Innovations in atrial fibrillation ablation.

BACKGROUND: Catheter-based ablation to perform pulmonary vein isolation (PVI) has established itself as a mainstay in the rhythm control strategy of atrial fibrillation. This review article aims to provide an overview of recent advances in atrial fibrillation ablation technology. METHODS: We reviewed the available literature and clinical trials of innovations in atrial fibrillation ablation technologies including ablation catheter designs, alternative energy sources, esophageal protection methods, electroanatomical mapping, and novel ablation targets. RESULTS: Innovative radiofrequency (RF) catheter designs maximize energy delivery while avoiding overheating associated with conventional catheters. Single-shot balloon catheters in the form of cryoballoons, radiofrequency, and laser balloons have proven effective at producing pulmonary vein isolation and improving procedural efficiency and reproducibility. Pulsed field ablation (PFA) is a highly anticipated novel nonthermal energy source under development, which demonstrates selective ablation of the myocardium, producing durable lesions while also minimizing collateral damage. Innovative devices for esophageal protection including esophageal deviation and cooling devices have been developed to reduce esophageal complications. Improved electroanatomical mapping systems are being developed to help identify additional non-pulmonary triggers, which may benefit from ablation, especially with persistent atrial fibrillation. Lastly, the vein of Marshall alcohol ablation has been recently studied as an adjunct therapy for improving outcomes with catheter ablation for persistent atrial fibrillation. CONCLUSIONS: Numerous advances have been made in the field of atrial fibrillation ablation in the past decade. While further long-term data is still needed for these novel technologies, they show potential to improve procedural efficacy and safety.

Etiologies of In-hospital cardiac arrest: A systematic review and meta-analysis.

BACKGROUND: Etiologies of in-hospital cardiac arrest (IHCA) in general wards may differ from etiologies of out-of-hospital cardiac arrest (OHCA) given the different clinical characteristics of these patient populations. An appreciation for the causes of IHCA may allow the clinician to appropriately target root causes of arrest. METHODS: MEDLINE/PubMed, EMBASE, and Google Scholar were queried from inception until May 31, 2021. Studies reporting etiologies of IHCA were included. A random effects meta-analysis of extracted data was performed using Review Manager 5.4. RESULTS: Of 12,451 citations retrieved from the initial literature search, 9 were included in the meta-analysis. The most frequent etiologies of cardiac arrest were hypoxia (26.46%, 95% confidence interval [CI] 14.19-38.74%), acute coronary syndrome (ACS) (18.23%, 95% CI 13.91-22.55%), arrhythmias (14.95%, 95% CI 0-34.93%), hypovolemia (14.81%, 95% CI 6.98-22.65%), infection (14.36%, 95% CI 9.46-19.25%), and heart failure (12.64%, 95% CI 6.47-18.80%). Cardiac tamponade, electrolyte disturbances, pulmonary embolism, neurological causes, toxins, and pneumothorax were less frequent causes of IHCA. Initial rhythm was unshockable (pulseless electrical activity or asystole) in 69.83% of cases and shockable (ventricular tachycardia or ventricular fibrillation) in 21.75%. CONCLUSION: The most prevalent causes of IHCA among the general wards population are hypoxia, ACS, hypovolemia, arrythmias, infection, heart failure, three of which (arrhythmia, infection, heart failure) are not part of the traditional "H's and T's" of cardiac arrest. Other causes noted in the "H's and T's" of advanced cardiac life support do not appear to be important causes of IHCA.

Innovations in Cardiac Implantable Electronic Devices.

Cardiac implantable electronic devices (CIEDs) are essential for the management of a variety of cardiac conditions, including tachyarrhythmias, bradyarrhythmias, and medically refractory heart failure (HF). Recent advancements in CIED technology have led to innovative solutions that overcome shortcomings associated with traditional devices or address unmet needs. Leadless pacemakers, subcutaneous implantable cardioverter defibrillators (ICDs), and extravascular ICDs eliminate lead-related complications common with conventional pacemakers or ICDs. Conduction system pacing (His bundle pacing and left bundle branch pacing) is a more physiologic method of pacing and avoids the deleterious consequences associated with long-term right ventricular pacing. For HF-related devices, cardiac contractility modulation is an emerging therapy that bridges a gap for many patients ineligible for cardiac resynchronization therapy and has been shown to improve HF symptoms and decrease hospitalizations and mortality in select patients. Implantable pulmonary artery pressure monitors help guide HF management and reduce hospitalizations. Lastly, new phrenic nerve stimulating devices are being utilized to treat central sleep apnea, a common comorbidity associated with HF. While further long-term studies are still underway for many of these new technologies, it is anticipated that these devices will become indispensable therapeutics in the expanding cardiovascular armamentarium.

Acute Cardiac Events in Patients With Severe Limb Infection.

Recent studies have shown an association between infections, such as influenza, pneumonia, or bacteremia, and acute cardiac events. We studied the association between foot infection and myocardial infarction, arrhythmia, and/or congestive heart failure. We analyzed the records of 318 consecutive episodes of deep soft tissue infection, gangrene, and/or osteomyelitis in 274 patients referred to a vascular surgery service at a tertiary center. We identified 24 acute cardiac events in 21 of 318 (6.6%) episodes of foot infection or foot gangrene. These 24 events included 11 new myocardial infarctions (3.5%), 8 episodes of new onset or worsening congestive heart failure (2.5%), and 5 new arrhythmias (1.6%). Tachycardia and systemic inflammatory response syndrome were associated with acute cardiac events ( P < .05 for each). The 1-year survival of patients with acute cardiac events was 50.4%, significantly lower than the 91.7% 1-year survival of patients without acute cardiac events ( P < .0015). Acute cardiac complications are not uncommon among patients presenting with severe foot infection and are associated with a high 1-year mortality. Primary care physicians, cardiologists, and vascular and orthopedic surgeons must keep a high index of suspicion for the occurrence of an acute cardiac event.

