Location, Location, Location: A Pilot Study to Compare Electrical with Echocardiographic-Guided Targeting of Left Ventricular Lead Placement in Cardiac Resynchronisation Therapy.

Introduction: Cardiac resynchronisation therapy is ineffective in 30-40% of patients with heart failure with reduced ejection fraction. Targeting non-scarred myocardium by selecting the site of latest mechanical activation using echocardiography has been suggested to improve outcomes but at the cost of increased resource utilisation. The interval between the beginning of the QRS complex and the local LV lead electrogram (QLV) might represent an alternative electrical marker. Aims: To determine whether the site of latest myocardial electrical and mechanical activation are concordant. Methods: This was a single-centre, prospective pilot study, enrolling patients between March 2019 and June 2021. Patients underwent speckle-tracking echocardiography (STE) prior to CRT implantation. Intra-procedural QLV measurement and R-wave amplitude were performed in a blinded fashion at all accessible coronary sinus branches. Pearson's correlation coefficient and Cohen's Kappa coefficient were utilised for the comparison of electrical and echocardiographic parameters. Results: A total of 20 subjects had complete data sets. In 15, there was a concordance at the optimal site between the electrically targeted region and the mechanically targeted region; in four, the regions were adjacent (within one segment). There was discordance (≥2 segments away) in only one case between the two methods of targeting. There was a statistically significant increase in procedure time and fluoroscopy duration using the intraprocedural QLV strategy. There was no statistical correlation between the quantitative electrical and echocardiographic data. Conclusions: A QLV-guided approach to targeting LV lead placement appears to be a potential alternative to the established echocardiographic-guided technique. However, it is associated with prolonged fluoroscopy and overall procedure time.

The impact of extracorporeal membrane oxygenation on mortality in patients with cardiogenic shock post-acute myocardial infarction: a systematic review and meta-analysis.

Aims: Cardiogenic shock remains the leading cause of death in patients hospitalized with acute myocardial infarction. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in the treatment of infarct-related cardiogenic shock. However, there is limited evidence regarding its beneficial impact on mortality. The aim of this study was to systematically review studies reporting the impact of VA-ECMO on mortality in patients with acute myocardial infarction complicated by cardiogenic shock. Methods and results: A comprehensive search of medical databases (Cochrane Register and PubMed) was conducted. Studies that reported mortality outcomes in patients treated with VA-ECMO for infarct-related cardiogenic shock were included. The database search yielded 1194 results, of which 11 studies were included in the systematic review. Four of these studies, with a total of 586 patients, were randomized controlled trials and were included in the meta-analysis. This demonstrated that there was no significant difference in 30-day all-cause mortality with the use of VA-ECMO compared with standard medical therapy [odds ratio (OR) 0.91; 95% confidence interval (CI) 0.65-1.27]. Meta-analysis of two studies showed that VA-ECMO was associated with a significant reduction in 12-month all-cause mortality (OR 0.31; 95% CI 0.11-0.86). Qualitative synthesis of the observational studies showed that age, serum creatinine, serum lactate, and successful revascularization are independent predictors of mortality. Conclusion: Veno-arterial extracorporeal membrane oxygenation does not improve 30-day all-cause mortality in patients with cardiogenic shock following acute myocardial infarction; however, there may be significant reduction in all-cause mortality at 12 months. Further studies are needed to delineate the potential benefit of VA-ECMO in long-term outcomes. Registration: The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42023461740).

Identifying the optimal time period for detection of atrial fibrillation after ischaemic stroke and TIA: An updated systematic review and meta-analysis of randomized control trials.

BACKGROUND: Atrial fibrillation (AF) is a major risk factor for ischaemic stroke (IS) and transient ischaemic attack (TIA). The timely detection of first-diagnosed or "new" AF (nAF) would prompt a switch from antiplatelets to anticoagulation to reduce the risk of stroke recurrence; however, the optimal timing and duration of rhythm monitoring to detect nAF remains unclear. AIMS: We searched MEDLINE, PubMed, Cochrane database, and Google Scholar to undertake a systematic review and meta-analysis of randomized controlled trials (RCT) between 2012 and 2023 investigating nAF detection after IS and TIA. Outcome measures were overall detection of nAF (control; (usual care) compared to intervention; (continuous cardiac monitoring >72 h)) and the time period in which nAF detection is highest (0-14 days, 15-90 days, 91-180 days, or 181-365 days). A random-effects model with generic inverse variance weights was used to pool the most adjusted effect measure from each trial. SUMMARY OF REVIEW: A total of eight RCTs investigated rhythm monitoring after IS, totaling 5820 patients. The meta-analysis of the studies suggested that continuous cardiac monitoring was associated with a pooled odds ratio of 3.81 (95% CI 2.14 to 6.77), compared to usual care (control), for nAF detection. In the time period analysis, the odds ratio for nAF detection at 0-14 days, 15-90 days, 91-180 days, 181-365 days were 1.79 (1.24-2.58); 2.01 (0.63-6.37); 0.98 (0.16-5.90); and 2.92 (1.30-6.56), respectively. CONCLUSION: There is an almost fourfold increase in nAF detection with continuous cardiac monitoring, compared to usual care. The results also demonstrate two statistically significant time periods in nAF detection; at 0-14 days and 6-12 months following monitoring commencement. These data support the utilization of different monitoring methods to cover both time periods and a minimum of 1 year of monitoring to maximize nAF detection in patients after IS and TIA.

