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AIMS: Patients undergoing catheter ablation (CA) of ventricular arrhythmias (VAs) are generally observed overnight in the hospital given the concern for complications. To evaluate the efficacy and safety of same-day discharge (SDD) of patients undergoing elective CA of premature ventricular complexes (PVCs). METHODS AND RESULTS: A retrospective evaluation of all patients undergoing elective VA ablation at Ascension St Vincent Hospital from 1 January 2018 to 31 December 2019 was undertaken. Of those, the patients undergoing PVC ablation were divided into SDD and non-SDD. Patients underwent SDD at the discretion of the operator. The primary safety outcome was the 30-day incidence of complications and death. The primary efficacy outcome was procedural success. Among 188 patients who underwent VA ablation, 98 (52.1%) were PVC ablations, and of those, 55 (56.1%) were SDD. There was no difference in age, gender, comorbidities, or ejection fraction between the two groups. Patients that were non-SDD were more likely to be on chronic anticoagulation (P = 0.03), have ablation in the LV (P = 0.04), have retrograde access (P = 0.03), and receive heparin during the procedure (P = 0.01). There were no complications in the SDD group compared with one (2.3%) in the non-SDD group. There was no difference in primary efficacy between the two groups with a 90.9% acute success in the SDD and 88.4% in the non-SDD (P = 0.68). CONCLUSION: Same-day discharge for CA of PVCs is feasible and could lower healthcare resource utilization without compromising outcomes in this unique population.
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Ablação por Cateter , Alta do Paciente , Complexos Ventriculares Prematuros , Humanos , Complexos Ventriculares Prematuros/cirurgia , Complexos Ventriculares Prematuros/fisiopatologia , Complexos Ventriculares Prematuros/diagnóstico , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Resultado do Tratamento , Idoso , Complicações Pós-Operatórias/epidemiologia , Fatores de TempoRESUMO
INTRODUCTION: Substrate-based ablation for ventricular tachycardia (VT) using Ripple map (RM) is an effective treatment strategy for patients with ischemic cardiomyopathy but has yet to be evaluated in patients with nonischemic cardiomyopathy (NICMO). The aim of this study is to determine the feasibility and effectiveness of an RM-based ablation for NICMO patients. METHODS AND RESULTS: This was a single-center, retrospective study including all NICMO patients undergoing VT ablation at St Vincent Hospital between January 1, 2018 and January 12, 2019. Retrospective RM analysis was performed on those that had a substrate-based ablation to identify the location and number of Ripple channels as well as their proximity to ablation lesions. Thirty-three patients met the inclusion criteria and had a median age of 65 (58, 73.5) with 15.2% of the population being female, and were followed for a median duration of 451 (217.5, 586.5) days. Of these patients, 23 (69.7%) had a substrate-based ablation with a median procedural duration of 196.4 (186.8, 339) min, 1946 (517, 2750) points collected per map, and 277 (141, 554) points were within the scar. Two (8.6%) procedural complications occurred, and 7 (30.4%) patients had VT recurrence during follow-up. RM analysis revealed an average of two Ripple channels and the patients without VT recurrence had ablation performed closer to the Ripple channels: 0 (0, 4.7) versus 14.3 (0, 23.5) cm; p = .02. CONCLUSION: An RM-based substrate ablation can be performed in NICMO patients and ablation within Ripple channels is a predictor of VT freedom.
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Cardiomiopatias , Ablação por Cateter , Isquemia Miocárdica , Taquicardia Ventricular , Humanos , Feminino , Lactente , Masculino , Estudos Retrospectivos , Arritmias Cardíacas/cirurgia , Isquemia Miocárdica/complicações , Resultado do Tratamento , Ablação por Cateter/efeitos adversosRESUMO
AIMS: Multiple re-entry circuits may operate simultaneously in the atria in the form of dual loop re-entry using a common isthmus, or multiple re-entrant loops without a common isthmus. When two or more re-entrant circuits coexist, ablation of an individual isthmus may lead to a seamless transition (without significant changes in surface electrocardiogram, coronary sinus activation or tachycardia cycle length) to a second rhythm, and the isthmus block can go unnoticed. METHODS AND RESULTS: We hypothesize and subsequently illustrate in three patient cases, methods to rapidly identify a transition in the rhythm and isthmus block using local electrogram changes at the ablation site. CONCLUSION: Local activation sequence changes, electrogram timing, and the behaviour of pre-existing double potentials can reveal isthmus block promptly when rhythm transitions occur during ablation of multiloop re-entry tachycardias.
