Comparison of cardiac magnetic resonance imaging and fluorodeoxyglucose positron emission tomography in the assessment of myocardial viability: meta-analysis and systematic review.

AIM: Contrast-enhanced cardiac magnetic resonance (Ce-CMR) and Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) are frequently utilized in clinical practice to assess myocardial viability. However, studies evaluating direct comparison between Ce-CMR and FDG-PET have a smaller sample size, and no clear distinction between the two imaging modalities has been defined. To address this gap, we conducted a meta-analysis of studies comparing Ce-CMR and FDG-PET for the assessment of myocardial viability. METHODS: We searched PubMed, EMBASE, Scopus, and Web of Science databases from their inception to 4/20/2022 with search terms "viability" AND "heart diseases" AND "cardiac magnetic resonance imaging" AND "positron-emission tomography." We extracted patient characteristics, segment level viability assessment according to Ce-CMR and FDG-PET, and change in regional wall motion abnormalities (RWMA) at follow-up. RESULTS: We included four studies in the meta-analysis which provided viability assessment with Ce-CMR and FDG-PET in all patients and change in RWMA at follow-up. There were 82 patients among the four included studies, and 585 segments were compared for viability assessment. There were 59 (72%) males, and mean age was 65 years. The sensitivity (95% confidence interval-CI) and specificity (CI) of Ce-CMR for predicting myocardial recovery were 0.88 (0.66-0.96) and 0.64 (0.49-0.77), respectively. The sensitivity (CI) and specificity (CI) of FDG-PET for predicting myocardial recovery were 0.91 (0.63-0.99) and 0.67 (0.49-0.81), respectively. CONCLUSION: FDG-PET and Ce-CMR have comparable diagnostic parameters in myocardial viability assessment and are consistent with prior research.

A Systematic Review and Single-center Experience of Azygos Vein Defibrillator Lead Insertion.

Defibrillation threshold (DFT) testing is performed in individuals with higher predicted risks of defibrillation failure. Many strategies have been explored to overcome the challenge of high DFT, including an insertion of a defibrillator lead into the azygos vein. We performed a systematic review of the literature to evaluate the safety and efficacy of azygos vein implantable cardioverter-defibrillator insertion for high DFT combined with the analysis of a single-center experience of the procedure at our institution. The literature search was performed in PubMed and Embase from database inception to December 2020 to identify all case reports and case series related to azygos vein defibrillator lead insertion. Our search identified 291 records. After excluding duplicate studies and those without DFT thresholds and non-azygos vascular destinations, 12 studies (23 cases) were reviewed from the current database. We also conducted a retrospective analysis of 5 cases performed at our institution, and a total of 28 patients were included in our final analysis. The mean age of the pooled cohort was 47 years (range, 17-88 years). Men composed 92% of the total cases, and the average body mass index was 34 kg/m2. The mean ejection fraction (EF) was 25%, with 78% having non-ischemic cardiomyopathy. The left axillary (36%) or subclavian (48%) vein was the common percutaneous access point. The mean duration of azygos vein access and lead delivery was 22 min (range, 13-60 min). The average DFT prior to azygos coil insertion was 35 J (range, 20-45 J). Fifty-seven percent of cases achieved substantial DFT improvement, whereas 18% achieved relative improvement compared to the pre-procedural threshold. No immediate or remote procedure-related complications were reported in 24 cases where data were available. During an average follow-up period of 18 months, 5 patients had ventricular arrhythmic events requiring device therapy and 4 had successful cardioversion from the device. One patient died from cardiac arrest with variable device therapies of both unsuccessful and successful events. In conclusion, azygos vein defibrillator lead insertion has a considerable rate of success, ease of vascular access with minimal procedural time, and lower risks and complications. Larger studies and longer follow-up periods are warranted to establish its efficacy and safety.

Meta-Analysis of Catheter Ablation Outcomes in Patients With Cardiac Sarcoidosis Refractory Ventricular Tachycardia.

