Uncovering the Invisible: The Role of High-density Catheters in Recognizing Fractionated Signals in Pulmonary Vein Isolation.

The HD Grid multipolar mapping catheter has emerged as an invaluable tool for greater effectiveness of pulmonary vein isolation (PVI). In the cases described here, fractionated signals seen with the HD Grid catheter at the left atrial appendage (LAA) and left superior pulmonary vein (LSPV) junction were ablated. These signals are not likely to be visualized with conventional catheters and may cause recurrences due to incomplete PVI. The directional sensitivity limitations of bipolar electrogram recordings and the unique anatomy of the LAA-LSPV ridge further contribute to the challenge of evaluating PVI. The HD Grid catheter's ability to record bipoles parallel and perpendicular to the catheter splines and its high-density mapping capabilities provide a superior means for identifying gaps in ablation and detecting the low-voltage isthmus. Furthermore, factors such as ablation quality, catheter stability, and thickness of the LAA-LSPV ridge influence the presence of fractionated signals and the success of PVI. Incorporating preprocedural imaging modalities, such as computed tomography or magnetic resonance imaging, and real-time intracardiac echocardiography could enhance the tailored approach to address these challenges. Future developments in the HD Grid technology, including the option for contact force measurement during mapping, may offer additional insights into the nature of these signals. This case series highlights the significance of using the HD Grid catheter for a detailed interrogation of the LAA-LSPV ridge, ultimately leading to more effective PVI and improved outcomes in patients with atrial fibrillation.

Clinical and Electrophysiological Outcomes of Left Bundle Area Pacing Compared to Biventricular Pacing: An Updated Meta-analysis.

Left bundle branch area pacing (LBBAP) is a novel pacing strategy that uses the conduction system distal to the left bundle branch block level for direct activation of the left bundle and right ventricular myocardium. Our meta-analysis compared the structural, electrophysiological, clinical, and procedural outcomes of LBBAP and biventricular pacing (BVP). The meta-analysis included two randomized controlled trials and showed significant reductions in the left ventricular (LV) systolic and diastolic volumes with LBBAP compared to BVP, together with statistically significant reductions in the QRS duration, New York Heart Association (NYHA) functional class, and heart failure (HF) hospitalizations. The fluoroscopic time was also significantly shorter in the LBBAP group. However, no significant change in the LV ejection fraction was noted. Procedural complications were slightly higher in the LBBAP group, albeit not to a statistically significant degree. Our findings suggest that LBBAP may be a superior alternative to standard BVP in improving the structural, electrophysiological, and clinical components of cardiomyopathy, including the NYHA class and HF hospitalizations. LBBAP is a more physiological pacing strategy that results in normal ventricular activation and may be a viable alternative to BVP for cardiac synchronization therapy.

An Uncommon Focus of a Common Phenomenon: Superior Vena Cava Triggering Atrial Fibrillation.

Ablation of atrial fibrillation most commonly involves the pulmonary veins; however, the superior vena cava (SVC) is an important potentially arrhythmogenic structure that should not be overlooked. This case report demonstrates an excellent example of triggering activity localized to the SVC and the subsequent conversion to sinus rhythm with ablation of the SVC.

An interesting case of infra-hisian block.

