Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter.

OBJECTIVE: We aimed to compare cryoballoon pulmonary vein isolation (PVI) with standard radiofrequency cavotricuspid isthmus (CTI) ablation as first-line treatment for typical atrial flutter (AFL). METHODS: Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter was an international, multicentre, open with blinded assessment trial. Patients with CTI-dependent AFL and no documented atrial fibrillation (AF) were randomised to either cryoballoon PVI alone or radiofrequency CTI ablation. Primary efficacy outcome was time to first recurrence of sustained (>30 s) symptomatic atrial arrhythmia (AF/AFL/atrial tachycardia) at 12 months as assessed by continuous monitoring with an implantable loop recorder. Primary safety outcome was a composite of death, stroke, tamponade requiring drainage, atrio-oesophageal fistula, pacemaker implantation, serious vascular complications or persistent phrenic nerve palsy. RESULTS: Trial recruitment was halted at 113 of the target 130 patients because of the SARS-CoV-2 pandemic (PVI, n=59; CTI ablation, n=54). Median age was 66 (IQR 61-71) years, with 98 (86.7%) men. At 12 months, the primary outcome occurred in 11 (18.6%) patients in the PVI group and 9 (16.7%) patients in the CTI group. There was no significant difference in the primary efficacy outcome between the groups (HR 1.11, 95% CI 0.46 to 2.67). AFL recurred in six (10.2%) patients in the PVI arm and one (1.9%) patient in the CTI arm (p=0.116). Time to occurrence of AF of ≥2 min was significantly reduced with cryoballoon PVI (HR 0.46, 95% CI 0.25 to 0.85). The composite safety outcome occurred in four patients in the PVI arm and three patients in the CTI arm (p=1.000). CONCLUSION: Cryoballoon PVI as first-line treatment for AFL is equally effective compared with standard CTI ablation for preventing recurrence of atrial arrhythmia and better at preventing new-onset AF. TRIAL REGISTRATION NUMBER: NCT03401099.

Atrial Flutter in Particular Patient Populations.

"Despite being one of the best understood cardiac arrhythmias, the clinical meaning of atrial flutter varies according to the specific context, and its optimal treatment may be limited by both the suboptimal response to rate/rhythm control drugs and by the complexity of the underlying substrate. In this article, we present a state-of-the-art overview of mechanisms, prognostic impact, and medical/interventional management options for atrial flutter in several specific patient populations, including heart failure, cardiomyopathies, muscular dystrophies, posttransplant patients, patients with respiratory disorders, athletes, and subjects with preexcitation, aiming to stimulate further research in this challenging field and facilitate appropriate patient care."

Admissions to the Emergency Department Due to Atrial Fibrillation/Atrial Flutter Incidents during the Third Wave of COVID-19 Pandemic.

(1) Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection increases the risk of atrial fibrillation/flutter (AF/AFL) incident. The study aimed to present the characteristics of admissions to the emergency department (ED) due to AF/AFL incidents during the third COVID-19 pandemic wave. (2) Methods: A retrospective analysis of the medical records of the ED patients: 8399 during 3 months of the second and 11,144 during the 3 months of the third pandemic wave. (3) Results: SARS-CoV-2 positive patients there were 295 (3.5%) during the second wave and 692 (6.2%) during the third wave (p < 0.001). Among patients with SARS-CoV-2 infection, there were 44 (14.9%) patients with known AF/AFL during the second wave and 75 (10.8%) during the third wave, respectively (0.07). There were 116 visits with a diagnosis of AF/AFL incident during the third wave (study group) and 76 visits during the second wave (control group). The SARS-CoV-2 test was positive in 11 (9.5%) visits in the study group and in 1 (1.3%) visit in the control group p = 0.047. During the third wave, the patients with AF/AFL incidents with positive tests were older and more often had new-onset AF/AFL than those with negative tests: 76.3 (13.2) years vs. 71.8 (12.6) years; and 4 (36.4%) patients vs. 7 (7.6%) patients, respectively. (5) Conclusions: During the third pandemic wave, the number of patients with SARS-CoV-2 infection increased in comparison to the second wave. Additionally, among patients with AF/AFL incidents, the percentage of SARS-CoV-2-positive patients increased. During the third wave, the patients with positive tests and AF/AFL incident were older and more often had new-onset AF/AFL than those with AF/AFL incident and negative test which indicate the arrhythmogenic effect at the onset of the disease, especially in the older population.