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Flutter Atrial , Ablação por Cateter , Humanos , Flutter Atrial/diagnóstico , Flutter Atrial/cirurgia , Arritmias Cardíacas , Átrios do Coração , Eletrocardiografia , Ablação por Cateter/métodosRESUMO
BACKGROUND: The use of a Left Ventricular Assist Device (LVAD) in patients with advanced heart failure refractory to optimal medical management has progressed steadily over the past two decades. Data have demonstrated reduced LVAD efficacy, worse clinical outcome, and higher mortality for patients who experience significant ventricular tachyarrhythmia (VTA). We hypothesize that a novel prophylactic intra-operative VTA ablation protocol at the time of LVAD implantation may reduce the recurrent VTA and adverse events postimplant. METHODS: We designed a prospective, multicenter, open-label, randomized-controlled clinical trial enrolling 100 patients who are LVAD candidates with a history of VTA in the previous 5 years. Enrolled patients will be randomized in a 1:1 fashion to intra-operative VTA ablation (n = 50) versus conventional medical management (n = 50) with LVAD implant. Arrhythmia outcomes data will be captured by an implantable cardioverter defibrillator (ICD) to monitor VTA events, with a uniform ICD programming protocol. Patients will be followed prospectively over a mean of 18 months (with a minimum of 9 months) after LVAD implantation to evaluate recurrent VTA, adverse events, and procedural outcomes. Secondary endpoints include right heart function/hemodynamics, healthcare utilization, and quality of life. CONCLUSION: The primary aim of this first-ever randomized trial is to assess the efficacy of intra-operative ablation during LVAD surgery in reducing VTA recurrence and improving clinical outcomes for patients with a history of VTA.
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Desfibriladores Implantáveis , Insuficiência Cardíaca , Coração Auxiliar , Taquicardia Ventricular , Humanos , Coração Auxiliar/efeitos adversos , Estudos Prospectivos , Qualidade de Vida , Fatores de Risco , Eletrocardiografia , Arritmias Cardíacas , Taquicardia Ventricular/etiologia , Resultado do TratamentoRESUMO
INTRODUCTION: Elevated left atrial pressure (LAP) during catheter ablation of atrial fibrillation (AF) is associated with an increased risk of AF recurrence, but it is unknown if this correlates with heart failure (HF). The objective of the study was to determine if elevated LAP after AF ablation correlates with HF events. METHODS: Prospective, single-center, cohort study measuring LAP and right atrial pressure (RAP) during AF ablation in 100 patients. The primary endpoint was clinical HF within 30 days of ablation. The secondary outcome was AF-free HF. RESULTS: One hundred patients (63% male, mean age 64.5) were enrolled and 20% had clinical HF within 30 days. Bivariate correlates included mitral valve (MV) disease, persistent AF, class III antiarrhythmics, LAP, and recurrent AF. Multivariate analysis revealed class III antiarrhythmics were protective (odds ratio [OR]: 0.24 [0.1-0.5], p = .04), while MV disease (OR: 8.7 [3.3-23], p = .03) and loop diuretics (OR: 4.8 [2.6-9.1], p = .01) were hazardous. AF-free HF occurred in 9% of patients and correlated with higher LAP and RAP, and chronic kidney disease. CONCLUSION: Patients with HF after AF ablation had higher LAP. MV disease, diuretic use, and class III antiarrhythmics also correlated to HF. These present opportunities to target future interventions to reduce a common complication of AF ablation.