INTRODUCTION: The management of patients with conduction disease and supraventricular arrhythmias presents a multitude of clinical challenges.Intra-Hisian block, a condition characterized by delayed or blocked electrical conduction within the His bundle, can result in debilitating symptoms, such as syncope or presyncope. This case report aims to elucidate the diagnostic and therapeutic considerations that were taken in a patient who presented with recurrent syncopal episodes that corresponded to atrial flutter (AFL) and subsequently underwent cavotricuspid isthmus ablation. CASE PRESENTATION: A 65-year-old male with paroxysmal AFL and a pre-existing right bundle branch block and left anterior fascicular block (RBBB+LAFB) experienced recurrent syncopal episodes that were found to be correlated with AFL episodes. Following CTI ablation, an electrophysiology study (EPS) revealed a prolonged HV interval of 101ms, which indicated potential conduction abnormalities. With coronary sinus pacing, an intra-Hisian delay of 211ms was observed. During instances of atrioventricular block, intra-Hisian delay was evident on conducted beats, followed by intra-Hisian block on non-conducted beats. Ultimately, the patient's syncopal episodes prompted the placement of a dual-chamber pacemaker, which resulted in the resolution of symptoms. CONCLUSION: Intra-Hisian block is a condition that is often associated with delayed or blocked electrical conduction within the His bundle. When symptomatic, patients often present with syncope or presyncope. Etiologies of this condition include degenerative changes, myocardial infarction, autoimmune disorders, infections, medications, and more. This case emphasizes the importance of electrophysiology studies (EPS) in the diagnosis and management of patients with intra-Hisian block. Prompt intervention, such as the placement of a dual-chamber pacemaker, can alleviate symptoms and improve patient outcomes. Thus, clinical awareness and utilization of EPS can aid in accurate diagnosis and appropriate treatment selection for patients with conduction abnormalities and supraventricular arrhythmias.cuspid isthmus (CTI) ablation.

Epicardial Potential in the Left Atrium During Posterior Wall Isolation in Persistent Atrial Fibrillation.

Pulmonary vein isolation (PVI) is used for rhythm control in atrial fibrillation (AF). Posterior wall isolation (PWI) is often an adjunct to PVI. Successful PWI is limited by esophageal location, epicardial bridging signals, tissue thickness, and mapping catheter resolution. High-density grid mapping catheters can assist with PWI. Here, we report a case of a 71-year-old woman with persistent AF who underwent PVI and PWI with high-density grid mapping catheters, thus demonstrating the use of omnipolar technology in facilitating successful PWI.

SGLT2 inhibitors and cardiovascular and renal outcomes: a meta-analysis and trial sequential analysis.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce cardiovascular events and renal outcomes in patients with diabetes mellitus (DM). This meta-analysis aimed to provide a thorough evaluation regarding the efficacy and safety of SGLT2 inhibitors. Data search of MEDLINE/PubMed, Embase, and Cochrane Library databases and ClinicalTrials.com from inception through November 26, 2020. We included randomized trials, SGLT2 inhibitors compared with placebo, patients with or without diabetes at recruitment, and reporting the incidence of cardiovascular or renal outcomes. Two authors extracted pertinent data into predefined data collection tables. Ten trials were included (71,553 patients). The mean age was 64.7 ± 8.4 years, with 65.1% male. Follow-up durations range 9-50 months. Inhibition of SGLT2 resulted in lower composite outcome of heart failure (HF) hospitalization or cardiovascular death (RR 0.76, 95% CI 0.73-0.81, P < 0.01) and lower risk of renal outcomes (RR 0.68, 95% CI 0.60-0.77, P < 0.01). Furthermore, SGLT2 inhibitors were associated with lower major adverse cardiovascular events (MACEs), HF hospitalization, cardiovascular mortality, all-cause mortality, myocardial infarction, and serious adverse events, compared with placebo (P < 0.05). Sensitivity analyses revealed lower MACE events also in patients with HF, and a lower HF hospitalization and cardiovascular mortality in non-diabetic patients (P < 0.05). While the amputation risk was comparable between the two groups, the risk of diabetic ketoacidosis was higher in the SGLT2 inhibitor group. Inhibition of SGLT2 in patients with DM and prevalent ASCVD reduces the risk of HF hospitalization, cardiovascular mortality, all-cause mortality, MACE, and renal outcomes without increasing the risk of serious adverse events or amputation.

Proton Pump Inhibitors Versus Histamine-2-Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients: A Meta-analysis and Trial Sequential Analysis.

