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BACKGROUND: Among patients with heart failure and left ventricular (LV) dysfunction despite guideline directed medical therapy, cardiac resynchronization (CRT) is an effective technology to reverse LV remodeling. Given that a large portion of patients are non-responders, alternatives to traditional LV-lead placement have been explored. A promising alternative is image targeted placement of an LV-lead to latest mechanically activated segment without scar. METHODS: Electronic database search for randomized controlled trials (RCTs) that evaluated the imaging-guided LV-lead placement on clinical, echocardiographic, and functional outcomes. The primary outcome was a composite of mortality and heart failure hospitalization. The secondary outcomes included CRT responders, New York Heart Association (NYHA), 6-minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and ejection fraction (EF) changes. RESULTS: Analysis included 4 RCTs of 691 patients with an average follow-up of 2 years (age 69.5 ± 10.3 years, 76% males, 54% ischemic cardiomyopathy, 81% with NYHA classes III/IV, and EF of 24.4% ± 8). The most common site for LV-lead paced segment was the anterolateral segment (45%) and at mid-LV (49%). Compared with the control, imaging-guided LV-lead placement was associated with a significant reduction of the primary outcome (hazard ratio [HR] = 0.60; 95% CI = 0.40-0.88; p = .01), higher CRT responders (odd ratio [OR] = 2.10; p < .01), more NYHA improvements by ≥1 (OR = 1.89; p = .01), increased 6MWT (mean difference [MD] = 25.78 feet; p < .01), and lower MLHFQ (MD = -4.04; p = .04), without significant differences in the LVEF (p = .08). CONCLUSIONS: In patients undergoing CRT, imaging-guided LV-lead placement was associated with improved clinical, echocardiographic, and functional status.
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Terapia de Ressincronização Cardíaca/métodos , Imagem por Ressonância Magnética Intervencionista , Implantação de Prótese/métodos , Radiografia Intervencionista , Ultrassonografia de Intervenção , Humanos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Catheter instability can limit ablation success of arrhythmia substrates at the right atrioventricular groove. We describe cases where cryoablation improved catheter stability, enabling ablation success. METHODS AND RESULTS: Four patients with supraventricular tachycardia (SVT) substrates at the right atrioventricular groove had radiofrequency ablation procedures limited by poor catheter contact. Cryoablation offered improved catheter stability, and all four patients achieved acute ablation success using cryoablation. Three patients had long-term success and one patient later required repeat radiofrequency ablation. CONCLUSIONS: For patients with arrhythmia substrates at the right atrioventricular groove, cryoablation may be a useful adjunctive technique in cases with catheter instability.
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INTRODUCTION: Late lead perforation (LLP), defined as perforation ≥30 days from cardiac implantable electronic device implant, is a rare diagnosis and little data exist regarding management practices and outcomes. The purpose of this study was to evaluate the occurrence, safety, and efficacy of transvenous management of clinically significant LLP. METHODS: The electronic medical records of a single-center tertiary hospital were reviewed for all patients who were referred for LLP or its sequelae. RESULTS: Eleven consecutive patients were identified from October 2011 to December 2018 with clinically significant LLP. Patients most often presented with pericardial symptoms with the exception of one asymptomatic patient. The median time from lead implant to intervention for LLP was 246 days. Nine patients were managed with an initial transvenous approach, with one requiring sternotomy (lead 6.3 years old). Two patients had a surgical approach, one performed at an outside hospital with subsequent death and another had a mini-thoracotomy, but the lead was removed percutaneously with no surgical repair. In this small cohort, there was no association between the lead extending beyond the parietal pericardium and surgical repair (P = .99). CONCLUSION: Our single-center experience suggests that LLP can be initially managed with a cautious transvenous approach in most patients, but intraprocedural ultrasound for pericardial monitoring and a rescue plan with immediate surgical back up is mandatory.
