Utilizing ambulatory electrocardiogram monitoring to reduce conduction related death after transcatheter aortic valve replacement.

OBJECTIVE: The purpose of this study is to assess the utility of ambulatory cardiac monitoring (ACM) in detecting delayed advanced conduction abnormalities (DACA) and associated 30-day mortality. BACKGROUND: DACA are well-known complications of TAVR and may be associated with post-discharge mortality within 30-days. METHODS: Between October 2019 and October 2020, TAVR patients who were discharged home without a permanent pacemaker (PPM) were monitored with an ACM device for 14-days. The incidence of DACA at follow up, mortality and readmission within 30-days were investigated. The risk of DACA was assessed in three patient categories based on a composite of their 12-lead electrocardiogram (ECG) data. Group I: Normal pre-TAVR, periprocedural, and discharge ECGs. Group II: Normal pre-TAVR and abnormal subsequent ECGs. Group III. Abnormal baseline and abnormal subsequent ECGs. RESULTS: Among 340 TAVR patients, 248 were discharged home with an ACM device. The overall incidence of DACA was 7% (n = 17), of whom 4% (n = 10) required a PPM. Mortality and readmission between discharge and 30 days was 0% and 8.3%, respectively. Stratification of patients identified 96 (38.7%) patients in Group I: 50 (20%) in Group II, and 102 (41%) in Group III. The incidence of DACA requiring a PPM was 0% in Group I, 4% (n = 2) in Group II, and 8.5% (n = 8) in Group III (p < 0.004). CONCLUSIONS: In TAVR patients who were discharged home with ACM, none died between discharge and 30-days. For those with normal baseline, perioperative and discharge ECG, there were no events of DACA at 14-days.

Does One's Socioeconomic Status Predispose to the Development of Stress-Induced Cardiomyopathy?

INTRODUCTION: Stress-induced cardiomyopathy (SIC) has a higher incidence in Caucasians (CAUCs) compared to African-Americans (AAs). Whether this is due to racial predisposition, selection bias, or environmental factors remains unclear. HYPOTHESIS: We hypothesize that people from lower socioeconomic strata (SES) have a lower incidence of SIC. It is possible that the incidence of SIC could be similar among CAUCs and AAs at the same SES. Stress preconditioning maybe protective in preventing SIC. METHODS: Data of patients with the discharge diagnosis of SIC were extracted from the Myocardial Infarction Data Acquisition System spanning the period from 2006 through 2015. The incidence of SIC among CAUCs and AAs was compared per 100,000 New Jersey population and examined across income brackets. CAUCs and AAs data were compared using two-sample proportion tests. RESULTS: During the study period, CAUCs had an overall higher incidence of SIC compared to AAs, 0.017% versus 0.0084% per 100,000 population (p value <0.0001). This difference persisted after a logistic regression adjustment (p = 0.0064). CAUCs in the income brackets of 30-40k had lower incidence of SIC than those in the 60-80k income bracket (p = 0.0156). Those with an income of 60-80k had lower incidence of SIC compared to those with an income of 80-100k. AAs with income between 30 and 60k had a lower incidence of SIC than CAUCs (p = 0.0330). CONCLUSIONS: CAUCs exhibited a trend towards less SIC as a function of lower income. This was not observed among AAs. AAs had a lower incidence of SIC. Our study suggests that SES has a protective effect among CAUCs.

Sex Disparities in the Treatment of Aortic Stenosis and Related Outcomes: An Analysis of the National Inpatient Sample.

