Atrial fibrillation inpatient management patterns and clinical outcomes during the conflict in Syria: An observational cohort study.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. However, there is no data on AF inpatient management strategies and clinical outcomes in Syria. OBJECTIVES: The study aims were to review the inpatient management of patients with AF and assess cardiovascular (CV) mortality in a tertiary cardiology centre in Latakia, Syria. METHODS: A single-centre retrospective observational cohort study was conducted at Tishreen's University Hospital, Latakia, Syria, from June 2021 to June 2023. Patients ≥16 years of age presenting and being treated for AF as the primary diagnosis with or without a thromboembolic event were included. Medical records were examined for patients' demographics, laboratory results, treatment plans and inpatient details. Studied outcomes include inpatient all-cause and CV mortality, ischemic and bleeding events, and conversion to sinus rhythm (SR). RESULTS: The study included 596 patients. The median age was 58, and 61% were males. 121 patients (20.3%) were known to have AF. A rhythm control strategy was pursued in 39% of patients. Ischemic and bleeding events occurred in 62 (11%) and 12 (2%), respectively. CV and all-cause mortality occurred in 28 (4.7%) and 31 patients (5%), respectively. The presence of valvular heart disease (VHD) (adjusted odds ratio (aOR) = 9.1, 95% confidence interval (CI): 1.7 to 55.1, p < .001), thyroid disease (aOR: 9.7, 95% CI = 1.2 to 91.6, p < .001) and chronic obstructive pulmonary disease (COPD) (aOR: 82, 95% CI: 12.7 to 71, p < .001) were independent risk factors of increased CV inpatient mortality. CONCLUSION: Syrian inpatients admitted with AF in Latakia are relatively younger than those in other countries. Active thyroid disease, COPD and VHD were independent risk factors of inpatient CV mortality with AF.

Bi-atrial thrombus straddling a patent foramen ovale with bilateral embolization: A therapeutic challenge.

Stroke is a leading cause of morbidity and mortality across the world and a significant portion of ischemic strokes have a cardiac source. We report a case of a 55-year-old male who presented with an ischemic stroke and bilateral pulmonary emboli secondary to an intra-cardiac thrombus straddling a patent foramen ovale, which was clearly seen using transesophageal echocardiography. We discuss the management dilemma associated with this clinical picture given the risk of hemorrhagic transformation in the acute phase of an ischemic stroke. Our case demonstrates the need for a multidisciplinary approach in an area of medicine that lacks clear guidelines.

Involuntary arm movements post-pacemaker insertion - real or Reel syndrome?

BACKGROUND: Twiddler syndrome, and the variant Reel syndrome, are rare but important complications of pacemaker implantation. CASE SUMMARY: We describe a rare complication of conventional permanent pacemaker implantation of rhythmic arm twitching secondary to brachial plexus stimulation from a displaced pacing lead caused by Reel syndrome. DISCUSSION: Twiddler syndrome and its variants are rare but important complications of pacemaker insertion. Holistic planning of cardiac procedures in elderly patients should identify those at risk to allow for targeted education and post-procedural care.

COVID-19 inpatient treatments and outcomes during the conflict in Syria: an observational cohort study.

Background: During the COVID-19 pandemic, countries undergoing conflict have faced difficulties in mounting an effective health response. This observational cohort study describes the treatments and outcomes for inpatients with COVID-19 in the Syrian city of Latakia. Design and methods: A single-centre observational cohort study was conducted at Tishreen University Hospital, involving all patients over 18 admitted between October 1 and December 31, 2021 with a positive RT-PCR test for SARS-CoV-2. Clinical features, investigations, treatments, and outcomes were reported. Results: In total, 149 patients fitted the study criteria. Only one patient was double vaccinated against COVID-19. Oxygen supplementation was required in 87% (n = 130) of participants. Invasive mechanical ventilation was required in 4% (n = 5). Therapeutic anticoagulation was administered in 97.3% (n = 144). Intravenous dexamethasone was received by 97.3% (n = 145) of participants. All patients received empiric antibiotic treatment. In-hospital mortality was 48.4% (n = 72), while only 40.9% (n = 61) were discharged during the study period. Conclusion: The pandemic has placed a compromised Syrian healthcare system under more significant strain. This requires urgent international relief efforts from health agencies in order to aid the pandemic response.