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Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo , Traumatismos Cardíacos/terapia , Marca-Passo Artificial/efeitos adversos , Pericárdio/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Registros Eletrônicos de Saúde , Feminino , Traumatismos Cardíacos/etiologia , Traumatismos Cardíacos/mortalidade , Traumatismos Cardíacos/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Pericárdio/lesões , Pericárdio/fisiopatologia , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Esternotomia , Toracotomia , Fatores de Tempo , Resultado do TratamentoRESUMO
Children at high risk for sudden cardiac death (SCD) receive implantable cardioverter-defibrillators (ICD) for prevention, but the cost effectiveness of ICDs in children at intermediate risk is unclear. Our objective was to create a cost-effectiveness model to compare costs and outcomes in children at risk of SCD, with and without ICD. Utilizing hypertrophic cardiomyopathy as the proxy disease, a theoretical cohort of 8150 children was followed for 69 years. Model inputs were derived from the literature, with an incremental cost-effectiveness ratio (ICER) willingness-to-pay threshold of $100,000/quality-adjusted life year (QALY) used to delineate cost effectiveness. Outcomes included prevalence of severe neurological morbidity (SNM), SCD, cost, and QALYs. In children at intermediate risk of SCD (4-6% over 5 years), ICD resulted in 56 fewer cases of SNM, 2686 fewer deaths. In children at high risk (> 6% over 5 years), ICD placement resulted in 74 fewer cases of SNM and 3663 fewer deaths from cardiac causes. The costs of ICD were higher, but placement was cost effective with an ICER of $3009 per QALY in intermediate risk children, but ICD therapy was a dominant strategy in high-risk children. Sensitivity analysis demonstrated ICD placement was cost-effective until the annual probability of SCD was < 0.22%. The model was robust over a wide range of values. For children at risk of SCD, prophylactic ICD implantation is cost effective, resulting in improved outcomes and increased QALYs, despite increased costs. These findings highlight the economic benefits of ICD utilization in this population.
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Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/economia , Anos de Vida Ajustados por Qualidade de Vida , Cardiomiopatia Hipertrófica/mortalidade , Cardiomiopatia Hipertrófica/cirurgia , Criança , Análise Custo-Benefício , Morte Súbita Cardíaca/etiologia , Humanos , Cadeias de MarkovRESUMO
BACKGROUND: Prevention of sudden cardiac arrest (SCA) in the young remains a largely unsolved public health problem, and sports activity is an established trigger. Although the presence of standard cardiovascular risk factors in the young can link to future morbidity and mortality in adulthood, the potential contribution of these risk factors to SCA in the young has not been evaluated. METHODS: We prospectively ascertained subjects who experienced SCA between the ages of 5 and 34 years in the Portland, Oregon, metropolitan area (2002-2015, catchment population ≈1 million). We assessed the circumstances, resuscitation outcomes, and clinical profile of subjects who had SCA by a detailed evaluation of emergency response records, lifetime clinical records, and autopsy examinations. We specifically evaluated the association of standard cardiovascular risk factors and SCA, and sports as a trigger for SCA in the young. RESULTS: Of 3775 SCAs in all age groups, 186 (5%) occurred in the young (mean age 25.9±6.8, 67% male). In SCA in the young, overall prevalence of warning signs before SCA was low (29%), and 26 (14%) were associated with sports as a trigger. The remainder (n=160) occurred in other settings categorized as nonsports. Sports-related SCAs accounted for 39% of SCAs in patients aged ≤18, 13% of SCAs in patients aged 19 to 25, and 7% of SCAs in patients aged 25 to 34. Sports-related SCA cases were more likely to present with shockable rhythms, and survival from cardiac arrest was 2.5-fold higher in sports-related versus nonsports SCA (28% versus 11%; P=0.05). Overall, the most common SCA-related conditions were sudden arrhythmic death syndrome (31%), coronary artery disease (22%), and hypertrophic cardiomyopathy (14%). There was an unexpectedly high overall prevalence of established cardiovascular risk factors (obesity, diabetes mellitus, hypertension, hyperlipidemia, smoking) with ≥1 risk factors in 58% of SCA cases. CONCLUSIONS: Sports was a trigger of SCA in a minority of cases, and, in most patients, SCA occurred without warning symptoms. Standard cardiovascular risk factors were found in over half of patients, suggesting the potential role of public health approaches that screen for cardiovascular risk factors at earlier ages.
