: 0.83 [0.74-0.94], p = .03), younger age (HR: 0.71 [0.61-0.83], p < .001], and lower CHA2DS2-VASc scores (HR: 0.68 [0.55-0.84], p < .001) were associated with lower risk of primary outcome with CA. CONCLUSION: In this study, CA for AF was associated with significantly lower AF and stroke-related admissions, but not to HF or all-cause readmission. Better outcomes were seen among males, younger patients, and in patients with less comorbidities and low CHA2DS2-VASc scores.

Controversy over smoking in COVID-19-A real world experience in New York city.

Data are conflicting regarding the impact of tobacco smoking in people with pneumonia due to SARS-CoV-2 infection (COVID-19). We performed a retrospective multicentre cohort study of 9991 consecutive patients hospitalized in a major New York academic center between March 7th and June 5th, 2020 with laboratory-confirmed COVID-19. The clinical outcomes assessed included risk of hospitalization, in-hospital mortality, risk of intensive care unit (ICU) admission, and need for mechanical ventilation among smokers (current and former). Multivariable logistic regression and propensity score models were built to adjust for potential confounders. Among 9991 consecutive patients diagnosed with COVID-19, 2212 (22.1%) patients were self-reported smokers (406 current and 1806 former). Current smoking was not associated with an increased risk of hospitalization (propensity score [PS]-adjusted OR 0.91; p = .46), in-hospital mortality (PS-OR 0.77; p = .12), ICU admission (PS-OR 1.18; p = .37), or intubation (PS-OR 1.04; p = .85). Similarly, former smoking was not associated with an increased risk of hospitalization (PS-OR 0.88; p = .11), in-hospital mortality (PS-OR 1.03; p = .78), ICU admission (PS-OR 1.03; p = .95), or intubation (PS-OR 0.93; p = .57). Furthermore, smoking (current or former) was not associated with an increased risk of hospitalization (PS-OR 0.85; p = .05), in-hospital mortality (PS-OR 0.94; p = .49), ICU admission (PS-OR 0.86; p = .17), or intubation (PS-OR 0.79; p = .06). Smoking is a well-known risk factor associated with greater susceptibility and subsequent increased severity of respiratory infections. In the current COVID-19 pandemic, smokers may have increased risk and severe pneumonia. In the current COVID-19 pandemic, smokers are believed to have an increased risk of mortality as well as severe pneumonia. However, in our analysis of real-world clinical data, smoking was not associated with increased in-patient mortality in COVID-19 pneumonia, in accordance with prior reports.

Safety and complications of catheter ablation for atrial fibrillation: Predictors of complications from an updated analysis the National Inpatient Database.

BACKGROUND: Catheter ablation is increasingly employed in the management of atrial fibrillation (AF). Data regarding safety of ablation of AF is largely derived from controlled clinical trials. OBJECTIVES: The aim of this study was to analyze safety and complications of AF ablation performed in a "real world" setting outside of clinical trials, and obtain insights on predictors of complications. METHODS: We utilized the National Inpatient Sample database, to identify all patients who underwent AF ablations between 2015 and 2017 using International Classification of Disease-Tenth revision codes. Complications were defined as per the Agency for Health Care Research and Quality Guidelines. Statistical tests including multivariate logistic regression were performed to determine predictors of complications. RESULTS: Among 14,875 cases of AF ablation between 2015 and 2017, a total of 1884 complications were identified among 1080 (7.2%) patients. Patients with complications were likely to be older and female with a higher burden of comorbidities. A 27% increase in complications was observed from 2015 to 2017, driven by an increase in pericardial complications. Multivariate regression analysis revealed that pulmonary hypertension (adjusted odds ratio [aOR]: 1.99, p = .041) and chronic kidney disease (CKD; aOR: 1.67, p = .024), were independent predictors of complications. Centers with higher procedural volumes were associated with lower complication rates. CONCLUSIONS: Complication rates related to AF ablations remain substantially high. Presence of pulmonary hypertension and CKD are predictive of higher procedural complications. Furthermore, hospital procedure volume is an important factor that correlates with complication rates.

