A comparative study of the two leadless pacemakers in clinical practice.

INTRODUCTION: AVEIR-VR leadless pacemaker (LP) was recently approved for clinical use. Although trial data were promising, post-approval real world data with regard to its effectiveness and safety is lacking. To report our early experience with AVEIR-VR LP with regard to its effectiveness and safety and compare it with MICRA-VR. METHODS: The first 25 patients to undergo AVEIR-VR implant at our institution between June and November 2022, were compared to 25 age- and sex-matched patients who received MICRA-VR implants. RESULTS: In both groups, mean age was 73 years and 48% were women. LP implant was successful in 100% of patients in both groups. Single attempt deployment was achieved in 80% of AVEIR-VR and 60% of MICRA-VR recipients (p = 0.07). Fluoroscopy, implant, and procedure times were numerically longer in the AVEIR-VR group compared to MICRA-VR group (p > 0.05). No significant periprocedural complications were noted in both groups. Incidence of ventricular arrhythmias were higher in the AVEIR-VR group (20%) compared to the MICRA-VR group (0%) (p = 0.043). At 2 and 8 weeks follow-up, device parameters remained stable in both groups with no device dislodgements. The estimated battery life at 8 weeks was significantly longer in the AVEIR-VR group (15 years) compared to the MICRA-VR group (8 years) (p = 0.047). With 3-4 AVEIR-VR implants, the learning curve for successful implantation reached a steady state. CONCLUSION: Our initial experience with AVEIR-VR show that it has comparable effectiveness and safety to MICRA-VR. Larger sample studies are needed to confirm our findings.

Anatomical location of leadless pacemaker and the risk of pacing-induced cardiomyopathy.

BACKGROUND: It is unclear if the location of implantation of the leadless pacemaker (LP) makes a difference in the incidence of pacing-induced cardiomyopathy (PICM). AIM: The aim of this study was to compare the incidence of PICM based on the location of implantation of LP. METHODS: A total of 358 consecutive patients [women: 171 (48%), mean age: 73 ± 15 years] with left ventricular ejection fraction (EF) > 50%, who received an LP (Micra) between January 2017 and June 2022, formed the study cohort. Micra-AV and Micra-VR were implanted in 122 (34%) and 236 (66%) patients, respectively. Fluoroscopically, the location of implantation of LP in the interventricular septum (IS) was divided into two equal halves (apex/apical septum [AS] and mid/high septum [HS]). During follow-up, PICM was defined as an EF drop of ≥10%. RESULTS: LP was implanted in 109 (34%) and 249 (66%) patients at AS and HS locations, respectively. During a mean 18 ± 8 months follow-up, 28 patients (7.8%) developed PICM. Among the 249 patients with HS placement of LP, 10 (4%) developed PICM, whereas among the 109 patients with AS placement of LP, 18 (16.5%) developed PICM (p = .002). AS location was associated with a higher risk of PICM compared to HS locations (adjusted hazard ratio: 4.42, p < .001). CONCLUSION: AS location of LP was associated with a higher risk of PICM compared to HS placement. Larger randomized studies are needed to confirm our findings.

Look before you place: A bizarre ECG artifact due to lead placement.

The Electrocardiogram (ECG) is a readily available non-invasive test used in the evaluation of a patient with angina. ECG artifacts are common and stem from a number of different reasons including lead placement and must be identified to appropriately manage patients. We present the case of an elderly patient for whom an ECG was performed to evaluate chest pain showing an abnormal waveform concerning for an ST elevation myocardial infarction (STEMI). Closer inspection of the ECG revealed a characteristic pattern documented in the literature known as Aslanger's Sign seen when an ECG lead is placed over an artery.

Baseline and decline in device-derived activity level predict risk of death and heart failure in patients with an ICD for primary prevention.