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Morte Súbita Cardíaca/epidemiologia , Parada Cardíaca Extra-Hospitalar/mortalidade , Saúde da População Urbana , Adolescente , Adulto , Distribuição por Idade , Criança , Pré-Escolar , Eletrocardiografia , Feminino , Humanos , Masculino , Oregon/epidemiologia , Parada Cardíaca Extra-Hospitalar/diagnóstico , Prevalência , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Esportes , Fatores de Tempo , Adulto JovemRESUMO
WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Electromagnetic interference from monopolar electrosurgery may disrupt implantable cardioverter defibrillators.Current management recommendations by the American Society of Anesthesiologists and Heart Rhythm Society are based on expert clinical opinion since there is a paucity of data regarding the risk of electromagnetic interference to implantable cardioverter defibrillators during surgery. WHAT THIS ARTICLE TELLS US THAT IS NEW: With protocolized electrosurgery dispersive electrode positioning in patients with implantable cardioverter defibrillators, the risk of clinically meaningful electromagnetic interference was 7% in above-the-umbilicus noncardiac surgery and 0% in below-the-umbilicus surgery. In cardiac surgery, clinically meaningful electromagnetic interference with use of an underbody dispersive electrode was 29%.Despite protocolized dispersive electrode positioning, the risk of electromagnetic interference in above-the-umbilicus surgery is high, supporting recommendations to suspend antitachycardia therapy when monopolar electrosurgery is used above the umbilicus.With protocolized dispersive electrode positioning, the risk of electromagnetic interference in below-the-umbilicus surgery is negligible, implying that suspending antitachycardia therapy might be unnecessary in these cases.With an underbody dispersive electrode, the risk of electromagnetic interference in cardiac surgery is high. BACKGROUND: The goal of this study was to determine the occurrence of intraoperative electromagnetic interference from monopolar electrosurgery in patients with an implantable cardioverter defibrillator undergoing surgery. A protocolized approach was used to position the dispersive electrode. METHODS: This was a prospective cohort study including 144 patients with implantable cardioverter defibrillators undergoing surgery between May 2012 and September 2016 at an academic medical center. The primary objectives were to determine the occurrences of electromagnetic interference and clinically meaningful electromagnetic interference (interference that would have resulted in delivery of inappropriate antitachycardia therapy had the antitachycardia therapy not been programmed off) in noncardiac surgeries above the umbilicus, noncardiac surgeries at or below the umbilicus, and cardiac surgeries with the use of an underbody dispersive electrode. RESULTS: The risks of electromagnetic interference and clinically meaningful electromagnetic interference were 14 of 70 (20%) and 5 of 70 (7%) in above-the-umbilicus surgery, 1 of 40 (2.5%) and 0 of 40 (0%) in below-the-umbilicus surgery, and 23 of 34 (68%) and 10 of 34 (29%) in cardiac surgery. Had conservative programming strategies intended to reduce the risk of inappropriate antitachycardia therapy been employed, the occurrence of clinically meaningful electromagnetic interference would have been 2 of 70 (2.9%) in above-the-umbilicus surgery and 3 of 34 (8.8%) in cardiac surgery. CONCLUSIONS: Despite protocolized dispersive electrode positioning, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with surgery above the umbilicus were high, supporting published recommendations to suspend antitachycardia therapy whenever monopolar electrosurgery is used above the umbilicus. For surgery below the umbilicus, these risks were negligible, implying that suspending antitachycardia therapy is likely unnecessary in these patients. For cardiac surgery, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with an underbody dispersive electrode were high. Conservative programming strategies would not have eliminated the risk of clinically meaningful electromagnetic interference in either noncardiac surgery above the umbilicus or cardiac surgery.