Role of immunosuppressive therapy in the management refractory postprocedural pericarditis.

OBJECTIVE: To assess the safety and efficacy of a novel immunosuppressive regimen-combination Methotrexate/Prednisone (cMtx/P)-in the management of severe refractory rPPP. METHODS: In this multicenter, nonrandomized, retrospective, observational study, 408 consecutive patients diagnosed with persistent rPPP between 2017 and 19 were included. Patients with refractory symptoms despite 3 months of conventional therapy were initiated on a 4-week regimen of oral steroids. Persistence of symptoms at this point, that is, rPPP (n = 25; catheter based = 18, open surgical = 7) prompted therapy with Methotrexate (7.5-15 mg weekly) with folate supplementation along with low dose prednisone (5 mg PO) for a further 3 months. Patients were followed for a total of 11.3 ± 1.8 months. RESULTS: Treatment refractory rPPP occurred in 6.1% of the study population prompting immunosuppressive therapy with cMtx/P. All patients demonstrated complete symptom resolution following 3 months of treatment with an 85% decline in clinically significant pericardial effusions. One patient developed recurrent pericarditis during the 11-month follow-up. Therapy was well tolerated with no significant drug related adverse effects. CONCLUSION: cMtx/P therapy is a safe and effective adjunct in the management of rPPP refractory to standard therapy.

Trans-nasal high-flow dehumidified air in acute migraine headaches: A randomized controlled trial.

BACKGROUND: Intranasal high flow of dehumidified (dry) air results in evaporative cooling of nasal passages. In this randomized clinical trial, we investigated the effect of dry gas induced nasal cooling on migraine headaches. METHODS: In this single-blind study, acute migraineurs were randomized to either nasal high-flow dry oxygen, dry air, humidified oxygen or humidified air (control) at 15 L/min for 15 min. All gases were delivered at 37°C. Severity of headache and other migraine associated symptoms (International Classification for Headache Disorders, 3rd edition criteria) were recorded before and after therapy. The primary endpoint was change in pain scores, while changes in nausea, photosensitivity and sound sensitivity scores served as secondary endpoints. A linear regression model was employed to estimate the impact of individual treatment components and their individual interactions. RESULTS: Fifty-one patients (48 ± 15 years of age, 82% women) were enrolled. When compared to the control arm (humidified air), all therapeutic arms showed a significantly greater reduction in pain scores (primary endpoint) at 2 h of therapy with dry oxygen (-1.6 [95% CI -2.3, -0.9]), dry air (-1.7 [95% CI -2.6, -0.7)]), and humidified oxygen (-2.3 [95% CI -3.5, -1.1]). A significantly greater reduction in 2-h photosensitivity scores was also noted in all therapeutic arms (-1.8 [95% CI -3.2, -0.4], dry oxygen; -1.7 [95% CI -2.9, -0.4], dry air; (-2.1 [95% CI -3.6, -0.6], humidified oxygen) as compared to controls. The presence of oxygen and dryness were independently associated with significant reductions in pain and photosensitivity scores. No adverse events were reported. CONCLUSION: Trans-nasal high-flow dry gas therapy may have a role in reducing migraine associated pain.Clinical Trial registration: NCT04129567.

The relationship between asthma, eosinophilia, and outcomes in coronavirus disease 2019 infection.

