Impact of an Organized Treatment Pathway on Management of Atrial Fibrillation: The ER2EP Study.

Background: Atrial fibrillation (AF) is the most common arrhythmia reported worldwide. There is significant heterogeneity in AF care pathways for a patient seen in the emergency room, impacting access to guideline-driven therapies. Objectives: The purpose of this study was to compare the difference in AF outcomes between those treated with an organized treatment pathway vs routine-care approach. Methods: The emergency room to electrophysiology service study (ER2EP) is a multicenter, prospective observational registry (NCT04476524) enrolling patients with AF from sites where a pathway for management of AF was put in place compared to sites where a pathway was not in place within the same health system and the same physicians providing services at all sites. Multivariable regression modeling was performed to identify predictors of clinical outcomes. Beta coefficient or odds ratio was reported as appropriate. Results: A total of 500 patients (ER2EP group, n = 250; control group, n = 250) were included in the study. The mean age was 73.4 ± 12.9 years, and 52.2% were males. There was a statistically significant difference in primary endpoint [time to ablation (56 ± 50.9 days vs 183.3 ± 109.5 days; P < 0.001), time to anticoagulation initiation (2.1 ± 1.6 days vs 19.7 ± 35 days, P < 0.001), antiarrhythmic drug initiation (4.8 ± 7.1 days vs 24.7 ± 44.4 days, P < 0.001) compared to the control group, respectively. As such, this resulted in reduced length of stay in the ER2EP group compared to the control group (2.4 ± 1.4 days vs 3.23 ± 2.5 days, P = 0.002). Conclusions: This study provides evidence that having an organized pathway from the emergency department for AF patients involving electrophysiology services can improve early access to definitive therapies and clinical outcomes.

Impact of Remote Cardiac Monitoring on Greenhouse Gas Emissions: Global Cardiovascular Carbon Footprint Project.

Background: Remote monitoring (RM) of patients with cardiac implantable electronic devices (CIEDs) is efficient and requires fewer resources than conventional monitoring. However, the impact of RM on the carbon footprint (CF) is not known. Objectives: The authors sought to evaluate the reduction in cost and greenhouse gas (GHG) emissions with RM as compared to conventional monitoring of CIEDs and its relevance to CF. Methods: Data were obtained from a third-party RM provider on 32,811 patients from 67 device clinics across the United States. Distance from home address to the device clinic for patients on RM was calculated. Savings in total distance traveled over 2 years was calculated using frequency of follow-up required for the device type. National fuel efficiency data and carbon emission data were obtained from the Bureau of Transportation Statistics and U.S. Environmental Protective Agency, respectively. The average gas price during the study period was obtained from U.S. Energy Information Administration. Results: In the study population, RM resulted in a total saving of 31.7 million travel miles at $3.45 million and reduction of 12,518 metric ton of GHG from gasoline. There was a reduction of 14.2-million-page printouts, $3 million in cost, and 78 tons of GHG. Improvement in workforce efficiency with RM resulted in savings of $3.7 million. There was a net saving of $10.15 million and 12,596 tons of GHG emissions. Conclusions: RM of patients with a CIED resulted in significant reductions in GHG emissions. Efforts to actively promoting RM can result in significant reduction in CF.

Sinus node sparing novel hybrid approach for treatment of inappropriate sinus tachycardia/postural sinus tachycardia: multicenter experience.