Hidden in plain sight: A case of arrhythmia and sudden cardiac failure masked by COVID-19 positivity

Background and Aim: Whilst most commonly recognised as a res-piratory pathogen, COVID-19 can also result in a variety of extrapulmonary manifestations including myocardial dysfunction and arrhythmia. We report a case of a 15 year old girl with repaired atrioventricular septal defect, presenting with arrhythmia and sud-den severe cardiac failure masked by COVID-19 positivity. Method(s): A 15 year old girl with repaired atrioventricular septal defect and tetralogy of Fallot, under regular follow up with asymp-tomatic moderate to severe atrioventricular valve dysfunction, pre-sented with one month's history of progressive breathlessness to her local hospital. Onset of illness coincided with typical COVID-19 symptoms;her family, attributing her deterioration to this, delayed seeking medical help. She was rapidly referred to our unit. The heart failure severity, which included diffuse dependent oedema, large pleural effusion and severe biventricular dysfunc-tion, could not be attributed to major valve function change. Moreover, deterioration had occurred rapidly without apparent ongoing cause, after extensive diagnostics. Tachyarrhythmia was suspected;initial adenosine challenge via peripheral vein was inconclusive. Diuretics, inotrope and empirical administration of amiodarone provided limited response;the patient was therefore ventilated, enabling further adenosine challenge via central line, which revealed atrial flutter. Shortly after conversion to sinus rhythm and pleural drainage, her biventricular function improved to near normal. Result(s): Redo surgery was undertaken. Firstly, this included mechanical valve replacement of left and right atrioventricular valves and ablation of the isthmus. Secondly, a permanent pace-maker was inserted a few days later. The patient made a quick and uneventful recovery and was discharged on day 10 with good biventricular function on minimal medical therapy and no symptoms. Conclusion(s): Our case highlights delayed presentation as a hidden effect of the COVID-19 pandemic, and that sudden deterioration in stable children with repaired congenital heart disease should prompt the clinician to exclude all reversible causes of de-stabili-sation, and in particular to maintain high suspicion of arrhythmia.

Pleural and pericardial effusions with cardiac conduction system and myocardial involvement: A rare presentation of sarcoidosis.

Sarcoidosis is a granulomatous immune disorder that can infiltrate many organ systems. When the cardiac system is involved, the myocardium and conduction system are frequently affected. We report the case of a patient presenting with complete heart block following cardioversion from atrial flutter accompanied by pleural and pericardial involvement whose diagnosis of sarcoidosis was subsequently made on pathological examination. Pericardial effusion and pleural effusion are rare manifestations of sarcoid, and the both of them happening simultaneously (less than 10 case reports) in conjunction with cardiac conduction system and myocardial involvement are almost nonexistent in the literature (one case report). As cardiac involvement in sarcoid can drastically increase the mortality, it is important to be vigilant for the diverse manifestations of cardiac involvement in all patients for which there is clinical suspicion of sarcoid.

Acute COVID-19-Associated Cardiac Arrhythmia: A Case Series and Literature Review.

Coronavirus disease 2019 (COVID-19) is a highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We report two cases of COVID-19-associated atrial fibrillation (AF) in two elderly females and a case of atrial flutter (AFlutter) in a middle-aged male patient. We believe this case series will contribute to the literature on new-onset AF and AFlutter in patients with acute COVID-19 infection. This case series illustrates various case scenarios of patients developing cardiac arrhythmia with acute COVID-19 infection without any prior history or other explicable cause of AF/AFlutter. The exact mechanism behind COVID-19 infection leading to AF or AFlutter is still unknown. Of the three patients reported, two converted to sinus rhythm following medical management, and one did not convert to sinus rhythm despite medical treatment.