Digitally enabled acute care for atrial fibrillation: conception, feasibility and early outcomes of an AF virtual ward.

BACKGROUND: Atrial fibrillation (AF) represents a growing healthcare challenge, mainly driven by acute hospitalisations. Virtual wards could be the way forward to manage acute AF patients through remote monitoring, especially with the rise in global access to digital telecommunication and the growing acceptance of telemedicine post-COVID-19. METHODS: An AF virtual ward was implemented as a proof-of-concept care model. Patients presenting acutely with AF or atrial flutter and rapid ventricular response to the hospital were onboarded to the virtual ward and managed at home through remote ECG-monitoring and 'virtual' ward rounds, after being given access to a single-lead ECG device, a blood pressure monitor and pulse oximeter with instructions to record daily ECGs, blood pressure, oxygen saturations and to complete an online AF symptom questionnaire. Data were uploaded to a digital platform for daily review by the clinical team. Primary outcomes included admission avoidance, readmission avoidance and patient satisfaction. Safety outcomes included unplanned discharge from the virtual ward, cardiovascular mortality and all-cause mortality. RESULTS: There were 50 admissions to the virtual ward between January and August 2022. Twenty-four of them avoided initial hospital admission as patients were directly enrolled to the virtual ward from outpatient settings. A further 25 readmissions were appropriately prevented during virtual surveillance. Patient satisfaction questionnaires yielded 100% positive responses among participants. There were three unplanned discharges from the virtual ward requiring hospitalisation. Mean heart rate on admission to the virtual ward and discharge was 122±26 and 82±27 bpm respectively. A rhythm control strategy was pursued in 82% (n=41) and 20% (n=10) required 3 or more remote pharmacological interventions. CONCLUSION: This is a first real-world experience of an AF virtual ward that heralds a potential means for reducing AF hospitalisations and the associated financial burden, without compromising on patients' care or safety.

UK Expert Consensus Statement for the Optimal Use and Clinical Utility of Leadless Pacing Systems on Behalf of the British Heart Rhythm Society.

Pacemakers are a key technology in the treatment of bradyarrhythmias. Leadless pacemakers (LP) were introduced to address limitations of transvenous devices. However, guidelines and other restrictions have led to LPs becoming niche products. The aim of this consensus statement was to determine the strength of opinion of UK implantation experts as to how LPs can be more optimally used. Using a modified Delphi approach, a panel of LP experts developed 36 statements that were used to form a survey that was distributed to LP implanters in the UK. Stopping criteria included a 3-month window for response, a minimum 25% response rate and at least 75% of statements achieving the threshold for consensus (agreed at 66%). In all, 31 of 36 statements reached consensus, and 23 of these achieved ≥90% agreement. Five statements did not achieve consensus. On the basis of these results, seven recommendations were proposed. The implementation of these recommendations may increase the use of LPs, with the aim of improving patient outcomes.

Atrioventricular synchronous pacing using leadless pacemaker in a heart transplant patient.

We report the first leadless pacemaker (L-PM) providing atrioventricular synchronous pacing implanted into a heart transplant patient receiving chronic immunosuppressive therapy. The patient presented with syncope corresponding to sinus rhythm with high-grade atrioventricular block. Previously, L-PMs provided only single-chamber ventricular sensing and pacing. A Micra AV lL-PM provides atrioventricular synchronous pacing by tracking mechanical atrial contraction. L-PMs, which now support broader indications, should be considered in patients at greater risk of infection.

Fluoroscopic Appearance of a Single-Wall Cryoballoon Breach During Pulmonary Vein Isolation.

Cryoballoon ablation therapy is increasingly used for pulmonary vein isolation. Its safety and efficacy profile is comparable to that of radiofrequency ablation therapy. Double-wall cryoballoon breaches have been described in published reports. This report presents a case of single-wall cryoballoon rupture captured under fluoroscopy, with no adverse effect on the patient. (Level of Difficulty: Intermediate.).

The use of a single chamber leadless pacemaker for the treatment of cardioinhibitory vasovagal syncope.