Exploring the Temporal Patterns of Right Ventricular Pacing Burden.

Elevated right ventricular pacing (RVP) burdens are associated with the development of pacing-induced cardiomyopathy. This association is alluded to in the recent European and American pacing guidelines where anticipated pacing burden forms part of the indications for conduction system pacing. Understanding the temporal pattern of RVP burden is important with respect to anticipating future burden and ensuring that the most appropriate pacing modality is selected for patients. To the best of our knowledge, this is the first study to assess how RVP burden changes over time in different pacing indications. A retrospective, single-center, observational study was performed. RVP burdens from pacing checks were extracted and plotted against 6-month time "bins." Graphical plots of RVP burdens for different pacing indications were produced. There was no significant change in the RVP burden across time, independent of the initial pacing indication. Individuals with sinus node disease (SND) and a P-R interval of >250 ms had increased RVP burden. Other than patients with SND and a P-R interval of <250 ms, individuals had pacing burdens higher than those proposed in both the European and American pacing guidelines for conduction system pacing.

Atrial fibrillation in embolic stroke of undetermined source: role of advanced imaging of left atrial function.

AIMS: Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications, and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of left atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS. METHODS AND RESULTS: We conducted a single-centre retrospective case-control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analysed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping. Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a transient ischaemic attack as adjudicated by a senior stroke physician. Atrial fibrillation of any duration was detected in 47.1%. The mean follow-up was 710 days. Following lasso regression with backwards elimination, we combined increasing lateral PA (the time interval from the beginning of the P wave on the surface electrocardiogram to the beginning of the A' wave on pulsed wave tissue Doppler of the lateral mitral annulus) [odds ratio (OR) 1.011], increasing Age (OR 1.035), higher Diastolic blood pressure (OR 1.027), and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula. Model discrimination was good [area under the curve (AUC) 0.72]. The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73. CONCLUSION: The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk stratification tool for decision-making regarding the screening strategy for AF in stroke.

One-third of patients with a type of stroke called embolic stroke of undetermined source (ESUS) also have a heart condition called atrial fibrillation (AF), which increases their risk of having another stroke. However, we do not know why some patients with ESUS develop AF. To figure this out, we studied 323 patients with ESUS and used a special device to monitor their heart rhythm continuously for up to 3 years, an implantable loop recorder. We also looked at their medical history, performed a heart ultrasound, and identified some factors that increase the risk of identifying AF in the future. Factors associated with future AF include older age, higher diastolic blood pressure, and problems with the co-ordination and function of the upper left chamber of the heart called the left atrium.Based on these factors, we created a new scoring system that can identify patients who are at higher risk of developing AF better than the current scoring systems, the PADS score. This can potentially help doctors provide more targeted and effective treatment to these patients, ultimately aiming to reduce their risk of having another stroke.

Electrocardiographic Predictors of Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most common pathological arrhythmia, and its complications lead to significant morbidity and mortality. However, patients with AF can often go undetected, especially if they are asymptomatic or have a low burden of paroxysms. Identification of those at high risk of AF development may help refine screening and management strategies. METHODS: PubMed and Embase databases were systematically searched for studies looking at electrocardiographic predictors of AF from inception to August 2021. RESULTS: A total of 115 studies were reported which examined a combination of atrial and ventricular parameters that could be electrocardiographic predictors of AF. Atrial predictors include conduction parameters, such as the PR interval, p-wave index and dispersion, and partial interatrial or advanced interatrial block, or morphological parameters, such as p-wave axis, amplitude and terminal force. Ventricular predictors include abnormalities in QRS amplitude, morphology or duration, QT interval duration, r-wave progression and ST segment, i.e., t-wave abnormalities. CONCLUSIONS: There has been significant interest in electrocardiographic prediction of AF, especially in populations at high risk of atrial AF, such as those with an embolic stroke of undetermined source. This review highlights the breadth of possible predictive parameters, and possible pathological bases for the predictive role of each parameter are proposed.

Risk Factors Associated With Post-COVID-19 Condition: A Systematic Review and Meta-analysis.