Wilms tumor with Mulibrey Nanism: A case report and review of literature.

BACKGROUND: Mulibrey-Nanism (Muscle-liver-brain-eye Nanism = dwarfism; MUL) is a rare genetic syndrome. The underlying TRIM37 mutation predisposes these children to develop tumors frequently. In the largest published series of MUL, 8% patients were reported to develop Wilms tumor (WT). The published literature lacks data regarding the best treatment protocol and outcome of this cohort of children with WT and MUL. We report here a 2-year-old boy with WT and MUL and present a review of literature on WT in MUL. CASE: Our patient had associated cardiac problems of atrial septal defect, atrial flutter and an episode of sudden cardiac arrest. We managed him successfully with chemotherapy, surgery and multi-speciality care. He is alive and in remission at follow-up of 6 months. CONCLUSION: A total of 14 cases (including present case) of WT have been reported in MUL and treatment details were available for six cases. They were managed primarily with surgery, chemotherapy with/without radiotherapy, and all achieved remission. The outcome data is available only for two cases, one has been followed up till 15 years post treatment for WT and other is our patient.

The Management of Acute Onset Complete Heart Block and Atrial Flutter in a Patient with COVID-19.

Coronavirus disease (COVID-19) has infected millions of people worldwide. Its cardiac presentations include myocarditis, arrhythmias and structural heart changes even in young and healthy individuals. The long-term sequelae of these manifestations are unknown. We describe a unique combination of complete heart block and atrial flutter in the setting of COVID-19. SARS-CoV-2 virulence mechanisms can cause fibrosis in the myocardium resulting in loss of sinus node dominance. The paradoxical finding of atrial flutter and complete heart block is very rare. Prompt cardiac evaluation and electrophysiological testing are important. Cardiac magnetic resonance imaging (cMRI) and endomyocardial biopsies are the gold standard investigations. Anticoagulation should be administered until atrioventricular synchrony is achieved. LEARNING POINTS: Simultaneous atrial flutter and third-degree atrioventricular block (AVB) caused by COVID-19 infection should be treated with a pacemaker according to heart block guidelines.During the COVID-19 pandemic, we recommend leadless pacemaker implantation for third-degree AVB as it has a lower risk of infection compared with traditional percutaneous procedures.Due to a lack of long-term data, patients with cardiac manifestations from COVID-19 require close follow-up with individualized surveillance schedules.

Anticoagulated de novo atrial flutter complicated by transitory ischemic attack in fatal COVID-19.

SARS-CoV-2 may not only manifest as pneumonia (COVID-19) but also in other organs, including the brain (neuro-COVID). One of the cerebral complications of SARS-CoV-2 is ischemic stroke. Transitory ischemic attack (TIA) in a SARS-CoV-2 positive has not been reported. A 78-year-old poly-morbid male (diabetes, hypertension, and coronary heart disease), admitted for COVID-19, developed atrial flutter on hospital day (hd) 2. Anticoagulation with enoxaparin was started. On hd5, he experienced a TIA despite sufficient anticoagulation. The patient expired on hd28 due to multi-organ failure from sepsis due to superinfection with staphylococcus aureus. Infection with SARS-CoV-2 may be complicated by atrial flutter. Atrial flutter may be complicated by TIA despite sufficient anticoagulation, suggesting that standard anticoagulation may be insufficient to meet SARS-CoV-2-associated hypercoagulability syndrome. Forced anticoagulation and adequate antibiosis in poly-morbid SARS-CoV-2-infected patients with hypercoagulability and cytokine storm are warranted.

Prevalence, Management, and Outcome of Atrial Fibrillation and Other Supraventricular Arrhythmias in COVID-19 Patients.

