Severe Periprocedural Complications After Ablation for Atrial Fibrillation: An International Collaborative Individual Patient Data Registry.

BACKGROUND: Catheter ablation for atrial fibrillation (AF) including pulmonary vein isolation and possibly further substrate ablation is the most common electrophysiological procedure. Severe complications are uncommon, but their detailed assessment in a large worldwide cohort is lacking. OBJECTIVES: The aim of this study was to determine the incidence of periprocedural severe complications and to provide a detailed characterization of the diagnostic evaluation and management of these complications in patients undergoing AF ablation. METHODS: Individual patient data were collected from 23 centers worldwide. Limited data were collected for all patients who underwent catheter ablation, and an expanded series of data points were collected for patients who experienced severe complications during periprocedural follow-up. Incidence, predictors, patient characteristics, management details, and overall outcomes of patients who experienced ablation-related complications were investigated. RESULTS: Data were collected from 23 participating centers at which 33,879 procedures were performed (median age 63 years, 30% women, 71% radiofrequency ablations). The incidence of severe complications (n = 271) was low (tamponade 6.8‰, stroke 0.97‰, cardiac arrest 0.41‰, esophageal fistula 0.21‰, and death 0.21‰). Age, female sex, a dilated left atrium, procedure duration, and the use of radiofrequency energy were independently associated with the composite endpoint of all severe complications. Among patients experiencing tamponade, 13% required cardiac surgery. Ninety-three percent of patients with complications were discharged directly home after a median length of stay of 5 days (Q1-Q3: 3-7 days). CONCLUSIONS: This large worldwide collaborative study highlighted that tamponade, stroke, cardiac arrest, esophageal fistula, and death are rare after AF ablation. Older age, female sex, procedure duration, a dilated left atrium, and the use of radiofrequency energy were associated with severe complications in this multinational cohort. One in 8 patients with tamponade required cardiac surgery.

HF Etiology and cardiac contractility modulation therapy.

OBJECTIVES: Our study aimed to assess the safety and efficacy of cardiac contractility modulation (CCM) therapy in patients with heart failure with reduced ejection fraction (HFrEF) depending on HF etiology. METHODS: We enrolled 166 patients with optimal medical therapy-resistant HFrEF (median age 59 years, 83.7% males, median NYHA class - 2, median left ventricular ejection fraction (LVEF) - 29.0%) who underwent CCM therapy device implantation from 2013 to 2019 in four medical centers in Russia. The HF etiology was determined based on invasive coronary angiography or cardiac MRI data. Transthoracic echocardiography (TTE), 6-minute walking test (6MWT), and NTproBNP-tests were performed at a baseline and 12 months after the implantation. RESULTS: The ischemic etiology of HF was revealed in 100 patients (61.5%) (ICM group); the non-ischemic group (NICM) evolved 66 patients (38.5%). Patients in the ICM group were significantly older (61[57-69] vs. 55 [42.8-61], p < 0.001), more frequently had hypertension (79% vs. 42.4%, p < 0.001) and chronic kidney disease (43% vs. 22.7%, p = 0.012). Patients in the NICM group had significantly more often atrial fibrillation (AF) (58% vs. 74%, p = 0.048), larger end-diastolic volume (EDV) (249 [208-309] vs. 220 [192-271], p = 0.019) and end-systolic volume (ESV) (183 [147-230] vs. 154 [128-199], p = 0.003). There were no significant differences in mortality between ICM and NICM groups (14.4 vs. 10.8%, p = 0.51). In 12 months, there was a significant increase in LVEF in the NICM group (+ 2.0 [2-6] vs. +7.7 [2-12], p < 0.001), while the improvement in the 6MWT (+ 75 [22-108] vs. +80 [10-160], p = 0.851) and NYHA class did not reach the level of significance. The subanalysis between patients with improved NYHA class and those without improvement revealed that patients without improvement more frequently had AF (56% vs. 89%; p < 0.01), chronic obstructive lung disease (18% vs. 35% p = 0.047), higher blood pressure (110 [105-120] vs. 120[110-129]; p = 0.032). CONCLUSION: In this multicenter retrospective study, patients with non-ischemic HFrEF showed a significantly higher improvement in LVEF and LV reverse remodeling following CCM therapy device implantation. There was no significant association between HF etiology and survival in drug-resistant HFrEF patients following CCM therapy.

