Impact of Co-existing Paroxysmal Atrial Fibrillation on Different Outcomes of Hospitalized COVID-19 Patients: Nationwide Inpatient Sample Analysis (2020) With Propensity Score Matching.

Various studies in the medical literature reported significant cardiovascular involvement in patients with coronavirus disease 2019 (COVID-19) pneumonia. Atrial fibrillation (AF) was identified as the most commonly observed arrhythmia complicating COVID-19 infection with an increased risk of short-term mortality. We used the National Inpatient Sample Database (NIS) of 2020 to conduct this retrospective cohort study. Our study's population consisted of adult patients hospitalized for COVID-19 Pneumonia with or without the presence of paroxysmal atrial fibrillation (PAF). Encounters with COVID-19 and co-existing PAF had higher adjusted odds of inpatient mortality (Adjusted odds ratio [aOR]: 1.19, 95% CI: 1.11-1.28, P < 0.001), longer mean length of hospital stay (LOS) of 1.17 days (95% confidence interval [CI]: 1.03-1.38, P < 0.001), and higher odds of different in-hospital complications. Based on these results, conducting more prospective/retrospective cohort studies with an emphasis on long-term follow-up on patients who develop PAF following COVID-19 infection is warranted.

A systematic review and meta-analysis comparing radiofrequency catheter ablation with medical therapy for ventricular tachycardia in patients with ischemic and non-ischemic cardiomyopathies.

BACKGROUND: In patients with cardiomyopathy, radiofrequency catheter ablation (CA) for ventricular tachycardia (VT) is an adjunctive and alternative treatment option to long-term anti-arrhythmic drug therapy. We sought to compare CA with medical therapy for the management of VT in patients with ischemic and non-ischemic cardiomyopathies. METHODS: MEDLINE, Cochrane, and ClinicalTrials.gov databases were evaluated for relevant studies. RESULTS: Eleven studies with 2126 adult patients were included (711 in CA, 1415 in medical therapy). In the randomized controlled trial (RCT) analysis, CA reduced risk of recurrent VT (risk ratio (RR) 0.79 [95% CI 0.67 to 0.93], p = 0.005), ICD shocks (RR 0.64 [95% CI 0.45 to 0.89] p = 0.008), and cardiac hospitalizations (RR 0.76 [95% CI 0.63 to 0.92] p = 0.005). There was no difference in all-cause mortality (RR 0.94, p = 0.71). In combined RCT and observational study analysis, there was a trend for reduction in all-cause mortality (RR 0.75 [95% CI 0.55 to 1.02] p = 0.07). In subgroup analysis of studies with mean left ventricular ejection fraction (LVEF) < 35%, CA demonstrated reduction in mortality (RR 0.71, p = 0.004), ICD shocks (RR 0.63, p = 0.03), VT recurrence (RR 0.76, p = 0.004), and cardiac hospitalizations (RR 0.75, p = 0.02). The subgroup of early CA prior to ICD shocks demonstrated reduction in ICD shocks (RR 0.57, p < 0.001) and VT recurrence (RR 0.74, p = 0.01). CONCLUSIONS: CA for VT demonstrated a lower risk of VT recurrence, ICD shocks, and hospitalization in comparison to medical therapy. The subgroups of early CA and LVEF < 35% demonstrated better outcomes.

Feasibility and safety of laser balloon pulmonary vein isolation in patients with prior left atrial appendage occlusion device implantation.

INTRODUCTION: With the increasing adoption of left atrial appendage occlusion (LAAO) procedures and the eligibility of patients for pulmonary vein isolation (PVI) post device placement, we examined the feasibility and safety of laser balloon (LB) for PVI in patients with prior LAAO. METHODS: We retrospectively examined consecutive patients with paroxysmal or persistent, drug-resistant atrial fibrillation (AF) who underwent LB PVI, after Watchman FLX device implantation at Rush University Medical Center between January 2020 and December 2021. RESULTS: Seven patients (four persistent and three paroxysmal) with a mean age of 64 ± 11 years, predominantly male sex (86%), were included in the study. Two (29%) patients had prior cryoablation PVI with recurrence of AF. The mean CHA2 DS2 VASc is 2.6 ± 0.5 and the mean HAS-BLED score is 3.4 ± 0.8. The mean follow-up duration was 10 ± 7 months. The mean duration between Watchman FLX device implantation and LB PVI was 592 days. Acute first pass left pulmonary vein (PV) isolation was achieved in 100% of the procedures. There were no periprocedural complications such as death, pericardial tamponade or effusion, phrenic nerve injury, PV stenosis, device perforation or embolization, or worsening peri-device leak in any of the patients. None of the patients had AF recurrence after the blanking period. CONCLUSION: LB PVI was safe and effective with 100% acute isolation of left-sided veins in patients with prior LAAO device.