Importance: Post-COVID-19 condition (PCC) is a complex heterogeneous disorder that has affected the lives of millions of people globally. Identification of potential risk factors to better understand who is at risk of developing PCC is important because it would allow for early and appropriate clinical support. Objective: To evaluate the demographic characteristics and comorbidities that have been found to be associated with an increased risk of developing PCC. Data sources: Medline and Embase databases were systematically searched from inception to December 5, 2022. Study Selection: The meta-analysis included all published studies that investigated the risk factors and/or predictors of PCC in adult (≥18 years) patients. Data Extraction and Synthesis: Odds ratios (ORs) for each risk factor were pooled from the selected studies. For each potential risk factor, the random-effects model was used to compare the risk of developing PCC between individuals with and without the risk factor. Data analyses were performed from December 5, 2022, to February 10, 2023. Main Outcomes and Measures: The risk factors for PCC included patient age; sex; body mass index, calculated as weight in kilograms divided by height in meters squared; smoking status; comorbidities, including anxiety and/or depression, asthma, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, immunosuppression, and ischemic heart disease; previous hospitalization or ICU (intensive care unit) admission with COVID-19; and previous vaccination against COVID-19. Results: The initial search yielded 5334 records of which 255 articles underwent full-text evaluation, which identified 41 articles and a total of 860 783 patients that were included. The findings of the meta-analysis showed that female sex (OR, 1.56; 95% CI, 1.41-1.73), age (OR, 1.21; 95% CI, 1.11-1.33), high BMI (OR, 1.15; 95% CI, 1.08-1.23), and smoking (OR, 1.10; 95% CI, 1.07-1.13) were associated with an increased risk of developing PCC. In addition, the presence of comorbidities and previous hospitalization or ICU admission were found to be associated with high risk of PCC (OR, 2.48; 95% CI, 1.97-3.13 and OR, 2.37; 95% CI, 2.18-2.56, respectively). Patients who had been vaccinated against COVID-19 with 2 doses had a significantly lower risk of developing PCC compared with patients who were not vaccinated (OR, 0.57; 95% CI, 0.43-0.76). Conclusions and Relevance: This systematic review and meta-analysis demonstrated that certain demographic characteristics (eg, age and sex), comorbidities, and severe COVID-19 were associated with an increased risk of PCC, whereas vaccination had a protective role against developing PCC sequelae. These findings may enable a better understanding of who may develop PCC and provide additional evidence for the benefits of vaccination. Trial Registration: PROSPERO Identifier: CRD42022381002.

The predictive value of abnormal P-wave axis for the detection of incident atrial fibrillation: A systematic review with meta-analysis.

INTRODUCTION: There is growing interest in the prediction of incident atrial fibrillation (AF). The 12-lead electrocardiogram (ECG) has been a particularly rich target for possible prediction strategies. PURPOSE: The P-wave axis is an ECG parameter that reflects the dominant vector of atrial depolarisation and is usually 0° -75°. There is a large body of literature suggesting that AF reflects structural and conduction abnormalities of the atria, and thus the P-wave axis may represent a sensitive parameter to detect such changes. METHODS: A systematic review and meta-analysis of published literature associating abnormal P-wave axis and the development of incident AF was performed. Electronic databases were systematically searched from inception to October 2021. A random-effects model with generic inverse variance weights was utilised to pool the most adjusted effect measure from each paper. A funnel plot was used to assess publication bias. RESULTS: After excluding duplicate studies, 568 studies were screened. A total of eleven studies were identified that associated an abnormal P-wave axis with the subsequent detection of AF. The eight studies that considered abnormal P-wave axis as being <0° or >75° were pooled for meta-analysis. In the pooled studies a total of 78,222 patients were included with 5656 cases of incident atrial fibrillation identified. The meta-analysis of the studies suggested that an abnormal P-wave axis was associated with a pooled risk ratio of 2.12 (95% CI 1.49 to 3.01) for the detection of incident atrial fibrillation. CONCLUSION: This comprehensive systematic review and meta-analysis, indicates the positive association of abnormal P wave axis and future detection of AF. Utilisation of abnormal P-wave axis, alongside other parameters, may allow clinicians to better risk-stratify individuals at increased risk of AF, and thus identify those who may benefit most from prolonged cardiac monitoring or targeted anticoagulation.

The Role of SGLT2 Inhibitors in Heart Failure: A Systematic Review and Meta-Analysis.