Embolization of percutaneous left atrial appendage closure devices: Timing, management and clinical outcomes.

BACKGROUND: Left atrial appendage (LAA) occluder embolization is an infrequent but serious complication. OBJECTIVES: We aim to describe timing, management and clinical outcomes of device embolization in a multi-center registry. METHODS: Patient characteristics, imaging findings and procedure and follow-up data were collected retrospectively. Device embolizations were categorized according to 1) timing 2) management and 3) clinical outcomes. RESULTS: Sixty-seven centers contributed data. Device embolization occurred in 108 patients. In 70.4 % of cases, it happened within the first 24 h of the procedure. The device was purposefully left in the LA and the aorta in two (1.9 %) patients, an initial percutaneous retrieval was attempted in 81 (75.0 %) and surgery without prior percutaneous retrieval attempt was performed in 23 (21.3 %) patients. Two patients died before a retrieval attempt could be made. In 28/81 (34.6 %) patients with an initial percutaneous retrieval attempt a second, additional attempt was performed, which was associated with a high mortality (death in patients with one attempt: 2.9 % vs. second attempt: 21.4 %, p < 0.001). The primary outcome (bailout surgery, cardiogenic shock, stroke, TIA, and/or death) occurred in 47 (43.5 %) patients. Other major complications related to device embolization occurred in 21 (19.4 %) patients. CONCLUSIONS: The majority of device embolizations after LAA closure occurs early. A percutaneous approach is often the preferred method for a first rescue attempt. Major adverse event rates, including death, are high particularly if the first retrieval attempt was unsuccessful. CONDENSED ABSTRACT: This dedicated multicenter registry examined timing, management, and clinical outcome of device embolization. Early embolization (70.4 %) was most frequent. As a first rescue attempt, percutaneous retrieval was preferred in 75.0 %, followed by surgical removal (21.3 %). In patients with a second retrieval attempt a higher mortality (death first attempt: 2.9 % vs. death second attempt: 24.1 %, p < 0.001) was observed. Mortality (10.2 %) and the major complication rate after device embolization were high.

Continuous cardiac monitoring in epilepsy: an implantable loop manual activation algorithm for improving ECG signal acquisition accuracy.

BACKGROUND: The muscle artifacts, caused by prominent muscle contractions, mimicking cardiac arrhythmias, might compromise the ECG signal quality and the implantable loop recorder memory capacity in patients with epilepsy. We developed an epileptic seizures clinical pattern-based implantable loop recorder manual activation algorithm, presenting its real-world efficacy here. METHODS: One hundred ninety-three patients (18-60 years) with drug-resistant focal epilepsy were consecutively enrolled and underwent a subcutaneous loop recorder implantation. Patients with focal onset-aware seizures and patients with focal impaired awareness seizures /bilateral tonic-clonic seizures without aura were recommended to use the activator once - just after the episode. Patients with focal impaired awareness seizures/bilateral tonic-clonic seizures with aura, the caregivers of patients experiencing status epilepticus, were advised to use the activator twice - during the aura and after the episode/ regaining consciousness. RESULTS: Six thousand four hundred ninety-four ECG traces (4826 - auto-triggered events, 1668 - person-activated events) were recorded and analyzed. The rate of true positive events in the person-activated group was statistically higher than in the autoactivation group (72.5% vs.19.4%, p < 0.0001). Person-activated false-positive events were observed in 30.5% of patients with focal impaired awareness seizures and 27.7% in patients with bilateral tonic-clonic seizures. The highest rate of false-positive events (61.5%) was detected in patients undergoing epileptic status, and the lowest rate (3.8%) - was in patients with focal onset aware seizures. The rate of false-positive events was significantly higher in patients with impaired awareness seizures without aura both in focal impaired awareness (45.5% vs. 19.3%, p < 0.0001) and bilateral tonic-clonic seizure groups (38.8% vs. 5.9%, p < 0.0001). CONCLUSIONS: Arrhythmias with varying clinical outcomes are expected in epilepsy patients and have been monitored continuously. The specified loop recorder external activation algorithm can improve the clinically relevant cardiac arrhythmia detection accuracy in epilepsy patients and the value of future studies.

Associations of adenovirus-reactive immunoglobulins with atrial fibrillation and body mass index.