BACKGROUND: The use of pacemakers in the treatment of cardioinhibitory vasovagal syncope is controversial with a mixed message from the limited evidence base. Single chamber leadless pacemakers have been shown to be an effective alternative option to conventional pacemakers. OBJECTIVE: This study examines the use of leadless pacemakers in a cardioinhibitory vasovagal population in the United Kingdom. METHODS: Observational data on 32 patients implanted with the Micra Transcatheter Pacemaker System for vasovagal syncope are presented. Data was collected on implant indications, implant procedure and follow up data from 12 centres across the United Kingdom that had elected to use a Micra leadless pacemaker in this patient population. RESULTS: 32 patients aged 37 ±â€¯14 years (range 18 to 64 years) with 62% of the patients being female were recruited to the study. Vasovagal syncope was diagnosed clinically and with the support of Holter monitoring, tilt table testing and implantable loop recorders. The duration of symptoms was 8 ±â€¯8 yrs. with an average frequency of syncope being 4 ±â€¯6 times/year. The Micra pacemaker was successfully implanted in all patients with a major complication rate of 3.1%. Patients were followed up for 404 ±â€¯237 days (range 63-928 days). At follow up 28 (87%) patients were free from symptoms. CONCLUSIONS: This observational study suggests that the use of a single chamber leadless pacemaker in the treatment of cardioinhibitory vasovagal syncope might be a reasonable clinical option.

A Comparison of the Efficacy of Voltage-directed Cavotricuspid Isthmus Ablation Using Mini Versus Conventional Electrodes.

Cavotricuspid isthmus (CTI) ablation is a current first-line management method for typical atrial flutter. A voltage-directed technique that systematically targets points of maximal voltage has be found to reduce procedure and fluoroscopy times without increasing recurrence. We hypothesized that this technique's efficiency would be enhanced by using signals from radial minielectrodes of a novel catheter (IntellaTip MiFi™; Boston Scientific, Natick, MA, USA). Prospectively, atrial flutter patients underwent voltage-directed ablation with a nonirrigated 8-mm-tip catheter. Ablation was either directed by conventional bipolar electrodes (group A, n = 13) or mini-electrodes (group B, n = 17) with the goal of achieving bidirectional block at the CTI and a subsequent observation time of 30 minutes. Total radiofrequency application time and lesion numbers were not significantly different. Group B had a lower mean power [38.7 watts (W) ± 2.0 W versus 44.8 W ± 1.9 W; p < 0.05] and a tendency for longer fluoroscopy and procedure times. In three of the cases in group B, a switch to an irrigated catheter was required in order to achieve bidirectional block. In group A, bidirectional block was obtained in all patients using the nonirrigated catheter with no significant increase in reconnection. Differences in the catheter performance between the two groups were driven by poorer performance of the MiFi™ catheter (Boston Scientific, Natick, MA, USA) in patients presenting in atrial flutter. Electroanatomical mapping revealed a more proximal localization of the maximal voltage by the minielectrodes as compared with the conventional bipolar electrodes, resulting in less efficient identification and ablation of the conducting muscle bundles. Final results indicated CTI ablation using minielectrodes is not superior to conventional bipolar electrodes in the use of 8-mm, nonirrigated electrodes.

Complement C3 and C-reactive protein are elevated in South Asians independent of a family history of stroke.

BACKGROUND AND PURPOSE: Complement components are emerging risk factors for cardiovascular disease. In this study, we examined the relation among C3, C-reactive protein (CRP), factor B, and features of the insulin resistance (IR) syndrome in 143 first-degree relatives of South Asian subjects with ischemic stroke, 141 South Asian controls, and 121 white controls. METHODS: C3, CRP (high-sensitivity assay), and factor B levels were measured by ELISAs, and their relation to features of the IR syndrome were assessed. Data are presented as geometric mean (95% CI). RESULTS: There was no significant difference in the levels of C3 between South Asian relatives (1.25 [1.21, 1.29] g/L) and South Asian controls (1.20 [1.15, 1.24] g/L, P=0.2). Levels in both South Asian groups were significantly higher than in white controls (0.95 [0.92, 0.98] g/L; P<0.001 for both comparisons). These differences remained significant after adjustment for covariates. Similarly, levels of CRP were not different between the 2 South Asian groups, but levels in both South Asian groups, after adjustment for covariates, were significantly higher than in white controls. There was no difference in the levels of factor B among the 3 groups. South Asian subjects with elevated C3 levels clustered risk factors associated with IR to a greater extent than those with high CRP. CONCLUSIONS: These results suggest that South Asians have a greater level of chronic subclinical inflammation than do whites, independent of a family history of stroke. In addition, C3 is more likely to cluster with features of the IR syndrome compared with CRP in South Asians.

