Impact of risk-factor modification on arrhythmia recurrence among morbidly obese patients undergoing atrial fibrillation ablation.

BACKGROUND: Morbid obesity is associated with prohibitively high arrhythmia recurrence rates following atrial fibrillation (AF) ablation. DESIGN: This was a single-center study comprising 239 patients with morbid obesity and symptomatic paroxysmal or persistent AF undergoing AF ablation compared to 239 patients with a body mass index less than 30 kg/m2 matched based on age, sex, ejection fraction, AF type, presence and type of heart failure, and left atrial volume index. METHODS: Our primary outcome of interest was arrhythmia recurrence. RESULTS: During a mean follow-up of 29 months, arrhythmia recurrence was observed in 65% of the morbidly obese cohort compared to 27% of the control group (P < .0001). Among those with morbid obesity, sleep apnea screening, and treatment (91% vs 40%; P < .0001), blood pressure control (62% vs 53%; P = .001), glycemic control (85% vs 56%; P = .004), and weight loss more than equal to 5% (33% vs 57% in those who lost less than 5% and 83% in those who gained weight, P < .0001) were associated with lower arrhythmia recurrence. Recurrent arrhythmia was observed in one (4%) patient who accomplished all four goals, compared to 36% who achieved 3 of 4, 85% who modified 2 of 4%, and 97% of those who modified zero or one risk-factor. Risk-factor modification (RFM) was also associated with substantial reductions in the need for repeat ablation or direct-current cardioversion and arrhythmia-related hospitalization (P < .0001). CONCLUSION: RFM through pragmatic noninvasive means such as blood pressure and glycemic control, sleep apnea screening and treatment, and weight loss is associated with substantially lower rates of recurrent arrhythmia among morbidly obese patients undergoing AF ablation.

Vacuum-assisted inferior vena cava thrombus removal using a percutaneous technique.

We report a patient with a massive inferior vena cava (IVC) thrombus requiring immediate intervention. The patient underwent successful thrombectomy using a percutaneous catheter aspiration system. Percutaneous removal of an IVC thrombus is a safe and effective treatment option for severely ill patients.

Perforated tricuspid valve leaflet resulting from defibrillator leads: a review of the literature.

Tricuspid valve (TV) perforation is a rare complication after implantable cardioverter defibrillator (ICD) and permanent pacemaker implantation. In reported cases of lead-related TV perforations, patients' present with symptoms months to years postimplantation. We describe a case where a patient presented with signs of severe TV regurgitation secondary to traumatic perforation of the septal leaflet two weeks after ICD implantation and review of the literature associated with this complication.

Remote Monitoring of Permanent Pacemakers and Implantable Cardioverter Defibrillators.

Remote monitoring of permanent pacemakers and implantable cardiac defibrillators has undergone considerable advances over the past several decades. Advancement of technology has created the ability for remote monitoring of implantable cardiac devices; a device can monitor its own function, record arrhythmias, and transmit data to health care providers without frequent in-office checks, shown to be as safe as in-office interrogation. Remote monitoring allows earlier detection of clinically actionable events, reduces incidence of inappropriate shocks, and allows earlier detection of atrial fibrillation. App-based remote monitoring provides patients with rapid access to their cardiac data, which may improve compliance with remote monitoring.

Clinical Characteristics and Outcomes of Non-ICU Hospitalization for COVID-19 in a Nonepicenter, Centrally Monitored Healthcare System.

BACKGROUND: The clinical characteristics and outcomes associated with non-intensive care unit (non-ICU) hospitalizations for coronavirus disease 2019 (COVID-19) outside disease epicenters remain poorly characterized. METHODS: Systematic analysis of all non-ICU patient hospitalizations for COVID-19 completing discharge between March 13 and May 1, 2020, in a large US health care system utilizing off-site central monitoring. Variables of interest were examined in relation to a composite event rate of death, ICU transfer, or increased oxygen requirement to high-flow nasal cannula, noninvasive ventilation, or mechanical ventilation. RESULTS: Among 350 patients (age, 64 ± 16 years; 55% male), most (73%) required 3 L/min or less of supplemental oxygen during admission. Telemetry was widely utilized (79%) yet arrhythmias were uncommon (14%) and were predominantly (90%) among patients with abnormal troponin levels or known cardiovascular disease. Ventricular tachycardia was rare (5%), nonsustained, and not associated with hydroxychloroquine/azithromycin treatment. Adverse events occurred in 62 patients (18%), including 22 deaths (6%), 48 ICU transfers (14%), and 49 patients with increased oxygen requirement (14%) and were independently associated with elevated C-reactive protein (odds ratio, 1.09 per 1 mg/dL; 95% CI, 1.01-1.18; P = .04) and lactate dehydrogenase (OR, 1.006 per 1U/L; 95% CI, 1.001-1.012; P = .03) in multivariable analysis. CONCLUSION: Among non-critically ill patients hospitalized within a nonepicenter health care system, overall survival was 94% with the development of more severe illness or death independently associated with higher levels of C-reactive protein and lactate dehydrogenase on admission. Clinical decompensation was largely respiratory-related, while serious cardiac arrhythmias were rare, which suggests that telemetry can be prioritized for high-risk patients.