Adenovirus (AdV) has been suggested to be involved in pathogenesis of atrial fibrillation (AF). We aimed to evaluate an association between AdV-specific immunoglobulins G in the serum (AdV-IgG) and AF. The present case-control study comprised two cohorts, including cohort 1 of patients with AF and cohort 2 of asymptomatic subjects. Initially, two groups, MA and MB, were selected from the cohorts 1 and 2, respectively, for serum proteome profiling using an antibody microarray to identify possible relevant protein targets. The data of microarray analysis indicated a possible overall increase in the total adenovirus signals in the group MA vs. group MB, suggesting potential relevance of adenoviral infection to AF. Then, the groups A (with AF) and B (control) were selected from the cohorts 1 and 2, respectively, to assay the presence and levels of AdV-IgG- by ELSA. The prevalence of AdV-IgG-positive status demonstrated a 2-fold increase in the group A (AF) compared with that in the group B (asymptomatic subjects); odds ratio 2.06 (95%CI: 1.11-3.84; P = 0.02). The prevalence of obesity demonstrated an approximately 3-fold increase in AdV-IgG-positive patients of the group A compared with that in AdV-IgG-negative patients of the same group A (odds ratio 2.7; 95% CI: 1.02-7.1; P = 0.04). Thus, AdV-IgG-positive reactivity was independently associated with AF, and AF was independently associated with BMI, indicating that adenoviral infection may be a possible etiological factor for AF.

Artificial Intelligence-Powered Clinical Decision Support and Simulation Platform for Radiology Trainee Education.

Technological tools can redesign traditional approaches to radiology education, for example, with simulation cases and via computer-generated feedback. In this study, we investigated the use of an AI-powered, Bayesian inference-based clinical decision support (CDS) software to provide automated "real-time" feedback to trainees during interpretation of clinical and simulation brain MRI examinations. Radiology trainees participated in sessions in which they interpreted 3 brain MRIs: two cases from a routine clinical worklist (one without and one with CDS) and a teaching file-based simulation case with CDS. The CDS software required trainees to input imaging features and differential diagnoses, after which inferred diagnoses were displayed, and the case was reviewed with an attending neuroradiologist. An observer timed each case, including time spent on education, and trainees completed a survey rating their confidence in their findings and the educational value of the case. Ten trainees reviewed 75 brain MRI examinations during 25 reading sessions. Trainees had slightly lower confidence in their findings and diagnosis and rated the educational value slightly higher for simulation cases with CDS compared to clinical cases without CDS (p < 0.05). There were no significant differences in ratings of clinical cases with or without CDS. No differences in overall timing were found among the reading scenarios. Simulation cases with "CDS-provided feedback" may improve the educational value of interpreting imaging studies at a workstation without adding additional time. Further investigation will help drive innovation in trainee education, which may be particularly relevant in this era of increasing remote work and asynchronous attending review.

The experiences of 33 national COVID-19 dashboard teams during the first year of the pandemic in the World Health Organization European Region: A qualitative study.

Background: Governments across the World Health Organization (WHO) European Region have prioritised dashboards for reporting COVID-19 data. The ubiquitous use of dashboards for public reporting is a novel phenomenon. Objective: This study explores the development of COVID-19 dashboards during the first year of the pandemic and identifies common barriers, enablers and lessons from the experiences of teams responsible for their development. Methods: We applied multiple methods to identify and recruit COVID-19 dashboard teams, using a purposive, quota sampling approach. Semi-structured group interviews were conducted from April to June 2021. Using elaborative coding and thematic analysis, we derived descriptive and explanatory themes from the interview data. A validation workshop was held with study participants in June 2021. Results: Eighty informants participated, representing 33 national COVID-19 dashboard teams across the WHO European Region. Most dashboards were launched swiftly during the first months of the pandemic, February to May 2020. The urgency, intense workload, limited human resources, data and privacy constraints and public scrutiny were common challenges in the initial development stage. Themes related to barriers or enablers were identified, pertaining to the pre-pandemic context, pandemic itself, people and processes and software, data and users. Lessons emerged around the themes of simplicity, trust, partnership, software and data and change. Conclusions: COVID-19 dashboards were developed in a learning-by-doing approach. The experiences of teams reveal that initial underpreparedness was offset by high-level political endorsement, the professionalism of teams, accelerated data improvements and immediate support with commercial software solutions. To leverage the full potential of dashboards for health data reporting, investments are needed at the team, national and pan-European levels.