GOALS AND BACKGROUND: Stress ulcer prophylaxis has been shown to lower gastrointestinal bleeding (GIB) rates. Various agents have been studied, and the optimal strategy continues to be contested. This study evaluates the efficacy between proton pump inhibitors (PPIs) and histamine-2-receptor antagonists. Small sample sizes and methodology flaws limited prior studies. STUDY: A systematic search of MEDLINE, EMBASE, CENTRAL, Web of Science, and ClinicalTrials.gov for randomized controlled trials reporting the use of PPI and histamine-2-receptor antagonist reporting rates of GIB and standardized intensive care outcomes. Risk ratios (RR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). A trial sequential analysis was performed to guard against errors. RESULTS: A total of 14 randomized controlled trials of 28,526 patients with a mean age of 57.83±17.35 years and 30.82% females. In our pooled analysis, PPI outperformed its comparator (RR: 0.68; 95% CI: 0.57-0.82) in clinically significant GIB. PPI re-demonstrated significant reduction in overt GIB (RR: 0.61; 95% CI: 0.39-0.97). No differences between groups was noted toward all-cause mortality (RR: 1.05; 95% CI: 1.00-1.10) or incidence of pneumonia (RR: 1.11; 95% CI: 0.82-1.51). Duration of stay (SMD: 0.07; 95% CI: -0.04-0.17) and ventilator days (SMD: 0.01; 95% CI: -0.01-0.04) were indifferent between the groups. CONCLUSIONS: Among critically ill patients, PPI was associated with reduced clinically significant or overt GIB. No differences in pneumonia were seen with the use of either agent. Trial sequential analysis for clinically significant GIB ruled out the risk for false-positive results, and thereby it is unlikely that future trials will affect our conclusions.

Omega-3 supplementation and heart failure: A meta-analysis of 12 trials including 81,364 participants.

Heart failure (HF) remains a leading cause of hospitalization and mortality. Marine omega-3 fatty acid supplements (omega-3 s) have shown efficacy in decreasing sudden cardiac death and improving the left ventricle ejection fraction percent (LVEF%). In this review, we evaluated the effect of marine omega-3 fatty acid supplements (omega-3 s) on HF hospitalization, recurrent HF hospitalization, and cardiovascular mortality in patients with heart failure. We found that omega-3 supplementation did not reduce first HF hospitalization or cardiovascular mortality but did significantly reduce recurrent HF hospitalizations, as compared with placebo.

Artificial intelligence (AI) real-time detection vs. routine colonoscopy for colorectal neoplasia: a meta-analysis and trial sequential analysis.

GOALS AND BACKGROUND: Studies analyzing artificial intelligence (AI) in colonoscopies have reported improvements in detecting colorectal cancer (CRC) lesions, however its utility in the realworld remains limited. In this systematic review and meta-analysis, we evaluate the efficacy of AI-assisted colonoscopies against routine colonoscopy (RC). STUDY: We performed an extensive search of major databases (through January 2021) for randomized controlled trials (RCTs) reporting adenoma and polyp detection rates. Odds ratio (OR) and standardized mean differences (SMD) with 95% confidence intervals (CIs) were reported. Additionally, trial sequential analysis (TSA) was performed to guard against errors. RESULTS: Six RCTs were included (4996 participants). The mean age (SD) was 51.99 (4.43) years, and 49% were females. Detection rates favored AI over RC for adenomas (OR 1.77; 95% CI: 1.570-2.08) and polyps (OR 1.91; 95% CI: 1.68-2.16). Secondary outcomes including mean number of adenomas (SMD 0.23; 95% CI: 0.18-0.29) and polyps (SMD 0.23; 95% CI: 0.17-0.29) detected per procedure favored AI. However, RC outperformed AI in detecting pedunculated polyps. Withdrawal times (WTs) favored AI when biopsies were included, while WTs without biopsies, cecal intubation times, and bowel preparation adequacy were similar. CONCLUSIONS: Colonoscopies equipped with AI detection algorithms could significantly detect previously missed adenomas and polyps while retaining the ability to self-assess and improve periodically. More effective clearance of diminutive adenomas may allow lengthening in surveillance intervals, reducing the burden of surveillance colonoscopies, and increasing its accessibility to those at higher risk. TSA ruled out the risk for false-positive results and confirmed a sufficient sample size to detect the observed effect. Currently, these findings suggest that AI-assisted colonoscopy can serve as a useful proxy to address critical gaps in CRC identification.

Initial optimal medical therapy with or without invasive strategy for stable coronary disease: a meta-analysis and systematic review.