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Fibrilação Atrial , Ablação por Cateter , Insuficiência Cardíaca , Hipertensão , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Estudos de Coortes , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Resultado do TratamentoRESUMO
AIMS: The response to premature atrial complexes (PACs) during tachycardia has been shown to differentiate atrioventricular nodal re-entrant tachycardia (AVNRT) from focal junctional tachycardia (JT). His refractory PAC (HrPACs) perturbing the next His (resetting with fusion) is diagnostic of AVNRT and such a late PAC fusing with the native beat cannot reset the focal source of JT. Early PAC advancing the immediate His with continuation of tachycardia suggests JT but can also occur in AVNRT due to simultaneous conduction through the AV nodal fast and slow pathways [two-for-one response (TFOR)]. The objective of this study was to evaluate the incidence and mechanism of TFOR after early premature atrial complexes (ePACs) during AVNRT and to differentiate it from the known response to ePACs during JT. METHODS AND RESULTS: Typical AVNRT cases were diagnosed using standard criteria. We evaluated the responses to scanning PACs delivered during tachycardia in 100 patients undergoing AV node slow pathway modification for AVNRT. The responses to HrPACs and ePACs delivered from coronary sinus os or high right atrium were retrospectively reviewed. In 10 patients, ePACs advanced the immediate His with continuation of tachycardia. In all 10 cases, HrPACs advanced the next His, confirming AVNRT as the mechanism, and indicating a TFOR. CONCLUSION: A TFOR can occur in a small number of patients during AVNRT and is therefore not diagnostic of JT. However, HrPACs always perturbed the next His in these cases, confirming the diagnosis of AVNRT and allowing for differentiation from JT.
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Complexos Atriais Prematuros , Ablação por Cateter , Taquicardia por Reentrada no Nó Atrioventricular , Complexos Atriais Prematuros/diagnóstico , Nó Atrioventricular/cirurgia , Eletrocardiografia , Frequência Cardíaca , Humanos , Estudos Retrospectivos , Taquicardia por Reentrada no Nó Atrioventricular/diagnóstico , Taquicardia por Reentrada no Nó Atrioventricular/cirurgiaRESUMO
BACKGROUND: Technical advances have improved the safety of cardiac implantable electronic device (CIED) insertion, but periprocedural complications persist. Despite ultrasound (US) guidance for vascular access being feasible and exhibiting shorter fluoroscopy times, it is not widely adopted for insertion of CIEDs. Thus, we studied the use of US for CIED insertion to (1) quantify the success rate of venous cannulation, (2) identify predictors of failed cannulation, and (3) quantify the rate of complications using US guidance. METHODS: We studied 166 consecutive patients who underwent US-guided CIED implantation. Anatomic parameters of the axillary vein were measured. The primary outcome was success (group 1) or failure (group 2) to obtain vascular access utilizing US guidance. Secondary outcomes included pneumothorax and hematoma. RESULTS: Successful US-guided cannulation occurred in 154 of 166 patients (93%). No patient had a pneumothorax. Hematoma occurred in 1 of 166 patients (0.01%). Group 2 exhibited higher male proportion at 11 of 12 (92%) compared with 94 of 154 (61%) in group 1 (P = .03), increased vein depth at 3.84 versus 2.85 cm (P = .003), more right-sided implants (P = .03), higher weight at 104.6 versus 85.3 kg (P = .017), higher body mass index at 35.6 versus 29.2 kg/m2 (P = .049), and higher body surface area at 2.24 versus 1.99 m2 (P = .013). Other parameters were statistically nonsignificant. In multivariate analysis, vein depth remained significantly associated with failure. CONCLUSION: Using US guidance for CIED implantation is successful in the vast majority (93%) of patients. Rare cases of unsuccessful cannulation were associated with right-sided implants and increased venous depth.