BACKGROUND: The ideal treatment of inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS) still needs to be defined. Medical treatments yield suboptimal results. Endocardial catheter ablation of the sinus node (SN) may risk phrenic nerve damage and open-heart surgery may be accompanied by unjustified invasive risks. METHODS: We describe our first multicenter experience of 255 consecutive patients (235 females, 25.94 ± 3.84 years) having undergone a novel SN sparing hybrid thoracoscopic ablation for drug-resistant IST (n = 204, 80%) or POTS (n = 51, 20%). As previously described, the SN was identified with 3D mapping. Surgery was performed through three 5-mm ports from the right side. A minimally invasive approach with a bipolar radiofrequency clamp was used to ablate targeted areas while sparing the SN region. The targeted areas included isolation of the superior and the inferior caval veins, and a crista terminalis line was made. All lines were interconnected. RESULTS: Normal sinus rhythm (SR) was restored in all patients at the end of the procedure. All patients discontinued medication during the follow-up. After a blanking period of 6 months, all patients presented stable SR. At a mean of 4.07 ± 1.8 years, normal SN reduction and chronotropic response to exercise were present. In the 51 patients initially diagnosed with POTS, no syncope occurred. During follow-up, pericarditis was the most common complication (121 patients: 47%), with complete resolution in all cases. Pneumothorax was observed in 5 patients (1.9%), only 3 (1.1%) required surgical drainage. Five patients (1.9%) required a dual-chamber pacemaker due to sinus arrest > 5 s. CONCLUSIONS: Preliminary results of this multicenter experience with a novel SN sparing hybrid ablation of IST/POTS, using surgical thoracoscopic video-assisted epicardial ablation combined with simultaneous endocardial 3D mapping may prove to be an efficient and safe therapeutic option in patients with symptomatic drug-resistant IST and POTS. Importantly, in our study, all patients had a complete resolution of the symptoms and restored normal SN activity.

Sinus Node Sparing Hybrid Thoracoscopic Ablation Outcomes in Patients with Inappropriate Sinus Tachycardia (SUSRUTA-IST) Registry.

BACKGROUND: Medical treatment of inappropriate sinus tachycardia (IST) remains suboptimal. Radiofrequency sinus node (RF-SN) ablation has poor success and higher complication rates. OBJECTIVE: We aimed to compare clinical outcomes of the novel SN sparing hybrid ablation technique with those of RF-SN modification for IST management. METHODS: This is a multicenter prospective registry comparing the SN sparing hybrid ablation strategy with RF-SN modification. The hybrid procedure was performed using an RF bipolar clamp, isolating superior vena cava/inferior vena cava with the creation of a lateral line across the crista terminalis while sparing the SN region (identified by endocardial 3-dimensional mapping). RF-SN modification was performed by endocardial and/or epicardial mapping and ablation at the site of earliest atrial activation. RESULTS: Of the 100 patients (hybrid ablation group, n = 50; RF-SN group, n = 50), 82% were women, and the mean age was 22.8 years. Normal sinus rhythm and rate were restored in all patients in the hybrid group (vs 84% in the RF-SN group; P = .006). Hybrid ablation was associated with significantly better improvement in mean daily heart rate and peak 6-minute walk heart rate compared with RF-SN ablation. The RF-SN group had a significantly higher rate of redo procedures (100% vs 8%; P < .001), phrenic nerve injury (14% vs 0%; P = .012), lower acute pericarditis (48% vs 92%; P < .0001), permanent pacemaker implantation (50% vs 4%; P < .0001) than did the hybrid ablation group. CONCLUSION: The novel sinus node sparing hybrid ablation procedure appears to be more efficacious and safer in patients with symptomatic drug-resistant IST with long-term durability than RF-SN ablation.

Diagnostic Utility of Smartwatch Technology for Atrial Fibrillation Detection - A Systematic Analysis.

