Device-related infection and mortality in patients with chronic kidney disease receiving cardiac implantable electronic devices: a propensity score-matched cohort study.

BACKGROUND: Chronic kidney disease (CKD) was reported to be a risk factor of cardiac implantable electronic device (CIED) infection. The application of bundled skin antiseptic preparation before CIED implantation decreased the risk of CIED infection, even in patients undergoing complex procedures. However, the effect of bundled skin antiseptic preparation to prevent CIED infection in patients with CKD was not tested. METHODS: Between July 2012 and December 2019, 1668 patients receiving CIEDs comprised this retrospective cohort study and were categorized into two groups by the diagnosis of CKD: group with CKD (n = 750, 45%) and group without CKD (n = 918, 55%). The primary outcome was clinical CIED infection, including major and minor infection, and the secondary outcomes were cardiovascular mortality and all-cause mortality. Propensity score matching (PSM) was applied to reduce selection bias between the study groups. RESULTS: During a 4-year follow-up period, 30 patients (1.8%) had a CIED infection. After PSM, the incidence of CIED infection was similar between the patients with CKD and without CKD (1.0% vs. 1.8%). The incidences of cardiovascular mortality and all-cause mortality were higher in patients with CKD compared to patients without CKD (6.5% vs. 3.0%, P = 0.009; 22.8% vs. 11.8%, P < 0.001, respectively). CONCLUSION: The incidence of clinical CIED infection in patients with CKD was as lower as in patients without CKD after applying the bundled skin antiseptic preparation strategy. The cumulative incidences of cardiovascular mortality and all-cause mortality were significantly higher in the matched CIED recipients with CKD compared to the matched cohort without CKD.

Left bundle branch pacing preserved left ventricular myocardial work in patients with bradycardia.

Background: Left bundle branch pacing (LBBP) is an emerging physiological pacing modality. Left ventricular (LV) myocardial work (MW) incorporates afterload and LV global longitudinal strain to estimate global and segmental myocardial contractility. However, the effect of LBBP on LV MW remains unknown. This study aimed to evaluate the impact of LBBP on LV MW in patients receiving pacemaker for bradyarrhythmia. Methods: We prospectively enrolled 70 bradycardia patients with normal LV systolic function receiving LBBP (n = 46) and non-selective His-bundle pacing (NS-HBP) (n = 24). For comparative analysis, patients receiving right ventricular pacing (RVP) (n = 16) and control subjects (n = 10) were enrolled. Two-dimensional speckle tracking echocardiography was performed. The LV pressure-strain loop was non-invasively constructed to assess global LV MW. Results: After 6-month follow-up, LBBP group (with >40% ventricular pacing during 6 months) had shorter peak strain dispersion (PSD) compared with RVP group, and higher LV global longitudinal strain compared with RVP group and NS-HBP group, but had no difference in left intraventricular mechanical dyssynchrony, including septal-to-posterior wall motion delay and PSD, compared with NS-HBP group. During ventricular pacing, LBBP group had higher global MW index (GWI) (2,189 ± 527 vs. 1,493 ± 799 mmHg%, P = 0.002), higher global constructive work (GCW) (2,921 ± 771 vs. 2,203 ± 866 mmHg%, P = 0.009), lower global wasted work (GWW) (211 ± 161 vs. 484 ± 281 mmHg%, P < 0.001) and higher global MW efficiency (GWE) (91.4 ± 5.0 vs. 80.9 ± 8.3%, P < 0.001) compared with RVP group, and had lower GWW (211 ± 161 vs. 406 ± 234 mmHg%, P < 0.001) and higher GWE (91.4 ± 5.0 vs. 86.4 ± 8.1%, P < 0.001) compared with NS-HBP group. Conclusions: In this study we found that in patients with mid-term (6-month) high ventricular pacing burden (>40%), LBBP preserved more LV MW compared with NS-HBP and RVP. Further studies are warranted to assess the association between LV MW and long-term clinical outcomes in LBBP with high ventricular pacing burden.

Delta Increment in Pacing QRS Duration Predicts Cardiovascular Mortality in Patients with Pre-Existing Bundle Branch Block Receiving Permanent Pacemakers.