Unruptured Arteriovenous Malformations in the Multidetector Computed Tomography Era: Frequency of Detection and Predictable Failures.

OBJECTIVES: While hemorrhage arising from ruptured arteriovenous malformations (AVMs) is usually evident on multidetector non-contrast computed tomography (NCCT), unruptured AVMs can be below the limits of detection. We performed a retrospective review of NCCT of patients with a proven diagnosis of unruptured AVM to determine if advances in CT technology have made them more apparent and what features predict their detection. MATERIAL AND METHODS: Twenty-five NCCTs met inclusion criteria of having angiography or MR proven AVM without hemorrhage, prior surgery, or other CNS disease. Demographic variables, clinical symptoms at presentation, abnormal CT imaging findings, attenuation of the superior sagittal sinus (SSS), and Spetzler-Martin grade of each AVM were recorded. We examined the relationship between AVM detection and SSS attenuation through Kruskal-Wallis test. Exploratory serial logistic principal components analysis was performed including demographics, symptoms, and CT features in the multivariate model. RESULTS: About 80% of the NCCTs showed an abnormality while 20% were normal. All those with an identifiable abnormality showed hyperdensity (80%). Logistic regression models indicate that clustered associations between several CT features, primarily calcifications, hyperdensity, and vascular prominence significantly predicted Spetzler-Martin grade (likelihood ratio 7.7, P = 0.006). SSS attenuation was significantly lower in subjects with occult AVMs when compared to those with CT abnormalities (median 47 vs. 55 HU, P < 0.04). CONCLUSION: Abnormal hyperdensity was evident in all detectable cases (80%) and multiple CT features were predictive of a higher Spetzler-Martin AVM grade. Moreover, SSS attenuation less than 50 HU was significantly correlated with a false-negative NCCT.

Economic impact of selective use of contrast for routine follow-up MRI of patients with multiple sclerosis.

BACKGROUND AND PURPOSE: Imaging and autopsy studies show intracranial gadolinium deposition in patients who have undergone serial contrast-enhanced MRIs. This observation has raised concerns when using contrast administration in patients who receive frequent MRIs. To address this, we implemented a contrast-conditional protocol wherein gadolinium is administered only for multiple sclerosis (MS) patients with imaging evidence of new disease activity on precontrast imaging. In this study, we explore the economic impact of our new MRI protocol. METHODS: We compared scanner time and Medicare reimbursement using our contrast-conditional methodology versus that of prior protocols where all patients received gadolinium. RESULTS: For 422 patients over 4 months, the contrast-conditional protocol amounted to 60% decrease in contrast injection and savings of approximately 20% of MRI scanner time. If the extra scanner time was used for performing MS follow-up MRIs in additional patients, the contrast-conditional protocol would amount to net revenue loss of $21,707 (∼3.7%). CONCLUSIONS: Implementation of a new protocol to limit contrast in MS follow-up MRIs led to a minimal decrease in revenue when controlled for scanner time utilized and is outweighed by other benefits, including substantial decreased gadolinium administration, increased patient comfort, and increased availability of scanner time, which depending on type of studies performed could result in additional financial benefit.

Regional pericarditis following uncomplicated catheter ablation procedure: a case report.

BACKGROUND: Acute post-ablation pericarditis is the most common complication of epicardial ablation of ventricular arrhythmias, while regional pericarditis following an initially uneventful endocardial catheter ablation (CA) procedure is a rare and elusive diagnosis. CASE SUMMARY: We report a case of a 66-year-old Russian female who developed chest pain accompanied by electrocardiogram (ECG) changes-biphasic T waves in V1-V4 leads after an initially uncomplicated premature ventricular complex CA procedure. After examination and investigations, including transthoracic echocardiography (TTE), cardiac magnetic resonance imaging (CMR) and cardiac computed tomography (CCT), she was diagnosed with regional pericarditis, which occurred even though the ablation was uneventful with the limited number of radiofrequency applications. Furthermore, the diagnosis was difficult due to normal body temperature and the absence of pericardial effusion and myocardial abnormalities on TTE, findings that are not characteristic of pericarditis. The patient's last office visit was in 6 months after the procedure. Neither patient had any complaintsnor there were any changes on ECG and TTE. DISCUSSION: Regional post-ablation pericarditis is a relatively rare type of post-cardiac injury syndrome (PCIS). The varying severity of the PCIS clinical course makes the diagnosis of post-ablation pericarditis initially difficult, especially in patients undergoing an uneventful CA procedure. Non-invasive imaging modalities as CMR and CCT should be considered initially in elusive cases of PCIS.

