Cardioneuroablation in a Woman with Ictal-Induced Cardiac Asystole

Background: Ictal-induced cardiac bradyarrhythmia and asystole is a rare phenomenon. The exact mechanism of ictal-induced cardiac bradyarrhythmia and asystole remains unclear. It was postulated that stimulation of central autonomic network during ictal episode may trigger an abrupt burst of hypervagotonia. Prolonged episode of cardiac bradyarrhythmia and asystole may result in syncope or death due to impairment of cerebral perfusion. The role of cardioneuroablation (CNA) in this condition has not been well-described in the literature. Objective(s): To describe a case of successful CNA in a patient with ictal-induced bradyarrhythmia and asystole. Method(s): n/a Results: A 47-year-old female has a 1.5-year history of intractable focal epilepsy and COVID-19 infection. She started having multiple episodes of seizures following a mild COVID-19 infection. Electroencephalogram (EEG) and brain MRI revealed right temporal onset seizures without structural lesions. Due to ongoing uncontrolled seizures with multiple semiologies despite multiple anti-epileptic drugs, she was admitted to Epilepsy Monitoring Unit for seizure classification. Her ictal EEGs (Figure 1) showed onset of ictal rhythm in the right temporal region with episodes of severe sinus bradycardia (15-30 bpm) and sinus pauses (15-16 seconds). Telemetry tracings demonstrated PP interval slowing with PR interval prolongation prior to the pauses consistent with a vagally-mediated mechanism. Cardiac electrophysiology team recommended CNA for treating the episodes of ictal-induced bradyarrhythmia and asystole. 3D anatomic maps of the right atrium (RA) and left atrium (LA) were created using CARTO system (Biosense Webster). Right superior ganglionated plexus (RSGP) was localized with fractionation mapping and intracardiac echocardiography guidance. RSGP was targeted from the RA using an irrigated radiofrequency catheter with power limit of 25 W. Post-ablations of RSGP, her heart rate increased from 60 - 99 bpm. Additional lesions were delivered from the LA site but no additional heart rate increase was not seen. An implantable loop recorder was implanted post-ablation procedure. During follow-up of 8 months, she had recurrent focal epilepsy, but no bradyarrhythmias or asystole was noted on her loop recorder. Resting heart rates at long-term follow up were between 70 - 100 bpm. Conclusion(s): This case highlights the utility of CNA in patient with ictal-induced cardiac bradyarrhythmia and asystole. CNA may be an approach to avoid permanent pacemakers in this population. [Formula presented]Copyright © 2023

An Otorhinolaryngology Perspective Into a Hospital COVID-19 Cluster

In this commentary, we share our experience of a COVID-19 cluster which developed within a frontline healthcare facility designated for treating COVID-19 patients. We provide an Otorhinolaryngology perspective into the key challenges, analyses and responses. We discuss how we identified and isolated infected patients and staff, uncovered the responsible COVID-19 variant strain B1.617.2 and instituted various measures to overcome this cluster. The measures include ceasing non-essential services, limiting transfers of patients, a heightened stance of personal protective equipment, ring-fencing of staff and enhanced COVID-19 testing. With rapid hospital wide efforts, there were no new non-isolated cases from our hospital cluster 3 days after the wards were locked down. The cluster which developed on 28-April-2021 was closed on 6-Jun-2021, with 48 cases, ten of whom were healthcare workers. Some of these lessons may be useful for consideration should another healthcare institution face a similar crisis in the future.Copyright © The Author(s) 2022.

Persistent respiratory failure in severe COVID-19 patients - A tertiary centre experience in Kuala Lumpur, Malaysia

Background: The evidence for management of severe COVID-19 with persistent respiratory failure (PRF) after acute treatment is scarce, despite some authors reported a good response to corticosteroid in histological proven secondary organising pneumonia (OP). Objective(s): This study aimed to study the disease course of COVID-19 patients with persistent respiratory failure, and its radiological pattern. Method(s): A single centre retrospective cohort study on severe COVID-19 patients was conducted from January 2021 to June 2021. All radiological imaging and data were retrieved from electronic database. Result(s): Severe COVID-19 pneumonia had a 78% (584/750) survival in our cohort. Among the survival, 48% (279/584) had PRF beyond 14 days of illness and 10% of them required oxygen therapy upon discharge. Eighty-six percent (240/279) of patients with PRF had a HRCT performed. Eighty percent (187/240) of them attended clinic follow up with 81% had a radiological pattern consistent with OP. The mean severity CT score was 10 (SD+/-3). [Jin C et al. Front Public Heal.2020;8] Seventy-eight percent of patients were perceived with WHO functional class of 1-2. Sixty-eight percent of patients (128/187) were given short course of prednisolone during admission with tapering doses. The mean prednisolone dose was 0.69mg/kg/day with a mean duration of 47 days (SD+/-18). Seventy-eight percent (146/187) had a follow up chest x-ray (CXR) at 12+/-8 weeks. Only 6.4% (12/187) of them had abnormal CXR findings whereby two patients were later confirmed to have pulmonary tuberculosis. Conclusion(s): Radiological pattern of OP is common in COVID-19 with PRF. HRCT is a non-invasive tool to assess this entity.

Implementing Systematic Screening Driven by Quality Improvement Education (QIE) for Atrial Fibrillation during the Covid-19 Pandemic: Insight from Primary Care Setting in the United States

Background: Asymptomatic patients with atrial fibrillation (AF) pose challenges to diagnosis. Early diagnosis can reduce morbidity and mortality. Systematic screening in primary care may result in early intervention. Objectives: We sought to examine the implementation outcomes of a systematic, team-based quality improvement education (QIE) intervention for AF screening in primary care during the COVID-19 pandemic. Methods: QIE intervention was implemented in academic-based (n=4) and community-based (n=2) practices to address COVID-19 challenges. Surveys administered by site identified existing approaches and provider teams developed screening protocol based on targeted education, deploying a mobile ECG device (Kardiamobile™). Patient charts were reviewed (Dec 2020-May 2021) to determine eligibility, i.e., patients aged 65-74 (with prior stroke/TIA or two other risk factors) or aged ≥75 (with one other risk factor) without prior AF. Patient EHR data were examined for demographic/clinical data and screening outcome. Provider interviews (n=12) and validation from representative patients (n=2) accounted for sustainability of outcomes. Results: A total of 1,221 patients were evaluated for AF risk, with 408 eligible for screening. Of these, 277 (68%) were female and CHA2DS2-VASc varied-score=3 (45%);score=4 (24%);score=5+ (31%). Patients (n=7;2%) who screened positive for AF were referred or started on anticoagulation, like other primary care studies. Figure 1 shows how systematic screening was re-imagined and implemented Satisfaction and engagement increased among providers and patients-attributed, in part, to benefits of team-based planning and targeted education. Conclusion: An AF screening program was adapted to improve patient care despite COVID-19 related challenges. A QIE toolkit was launched to assist primary care practices with implementing streamlined, sustainable, and patient-engaging strategies to reduce stroke.