Unnecessary shock from an implantable cardioverter-defibrillator following transcutaneous pacing.

As the population ages and cardiovascular disease becomes more prevalent, an increasing number of patients are receiving implantable cardioverter-defibrillators (ICDs). When these patients present to the emergency department, it is imperative that physicians are not only aware of the possible underlying medical issues that may have precipitated their admission but should also have a good understanding of the potential interactions that any medical intervention may have on the patient's device. We discuss a case in which a patient known to have an ICD in situ was transcutaneously paced for the management of bradycardia, leading to an unnecessary shock.

The peri-procedural use of dabigatran in patients undergoing left atrial ablation for atrial fibrillation.

INTRODUCTION: Pulmonary vein isolation is an effective strategy in patients with atrial fibrillation (AF). The peri-procedural use of anticoagulation is routinely employed to reduce thromboembolic risk. AIMS/METHODS: The aim of this study was to compare the use of Dabigatran to the other 2 strategies involving the use of Warfarin. Single centre observational study comparing 3 anticoagulation strategies: Group 1 consisted of patients maintained on Warfarin (5.15 ± 2.52 mg) with a therapeutic INR of 2-3. Group 2 comprised patients initially treated with Warfarin (6.98 ± 3.17 mg), which was discontinued 1 week prior to LA ablation, during which time patients were bridged with a therapeutic dose of Dalteparin. Group 3 included patients anticoagulated with Dabigatran (40 patients received 150 mg BID, 3 patients received 110 mg BID), which was discontinued 24-30 h prior to the procedure. RESULTS: A total of 207 patients were included in the study. There were no significant differences in age, sex, LA volume, CHADS2 score or proportion of patients with persistent AF. There were no significant differences in the number of patients with intra-cardiac thrombus found at TOE (Group 1: 2.3% vs. Group 2: 1.5% vs. Group 3: 0%; P = 0.37). Furthermore, there were no differences in the rate of groin hematoma (2.2% vs. 1.5% vs. 2.3%; P = 0.8) or the development of pericardial effusion (5.4% vs. 8.8% vs. 2.3%; P = 0.54). No thromboembolic events were seen. CONCLUSION: Peri-procedural use of Dabigatran during AF ablation procedures is safe, with no significant difference when compared to conventional anticoagulation with either Warfarin bridged with Dalteparin or uninterrupted Warfarin.

Long QT syndrome complicating atrioventricular block: arrhythmogenic effects of cardiac memory.

BACKGROUND: The magnitude of QT prolongation in response to bradycardia, rather than the bradycardia per se, determines the risk for torsade de pointes during atrioventricular block (AVB). However, we do not know why some patients develop more QT prolongation than others, despite similar bradycardia. We hypothesized that in patients who develop significant QRS vector changes during AVB, the effects of cardiac memory lead to excessive QT prolongation. METHODS AND RESULTS: We studied 91 patients who presented with AVB and who also had an ECG predating the bradyarrhythmia for comparison. We correlated changes in QRS morphology and axis taking place during AVB with the bradycardia-induced QT prolongation. Patients with and without QRS morphology changes at the time of AVB were of similar age and sex. Moreover, despite similar R-R interval during AVB, cases with a QRS morphology change had significantly longer QT (648 ± 84 versus 561 ± 84; P<0.001) than those without. Patients who developed a change in QRS morphology at the time of AVB had a 7-fold higher risk of developing long QT. This risk nearly doubled when the change in QRS morphology was accompanied by a change in QRS axis. CONCLUSIONS: Cardiac memory resulting from a change in QRS morphology during AVB is independently associated with QT prolongation and may be arrhythmogenic during AVB.

Procainamide infusion in the evaluation of unexplained cardiac arrest: from the Cardiac Arrest Survivors with Preserved Ejection Fraction Registry (CASPER).