COVID-19 mainly affects the respiratory system but has been correlated with cardiovascular manifestations such as myocarditis, heart failure, acute coronary syndromes, and arrhythmias. Cardiac arrhythmias are the second most frequent complication affecting about 30% of patients. Several mechanisms may lead to an increased risk of cardiac arrhythmias during COVID-19 infection, ranging from direct myocardial damage to extracardiac involvement. The aim of this review is to describe the role of COVID-19 in the pathogenesis of cardiac arrhythmias and provide a comprehensive guidance for their monitoring and management.

Outcomes and mortality associated with atrial arrhythmias among patients hospitalized with COVID-19: A systematic review and meta-analysis.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. Herein, is a systematic review with meta-analysis to determine the impact of AF/atrial flutter (AFL) on mortality, as well as individual complications in patients hospitalized with the coronavirus disease 2019 (COVID-19). METHODS: A systematic search of the SCOPUS, Medline, Web of Science, CINAHL and Cochrane databases was performed. The a priori primary outcome of interest was in-hospital mortality. A random-effects model was used to pool study results. RESULTS: Nineteen studies which included 33,296 patients were involved in this meta-analysis. Inhospital mortality for AF/AFL vs. no-AF/AFL groups varied and amounted to 32.8% vs. 14.2%, respectively (risk ratio [RR]: 2.18; 95% confidence interval [CI]: 1.79-2.65; p < 0.001). In-hospital mortality in new onset AF/AFL compared to no-AFAFL was 22.0% vs. 18.8% (RR: 1.86; 95% CI: 1.54-2.24; p < 0.001). Intensive care unit (ICU) admission was required for 17.7% of patients with AF/AFL compared to 10.8% for patients without AF/AFL (RR: 1.94; 95% CI: 1.04-3.62; p = 0.04). CONCLUSIONS: The present study reveals that AF/AFL is associated with increased in-hospital mortality and worse outcomes in patients with COVID-19 and may be used as a negative prognostic factor in these patients. Patients with AF/AFL are at higher risk of hospitalization in ICU. The presence of AF/AFL in individuals with COVID-19 is associated with higher risk of complications, such as bleeding, acute kidney injury and heart failure. AF/AFL may be associated with unfavorable outcomes due to the hemodynamic compromise of cardiac function itself or hyperinflammatory state typical of these conditions.

Usability and Perceived Usefulness of the AFib 2gether Mobile App in a Clinical Setting: Single-Arm Intervention Study.

BACKGROUND: Although the American Heart Association and other professional societies have recommended shared decision-making as a way for patients with atrial fibrillation (AF) or atrial flutter to make informed decisions about using anticoagulation (AC), the best method for facilitating shared decision-making remains uncertain. OBJECTIVE: The aim of this study is to assess the AFib 2gether mobile app for usability, perceived usefulness, and the extent and nature of shared decision-making that occurred for clinical encounters between patients with AF and their cardiology providers in which the app was used. METHODS: We identified patients visiting a cardiology provider between October 2019 and May 2020. We measured usability from patients and providers using the Mobile App Rating Scale. From the 8 items of the Mobile App Rating Scale, we reported the average score (out of 5) for domains of functionality, esthetics, and overall quality. We administered a 3-item questionnaire to patients relating to their perceived usefulness of the app and a separate 3-item questionnaire to providers to measure their perceived usefulness of the app. We performed a chart review to track the occurrence of AC within 6 months of the index visit. We also audio recorded a subset of the encounters to identify evidence of shared decision-making. RESULTS: We facilitated shared decision-making visits for 37 patients visiting 13 providers. In terms of usability, patients' average ratings of functionality, esthetics, and overall quality were 4.51 (SD 0.61), 4.26 (SD 0.51), and 4.24 (SD 0.89), respectively. In terms of usefulness, 41% (15/37) of patients agreed that the app improved their knowledge regarding AC, and 62% (23/37) agreed that the app helped clarify to their provider their preferences regarding AC. Among providers, 79% (27/34) agreed that the app helped clarify their patients' preferences, 82% (28/34) agreed that the app saved them time, and 59% (20/34) agreed that the app helped their patients make decisions about AC. In addition, 32% (12/37) of patients started AC after their shared decision-making visits. We audio recorded 25 encounters. Of these, 84% (21/25) included the mention of AC for AF, 44% (11/25) included the discussion of multiple options for AC, 72% (18/25) included a provider recommendation for AC, and 48% (12/25) included the evidence of patient involvement in the discussion. CONCLUSIONS: Patients and providers rated the app with high usability and perceived usefulness. Moreover, one-third of the patients began AC, and approximately 50% (12/25) of the encounters showed evidence of patient involvement in decision-making. In the future, we plan to study the effect of the app on a larger sample and with a controlled study design. TRIAL REGISTRATION: ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-21986.