The predictive role of early recurrences of atrial arrhythmias after pulmonary vein cryoballoon ablation. Is blanking period an outdated concept? Insights from 12-month continuous cardiac monitoring.

BACKGROUND: Early recurrences of atrial arrhythmias (ERAA) after atrial fibrillation (AF) catheter ablation do not predict procedural failure. A well-demarcated homogeneous lesion delivered by cryoballoon is less arrhythmogenic, and the recommended three-months blanking period may not refer to cryoballoon ablation (CBA). OBJECTIVE: We aimed to evaluate the predictive role of ERAA after second-generation CBA using an implantable loop recorder. METHODS: This prospective observational study enrolled 100 patients (58 males, median age 58) with paroxysmal/persistent AF undergoing pulmonary vein (PV) CBA using second-generation cryoballoon with simultaneous ECG loop recorder implantation. The duration of follow-up was 12 months, with scheduled visits at 3, 6 and 12 months. RESULTS: 99 patients from 100 completed the 12-month follow-up period. ERAA occurred in 31.3 % of patients. 83.9 % of patients with ERAA also developed late recurrences. The 12-month freedom from AF in patients with ERAA was significantly lower than in those without ERAA (p < 0.0001). Non-paroxysmal AF and longer arrhythmia history were associated with increased risk of both early (HR 3.27; 95 % CI 1.32-8.08; p = 0.010 and HR 1.0147; 95 % CI 1.008-1.086; p = 0.015, respectively) and late recurrences (HR 3.89; 95 % CI 1.67-9.04; p = 0.002 and HR 1.0142; 95 % CI 1.007-1.078; p = 0.019, respectively) of AF. ERAA were another predictor for procedural failure (HR 15.2; 95 % CI (6.42-35.99; p = 0.019). CONCLUSIONS: ERAA occurred in the third of the patients after PV second-generation CBA and are strongly associated with procedural failure. Longer duration of AF history and persistent AF are independent predictors of AF's early and late recurrence.

Going virtual for research training during the COVID-19 pandemic and beyond: e-SORT IT.

The Structured Operational Research and Training Initiative (SORT IT) model has contributed to building research capacity and has produced evidence for improving public health program performance in countries with limited research capacity. The model involves hands-on mentorship and consists of three modules/weeks. It is recognized to be an innovative research capacity building model. In a world changed by COVID-19, where bringing people together is not viable, an innovative, interactive, web-based, knowledge-transfer platform (e-SORT IT) for virtual implementation of SORT IT modules was created. The platform design imitated the residential course as closely as possible with the same lectures, plenary sessions, and breakout rooms. Despite the challenges, the platform performed well and even though participants and mentors were located in eight different time zones, the course was successful; 90% of participants achieved their milestones and 10 manuscripts were successfully completed. Participant evaluation revealed a satisfaction level that was nearly equivalent to the residential module. However, mentor evaluation indicated a number of shortcomings including capacity building, professional networking, communication, engagement, and contribution by participants, as well as overall module success. In conclusion, COVID-19 stimulated the creation of the e-SORT IT platform that provided a functional alternative to the residential version. Despite the limitations of reduced capacity building and networking, the e-SORT IT platform should be considered a success - it delivered the goods. This is an example of innovation and flexibility, two attributes that are sorely needed to maintain activities during the pandemic and beyond.

Antimicrobial Resistance in a Tertiary Care Hospital in Armenia: 2016-2019.