BACKGROUND: Implanted defibrillators are capable of recording activity data based on company-specific proprietary algorithms. This study aimed to determine the prognostic significance of baseline and decline in device-derived activity level across different device companies in the real world. METHODS: We performed a retrospective cohort study of patients (n = 280) who underwent a defibrillator implantation (Boston, Medtronic, St. Jude, and Biotronik) for primary prevention at the University of Michigan from 2014 to 2016. Graphical data obtained from device interrogations were retrospectively converted to numerical data. The activity level averaged over a month from a week postimplantation was used as baseline. Subsequent weekly average activity levels (SALs) were standardized to this baseline. SAL below 59.4% was used as a threshold to group patients. All-cause mortality and death/heart failure were the primary end-points of this study. RESULTS: Fifty-six patients died in this study. On average, they experienced a 50% decline in SAL prior to death. Patients (n = 129) who dropped their SAL below threshold were more likely to be older, male, diabetic, and have more symptomatic heart failure. They also had a significantly increased risk of heart failure/death (hazard ratio [HR] 3.6, 95% confidence interval [95% CI] 2.3-5.8, P < .0001) or death (HR 4.2, 95% CI 2.2-7.7, P < .0001) compared to those who had sustained activity levels. Lower baseline activity level was also associated with significantly increased risk of heart failure/death and death. CONCLUSION: Significant decline in device-derived activity level and low baseline activity level are associated with increased mortality and heart failure in patients with an ICD for primary prevention.

Role of diabetes and insulin use in the risk of stroke and acute myocardial infarction in patients with atrial fibrillation: A Medicare analysis.

BACKGROUND: Atrial fibrillation (AF) is associated with elevated risk for ischemic stroke and myocardial infarction (MI). The aim of the study is to assess the role of insulin use on the risk of stroke and MI in AF patients with diabetes. METHODS: We identified Medicare beneficiaries with new AF in 2011 to 2013. Primary outcomes were ischemic stroke and MI. Multivariate Cox regression models were used to assess the association between AF and time to stroke and MI. We adjusted for anticoagulant as a time-dependent covariate. RESULTS: Out of 798,592 AF patients, 53,212 (6.7%) were insulin-requiring diabetics (IRD), 250,214 (31.3%) were non-insulin requiring diabetics (NIRD) and 495,166 (62%) were non-diabetics (ND). IRD had a higher risk of stroke when compared to NIRD (adjusted HR: 1.15, 95% CI 1.10-1.21) and ND (aHR 1.24, 95% CI 1.18-1.31) (P < .01 for both). The risk of stroke was higher in NIRD compared to ND (aHR 1.08, 95% CI 1.05-1.12). For the outcome of MI, IRD had a higher risk compared to NIRD (aHR 1.24, 95% CI 1.18-1.31) and ND (aHR 1.46, 95% CI 1.38-1.54)]. NIRD had a higher risk compared to ND (aHR 1.17, 95% CI 1.13-1.22). Anticoagulation were most effective at preventing stroke in ND [0.72 (0.69-0.75)], and NIRD [0.88 (0.85-0.92)], but were not associated with significant reduction in stroke in IRD [0.96 (0.89-1.04)]. CONCLUSION: There is an incremental risk of ischemic stroke and MI from non-diabetics to non-insulin diabetics with the highest risk in insulin users. Protective effect of anticoagulation is attenuated with insulin use.

Temporal trends of in-hospital complications associated with catheter ablation of atrial fibrillation in the United States: An update from Nationwide Inpatient Sample database (2011-2014).

BACKGROUND: Catheter ablation is widely accepted intervention for atrial fibrillation (AF) refractory to antiarrhythmic drugs, but limited data are available regarding contemporary trends in major complications and in-hospital mortality due to the procedure. This study was aimed at exploring the temporal trends of in-hospital mortality, major complications, and impact of hospital volume on frequency of AF ablation-related outcomes. METHODS: The Nationwide Inpatient Sample database was utilized to identify the AF patients treated with catheter ablation. In-hospital death and common complications including vascular access complications, cardiac perforation and/or tamponade, pneumothorax, stroke, and transient ischemic attack, were identified using International Classification of Disease (ICD-9-CM) codes. RESULT: In-hospital mortality rate of 0.15% and overall complication rate of 5.46% were noted among AF ablation recipients (n = 50,969). Significant increase in complications during study period (relative increase 56.37%, P-trend < 0.001) was observed. Cardiac (2.65%), vascular (1.33%), and neurological (1.05%) complications were most common. On multivariate analysis (odds ratio [OR]; 95% confidence interval [95% CI]; P value), significant predictors of complications were female sex (OR = 1.40; CI = 1.17-1.68; P value < 0.001), high burden of comorbidity as indicated by Charlson Comorbidity Index ≥2 (OR = 2.84; CI = 2.29-3.52; P value < 0.001), and low hospital volume (< 50 procedures). CONCLUSION: Our study noted a decline in AF ablation-related hospitalizations and complications associated with the procedure. These findings largely reflect shifting trends of outpatient performance of the procedure and increasing safety profile due to improved institutional expertise and catheter techniques.

