Mortality post in-patient catheter ablation of atrial fibrillation in rural versus urban areas: Insights from national inpatient sample database.

BACKGROUND: A growing body of evidence is supportive of early atrial fibrillation (AF) ablation to maintain sinus rhythm. Disparities in health care between rural and urban areas in the United States are well known. Catheter ablation (CA) of AF is a complex procedure and its outcomes among rural versus urban areas has not been studied in the past. METHODS: The national inpatient sample database 2016-2020 was queried for all hospitalization with the primary diagnosis of AF who underwent AF catheter ablation at the index hospitalization. Then, hospitalizations were stratified into rural versus urban. The primary outcome was in-hospital mortality. Secondary outcomes were total hospitalization costs and likelihood for longer length of stay. RESULTS: A total of 78,735 patients underwent inpatient CA of AF between January 2016 and December 2020, mean age was 68.5 ± 11 with 44 % being females. 27,180 (35 %) CA were performed in rural areas, while the remaining CA  51,555 (65 %) were done in urban areas. While, there was very low risk of mortality, patients who underwent CA in rural areas had more comorbidities and also was associated with a 79 % increase in post-procedural in-hospital mortality compared with urban areas (aOR 1.79, 0.8 % vs 0.4 %, CI: 1.15-2.78, P < 0.01). CA of AF in rural areas had a longer length of hospital stay (aOR 1.11, 4.21 vs 3.79 days, 95 % CI: 1.02-1.2, P = 0.02), lower overall cost compared with urban areas (49,698 ± 1251 vs. $53,252 ± 1339, P = 0.03). Multivariate regression analysis showed end stage renal disease and congestive heart failure were independent risk factors associated with increase in post CA in-hospital mortality exceeding two-fold. CONCLUSION: Inpatient CA of AF in rural areas was associated with higher in-hospital mortality, longer length of stay and a lower overall cost when compared with urban areas.

Short Versus Long Duration of Dual Antiplatelet Therapy After Second-Generation Drug-Eluting Stents Implantation in Patients with Diabetes.

BACKGROUND: Duration of dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) remains uncertain, with increasing data suggestive of acceptable short-term duration. Metabolically accelerated atherosclerosis associated with diabetes makes it essential to study short-term DAPT in this subgroup. With limited studies determining optimal DAPT strategies after second-generation stents in this subset, we aimed to establish the optimal duration of DAPT in the diabetic population using second-generation stents. QUESTION: To determine optimal DAPT duration in diabetic population undergoing PCI in 2nd generation stents. DATA SOURCES: We conducted an electronic database search of randomized controlled trials from PubMed/Medline, Embase, Cochrane, and Web of Science databases. STUDY DESIGN: A meta-analysis was conducted comparing outcomes of short-term (3-6 months) DAPT therapy versus long-term (12 months) DAPT therapy in the diabetic population undergoing PCI with second-generation stents. RESULTS: A total of 5 randomized controlled trials were included with a total of 3117 diabetic patients. Short-term DAPT did not show any statistical difference from long-term DAPT in achieving primary outcomes (relative ratio: 0.96, 95% confidence interval (CI) 0.68-1.35, P = 0.84). Overall mortality (OR 0.92; 95% CI, 0.52-1.63, P = 0.98), myocardial infarction [odds ratio (OR)OR 1.02; 95% CI, 0.53-1.94, P = 0.85], stent thrombosis (OR 1.20; 95% CI, 0.55-2.60, P = 0.55), target vessel revascularization (OR 1.10; 95% CI, 0.45-2.73, P = 0.74), and stroke (OR 0.50; 95% CI, 0.082-2.43, P = 0.81) did not show any statistical difference between the 2 groups. Similarly, a subgroup analysis of study population comparing 6 versus 12 months of DAPT in diabetic population did not show any difference in net primary outcomes (relative ratio: 0.86, 95% CI 0.45-1.45, P = 0.60). There was no significant heterogeneity noted between the 2 groups. CONCLUSION: This meta-analysis showed no statistically significant benefit of longer DAPT over shorter DAPT therapy in patients undergoing PCI with drug-eluting stent in patients with diabetes.

