Incidence and predictors of atrial fibrillation and its impact on long-term survival in patients with supraventricular arrhythmias.

AIMS: To determine the incidence and predictors of atrial fibrillation (AF) and its impact on survival in patients with other forms of supraventricular arrhythmias (SVAs) including atrial flutter (AFL), atrial tachycardia (AT), atrioventricular reentrant (AVRT), and AV nodal reentrant tachycardia (AVNRT). We hypothesized that SVA may increase risk of AF and concomitant AF may influence long-term survival. METHODS AND RESULTS: All patients who underwent catheter ablation for SVA from 2000 to 2010 were included in this study. The patients were identified retrospectively and the vital status determined prospectively. Observed survival in the study cohort was compared with survival rates in the age- and sex-matched general population. The study group included 1573 patients (mean age 50.5 ± 18 years, 47% female) with AVNRT (38.5%), AFL (29.6%), AVRT (22.6%) and AT (9.3%). The patients were followed for a mean of 35 months (median 23 months). Atrial fibrillation was documented in 424 patients (27%) with a higher incidence in males (35 vs. 18%). Atrial fibrillation was present in 19.6% of patients before the ablation and developed in 9.07% after ablation. Atrial fibrillation commonly occurred in patients with AFL (57.5%), AT (27.4%), AVRT (13.5%), and AVNRT (9.7%). Older age, prolonged PR interval, dilated left atrium, low left ventricular ejection fraction and presence of AFL were independent predictors for concomitant AF. Long-term survival was worse in the presence of AF. CONCLUSION: The incidence of AF is high in patients with other forms of SVA. The most common association is between AFL and AF. Long-term survival is decreased in those who have concomitant AF, although AF did not emerge as an independent predictor of mortality when adjusted for other covariates.

Pathology of second-generation everolimus-eluting stents versus first-generation sirolimus- and paclitaxel-eluting stents in humans.

BACKGROUND: Clinical trials have demonstrated that the second-generation cobalt-chromium everolimus-eluting stent (CoCr-EES) is superior to the first-generation paclitaxel-eluting stent (PES) and is noninferior or superior to the sirolimus-eluting stent (SES) in terms of safety and efficacy. It remains unclear whether vascular responses to CoCr-EES are different from those to SES and PES because the pathology of CoCr-EES has not been described in humans. METHODS AND RESULTS: A total of 204 lesions (SES=73; PES=85; CoCr-EES=46) from 149 autopsy cases with duration of implantation >30 days and ≤3 years were pathologically analyzed, and comparison of vascular responses was corrected for duration of implantation. The observed frequency of late and very late stent thrombosis was less in CoCr-EES (4%) versus SES (21%; P=0.029) and PES (26%; P=0.008). Neointimal thickness was comparable among the groups, whereas the percentage of uncovered struts was strikingly lower in CoCr-EES (median=2.6%) versus SES (18.0%; P<0.0005) and PES (18.7%; P<0.0005). CoCr-EES showed a lower inflammation score (with no hypersensitivity) and less fibrin deposition versus SES and PES. The observed frequency of neoatherosclerosis, however, did not differ significantly among the groups (CoCr-EES=29%; SES=35%; PES=19%). CoCr-EES had the least frequency of stent fracture (CoCr-EES=13%; SES=40%; PES=19%; P=0.007 for CoCr-EES versus SES), whereas fracture-related restenosis or thrombosis was comparable among the groups (CoCr-EES=6.5%; SES=5.5%; PES=1.2%). CONCLUSIONS: CoCr-EES demonstrated greater strut coverage with less inflammation, less fibrin deposition, and less late and very late stent thrombosis compared with SES and PES in human autopsy analysis. Nevertheless, the observed frequencies of neoatherosclerosis and fracture-related adverse pathological events were comparable in these devices, indicating that careful long-term follow-up remains important even after CoCr-EES placement.

Left atrial appendage dimensions predict the risk of stroke/TIA in patients with atrial fibrillation.

UNLABELLED: Risk of Stroke/TIA in Patients With Atrial Fibrillation. INTRODUCTION: Most strokes in patients with atrial fibrillation (AF) arise from thrombus formation in left atrial appendage (LAA). Our aim was to identify LAA features associated with a higher stroke risk in patients with AF using magnetic resonance imaging and angiography (MRI/MRA). METHODS: The study included 144 patients with nonvalvular AF who were not receiving warfarin and who underwent MRI/MRA prior to catheter ablation for AF. LAA volume, LAA depth, short and long axes of LAA neck, and numbers of lobes were measured. RESULTS: Of the 144 patients, 18 had a prior stroke or transient ischemic attack (TIA) (13 and 5, respectively). Compared with patients who had no history of stroke/TIA, these patients were older, had higher prevalence of hypertension and hyperlipidemia and had higher LAA volume (22.9 ± 9.6 cm(3) vs. 14.5 ± 7.1 cm(3) , P < 0.001). Their LAA depth (3.76 ± 0.9 cm vs. 3.21 ± 0.8 cm, P = 0.006) and the long and short axes of the LAA neck (3.12 ± 0.7 cm vs. 2.08 ± 0.7 cm, P < 0.001; 2.06 ± 0.5 cm vs. 1.37 ± 0.4 cm, P < 0.001, respectively) were larger. Using stepwise logistic regression model, the only statistically significant multivariable predictors of events were age (OR = 1.21 per year, 95% CI 1.06-1.38, P = 0.004), aspirin use (OR = 0.039, 95% CI 0.005-0.28, P = 0.001), and LAA neck dimensions (short axis × long axis) (OR = 3.59 per cm(2) , 95% CI 1.93-6.69, P < 0.001). CONCLUSION: LAA dimensions predict strokes/TIAs in patients with AF. LAA assessment by MRI/MRA can potentially be used as an adjunctive tool for risk stratification for embolic events in AF patients.