BACKGROUND: Smartphone technologies have been recently developed to assess heart rate and rhythm, but their role in accurately detecting atrial fibrillation (AF) remains unknown. OBJECTIVE: We sought to perform a meta-analysis using prospective studies comparing Smartwatch technology with current monitoring standards for AF detection (ECG, Holter, Patch Monitor, ILR). METHODS: We performed a comprehensive literature search for prospective studies comparing Smartwatch technology simultaneously with current monitoring standards (ECG, Holter, and Patch monitor) for AF detection since inception to November 25th, 2019. The outcome studied was the accuracy of AF detection. Accuracy was determined with concomitant usage of ECG monitoring, Holter monitoring, loop recorder, or patch monitoring. RESULTS: A total of 9 observational studies were included comparing smartwatch technology, 3 using single-lead ECG monitoring, and six studies using photoplethysmography with routine AF monitoring strategies. A total of 1559 patients were enrolled (mean age 63.5 years, 39.5% had an AF history). The mean monitoring time was 75.6 days. Smartwatch was non-inferior to composite ECG monitoring strategies (OR 1.06, 95% CI 0.93 - 1.21, p=0.37), composite 12 lead ECG/Holter monitoring (OR 0.90, 95% CI 0.62 - 1.30, p=0.57) and patch monitoring (OR 1.28, 95% CI 0.84 - 1.94, p=0.24) for AF detection. The sensitivity and specificity for AF detection using a smartwatch was 95% and 94%, respectively. CONCLUSIONS: Smartwatch based single-lead ECG and photoplethysmography appear to be reasonable alternatives for AF monitoring.

Electrical delays in quadripolar leads with cardiac resynchronization therapy.

BACKGROUND: Pacing at sites of late intraventricular activation (QLV) or long interventricular conduction (right ventricle [RV]-left ventricular [LV]) have been associated with improved cardiac resynchronization therapy (CRT) outcomes. Quadripolar leads improve CRT outcomes by allowing for electrical repositioning to optimize pacing sites. However, little is known regarding the effect of such repositioning on electrical delay. OBJECTIVE: Determine the relationship between different electrical bipoles from a quadripolar lead and measures of electrical delay. METHODS: Forty-six patients underwent CRT with a quadripolar lead. The RV-LV and QLV intervals were measured for both the proximal and distal bipoles and the difference (Δ) between bipoles for each measure were calculated. Multivariate analyses were performed to identify predictors of electrical delays. RESULTS: This was a typical CRT population with a mean age of 65 years and ejection fraction of 27%, with left bundle branch block (LBBB) present in 70%. The regression model for ΔQLV was significant (p = .05), with both gender (p = .008) and LBBB status (p = .020) significant predictors. The overall regression model for ΔRV-LV was not significant. ΔQLV and ΔRV-LV were significant among LBBB patients. Among non-LBBB, only ΔRV-LV was significant (mean: 7.2 ms, p = .006). ΔRV-LV versus ΔQLV were strongly correlated in LBBB (R2 = .92) but not non-LBBB (R2 = .06). CONCLUSION: In LBBB, ΔRV-LV and ΔQLV are closely correlated suggesting that the proximal bipole and thus basal LV pacing sites should be selected when feasible. Greater variation in activation pattern is present in non-LBBB, so pacing sites should be individualized.

Management and long-term outcomes associated with recalled implantable cardioverter-defibrillator leads: A multicenter experience.

BACKGROUND: No comparative study of outcomes in Riata and Sprint Fidelis leads undergoing lead extraction (LE), lead abandonment (LA), and generator change only (GC) has been published. OBJECTIVES: Determine outcomes (major complications [MC]; death, extended hospitalization, or rehospitalization within 60 days [RH]; lead malfunction) of LE, LA, and GC for recalled leads. METHODS: Retrospective, multicenter, comparative study. RESULTS: A total of 298 LE, 85 LA, and 310 GC were performed. In the clinical setting of a lead intervention, there was no difference in a composite of MC, death, RH, lead revision, inappropriate shocks, or device infection between LE and LA groups (15% vs 22%, P = .140). In the clinical setting of a device at elective replacement interval (ERI), there were significantly more acute events at 60 days (MC, death, and RH) in the LE and LA groups at 15.4% (4) and 15.4% (4), and this was significantly (P = .017) higher than the GC group at 5.1% (16). There was no difference (P = 1.000) in the composite of MC, death, RH, lead malfunction, lead revisions, device infections, or inappropriate shocks between LE, LA, and GC groups at 15.4% (4), 15.4% (4), and 17.4% (54), respectively. Following generator change, 14 of 175 Fidelis leads and 3 of 135 Riata leads failed over a total of 12,714 months of follow-up. CONCLUSIONS: The failure rate of recalled leads was substantially lower compared to previous reports. It may be prudent to perform generator change only when the device is at ERI, especially when the recalled lead has historical performance that likely outweighs the risks of extraction/abandonment.