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Desfibriladores Implantáveis , Implantação de Prótese/métodos , Ultrassonografia de Intervenção , Idoso , Axila/irrigação sanguínea , Feminino , Hematoma/epidemiologia , Humanos , Masculino , Pneumotórax/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Electrophysiology study (EPS) is an important part of the diagnosis and workup for supraventricular tachycardia (SVT). Provocative medications are used to induce arrhythmias, when they are not inducible at baseline. The most common medication is the ß1-specific agonist, isoproterenol, but recent price increases have resulted in a shift toward the nonspecific agonist, epinephrine. OBJECTIVE: We hypothesize that isoproterenol is a better induction agent for SVT during EPS than epinephrine. METHODS: We created a retrospective cohort of 131 patients, who underwent EPS and required medication infusion with either isoproterenol or epinephrine for SVT induction. The primary outcome was arrhythmia induction. RESULTS: Successful induction was achieved in 71% of isoproterenol cases and 53% of epinephrine cases (P = 0.020). Isoproterenol was significantly better than epinephrine for SVT induction during EPS (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.14-4.85; P = 0.021). There was no difference in baseline variables or complications between the two groups. Other variables associated with successful arrhythmia induction included a longer procedure duration and atrioventricular nodal re-entry tachycardia as the clinical arrhythmia. In a multivariable model, isoproterenol remained significantly associated with successful induction (OR, 2.57; 95% CI, 1.002-6.59; P = 0.05). CONCLUSIONS: Isoproterenol was significantly better than epinephrine for SVT arrhythmia induction. However, epinephrine was safe and successfully induced arrhythmias in the majority of patients who received it. Furthermore, when atropine was added in epinephrine-refractory cases, in a post hoc analysis there was no difference in arrhythmia induction between medications. Cost savings could thus be significant without compromising safety.
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Agonistas Adrenérgicos beta/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/métodos , Epinefrina/efeitos adversos , Isoproterenol/efeitos adversos , Taquicardia Supraventricular/induzido quimicamente , Taquicardia Supraventricular/fisiopatologia , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
A 25-year-old man with severe nonischemic dilated cardiomyopathy underwent subcutaneous implantable cardioverter defibrillator (S-ICD) implant and subsequently underwent HeartWare ventricular assist device (HVAD) placement. Postoperative interrogation revealed both primary and secondary S-ICD vectors inappropriately regarded sinus rhythm as "noise," and the alternate vector significantly undersensed sinus rhythm. The S-ICD was reinterrogated using high-resolution capture to visually confirm EMI with a dominant frequency in both the primary and secondary vectors of 46.67 Hz that fell within the S-ICD operational range of 9-60 Hz. The 46.67 Hz frequency correlated with the HVAD operational speed of 2,800 RPM. The HVAD pump speed was increased from 2,800 to 3,000 RPM, resulting in a dominant frequency of 50 Hz. The notch filter is nonprogrammable in S-ICDs. However, the built-in filter is 50 Hz for countries in European time zones as opposed to 60 Hz in US time zones due to differences in the anticipated noise from electrical sources within each continent. Thus, the S-ICD time zone was reprogrammed from EST to GMT, which reduced the notch filter from 60 to 50 Hz, resulting in S-ICD successfully eliminating EMI when the patient was in a supine position. The EMI interference was still intermittently present in the upright patient position. This case demonstrates the utility of high-resolution electrogram capture to identify the source and frequency of EMI in S-ICD and offers a potential avenue to troubleshoot dominant frequency oversensing by changing the device time zone.