Antimicrobial resistance (AMR) is the acquired ability of pathogens to withstand antimicrobial treatment. To bridge the gap in knowledge for implementing effective and targeted interventions in relation to the AMR in Armenia, we designed this study to explore the performance of AMR diagnostics and the profile of AMR in the Nork Infection Clinical Hospital (NICH) for the period of 2016-2019, particularly to (i) determine the proportions of antimicrobial resistance among all samples tested at the hospital laboratory, (ii) determine the proportion of resistance against specific antimicrobials, and (iii) identify factors associated with AMR. A cross-sectional study was conducted with a secondary data analysis that included all the patients tested for AMR in the laboratory of the NICH for the period of 2016-2019. For this period, only 107 (0.3%) patients out of 36,528 had their AMR test results available and of them, 87 (81%) had resistance at least to one tested antimicrobial. This study has provided some valuable information on the AMR situation in Armenia. The results call for immediate actions to control the access to and the use of antimicrobials, strengthen AMR surveillance, and improve laboratory capacity for the proper and fast identification of drug resistance through a comprehensive system.

Higher Surgery and Recovery Room Air Pressures Associated with Reduced Surgical Site Infection Risk.

BACKGROUND: Incisional surgical site infections (SSIs) following coronary artery bypass grafting (CABG) prolong hospital stays, elevate healthcare costs and increase likelihood of further complications. High air pressure deactivates bacteria and is utilized for commercial food preservation, assuring microbiologically safe pharmaceuticals and sanitizing instruments. However, research on utilizing air pressure deactivation thresholds in surgical and postoperative rooms to reduce rates of SSIs is lacking. METHODS: A case-control study of 801 CABG patients, 128 SSI cases and 673 controls was conducted from January 1, 2006 through March 31, 2009 in Yerevan, Armenia. Patient and surgery characteristics, air pressure measurements and seasons were selected as independent variables with SSI rates as the outcome. The novel threshold regression analysis was used to determine potential air pressure bacterial deactivation thresholds. A final multivariate logistic regression model adjusted for confounders. RESULTS: Overall, bacterial deactivation air pressure threshold was 694.2 mmHg, with the presence of infection for higher air pressure values not statistically significant from zero. Individual deactivation thresholds for Staphylococcus epidermidis (threshold = 694.2 mmHg) and Escherichia coli (threshold = 689.2) showed similar patterns. Multivariate logistic regression showed air pressure above the deactivation threshold was highly protective against SSIs with adjOR = 0.27 (p-value = 0.009, 95%CI: 0.10-0.72). Other SSI risk factors included female sex, adjOR = 2.12 (p-value = 0.006, 95%CI: 1.24-3.62), diabetes, adjOR = 2.61 (p-value < 0.001, 95%CI: 1.72-3.96) and longer time on ventilator, adjOdds = 1.01 (p-value = 0.012, 95%CI: 1.00-1.02). CONCLUSION: Maintaining air pressures in operating and postoperative rooms exceeding bacterial-deactivation thresholds might substantially reduce SSI rates following surgery. Further research should identify specific bacterial-deactivation air pressure thresholds in surgical and postoperative rooms to reduce SSI rates, especially for drug-resistant bacteria.

Catheter ablation or medical therapy to delay progression of atrial fibrillation: the randomized controlled atrial fibrillation progression trial (ATTEST).

AIMS: Delay of progression from paroxysmal to persistent atrial fibrillation (AF) is an important measure of long-term success of AF treatment. However, published data on the impact of catheter ablation on AF progression are limited. This study evaluates whether radiofrequency (RF) catheter ablation delays the progression of AF compared with antiarrhythmic drug (AAD) treatment using current AF management guidelines. METHODS: This prospective, randomized, controlled, two-arm, open-label trial was conducted at 29 hospitals and medical centres across 13 countries. Patients were randomized 1 : 1 to RF ablation or AAD treatment. The primary endpoint was the rate of persistent AF/atrial tachycardia (AT) at 3 years. RESULTS: After early study termination following slow enrolment, 255 (79%) of the planned 322 patients were enrolled (RF ablation, n = 128, AAD, n = 127); 36% of patients in the RF ablation group and 41% in the AAD group completed 3 years of follow-up. For the primary endpoint, the Kaplan-Meier estimate of the rate of persistent AF/AT at 3 years was significantly lower with RF ablation [2.4% (95% confidence interval (CI), 0.6-9.4%)] than with AAD therapy [17.5% (95% CI, 10.7-27.9%); one-sided P = 0.0009]. Patients ≥65 years were ∼4 times more likely to progress to persistent AF/AT than patients <65 years, suggesting RF ablation can delay disease progression [hazard ratio: 3.87 (95% CI, 0.88-17.00); P = 0.0727]. Primary adverse events were reported for eight patients in the RF ablation group. CONCLUSIONS: Radiofrequency ablation is superior to guideline-directed AAD therapy in delaying the progression from paroxysmal to persistent AF.