Atrial Fibrillation in Patients Hospitalized With COVID-19: Incidence, Predictors, Outcomes, and Comparison to Influenza.

OBJECTIVES: The goal of this study is to determine the incidence, predictors, and outcomes of atrial fibrillation (AF) or atrial flutter (AFL) in patients hospitalized with coronavirus disease-2019 (COVID-19). BACKGROUND: COVID-19 results in increased inflammatory markers previously associated with atrial arrhythmias. However, little is known about their incidence or specificity in COVID-19 or their association with outcomes. METHODS: This is a retrospective analysis of 3,970 patients admitted with polymerase chain reaction-positive COVID-19 between February 4 and April 22, 2020, with manual review performed of 1,110. The comparator arm included 1,420 patients with influenza hospitalized between January 1, 2017, and January 1, 2020. RESULTS: Among 3,970 inpatients with COVID-19, the incidence of AF/AFL was 10% (n = 375) and in patients without a history of atrial arrhythmias it was 4% (n = 146). Patients with new-onset AF/AFL were older with increased inflammatory markers including interleukin 6 (93 vs. 68 pg/ml; p < 0.01), and more myocardial injury (troponin-I: 0.2 vs. 0.06 ng/ml; p < 0.01). AF and AFL were associated with increased mortality (46% vs. 26%; p < 0.01). Manual review captured a somewhat higher incidence of AF/AFL (13%, n = 140). Compared to inpatients with COVID-19, patients with influenza (n = 1,420) had similar rates of AF/AFL (12%, n = 163) but lower mortality. The presence of AF/AFL correlated with similarly increased mortality in both COVID-19 (relative risk: 1.77) and influenza (relative risk: 1.78). CONCLUSIONS: AF/AFL occurs in a subset of patients hospitalized with either COVID-19 or influenza and is associated with inflammation and disease severity in both infections. The incidence and associated increase in mortality in both cohorts suggests that AF/AFL is not specific to COVID-19, but is rather a generalized response to the systemic inflammation of severe viral illnesses.

Atrial arrhythmia related outcomes in critically ill COVID-19 patients.