Complications and failure modes of coronary embolic protection devices: Insights from the MAUDE database.

BACKGROUND: There is limited data on complications associated with the use of coronary embolic protection devices (EPDs). METHODS: We queried the Manufacturer and User Facility Device Experience database between November 2010 and November 2020 for reports on coronary EPDs: Spider FX (Medtronic, Minneapolis, MN) and Filterwire EZ (Boston Scientific, Natick, MA). RESULTS: We retrieved 119 reports on coronary EPD failure (Spider FX n = 33 and Filterwire EZ n = 86), most of which (78.2%) occurred during saphenous vein graft interventions. The most common failure mode was inability to retrieve the EPD (49.6%), with the filter trapped against stent struts in 76.2% of the cases. Other device complications included filter fracture (28.6%), failure to cross (7.6%), failure to deploy (7.6%), and failure to recapture the filter (3.4%). Filter fracture (54.5 vs. 29.1%) and failure to recapture (9.1 vs. 2.1%) were more commonly reported, while failure to deploy the filter (0 vs. 10.5%) was less commonly reported with the Spider-FX. CONCLUSIONS: The most common modes of failure of coronary EPDs are the failure of retrieval (49.6%), followed by the filter fracture (28.6%). When using EPDs, careful attention to the technique is essential to avoid failures and subsequent complications.

Outcomes with Drug-Coated Balloons in Percutaneous Coronary Intervention in Diabetic Patients.

BACKGROUND: Percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM) remains associated with inferior clinical outcomes and an increased risk of restenosis compared with non-diabetics even in the era of drug-eluting stents (DES). The outcomes with drug-coated balloons (DCBs) in diabetic patients have received limited study. METHODS: We performed a meta-analysis of all studies published between January 2000 and January 2019 reporting the outcomes with DCB vs. DES after PCI of de-novo coronary lesions in diabetic patients. Outcomes included major adverse cardiovascular events (MACE), target lesion revascularization (TLR), binary restenosis by quantitative coronary angiography (QCA), and late lumen loss (LLL). RESULTS: Three studies with 378 patients (440 lesions) were included in the meta-analysis. During 17.3 ±â€¯11.3 months follow-up, DCB were associated with a similar risk of MACE (OR: 0.63, 95% CI [0.36, 1.12], p = 0.11), TLR (OR: 0.51, 95% CI [0.25, 1.06] p = 0.07), binary restenosis (OR: 0.42, 95% CI [0.09, 1.92], p = 0.26), and LLL (mean difference: -0.13 mm, 95% CI [-0.41, 0.14], p = 0.34) compared with DES. CONCLUSION: In diabetic patients with de-novo coronary lesions undergoing PCI, DCBs are associated with similar outcomes compared with first-generation DES, with a signal toward potential benefit in lowering target lesion revascularization. Further randomized studies are needed to compare the newer-generation DCBs and DES in this setting.

Outcomes With Deferred Versus Performed Revascularization of Coronary Lesions With Gray-Zone Fractional Flow Reserve Values.

