Long-term outcomes with abandoning versus extracting sterile leads: A 10-year population-based study.

BACKGROUND: Long-term outcomes of sterile lead management strategies of lead abandonment (LA) or transvenous lead extraction (TLE) remain unclear. METHODS: We performed a retrospective study of a population residing in southeastern Minnesota with follow-up at the Mayo Clinic and its health systems. Patients who underwent LA or TLE of sterile leads from January 1, 2000, to January 1, 2011, and had follow-up for at least 10 years or until their death were included. RESULTS: A total of 172 patients were included in the study with 153 patients who underwent LA and 19 who underwent TLE for sterile leads. Indications for subsequent lead extraction arose in 9.1% (n = 14) of patients with initial LA and 5.3% (n = 1) in patients with initial TLE, after an average of 7 years. Moreover, 28.6% of patients in the LA cohort who required subsequent extraction did not proceed with the extraction, and among those who proceeded, 60% had clinical success and 40% had a clinical failure. Subsequent device upgrades or revisions were performed in 18.3% of patients in the LA group and 31.6% in the TLE group, with no significant differences in procedural challenges (5.2% vs. 5.3%). There was no difference in 10-year survival probability among the LA group and the TLE group (p = .64). CONCLUSION: An initial lead abandonment strategy was associated with more complicated subsequent extraction procedures compared to patients with an initial transvenous lead extraction strategy. However, there was no difference in 10-year survival probability between both lead management approaches.

Chronic kidney disease is associated with increased all-cause mortality in transvenous lead extraction: A systematic review and meta-analysis.

BACKGROUND: The impact of chronic kidney disease (CKD) or end-stage renal disease (ESRD) on patients receiving transvenous lead extraction (TLE) is not well-established. We performed a systematic review and meta-analysis to explore the association between CKD and all-cause mortality in TLE. METHODS: We searched the databases of PubMed and EMBASE from inception to April 2022. Included studies were published TLE studies that compared the risk of mortality in CKD patients compared to control patients. Data from each study were combined using the random-effects model. RESULTS: Eight studies (5,013 patients) were included. Compared with controls, CKD patients had a significantly higher risk of overall all-cause mortality (hazard ratio [HR] = 2.14, 95% confidence interval [CI]: 1.65-2.77, I2  = 51.1%, p < .001). The risk of overall all-cause mortality increased with the severity of CKD for nonspecific CKD (HR = 2.01, 95% CI: 1.49-2.69, I2  = 53.4, p < .001) and ESRD (HR = 2.79, 95% CI: 1.85-4.23, I2  = 0%, p < .001). The risk of all-cause mortality in CKD is double at follow-up ≤1 year (HR = 1.99, 95% CI: 1.29-3.09, I2  = 50.9%, p = .002) and higher at follow-up >1 year (HR = 2.36, 95% CI: 1.63-3.42, I2   = 59.7%, p < .001). CONCLUSIONS: Our meta-analysis demonstrates a significantly increased risk of overall all-cause mortality in patients with CKD who underwent TLE compared to controls.

A Rare Case of ANCA-negative Rapidly Progressive Glomerulonephritis: A Case Report.

ANCA-negative rapidly progressive glomerulonephritis (RPGN) is a rare condition caused by glomerular injury in the absence of detectable antineutrophil cytoplasmic antibodies (ANCAs). While comprehensive epidemiologic data is limited, ANCA-negative RPGN is known to comprise 5-20% of all glomerulonephritis cases. We report the case of a 43-year-old male who presented to the hospital after a snowmobile accident with symptoms of general malaise along with the emergence of a new-onset rash and tea-colored urine. Further workup with CT-guided kidney biopsy confirmed the diagnosis of RPGN by revealing histopathological findings of crescentic glomerulonephritis and significant glomerular inflammation. Treatment was promptly initiated with prednisone and Cytoxan and the patient was subsequently discharged in stable condition. We aim to enrich the existing literature by describing the clinical presentation, diagnostic workup and management of ANCA-negative RPGN.

Left Main Coronary Artery Spasm During Cryoballoon Ablation for Atrial Fibrillation: A Case Report and Literature Review.

Although phrenic nerve and esophageal injury are commonly known risks associated with cryoablation, there is limited literature regarding coronary artery spasm (CAS), a serious and potentially fatal complication of cryoablation. We report the case of a 68-year-old Caucasian female who developed a left main CAS with a significant hemodynamic compromise during cryoablation. The patient, with a history of hyperlipidemia, hypertension, and symptomatic persistent atrial fibrillation, was admitted for elective catheter ablation for atrial fibrillation. During the ablation of the left superior pulmonary vein (LSPV), the patient developed severe hypotension and bradycardia. The patient's monitor revealed ST elevation, confirmed by a 12-lead ECG. Immediate coronary angiography revealed the left main coronary spasm, which improved with nitroglycerine administration with resolution of ST elevation and return of the patient's hemodynamics to stability. The patient's left main CAS was induced by cryoablation of LSPV. Literature on atrial fibrillation ablation-induced CAS is scant, but a Japanese study has shown that it occurs more commonly in cryoablation than in radiofrequency, hot balloon, or laser ablation. The study showed LSPV as the most common site of ablation right before the spasms happened. Further studies about this topic are needed to delineate further the risk factors and the precautions that could prevent CAS. In the meantime, prompt recognition and appropriate intervention are critical for a good patient outcome.