Cardiac arrhythmias and sudden unexpected death in epilepsy: Results of long-term monitoring.

BACKGROUND: Cardiac rhythm and conduction disorders are common in patients with epilepsy and are presumably one of the leading causes of sudden unexpected death. There are only a few published reports on ictal cardiac arrhythmias detected by continuous monitoring, and the majority had a small sample size. OBJECTIVE: The aim of this study was to evaluate the frequency and type of cardiac arrhythmias recorded by an implantable loop recorder in patients with drug-resistant epilepsy. METHODS: We implanted a subcutaneous loop recorder to 193 patients with drug-resistant epilepsy. Automatic triggers to initiate cardiac rhythm recording were cardiac pauses of >3 seconds and any episodes of bradycardia (≤45 beats/min) or tachycardia (≥150 beats/min). Patients/relatives were instructed to begin peri-ictal rhythm recording by using an external activator device. The follow-up duration was 36 months, with scheduled follow-up visits every 3 months. RESULTS: A total of 6494 electrocardiogram traces were recorded during the median follow-up of 36 months (interquartile range 3-36 months). Ictal heart rhythm and rate changes were detected in 143 patients (74%). The most common finding was ictal sinus tachycardia (66.8%). Sinus bradycardia was observed in 13 patients (6.7%). Three patients had clinically relevant cardiac pauses of >6 seconds, requiring permanent pacemaker implantation. Five patients (2.6%) died suddenly. CONCLUSION: Ictal heart rhythm and rate changes occur in most of the patients with drug-resistant epilepsy. Clinically relevant cardiac events, related to ictal and postictal periods, are rare. No potentially malignant arrhythmias were detected in patients who died suddenly during the preceding follow-up period.

Comparative Safety and Efficacy of Left Atrial Appendage Occlusion with the Watchman Device and Amplatzer Cardiac Plug: Results of the Russian National Registry.

PURPOSE: This multicenter, prospective registry evaluated the comparative safety and efficacy of left atrial appendage occlusion (LAAO) using the Watchman device (WD) and the Amplatzer Cardiac Plug (ACP) in patients with nonvalvular atrial fibrillation (NVAF) in real-world clinical practice in Russia. METHODS: The study included data from 200 consecutive NVAF patients (66.8 ± 7.8 years, 44.5% female, median CHA2DS2VASc 4, median HAS-BLED 3) who had undergone LAAO implantation using WD (n = 108) or ACP (n = 92) from September 2015 to December 2017 in 5 medical centers in Russia. The primary safety endpoint was the procedure-related major adverse events, and the primary efficacy endpoint was the composite of thromboembolic events, device thrombosis, hemorrhagic events, and unexplained death during the 12-month follow-up. RESULTS: Successful LAAO was performed in all 92 (100%) patients with ACP and 105 (97.2%) with WD (p = 0.053). At 12 months, primary safety endpoint occurred in 6.5% of patients in the ACP group with no events in the WD group (6.5% vs. 0%, p = 0.008). During the 12-month follow-up, the primary efficacy endpoint has occurred in 8.3% of patients in the WD group (n = 9) and 1.1% of patients in the ACP group (n = 1) (p = 0.016). CONCLUSIONS: In this multicenter prospective registry, LAA closure with the WD was associated with significantly higher thromboembolic events rate in NVAF patients. Patients, receiving the ACP, had more procedure-related major adverse events. However, further multicenter studies are necessary to evaluate these findings.

Tuberculosis in key populations in Tajikistan - a snapshot in 2017.