Background: The clinical implication of pre-existing intraventricular conduction disturbance (IVCD) in permanent pacemaker (PPM) recipients is unknown. Objectives: To explore the clinical outcomes in patients with pre-existing IVCD after implantation of PPMs. Methods: A total of 1424 patients who received PPMs were categorized into three groups by pre-procedural electrocardiography: patients without IVCD (n = 1045), patients with right bundle branch block (RBBB) (n = 309), and patients with left bundle branch block (LBBB) (n = 70). The primary outcome was cardiovascular (CV) mortality. Receiver operating characteristic curve analysis was performed to determine the optimal cut-off values of variable in predicting CV mortality. Results: During follow-up, there was no significant difference in CV mortality between patients with and without IVCD. In multivariate analysis, independent predictors of CV mortality were age [hazard ratio (HR): 1.03; 95% confidence interval (95% CI): 1.00-1.05; p = 0.026], history of heart failure [HR: 1.98; 95% CI: 1.19-3.29; p = 0.009], chronic kidney disease [HR: 1.75; 95% CI: 1.11-2.74; p = 0.015] and increment in pacing QRS duration [HR: 1.01; 95% CI: 1.00-1.04; p = 0.038]. Delta increments in pacing QRS duration ≥ 43 msec [HR: 2.91; 95% CI: 1.23-6.83; p = 0.014] in patients with pre-existing RBBB, and ≥ 33 msec [HR: 11.44; 95% CI: 2.03-64.30; p = 0.006] in patients with pre-existing LBBB were independent determinants of CV mortality. Conclusions: There was no difference in CV mortality between patients with or without IVCD. However, wider pacing QRS duration increased the risk of CV mortality in PPM recipients, and delta increment in pacing QRS duration increased the risk of CV mortality in patients with pre-existing IVCD.

Diabetes Increases Risk of Cardiovascular Events in Patients Receiving Permanent Pacemaker: A Propensity Score-Matched Cohort Study.

Background: Type 2 diabetes was associated with a higher risk for permanent pacemaker (PPM) treatment. The difference in cardiovascular outcomes between patients with and without diabetes receiving PPM treatment remains unexplored. Method: Between January 2003 and December 2017, 1742 patients receiving naïve PPM treatment comprised this retrospective cohort study and were categorized into two groups by the diagnosis of diabetes: group with diabetes (n = 632, 36.3%) and group without diabetes (n = 1110, 63.7%). The primary outcome was cardiovascular events including heart failure (HF) hospitalization and acute myocardial infarction (AMI). The secondary outcomes of this study included pacemaker infection, pacing-induced cardiomyopathy, cerebrovascular accident, cardiovascular mortality, and all-cause mortality. Propensity score matching (PSM) was applied to reduce selection bias between the study groups. Result: During a mean follow-up period of 7.8 ± 4.8 years, 264 patients had a cardiovascular event. Before PSM, the incidence of cardiovascular events was higher in patients with diabetes compared to patients without diabetes (19.8% vs. 12.5%, P < 0.001), and the incidences of pacing-induced cardiomyopathy, cardiovascular mortality, and all-cause mortality were all higher in patients with diabetes compared to patients without diabetes. After PSM, the incidence of cardiovascular events was higher in patients with diabetes compared to patients without diabetes (18.8% vs. 12.3%, P = 0.015). The incidence of HF hospitalization was higher in patients with diabetes compared to patients without diabetes (15.3% vs. 10.2%, P = 0.037), whereas the incidence of AMI did not differ between the two groups. Moreover, after PSM, patients with diabetes had higher cumulative incidences of pacing-induced cardiomyopathy and all-cause mortality compared to patients without diabetes. Conclusions: The prevalence of diabetes was over one-third of naïve PPM recipients of this cohort, and diabetes increased the risk of cardiovascular events in PPM recipients, especially for HF hospitalization.

Intravascular ultrasound-guided treatment for simultaneous ostial left main intramural hematoma and anomalous right aortocoronary dissection.

