Esophageal injury, perforation, and fistula formation following atrial fibrillation ablation.

BACKGROUND: Esophageal perforation and fistula formation are rare but serious complications following atrial fibrillation ablation. In this review article, we outline the incidence, pathophysiology, predictors, and preventative strategies of this dreaded complication. METHODS: We conducted an electronic search in 10 databases/electronic search engines to access relevant publications. All articles reporting complications following atrial fibrillation ablation, including esophageal injury and fistula formation, were included for systematic review. RESULTS: A total of 130 manuscripts were identified for the final review process. The overall incidence of esophageal injury following atrial fibrillation ablation was significantly higher with thermal ablation modalities (radiofrequency 5-40%, cryoballoon 3-25%, high-intensity focused ultrasound < 10%) as opposed to non-thermal ablation modalities (no cases reported to date). The incidence of esophageal perforation and fistula formation with the use of thermal ablation modalities is estimated to occur in less than 0.25% of all atrial fibrillation ablation procedures. The use of luminal esophageal temperature monitoring probe and mechanical esophageal deviation showed protective effect toward reducing the incidence of this complication. The prognosis is very poor for patients who develop atrioesophageal fistula, and the condition is rapidly fatal without surgical intervention. CONCLUSIONS: Esophageal perforation and fistula formation following atrial fibrillation ablation are rare complications with poor prognosis. Various strategies have been proposed to protect the esophagus and reduce the incidence of this fearful complication. Pulsed field ablation is a promising new ablation technology that may be the future answer toward reducing the incidence of esophageal complications.

Percutaneous Coronary Intervention and Discretionary Atherectomy in Patients with Aortic Stenosis: 2016-2019 National Inpatient Sample.

BACKGROUND: Patients with aortic stenosis (AS) usually have concomitant calcified coronary artery disease (CAD) requiring atherectomy to improve lesion compliance and odds of successful percutaneous coronary intervention (PCI). However, there is a paucity of data regarding PCI with or without atherectomy in patients with AS. METHODS: The National Inpatient Sample (NIS) database was queried from 2016 through 2019 using ICD-10 codes to identify individuals with AS who underwent PCI with or without atherectomy (Orbital Atherectomy [OA], Rotational or Laser Atherectomy [non-OA]). Temporal trends, safety, outcomes, costs, and correlates of major adverse cardiovascular events (MACE) were assessed using discharge weighted data. RESULTS: Hospitalizations of 45,420 AS patients undergoing PCI with or without atherectomy were identified and of those, 88.6 %, 2.3 %, and 9.1 % were treated with PCI-only, OA, or non-OA, respectively. There was an increase in PCIs (8855 to 10,885), atherectomy [OA (165 to 300) and non-OA (795 to 1255)], and intravascular ultrasound (IVUS) use (625 to 1000). The median cost of admission was higher in the atherectomy cohorts ($34,340.77 in OA, $32,306.2 in non-OA) as compared to the PCI-only cohort ($23,683.98). Patients tend to have decreased odds of MACE with IVUS guided atherectomy and PCI. CONCLUSIONS: This large database revealed a significant increase in PCI with or without atherectomy in AS patients from 2016 to 2019. Considering the complex comorbidities of AS patients, the overall complication rates were well distributed among the different cohorts, suggesting that IVUS guided PCI with or without atherectomy in patients with AS is feasible and safe.

Dual Antiplatelet Therapy in Patients Aged 75 Years and Older with Coronary Artery Disease: A Meta-Analysis and Systematic Review.