INTRODUCTION: The impact of transcatheter aortic valve replacement (TAVR) on sex disparities has not been well established. This study sought to examine the impact of sex on outcomes following aortic valve replacement (AVR) for aortic stenosis (AS) in the era of routine TAVR. METHODS: We performed a cross-sectional analysis of the National Inpatient Sample (2009-18) to study AS visits for all AVR and in-hospital outcomes as a function of sex. Survey estimation commands were used to provide national estimates. RESULTS: There were an estimated 431,344 surgical AVR (SAVR) and 189,137 TAVR inpatient visits. Mortality was higher in women after SAVR (3.8% ± 0.1 vs. 2.7% ± 0.07, p < 0.001) and TAVR (2.4% ± 0.1 vs. 1.7% ± 0.1, p < 0.001) compared to men. Female patients undergoing SAVR had higher rates of permanent pacemaker (PPM) implantation, stroke, and bleeding (5.9% ± 0.1 vs. 5% ± 0.1, 2.8% ± 0.1 vs. 2.3% ± 0.07, and 37.8% ± 0.8 vs. 29.8% ± 0.6; p < 0.001, respectively) but lower rates of acute kidney injury (AKI) (16.4% ± 0.3 vs. 20.3% ± 0.3, p < 0.001). Women undergoing TAVR had higher rates of stroke and bleeding (2.4% ± 0.1 vs. 1.6% ± 0.09 and 28.7% ± 0.6 vs. 22% ± 0.5; p < 0.001, respectively) but lower rates of PPM and AKI (9.5% ± 0.3 vs. 10.7% ± 0.2 and 11.3% ± 0.3 vs. 13.4% ± 0.3; p < 0.001, respectively). Compared with isolated SAVR, isolated TAVR was associated with lower mortality in women during 2016-18, both after multivariable adjustment (OR = 0.40; 95% CI, 0.27-0.60) and propensity matching (mean difference 0.66% ± 0.2); however, there was no difference in men. CONCLUSION: Although women continue to have higher in-hospital mortality following both TAVR and SAVR as compared to men, TAVR is associated with a lower in-hospital mortality in women compared to SAVR. Thus, TAVR may represent a potential intervention to narrow the sex-based disparities in the management of AS.

Contemporary trends and in-hospital outcomes of mechanical and bioprosthetic surgical aortic valve replacement in the United States.

INTRODUCTION: The choice between a mechanical versus a bioprosthetic valve in aortic valve replacement (AVR) is based on life expectancy, bleeding risk and comorbidities, since bioprosthetic AVR (bAVR) are associated with a more rapid structural deterioration compared to mechanical AVR (mAVR). The impact of widespread transcatheter valve replacements, on the decision to use bAVR versus mAVR, in the contemporary era and subsequent outcomes remain to be determined. METHODS: The National Inpatient database (2009-2018) was used to study trends in admissions for bAVR and mAVR and in-hospital mortality and outcomes over time. Survey estimation commands were used to determine weighted national estimates. RESULTS: There were 700,896 ± 18,285 inpatient visits for AVR with 70.1% (95% CI 69.2%-71.1%) and 29.9% (95% CI 28.9%-30.8%) visits for bAVR and mAVR, respectively. Those undergoing bAVR were significantly older (bAVR [69.8 years] vs. mAVR [62.7 years] p < .001]. The rates of mAVR decreased across all age groups during the study period (ptrend < .001), including patients ≤50 years (ptrend < .001). In-hospital mortality for mAVR recipients was higher, both after multivariable adjustment (OR 1.35 95% CI 1.26-1.45 p < .001) and propensity matching (mean difference 0.846% ± 0.19%). CONCLUSION: In the contemporary era, the utilization of mAVR has decreased across all age groups, including those younger than 50 years old. Although mAVR recipients were healthier with less comorbidities, inpatient mortality was higher after mAVR compared to bAVR. In addition to understanding causes for higher in-hospital mortality after mAVR, future research should focus on developing transcatheter valve replacement friendly bAVR.

Racial disparities in the treatment of aortic stenosis: Has transcatheter aortic valve replacement bridged the gap?