Cardiac sarcoidosis (CS) frequently leads to ventricular tachycardia (VT), which is often refractory to antiarrhythmic and/or immunosuppressive medications and requires catheter ablation. We conducted a systematic review and meta-analysis to evaluate the role of catheter ablation in patients with refractory VT undergoing catheter ablation. We searched PubMed, Embase, and Scopus databases from their inception to December 31, 2021 with search terms "cardiac sarcoidosis" AND "electrophysiological studies OR ablation." Fifteen studies were ultimately included for evaluation. Patient demographics, VT mapping, and acute and long-term procedural outcomes were extracted. A total of 15 studies were included in our meta-analysis, with a total of 401 patients, of whom 66% were male, with ages ranging from 39 to 64 years. A total of 95% of patients were on antiarrhythmics and 79% of patients were on immunosuppressants. Left ventricular ejection fraction ranged from 35% to 49% and procedure duration ranged from 269 to 462 minutes. Ablation was reported using both irrigated and nonirrigated catheter tips. A total of 25% of patients (84/339) underwent repeat ablation. Acute procedural success was achieved in 57% (161/285). Procedure complications occurred in 5.7% (17/297) procedures. VT recurrence after first ablation was 55% (confidence interval 48% to 63%, 213/401); VT recurrence after multiple ablations was 37% (81/220). The composite end point of death, heart transplant, and left ventricular assist device implantation was 21% (confidence interval 14% to 30%, 55/297). In conclusion, catheter ablation is a useful modality in patients with CS with refractory VT. However, patients with CS presenting with refractory VT after undergoing VT ablation carry a poor prognosis.

Clinical features and outcomes of patients in different age groups with non-valvular atrial fibrillation receiving oral anticoagulants.

Background: Patients with non-valvular atrial fibrillation (NVAF) need prophylactically antithrombotic therapies to reduce the risk of stroke. We hypothesized that the prognostic benefits of prophylactic antithrombotic therapies outweighed the bleeding risk among very elderly (≥85 years old) patients. Methods: We analyzed clinical characteristics and outcomes of patients with NVAF in different age groups who had received different prophylactic antithrombotic therapies. We enrolled 3895 consecutive NVAF patients in the Macau Special Administrative Region (Macau SAR) of China from January 1, 2010, to December 31, 2018. Among 3524 patients [including 1252 (35.53%) very elderly patients] who completed the entire study, 2897 (82.21%) patients had a CHA2DS2-VASc score ≥ 2, 2274 (64.53%) had HAS-BLED score < 3, and 1659 (47.08%) had both of the above. The follow-up time was 3.80 (median, interquartile range 1.89-6.56) years. The primary outcome was the first occurrence of ischemic stroke, major bleeding, clinically relevant non-major gastrointestinal bleeding (CRNM-GIB), and all-cause mortality. Results: A total of 2012 patients (57.09%) received no antithrombotic (NAT), 665 (18.87%) received antiplatelet (AP) agents, 371 (10.53%) received vitamin K antagonist (VKA), and 476 (13.51%) received non-vitamin K antagonist oral anticoagulants (NOACs). Eventually, 610 (17.31%) patients experienced thromboembolic events, with 167 (4.74%) strokes and 483 (13.71%) transient ischemia attack (TIA)/strokes. Bleeding events occurred in 614 (17.42%) patients, with 131 (3.72%) major bleeding, 381 (10.81%) CRNM-GIB and 102 (2.89%) minor bleeding events. All-cause deaths occurred in 483 (13.71%) patients. Compared with patients receiving NAT, patients receiving NOACs and VKA had fewer strokes (hazard ratio [HR]: 0.038; 95 %CI 0.004-0.401; p  = 0.006 and HR: 0.544; 95 %CI 0.307-0.965; p  = 0.037, respectively), and lower all-cause mortality (HR: 0.270; 95 %CI 0.170-0.429; p  < 0.001 and HR: 0.531; 95 %CI 0.373-0.756; p  < 0.001, respectively). Of note, very elderly patients with NVAF receiving NOACs had fewer strokes (adjust hazard ratio [adjHR]: 0.042; 95 %CI 0.002-1.003; p  = 0.050) and lower all-cause mortality (adjHR: 0.308; 95 %CI 0.158-0.601; p  = 0.001). Meanwhile, despite higher CRNM-GIB events (adjHR: 1.736; 95 %CI 1.042-2.892; p  = 0.034), major bleeding events (adjHR: 1.045; 95 %CI 0.366-2.979; p  = 0.935) did not significantly increase. VKA neither reduced strokes (adjHR: 1.015; 95 %CI 0.529-1.948; p  = 0.963), nor improved all-cause mortality (adjHR: 0.995; 95 %CI 0.641-1.542; p  = 0.981) in very elderly patients with NVAF. Conclusions: Antithrombotic treatment (VKA and NOACs) reduces stroke and improves prognosis in patients in different age groups with NVAF. The prognostic benefits of NOACs outweigh their bleeding risks in very elderly patients with NVAF.