Objectives: This systematic review and meta-analysis evaluates the safety and efficacy of dual antiplatelet therapy (DAPT) in elderly patients with acute coronary syndrome (ACS). Background: The safety and efficacy of DAPT in elderly patients with ACS is not well characterized. Methods: We performed a systematic literature review to identify clinical studies that reported safety and efficacy outcomes after DAPT for ACS in elderly patients. The primary outcomes of primary efficacy endpoint rates and bleeding event rates were reported as random effects risk ratio (RR) with 95% confidence interval. No prior ethical approval was required since all data are public. Results: Our search yielded 660 potential studies. We included 8 studies reporting on 29,217 patients. There was a higher risk of bleeding event rates in elderly patients treated with prasugrel or ticagrelor when compared to clopidogrel with a risk ratio of 1.17 (95% CI 1.08 to 1.27, p < 0.05). There was no difference in primary efficacy endpoint rates between elderly patients treated with prasugrel or ticagrelor when compared to clopidogrel with a risk ratio of 0.85 (95% CI 0.68 to 1.07, p=0.17). Conclusions: This systematic review and meta-analysis suggests that DAPT with prasugrel or ticagrelor compared to clopidogrel is associated with a higher risk of bleeding events in elderly patients with ACS. There was no difference in the primary efficacy endpoints between the two treatment groups.

Multiple Strokes in a Latin American Patient.

We present a case of a recent immigrant from El Salvador without past medical history who presented to our hospital with symptoms concerning for acute stroke. Brain magnetic resonance imaging (MRI) with gadolinium confirmed an acute stroke along with multiple prior infarcts involving different vascular beds. Head magnetic resonance arteriogram did not reveal any occlusions/stenosis or aneurysmal changes. His subsequent extensive evaluation included an electrocardiogram (ECG) that revealed bifascicular block and echocardiography that suggested an apical aneurysm, but images were limited to assess. To further assess the likelihood of cardiac embolism, he underwent cardiac MRI with gadolinium, which confirmed the apical aneurysm. Because of his country of origin and classic ECG and echo findings, Chagas disease was suspected, and both commercial ELISA and confirmatory ELISA and TESA blots were positive. This is both a classic presentation of Chagas cardiomyopathy and an important reminder that Chagas disease should be considered in the differential diagnosis of cardioembolic stroke in Latin American immigrants from an endemic country.

Clinical Presentations of Chagas Cardiomyopathy.

Chronic Chagas cardiomyopathy (CCC) is the most common cause of nonischemic cardiomyopathy in endemic Latin American countries. Immigrants to the United States suffer from this disease, but it is underrecognized. We describe the three hallmark clinical presentations: stroke, ventricular arrhythmias, and heart failure, which should prompt suspicion for CCC.

Acute Pericarditis-Induced Brugada Phenocopy: A Case Report and Review of the Literature.

Brugada phenocopies are interesting clinical entities with electrocardiographic (ECG) patterns indistinguishable from the inherited Brugada syndrome. In patients with Brugada phenocopies, these ECG patterns are expected to resolve with resolution of the underlying condition.

Ineffective implantable cardioverter-defibrillator shocks among patients on continuous left ventricular assist device support: Clinical characteristics and management.

BACKGROUND: Placement of a left ventricular assist device (LVAD) has been described to compromise implantable cardioverter-defibrillator (ICD) defibrillation threshold (DFT). Elevated DFT will have negative consequences and increases the risk of ineffective ICD shocks, morbidity, and mortality. DFT testing is not routinely performed in clinical practice, despite this fact. OBJECTIVE: We describe the clinical characteristics of 7 LVAD patients who presented with multiple ineffective ICD shocks, along with the management strategy in such patients. METHODS: Seven patients (5 male, mean age 52.2 ± 9 years, 85.7% nonischemic cardiomyopathy) with an ICD in situ who progressed to NYHA class IV, ACC/AHA stage D chronic systolic congestive heart failure who underwent successful LVAD implantation presented to our institution in the setting of ventricular tachyarrhythmia and ineffective ICD shocks. Six patients underwent implantation of azygos and subclavian coils with subsequent DFT testing. The remaining patient was made comfort care. RESULTS: Five patients had successful DFT testing with azygos (n = 4) and subclavian (n = 1) defibrillation coil implantation. One patient had unsuccessful DFT testing despite evaluation of multiple shock vectors. There were no major or minor vascular complications in any of the cases. There were no procedural-related deaths. CONCLUSION: This case series highlights the need for a systematic approach to management of ICDs and DFT testing in LVAD patients. The addition of new shock vectors with azygos and subclavian coil implantation may reduce DFT, shock burden, morbidity, and mortality.