Outcomes of femtosecond laser-assisted cataract surgery performed by surgeons-in-training.

PURPOSE: To compare intraoperative factors and post-operative outcomes of femtosecond laser-assisted cataract surgery (FLACS) and manual cataract surgery performed by resident surgeons. METHODS: All cases of FLACS performed by resident surgeons during the 2013-2014 academic year were compared to a control group of manual cataract surgery cases with regards to pre-operative patient data, operative complications, cumulative dissipated energy (CDE), postoperative corrected distance visual acuity (CDVA), refractive prediction error (RPE), and corneal edema. RESULTS: There were no significant preoperative differences in the FLACS (n = 57) and manual (n = 68) groups. Operative complication rates were similar in cases with sufficient data and follow-up with a higher rate of posterior capsule tear in the manual group. CDE (percent-seconds) was lower in the FLACS group (FLACS: 14.5 ± 7.5; manual: 21.6 ± 11.5; p < 0.01). CDVA (LogMAR) was comparable at 1 month postoperatively (FLACS: 0.004 ± 0.08; manual: 0.024 ± 0.11; p = 0.24) and 1 year postoperatively (FLACS: 0.013 ± 0.06; manual: 0.032 ± 0.09; p = 0.37). No difference in RPE was found at 1 month postoperatively (FLACS: 0.38 ± 0.24 D; manual: 0.41 ± 0.49 D; p = 0.66) and 1 year postoperatively (FLACS: 0.49 ± 0.63 D; manual: 0.34 ± 0.26 D; p = 0.31). CONCLUSIONS: Femtosecond laser-assisted cataract surgery is safe and effective compared to manual cataract surgery when performed by resident surgeons. Both 1-month and 1-year outcomes show no difference in refractive predictive error in FLACS compared to manual cataract surgery in surgeons in training.

Evaluation and management of the swollen optic disk in cryptococcal meningitis.

Cryptococcal meningitis is the most common and severe form of cryptococcal infection. In addition to infiltrative and inflammatory mechanisms, intracranial hypertension commonly complicates cryptococcal meningitis and may cause significant visual and neurological morbidity and mortality. The mainstays of treatment for cryptococcal meningitis include standard antifungal therapy, management of intracranial hypertension, and treatment of underlying immunosuppressive conditions. Early and aggressive management of intracranial hypertension in accordance with established guidelines reduces the risk of long-term visual and neurological complications and death. Traditional recommendations for treating elevated intracranial pressure in idiopathic intracranial hypertension including acetazolamide, weight loss, and avoiding serial lumbar punctures-are not helpful in cryptococcal meningitis and may be harmful.

Optic Neuropathy Due to Chronic Lymphocytic Leukemia Proven With Optic Nerve Sheath Biopsy.

Central nervous system involvement from chronic lymphocytic leukemia (CLL) occurs infrequently, and manifestations include cognitive and cerebellar dysfunction and cranial nerve palsies. We report a 45-year-old man with CLL believed to be in clinical remission, who presented with vision loss and bilateral optic disc edema. His optic neuropathy due to CLL was proven by optic nerve sheath biopsy, and he experienced visual recovery after treatment with ibrutinib and intrathecal methotrexate.

Suprasellar Primitive Neuroectodermal Tumor in an Adult.

Primitive neuroectodermal tumors (PNET) of the central nervous system (CNS) are a heterogeneous group of embryonal malignancies that are composed of undifferentiated or poorly differentiated neuroepithelial cells. Supratentorial PNET is the second most common CNS embryonal malignancy in children, but it is rare in adults. We report the case of a 31-year-old woman with bilateral vision loss and a bitemporal hemianopia. Neuroimaging revealed a suprasellar mass, and pathology was consistent with PNET. After surgical debulking of the tumor followed by radiation therapy and chemotherapy, the patient had significant visual recovery and remained stable over 14 months of follow-up.

A Rapid, Simple, Effective, and Inexpensive Reconstructed Nipple Flap Guard.

Nipple reconstruction is a commonly performed component of breast reconstruction. A nipple reconstructed using local skin flaps requires protection from trauma. Here we describe a novel, effective, simple, rapid, inexpensive, and convenient method to protect a reconstructed nipple in the early postoperative period.

The Superomedial Pedicle Wise-Pattern Breast Reduction: Reproducible, Reliable, and Resilient.

The combination of the superomedial pedicle with the traditional Wise-pattern skin resection has gained increasing popularity for its versatility and ability to achieve significant reduction of breast parenchyma and skin envelope with improved contour and lasting results. Here the authors review the pertinent anatomy and discuss their surgical technique and its benefits. In addition, a retrospective chart review of 80 patients (151 breasts) who underwent superomedial pedicle Wise-pattern breast reduction between 2010 and 2014 was performed. Mean specimen weights and complication rates, including seroma, delayed wound healing, nipple loss, infection, and reoperation were calculated for the cohort.