Prognostic Value of Coronary Artery Calcium Score in Acute Chest Pain Patients Without Known Coronary Artery Disease: Systematic Review and Meta-analysis.

STUDY OBJECTIVE: Coronary artery calcium score (CACS) is a well-established test for risk stratifying asymptomatic patients. Recent studies also indicate that CACS may accurately risk stratify stable patients presenting to the emergency department (ED) with acute chest pain; however, many were underpowered. The purpose of this systematic review and meta-analysis is to evaluate the prognostic value and accuracy of a zero (normal) CACS for identifying patients at acceptable low risk for future cardiovascular events who might be safely discharged home from the ED. METHODS: We searched multiple databases for longitudinal studies of CACS in symptomatic patients without known coronary artery disease that reported major adverse cardiovascular events (MACEs), including death and myocardial infarction. Pooled risk ratios, sensitivity, specificity, and likelihood ratios were analyzed. RESULTS: Eight studies evaluated 3,556 patients, with a median follow-up of 10.5 months. Pooled prevalence of zero CACS was 60%. Patients with CACS=0 had a significantly lower risk of cardiovascular events compared with those with CACS greater than 0 (MACEs: relative risk 0.06, 95% confidence interval 0.04 to 0.11, I2=0%; death/myocardial infarction: relative risk 0.19; 95% confidence interval 0.08 to 0.47, I2=0%). The pooled event rates for CACS=0 (MACEs 0.8%/year; death/myocardial infarction 0.5%/year) were significantly lower than for CACS greater than 0 (MACEs 14.6%/year; death/myocardial infarction 3.5%/year). Analysis of summary testing parameters showed a sensitivity of 96%, specificity of 60%, positive likelihood ratio of 2.36, and negative likelihood ratio of 0.07. CONCLUSION: Acute chest pain patients without history of coronary artery disease, ischemic ECG changes, or increased cardiac enzyme levels commonly have a CACS of zero, with a very low subsequent risk of MACEs or death or myocardial infarction. This meta-analysis proffers the potential role of initial CACS testing for avoiding unnecessary hospitalization and further cardiac testing in acute chest pain patients with a CACS of zero.

Impact of access site choice on outcomes of patients with cardiogenic shock undergoing percutaneous coronary intervention: A systematic review and meta-analysis.

BACKGROUND: The benefit of transradial access (TRA) in patients with cardiogenic shock (CS) is uncertain. We sought to determine the benefits of TRA in patients with CS undergoing coronary angiography/intervention. METHODS: MEDLINE, Embase, Cochrane Central, and electronic databases were searched for studies that assessed the following: (1) patients with CS who underwent percutaneous coronary intervention (PCI) and (2) the association between choice of arterial access, 30-day all-cause mortality, and 30-day major adverse cardiac and cerebral events (MACCEs) using random-effects model. RESULTS: From 3,652 retrieved citations, 8 studies involving 8,131 patients with CS undergoing PCI (via TRA: 2,321 patients, via TFA: 5,810 patients) were included. Transradial access was associated with significantly reduced risk for all-cause mortality (unadjusted: risk ratio [RR] 0.60, 95% CI 0.52-0.71, P < .001, I(2) = 29%, 8 included studies; adjusted: RR 0.55, 95% CI 0.46-0.65, P < .001, I(2) = 0%, 6 included studies) and MACCE (unadjusted: RR 0.68, 95% CI 0.63-0.73, P < .001, I(2) = 0%, 6 included studies; adjusted: RR 0.63, 95% CI 0.52-0.75, P < .001, I(2) = 0%, 4 included studies) at 30 days when compared with TFA. CONCLUSIONS: Transradial access is associated with reduced mortality and MACCE at 30 days in patients with CS undergoing PCI. Considering the possible influence of selection bias on the effect estimate in our analysis, randomized controlled trials are needed to better assess this association.

