Atrial fibrillation in heart failure: catheter and surgical interventional therapies.

Atrial fibrillation and heart failure commonly coexist in the same patient. Each may adversely affect the other. Atrial fibrillation leads to heart failure exacerbation, left ventricular function deterioration and an increase in thrombo-embolic risk. Therapeutic options targeting atrial fibrillation in heart failure patients include pharmacological and non-pharmacological means. Pharmacological therapy is directed at either rate control using nodal blocking agents or rhythm control using anti-arrhythmic agents, of which the options are limited in patients with heart failure. The landmark AF-CHF trial did not show any benefit of rhythm control strategy as opposed to rate control in patients with heart failure and atrial fibrillation. However, patients in this trial as well as in others used mostly amiodarone for rhythm control. This might have negated any positive effects of achieving normal sinus rhythm. Non-pharmacological therapy both for rate and rhythm control is appealing. This includes AV node ablation for rate control, catheter ablation of atrial fibrillation and surgical therapy of atrial fibrillation. This review will address non-pharmacologic treatment of AF in heart failure patients.

Extracorporeal Membrane Oxygenation (ECMO): What We Need to Know.

Extracorporeal membrane oxygenation (ECMO) is a form of circulatory support used in patients with refractory cardiac and/or respiratory failure. The main role of such support is to allow the lungs and heart to rest and heal while providing adequate oxygenation to vital organs. During extracorporeal support, the venous blood removed is decarboxylated, oxygenated, warmed, and infused back into the circulation. Physicians and nursing staff should be familiar with ECMO in order to provide the best care for critically ill patients. The aim of this paper is to review the technical aspects, indications, contraindications, complications, and management of both veno-venous (VV) and veno-arterial (VA) ECMO.

Evaluation of the appropriateness criteria for coronary computed tomography angiography in an academic medical center in a developing country: comparison of the 2006 and 2010 criteria.

BACKGROUND: The aims of this study are to analyze the risk profile and evaluate the appropriateness of patient referral to coronary CT angiography in a new MSCT laboratory in an academic medical center in a developing country. METHODS AND RESULTS: The study population consisted of 100 consecutive patients (mean age 53 ± 13 years, 83% males) who were referred to the new 64 slice MSCT laboratory at the American University of Beirut between July 2008 and July 2009. 52% of patients had chest pain and 48% were asymptomatic. By the 2006 ACCF criteria, only 8% of the referrals fitted the "Appropriate" criteria, 49% were "Inappropriate", and 43% were "Uncertain". The percentage of "Appropriate" indications increased from 8% by the 2006 criteria to 38% by the 2010 ACCF criteria. Framingham risk score (FRS) calculation showed a substantial percentage (46%) of patients to be at low risk, with 32% being at intermediate risk, and 22% at high risk. The prevalence of high calcium score (>400) (0% vs 22%, vs 27%, P < .001) and of obstructive CAD (4% vs 23% vs 40%, P < .001) increased steadily across the low, intermediate, and high FRS groups, respectively. CONCLUSIONS: There was a significant increase in the percentage of "Appropriate" indications for MSCT when comparing the 2010 to the 2006 ACCF appropriateness criteria. However, in spite of that, there was still significant deviation from the ACCF appropriateness criteria among patients referred for coronary CT angiography in this new MSCT laboratory in a developing country.

Arrhythmogenic Right Ventricular Dysplasia and Brugada Syndrome Overlap.

Arrhythmogenic right ventricular dysplasia (ARVD) and Brugada syndrome( BS) are associated with an increased risk of sudden cardiac death. Although they are described as two different entities, research suggests that they are not entirely separate. This paper presents a 55 years old male who presented for syncope. Interestingly, his electrocardiogram met the diagnostic criteria for both ARVD and BS. Subsequently, an implantable cardioverter-defibrillator (ICD) was implanted before discharge due to his high risk of sudden cardiac death. This case revealed that ARVD and BS clinical features can coexist in a single patient, and therefore supports the existence of a common pathophysiological basis of both diseases.

Dopamine in Idiopathic Polymorphic Ventricular Tachycardia/Ventricular Fibrillation.

The role of medical therapy in the treatment of idiopathic polymorphic ventricular tachycardia (IPMVT) and idiopathic ventricular fibrillation (IVF) is not well established. Current medications in use include amiodarone, lidocaine, isoproterenol, verapamil, and quinidine. However, the use of dopamine for controlling such arrhythmias has never been described. We present an interesting case of IPMVT/IVF storm induced by short-coupled premature ventricular contractions. The arrhythmia was terminated acutely using dopamine infusion and was suppressed chronically using verapamil.

Sensor Enabled Catheter Ablation Study (SECAS).