AIMS: Recent randomised controlled trials (RCTs) have shown a significant prognostic benefit of sodium-glucose cotransporter 2 (SGLT2) inhibitors in the cardiovascular (CV) profile of patients with diabetes. This systematic review and meta-analysis aim to provide a concise evaluation of all the available evidence for the use of these agents in patients with heart failure (HF) regardless of their baseline diabetes status. METHODS AND RESULTS: PubMed, Web of Science, and Cochrane library databases were systematically searched from inception until November 20th 2020. Eight studies consisting of 13,275 patients were included in the meta-analysis. For the total population, SGLT2 inhibitors reduced the risk of all-cause mortality (HR: 0.83; 95% CI: 0.75-0.91; I 2 0%), hospitalisation for HF (HR: 0.68; 95% CI: 0.61-0.75; I 2: 0%), CV death (HR: 0.82; 95% CI: 0.74-0.92; I 2: 0%), and hospitalisation for HF or CV death (HR: 0.72; 95% CI: 0.66-0.78; I 2: 0%). Subgroup analyses of the total population according to the diabetes status showed that SGLT2 inhibitors significantly reduced the risk of hospitalisation for HF (HR: 0.68; 95% CI: 0.61, 0.75; I 2: 0%), as well as the risk of hospitalisation for HF or CV death (HR: 0.72; 95% CI: 0.66, 078; I 2: 0%) and CV death (HR: 0.82; 95% CI: 0.74, 0.91; I 2: 0%). CONCLUSIONS: The results of this meta-analysis confirm the growing evidence in the literature of the favourable profile of SGLT2 inhibitors in cardiovascular outcomes and mortality in patients with heart failure regardless of the baseline diabetes status. This systematic review has been registered with PROSPERO (CRD42021224777).

Safety, Feasibility and Economic Impact of Same-Day Discharge Following Atrial Fibrillation Ablation.

BACKGROUND: The widely accepted model for atrial fibrillation (AF) ablation involves overnight hospital stay post-procedure. Day case AF ablation has been carried out at Royal Papworth Hospital (RPH) since early 2017. We evaluated the feasibility, safety and efficacy of day case AF ablation at RPH. METHOD: This was a retrospective, single-centre study of consecutive AF ablations at RPH between March 2017 and April 2018. Demographic, procedural and outcome data were analysed. RESULTS: Over the study period, 452 AF ablations were performed in 448 patients. One hundred and twenty-nine (129) (28.5%) were planned day cases; of these 128 were discharged on the same day. Two hundred and eighty-three (283) procedures resulted in at least one night admission. There was no significant difference in age or sex between the groups. Of note, day case procedures were significantly shorter, more likely to commence in the morning and less likely to require general anaesthetic than overnight stays. Patients listed as day cases also had less far to travel. The overall complication rate was 3.3%, with no significant difference between groups. Follow-up data was available for 448 cases (99.1%). Procedural success rates were comparable between groups. The overall cost saving attributable to providing AF ablation as a day case was £67,200 over the 13-month period. CONCLUSIONS: Day case AF ablation is efficacious and associated with a low event rate, even without strict standardisation of patient selection or procedural protocols, in a high-volume centre. Substantial reduction in health care expenditure can be achieved with more widespread implementation of outpatient AF ablation.

A Prospective Comparison of Short-Term Outcomes of Subpectoral and Prepectoral Strattice-Based Immediate Breast Reconstruction.

BACKGROUND: Prepectoral acellular dermal matrix-assisted immediate implant-based breast reconstruction is gaining popularity, involving complete implant coverage with acellular dermal matrix. The authors aimed to compare pain, patient-reported outcome measures (including implant rippling), and safety of prepectoral and subpectoral Strattice-assisted implant-based breast reconstruction. METHODS: Consecutive patients were recruited prospectively, having either therapeutic or risk-reducing mastectomy. Patients scored their pain three times per day for the first 7 postoperative days on a Likert scale, and completed the BREAST-Q reconstruction module 3 months postoperatively. Clinical records and the authors' prospective complications database were used to compare the early morbidity of the two procedures. RESULTS: Forty patients were recruited into the study. There was no significant difference in pain scores between the prepectoral group (mean, 1.5) and the subpectoral cohort (mean, 1.5; p = 0.45) during the first 7 days. Thirty-one BREAST-Q questionnaires were returned; mean Q scores were similar for both prepectoral and subpectoral (72 and 71, respectively; p = 0.81) groups. Patients reported significantly more visible implant rippling in the prepectoral group than in the subpectoral group (seven of 13 versus two of 17; p = 0.02). There was no significant difference in length of stay or early morbidity, with implant loss being 4.7 percent in the prepectoral group compared with 0 percent in the subpectoral group. CONCLUSIONS: Early postoperative pain and quality of life at 3 months are equivalent between groups. Early experience of prepectoral implant placement with complete acellular dermal matrix coverage suggests this is safe and provides good quality of life for patients. Further studies are required to compare short- and long-term outcomes with the current standard forms of reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.