Aspiration Thrombectomy in Patients Undergoing Primary Angioplasty for ST Elevation Myocardial Infarction: An Updated Meta-Analysis.

BACKGROUND: The Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in patients with STEMI (TOTAL trial) refuted the salutary effect of routine aspiration thrombectomy (AT) in PPCI for patients with ST-elevation myocardial infarction (STEMI). OBJECTIVES: We performed an updated meta-analysis to assess clinical outcomes with AT prior to PPCI compared with conventional PPCI alone including the additional trial data. METHODS AND RESULTS: Clinical trials (n = 20) that randomized patients (n = 21,281) with STEMI between Routine AT (n = 10,619) and PPCI (n = 10,662) were pooled. There was no difference in all-cause mortality between the 2 groups (RR: 0.89, 95%CI: 0.78-1.01, P = 0.08). Stratifying by follow up at 1-month (RR: 0.87, 95%CI: 0.69-1.10, P = 0.25), up to 6 months (RR: 0.91, 95%CI: 0.74-1.13, P = 0.39 and beyond 6 months (RR: 0.88, 95%CI: 0.74-1.05, P = 0.16) yielded similar results. There was a statistically significant increase risk of stoke rate in the AT arm (RR: 1.51, 95%CI: 1.01-2.25, P = 0.04). The 2 groups were similar with regards to target vessel revascularization (0.94, 95%CI: 0.83-1.06, P = 0.28) recurrent MI (RR: 0.96, 95%CI: 0.80-1.16, P = 0.68, MACE events (RR: 0.91 95%CI: 0.81-1.02, P = 0.11), early (0.59, 95%CI: 0.23-1.50, P = 0.27) and late (RR: 0.91, 95%CI: 0.69-1.18, P = 0.47) stent thrombosis and net clinical benefit (RR 0.99, 95%CI: 0.91-1.07, P = 0.76). CONCLUSION: Routine AT prior to PPCI in STEMI is associated with higher risk of stroke. There is no statistical difference in clinical outcome parameters of mortality, major adverse cardiac events, target vessel revascularization, stent thrombosis, and net clinical benefit between AT and PCI alone.

Effect of renal sympathetic denervation on apnea-hypopnea index in patients with obstructive sleep apnea: a systematic review and meta-analysis.

PURPOSE: Recent evidence associates sympathetic tone with severity of obstructive sleep apnea (OSA). Renal sympathetic denervation (RDN), by decreasing sympathetic tone, has the potential to decrease OSA severity. Small observational studies that assessed this hypothesis lacked precision. Hence, in this meta-analysis, we have attempted to pool available data from studies that have assessed the effect of RDN on OSA severity in patients with OSA. METHODS: Medline, Embase, Cochrane central, Ovid, Cinahl, web of science, and conference abstracts were searched for eligible citations by two independent reviewers using key words "renal denervation," "hypertension," and "obstructive sleep apnea." From a total of 2,863 identified citations, using meta-analysis of observational studies in epidemiology method, five studies were assessed eligible and included in the meta-analysis. RESULTS: All five studies followed an observational study design, involved patients with OSA and HTN, and reported an apnea-hypopnea index (AHI) 6 months post-RDN. Four were "before and after" studies and one compared continuous positive airway pressure with RDN. In the pooled analysis, involving 49 patients, RDN was associated with a significant reduction in mean AHI [weighted mean difference -9.61 (95 % CI -15.43 to -3.79, P = 0.001)] 6 months post-RDN. One study also reported improvement in oxygen desaturation index and Epworth sleepiness scale score 6 months post-RDN. CONCLUSIONS: RDN is associated with significant improvement in OSA severity. However, our results need validation in RCTs that assess effect of RDN in patients with OSA, which can potentially broaden the clinical applicability of RDN.

Role of dofetilide in patients with ventricular arrhythmias.