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Cardiomiopatia Dilatada/terapia , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Campos Eletromagnéticos , Coração Auxiliar , Falha de Prótese , Disfunção Ventricular Esquerda/terapia , Função Ventricular Esquerda , Adulto , Cardiomiopatia Dilatada/diagnóstico , Cardiomiopatia Dilatada/fisiopatologia , Técnicas Eletrofisiológicas Cardíacas , Humanos , Masculino , Posicionamento do Paciente/métodos , Desenho de Prótese , Decúbito Dorsal , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/fisiopatologiaAssuntos
Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/fisiopatologia , Técnicas Eletrofisiológicas Cardíacas/tendências , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/fisiopatologia , Idoso de 80 Anos ou mais , Bloqueio de Ramo/complicações , Feminino , Humanos , Taquicardia Supraventricular/complicaçõesRESUMO
BACKGROUND: Pericarditis is common after radiofrequency ablation for atrial fibrillation (AF). OBJECTIVES: Study investigators hypothesized an empirical post-AF ablation treatment protocol with colchicine may reduce the incidence and severity of pericarditis. PAPERS (Post-Ablation PEricarditis Reduction Study) aimed to quantify the risks and benefits associated with prophylactic use of colchicine to prevent pericarditis following AF ablation. METHODS: PAPERS is a multicenter, prospective, randomized controlled study. Patients were randomized on the day of the procedure to receive no postprocedure prophylaxis (group A; standard of care arm) or colchicine 0.6 mg orally twice daily for 7 days starting immediately post-procedure (group B; study arm). All participants underwent a follow-up survey at 14 days postoperatively. The primary endpoint was the development of clinical pericarditis within 2 weeks following ablation. Secondary outcomes included the incidence of pericarditis by ablation type and medical therapy. RESULTS: Among 139 patients enrolled, 66 were randomized to standard of care (group A), and 73 patients were randomized to the colchicine arm (group B). The primary outcome of clinical pericarditis was reached in 7 of 66 (10.6%) patients in group A and in 7 of 73 (9.6%) patients in group B (P = 0.84). The rate of gastrointestinal discomfort was 10 of 66 (15%) in group A and 34 of 73 (47%) in group B (P < 0.001). There was an increased incidence of pericarditis in patients who underwent cavotricuspid isthmus ablation (17 of 50; 34%) in addition to pulmonary vein isolation (6 of 69; 8.7%; P = 0.001). CONCLUSIONS: Prophylactic colchicine therapy initiated after the ablation procedure in patients with AF did not affect the incidence of post-ablation pericarditis and was associated with an increased incidence of gastrointestinal side effects.
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Fibrilação Atrial , Ablação por Cateter , Pericardite , Humanos , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/cirurgia , Fibrilação Atrial/etiologia , Colchicina/efeitos adversos , Estudos Prospectivos , Resultado do Tratamento , Recidiva Local de Neoplasia/etiologia , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Pericardite/epidemiologia , Pericardite/prevenção & controle , Pericardite/complicaçõesRESUMO
PURPOSE: Atrial fibrillation (AF) ablation is a common procedure to reduce cardiovascular morbidity but is limited by recurrence. The objective of this study was to determine if post-ablation acute surface P wave morphology and other electrocardiographic parameters correlate with AF recurrence. METHODS: The Avoiding Bladder Catheters During AF ablation (ABCD-AF) trial was a randomized, prospective trial in 160 subjects undergoing AF ablation. The present study examined correlation between AF recurrence in follow-up and acute post-ablation electrocardiographic P wave parameters. RESULTS: Median follow-up was 255 (188, 306) days. The ABCD-AF cohort had a mean age of 62.7 ± 12.8 with 32.1% being females. Rate of recurrent AF was 35.8%, with a median time to AF of 135 (109, 182) days. There was no baseline demographic associated with AF recurrence. There was more AF recurrence in those with longer follow-up (p = 0.001). Lead 2 PR interval, lead 2 P wave duration/PR (Pdur/PR), lead V1 PR interval, and lead V1 Pdur/PR were all significantly associated with recurrent AF (p = 0.03, 0.02, 0.01, 0.01). Longer PR and shorter Pdur/PR predicted AF recurrence. In a multivariable model, lead V1 Pdur/PR provided the best predictor of AF recurrence, with an odds ratio of 0.018 (p = 0.016) per standard deviation change. CONCLUSIONS: Shorter P wave duration combined with longer AV node delay, as measured by proportion of the PR that the P wave occupies, was the best predictor of AF recurrence post-ablation.
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Fibrilação Atrial , Ablação por Cateter , Idoso , Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Eletrocardiografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Resultado do TratamentoRESUMO
We present a case of persistent dual AV node conduction during AV node reentry tachycardia as a new clinical manifestation of 2-for-1 AV node conduction. The interpretation of the complex physiology ponders the possibility of an accessory pathway mediated atrioventricular reentry existing with more ventricular than atrial events.