The role of electrophysiology study in risk stratification of cardiac sarcoidosis patients: Meta-analyses and systemic review.

BACKGROUND: The utility of an electrophysiologic study (EPS) in the risk stratification of cardiac sarcoidosis (CS) patients is not clear. We conducted a systemic review and meta-analysis to evaluate the utility of EPS in the risk stratification of CS patients. METHODS: We searched PubMed, Embase, and Scopus databases from their inception to 12/4/2020 with search terms "Cardiac sarcoidosis" And "Electrophysiological studies OR ablation". The first and second authors reviewed all the studies. We extracted the data of positive and negative EPS, and outcomes defined as ventricular arrhythmias, implantable cardioverter defibrillator therapy, death, left ventricular assist device placement, or heart transplantation. Risk of bias assessment was done by the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Subgroup analysis of patients with left ventricular ejection fraction (LVEF) >35%, and probable CS, no prior ventricular tachycardia (VT) and LVEF >35% were performed. RESULTS: We found 544 articles after removing duplicates. A total of 52 full articles were reviewed, and eight studies were included in the meta-analysis. The pooled sensitivity and specificity (95% confidence interval) of EPS in predicting clinical outcomes were 0.70 (0.51-0.85) and 0.93 (0.85-0.97), respectively. Subgroup analysis of patients with LVEF >35% resulted in pooled sensitivity of 0.63 (0.29-0.88) and pooled specificity of 0.97 (0.92-0.99), and subgroup analysis of patients with probable CS, no prior VT, and LVEF >35% resulted in pooled sensitivity of 0.71 (0.33-0.93) and pooled specificity of 0.96 (0.88-0.99) in predicting adverse clinical outcomes. CONCLUSIONS: EPS is an effective risk stratification tool in patients with CS across all subgroups with high sensitivity and specificity.

Trends and Outcomes of Atrial Fibrillation-Flutter Hospitalizations Among Heart Transplant Recipients (From the National Inpatient Sample).

Atrial fibrillation-flutter (AF) has been described in 10% to 24% of patients after heart transplant (HT). Data on AF hospitalizations after HT are limited to single-center experiences. To bridge this gap, we performed an analysis of admissions for AF in HT patients from the National Inpatient Sample (NIS) years 2000 to 2014. All hospitalizations with a primary diagnosis of 427.31 or 427.32 and V42.1 were used to identify hospitalizations with AF and previous HT respectively. Among a total of 211,961 HT related hospitalizations, 1,304 (0.62%) (955 males, 349 females, mean age 59 years, median CHA2DS2Vasc score 2 [Interquartile range 1 to 3]) were admitted with a primary diagnosis AF. Most hospitalizations were nonelective (80.17%). In-hospital mortality was 2.3% and the mean length of stay (LOS) was 3.7 days. Among those patients who were discharged from hospital, 85 % were discharged to home with self-care. Most commonly reported secondary diagnoses included hypertension (57.9%), diabetes (33%), renal failure (31.3%), and congestive heart failure (22%). The event rates for ischemic stroke and gastrointestinal bleeding in the same admission with the AF hospitalization were low (1.2% and 1.2% respectively). Cardioversion was performed in 37% and ablation in 11.2% of admissions. The adjusted median cost of hospitalization was $6478.7 (IQR $3561.8 to $12352.3) and did not change significantly during the study period. AF is a relatively infrequent cause of hospitalization among HT recipients. The number of hospitalizations, ablations, cardioversions, disposition, LOS, and cost of hospitalization for AF remained stable during the study period.