BACKGROUND OR PURPOSE: To assess effectiveness of dofetilide in reducing the burden of ventricular arrhythmias (VAs). BACKGROUND: Prior small sample studies show that dofetilide has benefit in reducing VA. However, large sample investigations with long-term follow-up are lacking. METHODS: Two hundred seventeen consecutive patients admitted between January 2015 and December 2021 for dofetilide initiation for control of VA were assessed. Dofetilide was successfully started in 176 patients (81%) and had to be discontinued in the remaining 41 patients (19%). Dofetilide was initiated for control of ventricular tachycardia (VT) in 136 patients (77%), whereas 40 (23%) patients were initiated on dofetilide for reducing the burden of premature ventricular complexes (PVCs). RESULTS: The mean follow-up was 24 ± 7 months. In total, among the 136 VT patients, 33 (24%) died, 11 (8%) received a left ventricular assist device (LVAD), and 3 (2%) received a heart transplant during follow-up. Dofetilide was discontinued in 117 (86%) patients due to lack of sustained effectiveness during follow-up. Dofetilide use was associated with similar odds of the composite outcome of all-cause mortality/LVAD/heart transplant (OR: 0.97, 0.55-4.23) in patients with ischemic cardiomyopathy (ICM) compared to those with non-ischemic cardiomyopathy (NICM). Dofetilide did not reduce PVC burden during follow-up in the 40 patients with PVCs (mean baseline PVC burden: 15%, at 1-year follow-up: 14%). CONCLUSIONS: Dofetilide use was less effective in reducing VA burden in our cohort of patients. Randomized controlled studies are needed to confirm our findings.

Safety and efficacy of direct oral anticoagulants in comparison to warfarin in obese patients with atrial fibrillation: A systematic review and meta-analysis.

Background and Aim: Obesity affects nearly 650 million adults worldwide, and the prevalence is steadily rising. This condition has significant adverse effects on cardiovascular health, increasing the risk of hypertension, coronary artery disease, heart failure, and atrial fibrillation (AF). While anticoagulation for obese patients with AF is a well-established therapy for the prevention of thromboembolism, the safety and efficacy of different anticoagulants in this specific population are not well explored. This meta-analysis aimed to compare direct oral anticoagulants (DOAC) to vitamin K antagonists in obese populations with AF. Methods: The PRISMA guidelines were followed for this meta-analysis, registered in PROSPERO (CRD42023392711). PubMed, PubMed Central, Embase, Cochrane Library, and Scopus databases were searched for relevant articles from inception through January 2023. Two independent authors screened titles and abstracts, followed by a full-text review in Covidence. Data were extracted in Microsoft Excel and analyzed using RevMan v5.4 using odds ratio as an effect measure. Results: Two thousand two hundred fifty-nine studies were identified from the database search, and 18 were included in the analysis. There were statistically significant reductions in the odds of ischemic and hemorrhagic stroke in the DOAC group compared with the VKA group (OR 0.70, CI 0.66-0.75) and (OR 0.47, CI 0.35-0.62), respectively. In addition, the DOAC group exhibited lower odds of systemic embolism (OR 0.67, CI 0.54-0.83), major bleeding (OR 0.62, CI 0.54-0.72), and composite outcome (OR 0.72, CI 0.63-0.81). Conclusion: Based on the findings from this meta-analysis, DOACs demonstrate superior safety and efficacy in obese patients with AF compared with VKAs. These results may have significant implications for guiding anticoagulation strategies in this patient population.

Direct oral anticoagulants (DOAC) versus vitamin K antagonist in left ventricular thrombus: An updated meta-analysis.

Background and Aims: Current clinical guidelines for treating left ventricular thrombus (LVT) are limited by inadequate evidence to inform the comparative efficacy of oral anticoagulants. In this meta-analysis, we aimed to compare the efficacy and safety of direct oral anticoagulants (DOAC) to vitamin K antagonists (VKA) in patients with LVT. Methods: Four standard databases were searched for relevant literature comparing the efficacy and safety between DOAC and VKA for LVT treatment, published before August 19, 2023. Both the randomized controlled trials and observational studies were included in the analysis. The outcomes of interest were the resolution of LVT, all-cause mortality, stroke, systemic embolism, and bleeding. Data from the selected studies were extracted and analyzed using RevMan 5.4 using odds ratio. Results: Among 3959 studies from the database search and bibliography review, 33 were included in the analysis. LVT resolution was observed in 72.59% in the DOAC group versus 67.49% in the VKA group (odds ratio [OR]: 1.28, confidence interval [CI]: 1.07-1.53). Mortality was lower in the DOAC group (11.71% vs. 18.56%) (OR: 0.60, CI: 0.36-1.00; borderline statistical significance). Likewise, bleeding events (9.60% vs. 13.19%) (OR: 0.65, CI: 0.52-0.81) and stroke (7.54% vs. 11.04%) (OR: 0.71, CI: 0.53-0.96) were also significantly lower in the DOAC group. Conclusion: DOAC use for LVT showed better thrombus resolution and reduced risk of bleeding and stroke compared to VKA. Likewise, DOAC use was associated with lower mortality with borderline statistical significance.