BACKGROUND: The impact of asthma diagnosis and asthma endotype on outcomes from coronavirus disease 2019 (COVID-19) infection remains unclear. OBJECTIVE: To describe the association between asthma diagnosis and endotype and clinical outcomes among patients diagnosed as having COVID-19 infection. METHODS: Retrospective multicenter cohort study of outpatients and inpatients presenting to 6 hospitals in the Mount Sinai Health System New York metropolitan region between March 7, 2020, and June 7, 2020, with COVID-19 infection, with and without a history of asthma. The primary outcome evaluated was in-hospital mortality. Secondary outcomes included hospitalization, intensive care unit admission, mechanical ventilation, and hospital length of stay. The outcomes were compared in patients with or without asthma using a multivariate Cox regression model. The outcomes stratified by blood eosinophilia count were also evaluated. RESULTS: Of 10,523 patients diagnosed as having COVID-19 infection, 4902 were hospitalized and 468 had a diagnosis of asthma (4.4%). When adjusted for COVID-19 disease severity, comorbidities, and concurrent therapies, patients with asthma had a lower mortality (adjusted odds ratio [OR], 0.64 (0.53-0.77); P < .001) and a lower rate of hospitalization and intensive care unit admission (OR, 0.43 (0.28-0.64); P < .001 and OR, 0.51 (0.41-0.64); P < .001, respectively). Those with blood eosinophils greater than or equal to 200 cells/µL, both with and without asthma, had lower mortality. CONCLUSION: Patients with asthma may be at a reduced risk of poor outcomes from COVID-19 infection. Eosinophilia, both in those with and without asthma, may be associated with reduced mortality risk.

Current practice and future prospects in left atrial appendage occlusion.

The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion.

Electromagnetic interference from left ventricular assist device in patients with transvenous implantable cardioverter-defibrillator.

BACKGROUND: Many advanced heart failure patients have both a left ventricular assist device (LVAD) and an implantable cardioverter-defibrillator (ICD). This study examines incidence, clinical impact, and management of LVAD-related EMI. METHODS: We performed a three-center retrospective analysis of transvenous ICD implanted patients with LVAD implanted between January 1, 2005 and December 31, 2020. The primary outcome was EMI after LVAD implantation, categorized as LVAD-related noise or telemetry interference. RESULTS: The rate of LVAD-related EMI among the 737 patients (mean age 58.6 ± 12.8 years) studied was 5.0%. Telemetry interference (1.5%) compromised ICD interrogation in all patients. This was resolved successfully with use of a metal shield, encased wand, radiofrequency tower, different ICD programmer or by increasing distance between ICD programmer and LVAD (n = 6). ICD replacement was required to reestablish successful communication in three patients. LVAD-related noise (3.5%) led to oversensing (n = 4), inappropriate mode switches (n = 4), noise reversion (n = 3), inhibition of pacing (n = 2), inappropriate detection as atrial fibrillation (AF) (n = 2) and inappropriate detection as ventricular tachycardia (VT) and/or ventricular fibrillation (VF) (n = 2). This noise interference persisted (n = 3), resolved spontaneously (n = 16), resolved with programming change (n = 6) or required lead revision (n = 1). CONCLUSIONS: EMI from LVAD impacts ICD function, although, the incidence rate is low. Physicians implanting both, LVAD in patients with ICD (more common) or ICD in patients with LVAD, should be aware of possible interferences. Telemetry failure not resolved by metal shielding was overcome by ICD generator replacement to a different manufacturer. In most cases, LVAD-related noise resolves spontaneously.

Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies.

Catheter ablation has become an important element in the management of atrial fibrillation. Several technical advances allowed for better safety profiles and lower recurrence rates, leading to an increasing number of ablations worldwide. Despite that, major complications are still reported, and esophageal thermal injury remains a significant concern as atrioesophageal fistula (AEF) is often fatal. Recognition of the mechanisms involved in the process of esophageal lesion formation and the identification of the main determinants of risk have set the grounds for the development and improvement of different esophageal protective strategies. More sensitive esophageal temperature monitoring, safer ablation parameters and catheters, and different energy sources appear to collectively reduce the risk of esophageal thermal injury. Adjunctive measures such as the prophylactic use of proton-pump inhibitors, as well as esophageal cooling or deviation devices, have emerged as complementary methods with variable but promising results. Nevertheless, as a multifactorial problem, no single esophageal protective measure has proven to be sufficiently effective to eliminate the risk, and further investigation is still warranted. Early screening in the patients at risk and prompt intervention in the cases of AEF are important risk modifiers and yield better outcomes.