Subclavian and Axillary Vein Access Versus Cephalic Vein Cutdown for Cardiac Implantable Electronic Device Implantation: A Meta-Analysis.

OBJECTIVES: This study sought to evaluate the efficacy and safety of venous access techniques for cardiac implantable electronic device (CIED) implantation. BACKGROUND: Minimally invasive transvenous access is a fundamental step during implantation of CIEDs. However, the preferred venous access is still subject to ongoing debate, and the decision depends on patient characteristics and operator experience. METHODS: A comprehensive search for studies comparing subclavian vein puncture (SVP) and axillary vein puncture (AVP) versus cephalic vein cutdown (CVC) for CIED implantation was performed in PubMed, Google Scholar, EMBASE, SCOPUS, ClinicalTrials.gov, and various scientific conferences from inception to July 1, 2019. A meta-analysis was performed by using a random effects model to calculate risk ratios (RRs) and mean differences with 95% confidence interval (CIs). RESULTS: Twenty-three studies were eligible that included 35,722 patients (SVP, n = 18,009; AVP, n = 409; and CVC, n = 17,304). Compared with CVC, SVP was associated with a higher risk of pneumothorax (RR: 4.88; 95% CI: 2.95 to 8.06) and device/lead failure (RR: 2.09; 95% CI: 1.07 to 4.09), whereas there was no significant difference in these outcomes compared with AVP. Acute procedural success was significantly higher with SVP compared with CVC (RR: 1.24; 95% CI: 1.00 to 1.53). There was no significant difference in other complications such as pocket hematoma/bleeding, device infection, or pericardial effusion between SVP or AVP compared with CVC. CONCLUSIONS: CVC was associated with a lower risk of pneumothorax and lead failure compared with SVP. AVP and CVC are both effective approaches for CIED lead implantation and offer the potential to avoid the complications usually observed with traditional SVP.

Safety and efficacy of leadless pacemaker for cardioinhibitory vasovagal syncope.

BACKGROUND: Single-chamber leadless pacemakers (LPs) have been shown to be an effective alternative to conventional transvenous pacemakers (CTPs), but their benefit in the context of cardioinhibitory vasovagal syncope (CI-VVS) is unknown. OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of LP compared with dual-chamber CTP for CI-VVS. METHODS: We conducted a multicenter, retrospective study comparing patients who received LP or dual-chamber CTP for drug-refractory CI-VVS. CI-VVS was diagnosed clinically and supported by cardiac monitoring and head-up tilt table testing. The primary efficacy endpoint was freedom from syncope during follow-up. Secondary endpoints included device efficacy and safety estimated by device-related major and minor adverse events (AEs). RESULTS: Seventy-two patients (24 LP, 48 CTP; age 32 ± 5.5 years; 90% female; syncope frequency 7.6 ± 3.4 per year) were included. At 1 year, 91% of patients (22/24) in the LP group and 94% of patients (43/48) in the CTP group met the primary efficacy endpoint (P = .7). Device efficacy endpoint was met in 92% of the LP group and 98% of the CTP group (P = .2). Early major AEs occurred in 2 of 24 in the LP group and 3 of 48 in the CTP group (P = .4). Late major AEs occurred in 0 of 24 in the LP group and 2 of 48 in the CTP group (P = 1). CONCLUSION: In patients with CI-VVS, single-chamber LP demonstrated equivalent efficacy in reducing syncopal events compared to dual-chamber CTP, with a similar safety profile.

Higher initial weight-based heparin dosing is required with direct oral anticoagulants during catheter ablation for atrial fibrillation.