Efficacy and Safety of Pulsed Field Ablation in Atrial Fibrillation: A Systematic Review.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with high morbidity and mortality. AF treatment is guided by a patient-provider risk-benefit discussion regarding drug versus ablation or combination. Thermal ablation has a high rate of adverse events compared to pulsed field ablation (PFA). In this systematic review, we aimed to determine the safety and efficacy of PFA. METHODS: The electronic search for relevant articles in English was completed in PubMed, PubMed Central, Cochrane library, Scopus, and Embase databases till July 2022. The screening was completed via the use of Covidence software. The risk of bias assessment and data extraction from the included studies was performed, and the narrative synthesis was performed accordingly. RESULTS: A total of six studies were selected for review and 1897 patients receiving PFA were involved in these studies. Our review was focused on pulmonary vein isolation success, major adverse events, and arrhythmia recurrence. Successful pulmonary vein isolation (PVI) was completed in 100% of cases except in two studies. In one of them, six out of seven patients (86%) in the epicardial cohort had successful PVI. In the MANIFEST-PF survey, the acute PVI success rate was 99.9%. The major complications were rare and included pericardial tamponade, vascular complications requiring surgery, and stroke. The atrial arrhythmia recurrence was higher in the thermal group than in the PFA group (39% vs. 11%). CONCLUSIONS: The success rate of PVI by PFA is high, and major adverse events are low. PFA is found to decrease the recurrence of atrial arrhythmia compared to thermal ablation. Substantial randomized controlled trials (RCTs) are needed to validate the efficacy and safety of PFA over conventional methods.

Electric Cardioversion vs. Pharmacological with or without Electric Cardioversion for Stable New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: There is no clear consensus on the preference for pharmacological cardioversion (PC) in comparison to electric cardioversion (EC) for hemodynamically stable new-onset atrial fibrillation (NOAF) patients presenting to the emergency department (ED). METHODS: A systematic review and meta-analysis was conducted to assess PC (whether being followed by EC or not) vs. EC in achieving cardioversion for hemodynamically stable NOAF patients. PubMed, PubMed Central, Embase, Scopus, and Cochrane databases were searched to include relevant studies until 7 March 2022. The primary outcome was the successful restoration of sinus rhythm, and secondary outcomes included emergency department (ED) revisits with atrial fibrillation (AF), hospital readmission rate, length of hospital stay, and cardioversion-associated adverse events. RESULTS: A total of three randomized controlled trials (RCTs) and one observational study were included. There was no difference in the rates of successful restoration to sinus rhythm (88.66% vs. 85.25%; OR 1.14, 95% CI 0.35-3.71; n = 868). There was no statistical difference across the two groups for ED revisits with AF, readmission rates, length of hospital stay, and cardioversion-associated adverse effects, with the exception of hypotension, whose incidence was lower in the EC group (OR 0.11, 95% CI 0.04-0.27: n = 727). CONCLUSION: This meta-analysis suggests that there is no difference in successful restoration of sinus rhythm with either modality among patients with hemodynamically stable NOAF.

Outcome of In-Hospital Cardiac Arrest among Patients with COVID-19: A Systematic Review and Meta-Analysis.