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Desfibriladores Implantáveis/normas , Eletrodos Implantados/normas , Fenômenos Eletromagnéticos , Eletrocirurgia/normas , Marca-Passo Artificial/normas , Adulto , Idoso , Desfibriladores Implantáveis/efeitos adversos , Eletrodos Implantados/efeitos adversos , Eletrocirurgia/instrumentação , Eletrocirurgia/métodos , Feminino , Cardiopatias/fisiopatologia , Cardiopatias/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial/efeitos adversosRESUMO
The simultaneous use of 2 external defibrillators to administer either dual or sequential cardioversion or defibrillation for refractory cardiac arrhythmias is increasing in both the out-of-hospital and inhospital settings. Using 2 defibrillators to administer higher energy levels than can be achieved with a single defibrillator is considered off-label and is currently not part of published advanced cardiac life support guidelines. We report the first case in which the use of dual-dose cardioversion was associated with external defibrillator damage. Because defibrillator damage, especially if undetected, jeopardizes patient safety and off-label medical product use may void the manufacturer's warranty, this case should urge users to proceed with caution when contemplating this technique.
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Desfibriladores , Cardioversão Elétrica/instrumentação , Falha de Equipamento , Taquicardia Ventricular/terapia , Adulto , Cardioversão Elétrica/métodos , Humanos , MasculinoRESUMO
BACKGROUND: Economic, personnel, and procedural challenges often complicate and interfere with efficient and safe perioperative care of patients with cardiovascular implantable electronic devices (CIEDs). In the context of a process improvement initiative, we created and implemented a comprehensive anesthesiologist-run perioperative CIED service to respond to all routine requests for perioperative CIED consultations at a large academic medical center. This study was designed to determine whether this new care model was associated with improved operating room efficiency, reduced institutional cost, and adequate patient safety. METHODS: We included patients with a CIED and a concurrent cohort of patients with the same eligibility criteria but without a CIED who underwent first-case-of-the-day surgery during the periods between February 1, 2008, and August 17, 2010 (preintervention) and between March 4, 2012, and August 1, 2014 (postintervention). The primary end point was delay in first-case-of-the day start time. We used multiple linear regression to compare delays in start times during the preintervention and postintervention periods and to adjust for potential confounders. A patient safety database was queried for CIED-related complications. Cost analysis was based on labor minutes saved and was calculated using nationally published administrative estimates. RESULTS: A total of 18,148 first-case surgical procedures were performed in 15,100 patients (preintervention period-7293 patients and postintervention period-7807 patients). Of those, 151 (2.1%) patients had a CIED in the preintervention period, and 146 (1.9%) had a CIED in the postintervention period. After adjustment for imbalances in baseline characteristics (age, American Society of Anesthesiologists physical status, and surgical specialty), the difference in mean first-case start delay between the postintervention and preintervention periods in the cohort of patients with a CIED was -16.7 minutes (95% confidence interval [CI], -26.1 to -7.2). The difference in mean delay between the postintervention and preintervention periods in the cohort without a CIED was -4.7 minutes (95% CI, -5.4 to -3.9). There were 3 CIED-related adverse events during the preintervention period and none during the postintervention period. Based on reduction in first-case start delay, the intervention was associated with cost savings (estimated institutional savings $14,102 annually, or $94.06 per CIED patient), with a return on investment ratio of 2.18 over the course of the postintervention period. CONCLUSIONS: Based on our experience, specially trained anesthesiologists can provide efficient and safe perioperative care for patients with CIEDs. Other centers may consider implementing a similar strategy as our specialty adopts the perioperative surgical home model.