BACKGROUND: Management of coronary lesions with fractional flow reserve values in the gray zone (0.75-0.80) remains controversial due to conflicting data on the performance versus deferral of revascularization. METHODS: We performed a systematic review and meta-analysis of 7 observational studies including 2683 patients that compared the outcomes of deferred versus performed revascularization of coronary lesions with gray-zone fractional flow reserve values. RESULTS: During a mean follow-up of 31±9 months, the incidence of major adverse cardiovascular events (12.54 % versus 11.25%; odds ratio [OR], 1.64 [95% CI, 0.78-3.44]; P=0.19, I2=84%), cardiac mortality (1.25% versus 0.72%; OR, 1.78 [95% CI, 0.58-5.46]; P=0.31, I2=18%), and myocardial infarction (1.28% versus 2.66%; OR, 0.79 [95% CI, 0.22-2.79]; P=0.71, I2=65%) was similar with deferral versus performance of revascularization in coronary lesions with gray-zone fractional flow reserve. Deferral of revascularization was associated with a higher incidence of target vessel revascularization (9.12% versus 5.78%; OR, 1.85 [95% CI, 1.03-3.33]; P=0.04, I2=62%). When the analysis was limited only to studies that used percutaneous coronary intervention for revascularization, deferred revascularization remained associated with a higher risk of target vessel revascularization (18% versus 7.3%; OR, 3.04 [95% CI, 1.53-6.02]; P<0.001) and was associated with a higher risk of major adverse cardiovascular event (23.2% versus 13.4%; OR, 3.38 [95% CI, 1.92-5.95]; P<0.001). CONCLUSIONS: In lesions with gray-zone fractional flow reserve, revascularization was associated with a similar incidence of major adverse cardiovascular event but a lower incidence of target vessel revascularization over a mean follow-up of approximately 2.5 years. CLINICAL TRIAL REGISTRATION: URL: https://www.crd.york.ac.uk/prospero/. Unique identifier: CRD42019128076.

Evaluation of YouTube as a reliable source for patient education on aortic valve stenosis.

BACKGROUND: Aortic stenosis (AS) is a prevalent disease in the elderly population and has been a public health concern for decades. YouTube is currently being used for obtaining healthcare related information. We evaluated the quality of information about AS on YouTube for patient education. METHODS: YouTube was queried for the search phrases "aortic valve stenosis", "aortic valve replacement", "transcatheter aortic valve replacement" and "TAVR". Videos were assessed for their reliability and content with two five-point scales. They were categorized into groups according to usefulness and uploader source. All videos were assessed for audience interaction. Videos were viewed and analyzed by 2 independent investigators. Conflicts were resolved by a third investigator. RESULTS: Search phrases yielded 69,300 videos, among which, 120 videos were evaluated and 85 videos were included in the final analysis. Of the 85 videos, only 45 videos (53%) were found to be useful while 40 videos (47%) were found to be non-useful. The majority (98%) of the useful videos were uploaded by professional sources. Overall, videos uploaded by non-professional sources had higher number of views (23,553 vs. 11,110, P≤0.001) despite of being less useful (14% vs. 67%, P<0.001) when compared to videos uploaded by professional sources. CONCLUSIONS: There is a potential to increase public awareness about aortic valve stenosis and the available treatment options by utilizing YouTube. Professional societies are encouraged to provide more useful material that can deliver comprehensive and reliable information in an entertaining and intuitive manner to the public.

Mesalamine-induced Myocarditis in a Young Athlete: Can He Run Again?

Mesalamine is often used in the treatment of inflammatory bowel disease (IBD). Mesalamine-induced cardiotoxicity has been reported in the literature and is a rare entity. The mechanism of cardiotoxicity remains unclear, however, it is believed to be due to a humoral-mediated hypersensitivity reaction. Patients with mesalamine-induced cardiotoxicity could present with a wide range of cardiovascular symptoms ranging from mild chest pain and shortness of breath (SOB) to cardiogenic shock secondary to left ventricular systolic dysfunction. Symptoms could be associated with elevation in cardiac biomarkers and electrocardiogram (EKG) changes including ST-segment or T-wave abnormalities. We report a case of mesalamine-induced myocarditis in a young athlete presenting with chest pain 10 days after mesalamine therapy was initiated for recently diagnosed Crohn's disease. Workup was significant for elevated cardiac biomarkers. The diagnosis was confirmed with cardiovascular magnetic resonance imaging (CMR). Immediate cessation of the medication resulted in resolution of symptomatology and normalization of cardiac biomarkers over a 48-hour period. Mesalamine-induced cardiotoxicity is a rare, yet serious side effect that necessitates medical community awareness. CMR is the confirmatory diagnostic modality of choice.