BACKGROUND: Outcomes following in-hospital cardiac arrest (IHCA) in patients with COVID-19 have been reported by several small single-institutional studies; however, there are no large studies contrasting COVID-19 IHCA with non-COVID-19 IHCA. The objective of this study was to compare the outcomes following IHCA between COVID-19 and non-COVID-19 patients. METHODS: We searched databases using predefined search terms and appropriate Boolean operators. All the relevant articles published till August 2022 were included in the analyses. The systematic review and meta-analysis were conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. An odds ratio with a 95% confidence interval (CI) was used to measure effects. RESULTS: Among 855 studies screened, 6 studies with 27,453 IHCA patients (63.84% male) with COVID-19 and 20,766 (59.7% male) without COVID-19 were included in the analysis. IHCA among patients with COVID-19 has lower odds of achieving return of spontaneous circulation (ROSC) (OR: 0.66, 95% CI: 0.62-0.70). Similarly, patients with COVID-19 have higher odds of 30-day mortality following IHCA (OR: 2.26, 95% CI: 2.08-2.45) and have 45% lower odds of cardiac arrest because of a shockable rhythm (OR: 0.55, 95% CI: 0.50-0.60) (9.59% vs. 16.39%). COVID-19 patients less commonly underwent targeted temperature management (TTM) or coronary angiography; however, they were more commonly intubated and on vasopressor therapy as compared to patients who did not have a COVID-19 infection. CONCLUSIONS: This meta-analysis showed that IHCA with COVID-19 has a higher mortality and lower rates of ROSC compared with non-COVID-19 IHCA. COVID-19 is an independent risk factor for poor outcomes in IHCA patients.

Comparative assessment of safety with leadless pacemakers compared to transvenous pacemakers: a systemic review and meta-analysis.

BACKGROUND: Leadless pacemakers (LP) and transvenous pacemakers (TVP) are two stable pacing platforms currently available in clinical practice. Observational data show mixed results with regards to their comparative safety. This meta-analysis was aimed to evaluate the comparative safety of LP over TVP. METHODS: The study protocol was registered in PROSPERO registry (CRD42022325376). Six databases were searched for published literature from inception to April 12, 2022. RevMan 5.4.1 was used for statistical analysis. Odds ratio (OR) and mean difference were used to estimate the outcome with a 95% confidence interval (CI). RESULTS: A total of 879 studies were imported from the databases. Among these, 41 papers were screened for full text and 17 meet the inclusion criteria. Among them, pooled results showed 42% lower odds of occurrence of complications in the LP group (OR 0.58, CI 0.42-0.80) compared to TVP group. Notably, 70% lower odds of device dislodgment (OR 0.30, CI 0.21-0.43), 46% lower odds of re-intervention (OR 0.54, CI 0.45-0.64), 87% lower odds of pneumothorax (OR 0.13, CI 0.03-0.57), albeit, 2.65 times higher odds of pericardial effusion (OR 2.65, CI 1.49-4.70) were observed in the LP group. CONCLUSIONS: This meta-analysis showed LP to be a significantly safer modality compared to TVP, in terms of re-intervention, device dislodgment, pneumothoraxes, and overall complications. However, there were higher rates of pericardial effusion in the LP group. There was a diverse number of patients included, and all studies were observational. Randomized trials are needed to validate our findings.

Catheter ablation using pulmonary vein isolation with versus without left atrial posterior wall isolation for persistent atrial fibrillation: an updated systematic review and meta-analysis.

BACKGROUND: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF); however, the results are suboptimal for persistent AF. The left atrial posterior wall (LAPW) is thought to be a major additional area in initiation and perpetuation of persistent AF. Therefore, adjunctive ablation of the posterior wall may reduce AF recurrence in patients with persistent AF. OBJECTIVE: The objective of this study was to compare outcomes of catheter ablation in patients with persistent AF using PVI alone versus a combination of PVI and LAPW isolation. METHODS: Literature search was conducted in PubMed, PubMed Central, Scopus, and Embase since inception to February 2023. Screening of studies was done via Covidence software. Risk of bias assessment was done using appropriate tools. Data extraction and a narrative synthesis were carried out accordingly. RESULTS: Ten studies were included, of which five were randomized controlled trials. PVI with LAPW ablation group had significantly lower recurrence of overall atrial tachyarrhythmia (OR 0.47, CI 0.32-0.70) and AF (OR 0.39, CI 0.23-0.69). In sensitivity analysis, freedom from atrial arrhythmias was noted to be significantly higher in the PVI with LAPW ablation group (OR 2.22, CI 1.36-3.64). However, there was no significant difference in occurrence of atrial flutter (OR 1.36, CI 0.86-2.14) or with periprocedural adverse events (OR 1.10, CI 0.60-1.99). CONCLUSION: LAPW ablation, in addition to PVI, significantly improves the rates of arrhythmia freedom and reduces the recurrence of overall atrial tachyarrhythmia. There was no significant difference in atrial flutter or periprocedural adverse events.