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Procedimentos Cirúrgicos Cardíacos/métodos , Desfibriladores Implantáveis , Avaliação de Processos e Resultados em Cuidados de Saúde , Marca-Passo Artificial , Assistência Perioperatória/métodos , Centros Médicos Acadêmicos , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/economia , Sistema Cardiovascular , Estudos de Coortes , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas , Segurança do Paciente , Período Perioperatório , Medição de Risco , Fatores de TempoRESUMO
BACKGROUND: Sudden cardiac arrest (SCA) is a major contributor to mortality, but data are limited among nonwhites. Identification of differences in clinical profile based on race may provide opportunities for improved SCA prevention. METHODS AND RESULTS: In the ongoing Oregon Sudden Unexpected Death Study (SUDS), individuals experiencing SCA in the Portland, OR, metropolitan area were identified prospectively. Patient demographics, arrest circumstances, and pre-SCA clinical profile were compared by race among cases from 2002 to 2012 (for clinical history, n=126 blacks, n=1262 whites). Incidence rates were calculated for cases from the burden assessment phase (2002-2005; n=1077). Age-adjusted rates were 2-fold higher among black men and women (175 and 90 per 100 000, respectively) compared with white men and women (84 and 40 per 100 000, respectively). Compared with whites, blacks were >6 years younger at the time of SCA and had a higher prearrest prevalence of diabetes mellitus (52% versus 33%; P<0.0001), hypertension (77% versus 65%; P=0.006), and chronic renal insufficiency (34% versus 19%; P<0.0001). There were no racial differences in previously documented coronary artery disease or left ventricular dysfunction, but blacks had more prevalent congestive heart failure (43% versus 34%; P=0.04) and left ventricular hypertrophy (77% versus 58%; P=0.02) and a longer QTc interval (466±36 versus 453±41 milliseconds; P=0.03). CONCLUSIONS: In this US community, the burden of SCA was significantly higher in blacks compared with whites. Blacks with SCA had a higher prearrest prevalence of risk factors beyond established coronary artery disease, providing potential targets for race-specific prevention.
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População Negra/etnologia , Morte Súbita Cardíaca/etnologia , Morte Súbita Cardíaca/epidemiologia , População Branca/etnologia , Idoso , Idoso de 80 Anos ou mais , População Negra/estatística & dados numéricos , Morte Súbita Cardíaca/etiologia , Complicações do Diabetes/complicações , Complicações do Diabetes/epidemiologia , Complicações do Diabetes/etnologia , Feminino , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Hipertensão/etnologia , Incidência , Masculino , Pessoa de Meia-Idade , Oregon , Prevalência , Estudos Prospectivos , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/etnologia , Estudos Retrospectivos , Fatores de Risco , População Branca/estatística & dados numéricosAssuntos
Arritmias Cardíacas , COVID-19 , Serviço Hospitalar de Cardiologia , Eletrocardiografia Ambulatorial , Técnicas Eletrofisiológicas Cardíacas/métodos , Telemedicina , Antivirais/farmacologia , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/terapia , COVID-19/epidemiologia , COVID-19/terapia , Serviço Hospitalar de Cardiologia/organização & administração , Serviço Hospitalar de Cardiologia/tendências , Eletrocardiografia Ambulatorial/instrumentação , Eletrocardiografia Ambulatorial/métodos , Previsões , Humanos , Cooperação Internacional , Inovação Organizacional , SARS-CoV-2 , Sociedades Médicas/tendências , Telemedicina/métodos , Telemedicina/organização & administração , Telemedicina/tendênciasRESUMO
BACKGROUND: Atrial fibrillation (AF) is rare in teenagers. There are few reports and no clear guidelines on the management of AF with catheter ablation in teenagers. METHODS: A case series of teenagers (<18 years) with paroxysmal AF and a structurally normal heart who underwent catheter ablation was undertaken. RESULTS: Four teenage boys aged 15-17 years underwent catheter ablation of AF. All but one had failed antiarrhythmic medical therapy. Two had focal triggers and underwent culprit vein isolation (one recurred and so underwent isolation of an additional vein), and two had no focal triggers identified and so underwent isolation of all four pulmonary veins (PVs). At follow-up ranging from 2-6 years, one patient who underwent isolation of all four veins had recurrence of paroxysmal AF. All others have had medium and long-term success with complete absence of AF. None are on long-term antiarrhythmic therapy. No patient had a procedural or postprocedure complication. CONCLUSIONS: A cautious attempt at catheter ablation may be appropriate in teenagers with paroxysmal AF and a structurally normal heart who fail pharmacologic therapy. Culprit vein(s) isolation should be preferred if possible but if no focal triggers are identified, isolation of all PVs appears to be beneficial.