Prevalence of Heart Failure With Preserved Ejection Fraction in Patients Undergoing Atrial Fibrillation Ablation Based on Resting and Post-Tachycardia Pacing Left Atrial Pressure.

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are frequent co-morbid conditions. In patients with symptomatic AF and preserved left ventricular ejection fraction the clinical diagnosis of HFpEF may be difficult, as history, examination, and echocardiography are not sensitive or specific. This study sought to assess the prevalence of HFpEF in patients undergoing AF ablation utilizing resting and post-tachycardia pacing left atrial pressure (LAP) measurements. This retrospective cohort study consisted of consecutive patients with symptomatic AF and preserved left ventricular ejection fraction who had invasive hemodynamic assessment (IHA) of LAP under resting and post-tachycardia pacing conditions while undergoing AF ablation from 2020 to 2022 at a tertiary care academic medical center. Elevated LAP was defined as ≥15 mm Hg at rest and ≥15 mm Hg post-tachycardia pacing. Patients were stratified into 3 groups: (1) normal resting and post-tachycardia pacing LAP (control group), (2) elevated resting LAP (apparent HFpEF), (3) normal resting but elevated post-tachycardia pacing LAP (occult HFpEF). A total of 78 patients were included with age 64.6 ± 9.1 years, 28 (36%) female, body mass index 33.3 ± 6.5 kg/m2, 5 (6%) paroxysmal and 73 (94%) persistent AF, and CHA2DS2-VASc 3.0 ± 1.5. IHA categorized 31 (40%), 32 (41%), and 15 patients (19%) into groups 1, 2, and 3 respectively. Notably, while only 9 patients (12%) were diagnosed with HFpEF based on clinical evaluation, 47 patients (60%) were diagnosed by IHA. IHA in patients undergoing AF ablation suggests a high prevalence of clinically undiagnosed HFpEF through a novel methodology measuring resting and post-tachycardia pacing LAP.

Cardiogenic Shock Due to Serotonin Syndrome Induced Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy causes transient left ventricular dysfunction. It typically has a favorable prognosis but rarely leads to complications such as cardiogenic shock. Also known as stress-induced cardiomyopathy, it is precipitated by emotional or physical stress. Serotonin syndrome can cause severe stress due to excessive serotonergic activity in the central nervous system. We report a case of cardiogenic shock precipitated by serotonin syndrome-induced takotsubo cardiomyopathy. Only one other documented case has exhibited cardiogenic shock in this setting.

Outcomes of Ventricular Tachycardia Catheter Ablation in Patients Who Underwent Cardiac Defibrillator Implantation Nationwide Readmission Database Analysis.

The timing of when to perform ventricular tachycardia (VT) ablation while receiving an implantable cardioverter defibrillator (ICD) during the same hospitalization has not been explored. This study aimed to investigate the use and outcomes of VT catheter ablation in patients with sustained VT receiving ICD in the same hospital stay. The Nationwide Readmission Database 2016 to 2019 was queried for all hospitalizations with a primary diagnosis of VT with subsequent ICD during the same admission. Hospitalizations were later stratified according to whether a VT ablation was performed. All catheter ablation of VT were performed before ICD implantation. The outcomes of interest were in-hospital mortality and 90-day readmission. A total of 29,385 VT hospitalizations were included. VT ablation was performed with subsequent ICD placement in 2,255 (7.6%), whereas 27,130 (92.3%) received an ICD only. No differences were found regarding in-hospital mortality (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.35 to 1.9, p = 0.67) and all-cause 90-day readmission rate (aOR 1.1, 95% CI 0.95 to 1.3, p = 0.16). An increase in readmission because of recurrent VT was noted in the VT ablation group (aOR 1.53, 8% vs 5% CI 1.2 to 1.9, p <0.01); the VT ablation group encompassed a higher number of patients with heart failure with reduced ejection fraction (p <0.01), cardiogenic shock (p <0.01), and mechanical circulatory support use (p <0.01). In conclusion, the use of VT ablation in patients admitted with sustained VT is low and reserved for higher risk patients with significant co-morbidities. Despite the higher risk profile of VT ablation cohort, no differences were found in the short-term mortality and readmission rate between the groups.