BACKGROUND: Provocative testing with sodium channel blockers is advocated for the evaluation of unexplained cardiac arrest (UCA) with the primary purpose of unmasking the typical ECG features of Brugada syndrome. The Cardiac Arrest Survivors with Preserved Ejection Fraction Registry (CASPER) systematically assesses subjects with UCA or a family history of sudden death (FHSD). OBJECTIVE: The purpose of this study was to determine the clinical yield of procainamide infusion in a national registry of subjects with either UCA or a FHSD. METHODS: Subjects with either UCA or a FHSD without evidence of a Brugada pattern at baseline underwent procainamide testing (15 mg/kg to a maximum of 1 g at 50 mg/min). A test was considered positive for Brugada pattern if there was an increase in ST elevation >1 mm or if there was >1 mm of new ST elevation in leads V1 and/or V2. Genetic testing was performed on the basis of phenotype detection. RESULTS: Procainamide testing was performed in 174 subjects (age 46.8 ± 15.4 years, 47% female). Testing provoked a Brugada pattern in 12 subjects (6.9%), 5 of whom had no ST abnormalities at baseline. No subjects with a negative procainamide challenge were subsequently diagnosed with Brugada syndrome. Genetic testing was conducted in 10 of the 12 subjects with a provoked Brugada pattern and was positive for a mutation in the SCN5A gene in 1. CONCLUSION: Irrespective of the baseline ECG, procainamide testing provoked a Brugada pattern in a significant proportion of subjects with UCA or a FHSD, thereby facilitating a diagnosis of Brugada syndrome, and is recommended in the workup of UCA.

Elevated properdin and enhanced complement activation in first-degree relatives of South Asian subjects with type 2 diabetes.

OBJECTIVE: Emerging data implicate activation of the complement cascade in the pathogenesis of type 2 diabetes. The objective of the current study was to evaluate the relationships between components of the complement system, metabolic risk factors, and family history of type 2 diabetes in healthy South Asians. RESEARCH DESIGN AND METHODS: We recruited 119 healthy, first-degree relatives of South Asian subjects with type 2 diabetes (SARs) and 119 age- and sex-matched, healthy South Asian control subjects (SACs). Fasting blood samples were taken for measurement of complement factors and standard metabolic risk factors. RESULTS: SARs were characterized by significantly higher properdin (mean concentration 12.6 [95% CI 12.2-13.1] mg/L vs. SACs 10.1 [9.7-10.5] mg/L, P < 0.0001), factor B (187.4 [180.1-195.0] mg/L vs. SACs 165.0 [158.0-172.2] mg/L, P < 0.0001), and SC5b-9 (92.0 [86.1-98.3] ng/mL vs. SACs 75.3 [71.9-78.9] ng/mL, P < 0.0001) and increased homeostasis model assessment of insulin resistance (2.86 [2.61-3.13] vs. SACs 2.31 [2.05-2.61], P = 0.007). C-reactive protein did not differ between SARs and SACs (P = 0.17). In subgroup analysis of 25 SARs and 25 SACs with normal oral glucose tolerance tests, properdin, factor B, and SC5b-9 remained significantly elevated in SARs. CONCLUSIONS: Increased properdin and complement activation are associated with a family history of type 2 diabetes in South Asians independent of insulin resistance, and predate the development of impaired fasting glucose and impaired glucose tolerance. Properdin and SC5b-9 may be novel biomarkers for future risk of type 2 diabetes in this high-risk population and warrant further investigation.

Complement C3 is a novel plasma clot component with anti-fibrinolytic properties.

BACKGROUND AND METHOD: Increased plasma clot density and prolonged lysis times are associated with cardiovascular disease. In this study, we employed a functional proteomics approach to identify novel clot components which may influence clot phenotypes. RESULTS: Analysis of perfused, solubilised plasma clots identified inflammatory proteins, including complement C3, as novel clot components. Analysis of paired plasma and serum samples confirmed concentration-dependent incorporation of C3 into clots. Surface plasmon resonance indicated high-affinity binding interactions between C3 and fibrinogen and fibrin. Turbidimetric clotting and lysis assays indicated C3 impaired fibrinolysis in a concentration-dependent manner, both in vitro and ex vivo. CONCLUSION: These data indicate functional interactions between complement C3 and fibrin leading to prolonged fibrinolysis. These interactions are physiologically relevant in the context of protection following injury and suggest a mechanistic link between increased plasma C3 concentration and acute cardiovascular thrombotic events.