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Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Adolescente , Cardiomiopatias/diagnóstico , Humanos , Masculino , Resultado do TratamentoAssuntos
Fibrilação Atrial/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Fibrilação Atrial/epidemiologia , Doença da Artéria Coronariana/epidemiologia , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controleRESUMO
The most recent Oregon Medicaid experiment is the boldest attempt yet to limit health care spending. Oregon's approach using a Medicaid waiver from the Centers for Medicare and Medicaid Services utilizes global payments with two-sided risk at two levels - coordinated care organizations (CCOs) and the state. Equally important, the Oregon experiment mandates coverage of medical, behavioral, and dental health care using flexible coverage, with the locus of delivery innovation focused at the individual CCO level and with financial consequences for quality-of-care metrics. But insightful design alone is insufficient to overcome the vexing challenge of cost containment on a two- to five-year time horizon; well-tuned execution is also necessary. There are a number of reasons that the Oregon CCO model faces an uphill struggle in implementing the envisioned design.
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Reforma dos Serviços de Saúde , Assistência Centrada no Paciente/organização & administração , Controle de Custos , Planos de Pagamento por Serviço Prestado , Humanos , Medicaid , Oregon , Estados UnidosRESUMO
Background: Cardiovascular diseases are the leading cause of morbidity and mortality in the United States. Despite the complexity of cardiovascular disease etiology, we do not fully comprehend the interactions between non-modifiable factors (e.g., age, sex, and race) and modifiable risk factors (e.g., health behaviors and occupational exposures). Objective: We examined proximal and distal drivers of cardiovascular disease and elucidated the interactions between modifiable and non-modifiable risk factors. Methods: We used a machine learning approach on four cohorts (2005-2012) of the National Health and Nutrition Examination Survey data to examine the effects of risk factors on cardiovascular risk quantified by the Framingham Risk Score (FRS) and the Pooled Cohort Equations (PCE). We estimated a network of risk factors, computed their strength centrality, closeness, and betweenness centrality, and computed a Bayesian network embodied in a directed acyclic graph. Results: In addition to traditional factors such as body mass index and physical activity, race and ethnicity and exposure to heavy metals are the most adjacent drivers of PCE. In addition to the factors directly affecting PCE, sleep complaints had an immediate adverse effect on FRS. Exposure to heavy metals is the link between race and ethnicity and FRS. Conclusion: Heavy metal exposures and race/ethnicity have similar proximal effects on cardiovascular disease risk as traditional clinical and lifestyle risk factors, such as physical activity and body mass. Our findings support the inclusion of diverse racial and ethnic groups in all cardiovascular research and the consideration of the social environment in clinical decision-making.