Low voltage area guided substrate modification in nonparoxysmal atrial fibrillation: A systematic review and meta-analysis.

BACKGROUND: Low voltage areas (LVAs) on left atrial (LA) bipolar voltage mapping correlate with areas of fibrosis. LVAs guided substrate modification was hypothesized to improve the success rate of atrial fibrillation (AF) ablation particularly in nonparoxysmal AF population. However, randomized controlled trials (RCTs) and observational studies yielded mixed results. METHODS: The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to August 2022. Relevant studies comparing LVA guided substrate modification (LVA ablation) versus conventional AF ablation (non LVA ablation) in patients with nonparoxysmal AF were identified and a meta-analysis was performed (Graphical Abstract image). The efficacy endpoints of interest were recurrence of AF and the need for repeat ablation at 1-year. The safety endpoint of interest was adverse events for both groups. Procedure related endpoints included total procedure time and fluoroscopy time. RESULTS: A total of 11 studies with 1597 patients were included. A significant reduction in AF recurrence at 1-year was observed in LVA ablation versus non LVA ablation group (risk ratio [RR] 0.63 (27% vs. 36%),95% confidence interval [CI] 0.48-0.62, p < .001]. Also, redo ablation was significantly lower in LVA ablation group (RR 0.52[18% vs. 26.7%], 95% CI 0.38-0.69, p < .00133). No difference was found in the overall adverse event (RR 0.7 [4.3% vs. 5.4%], 95% CI 0.36-1.35, p = .29). CONCLUSION: LVA guided substrate modification provides significant reduction in recurrence of all atrial arrhythmias at 1-year compared with non LVA approaches in persistent and longstanding persistent AF population without increase in adverse events.

Role of Adjunctive Cryoballoon Left Atrial Posterior Wall Isolation in Non-paroxysmal Atrial Fibrillation: A Meta-analysis.

Progressive remodeling of left atrial posterior wall (LAPW) plays an important role in the pathology of persistent/ long-standing persistent atrial fibrillation. The role of pulmonary veins isolation (PVI) and adjunctive LAPW isolation using cryothermal energy in non-paroxysmal atrial fibrillation is yet to be established. The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to April 2022. Relevant randomized trials and observational studies comparing de novo cryoballoon PVI only versus PVI+LAPWI in patients with non paroxysmal AF were identified and a meta-analysis was performed using the random effect model. The efficacy endpoints of interest were recurrence of AF, recurrence of non-AF and all atrial arrhythmias at 1-year post ablation. The safety endpoint of interest was all adverse events between the two groups. A total of 6 studies (3 prospective trials and 3 observational studies) with 1037 patients were included. A significant reduction in AF recurrence at 1-year was observed in PVI+LAPWI group (OR 0.36 (17% vs 39%), 95% CI 0.26-0.49, P < 0.001). Also, lower incidence of overall atrial arrhythmias was found in PVI+LAPWI (OR 0.37 (23% vs 47%),95% CI 0.28-0.49, P < 0.001). For safety endpoints, the overall adverse event rate was low without the significant difference between the groups (OR: 0.86, (3% vs 3.5%) 95% CI 0.36-2.07, P = 0.74). Cryoballoon LAPWI plus PVI provides a significant reduction in recurrence of all atrial arrhythmias and AF at 1-year compared with PVI alone in non paroxysmal AF population without increase in adverse events rate.

Impact of Chronic Obstructive Pulmonary Disease on Atrial Fibrillation Ablation Outcomes According to the National Readmission Database.