Impact of Pre-Existing and New-Onset Atrial Fibrillation on Outcomes After Transcatheter Aortic Valve Replacement.

OBJECTIVES: This study sought to evaluate impact of new-onset and pre-existing atrial fibrillation (AF) on transcatheter aortic valve replacement (TAVR) long-term outcomes compared with patients without AF. BACKGROUND: Pre-existing and new-onset AF in patients undergoing TAVR are associated with poor outcomes. METHODS: The study identified 72,660 patients ≥65 years of age who underwent nonapical TAVR between 2014 and 2016 using Medicare inpatient claims. History of AF was defined by diagnoses on claims during the 3 years preceding the TAVR, and new-onset AF was defined as occurrence of AF during the TAVR admission or within 30 days after TAVR in a patient without prior history of AF. Outcomes included all-cause mortality, and readmission for bleeding, stroke, and heart failure (HF). RESULTS: Overall, 40.7% had pre-existing AF (n = 29,563) and 6.8% experienced new-onset AF (n = 2,948) after TAVR. Mean age was 81.3, 82.4, and 83.8 years in patients with no AF, pre-existing, and new-onset AF, respectively. Pre-existing AF patients had the highest burden of comorbidities. After follow-up of 73,732 person-years, mortality was higher with new-onset AF compared with pre-existing and no AF (29.7, 22.6, and 12.8 per 100 person-years, respectively; p < 0.001). After adjusting for patient characteristics and hospital TAVR volume, new-onset AF remained associated with higher mortality compared with no AF (adjusted hazard ratio: 2.068, 95% confidence interval [CI]: 1.92 to 2.20; p < 0.01) and pre-existing AF (adjusted hazard ratio: 1.35; 95% CI: 1.26 to 1.45; p < 0.01). In competing risk analysis, new-onset AF was associated with higher risk of bleeding (subdistribution hazard ratio [sHR]: 1.66; 95% CI: 1.48 to 1.86; p < 0.01), stroke (sHR: 1.92; 95% CI: 1.63 to 2.26; p < 0.01), and HF (sHR: 1.98; 95% CI: 1.81 to 2.16; p < 0.01) compared with pre-existing AF. CONCLUSIONS: In patients undergoing TAVR, new-onset AF is associated with increased risk of mortality and bleeding, stroke, and HF hospitalizations compared with pre-existing AF or no AF.

Patient with a PRKAG2 mutation who developed Immunoglobulin A nephropathy: a case report.

BACKGROUND: PRKAG2 syndrome (PS) is a rare, early-onset autosomal dominant inherited disease caused by mutations in PRKAG2, the gene encoding the regulatory γ2 subunit of adenosine monophosphate-activated protein kinase. PRKAG2 syndrome is associated with many cardiac manifestations, including pre-excitation, arrhythmias, left ventricular hypertrophy, and chronotropic incompetence frequently leading to early pacemaker placement. A meta-analysis of genome-wide association data in subjects with chronic kidney disease (CKD) identified a susceptibility locus in an intron of PRKAG2, which has been replicated in other studies. However, CKD has not been reported in patients with PS or mutations in PRKAG2. CASE SUMMARY: We report a case of a woman diagnosed at age 27 with PS when she presented with atrial fibrillation and pre-excitation on electrocardiogram. By age 35, she had developed mild renal insufficiency and a biopsy demonstrated IgA nephropathy (IGAN). DISCUSSION: This is the first reported case of IGAN in a patient with PS. We discuss both PS and IGAN and the potential mechanisms by which they could be related.

Temporal trends and factors associated with increased mortality among atrial fibrillation weekend hospitalizations: an insight from National Inpatient Sample 2005-2014.