BACKGROUND: Racial disparities in outcomes and utilization of surgical aortic valve replacement (SAVR) for the treatment of severe aortic stenosis (AS) is well known. While transcatheter aortic valve replacement (TAVR) has become more widespread, its impact on racial disparities remains unclear. OBJECTIVES: Our goal was to assess the utilization of SAVR and TAVR and their clinical outcomes among various racial groups. METHODS: The National Inpatient database (2009-2015) was used to study the racial distribution of admissions for SAVR and TAVR, and their impact on inpatient outcomes. Survey estimation commands were used to determine weighted national estimates. RESULTS: There were 3,445,267; 294,108; and 52,913 inpatient visits for AS, SAVR, and TAVR, respectively. SAVR visits were 86% White, 3.8% Black, 5.5% Hispanic, 1.2% Asian/Pacific Islander (A/PI), 0.4% Native American (NA), and 2.9%; TAVR were 87.7% White, 3.7% Black, 3.8% Hispanic, 1.0% A/PI, 0.2% NA, and 3.5% Other while AS visits were 83.7% White, 6.7% Black, 5.3% Hispanic, 1.7% A/PI, 0.4% NA, and 2.2% Other. Racial minorities generally had more co-morbidities compared with Whites. After SAVR, Black patients had a higher unadjusted inpatient mortality than Whites, however, there was no difference after adjustment for other variables. A/PI were more likely to require a permanent pacemaker after SAVR. Need for blood transfusion was significantly higher among the minorities compared with Whites, except for NA, but there were no racial differences in stroke rates. There was no difference in inpatient mortality, pacemaker implantation, stroke, and bleeding after TAVR, but acute kidney injury occurred more often in Hispanics, A/PI, and "others" compared with Whites. CONCLUSIONS: Racial disparities in the treatment of AS continues in the contemporary era; however it was found that TAVR resulted in comparable inpatient outcomes, despite higher comorbidities, and adverse socioeconomic factors in minorities.

Reversible complete heart block in a patient with coronavirus disease 2019.

Patients infected with novel coronavirus (SARS-CoV-2) can present with a variety of arrhythmias. We report an unusual case of reversible complete heart block (CHB) in the setting of acute coronavirus disease 2019 (COVID-19). A 23-year-old male with a history of Hodgkin's Lymphoma presented with dizziness and syncope. He was found to be in CHB associated with hypotension requiring a transvenous pacemaker. Methylprednisolone and remdesivir were started with rapid resolution of the CHB. Further study is needed to determine the mechanism of CHB in COVID-19. This case underscores the importance of including COVID-19 in one's differential diagnosis for acute CHB.

Does the Presence of Significant Mitral Regurgitation prior to Transcatheter Aortic Valve Implantation for Aortic Stenosis Impact Mortality? - Meta-Analysis and Systematic Review.

BACKGROUND: Mitral regurgitation (MR) is commonly encountered in patients with severe aortic stenosis (AS). However, its independent impact on mortality in patients undergoing transcatheter aortic valve implantation (TAVI) has not been established. METHODS: We performed a systematic search for studies reporting characteristics and outcome of patients with and without significant MR and/or adjusted mortality associated with MR post-TAVI. We conducted a meta-analysis of quantitative data. RESULTS: Seventeen studies with 20,717 patients compared outcomes and group characteristics. Twenty-one studies with 32,257 patients reported adjusted odds of mortality associated with MR. Patients with MR were older, had a higher Society of Thoracic Surgeons score, lower left ventricular ejection fraction, a higher incidence of prior myocardial infarction, atrial fibrillation, and a trend towards higher NYHA class III/IV, but had similar mean gradient, gender, and chronic kidney disease. The MR patients had a higher unadjusted short-term (RR = 1.46, 95% CI 1.30-1.65) and long-term mortality (RR = 1.40, 95% CI 1.18-1.65). However, 16 of 21 studies with 27,777 patients found no association between MR and mortality after adjusting for baseline variables. In greater than half of the patients (0.56, 95% CI 0.45-0.66) MR improved by at least one grade following TAVI. CONCLUSION: The patients with MR undergoing TAVI have a higher burden of risk factors which can independently impact mortality. There is a lack of robust evidence supporting an increased mortality in MR patients, after adjusting for other compounding variables. MR tends to improve in the majority of patients post-TAVI.

Pulmonary vein antral isolation causes depolarization of vein sleeves: Implications for the assessment of isolation.