INTRODUCTION: WHO End TB Strategy aims at achieving targets of 90% mortality reduction and 80% reduction in tuberculosis (TB) incidence by 2030, recommending better addressing TB and multidrug-resistant TB (MDR-TB) issues in key populations. AIM: The study aimed at having a snapshot of the epidemiological characteristics of the key populations among the new TB patients, registered in Tajikistan during 2017. METHODOLOGY: A cross-sectional study was conducted, using official TB registration data for all new TB case notification in Tajikistan in 2017. RESULTS: The key population included 1,029 (19.8%) patients among all 5,182 new TB cases registered in 2017. The following selected sub-populations were identified: migrant workers - 728 (70.7%), diabetics - 162 (15.7%), HIV-positive - 138 (13.4%), heavy drinkers - 74 (7.2%), drug users - 50 (4.8%), ex-prisoners - 50 (4.8%), and homeless - 9 (0.9%). Among the key population, 307 (29.8%) patients were smear-positive, 145 (14.1%) were drug-sensitive and 116 (11.3%) had MonoDR/MDR-TB. Time to treatment initiation for smear-positive cases was ≤ 5 days for 303 (98.7%) patients. Being a key population was inversely related to gender (female) (OR = 0.25, 95% CI (0.21, 0.29)) and population type (rural) (OR = 0.64, 95% CI (0.55, 0.74)). CONCLUSION: Among the key population the identified overlaps of selected sub-populations would enable more efficiently reaching the certain groups. TB case detection at PHC levels needs to be targeted for improved rates for key population detection. In the key population sub-group of migrant workers' special migration destinations are recommended to be explored and find out possible associations with drug resistance.

New approach for tuberculosis contact tracing implemented in the two regions of Kyrgyz Republic during 2017-2018.

INTRODUCTION: Tuberculosis (TB) contact investigation as a proved approach for finding new TB cases, is not fully performed in Kyrgyzstan. In 2018, the country started aligning the National Guidelines for tracking contacts with the WHO recommendations by expanding the definition for TB index cases to all close contacts, regardless of their TB risk status. METHODOLOGY: This cross-sectional census aimed to determine the active case detection changes among TB contacts after implementation of a new TB tracing strategy using the National Surveillance data. We compared populations in Chui and Issyk-Kul regions of Kyrgyzstan who had contacts with TB index cases before (2017) and after (2018) strategic changes for the rates of indexes, contacts, screened contacts, and detected TB among screened contacts. RESULTS: New TB tracing strategy resulted in increased numbers of indexes (21%) and contacts (36%). Though the smaller number of contacts (1730 vs. 1590) have been screened in 2018, the proportion of TB diagnosed was substantially higher (95% CI: 0.024-0.005; p = 0.002) in 2018 vs. 2017. The mean numbers of TB contacts per-one-index-case also has increased dramatically by 117% (1.8 vs. 3.9) in Chui and by 43% (3.0 vs. 4.3) in Issyk-Kul regions (95% CI: 3.20-3.37; p < 0.001 and 95% CI: 2.97-3.09; p < 0.001, respectively) between 2018 and 2017. CONCLUSION: Extending new tracing approach to other regions of Kyrgyzstan will increase the number of identified contacts, leading to better TB control in the country and prevention of more severe TB development among the unidentified contacts.

Antiretroviral therapy among patients with HIV in Almaty, Kazakhstan: the implication for HIV-associated tuberculosis control.

INTRODUCTION: Antiretroviral therapy (ART) is an effective preventive strategy against tuberculosis (TB) in people living with HIV (PLWH). In Kazakhstan, according to the revised HIV treatment guideline (2017), ART should be initiated immediately after HIV diagnosis established, regardless of CD4+ count. AIM: To evaluate the impact of early initiation of ART on TB infection in PLWH registered in the Center of Prevention and Control of AIDS, Almaty, Kazakhstan, between 2008 and 2018. METHODOLOGY: A retrospective cohort study was conducted using the data of 4,053 patients from electronic HIV case management system (2008-2018) (EHCMS). RESULTS: The study revealed low rates (12.6%) of rapid ART (≤ 1 month after HIV diagnosis). Patients in the rapid ART initiation group were less likely to develop TB compared with those who started treatment >1 month after the HIV detection (odds ratio 1.6; 95% confidence interval [1.1, 2.2]; p = 0.00799). Interestingly, the risk for developing TB among patients receiving ART ≥ 1 month after HIV diagnosis was significantly higher compared with those not taking any treatment. The latter was explained by several confounding not addressed during the analysis, since ART was prescribed to patients with primarily deeper immunodeficiency, while the patients not receiving ART were less immunocompromised. CONCLUSION: Despite the recently changed HIV treatment guideline in Kazakhstan, ART is still initiated based on the disease severity. In 2018, the initiation of ART during the first month after HIV diagnosis increased by 50%. However, it is necessary to reduce the time to initiation of ART for all patients.