A Partial Anomalous Pulmonary Venous Connection in a Severely Symptomatic Patient, Is Surgery Always Recommended?

Partial anomalous pulmonary venous connection (PAPVC) is a rare cardiac anomaly occurring when a pulmonary vein drains into the right atrium, coronary sinus or a systemic vein creating a left-to-right shunt. Symptoms develop from right-sided fluid overload and pulmonary vascular disease. We report a rare case of a severely symptomatic patient with an incidentally discovered PAPVC in the setting of underlying severe pulmonary hypertension from multifactorial severe restrictive lung disease. Despite his worsening symptoms, a multi-disciplinary meeting decided against surgical intervention. Nine months after the decision was made, the patient showed no signs or symptoms of clinical deterioration. Prior studies recommend surgery for PAPVCs with evidence of right ventricular dilation, mild-to-moderate tricuspid regurgitation, or early stages of pulmonary vascular disease. However, our case demonstrates how decision making should consider the shunt's contribution to the overall clinical picture and underlying comorbidities. If a decision is made to defer surgical intervention, strict follow up and repeat re-evaluations for possible risk re-stratification and surgery reconsideration are warranted.

Elevated end-diastolic wall stress after acute myocardial infarction predicts adverse cardiovascular outcomes and longer hospital length of stay.

BACKGROUND: Acute myocardial infarction (MI) leads to ventricular remodeling in response to oxygen demand. Such changes include left ventricular (LV) dilatation and increased myocardial wall stress. Prior studies showed that wall stress is a vital parameter of cardiac remodeling. However, outcome data are lacking. We aim to investigate wall stress post-MI in relation to biomarkers of cardiac remodeling and cardiovascular outcomes. METHODS: Patients presenting with ST-elevation MI (STEMI) requiring primary percutaneous intervention (PCI) were enrolled prospectively. LVEF and volume-based end-diastolic (EDWS) and end-systolic (ESWS) wall stress were measured from predischarge echocardiograms. Serum samples were collected for measurement of serum biomarkers. We identified 81 patients meeting inclusion criteria (64% men, 36% women) with a mean age of 61. The primary outcome was major adverse cardiovascular events (MACE) defined as 1-year composite endpoint of cardiac mortality, recurrent MI, revascularization, or stroke. Length of hospitalization (LOH) was recorded. RESULTS: Major adverse cardiovascular events-positive patients (n = 12) had significantly higher EDWS levels (15.87 vs 12.33, P = 0.045), and galectin-3 levels (19.07 vs 11.75, P = 0.015), and lower LVEF (40.0% vs 48.4%, P = 0.023) compared to MACE-negative patients. Patients with LOH > 72 hours (n = 33) had significantly higher EDWS, galectin-3, and peak troponin, and lower LVEF compared to patients with LOH < 72 hours. EDWS positively correlated with LOH and galectin-3. EDWS was an independent predictor of MACE by binomial regression analysis. CONCLUSION: End-diastolic walls tress is a potential prognostic tool for risk stratifying STEMI patients, providing an assessment of the functional consequences of myocardial remodeling. It is predictive of MACE independent of LVEF, associated with longer hospitalizations, and correlates with galectin-3, a biomarker of cardiac remodeling.

Quality of life outcomes in transcatheter aortic valve replacement patients requiring pacemaker implantation.

