Bachmann's Bundle's Unique Physiology: Reviewing How it Made an Atypical Flutter Even More Atypical.

A 69-year-old man with a history of previous ablation and cardiac surgery was found on cardiac electrophysiology study to have a macro-re-entrant left atrial flutter initially misdiagnosed as a micro-re-entrant right atrial tachycardia resulting from the unique conduction properties of Bachmann's bundle. (Level of Difficulty: Advanced.).

Safety and Feasibility of Performing Pericardiocentesis on Patients with Significant Pulmonary Hypertension.

BACKGROUND/PURPOSE: Pericardial effusion (PE) is a complication of pulmonary hypertension (PHT) and, specifically, pulmonary arterial hypertension (PAH), that confers a worse prognosis. The safety of performing pericardiocentesis in patients with PHT has not been established. We aimed to assess the safety and feasibility of performing pericardiocentesis in patients with significant PHT. METHODS/MATERIALS: We performed a retrospective analysis from August 2013 to December 2018 at our tertiary-care center of patients who underwent a pericardiocentesis procedure. Patients, procedure, echocardiographic findings, any major intraprocedural complications, and post-procedural related complications up to 30 days were recorded. Specifically, we studied patients with significant PHT. RESULTS: The cohort included 170 patients, with an average age of 62.6 years and an even distribution of gender and co-morbidities. The etiology for the PE varied. Major complications were rare (1.7%) and only 10 patients (5.9%) required re-intervention for reaccumulation of fluid. There were 27 patients (15.9%) with significant PHT, 5 with World Health Organization (WHO) Group I PAH (2.94%). In the entire cohort, there were only 3 major complications (1.7%), none among PHT patients. CONCLUSIONS: Pericardiocentesis is a safe procedure, including in patients with significant PHT, including those with WHO Group I PAH. We advocate the use of invasive hemodynamic monitoring in patients with significant PHT. SUMMARY: Pericardiocentesis tends to be a safe procedure. However, the safety of performing pericardiocentesis in patients with significant pulmonary hypertension has not been well established. We aimed to assess the safety and feasibility of performing pericardiocentesis, and specifically in patients with significant PHT out our tertiary center by performing a retrospective analysis.

Eliminating Inappropriate Telemetry Monitoring: An Evidence-Based Implementation Guide.

In-hospital continuous electrocardiographic monitoring, commonly referred to as telemetry, has allowed for rapid recognition of life-threatening conditions, including complex arrhythmias and myocardial ischemia. However, inappropriate use can lead to unnecessary downstream testing from "false alarms," which in turn affects clinician efficiency and increases health care costs without benefiting patients. For these reasons, the Society of Hospital Medicine's Choosing Wisely campaign recommended use of a protocol-driven discontinuation of telemetry. The American Heart Association (AHA) developed a set of Practice Standards for the appropriate use of telemetry monitoring in 2004, which they updated in 2017. Unfortunately, the AHA Practice Standards have not been widely adopted-with as many as 43% of monitored patients lacking a recommended indication for monitoring. Thus, we created an overview discussing the safety and efficacy of incorporating the AHA Practice Standards and a review of studies highlighting their successful incorporation within patient care workflow. We conclude by outlining an "implementation blueprint" for health system professionals and administrators seeking to change their institution's culture of telemetry use. As the health care landscape continues to shift, enacting high-value initiatives that improve patient safety and efficiency of care will be critical.