Gender differences, outcomes and trends among nonagenarian with atrial fibrillation: insight from National Inpatient Sample database.

BACKGROUND: Nonagenarians (NG), individuals aged ≥ 90 years, constitute an increasing proportion of hospitalizations presenting with atrial fibrillation (AF). However, not much is known about demographics, clinical outcomes, and trends of hospitalizations. Therefore, we analyzed data about hospitalizations and clinical outcomes among NGs with AF over ten years from 2005 to 2014 using a publically available database, the National Inpatient Sample. METHODS: All hospitalizations and major outcomes of subjects ≥ 90 years with a primary diagnosis of AF (ICD-9-CM code 427.31) over a ten-year period were assessed in this study by multivariate logistic regression analysis. RESULTS: There were more females than males (176,268 females, 51,384 males) in this analysis. The number of hospitalizations for AF among NG increased by 50% (17,295 in 2005 to 25,830 in 2014). Males were more likely to undergo cardioversion (6.14% of males vs. 5.06% of females, P < 0.0001). Over this period, in-hospital mortality declined from 3.21% in 2005 to 2.38% in 2014 ( P = 0.0041), with higher in-hospital mortality in males (3.23% in males vs. 2.76% in females, P = 0.0138), mean length of hospitalization decreased from 4.53 days to 4.13 days (P < 0.0001), the prevalence of congestive heart failure fell from 0.48% to 0.23% ( P = 0.0257), and the use of anticoagulation increased from 6.09% to 14.54% (P < 0.0001). In a multivariate analysis, hospital admission on the weekend, Elixhauser comorbidity index, CHA 2DS2VASc score, acute respiratory failure, and the length of hospital stay were associated with a higher risk of in-hospital mortality. CONCLUSIONS: From 2005 to 2014, AF-related hospitalizations among NGs increased, more so in in females population, mortality trends improved, rates of anticoagulation increased, and cardioversions increased. Despite the decreasing trend of in-hospital mortality since 2005, the relatively high mortality rate in males warrants further studies.

Catheter ablation of the left and right atrial appendages without isolation in persistent atrial fibrillation.

BACKGROUND: Electrical isolation of the left atrial appendage (LAA) improves outcomes of patients with persistent atrial fibrillation (AF) but may increase the risk of thromboembolism. OBJECTIVE: The purpose of this study was to describe a method to map and ablate appendage drivers without complete electrical isolation. METHODS: One hundred thirteen patients underwent an ablation procedure for persistent AF. The procedure was performed during AF and consisted of pulmonary vein and posterior LA isolation as well as ablation of the LAA. The right atrium (RA) was targeted in patients with a right-to-left gradient in cycle length (CL). The end point of appendage ablation was CL slowing or AF termination but not complete isolation. RESULTS: Among the 113 patients (mean age 64.6 ± 8.6 years; ejection fraction 54% ± 13%; LA diameter 46 ± 6.5 mm), radiofrequency ablation terminated AF in 51 patients (45%). RA ablation was performed in 41 patients (36%) at the index or repeat procedure. The mean AF CL in the RA appendage (RAA) was shorter than that in the LAA (160 ± 32 ms vs 186 ± 29 ms; P < .01) in these patients. The most frequent target in the RA was the RAA (CLs approaching 50-60 ms). Discontinuing radiofrequency ablation upon AF termination or conduction slowing prevented LAA isolation. After a mean follow-up of 24 ± 15 months, 89 patients (78%) remained arrhythmia-free without antiarrhythmic medications. CONCLUSION: An ablation strategy guided by the AF CL addresses LAA drivers without complete electrical isolation and also helps identify the RAA as a source of persistent AF.