Cardiac Resynchronization Therapy With or Without Defibrillation in Patients With Nonischemic Cardiomyopathy: A Systematic Review and Meta-Analysis.

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Transforming patient and family access to medical information: utilisation patterns of a patient-accessible electronic health record.

OBJECTIVE: The purpose of this study was to evaluate the utilisation of a web-based multimedia patient-accessible electronic health record, for patients with congenital cardiac disease. PATIENTS AND METHODS: This was a prospective analysis of patients undergoing congenital cardiac surgery at a single institution from 1 September, 2006 to 1 February, 2009. After meetings with hospital administration, physicians, nurses, and patients, we configured a subset of the cardiac program's web-based clinical electronic health record for patient and family access. The Electronic Health Record continuously measured frequency and time of logins, logins during and between hospitalisations, and page views by type (imaging versus textual data). RESULTS: Of the first 270 patients offered access to the system, 252 became users (93% adoption rate). System uptime was 99.9%, and no security breaches were reported. Users accessed the system more often while the patients were in hospital (67% of total logins) than after discharge (33% of total logins). The maximum number of logins by a family was 440, and the minimum was 1. The average number of logins per family was 25. Imaging data were viewed significantly more frequently than textual data (p 0.001). A total of 12 patients died during the study period and 11 members of their families continued to access their Electronic Health Records after the date of death. CONCLUSIONS: A web-based Patient Accessible Electronic Health Record was designed for patients with congenital cardiac disease. The adoption rate was high, and utilisation patterns suggest that the Electronic Health Record could become a useful tool for health information exchange.

Prevalence, Incidence, and Impact on Mortality of Conduction System Disease in Transthyretin Cardiac Amyloidosis.

Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognized infiltrative cardiomyopathy in which conduction system disease is common. The aim of our study was to define the incidence and prevalence of high-grade atrioventricular (AV) block requiring pacemaker implantation in our quaternary referral center. This was a single-center retrospective cohort study of 369 consecutive patients with ATTR-CA who underwent 12-lead electrocardiogram at the time of ATTR-CA diagnosis. During a mean follow-up of 28 months, serial ECGs and the electronic medical record were examined for the development of high-grade AV block and pacemaker implantation. Wild-type ATTR-CA (wtATTR-CA) was diagnosed in 261 patients and 108 had hereditary ATTR-CA (hATTR-CA). A total of 35 (9.5%) had high-grade AV block requiring pacemaker implantation at the time of diagnosis of ATTR-CA. The most common conduction abnormalities evident on the baseline ECG were a wide QRS complex, present in 51% with wtATTR-CA and 48% with hATTR-CA (p = 0.62), followed by first-degree AV block, which was present in 49% with wtATTR-CA and 43% with hATTR-CA (p = 0.31). During follow-up, high-grade AV block developed in 10% of those with hATTR-CA and 12% of patients with wtATTR-CA (p = 0.64). On multivariable models, high-grade AV block was not significantly associated with increased mortality. More advanced ATTR-CA stage and a history of obstructive coronary artery disease were associated with increased mortality on multivariable models. In conclusion, the incidence and prevalence of high-grade AV block is high in patients with ATTR-CA. Patients with ATTR-CA require close monitoring during follow-up for the development of conduction system disease.

Impact of Nonalcoholic Fatty Liver Disease on Arrhythmia Recurrence Following Atrial Fibrillation Ablation.