OBJECTIVE: Atrial fibrillation (AF) weekend hospitalizations were reported to have poor outcomes compared to weekday hospitalizations. The relatively poor outcomes on the weekends are usually referred to as 'weekend effect'. We aim to understand trends and outcomes among weekend AF hospitalizations. The primary purpose of this study is to evaluate the trends for weekend AF hospitalizations using Nationwide Inpatient Sample 2005-2014. Hospitalizations with AF as the primary diagnosis, in-hospital mortality, length of stay, co-morbidities and cardioversion procedures have been identified using the international classification of diseases 9 codes. RESULTS: Since 2005, the weekend AF hospitalizations increased by 27% (72,216 in 2005 to 92,220 in 2014), mortality decreased by 29% (1.32% in 2005 to 0.94% in 2014), increase in urban teaching hospitalizations by 72% (33.32% in 2005 to 57.64% in 2014), twofold increase in depression and a threefold increase in the prevalence of renal failure were noted over the period of 10 years. After adjusting for significant covariates, weekend hospitalizations were observed to have higher odds of in-hospital mortality OR 1.17 (95% CI 1.108-1.235, P < 0.0001). Weekend AF hospitalizations appear to be associated with higher in-hospital mortality. Opportunities to improve care in weekend AF hospitalizations need to be explored.

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.

Procedural Outcomes of Patients With Heart Failure Undergoing Catheter Ablation of Atrial Fibrillation.

BACKGROUND: Catheter ablation is being increasingly performed for rhythm control of atrial fibrillation (AF). Heart failure (HF) frequently coexists with AF because they share common risk factors. STUDY QUESTION: This study aims at identifying the characteristics and procedural outcomes of patients with HF undergoing catheter ablation of AF. STUDY DESIGN: In this retrospective cohort study, we analyzed 264 consecutive patients who underwent catheter ablation for AF. Seventy-three patients (28%) had a known history of stage C HF either with reduced ejection fraction or preserved ejection fraction. MEASURES AND OUTCOMES: We compared procedural outcomes between patients who had known HF with those who did not. RESULTS: Patients with HF were more likely to have higher rates of atrial fibrillation recurrence at both 3 months (odds ratio 2.9, confidence interval = 1.5-5.7, P = 0.0022) and 1 year after the procedure (odds ratio 2.3, confidence interval 1.2-4.3, P = 0.0097) and risk factors for recurrence of AF including left atrial enlargement, persistent AF, and a higher CHA2DS2-VASc score. However, on logistic regression analysis adjusting for left atrial size, atrial fibrillation type (persistent vs. paroxysmal), and CHA2DS2-VASc score as covariates, there was no significant difference in AF recurrence rates at both 3 months and 1 year. Recurrence rates did not differ significantly between patients with HF either with reduced ejection fraction or preserved ejection fraction. Among patients with paroxysmal AF, HF was predictive of AF recurrence at both 3 months and 1 year after ablation. The procedure length was longer in patients with HF, but there were no differences in periprocedural complications. CONCLUSION: Patients with HF undergoing catheter ablation of AF tend to have more risk factors for recurrence, but after adjustment for risk factors, the recurrence rates were similar at 3 months and 1 year. Among patients with paroxysmal atrial fibrillation, HF was predictive of higher recurrence rates.

Outcomes of hospitalizations with atrial fibrillation-flutter on a weekday versus weekend: an analysis from a 2014 nationwide inpatient sample.

BACKGROUND: Patients with atrial fibrillation-flutter (AF) admitted on the weekends were initially reported to have poor outcomes. The primary purpose of this study is to re-evaluate the outcomes for weekend versus weekday AF hospitalization using the 2014 Nationwide Inpatient Sample (NIS). METHODS: Included hospitalizations were aged above 18 years. The hospitalizations with AF were identified using the international classification of diseases 9 (ICD-9) codes (427.31, 427.32). In-hospital mortality, length of stay (LOS), other co-morbidities, cardioversion procedures, and time to cardioversion were recorded. All analysis was performed using SAS 9.4 statistical software (Cary, North Carolina). RESULTS: A total of 453,505 hospitalizations with atrial fibrillation and flutter as primary discharge diagnosis were identified. Among the total hospitalizations with a primary diagnosis of AF, 20.3% were admitted on the weekend. Among the weekend hospitalizations, 0.19% died in hospital compared to 0.74% among those admitted during the week. After adjusting for patient characteristics, hospital characteristics and disease severity, the adjusted odds for in-hospital mortality were not significantly different for weekend vs. weekday hospitalizations (OR = 0.91, 95% CI [0.77-1.11]; p = 0.33). The weekend admissions were associated with significantly lower odds of cardioversion procedures (OR = 0.72, 95% CI [0.69-0.76], P < 0.0001), lower cost of hospitalization (USD 8265.8 on weekends vs. USD 8966.5 on the weekdays, P < 0.001), slightly lower rate of anticoagulation (17.09% on the weekends vs. 18.73% on the weekdays. P < 0.0001), and slightly increased time to cardioversion (1.94 days on the weekend vs. 1.73 days on weekdays, P < 0.0005). The mean length of hospital stay (LOS) was statistically not different in both groups: (3.49 days ± 3.70 (SD) in the weekend group vs. 3.47 days ± 3.50 (SD) in the weekday group, P = 0.42). DISCUSSION: The weekend AF hospitalizations did not have a clinically significant difference in mortality and LOS compared to those admitted on a weekday. However, the use of cardioversion procedures and cost of hospitalization was significantly lower on the weekends.