BACKGROUND: Permanent pacemaker implantation is the most common complication after Transcatheter aortic valve replacement (TAVR) and is associated with worse outcomes and mortality. However, its impact on quality-of-life (QoL) outcomes remains unknown. METHODS: We included 383 consecutive patients undergoing TAVR from January 2012 to 2016 who completed a baseline Kansas City Cardiomyopathy Questionnaire (KCCQ-12) health survey. The clinical, laboratory, angiographic, QoL, mortality, and occurrence of poor outcomes (KCCQ-12 score < 45 or KCCQ decrease of ≥10 points) were obtained. RESULTS: The mean age was 83 ± 8 years, 51% were men, and majority were Caucasians (n = 364, 95%). Permanent pacemaker (PPM) was implanted in 11.5% of patients post-TAVR. PPM patients were more likely to have prior conduction disease including RBBB (25% vs 12%, P = .02) and PQ interval >250 ms (11% vs 5%, P = .07). One-month median KCCQ-12 scores were significantly lower among PPM patients (84.7 vs 68.8, P = .04), but did not differ significantly at 1-year (86.5 vs 90.6, P = .5) post-TAVR. Occurrence of poor outcomes did not differ significantly among those with or without PPM at 1 month (11% vs 7%, P = .39) and 1 year (13% vs 9%, P = .45), respectively. However, patients with poor QoL outcomes at 1 month post-TAVR also had significantly worse mortality during follow-up in unadjusted (31.3% vs 4.5%, P < .001) and adjusted (HR = 5.30, 95% [CI: 1.85-15.22, P = .002])analyses, respectively. CONCLUSION: Permanent pacemaker implantation is associated with short-term reduction in QoL without long-term implications post-TAVR. Patients with poor QoL post-TAVR also have significantly higher mortality.

Comparison of Computed Tomography derived Fractional Flow Reserve to invasive Fractional Flow Reserve in Diagnosis of Functional Coronary Stenosis: A Meta-Analysis.

Computed Tomography derived Fractional Flow Reserve (CTFFR) is an emerging non-invasive imaging modality to assess functional significance of coronary stenosis. We performed a meta-analysis to compare the diagnostic performance of CTFFR to invasive Fractional Flow reserve (FFR). Electronic search was performed to identify relevant articles. Pooled Estimates of sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-) and diagnostic odds ratio (DOR) with corresponding 95% confidence intervals (CI) were calculated at the patient level as well as the individual vessel level using hierarchical logistic regression, summary receiver operating characteristic (SROC) curve and area under the curve were estimated. Our search yielded 559 articles and of these 17 studies was included in the analysis. A total of 2,191 vessels in 1294 patients were analyzed. Pooled estimates of sensitivity, specificity, LR+, LR- and DOR with corresponding 95% CI at per-patient level were 83% (79-87), 72% (68-76), 3.0 (2.6-3.5), 0.23 (0.18-0.29) and 13 (9-18) respectively. Pooled estimates of sensitivity, specificity, LR+, LR- and DOR with corresponding 95% CI at per-vessel level were 85% (83-88), 76% (74-79), 3.6 (3.3-4.0), 0.19 (0.16-0.22) and 19 (15-24). The area under the SROC curve was 0.89 for both per patient level and at the per vessel level. In our meta-analysis, CTFFR demonstrated good diagnostic performance in identifying functionally significant coronary artery stenosis compared to the FFR.

The Therapeutic Potential of Blocking Galectin-3 Expression in Acute Myocardial Infarction and Mitigating Inflammation of Infarct Region: A Clinical Outcome-Based Translational Study.

INTRODUCTION: Increased galectin-3 is associated with ischemic cardiomyopathy, although its role in early remodeling post-myocardial infarction (MI) has not been fully elucidated. There are no data demonstrating that blocking galectin-3 expression would have an impact on the heart and that its relationship to remodeling is not simply an epiphenomenon. The direct association between galectin-3 and myocardial inflammation, dysfunction, and adverse cardiovascular outcomes post-MI was examined using clinical and translational studies. METHODS: We performed expression analysis of 9753 genes in murine model of acute MI. For galectin-3 loss of function studies, homozygous galectin-3 knock-out (KO) mice were subjected to coronary artery ligation procedure to induce acute MI (MI, N = 6; Sham, N = 6). For clinical validation, serum galectin-3 levels were measured in 96 patients with ST-elevation MI. Echocardiographic and angiographic parameters of myocardial dysfunction and 3-month composite outcome including mortality, recurrent MI, stroke, and heart failure hospitalization were measured. RESULTS: In the infarct regions of murine models, galectin-3 was a robustly expressed gene. Elevated galectin-3 expression strongly correlated with macrophage-mediated genes. Galectin-3 KO mice showed reduced myocardial macrophage infiltration after acute MI. Galectin-3 levels were higher in patients with early systolic dysfunction, and predicted 3-month major adverse cardiovascular events (area under the curve [AUC]: 0.917 ± 0.063; P = .001). CONCLUSIONS: Galectin-3 is directly associated with early myocardial inflammation post-MI and may represent a potential target for therapeutic inhibition.