OBJECTIVES: This study sought to investigate the association between nonalcoholic fatty liver disease (NAFLD) and arrhythmia recurrence following atrial fibrillation ablation; and to examine the impact of NAFLD stage on outcomes. BACKGROUND: Metabolic derangements, including obesity and diabetes, are associated with incident and recurrent atrial fibrillation (AF), in addition to the development of NAFLD. METHODS: This was a retrospective study of 267 consecutive patients undergoing AF ablation, 89 of whom were diagnosed with NAFLD prior to ablation and matched in a 2:1 manner based on age, sex, body mass index, ejection fraction, and AF type with 178 patients without NAFLD. Patients were monitored for arrhythmia recurrence during a mean follow-up of 29 months. RESULTS: Recurrent arrhythmia was observed in 50 (56%) patients with NAFLD compared with 37 (21%) without NAFLD. Epicardial fat volume was measured on computed tomography and was significantly higher among those with NAFLD (248 ± 125 ml vs. 223 ± 97 ml; p = 0.01). On multivariable models adjusting for sleep apnea, body mass index, heart failure, AF type, and left atrial size, NAFLD was independently associated with increased rates of arrhythmia recurrence (hazard ratio: 3.010; 95% confidence interval: 1.980 to 4.680; p < 0.0001). CONCLUSIONS: NAFLD is associated with significantly increased arrhythmia recurrence rates following AF ablation. Identification and reversal, where possible, may result in improved arrhythmia-free survival.

Geographic Trends, Patient Characteristics, and Outcomes of Infective Endocarditis Associated With Drug Abuse in the United States From 2002 to 2016.

Background There has been an increase in the prevalence of drug abuse (DA) in the national opioid epidemic. With increasing DA, there is an increased risk of infective endocarditis (IE). There are limited recent data evaluating national trends on the incidence and geographical distribution of DA-IE. We aim to investigate those numbers as well as the determinants of outcome in this patient population. Methods and Results Hospitalized patients with a primary or secondary diagnosis of IE based on the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9, ICD-10) were included. We described the national and geographical trends in DA-IE. We also compared DA-IE patients' characteristics and outcomes to those with IE, but without associated drug abuse (non-DA-IE) using Poisson regression models. Incidence of DA-IE has nearly doubled between 2002 and 2016 All US regions were affected, and the Midwest had the highest increase in DA-IE hospitalizations (annual percent change=4.9%). Patients with DA-IE were younger, more commonly white males, poorer, had fewer comorbidities, and were more likely to have human immunodeficiency virus, hepatitis C, concomitant alcohol abuse, and liver disease. Their length of stay was longer (9 versus 7 days; P<0.001) and were more likely to undergo cardiac surgery (7.8% versus 6.2%; P<0.001), but their inpatient mortality was lower (6.4% versus 9.1%; P<0.001). Conclusions DA-IE is rising at an alarming rate in the United States. All regions of the United States are affected, with the Midwest having the highest increase in rate. Young-adult, poor, white males were the most affected.

Dynamic Relation of Changes in Weight and Indices of Fat Distribution With Cardiac Structure and Function: The Dallas Heart Study.

BACKGROUND: Obesity may increase heart failure risk through cardiac remodeling. Cross-sectional associations between adiposity and cardiac structure and function have been elucidated, but the impact of longitudinal changes in adiposity on cardiac remodeling is less well understood. METHODS AND RESULTS: Participants in the Dallas Heart Study without cardiovascular disease or left ventricular dysfunction underwent assessment of body weight, anthropometrics, and cardiac magnetic resonance imaging at baseline and 7 years later. Associations between changes in indices of generalized and central adiposity with changes in left ventricular mass, volume, mass/volume ratio (concentricity), wall thickness, and ejection fraction were assessed using multivariable linear regression. The study cohort (n=1262) mean age was 44 years with 57% women, 44% black, and 36% obese participants. At follow-up, 41% had ≥5% weight gain, and 15% had ≥5% weight loss. Greater weight gain was associated with younger age, lower risk factor burden, and lower body mass index at baseline. In multivariable models adjusting for age, sex, race, comorbid conditions at baseline and follow-up, baseline adiposity, and cardiac measurement, increasing weight was associated with increases in left ventricular mass (ß=0.10, P<0.0001), wall thickness (ß=0.10, P<0.0001), and concentricity (ß=0.06, P=0.002), with modest effects on end-diastolic volume (ß=0.04, P=0.044) and ejection fraction (ß=0.05, P=0.046). Similar results were seen with other adiposity indices. CONCLUSIONS: Concentric left ventricular remodeling is the predominant phenotype linked to increasing adiposity in middle age. Our findings support the importance of weight management to prevent secular changes in adiposity, concentric remodeling, and eventual heart failure over time.