Chronic obstructive pulmonary disease (COPD) is a risk factor for the development of atrial fibrillation (AF). There is a paucity of contemporary data studying the association between COPD and outcomes of AF ablation. The objective of this study was to investigate the impact of COPD on AF ablation outcomes using a large nationwide database. This study was a retrospective analysis of the National Readmission Database for the years 2016-2018 and included patients admitted with a diagnosis of AF who underwent catheter ablation. Admissions were stratified according to COPD diagnosis using International Classification of Diseases, 10th Revision, Clinical Modification codes. Multivariate, linear, Cox, and logistic regressions were performed to study the impact of COPD on AF ablation. A total of 18,224 admissions (mean age, 68 years; standard deviation, 10 years) were included, of whom 3,494 (19%) had a diagnosis of COPD. The COPD group was older (72 ± 8 vs. 67 ± 11 years, P < .001) and more likely to have congestive heart failure (73% vs. 44%, P < .001) and renal failure (31% vs. 17%, P < .001). COPD was associated with an increased risk of readmission (adjusted hazard ratio [aHR], 1.40; 95% confidence interval [CI], 1.26-1.56; P < .001) and all-cause in-hospital mortality (adjusted odds ratio, 2.83; 95% CI, 1.74-4.60; P < .001). However, COPD was not associated with an increased risk of readmission due to recurrent AF (aHR, 0.97; 95% CI, 0.75-1.27; P = .844) or the need for re-ablation (aHR, 0.85; 95% CI, 0.44-1.65; P = .639), respectively. In conclusion, COPD was not associated with an increased risk of recurrent AF after ablation despite higher periprocedural risks. The present study contributes to a better understanding of this high-risk subgroup of patients undergoing AF ablation.

Steerable versus nonsteerable sheath technology in atrial fibrillation ablation: A systematic review and meta-analysis.

Introduction: Catheter placement and stability are well-known challenges in atrial fibrillation (AF) ablation. As a result, steerable sheaths (SS) were developed to improve catheter stabilization and maintain proper catheter-tissue contact. The purpose of this systematic review and meta-analysis is to see if employing a SS influences procedure outcome. Method: We performed a comprehensive literature search for studies that evaluated the efficacy and safety of SS compared to nonsteerable sheaths (NSS) in AF ablation. The primary outcome was the rate of atrial arrhythmia (AA) freedom by the time of the last follow-up. The secondary outcomes were the procedure-related complications and procedural characteristics. Risk ratio (RR) or the mean difference (MD) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. Results: A total of 10 studies, including 967 AF patients (mean age: 59.2 ± 11.1 years, 516 patients managed with SS vs. 454 with NSS), were included. SS group showed a higher rate of freedom of AA compared to NSS (RR: 1.19; 95% CI 1.09-1.29; p < .001). Both techniques had similar rate for procedural-related complication (RR: 1.09, 95% CI 0.50-2.39; p = .83). The SS strategy had a shorter procedure time (MD -10.6 [min], 95% CI -20.97, -0.20; p = .05) but comparable fluoroscopic and radiofrequency application times to the NSS group. Conclusions: The SS for AF catheter ablation not only reduced the total procedure time but also significantly increased the rate of successful ablation while maintaining a similar safety profile when compared to the traditional NSS.

Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: A systematic review and meta-analysis.

INTRODUCTION: Endocardial catheter ablation (ECA) for atrial fibrillation (AF) has limited efficacy. Hybrid convergent procedure (HCP) with both epicardial and endocardial ablation is a novel strategy for AF treatment. In this meta-analysis, we aimed to evaluate the efficacy and safety of HCP in AF ablation. METHOD: We performed a comprehensive literature search for studies that evaluated the efficacy and safety of HCP compared with ECA for AF. The primary outcome was freedom of atrial arrhythmia (AA). The secondary outcome was the periprocedural complication rate. Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated using the random effects model. RESULTS: A total of eight studies, including 797 AF patients (mean age: 60.7 ± 9.8 years, 366 patients with HCP vs. 431 patients with ECA alone), were included. HCP showed a higher rate of freedom of AA compared with ECA (RR: 1.48, 95% CI: 1.13-1.94, p = .004). However, HCP was associated with higher rates of periprocedural complications (RR: 3.64, 95% CI: 2.06-6.43; p = .00001). Moreover, the HCP had a longer procedure time and postprocedural hospital stay. CONCLUSIONS: Although hybrid ablation was associated with a higher success rate, this should be judged for increased periprocedural adverse events and extended hospital stay. Prospective large-scale randomized trials are needed to validate these results.

Adjunctive Vein of Marshall Ethanol Infusion During Atrial Fibrillation Ablation: A Systematic Review and Meta-Analysis.