RATIONALE: Coronavirus disease 2019 (COVID-19) is associated with many clinical manifestations including respiratory failure and cardiovascular compromise. OBJECTIVES: We examine outcomes in critically ill individuals with COVID-19 who develop atrial tachyarrhythmias. METHODS: We collected data from electrocardiograms and the electronic medical record of COVID-19 positive (COVID+ ) and negative (COVID- ) individuals admitted to our medical intensive care unit between February 29 and June 28, 2020. We compared clinical and demographic characteristics, new onset atrial tachyarrhythmia, hemodynamic compromise following atrial tachyarrhythmia, and in-hospital mortality in COVID+ versus COVID- . Hemodynamic compromise was defined as having a new or increased vasopressor requirement or the need for direct current cardioversion for hemodynamic instability within 1 hour of atrial tachyarrhythmia onset. RESULTS: Of 300 individuals included, 200 were COVID+ and 100 were COVID- . Mean age was 60 ± 16 years, 180 (60%) were males, and 170 (57%) were African American. New onset atrial tachyarrhythmia occurred in 16% of COVID+ and 19% of COVID- individuals (P = .51). When compared to COVID- participants without atrial tachyarrhythmia, COVID+ individuals with new onset atrial tachyarrhythmia had higher mortality after multivariable adjustment (OR 5.0, 95% CI 1.9-13.5). New onset atrial tachyarrhythmia was followed by hemodynamic compromise in 18 COVID+ but no COVID- participants (P = .0001). COVID+ individuals with hemodynamic compromise after atrial tachyarrhythmia required increased ventilatory support at the time of atrial tachyarrhythmia onset. CONCLUSIONS: Atrial tachyarrhythmia is associated with increased mortality in critically ill individuals with COVID-19, especially those mechanically ventilated. Recognition of this could assist with clinical care for individuals with COVID-19.

Worldwide Survey of COVID-19-Associated Arrhythmias.

[Figure: see text].

Atrial Flutter in Patient With Critical COVID-19: Beneficial Effects of Rhythm Control on Respiratory Distress.

We report the case of a patient critically ill with coronavirus disease-2019 (COVID-19) in which atrial flutter with high ventricular response rate occurred, contributing to worsening of the respiratory distress. After failure of noninvasive rate and rhythm control strategies, successful transcatheter ablation was performed and the respiratory distress of the patient improved. (Level of Difficulty: Beginner.).

Outcomes and mortality associated with atrial arrhythmias among patients hospitalized with COVID-19.

INTRODUCTION: The impact of atrial arrhythmias on coronavirus disease 2019 (COVID-19)-associated outcomes are unclear. We sought to identify prevalence, risk factors and outcomes associated with atrial arrhythmias among patients hospitalized with COVID-19. METHODS: An observational cohort study of 1053 patients with severe acute respiratory syndrome coronavirus 2 infection admitted to a quaternary care hospital and a community hospital was conducted. Data from electrocardiographic and telemetry were collected to identify atrial fibrillation (AF) or atrial flutter/tachycardia (AFL). The association between atrial arrhythmias and 30-day mortality was assessed with multivariable analysis. RESULTS: Mean age of patients was 62 ± 17 years and 62% were men. Atrial arrhythmias were identified in 166 (15.8%) patients, with AF in 154 (14.6%) patients and AFL in 40 (3.8%) patients. Newly detected atrial arrhythmias occurred in 101 (9.6%) patients. Age, male sex, prior AF, renal disease, and hypoxia on presentation were independently associated with AF/AFL occurrence. Compared with patients without AF/AFL, patients with AF/AFL had significantly higher levels of troponin, B-type natriuretic peptide, C-reactive protein, ferritin and d-dimer. Mortality was significantly higher among patients with AF/AFL (39.2%) compared to patients without (13.4%; p < .001). After adjustment for age and co-morbidities, AF/AFL (adjusted odds ratio [OR]: 1.93; p = .007) and newly detected AF/AFL (adjusted OR: 2.87; p < .001) were independently associated with 30-day mortality. CONCLUSION: Atrial arrhythmias are common among patients hospitalized with COVID-19. The presence of AF/AFL tracked with markers of inflammation and cardiac injury. Atrial arrhythmias were independently associated with increased mortality.

Atrial Arrhythmias in a Patient Presenting With Coronavirus Disease-2019 (COVID-19) Infection.

The coronavirus disease-2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) that has significant potential cardiovascular implications for patients. These include myocarditis, acute coronary syndromes, cardiac arrhythmias, cardiomyopathies with heart failure and cardiogenic shock, and venous thromboembolic events. We describe a Caribbean-Black gentleman with COVID-19 infection presenting with atrial arrhythmias, namely, atrial flutter and atrial fibrillation, which resolved with rate and rhythm control strategies, and supportive care.