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Teorema de Bayes , Doenças Cardiovasculares , Etnicidade , Inquéritos Nutricionais , Humanos , Feminino , Masculino , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Adulto , Etnicidade/estatística & dados numéricos , Fatores de Risco , Grupos Raciais/estatística & dados numéricos , Aprendizado de Máquina , Fatores de Risco de Doenças CardíacasRESUMO
BACKGROUND: During the COVID-19 pandemic, professional societies recommended deferral of elective procedures for optimal resource utilization. OBJECTIVE: We sought to assess changes in procedural trends and outcomes of electrophysiology (EP) procedures during the pandemic. METHODS: National Inpatient Sample databases were used to identify all EP procedures performed in the United States (2016-2020) by International Classification of Diseases, Tenth Revision codes. We evaluated trends in utilization, cost/revenue, and outcomes from EP procedures performed. RESULTS: An estimated 1.35 million EP procedures (82% devices and 18% catheter ablations) were performed (2016-2020) with significant yearly uptrend. During the pandemic, there was a substantial decline in EP procedure utilization from a 5-year peak of 298 cases/million population in the second quarter of 2019 to a nadir of 220 cases in the second quarter of 2020. In 2020, the pandemic was associated with the loss of 50,233 projected EP procedures (39,337 devices and 10,896 ablations) with subsequent revenue loss of $7.06 billion. This deficit was driven by revenue deficit from dual-chamber permanent pacemaker (PPM) utilization ($2.88 billion, 49.3% of lost cases), ablation procedures ($1.84 billion, 21.7% of lost cases), and implantable cardioverter-defibrillator implantation ($1.36 billion, 12.0% of lost cases). To the contrary, there was a 9.4% increase in the utilization of leadless PPM. EP device implantation during the pandemic was associated with higher adverse in-hospital events (9.4% vs 8.0%; P < .001). CONCLUSION: In the United States, the significant decline in EP procedures during the pandemic was primarily driven by the reduction in dual-chamber PPM utilization, followed by arrhythmia ablation and implantable cardioverter-defibrillator implantation. There was a substantial increase in leadless PPM utilization during the pandemic.
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COVID-19 , Técnicas Eletrofisiológicas Cardíacas , Humanos , COVID-19/epidemiologia , Estados Unidos/epidemiologia , Masculino , Feminino , Técnicas Eletrofisiológicas Cardíacas/economia , Técnicas Eletrofisiológicas Cardíacas/métodos , SARS-CoV-2 , Idoso , Arritmias Cardíacas/terapia , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/economia , Ablação por Cateter/economia , Ablação por Cateter/métodos , Ablação por Cateter/estatística & dados numéricos , Pandemias , Pessoa de Meia-IdadeRESUMO
Background: Safe and effective management of venous vascular access is a key component of electrophysiology (EP) procedures. Recently, the Z-stitch method has been developed for effective venous hemostasis. However, the standard postprocedure protocol often includes prolonged bed rest, which may affect patient satisfaction. The ZEBRA (Z stitch Early Bed Rest Assessment) study aims to systematically investigate and quantify patient satisfaction metrics and safety parameters associated with the early mobilization after Z-stitch placement. Objective: This study primarily investigates whether early mobilization following Z-stitch placement in venous vascular access management during EP procedures enhances patient satisfaction without compromising safety. Methods: In this prospective, multicenter, randomized clinical trial, approximately 200 patients undergoing various EP procedures at Oregon Health and Science University and Veterans Affairs Portland Health Care System will be randomly assigned to either a 1- or 4-hour bed rest regimen post-Z stitch. Patient satisfaction will be assessed through survey, alongside monitoring for hematomas, bleeding complications, and other safety endpoints. The study includes stratification based on heparin administration and sheath size to ensure robust and nuanced data analysis. Results: We anticipate that early mobilization will lead to higher patient satisfaction scores. We also expect to closely monitor and report the incidence of hematomas, pain medication use, healthcare costs, patient outcomes at 30 days, time to ambulation, and hospital readmissions or emergency visits related to groin complications. Conclusion: The ZEBRA study is poised to fill a critical knowledge gap in postprocedure care in EP labs. By rigorously evaluating the impact of early mobilization on patient satisfaction and safety, this study could significantly influence future guidelines and improve patient experiences in EP procedures.