The prevalence of iatrogenic catheter-induced ostial coronary artery dissection is very low (0.09%) (1). The incidence of coronary anomalies (total) is 5.64% and ectopic right coronary artery (RCA) (left cuspid) is also rare (0.92%) (2). To the best of our knowledge, this is the first case report of a simultaneous iatrogenic catheter-induced ostial RCA dissection and propagation to the ostial left main (LM) coronary artery by intramural hematoma (IMH). We report a case of a 61-year-old male with underlying disease of type 2 diabetes mellitus and hypertension under regular medication control. He had experienced intermittent chest pain for more than 3 months. He came to our hospital after suffering acute RCA occlusion with cardiogenic shock without management while receiving diagnostic catheterization in another hospital. To perform the initial diagnostic, we used a 6 French Ikari Left 4 (Terumo, Japan) guiding catheter and changed to a 6 French SAL1 (Medtronic, U.S.A.) guiding catheter to determine the origin of the RCA anomaly in the left coronary cuspid. Initially, ostial dissection with intramural hemorrhage at the RCA without flow compromised with the acknowledgement of LM propagation (Panel A) (Video 1). Ostial RCA was managed directly with a Xience Sierra stent (3.5 × 23 mm; Abbott, U.S.A) to seal the entry of dissection, followed by NC emerge 3.5 × 15 mm balloon (Boston, U.S.A.) inflated up to 24 atmosphere (atm). Intravascular ultrasound (IVUS) confirmed that the stent fully covered the entry point of the ostial RCA (Panel B). The left main (Panel C) was then managed by IVUS-guided (Boston iLAB Opticross, U.S.A.) cutting balloon (Wolverine 4.0 × 6 mm; Boston, U.S.A.) inflated at up to 12 atm to fenestrate the IMH (Panel D; Video 2) at the LM level, followed by the implantation of a bailout stenting Xience Sierra (4.0 × 18 mm; Abbott, U.S.A) and by NC emerge 5.0 × 15 mm balloon (Boston, U.S.A.) inflated up to 18 atm. Post procedure angiogram and IVUS confirmed the effectiveness of the intervention. (Panel E, F). In this case, due to the origin of the RCA anomaly, the dissection and IMH immediately propagated to the LM. Fortunately, the patient was hemodynamically stable. We chose to use the cutting balloon and IVUS-guided intervention strategy, which resulted in the remission of the patient's condition.

Differential Risk of Dementia Between Patients With Atrial Flutter and Atrial Fibrillation: A National Cohort Study.

Objectives: Atrial fibrillation (AF) is linked to an increased risk of stroke and dementia. Atrial flutter (AFL) is also linked to an increased risk of stroke but at a different level of risk as compared to AF. Little is known about the difference in the risk of dementia between AF and AFL. This study aims to investigate whether the risk of dementia is different between AF and AFL. Methods: Patients with newly diagnosed AF and AFL during 2001-2013 were retrieved from Taiwan's National Health Insurance Research Database. Patients with incomplete demographic data, aged <20 years, history of valvular surgery, rheumatic heart disease, hyperthyroidism, and history of dementia were excluded. The incidence of new-onset dementia was set as the primary outcome and analyzed in patients with AF and AFL after propensity score matching (PSM). Results: A total of 232,425 and 7,569 patients with AF and AFL, respectively, were eligible for analysis. After 4:1 PSM, we included 30,276 and 7,569 patients with AF and AFL, respectively, for analysis. Additionally, patients with AF (n = 29,187) and AFL (n = 451) who received oral anticoagulants were enrolled for comparison. The risk of dementia was higher in patients with AF compared with patients with AFL (subdistribution hazard ratio (SHR) = 1.52, 95% CI 1.39-1.66; p < 0.0001) before PSM and remained higher in patients with AF (SHR = 1.14, 95% CI 1.04-1.25; p = 0.0064) after PSM. The risk of dementia was higher in patients with AF without previous history of stroke after PSM but the risk did not differ between patients with AF and AFL with previous history of stroke. Among patients who received oral anticoagulants, the cumulative incidences of dementia were significantly higher in patients with AF than in patients with AFL before and after PSM (all P < 0.05). Conclusions: This study found that, among patients without history of stroke, the risk of dementia was higher in patients with AF than in patients with AFL, and CHA2DS2-VASc score might be useful for risk stratification of dementia between patients with AF and AFL.

Corrigendum: Differential Risk of Dementia Between Patients With Atrial Flutter and Atrial Fibrillation: A National Cohort Study.

[This corrects the article DOI: 10.3389/fcvm.2021.787866.].

Outcomes of Patients with and without Malignancy Undergoing Percutaneous Pericardiocentesis for Pericardial Effusion.

(1) Background: This study aimed to evaluate the etiologies and clinical outcomes of patients with pericardial effusion (PE) treated with echo-guided percutaneous pericardiocentesis. (2) Methods: Between July 2010 and December 2020, a total of 502 patients underwent echo-guided percutaneous pericardiocentesis for PE at our hospital. The reasons for PE were malignancy (N = 277), and non-malignancy (N = 225). The comorbidities, complications, and all-cause mortality were compared between the malignancy and non-malignancy groups. (3) Results: In multivariable Cox regression analyses for 1-year mortality, malignancy related PE, nasopharyngeal and oropharyngeal cancer, and metastatic status were positive predictors. A higher incidence of in-hospital and 1-year mortality were observed in patients with malignancy-related PE than with non-malignancy-related PE. In patients with malignancy-related PE, the Kaplan-Meier curve of 1-year all-cause mortality significantly differed between patients with or without metastasis; however, PE with or without malignant cells did not influence the prognosis. (4) Conclusions: In the patients with large PE requiring percutaneous pericardiocentesis, malignancy-related PE, nasopharyngeal and oropharyngeal cancer, and metastatic status were positive predictors of 1-year mortality. In patients with malignancy, a higher incidence of all-cause mortality was noted in patients with metastasis but did not differ between the groups with and without malignant cells in PE.