Cardiac troponin T elevation after coronary artery bypass grafting is associated with increased one-year mortality.

The results of the present study extend the value of assessing troponin T for the prediction of mortality rate 1 year after coronary artery bypass grafting; this study supports previous work that demonstrated the value of postoperative assessment of troponin T for the prediction of in-hospital adverse outcome after coronary artery bypass grafting.

Postoperative troponin-T predicts prolonged intensive care unit length of stay following cardiac surgery.

OBJECTIVE: To evaluate the use of postoperative cardiac troponin T (cTnT) for the prediction of prolonged intensive care unit length of stay following cardiac surgery. DESIGN: Prospective, single-center, observational cohort study of patients following cardiac surgical procedures. The enrollment period was from October through December 2000. Patients were enrolled on admission to the intensive care unit and followed until hospital discharge. SETTING: The cardiac surgical intensive care unit of the Massachusetts General Hospital. PATIENTS: A total of 222 consecutive patients were enrolled. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Perioperative clinical factors and serum concentrations of cTnT measured every 8 hrs after surgery were recorded. These clinical factors and the results of serum cTnT measurement were correlated with the need for prolonged intensive care unit length of stay (defined as >24 hrs). Univariable analysis identified factors predictive of prolonged intensive care unit length of stay. Stepwise logistic regression identified independent predictors of prolonged intensive care unit length of stay. Multiple linear regression was used to explore the direct relationship between cTnT concentrations at several postoperative time points and intensive care unit length of stay. At each time point assessed, cTnT concentrations from patients requiring a prolonged intensive care unit length of stay were significantly higher (all p <.001) than in those individuals with normal length of stay. In contrast, creatine kinase isoenzymes were not significantly different between patients with normal or prolonged intensive care unit length of stay. Multivariable analysis demonstrated that an immediate postoperative cTnT concentration > or =1.58 ng/mL was the strongest predictor of a prolonged intensive care unit length of stay (odds ratio, 5.6; 95% confidence interval, 2.9-10.8). Multiple linear regression analysis revealed that intensive care unit length of stay increased by 0.32 days with each incremental 1.0 ng/mL increase in cTnT measured at 18-24 hrs postprocedure. CONCLUSIONS: Elevated postoperative cTnT concentrations can prospectively identify patients requiring prolonged intensive care unit length of stay after cardiac surgery.

A comparison of cardiac troponin T and creatine kinase-MB for patient evaluation after cardiac surgery.

OBJECTIVES: The aim of this study was to assess the role of serum markers of myocardial necrosis after cardiac surgery. BACKGROUND: The role of serum troponin T (TnT) and creatine kinase-MB (CK-MB) for the risk stratification of patients after cardiac surgery remains undefined. METHODS: Serum levels of TnT and CK-MB were measured from 224 patients every 8 h after cardiac surgery. The results of serum cardiac marker testing were correlated with adverse events, including new myocardial infarction (MI), cardiogenic shock or death. Univariable analysis identified factors predictive of complications, while stepwise logistic regression identified independent predictors of postoperative complications. RESULTS: Cardiac marker elevation was universal after cardiac surgery. At all time points measured, compared with those patients without complications, the TnT levels from patients with complications were more significantly elevated (all: p < 0.0005). In contrast, among identically timed specimens, the levels of CK-MB from complicated patients were less reliably discriminatory. Multivariable analysis suggested that a TnT level in the highest quintile (> or = 1.58 ng/ml) was the strongest predictor of complications, including death (post-op, odds ratio [OR] = 31.0, 95% confidence interval [CI] = 3.67 to 263.1, p = 0.002) or shock (post-op: OR = 18.9, 95% CI = 2.29 to 156.1, p = 0.006; 18 h to 24 h: OR = 30.7, 95% CI = 3.75 to 250.7, p = 0.001), as well as the composite end points of death/MI (18 h to 24 h: OR = 60.1, 95% CI = 7.34 to 492.1, p < 0.0005), shock/MI (post-op: OR = 23.3, 95% CI = 2.82 to 191.4, p = 0.003; 18 h to 24 h: OR = 37.8, 95% CI = 4.66 to 307.3, p = 0.001) or death/shock/MI (post-op: OR = 20.0, 95% CI = 2.81 to 142.0, p = 0.003; 18 h to 24 h: OR = 67.4, 95% CI = 6.96 to 652.3, p < 0.0005). In contrast, in the presence of TnT, the results of CK-MB measurement added no independent prognostic information. CONCLUSIONS: Troponin T is superior to CK-MB for the prediction of impending complications after cardiac surgical procedures.