Outcomes with physiologic His bundle pacing in patients with narrow QRS complex.

BACKGROUND: In patients with narrow QRS complex, both ventricular and biventricular pacing is associated with increased cardiac morbidity and mortality. This risk is not decreased by ventricular pacing avoidance algorithms, which cause nonphysiologic atrioventricular (AV) delays. OBJECTIVE: This study aimed to report outcomes in patients with narrow QRS complex when the paced complex is in normal range and physiologic AV delays are programmed. METHODS: In 196 patients with QRS duration of 92 ± 10 ms, permanent pacing was done at the site of the His bundle electrogram. The pacemakers were then programmed to maintain physiologic AV delays and to increase heart rates in response to exercise. Patients received usual care and were observed for 3 years. RESULTS: The paced complex exhibited a delta wave, and the ventricular activation time, QRS axis, and lead I voltage remained in normal range. Physiologic programming resulted in His bundle pacing burden of 92%. In patients with decreased ejection fraction, there was significant improvement in left ventricular function, left ventricular dilation, and mitral regurgitation (P < .003). In patients with normal ejection fraction, left ventricular function remained normal without new valvular abnormalities. The 3-year all-cause mortality was 10%, and there was no increase in heart failure admissions. CONCLUSION: In patients with narrow QRS complex, when paced QRS morphology is maintained in normal range and AV dyssynchrony is avoided, His bundle pacing is associated with low all-cause mortality and improvement in abnormal echocardiographic parameters. The paced QRS morphology and physiologic AV delays may be important factors to evaluate in future trials of conduction system pacing.

Thirty-day hospital readmission in females with acute heart failure and breast cancer: A retrospective cohort study from national readmission database.

BACKGROUND: Breast Cancer and cardiovascular diseases are amongst the two leading causes of mortality in the United States, and the two conditions are connected in part because of recognized cardiotoxicity of cancer treatments. The aim of this study is to investigate the predictors risk factors for thirty-day readmission in female breast cancer survivors presenting with acute heart failure. METHODS: This is a retrospective cohort study of acute heart failure (AHF) hospitalization in female patients with breast cancer in 2019 using the National Readmission Database (NRD), which is the largest publicly available all-payer inpatient readmission database in the United States. Our study sample included adult female patients aged 18 years and older. The primary outcome of interest was the rate of 30- day readmission. RESULTS: In 2019, there were 8332 total index admissions for AHF in females with breast cancer and 7776 patients were discharged alive. The mean age was 74.4 years (95% CI: 74, 74.7). The percentage of readmission at 30 days among those discharged alive was 21.8% (n = 1699). Hypertensive heart disease with chronic kidney disease accounted for the majority of readmission in AHF with breast cancer followed by sepsis, acute kidney injury, respiratory failure, pneumonia, and atrial fibrillation. Demographic factors including higher burden of comorbidities predict readmission. The total in-hospital mortality in index admission was 6.67% (n = 556) and for readmitted patients was 8.77% (n = 149). The mean length of stay for index admission was 7.5 days (95% CI: 7.25, 7.75). CONCLUSIONS: Readmission of female breast cancer survivors presenting with AHF is common and largely be attributed to high burden of comorbidities including hypertension, and chronic kidney disease. A focus on close outpatient follow-up will be beneficial in lowering readmissions.

Impact of infective versus sterile transvenous lead removal on 30-day outcomes in cardiac implantable electronic devices.

BACKGROUND: Transvenous lead removal (TLR) is associated with increased mortality and morbidity. This study sought to evaluate the impact of TLR on in-hospital mortality and outcomes in patients with and without CIED infection. METHODS: From January 1, 2017, to December 31, 2020, we utilized the nationally representative, all-payer, Nationwide Readmissions Database to assess patients who underwent TLR. We categorized TLR as indicated for infection, if the patient had a diagnosis of bacteremia, sepsis, or endocarditis during the initial admission. Conversely, if none of these conditions were present, TLR was considered sterile. The impact of infective vs sterile indications of TLR on mortality and major adverse events was studied. RESULTS: Out of the total 25,144 patients who underwent TLR, 14,030 (55.8%) received TLR based on sterile indications, while 11,114 (44.2%) received TLR due to device infection, with 40.5% having systemic infection and 59.5% having isolated pocket infection. TLR due to infective indications was associated with a significant in-hospital mortality (5.59% vs 1.13%; OR = 5.16; 95% CI 4.33-6.16; p < 0.001). Moreover, when compared with sterile indications, TLR performed due to device infection was associated with a considerable risk of thromboembolic events including pulmonary embolism and stroke (OR = 3.80; 95% CI 3.23-4.47, p < 0.001). However, there was no significant difference in the conversion to open heart surgery (1.72% vs. 1.47%, p < 0.111), and infection was not an independent predictor of cardiac (OR = 1.12; 95% CI 0.97-1.29) or vascular complications (OR = 1.12; 95% CI 0.73-1.72) between the two groups. CONCLUSION: Higher in-hospital mortality and rates of thromboembolic events associated with TLR resulting from infective indications may warrant further pursuing this diagnosis in patients.