PURPOSE: Pulmonary vein isolation (PVI) for atrial fibrillation has been shown to result in inexcitability of a large fraction of pulmonary veins (PVs), but the mechanism is unknown. We investigated the mechanism of PV inexcitability by assessing the effects of PVI on the electrophysiology of PV sleeves. METHODS: Patients undergoing first-time radiofrequency PVI were studied. Capture threshold, effective refractory period (ERP), and excitability were measured in PVs and the left atrial appendage (LAA) before and after ablation. Adenosine was used to assess both transient reconnection and transient venous re-excitability. RESULTS: We assessed 248 veins among 67 patients. Mean PV ERP (249.7 ± 54.0 ms) and capture threshold (1.4 ± 1.6 mA) increased to 300.5 ± 67.1 and 5.7 ± 5.6 mA, respectively (P < .0001 for both) in the 26.9% PVs that remained excitable, but no change was noted in either measure in the LAA. In 16.3% of the 73.1% inexcitable veins, transient PV re-excitability (as opposed to reconnection) was seen with adenosine administration. CONCLUSIONS: Antral PVI causes inexcitability in a majority of the PVs, which can transiently be restored in some with adenosine. Among PVs that remain excitable, ERP and capture threshold increase significantly. These data imply resting membrane potential depolarization of the of PV myocardial sleeves. As PV inexcitability hampers the assessment of entrance and exit block, demonstrating transient PV re-excitability during adenosine administration helps ensure true isolation.

Surgical and endoscopic management of a pericardioesophageal fistula after radiofrequency pulmonary vein isolation.

INTRODUCTION: The most feared complication of pulmonary vein isolation (PVI) is an atrioesophageal fistula (AEF). While rare (0.1-0.25%), primary surgical closure (as opposed to esophageal stenting) is associated with lower mortality. Pericardioesophageal fistula (PEF) may present prior to fistulization into the atrium. Unfortunately, data on the optimal management of PEFs are lacking. CASE REPORT: Seventy-one-year-old male with AF presented with chest pain 3 weeks after radiofrequency PVI. Computed tomography angiography (CTA) chest and echocardiogram showed pneumopericardium. Barium esophagram showed extravasation from esophagus into the pericardium without connection to the left atrium. Sternotomy with mediastinal exploration exposed the pericardial defect, over which a CorMatrix patch was placed. The fistula was then stented endoscopically with endosuture fixation. Poststent esophagram did not show barium leak, and the patient was discharged home. One week later, the patient returned with enterococcal and candida bacteremia and an acute right parietal/occipital lobe infarct. Barium esophagram showed contrast extravasation into the pericardium. The patient rapidly succumbed to his illness and died. Autopsy revealed pericardial abscess posterior to the LA in communication with the esophagus. Extension to the LA was not seen. CONCLUSION: While the surgical treatment of AEF is relatively well established, there is no consensus in the management of PEF. While prior small series have suggested PEF may be managed with esophageal stenting, our case illustrates the limitations of this approach.

Is isolated ST segment elevation in Lead aVR associated with high grade coronary artery disease?

BACKGROUND: The diagnostic accuracy of lead aVR ST-segment elevation for left main or triple vessel disease (LM/3VD) has not been universally accepted. In the present analysis we sought to evaluate the diagnostic accuracy of STEaVR in patients presenting with an acute coronary syndrome (ACS). METHODS: Pooled sensitivity, specificity, positive, and negative likelihood ratios were calculated using a random effects model (DerSimonian-Laird Method) for computing summary estimates and receiver operator curve (ROC) analysis for evaluating overall diagnostic accuracy. RESULTS: This meta-analysis included 14 studies. The pooled sensitivity of STEaVR for LM/3VD was 0.40 (95% CI; 0.38 0.43, p < 0.001), specificity 0.82 (95% CI; 0.81-0.83, p < 0.001). Pooled positive likelihood ratio 2.49 (95% CI; 1.62-3.81, p < 0.001) and negative likelihood 0.54 (95% CI; 0.39-0.76, p < 0.001). The pooled sensitivity of STEaVR for LM was 0.39 (95% CI; 0.34-0.45, p < 0.001) specificity was 0.86 (95% CI; 0.85-0.87, p < 0.001) with an AUC of 0.79. The pooled positive likelihood ratio (LR) for LM was 2.78 (95% CI, 2.28-3.39, p < 0.001) negative likelihood ratio 0.51 (95% CI, 0.33-0.78, p < 0.001). CONCLUSION: Our study shows that in patients presenting with an ACS, presence of STEaVR may indicate the presence of LM or 3VD. STEaVR has a high specificity for both LM and 3VD, with a high pooled LR.