BACKGROUND: Heparin dosing of patients anticoagulated with direct oral anticoagulants (DOACs) undergoing atrial fibrillation (AF) ablation can be challenging as they require more heparin than those on warfarin therapy. We sought to compare periprocedural activated clotting times (ACTs) of patients on warfarin vs. DOAC and determine an optimal weight-based heparin dosage strategy. METHODS: Patients who underwent AF ablation over 28 months were reviewed for type of anticoagulation, intraprocedural heparin dosing, ACTs, and adverse outcomes. A heparin dosing strategy was then tested in a prospective validation cohort. RESULTS: There were 89 patients in the DOAC group and 43 in the warfarin group. Demographics, comorbidities, and complication rates were similar. Mean ACT and percentage of therapeutic ACTs were lower in the DOAC group, most significantly in those with a weight > 90 kg. In DOAC patients, a higher initial heparin bolus ≥ 150 units/kg yielded a higher percentage of therapeutic intraprocedural ACTs (49% ± 10 vs. 29% ± 7, p = 0.0008). In a prospective validation cohort of 25 patients administered an initial heparin bolus ≥ 150 units/kg, the mean ACT was 295 ± 33 and 49% of the ACTs collected were therapeutic, similar to findings of our high-dose retrospective subgroup. CONCLUSION: Patients on DOACs require more heparin during AF ablation to achieve therapeutic ACT. We suggest an initial heparin dose of at least 150 units/kg in this subset of patients, particularly in those with a weight > 90 kg.

Efficacy and safety of single vs dual antiplatelet therapy in patients on anticoagulation undergoing percutaneous coronary intervention: A systematic review and meta-analysis.

BACKGROUND: Selection of an appropriate antithrombotic regimen in patients requiring oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) still remains a challenge. An ideal 9-2regimen should balance the risk of bleeding against ischemic benefit. METHODS: A comprehensive literature search for studies comparing triple antithrombotic therapy (TAT) vs double antithrombotic therapy (DAT) in patients requiring OAC undergoing PCI was performed in clinicalTrials.gov, PubMed, Web of Science, EBSCO Services, Cochrane Central Register of Controlled Trials, Google Scholar, and various scientific conference sessions from inception to May 1st, 2019. A meta-analysis was performed using random-effects model to calculate risk ratio (RR) and 95% confidence interval (CI). RESULTS: Fifteen studies were eligible and included 13 967 patients, of which 7349 received TAT and 6618 received DAT. Compared with DAT, TAT was associated with lower risk of myocardial infarction (RR, 0.82; 95%CI, 0.69-0.98; P = .03) and stent thrombosis (RR, 0.66; 95%CI, 0.46-0.96; P = .03). There was no difference in risk of trial defined major adverse cardiac events, all-cause mortality, and stroke between two groups. Compared with DAT, TAT was associated with higher risk of trial defined major bleeding (RR, 1.67; 95%CI, 1.38-2.01; P < .00001), including thrombolysis in myocardial infarction major bleeding (RR, 1.81; 95%CI, 1.47-2.24; P < .00001) but no significant difference in risk of intracranial bleeding. CONCLUSION: In patients requiring OAC undergoing PCI, TAT was associated with a lower risk of myocardial infarction but with a significantly higher risk of major bleeding when compared with DAT.

Prophylactic pulmonary vein isolation during cavotricuspid isthmus ablation for atrial flutter: A meta-analysis.

BACKGROUND: Atrial arrhythmias (AA), including atrial fibrillation (AF), have been reported in patients after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFL). Several studies have examined the effect of performing concomitant pulmonary vein isolation (PVI) with CTI on recurrent AA. These studies were analyzed to determine the overall effect of this approach on recurrent AA. METHODS: PubMed and Google Scholar were searched for randomized trials comparing the incidence of AA after CTI versus CTI + PVI until June 2018. Only patients without prior history of AF were included in the recurrent AA analysis. All patients were included in the analyses of other clinical outcomes. RESULTS: Four randomized control trials were included in the meta-analysis. In the recurrent AA analysis, a total of 314 patients were randomized in the studies (n = 158 CTI, n = 156 CTI + PVI). Freedom from AA at 1 year was significantly higher in the CTI + PVI group versus CTI alone (odds ratio [OR] 0.25 [0.14, 0.44] 95% confidence interval [CI], P < 0.00001). A total of 550 patients (n = 336 CTI, n = 214 CTI + PVI) were included in analyses for procedure time, fluoroscopy time, and complications rates. Procedure time and fluoroscopy time were significantly longer in the CTI + PVI group (mean difference [MD]: 103.31 min [94.40, 112.23] 95% CI, P < 0.00001) and (MD: 16.47 min [14.89, 18.05] 95% CI, P < 0.00001), respectively. Total complications were statistically similar between groups. CONCLUSION: This meta-analysis shows addition of a prophylactic PVI during CTI ablation significantly reduces recurrent AA at 1 year without significantly increasing major complications.