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Advanced heart failure (HF) therapies improve survival in patients with stage D HF. We sought to evaluate differences by race/ethnicity and sex in advanced HF therapy referrals and decision-making across a multicenter survey. We performed a retrospective analysis of patients referred for evaluation for advanced HF therapies at 9 centers (n = 515) across the United States. The median age was 58 years, and 73% were male. White patients comprised 55.7% of referrals, whereas non-White patients comprised 44.3%. Non-ischemic etiology was more common in non-White patients (66.6% vs 47.4% p = 0.0005), and ischemic etiology was more common in men (37.8% vs 20.4% p = 0.0005). The primary reason for referral differed by race/ethnicity but not sex, with ventricular arrhythmias (7.6% vs 3%, p = 0.024) and pulmonary hypertension (3.4% vs 0.4% p = 0.018) being more common in White patients, whereas worsening HF was less common (25.4% vs 35.9%; p = 0.009). White patients were offered left ventricular assist devices (LVADs) (60.3% vs 54.7 p = 0.039) and heart transplants (51.8% vs 33.1% p = 0.0007) more often than non-White patients. The preference not to pursue LVAD therapy was more common in non-White patients (17.6% vs 9.6%; p = 0.049). Men were more often declined for a heart transplant because of psychosocial contraindications (34% vs 15%, p = 0.005). In conclusion, in this multicenter analysis of referrals for advanced HF therapies, we observed significant differences by race, ethnicity, and sex in both referral characteristics and evaluation outcomes. Further investigation is warranted to better understand why rates of LVAD and transplantation may be lower in non-White patients who are referred for advanced therapies.
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Insuficiência Cardíaca , Transplante de Coração , Coração Auxiliar , Humanos , Masculino , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Etnicidade , Coração Auxiliar/efeitos adversos , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Encaminhamento e ConsultaRESUMO
BACKGROUND: His-refractory premature ventricular complexes perturbing a supraventricular tachycardia (SVT) establish the presence of an accessory pathway (AP). Earlier premature ventricular complexes (ErPVCs) may perturb SVTs but are considered nondiagnostic. OBJECTIVE: The purpose of this study was to test the hypothesis that an ErPVC will always show a difference >35 ms in its advancement of the next atrial activation during atrioventricular nodal reentrant tachycardia (AVNRT). During atrioventricular reentrant tachycardia (AVRT), a PVC delivered close to the circuit can result in greater advancement of atrial activation due to retrograde conduction via an AP. Thus, an AP response, defined as ErPVC (H1S2) advancing the subsequent atrial activation (A1-A2) more than this minimum difference (A1A2 ≤ H1S2+35 ms), establishes the presence of an AP. METHODS: Sixty-five consecutive patients with SVT were retrospectively evaluated. ErPVCs were defined when the ventricular pacing stimulus was >35 ms ahead of the His during tachycardia. RESULTS: Among the 65 cases, 43 were AVNRT and 22 AVRT. Fourteen AVRT cases had an AP response with a mean H1S2+35 ms of 336 ± 58 ms and A1A2 of 309 ± 51ms. No AVNRT cases had an AP response. The specificity of an AP response to ErPVC in predicting AVRT was 100%. CONCLUSION: An AP response to PVCs (A1A2 ≤ H1S2+35 ms) is 100% specific for the presence of an AP.
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Feixe Acessório Atrioventricular , Fibrilação Atrial , Taquicardia por Reentrada no Nó Atrioventricular , Taquicardia Paroxística , Taquicardia Supraventricular , Complexos Ventriculares Prematuros , Humanos , Sistema de Condução Cardíaco , Estudos Retrospectivos , Estimulação Cardíaca Artificial , Taquicardia Supraventricular/diagnóstico , Complexos Ventriculares Prematuros/diagnóstico , EletrocardiografiaRESUMO
Systemic lupus erythematosus is a chronic inflammatory disorder that predisposes to acute coronary thrombosis. To demonstrate how the pathophysiology of lupus-mediated coronary events may be unique, we offer the case and management of a young woman with lupus who presented with acute myocardial infarction. She was initially managed with medical therapy including the standard regimen of aspirin, heparin, and clopidogrel. Despite a Thrombolysis in Myocardial Infarction risk score of only 2, she was also given eptifibatide infusion because of clinical concerns. Repeated cardiac catheterization showed marked regression of the thrombus, and coronary fractional flow reserve calculation demonstrated full recovery of coronary vasculature with this therapy. This case demonstrates effective management of life-threatening coronary thrombosis with medical therapy only in a young woman with lupus. We briefly review the pathophysiology of acute coronary thrombosis in lupus patients and distinguish this from the more common process of age-related atherosclerosis. Given the lack of evidence in this specific population, we discuss a pathophysiology-based clinical decision-making tool. Assessing clinical risk factors and using technologies such as intravascular ultrasound can help make the correct treatment decision.