INTRODUCTION: There is a persistent controversy regarding the benefit and timing of angiography in patients with stable coronary artery disease (CAD). With this meta-analysis of randomized controlled trials (RCTs) the advantages of initial invasive strategy and medical therapy compared with only medical therapy. METHODS: We conducted a literature search of the following databases Pubmed/MEDLINE, Cochrane Library and Embase. Data was collected from all the RCTs that compared early invasive approach with medical therapy alone in treating stable CAD which was conducted by two independent authors. Primary outcomes were all-cause mortality and myocardial infarction (MI), while the secondary outcomes included major adverse cardiovascular events (MACE), cardiovascular mortality, cardiovascular hospitalization, hospitalization due to unstable angina and revascularization events. The Mantel-Haenszel random-effects model was used to estimate risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS: We included 15 RCTs (13 916 patients, mean age 63.1, 78.9% men). The early invasive strategy, compared with medical therapy alone, did not reveal a significant reduction in the incidence of all-cause mortality (RR, 0.94; 95% CI, 0.84-1.05, P = 0.30) or MI (RR, 0.93; 95% CI, 0.79-1.10, P = 0.42). Furthermore, the early invasive strategy did not reduce the incidence of cardiovascular mortality, cardiovascular hospitalization or the revascularization rate compared with medical therapy alone (P > 0.05). However, the incidence of MACE and hospitalization due to unstable angina were lower in patients treated with early invasive strategy (RR, 0.79; 95% CI, 0.63-0.99, P = 0.04), and (RR, 0.46; 95% CI, 0.32-0.67, P < 0.0001), respectively. CONCLUSIONS: Early invasive strategy with medical therapy did not reduce the incidence of all-cause mortality and MI when compared with medical therapy alone among patients with stable CAD with significant stenosis. However, there was a significant reduction in the incidence of MACE and hospitalization due to unstable angina in the early invasive group.

An Enigmatic Elevation of Troponin in a Patient With Seizures.

A 64-year-old African American male, with past medical history of hypertension, depression, and seizure disorder, presented with an episode of generalized tonic-clonic seizure. He was treated for seizures, and after 48 hours seizure-free, the patient started complaining of chest tightness and troponin levels were found to be 34.71 ng/mL. No evidence of myocardial infarction was found after extensive diagnostic workup, including cardiac catheterization. We suspect alternative causes of elevated troponin including post-seizure and transient takosubo cardiomyopathy.

A Case of Adult-Onset Still's Disease with Positive Antinuclear Antibodies.

Adult-onset Still's disease (AOSD) is a rare inflammatory disorder involving multiple systems. It can present a wide range of symptoms like maculopapular rash, fever, and arthralgia, which may overlap with many other disorders, making it difficult to diagnose. Unknown etiology and no diagnostic tests further make it complex to establish the diagnosis of AOSD. We report the case of a 30-year-old female who presented with persistent rash, joint pain, and fever, along with positive antinuclear antibodies (ANA), diagnosed with this condition. The patient improved with corticosteroids and the plan is to start disease-modifying antirheumatic drugs (DMARDs) after tapering off steroids.

Black Esophagus in the Setting of Alcohol Abuse after External Beam Radiation.

Acute esophageal necrosis (AEN), black esophagus, or Gurvits syndrome is a rare clinical disorder characterized by a striking endoscopic appearance of necrotic esophageal mucosa, universally affecting the distal esophagus and ending abruptly at the gastroesophageal junction. It has been gaining traction as a demonstrable cause of upper gastrointestinal bleeding in the 21st century. Its pathophysiology is multifactorial affecting men and the elderly disproportionally, with a mortality rate nearing 36%. AEN has been associated with numerous conditions in the past, and we aim to present an unusual case of AEN on the setting of chronic alcohol use.

A Case of May-Thurner Syndrome.