INTRODUCTION: Catheter ablation (CA) for atrial fibrillation (AF) can be associated with limited efficacy. Due to its autonomic innervation, the vein of Marshall (VOM) is an attractive target during AF ablation. In this meta-analysis, we aimed to evaluate the efficacy and safety of adjunctive ethanol infusion of VOM (VOM-EI) in AF ablation. METHODS: We performed a comprehensive literature search for studies that evaluated the efficacy and safety of VOM-EI in AF ablation compared to AF catheter ablation alone. The primary outcome of interest was late (≥3 months) AF or atrial tachycardia (AT) recurrence. The secondary outcomes included acute mitral isthmus bidirectional block (MIBB) and procedural complications (pericardial effusion, stroke, or atrio-esophageal fistula). Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. RESULTS: A total of four studies, including 804 AF patients (68.2% with persistent AF, the mean age of 63.5±9.9 years, 401 patients underwent VOM-EI plus CA vs. 403 patients who had CA alone), were included in the final analysis. VOM-EI group was associated with a lower risk of late AF/AT recurrence (RR:0.63; 95% CI:0.46-0.87; P = 0.005), and increased probability to achieve acute MIBB (RR:1.39; 95% CI:1.08-1.79; P = 0.009) without an increase in procedural complications (RR:1.05; 95% CI:0.57-1.94; P = 0.87). CONCLUSIONS: Our meta-analysis demonstrated that adjunctive VOM-EI strategy is more effective than conventional catheter ablation with similar safety profiles.

Serum versus Imaging Biomarkers in Friedreich Ataxia to Indicate Left Ventricular Remodeling and Outcomes.

Patients with Friedreich ataxia typically die of cardiomyopathy, marked by myocardial fibrosis and abnormal left ventricular (LV) geometry. We measured procollagen I carboxyterminal propeptide (PICP), a serum biomarker of collagen production, and characterized genotypes, phenotypes, and outcomes in these patients. Twenty-nine patients with Friedreich ataxia (mean age, 34.2 ± 2.2 yr) and 29 healthy subjects (mean age, 32.5 ± 1.1 yr) underwent serum PICP measurements. Patients underwent cardiac magnetic resonance imaging and outcome evaluations at baseline and 12 months. Baseline PICP values were significantly higher in the patients than in the control group (1,048 ± 77 vs 614 ± 23 ng/mL; P <0.001); severity of genetic abnormality did not indicate severity of PICP elevation. Higher PICP levels corresponded to greater LV concentric remodeling only at baseline (r=0.37, P <0.05). Higher baseline PICP strongly indicated subsequent increases in LV end-diastolic volume (r=0.52, P=0.02). The PICP levels did not distinguish between 14 patients with evident myocardial fibrosis identified through positive late gadolinium enhancement and 15 who had no enhancement (1,067 ± 125 vs 1,030 ± 98 ng/mL; P=0.82). At 12 months, cardiac events had occurred in 3 of 14 fibrosis-positive and none of 15 fibrosis-negative patients (P=0.1); their baseline PICP levels were similar. We conclude that PICP, a serum marker of collagen synthesis, is elevated in Friedreich ataxia and indicates baseline abnormal LV geometry and subsequent dilation. Cardiac magnetic resonance and PICP warrant consideration as complementary biomarkers in therapeutic trials of Friedreich ataxia cardiomyopathy.

Comparative efficacy of different modalities for treatment of right heart thrombi in transit: a pooled analysis.