Percutaneous ventricular assist device in ventricular tachycardia ablation: a systematic review and meta-analysis.

BACKGROUND: There is a lack of compelling data regarding the benefit of percutaneous ventricular assist devices (PVAD) in patients undergoing ventricular tachycardia (VT) ablation. The study aims to conduct a meta-analysis comparing the safety and efficacy of PVAD versus no-PVAD (N-PVAD) during VT ablation. METHODS: Studies meeting criteria were systematically reviewed. Baseline characteristics and clinical outcomes were extracted and analyzed. A meta-analysis was performed using random-effects model to calculate risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI). RESULTS: The meta-analysis included five retrospective, observational studies consisting of 2026 patients (PVAD group-284 patients versus N-PVAD group-1742 patients). The PVAD group was sicker with significantly higher VT storm, lower LVEF and greater proportion of NYHA class ≥ III than N-PVAD (p < 0.050). The acute procedural success [RR 0.95, 95% CI, (0.89-1.00), p = 0.070], VT recurrence [RR 0.94, 95% CI, (0.66-1.34), p = 0.740] and mortality [RR 1.28, 95% CI, (0.43-3.83), p = 0.660] were similar on follow-up between PVAD versus N-PVAD. PVAD group also had significantly higher complications [RR 1.83, 95% CI (1.21-2.76), p = 0.004] and longer fluoroscopy [MD + 7.31 min, 95% CI (0.91-13.71), p = 0.030] and procedure time [MD + 71.41 min, 95% CI (31.67-111.14), p < 0.001] than N-PVAD. CONCLUSION: Patients receiving PVAD support during VT ablation were sicker with no significant difference in acute procedural success, VT recurrence, and mortality compared with N-PVAD. PVAD support was also associated with higher complications and longer fluoroscopy and procedure time. A prospective randomized controlled trial will identify if using PVAD support in unstable patients undergoing VT ablation will impact clinical outcomes.

Surgical left atrial appendage occlusion during cardiac surgery: A systematic review and meta-analysis.

AIM: To evaluate the safety and efficacy of surgical left atrial appendage occlusion (s-LAAO) during concomitant cardiac surgery. METHODS: We performed a comprehensive literature search through May 31st 2018 for all eligible studies comparing s-LAAO vs no occlusion in patients undergoing cardiac surgery. Clinical outcomes during follow-up included: embolic events, stroke, all-cause mortality, atrial fibrillation (AF), reoperation for bleeding and postoperative complications. We further stratified the analysis based on propensity matched studies and AF predominance. RESULTS: Twelve studies (n = 40107) met the inclusion criteria. s-LAAO was associated with lower risk of embolic events (OR: 0.63, 95%CI: 0.53-0.76; P < 0.001) and stroke (OR: 0.68, 95%CI: 0.57-0.82; P < 0.0001). Stratified analysis demonstrated this association was more prominent in the AF predominant strata. There was no significant difference in the incidence risk of all-cause mortality, AF, and reoperation for bleeding and postoperative complications. CONCLUSION: Concomitant s-LAAO during cardiac surgery was associated with lower risk of follow-up thromboembolic events and stroke, especially in those with AF without significant increase in adverse events. Further randomized trials to evaluate long-term benefits of s-LAAO are warranted.