May-Thurner syndrome, which is also known as iliac vein compression syndrome, is caused when an anatomical variant of the left common iliac vein with a lateral or anterior spur is compressed by the right iliac artery, resulting in thrombosis of the vein. It can present as left deep vein thrombosis which can lead to pulmonary embolism or chronic changes of venous insufficiency in the left lower limb. We report a 27-year-old female with pain abdomen, who was diagnosed to have May-Thurner syndrome.

Targeted Temperature Management in Cardiac Arrest Patients With an Initial Non-Shockable Rhythm: A Systematic Review and Meta-Analysis.

BACKGROUND: Targeted temperature management (TTM) is now recommended for patients presenting with an out-of-hospital cardiac arrest. However, there are limited data that support its use in patients with an initial non-shockable rhythm (NSR). METHODS: A literature search of PubMed/MEDLINE, Cochrane Library, and Embase was conducted by two independent authors for studies that compared TTM along with standard care versus standard care alone in treating cardiac arrest with initial NSR. Outcomes were short-term and long-term survival, and a Cerebral Performance Category (CPC) score of 1 to 2 at the longest follow-up period. The Mantel-Haenszel random-effects model was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Trial sequential analysis (TSA) was performed on the randomized controlled trials (RCTs). RESULTS: Thirty studies were included in the final analysis: 25 observational and five RCTs, totalling 10,703 patients, 4,023 of whom received TTM and 6,680 received standard care alone. Compared with standard care, patients who presented with an initial NSR cardiac arrest and received TTM (target of 32°C -34°C) had a significantly higher short-term survival (OR 1.44 95% CI 1.15-1.81; P = 0.002), long-term survival (OR 1.52 95% CI 1.03-2.26; P = 0.04), and CPC score of 1 to 2 (OR 1.63 95% CI 1.22-2.17; P = 0.0010). Sensitivity analyses by including only RCTs showed a trend, although not significant, toward better short-term survival (OR 1.25 95% CI 0.82-1.89; P = 0.30), long-term survival (OR 1.15 95% CI 0.80-1.66; P = 0.46), and neurologic outcomes (OR 1.51 95% CI 0.81-2.80; P = 0.19). However, TSA performed on the RCTs revealed that the results were inconclusive. CONCLUSION: Among patients who survived cardiac arrest with an initial NSR, TTM is associated with a higher rate of survival and favorable neurological outcomes compared with no TTM. However, analyses from the included RCTs did not support this conclusion.

Complete Revascularization in Patients With STEMI and Multi-Vessel Disease: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Percutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). However, efficacy of complete vs culprit only revascularization in patients with STEMI and multivessel disease remains unclear. METHODS: We searched PubMed/MEDLINE, and Cochrane library. The primary endpoint was major adverse cardiovascular events (MACE). Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), repeat revascularization, stroke, major bleeding, and contrast induced nephropathy. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI). RESULTS: Twelve trials with 7592 patients were included. There was a significantly lower risk of MACE [HR 0.61; 95% CI (0.43-0.60); p = 0.0009; I2 = 72%], cardiovascular mortality [HR 0.74; 95% CI (0.56-0.99); p = 0.04; I2 = 2%], and repeat revascularization [HR 0.43; 95% CI (0.31-0.59); p < 0.00001; I2 = 67%] in patients treated with complete compared with culprit-only revascularization. There was no statistically significant difference in MI [HR 0.77; 95% CI (0.52-1.12); p = 0.17; I2 = 49%], all-cause mortality [HR 0.86; 95% CI (0.65-1.13); p = 0.28; I2 = 14%], heart failure [HR 0.82 95% CI (0.51-1.32); p = 0.42; I2 = 26%], major bleeding [HR 1.07; 95% CI (0.66-1.75); p = 0.78; I2 = 25%], stroke [HR 0.67; 95% CI (0.24-1.89); p = 0.45; I2 = 54%], or contrast induced nephropathy, although higher contrast volumes were used in the complete revascularization group [HR 1.22; 95% CI (0.78-1.92); p = 0.39; I2 = 0%]. CONCLUSION: Complete revascularization was associated with a significantly lower risk of MACE, cardiovascular mortality, and repeat revascularization compared with culprit-only revascularization. These results suggest complete revascularization with PCI following STEMI and multivessel disease should be considered.