Cardiac resynchronization therapy and outcomes in patients with left ventricular assist devices: a systematic review and meta-analysis.

The impact of cardiac resynchronization therapy (CRT) on clinical outcome in patients with a continuous-flow left ventricular assist device (LVAD) is currently not well understood. We conducted a systematic literature review and meta-analysis with an intention to summarize all published clinical evidence. We searched MEDLINE and EMBASE databases through March 2018 for studies that compared the outcomes in patients with LVAD and CRT. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random-effects model, inverse variance method. The between-study heterogeneity was assessed using the Q statistic and I2. A total of seven studies that included 1157 (575 CRT; 582 non-CRT) patients were identified. Our meta-analysis did not demonstrate a significant difference in the risk of mortality (pooled OR = 1.21, 95% CI 0.90-1.63, P = 0.21), ventricular arrhythmia incidence (pooled OR = 1.36, 95% CI 0.99-1.86, P = 0.06), hospitalization (pooled OR = 1.36, 95% CI 0.59-3.14, P = 0.48), or implantable cardioverter defibrillator therapies (pooled OR = 1.08, 95% CI 0.51-2.30, P = 0.84) among the CRT group compared with the non-CRT group. There was high heterogeneity with an I2 of 75% for ICD therapies. Among LVAD patients, CRT combined did not significantly affect mortality, re-hospitalization, ventricular arrhythmia incidence, and ICD therapies.

Usefulness of Cardiac Resynchronization Therapy in Patients With Continuous Flow Left Ventricular Assist Devices.

The benefit of cardiac resynchronization therapy in patients supported by a left ventricular assist device (LVAD) is unknown. There are currently no guidelines regarding the continuation, discontinuation or pacemaker (PM) settings post-LVAD implant. The aim of the study was to assess the hemodynamic benefit of biventricular (BiV) pacing in LVAD patients. We studied 22 patients supported by LVADs (age 62 ± 9, 21 males) who had received a BiV PM before LVAD implant. A total of 123 complete sets of hemodynamics were obtained during BiV pacing (n = 54), right ventricular (RV) pacing (n = 54), and intrinsic rhythm (n = 15). There were no significant differences in right atrial (RA) pressure, mean pulmonary artery pressure (mPA), PCWP, cardiac output, PA saturation (PASat) and right ventricular stroke work index between BiV and RV pacing. Hemodynamics obtained during intrinsic rhythm in 15 non-PM-dependent patients were not significantly different compared with those obtained during BiV or RV pacing. Furthermore, hemodynamics were similar at different heart rates ranging 50 to 110 beats/min. Right ventricular stroke work index was significantly lower at the highest heart rate compared with baseline and lowest heart rates suggesting decreased RV performance at higher heart rate. In conclusion, BiV pacing does not have any acute hemodynamic benefit compared with RV pacing or intrinsic rhythm in LVAD patients. A lower heart rate may confer better RV performance.

Association between diabetes mellitus and poor patient outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis.