Background EnSite Precision technology (Abbott, Chicago, Illinois) is a novel mapping and navigation system facilitating the visualization and manipulation of intracardiac catheters during arrhythmia ablation procedures. When using Sensor Enabled (SE) catheters (Abbott, Chicago, Illinois), the mapping system uses both electrical impedance and magnetic data to facilitate more accurate mapping and navigation. Whether this translates into better clinical outcomes is unknown. Methods This retrospective study will examine whether SE catheters improve the success rate or decrease the risks compared to Biosense Thermocool catheters (Biosense Webster Inc., Irvine, California) not employing sensor-enabled technology utilizing NavX EnSite Precision algorithms. Charts of 146 patients who underwent radiofrequency ablations for supraventricular and ventricular arrhythmias between 2016 and 2019 in the Beirut Cardiac Institute were reviewed and analyzed. It was concluded that SE catheters have the same success rate as electrical impedance catheters. Results A total of 70% of the ablations carried using the impedance-based catheter were successful compared to 74% using the SE catheter. However, the difference was statistically non-significant (p-value: 0.7). As for complications, the ventricular fibrillation rate was increased in the SE catheter group. Three procedures were complicated by pericardial effusion, three patients had reversible heart block, and one death was recorded, all reported while using the standard catheter (p-value: 0.01). Conclusion SE catheters have the same success rates compared to standard catheters using the EnSite Precision mapping system.

The Correlation Between Gender and Accessory Pathways.

Background Accessory pathways (APs) are muscular bundles capable of rapid conduction between atria and ventricles. They can be located anywhere along the atrioventricular groove or septum. The etiology of such pathways is generally unknown. This study aims to evaluate the correlation between gender, AP location, and clinical presentation. Methods This is a retrospective study of 139 patients who underwent radiofrequency ablations for newly diagnosed accessory pathways between years 2010 and 2016. Information extracted from the medical records included: age at the time of diagnosis, gender, characteristics, and anatomical location of the accessory pathways. Results A total of 139 patients with AP were enrolled in the study. The mean age of diagnosis was 32.2 ± 13.5 years. With regards to gender, APs were more common among men (p-value 0.04). Males were predominant in both the right and left AP groups (p-value 0.025), although, overall, most of the AP were left located. Also, males were more commonly diagnosed with right posteroseptal (RPS) accessory pathways while females with left lateral (LL) pathways. Concerning the clinical presentation, the manifest form was more frequent than concealed. Males were prevalent in both groups (p-value 0.38). Conclusion Gender components might have a role in the pathogenesis of AP formation.

Periodontal parameters in adult patients with clear aligners orthodontics treatment versus three other types of brackets: A cross-sectional study.

OBJECTIVE: To assess the gingival parameters in the clear aligner treatment versus the three other types of brackets, i.e., conventional metal, conventional ceramic, and metal self-ligating. MATERIALS AND METHODS: Eighty patients coming for regular appointments undergoing orthodontic treatment were included. They were further divided into four groups with 20 patients in each: Group one underwent conventional brackets (CB) treatment; Group two had conventional ceramic brackets (CCB); Group three was treated with self-ligating (SL) brackets; Group four underwent with clear aligner (CA) treatment. Inclusion criteria were any patient with a minimum age of 18 years having Class II, Class III skeletal relationship, undergoing orthodontic treatment for at least 6 months with fixed orthodontic appliances (FOA) on both arches. While smokers, pregnant, diabetics, or those taking medication affecting gingival health or having cardiovascular diseases were excluded. Also excluded were patients who used antiseptic solutions or mouthwash during the past 6 months, underwent any periodontal treatments in the past 6 months, or who had fixed bridges and crowns or extensive restorations close to the gingival margins. Seven indices, namely plaque index, gingival index, gingival bleeding index, sulcus bleeding index, papillary bleeding index, basic periodontal examination index, and bleeding on probing index, were recorded for all groups. RESULTS: Mean age for Group 1 with CB was 26.65 ± 5.15 years, whereas it was 27.65 ± 8.15 years for Group 2 with CCB, and 26.85 ± 5.19 for Group 3 with SB. Group-4 with CA treatment had a mean age of 26.85 ± 4.83 years. Multivariate analysis and a Bonferroni correction was performed (P = 0.008). CA treatment has better periodontal parameter values compared with the CB and the CCB groups, and no significance difference with the SL brackets group. CONCLUSION: CA treatment has better periodontal indices levels compared to other types of orthodontic treatments such as CB and the CCB groups; no significant difference with the SL brackets group. Importance should be given to oral hygiene instructions before, during, and after the treatment.

Current reperfusion strategies for ST-elevation myocardial infarction in an academic medical center in a developing country: efficacy of primary percutaneous coronary intervention.

OBJECTIVES: To study the reperfusion strategies currently being used in the treatment of ST-elevation myocardial infarction (STEMI) at an academic medical center in a developing country and to analyze the door-to-balloon time (DBT) in those patients undergoing primary percutaneous coronary intervention (PCI). METHODS: The study included all patients presenting with STEMI to the emergency department at the American University of Beirut Medical Center between July 2008 and February 2010. Data were collected prospectively from the patients' medical records. RESULTS: The study population consisted of 100 consecutive patients. Compared with an earlier study from American University of Beirut Medical Center done in 2002-2005, there was a significant increase in the utilization of primary PCI for reperfusion (81% vs. 2.5%; P < 0.001). However, the median DBT was 110 minutes, with only 30% of patients achieving a DBT ≤90 minutes. The predictors of delayed DBT (>90 minutes) were culprit lesions in the circumflex artery (P = 0.007) and delayed time from electrocardiogram to arrival in the catheterization laboratory (P < 0.001). CONCLUSIONS: There was a significant increase in the utilization of primary PCI for reperfusion of STEMI in this academic medical center in a developing country. However, achieving a target DBT ≤90 minutes was suboptimal. Future studies are needed to analyze the logistic factors associated with delayed reperfusion to institute policies and systems that can enhance the efficacy of primary PCI as a reperfusion modality in these countries.