Does Caffeine Consumption Increase the Risk of New-Onset Atrial Fibrillation?

OBJECTIVE: Caffeine has been considered a trigger for atrial fibrillation (AF). We conducted a meta-analysis including a dose-response analysis to assess the relationship between caffeine consumed and incidence of AF. METHODS: Data from selected studies represented 176,675 subjects (AF in 9,987 [5.7%]). Caffeine content varied widely, ranging from 40 to 180 mg per cup of coffee. For purposes of the calculations in this study, we assumed 140 mg of caffeine in a standard 12-oz cup of coffee. RESULTS: No significant difference was found in AF incidence when the subjects consuming less than 2 cups of coffee per day were compared to subjects with higher consumption, 1.068 (0.937-1.216). The risk of AF was higher among subjects consuming less than 2 cups of coffee daily when compared to higher daily consumption subjects. A lower incidence of AF was found among people consuming more than 436 mg daily. CONCLUSION: The incidence of AF is not increased by coffee consumption. In fact, we found a lower incidence of AF when caffeine consumption exceeded 436 mg/day. Therefore, based on available evidence there is no association between caffeine intake and AF risk.

Novel function of α1D L-type calcium channel in the atria.

Ca entry through atrial L-type Calcium channels (α1C and α1D) play an important role in muscular contraction, regulation of gene expression, and release of hormones including atrial natriuretic peptide (ANP), and brain natriuretic peptide (BNP). α1D Ca channel is exclusively expressed in atria, and has been shown to play a key role in the pathogenesis of atrial fibrillation. Recent data have shown that the small conductance calcium-activated potassium channel, SK4 is also atrial specific and also contributes prominently to the secretion of ANP and BNP. However, its functional role in the heart is still poorly understood. Here we used α1D gene heterozygous (α1D+/-) mice and HL-1 cells to determine the functional contribution of SK4 channels to α1D-dependent regulation of ANP and BNP secretion in response to endothelin (ET), and/or mechanical stretch. Immunoprecipitation with α1D specific antibody and western blotting with SK4 specific antibody on the immuno-precipitated protein complex showed a band at 50 KDa confirming the presence of SK4 in the complex and provided evidence of interaction between SK4 and α1D channels. Using RT-PCR, we observed a 2.9 fold decrease in expression of Cacna1d (gene encoding α1D) mRNA in atria from α1D+/-mice. The decrease in α1D mRNA corresponded with a 4.2 fold decrease in Kcnn4 (gene encoding SK4) mRNA from α1D+/- mice. These changes were paralleled with a 77% decrease in BNP serum levels from α1D+/- mice. When α1D was knocked down in HL-1cardiomyocytes using CRISPR/Cas9 technology, a 97% decrease in secreted BNP was observed even in cells subjected to stretch and endothelin. In conclusion, our data are first to show that α1D Ca and SK4 channels are coupled in the atria, and that deletion of α1D leads to decreased SK4 mRNA and BNP secretion providing evidence for a novel role of α1D in atrial endocrine function. Elucidating the regulatory factors that underlie the secretory function of atria will identify novel therapeutic targets for treatment and prevention of cardiac arrhythmias such as atrial fibrillation.

Early Hemodynamic Changes during Head-Up Tilt Table Testing Can Predict a Neurocardiogenic Response in an African-American Patient Population.

BACKGROUND: Head-up tilt table testing (HUTT) is time-consuming and associated with increased patient morbidity. Hemodynamic changes that occur during the early phase of HUTT may be predictive of neurocardiogenic syncope. METHODS: A retrospective chart review was performed in 119 consecutive African Americans ( 57 ± 19) who underwent HUTT for evaluation of syncope of unknown etiology. Positive responses were defined as the development of symptoms linked with a systolic blood pressure (BP) <90 mm Hg, heart rate <50 b.p.m. or sinus arrest >3 s. Hemodynamic variables during the passive phase of HUTT were analyzed and results were then classified as a function of various predictors. RESULTS: Sixty-two subjects (52%) had positive HUTT, and 57 (48%) had negative HUTT. Early changes in BP variables from baseline significantly predicted HUTT responses (p < 0.05). There was also a significant interaction between age and BP. An algorithm based on age and BP was developed which had positive and negative predictive values of 67.7 and 93%, respectively, with an accuracy of 79.8%. CONCLUSION: A novel algorithm utilizing the patients' age and changes in both systolic and diastolic BP during the early phase of HUTT enables the prediction of HUTT results without the use of vasoactive stimulation, allowing for rapid diagnosis, decreased patient morbidity and reduction in costs.