GJA1 Expression and Left Atrial Remodeling in the Incidence of Atrial Fibrillation in Patients with Obstructive Sleep Apnea Syndrome.

Obstructive sleep apnea syndrome (OSAS) is an important risk factor for atrial fibrillation (AF). GJA1 gene encoding connexin43, a major protein in cardiac gap junctions, plays a crucial role in the synchronized contraction of the heart and in cardiac arrhythmia. However, little is known regarding the role of GJA1 expression in the incidence of AF in patients with OSAS. All prospectively enrolled OSAS patients underwent polysomnography, electrocardiography, a 24-h Holter test, and echocardiography. Moderate-to-severe OSAS was defined as an apnea-hypopnea index (AHI) ≥ 15. Exosomes were purified from the plasma of all OSAS patients and incubated in HL-1 cells to investigate the effect of exosomes from patients with and without AF on GJA1 expression. A total of 129 patients were recruited for this study; 26 were excluded due to an AHI < 15. Of the 103 enrolled patients, 21 had AF, and 82 did not. Multivariate analysis showed diabetes mellitus, lower sleep efficiency, lower left ventricular ejection fraction, and larger left atrial (LA) size were independent predictors of AF occurrence in OSAS patients. The area under the receiver operating characteristic curve for LA with a size ≥38.5 mm for predicting AF occurrence in OSAS patients was 0.795 (95% confidence interval [0.666, 0.925]); p < 0.001). GJA1 expression in HL-1 cells incubated with exosomes from OSAS patients with AF was lower than that with exosomes from patients without AF after controlling for age and sex and was negatively correlated with the AHI and oxygen desaturation index (ODI), especially during the non-rapid eye movement period (NREM) of OSAS patients with AF (all p < 0.05). LA size was an independent predictor of AF occurrence in OSAS patients. The AHI and ODI in the NREM period of OSAS patients with AF were negatively correlated with GJA1 expression in HL-1 cells, which offers a hint that GJA1 may play a crucial role in the development of AF in patients with OSAS.

Sex Difference in the Risk of Dementia in Patients with Atrial Fibrillation.

Atrial fibrillation (AF) is one of the risk factors for dementia. Female sex is an inconsistent risk factor for dementia after adjusting for age in the general population, and there lacks research on its impact in developing dementia in patients with AF. This paper aims to investigate whether female sex is a risk factor for dementia in AF patients. Data of patients with newly diagnosed AF between 2001-2013 were retrieved from Taiwan's National Health Insurance Research Database. Exclusion criteria were: patients with incomplete demographic data, age < 20 years, rheumatic heart disease, hyperthyroidism, past valvular heart surgery, and a history of dementia. Propensity score matching (PSM) between sexes was performed, including comorbidities, medications and index date stratified by age. The primary outcome was a new diagnosis of dementia at follow-up. A total of 117,517 men and 156,705 women were eligible for analysis. After 1:1 PSM, both 100,065 men and women (aged 72.5 ± 12.5 years) were included for analysis. Dementia risk varied with age in women compared with men. The difference was negligible for ≤55 years (sub distribution HR (SHR) = 0.89, 95% CI 0.73-1.07), but increased between 56-65 years (SHR = 1.13, 95% CI 1.02-1.25), 66-75 years (SHR = 1.14, 95% CI 1.09-1.20), 75-85 years (SHR = 1.11, 95% CI 1.07-1.15) and >85 years (SHR 1.10, 95% CI 1.04-1.16) for females. This study establishes that female sex increases the risk of developing dementia compared to male sex in AF patients aged >56 years. However, the impact of female sex on dementia in AF patients differs between dementia types.

Proposed A2C2S2-VASc score for predicting atrial fibrillation development in patients with atrial flutter.