Role of diabetes and insulin use in the risk of stroke and acute myocardial infarction in patients with atrial fibrillation: A Medicare analysis.

BACKGROUND: Atrial fibrillation (AF) is associated with elevated risk for ischemic stroke and myocardial infarction (MI). The aim of the study is to assess the role of insulin use on the risk of stroke and MI in AF patients with diabetes. METHODS: We identified Medicare beneficiaries with new AF in 2011 to 2013. Primary outcomes were ischemic stroke and MI. Multivariate Cox regression models were used to assess the association between AF and time to stroke and MI. We adjusted for anticoagulant as a time-dependent covariate. RESULTS: Out of 798,592 AF patients, 53,212 (6.7%) were insulin-requiring diabetics (IRD), 250,214 (31.3%) were non-insulin requiring diabetics (NIRD) and 495,166 (62%) were non-diabetics (ND). IRD had a higher risk of stroke when compared to NIRD (adjusted HR: 1.15, 95% CI 1.10-1.21) and ND (aHR 1.24, 95% CI 1.18-1.31) (P < .01 for both). The risk of stroke was higher in NIRD compared to ND (aHR 1.08, 95% CI 1.05-1.12). For the outcome of MI, IRD had a higher risk compared to NIRD (aHR 1.24, 95% CI 1.18-1.31) and ND (aHR 1.46, 95% CI 1.38-1.54)]. NIRD had a higher risk compared to ND (aHR 1.17, 95% CI 1.13-1.22). Anticoagulation were most effective at preventing stroke in ND [0.72 (0.69-0.75)], and NIRD [0.88 (0.85-0.92)], but were not associated with significant reduction in stroke in IRD [0.96 (0.89-1.04)]. CONCLUSION: There is an incremental risk of ischemic stroke and MI from non-diabetics to non-insulin diabetics with the highest risk in insulin users. Protective effect of anticoagulation is attenuated with insulin use.

Role of dofetilide in patients with ventricular arrhythmias.

BACKGROUND OR PURPOSE: To assess effectiveness of dofetilide in reducing the burden of ventricular arrhythmias (VAs). BACKGROUND: Prior small sample studies show that dofetilide has benefit in reducing VA. However, large sample investigations with long-term follow-up are lacking. METHODS: Two hundred seventeen consecutive patients admitted between January 2015 and December 2021 for dofetilide initiation for control of VA were assessed. Dofetilide was successfully started in 176 patients (81%) and had to be discontinued in the remaining 41 patients (19%). Dofetilide was initiated for control of ventricular tachycardia (VT) in 136 patients (77%), whereas 40 (23%) patients were initiated on dofetilide for reducing the burden of premature ventricular complexes (PVCs). RESULTS: The mean follow-up was 24 ± 7 months. In total, among the 136 VT patients, 33 (24%) died, 11 (8%) received a left ventricular assist device (LVAD), and 3 (2%) received a heart transplant during follow-up. Dofetilide was discontinued in 117 (86%) patients due to lack of sustained effectiveness during follow-up. Dofetilide use was associated with similar odds of the composite outcome of all-cause mortality/LVAD/heart transplant (OR: 0.97, 0.55-4.23) in patients with ischemic cardiomyopathy (ICM) compared to those with non-ischemic cardiomyopathy (NICM). Dofetilide did not reduce PVC burden during follow-up in the 40 patients with PVCs (mean baseline PVC burden: 15%, at 1-year follow-up: 14%). CONCLUSIONS: Dofetilide use was less effective in reducing VA burden in our cohort of patients. Randomized controlled studies are needed to confirm our findings.

Postural Orthostatic Tachycardia Syndrome in COVID-19: A Contemporary Review of Mechanisms, Clinical Course and Management.