Trends in the incidence, mortality and clinical outcomes in patients with ventricular septal rupture following an ST-elevation myocardial infarction.

BACKGROUND: Despite improvements in outcomes of ST elevation myocardial infarction (STEMI), ventricular septal rupture (VSR) remains a known complication, carrying high mortality. The contemporary incidence, mortality, and management of post-STEMI VSR remains unclear. METHODS: The National Inpatient Sample database (2009-2020) was used to study trends in admissions and outcomes of post-STEMI VSR over time. Survey estimation commands were used to determine weighted national estimates. RESULTS: There were 2 315 186 ±â€…22 888 visits for STEMI with 0.194 ±â€…0.01% experiencing VSR during 2009-2020 in the USA. Patients with VSR were more often older, white, female, and presented with an anterior STEMI; there was no difference in the rates of fibrinolysis. In-hospital mortality was 73.6 ±â€…1.8%, but only 29.2 ±â€…1.9 and 10 ±â€…1.2% received surgical repair and transcatheter repair (TCR), respectively. TCR was associated with higher and surgical repair with lower mortality. Days to surgery were longer for those who survived (5.9 ±â€…2.75) compared with those who died (2.44 ±â€…1). In a multivariable analysis, surgical repair at greater than or equal to day 4 was associated with lower in-hospital mortality (odds ratio = 0.39, 95% confidence interval: 0.17-0.88). CONCLUSION: Mortality in post-STEMI VSR remains high with no improvement over time. Most patients are managed conservatively, and the frequency of surgical repair has decreased, while TCR has increased over the study period. Despite design limitations and survival bias, surgical repair at greater than or equal to 4 days was associated with a lower mortality.

Effects of envelopes on cardiac implantable electronic device pocket healing: A head-to-head preclinical evaluation.

BACKGROUND: The healing response to cardiac implantable electronic device (CIED) implantation results in inflammation that can lead to fibrous pocket formation, which may disrupt pocket healing or complicate future interventions. OBJECTIVE: The purpose of this study was to assess CIED pocket healing with use of the second-generation TYRX absorbable antibacterial envelope (T2), the next-generation (NG) TYRX absorbable antibacterial envelope under development, and the CanGaroo® extracellular matrix envelope (ECM) compared to no envelope. METHODS: A total of 110 CIEDs were implanted in an ovine model, either with (T2, NG, or ECM) or without envelopes. Histopathologic and morphometric analyses were completed at several timepoints after implant (3 days, 7 days, 4 weeks, 12 weeks, 24 weeks). An independent pathologist completed a blinded histopathology assessment of the pockets. RESULTS: TYRX (T2/NG) pockets showed similar inflammatory and healing profiles to controls with more rapid provisional matrix formation compared to controls and ECM. ECM pockets exhibited increased acute (3 and 7 days) and chronic (24 weeks) inflammation. T2/NG had almost complete (T2) or complete (NG) absorption by week 12. ECM remained present at week 24 and was associated with significantly thicker capsules (ECM 0.80 ± 0.14 mm; NG 0.37 ± 0.10 mm; control 0.56 ± 0.17 mm). CONCLUSION: Compared to ECM, pockets with TYRX showed less inflammation, more rapid provisional matrix formation, faster absorption, and thinner capsules. TYRX pockets had low inflammation comparable to controls with accelerated provisional matrix deposition and tissue adhesion. The healing response to CIEDs used with TYRX fosters the formation of a well-healed pocket, which may bring patient benefit beyond its proven infection reduction.