AIMS: The clinical outcome and threshold of oral anticoagulation differs between patients with solitary atrial flutter (AFL) and those with AFL developing atrial fibrillation (AF) (AFL-DAF). We therefore investigated previously unevaluated predictors of AF development in patients with AFL, and also the predictive values of risk scores in predicting the occurrence of AF and ischaemic stroke. METHODS AND RESULTS: Participants were those diagnosed with AFL between 1 January 2001 and 31 December 2013. Patients were classified into solitary AFL and AFL-DAF groups during follow-up. Finally, 4101 patients with solitary AFL and 4101 patients with AFL-DAF were included after 1:1 propensity score matching with CHA2DS2-VASc scores and their components, AFL diagnosis year and other comorbidities. The group difference in the prevalence of ischaemic stroke/transient ischaemic attack (TIA) and congestive heart failure (CHF) was substantial, that of vascular disease was moderate, and that of diabetes and hypertension was negligible. Therefore, we reweighted the component of heart failure as 2 (the same with stroke/TIA) and vascular disease as 1 in the proposed A2C2S2-VASc score. The proposed A2C2S2-VASc and CHA2DS2-VASC scores showed patients with AFL who had higher delta scores and follow-up scores had higher risk of AF development. The delta score outperformed the follow-up score in both scoring systems in predicting ischaemic stroke. CONCLUSION: This study showed that new-onset CHF, stroke/TIA and vascular disease were predictors of AF development in patients with AFL. The dynamic score and changes in both CHA2DS2-VASC and the proposed A2C2S2-VASc score could predict the development of AF and ischaemic stroke.

Residual Right Coronary Artery Stenosis after Left Main Coronary Artery Intervention Increased the 30-Day Cardiovascular Death and 3-Year Right Coronary Artery Revascularization Rate.

BACKGROUND: The outcomes of patients with concomitant left main coronary artery (LMCA) and right coronary artery (RCA) diseases are reportedly worse than those with only LMCA disease. To date, only few studies have investigated the clinical impact of percutaneous coronary intervention (PCI) on RCA stenosis during the same hospitalization, in which LMCA disease was treated. This study was aimed at comparing the outcomes between patients with and without right coronary artery intervention during the same hospital course for LMCA intervention. METHODS AND RESULTS: From a total of 776 patients who were undergoing PCI to treat LMCA disease, 235 patients with concomitant RCA significant stenosis (more than 70% stenosis) were enrolled. The patients were divided into two groups: 174 patients received concomitant PCI for RCA stenosis during the same hospitalization, in which LMCA disease was treated, and 61 patients did not receive PCI for RCA stenosis. Patients without intervention to the right coronary artery had higher 30-day cardiovascular mortality rates and 3-year RCA revascularization rates compared to those with right coronary artery intervention. Patients without RCA intervention at the same hospitalization did not increase the 30-day total death, 3-year myocardial infarction rate, 3-year cardiovascular death, and 3-year total death. CONCLUSIONS: In patients with LM disease and concomitant above or equal to 70% RCA stenosis, PCI for RCA lesion during the same hospitalization is recommended to reduce the 30-day cardiovascular death and 3-year RCA revascularization rate.

Associations with the In-Hospital Survival Following Extracorporeal Membrane Oxygenation in Adult Acute Fulminant Myocarditis.

BACKGROUND: Acute fulminant myocarditis (AFM) is a serious disease that progresses rapidly, and leads to failing respiratory and circulatory systems. When medications fail to reverse the patient's clinical course, extracorporeal membrane oxygenation (ECMO) is considered the most effective, supportive and adjunct strategy. In this paper we analyzed our experience in managing AFM with ECMO support. METHODS: During October 2003 and February 2017, a total of 35 patients (≥18 years) were enrolled in the study. Twenty patients survived, and another 15 patients expired. General demographics, the hemodynamic condition, timing of ECMO intervention, and laboratory data were compared for the survival and non-survival groups. Univariate and multivariate Cox regression analyses were performed to identify the associations with in-hospital mortality following ECMO use in this situation. RESULTS: The survival rate was 57.1% during the in-hospital period. The average age, gender, severity of the hemodynamic condition, and cardiac rhythm were similar between the survival and non-survival groups. Higher serum lactic acid (initial and 24 h later), higher peak cardiac biomarkers, higher incidence of acute kidney injury and the need for hemodialysis were noted in the non-survival group. Higher 24-h lactic acid levels and higher peak troponin-I levels were associated with in-hospital mortality. CONCLUSIONS: When ECMO was used for AFM, related cardiogenic shock and decompensated heart failure, higher peak serum troponin-I levels and 24-h serum lactic acid levels following ECMO use were independently associated with in-hospital mortality.