Prophylactic catheter ablation of ventricular tachycardia in ischemic cardiomyopathy: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Catheter ablation is proven to be an effective strategy for drug refractory ventricular tachycardia (VT) in ischemic cardiomyopathy. However, the appropriate timing of VT ablation and identifying the group of patients that may receive the greatest benefit remains uncertain. There is limited data on the effect on prophylactic catheter ablation (PCA) in the prevention of implantable cardioverter defibrillator (ICD) therapy, electrical storm, and mortality. METHODS: We performed a comprehensive literature search through November 1, 2017, for all eligible studies comparing PCA + ICD versus ICD only in eligible patients with ischemic cardiomyopathy. Clinical outcomes included all ICD therapies including ICD shocks and electrical storm. Additional outcomes included all-cause mortality, cardiovascular mortality, and complications. RESULTS: Three randomized controlled trials (RCTs) (N = 346) met inclusion criteria. PCA was associated with a significantly lower ICD therapies (OR 0.49; CI 0.28 to 0.87; p = 0.01) including ICD shocks [OR 0.38; CI 0.22 to 0.64; p = 0.0003) and electrical storm (OR 0.55; CI 0.30 to 1.01; p = 0.05) when compared with ICD only. There was no significant difference in all-cause mortality (OR 0.77; CI 0.41 to 1.46; p = 0.42), cardiovascular mortality (OR 0.49; CI 0.16 to 1.50; p = 0.21), and major adverse events (OR 1.45; CI 0.52 to 4.01; p = 0.47) between two groups. CONCLUSION: These results suggest prophylactic catheter ablation decreases ICD therapies, including shocks and electrical storm with no improvement in overall mortality. There is a need for future carefully designed randomized clinical trials.

Use of antibiotic envelopes to prevent cardiac implantable electronic device infections: A meta-analysis.

INTRODUCTION: The rates of cardiac implantable electronic device (CIED) infections have risen over the past decade and are associated with increased hospitalizations and mortality. A number of preventative strategies have been developed including an antibiotic coated envelope, but it has yet to gain widespread use. METHODS: A meta-analysis was performed on controlled studies of the antibiotic envelope. PubMed and Google Scholar were searched for studies comparing infection rates with and without the use of an antibiotic envelope. Studies including both new implants and pulse generator replacements were included in the analysis. RESULTS: Five studies were included in the meta-analysis. A total of 4,490 patients underwent CIED implantation, 1,798 with an antibiotic envelope and 2,692 without an envelope. In the pooled cohort, the envelope was associated with a 69% relative risk reduction in CIED infection (0.31 [0.17, 0.58] 95% CI, P = 0.0002). Propensity matched data from three studies were analyzed to ensure accurate comparison. In the risk-matched cohort, infections were significantly lower in the envelope group (3 vs. 26, P < 0.0003). CONCLUSION: The use of antibiotic envelopes in CIED implant is associated with a significantly lower rate of infection.

Management of bleeding in patients receiving non-vitamin K antagonists.

Anticoagulation with non-vitamin K antagonists (Non vitamin K oral anticoagulant (NOACs)) including dabigatran, rivaroxaban, apixaban and edoxaban is at least as effective as warfarin, has fewer drug and food interactions and does not require monthly monitoring. Although major bleeding with NOACs is infrequent, there remains concern about the ability to effectively treat episodes of major bleeding. New agents have been developed that are capable of providing rapid reversal of the anticoagulation effect of NOACs. Idarucizumab normalises the dilute thrombin time and the ecarin clotting time, both of which are elevated with dabigatran. Andexanet alfa reduces increased anti-factor Xa activity seen with the use of rivaroxaban and apixaban. A universal reversal agent is in development. These agents, unlike agents to reverse the anticoagulation effect of vitamin K antagonists, appear to reverse the specific NOAC anticoagulant. The development of reversal agents is a major advancement in managing bleeding in the era of NOACs. Future studies will be required to determine the impact on important clinical outcomes.