Defibrillation waveform duration adjustment increases the proportion of acceptable defibrillation thresholds in patients implanted with single-coil defibrillation leads.

The aim of this study was to determine whether defibrillation waveform duration adjustment with single-coil defibrillation leads can be used to increase the proportion of patients with satisfactory defibrillation thresholds (DFTs). A retrospective analysis of the DFT levels for 105 patients with implantable cardioverter-defibrillator devices and a single-coil defibrillation lead was performed. Two groups of patients were compared: 34 patients who had undergone waveform tuning (group A) and 71 patients with a fixed-tilt waveform (group B). Additional data including demographics, etiology, New York Heart Association functional class, left ventricular ejection fraction, high-voltage lead impedance and medications were gathered to determine what effect these variables had on the DFT levels. Of the 34 patients who had undergone waveform adjustment (group A), 27 (79%) were found to have satisfactory DFTs, while 41 (58%) of the 71 patients with fixed-tilt devices (group B) had satisfactory DFTs. Waveform duration adjustment was found to significantly increase the proportion of patients with satisfactory DFTs (p = 0.03).

An Unusual Cause of AV Dyssynchrony: Dual AV Node Physiology With Retrograde Decremental Conduction.

A 71-year-old male with persistent atrial fibrillation and a dual chamber permanent pacemaker presented complaining of dyspnea on exertion, easy fatiguability, and intermittent cough. A 12-lead electrocardiogram revealed ventricular paced complexes, native QRS complexes, and irregular atrial activity. Herein we present an unusual mechanism of atrioventricular dyssynchrony. (Level of Difficulty: Intermediate.).

Racial Disparity Among Patients Undergoing Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Replacement in the United States.

Transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative to surgical aortic valve replacement (SAVR). However, racial disparities in the utilization of TAVR persist. This meta-analysis attempts to determine whether the prevalence of adverse outcomes (procedure-related complications) represent barriers to the use of TAVR among African Americans (AA). The TAVR cohort consisted of 89.6% Caucasian (C) and 4.7% AA, while the SAVR cohort included 86.9% C and 6.4% AA. The utilization rate (UR) of TAVR was 1.48 and .35 among C and AA, respectively, while the UR of SAVR was 1.44 and .48 among C and AA, respectively. Following TAVR, for AA the odds ratio (OR) was greater for stroke (OR = 1.22, P = .02) and transient ischemic attack (TIA) (OR = 1.57, P < .001) and lower for undergoing the insertion of a permanent pacemaker (OR = .81, P < .001). While there was a significant difference between C and AA in TAVR and SAVR utilization, outcomes between groups following TAVR are comparable; therefore, adverse outcomes do not appear to be a barrier to the use of TAVR among eligible AA.

A Survey of Antibiotic Use During Insertion of Cardiovascular Implantable Devices Among United States Implanters.

Antibiotic use for cardiovascular implantable devices (CIED) prophylaxis is well-accepted despite a paucity of data. Pre-procedural prophylaxis lowers the rate of CIED infections; however, data is lacking for intra- or post-procedural antibiotic use. Antibiotic-eluting envelopes (ENVELOPE) [TYRX®TM] have been shown to reduce post-procedural infections. Understanding implanter practices may provide insight as to the need for antibiotic stewardship. The purpose of this survey was to assess the practices of implanters nationally. A survey was completed by 150 implanters across the US. Participants were board certificated, implanters of CIEDs, with varying experience (1-25 years), in various hospital settings. Of the respondents, 97% reported routine use of systemic antibiotics pre-operatively. About two-thirds of implanters continue systemic antibiotics post-operatively, with half continuing antibiotics for >24 h; 83% of implanters add antibiotic to saline for the purpose of irrigating the wound; 55% routinely use ENVELOPE on approximately 38% of patients. Common reasons cited for ENVELOPE use were infection concerns, significant risk factors, prior device infection, and immunosuppressed status. Two-thirds of respondents use systemic antibiotics during generator changes, with >50% continuing antibiotics for >24 h. This study suggests wide variations in practice among implanters. Additional attention to existing guidelines and evidence regarding appropriate use of ENVELOPE is still needed.