The long-term implications of COVID-19 have garnered increasing interest in recent months, with Long-COVID impacting over 65 million individuals worldwide. Postural orthostatic tachycardia syndrome (POTS) has emerged as an important component of the Long-COVID umbrella, estimated to affect between 2 and 14% of survivors. POTS remains very challenging to diagnose and manage - this review aims to provide a brief overview of POTS as a whole and goes on to summarize the available literature pertaining to POTS in the setting of COVID-19. We provide a review of available clinical reports, outline proposed pathophysiological mechanisms and end with a brief note on management considerations.

Experimental drugs for supraventricular tachycardia: an analysis of early phase clinical trials.

INTRODUCTION: Supraventricular tachycardias (SVT) are a diverse group of commonly encountered arrhythmias arising at or above the atrioventricular (AV) node. Conventional anti-arrhythmic medications are restricted by extensive side-effect profiles and limited efficacy. Catheter ablation has emerged as a first-line therapy for many arrhythmias but is not a suitable option for all patients. This has prompted the exploration of novel pharmacological approaches targeting specific molecular mechanisms of SVT. AREAS COVERED: This review article aims to summarize recent advancements in pharmacological therapeutics for SVT and their clinical implications. The understanding of molecular mechanisms underlying these arrhythmias, particularly atrial fibrillation, has opened up new possibilities for targeted interventions. Beyond the manipulation of ion channels and membrane potentials, pharmacotherapy now focuses on upstream targets such as inflammation, oxidative stress, and structural remodeling. This review strives to provide a comprehensive overview of recent advancements in pharmacological therapeutics directed at the management of SVT. We begin by providing a brief summary of the mechanisms and management of commonly encountered SVT before delving into individual agents, which in turn are stratified based on their molecular treatment targets. EXPERT OPINION: The evolving landscape of pharmacologic therapy offers hope for more personalized and tailored interventions in the management of SVT.

Genetic and Molecular Mechanisms in Brugada Syndrome.

Brugada syndrome is a rare hereditary arrhythmia disorder characterized by a distinctive electrocardiogram pattern and an elevated risk of ventricular arrhythmias and sudden cardiac death in young adults. Despite recent advances, it remains a complex condition, encompassing mechanisms, genetics, diagnosis, arrhythmia risk stratification, and management. The underlying electrophysiological mechanism of Brugada syndrome requires further investigation, with current theories focusing on abnormalities in repolarization, depolarization, and current-load match. The genetic basis of the syndrome is strong, with mutations found in genes encoding subunits of cardiac sodium, potassium, and calcium channels, as well as genes involved in channel trafficking and regulation. While the initial discovery of mutations in the SCN5A gene provided valuable insights, Brugada syndrome is now recognized as a multifactorial disease influenced by several loci and environmental factors, challenging the traditional autosomal dominant inheritance model. This comprehensive review aims to provide a current understanding of Brugada syndrome, focusing on its pathophysiology, genetic mechanisms, and novel models of risk stratification. Advancements in these areas hold the potential to facilitate earlier diagnosis, improve risk assessments, and enable more targeted therapeutic interventions.

Safety and Efficacy of Direct Oral Anticoagulants Versus Warfarin for Atrial Fibrillation in End-Stage Renal Disease on Hemodialysis: A Meta-Analysis of Randomized Control Trials.

End-stage renal disease (ESRD) and atrial fibrillation (AF) are commonly encountered, with ESRD itself serving as a well-established risk factor for AF.1 The 2018 AF guidelines have recommended apixaban across all the spectrums of renal impairment, including patients on hemodialysis (HD), and the 2019 American Heart Association/American College of Cardiology/Heart Rhythm Society updated guidelines have suggested careful consideration of reduced dose of direct oral anticoagulants (DOACs) in patients with ESRD.2,3 The current data on the safety and efficacy of warfarin versus DOACs in patients with AF with ESRD and HD is variable. This study aimed to perform a study-level meta-analysis to evaluate the effectiveness and safety of warfarin and DOACs in patients with AF who require dialysis.