Diabetes mellitus (DM) serves as an important prognostic indicator in patients with cardiac-related illness. Our objective is to compare survival and neurological outcomes among diabetic and non-diabetic patients who were admitted to the hospital after an out-of-hospital cardiac arrest (OHCA). We searched MEDLINE and EMBASE for relevant articles from database inception to July 2018 without any language restriction. Studies were included if they evaluated patients who presented with OHCA, included mortality and neurological outcome data separately for DM patients and Non-DM patients and reported crude data, odds ratio (OR), relative risk (RR) or hazard ratio (HR). Two investigators independently reviewed the retrieved citations and assessed eligibility. The quality of included studies was evaluated using Newcastle-Ottawa quality assessment scale for cohort studies. Random-effect models using the generic variance method were used to create pooled odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 value. Survival and neurological outcomes (using modified rankin scale and cerebral performance category scale) after OHCA in hospitalized patients with DM compared with patients without DM. Out of 57 studies identified, six cohort studies met the inclusion criteria. In an analysis of unadjusted data, patients with DM had lower odds of survival, pooled OR 0.64; 95% CI, 0.52-0.78, [I2 = 90%]. When adjusted ORs were pooled, the association between DM and survival after OHCA was still significantly reduced, pooled OR 0.78, 95% CI, 0.68-0.89 [I2 = 55%]. Unadjusted pooled OR revealed poor neurological outcomes in patients with DM, pooled OR 0.55, 95% CI, 0.38-0.80 [I2 = 90%]. The result demonstrates significant poor outcomes of in-hospital survival and neurological outcomes among DM patients after OHCA.

Role of obstructive sleep apnea on the response to cardiac resynchronization therapy and all-cause mortality.

BACKGROUND: The role of obstructive sleep apnea (OSA) on the response to cardiac resynchronization therapy (CRT) and all-cause mortality in patients with advanced heart failure (HF) is unknown. OBJECTIVE: We assessed the association between OSA, response to CRT, and all-cause mortality in patients with HF. METHODS: We analyzed records of 548 consecutive patients (mean age 65 ± 13 years; 216 (39%) women; mean follow-up period 76 ± 17 months) who received a CRT-defibrillator device from January 15, 2007 to March 30, 2016 at our tertiary care referral center. RESULTS: A total of 180 patients (33%) had OSA. Fewer patients in the OSA group (109 [61%]) had improvement in left ventricular ejection fraction (EF) than did those in the non-OSA group (253 [69%]) (P = .001). A total of 144 patients (27%) died by the end of follow-up (OSA group: 61 [33%]; non-OSA group 83 [23%]; P < .001). OSA diagnosis was associated with a lower chance of improvement in EF (hazard ratio 0.71; 95% confidence interval 0.60-0.89) and a higher risk of all-cause mortality (hazard ratio 3.7; 95% confidence interval 2.5-6.8). This was true in continuous positive airway pressure-compliant patients and in patients with nonischemic cardiomyopathy. However, among patients with ischemic cardiomyopathy, the chance of improvement in EF and all-cause mortality was similar in patients with OSA and those without OSA. CONCLUSION: OSA is associated with a decreased response to CRT and an increase in all-cause mortality in patients with HF. The differential effect of OSA on CRT response in patients with ischemic cardiomyopathy and nonischemic cardiomyopathy needs further study.

Clinical Course and Quality of Life in High-Risk Patients With Hypertrophic Cardiomyopathy and Implantable Cardioverter-Defibrillators.

BACKGROUND: High-risk patients with hypertrophic cardiomyopathy (HCM) are identified by contemporary risk stratification and effectively treated with implantable cardioverter-defibrillators (ICDs). However, long-term HCM clinical course after ICD therapy for ventricular tachyarrhythmias is incompletely understood. METHODS AND RESULTS: Cohort of 486 high-risk HCM patients with ICDs was assembled from 8 international centers. Clinical course and device interventions were addressed, and survey questionnaires assessed patient anxiety level and psychological well-being related to ICD therapy. Of 486 patients, 94 (19%) experienced appropriate ICD interventions terminating ventricular tachycardia/ventricular fibrillation, 3.7% per year for primary prevention, over 6.4±4.7 years. Of 94 patients, 87 were asymptomatic or only mildly symptomatic at the time of appropriate ICD interventions; 74 of these 87 (85%) remained in classes I/II without significant change in clinical status over the subsequent 5.9±4.9 years (up to 22). Among the 94 patients, there was one sudden death (caused by device failure; 1.1%); 3 patients died from other HCM-related processes unrelated to arrhythmic risk (eg, end-stage heart failure). Post-ICD intervention, freedom from HCM mortality was 100%, 97%, and 92% at 1, 5, and 10 years, distinctly lower than in ischemic or nonischemic cardiomyopathy ICD trials. HCM patients with ICD interventions reported heightened anxiety in expectation of future shocks, but with intact general psychological well-being and quality of life. CONCLUSIONS: In HCM, unlike ischemic heart disease, prevention of sudden death with ICD therapy is unassociated with significant increase in cardiovascular morbidity or mortality, or transformation to heart failure deterioration. ICD therapy does not substantially impair overall psychological and physical well-being.