Neutrophil-to-lymphocyte ratio predicts heart failure readmissions and outcomes in patients undergoing transcatheter aortic valve replacement.

OBJECTIVE: Neutrophil-to-lymphocyte ratio (NLR) has prognostic value in acute coronary syndromes. We investigated its utility for predicting heart failure (HF) admissions and major adverse cardiac outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS: Data on clinical, laboratory, procedural, HF admissions, and major adverse cardiac events (MACEs) (all-cause mortality, recurrence of myocardial infarction requiring intervention, stroke) for 298 consecutive patients who underwent TAVR between 2012 and 2016 in our tertiary center were collected. RESULTS: Analysis included 298 patients. The mean age was 83 ± 8 years, 51% were males, and 95% were Caucasians. The median Society of Thoracic Surgeons risk score was 9 (interquartile range: 6.3-11.8). Receiver-operating curve analysis identified a cutoff value of NLR of 4.0 for MACE after TAVR and sensitivity of 68% and specificity of 68% {area under the curve [AUC] = 0.65 [95% confidence interval (CI): 0.51-0.79], p = 0.03}. An NLR of 4.0 for HF hospitalizations after TAVR and sensitivity of 60% and specificity of 57% [AUC = 0.61 (95% CI: 0.53-0.69), p = 0.01]. NLR ≥4.0 before TAVR significantly predicted MACE after TAVR (68.4% vs. 31.6%, p = 0.02) and HF hospitalizations (58.3% vs. 41.7%, p = 0.03). NLR with TAVR risk score increased the predictive value for MACE after TAVR from AUC = 0.61 (95% CI: 0.50-0.72, p = 0.06) to AUC = 0.69 (95% CI: 0.57-0.80, p = 0.007). CONCLUSION: NLR predicts all-cause mortality, MACE, and HF hospitalization 1 year after TAVR. NLR with TAVR risk score improved predictability for MACE. Further studies for prognostication using NLR are warranted.

Safety of Large-Volume, Same-Day Oral Bowel Preparations During Deep Sedation: A Prospective Observational Study.

BACKGROUND: Colonoscopy quality is directly related to the bowel preparation. It is well established that bowel preparations are improved when at least part of the laxative is ingested on the day of the procedure. However, there is concern that this can result in higher gastric residual volumes (GRV) and increase the risk of pulmonary aspiration. The aim of this study is to evaluate GRV and gastric pH in patients who received day-before bowel preparation versus those ingesting their laxative on the day of colonoscopy under anesthesiologist-directed propofol deep sedation. METHODS: This is a prospective observational study for patients undergoing same-day upper endoscopy and colonoscopy. All included patients had large-volume polyethylene glycol lavage preparation and received propofol sedation. Gastric fluid was collected during the upper endoscopy for volume and pH measurement. RESULTS: The study included 428 patients with 56% receiving same-day laxative preparation and the remainder evening-before preparation. Mean ± SD GRV was 18.1 ± 10.2 mL, 16.3 ± 16.5 mL in each of these preparation groups, respectively (P = .69). GRV ≥ 25 mL or higher than expected GRV adjusted by weight (0.4 mL/kg) were also not different among the study groups (P = .90 and P = .87, respectively). Evaluating GRV based on time since last ingestion of preparation (3-5, 5-7, >7 hours) did not result in any differences (P = .56). Gastric pH was also similar between the bowel preparation groups (P = .23), with mean ± SD of 2.5 ± 1.4 for evening-before and 2.5 ± 1.3 for the same-day preparation. There were more inadequate bowel preparations in day before bowel preparations (P = .001). CONCLUSIONS: A large-volume bowel preparation regimen finished on the day of colonoscopy as close as 3 hours before the procedure results in no increase in GRV or decrease in gastric pH.