Pneumomediastinum and pneumothorax in coronavirus disease-2019: Description of a case series and a matched cohort study.

Objective: To describe the characteristics of COVID-19 patients with pneumothorax and pneumomediastinum (PTX/PM) and their association with patient outcomes. Patients and methods: Adults admitted to five Mayo Clinic hospitals with COVID-19 between 03/2020-01/2022 were evaluated. PTX/PM was defined by imaging. Descriptive analyses and a matched (age, sex, admission month, COVID-19 severity) cohort comparison was performed. Hospital mortality, length of stay (LOS), and predisposing factors were assessed. Results: Among 6663 patients, 197 had PTX/PM (3 %) (75 PM, 40 PTX, 82 both). The median age was 59, with 71 % males. Exposure to invasive and non-invasive mechanical ventilation and high-flow nasal cannula before PTX/PM were 42 %, 17 %, and 20 %, respectively. Among isolated PTX and PM/PTX patients 70 % and 53.7 % underwent an intervention, respectively, while 96 % of the PM-only group was followed conservatively.A total of 171 patients with PTX/PM were compared to 171 matched controls. PTX/PM patients had more underlying lung disease (40.9 vs. 23.4 %, p < 0.001) and lower median body mass index (BMI) (29.5 vs. 31.3 kg/m2, p = .007) than controls. Among patients with available data, PTX/PM patients had higher median positive end-expiratory and plateau pressures than controls; however, differences were not significant (10 vs. 8 cmH2O; p = 0.38 and 28 vs. 22 cmH2O; p = 0.11, respectively). PTX/PM patients had a higher odds of mortality (adjusted odds ratio [95%CI]: 3.37 [1.61-7.07]) and longer mean LOS (percent change [95%CI]: 39 [9-77]) than controls. Conclusion: In COVID-19 patients with similar severity, PTX/PM patients had more underlying lung disease and lower BMI. They had significantly increased mortality and LOS.

Heart failure is associated with increased risk of all-cause mortality after transvenous lead extraction: A systematic review and meta-analysis.

Background: Transvenous lead extraction (TLE) is increasingly considered in cardiac implantable electronic device management. Heart failure (HF) might be associated with mortality risks after the TLE procedure. This study aims to assess mortality risk in HF patients undergoing TLE. Method: We searched MEDLINE and Embase databases from inception to June 2022 to identify articles that included patients with and without HF who underwent TLE, which reported mortality in both groups. The pooled effect size was calculated with a random-effects model and 95% CI to compare post-TLE mortality between the two groups. Results: Eleven studies were included in the analysis. Each left ventricular ejection fraction (LVEF) increased by 1% was associated with reduced mortality by 2% (HR = 0.98, 95% CI: 0.97-0.99, I 2 = 74.9%, p < .01). The presence of HF compared to those without HF was associated with higher mortality rates (OR: 3.04, 95% CI: 2.56-3.61, I 2 = 0.0%, p < .531). There was a significant increase in the mortality rates in patients with New York Heart Association (NYHA) function class III (OR: 2.29, 95% CI: 1.29-4.06, I 2 = 0.0%, p = .498) and NYHA IV (OR: 8.5, 95% CI: 2.98-24.3, I 2 = 0.0%, p = .997). Conclusions: Our study found that post-TLE mortality decreases by 2% as LVEF increases by 1%, also mortality is higher in patients with NYHA III and IV.

New-onset atrial fibrillation among COVID-19 patients: A narrative review.

Over the last three years, research has focused on examining cardiac issues arising from coronavirus disease 2019 (COVID-19) infection, including the emergence of new-onset atrial fibrillation (NOAF). Still, no clinical study was conducted on the persistence of this arrhythmia after COVID-19 recovery. Our objective was to compose a narrative review that investigates COVID-19-associated NOAF, emphasizing the evolving pathophysiological mechanisms akin to those suggested for sustaining AF. Given the distinct strategies involved in the persistence of atrial AF and the crucial burden of persistent AF, we aim to underscore the importance of extended follow-up for COVID-19-associated NOAF. A comprehensive search was conducted for articles published between December 2019 and February 11, 2023, focusing on similarities in the pathophysiology of NOAF after COVID-19 and those persisting AF. Also, the latest data on incidence, morbidity-mortality, and management of NOAF in COVID-19 were investigated. Considerable overlaps between the mechanisms of emerging NOAF after COVID-19 infection and persistent AF were observed, mostly involving reactive oxygen pathways. With potential atrial remodeling associated with NOAF in COVID-19 patients, this group of patients might benefit from long-term follow-up and different management. Future cohort studies could help determine long-term outcomes of NOAF after COVID-19.