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Trombose Coronária/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Heparina/uso terapêutico , Lúpus Eritematoso Sistêmico/complicações , Inibidores da Agregação Plaquetária/uso terapêutico , Adulto , Aspirina/uso terapêutico , Clopidogrel , Trombose Coronária/etiologia , Eptifibatida , Feminino , Humanos , Peptídeos/uso terapêutico , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêuticoRESUMO
OBJECTIVES: The objective of this study was to describe the risk of cardiac implantable electronic devices (CIEDs) complications in patients with left ventricular assist devices (LVADs). BACKGROUND: Patients with LVADs are predisposed to ventricular arrhythmias and frequently have CIEDs before receiving their LVAD. However, the role of CIED procedures such as generator changes (GC) are unclear in this population, given the potential complications of bleeding and infection. METHODS: This was a retrospective, multicenter study from January 1, 2012, to September 30, 2018. All patients with LVADs were screened and those who had a CIED GC, implantation, or revision were included in the study and followed until December 31, 2018. RESULTS: A total of 179 patients across 6 centers had a CIED procedure after LVAD implantation. The mean age was 59.5 ± 13.4, with the cohort comprising mostly men (78%), destination LVAD therapy (53.8%), and GC (66%). The 30-day primary composite endpoint of hematoma or device infection occurred in 34 (19%) patients. The secondary endpoints of rehospitalization within 30 days and appropriate device therapy during follow-up occurred in 40 (22%) and 42 (24%) patients respectively. Of the 126 patients without previous device therapy, 14.3% received appropriate therapy during follow-up. CONCLUSIONS: In this large, multicenter cohort, we report the incidence of complications for CIED procedures in the LVAD population; specifically, LVAD patients are at increased risk of pocket hematomas, without downstream risk of infection, and do experience a high rate of appropriate device therapies.
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Insuficiência Cardíaca , Coração Auxiliar , Eletrônica , Insuficiência Cardíaca/epidemiologia , Coração Auxiliar/efeitos adversos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVE: To evaluate the prognosis of patients with ischemic stroke according to the timing of an atrial fibrillation (AF) diagnosis, we created an inception cohort of incident stroke events and compared the risk of death between patients with stroke with (1) sinus rhythm, (2) known AF (KAF), and (3) AF diagnosed after stroke (AFDAS). METHODS: We used the Penn AF Free study to create an inception cohort of patients with incident stroke. Mortality events were identified after linkage with the National Death Index through June 30, 2017. We also evaluated initiation of anticoagulants and antiplatelets across the study duration. Cox proportional hazards models evaluated associations between stroke subtypes and death. RESULTS: We identified 1,489 individuals who developed an incident ischemic stroke event: 985 did not develop AF at any point during the study period, 215 had KAF before stroke, 160 had AF detected ≤6 months after stroke, and 129 had AF detected >6 months after stroke. After a median follow-up of 4.9 years (interquartile range 1.9-6.8), 686 deaths occurred. The annualized mortality rate was 8.8% in the stroke, no AF group; 12.2% in the KAF group; 15.8% in the AFDAS ≤6 months group; and 12.7% in the AFDAS >6 months group. Patients in the AFDAS ≤6 months group had the highest independent risk of all-cause mortality even after multivariable adjustment for demographics, clinical risk factors, and the use of antithrombotic therapies (hazard ratio 1.62 [1.22-2.14]). Compared to the stroke, no AF group, those with KAF had a higher mortality risk that was rendered nonsignificant after adjustment. CONCLUSIONS: The AFDAS group had the highest risk of death, which was not explained by comorbidities or use of antithrombotic therapies.