The objective was to compare the efficacy of treatment options for right heart thrombi (RHT) in transit. All published reports between 1992 and 2013 were identified and pooled. We analyzed 328 patients with RHT and pulmonary embolism (PE). The treatments administered were none in 11 patients (3.4%), anticoagulation (AC) with heparin in 70 patients (21.3%), thrombolytics in 122 patients (37.2%), catheter-related treatments in five patients (1.5%) and surgical embolectomy in 120 patients (36.6%). The overall short-term mortality for the entire cohort was 23.2%. The mortality rate associated with no therapy was highest at 90.9%. The mortality associated with AC alone was significantly higher than surgical embolectomy or thrombolysis (37.1% vs 18.3% vs 13.7%, respectively). In univariate analysis, any therapy was better than no therapy with a favorable odds of 16.92 (95% CI 2.05-139.87) for AC, 61.76 (95% CI 7.42-513.81) for thrombolysis and 44.54 (95% CI 5.42-366.32) for surgical embolectomy. In multivariate analysis with age and hemodynamic status entered as covariates, thrombolytic therapy was better than AC with favorable odds of 4.83 (95% CI 1.52-15.36). Similarly, there was a trend in favor of surgical embolectomy with an odds of 2.61 (95% CI 0.90-7.58). The estimated probability of survival in hemodynamically unstable patients with AC, surgical embolectomy and thrombolysis was 47.7%, 70.45% and 81.5%, respectively. There was no significantly increased risk of complications with thrombolytic therapy. In conclusion, left untreated, patients with RHT and PE have very high mortality. Aggressive management with thrombolysis or surgical thrombectomy may be more effective than AC alone in the management of these patients.

Late stroke: comparison of percutaneous coronary intervention versus coronary artery bypass grafting in patients with multivessel disease and unprotected left main disease: a meta-analysis and review of literature.

BACKGROUND AND PURPOSE: Studies have suggested that the early excess risk of stroke in coronary artery bypass grafting (CABG) may be compensated for by a slow but progressive catch-up phenomenon in patients undergoing percutaneous coronary intervention (PCI). We therefore undertook this analysis to compare the temporal stroke risk between PCI and CABG in patients with unprotected left main stenosis and multivessel coronary artery disease. METHODS: Studies of PCI versus CABG for unprotected left main stenosis and multivessel disease published between January 1994 (stent era) and July 2013 were identified using an electronic search and reviewed using meta-analytic techniques. RESULTS: We selected 57 reports for the meta-analysis by applying the inclusion and exclusion criteria. The analysis was performed on 80,314 patient records. There was a significantly lower risk of cumulative stroke in patients undergoing PCI with stenting at 1 year (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.42-0.71), 2 years (OR, 0.78; 95% CI, 0.66-0.92), 3 years (OR, 0.79; 95% CI, 0.67-0.92), 4 years (OR, 0.74; 95% CI, 0.56-0.97), and 5 years (OR, 0.79; 95% CI, 0.69-0.91). There was no significant difference in the incidence of stroke because of the small sample size (OR, 0.71; 95% CI, 0.46-1.08) at >5 years between PCI and CABG. Similar results were observed on subgroup analysis (multi-vessel coronary artery disease, unprotected left main, diabetics, and randomized trials) and for stroke within 30 days. Late stroke (stroke>30 days) was similar between the 2 groups. CONCLUSIONS: There is a significantly lower risk of stroke within 30 days and cumulative stroke with PCI as compared with CABG up to year 5. There is no late catch up of stroke in the PCI arm. The risk of stroke should be weighed in deciding between revascularization strategies.

Myocardial infarction in sickle cell disease: use of translational imaging to diagnose an under-recognized problem.

Sickle cell disease (SCD) is an inherited disorder in which microvascular occlusion causes complications across multiple organ systems. The precise incidence of myocardial ischemia and infarction (MI), potentially under-recognized microvascular disease-related complications, remains unknown. The absence of typical atherosclerotic lesions seen in other patients with MI suggests a microvascular mechanism of myocardial injury. Cardiac magnetic resonance (CMR) can demonstrate microvascular disease, making it an appealing modality to assess symptomatic SCD patients. We demonstrate in several dramatic instances how CMR is uniquely able to depict cardiac microvascular obstruction in patients with SCD and chest pain, without which the possibility of myocardial injury would almost certainly be otherwise neglected. Much remains unknown regarding ischemic heart disease in patients with SCD including prevalence, detection, and management. Further work to define evaluation and management algorithms for chest pain in SCD and to develop risk assessment tools may reduce sudden cardiac death in this population.

Emergency department presentation of heart transplant recipients with acute heart failure.

With an increasing number of heart transplants being performed around the world and the improvement in survival rates, more transplant recipients may present to the emergency department with comorbidities unique to the transplanted heart and related immunosuppression, including heart failure. This article is aimed at enabling the emergency department physician identify and better manage this unique group of patients for whom time is life.