Right ventricular lead location, right-left ventricular lead interaction, and long-term outcomes in cardiac resynchronization therapy patients.

BACKGROUND: The effects of right ventricular (RV) lead location and the combination of RV and left ventricular (LV) lead locations on long-term outcomes in patients receiving cardiac resynchronization therapy with defibrillator (CRT-D) are not well understood. METHODS: Our cohort consisted of 743 CRT-D patients from MADIT-CRT. We evaluated long-term death and combined heart failure or death (HF/death) in patients with non-apical RV vs. apical RV leads. We further assessed these long-term outcomes based on the combination of RV and LV leads, termed "RV-LV lead interaction." Patients with non-apical RV and apical LV leads and those with apical RV and non-apical LV leads were described to have "discordant RV and LV leads." Patients with RV and LV leads that were both non-apical or both apical were defined to have "concordant RV and LV leads." RESULTS: There were no differences in death and HF/death between patients with non-apical RV vs. apical RV leads. However, patients with non-apical RV and apical LV leads had higher mortality risk, relative to those with apical RV and non-apical LV leads (HR = 4.06, 95% CI 1.73-9.53, p = 0.001) as well as those with both leads in the non-apical (HR = 3.82, 95% CI 1.33-10.98, p = 0.013) or apical (HR = 3.40, 95% CI 1.24-9.37, p = 0.018) positions. There was no difference in HF/death by RV-LV lead sub-groups. CONCLUSION: Among CRT-D patients, long-term outcomes were similar for non-apical RV and apical RV leads. However, mortality risk was increased with discordant RV and LV leads, when a non-apical RV lead was combined with an apical LV lead.

Trends in the rates of hospitalizations for acute stroke among patients over 90 years of age with atrial fibrillation in the United States: from 2005 to 2014.

BACKGROUND: Acute stroke (AS) rates in patients over 90 years of age (very elderly) with atrial fibrillation (AF) in the United States (US) are not known. We assessed trends in hospitalizations for AS among very elderly with AF in the US from 2005 to 2014. METHODS: We used the nationwide inpatient sample (NIS) from the USA; 2005-2014. AF and AS diagnoses were abstracted using international classification of diseases, 9th Revision, clinical modification (ICD-9-CM) codes. RESULTS: From 2005 to 2014, 3,606,073 hospitalizations of very elderly with AF were reported. Of these, 188,948 hospitalizations (141,822 hospitalizations in women and 47,126 hospitalizations in men) had AS as the primary diagnosis. Age adjusted AS hospitalizations increased in the total cohort (3217/million in 2005 to 3871/million in 2014), in women (3540/million in 2005 to 4487/million in 2014) and in men (2490/million in 2005 to 3173/million in 2014) (P < 0.001). Anticoagulation rates increased in women (8% in 2005 to 19.9% in 2014) and in men (8.9% in 2005 to 21.6% in 2014). AS rates, though numerically lower than the total cohort, showed an increasing trend in anticoagulated patients as well (all anticoagulated patients: 212/million in 2005 to 513/million in 2014; anticoagulated women: 224/million in 2005 to 529/million in 2014, anticoagulated men: 184/million in 2005 to 518/million in 2014). CONCLUSIONS: There is an increasing trend in AS hospitalizations among nonagenarians with AF in the US despite improving utilization of anticoagulants in this patient population. The etiologies driving this alarming trend are unclear and require further study.