Electrocardiogram changes as predictors for new imaging findings in repeat transthoracic echocardiography.

Aim: To determine if electrocardiogram (EKG) findings may be a useful tool to predict changes in repeat transthoracic echocardiogram (TTE). Methods: We evaluated patients who underwent TTE during hospitalization and their EKGs, and whether findings differed between studies. Results: Of 229 hospitalized patients who underwent repeat TTE, 183 (80%) were abnormal. Each minor and major EKG abnormality resulted in a 1.8 (1.2 to 2.6; p = 0.002) and 2.1 (1.3 to 3.3; p < 0.001) increased odds of abnormal imaging on TTE, respectively. The negative likelihood ratio for an unchanged EKG to predict an unchanged TTE was 0.68 (95% CI = 0.62 to 0.73). Conclusion: Among hospitalized patients with prior imaging results, an unchanged EKG predicts an unchanged TTE.

Transcatheter Leadless Pacemaker for the Treatment of Vasovagal Syncope.

Vasovagal syncope (VVS) is largely a benign condition focused on patient education, lifestyle modification, and avoidance of triggers. However, a subset of patients may benefit from permanent pacemaker placement. Commonly, patients with VVS are younger and those requiring pacing have symptoms associated with severe cardioinhibitory syncope. With the advent of leadless pacemaker systems, a lot of the risks associated with traditional transvenous pacemaker systems are mitigated. In this article, we provide a comprehensive review of the data available for the treatment of cardioinhibitory vasovagal syncope using leadless pacemaker systems.

Same-Day Discharge After Left Bundle Area Pacing.

BACKGROUND: Left bundle area pacing (LBAP) has emerged as an area that appears to be an attractive alternative to other forms of physiological pacing owing to its ease and favorable pacing parameters. Same-day discharge after conventional pacemakers, implantable cardioverter defibrillators, and more recently leadless pacemakers have become routine, especially after the COVID-19 pandemic. With the advent of LBAP, the safety and feasibility of same-day discharge remain unclear. METHODS: This is a retrospective, observational case series of consecutive, sequential patients undergoing LBAP at Baystate Medical Center, an academic teaching hospital. We included all patients who underwent LBAP and were discharged on the same day of procedure completion. Safety parameters included any procedure-related complications including pneumothorax, cardiac tamponade, septal perforation, and lead dislodgement. Pacemaker parameters included pacing threshold, R-wave amplitude, and lead impedance pre-discharge the following day of implantation and up to 6 months of follow-up. RESULTS: A total of 11 patients were included in our analysis, the average age was 70.3 ± 6.74 years. The most common indication for pacemaker insertion was AV block (73%). No complications were seen in any of the patients. The average time between the procedure and discharge was 5.6 hours. Pacemaker and lead parameters were stable after 6 months of follow-up. CONCLUSIONS: In this case series, we find that same-day discharge after LBAP for any indication is a safe and feasible option. As this mode of pacing becomes increasingly more common, larger prospective studies evaluating the safety and feasibility of early discharge after LBAP will be needed.

Periprocedural anticoagulation therapy in patients undergoing micra leadless pacemaker implantation.

Over the past decade, there has been significant improvement in the treatment cardiac diseases and symptomatic bradyarrhythmias with the development of leadless pacemaker systems. The Micra transcatheter pacemaker system has been shown to mitigate a lot of the complications associated with traditional pacing systems, which are notably skin pocket and lead-related complications. Numerous studies have shown the low complication rates associated with Micra procedure; however, there have been no specific guidelines or recommendations surrounding periprocedural anticoagulant therapy. This is important because a significant percentage of patients requiring pacemaker therapy have an indication for anticoagulation therapy as well. Multiple studies have shown the safety of uninterrupted anticoagulation during Micra implant, however, there is insufficient high-quality data to recommend periprocedural systemic use of anticoagulation. In this paper, we review the available data surrounding anticoagulation therapy in patients undergoing Micra implantation and the potential bleeding risks associated with this procedure.

Impact of Wire Sensor Location on Coronary Physiological Measurement.

BACKGROUND: The location of the wire sensor to measure fractional flow reserve (FFR) and diastolic pressure ratio (dPR) has not been systematically studied. Therefore, we hypothesize that the coronary physiological measurements will vary with the location of the sensor. METHODS: Fifty-four patients were screened, and 30 consecutive patients were enrolled. The OptoWire 2 or 3 generation fiberoptic pressure wire was used to assess whole cycle pressure distal/pressure aorta, dPR, and FFR. Our primary goal is to test if those measurements vary with the wire sensor placed at 10 mm (proximal), 35-45 mm (mid), and greater than or equal to 60-70 mm (distal) distal to the target lesion, respectively. We used a multilevel linear regression approach. RESULTS: Of 30 patients enrolled, 23 (76.6%) were males, mean age was 64.7 years (± 11.0 years), and mean stenosis was 61.6% (±13.4%). Adjusting for age, gender, and severity of stenosis, results showed that for all 3 measures (whole cycle pressure distal/pressure aorta, dPR, and FFR), pressure decreased in a linear fashion the further the sensor was from the target lesion ( P < 0.001). Further, pairwise comparisons of the measurements at adjacent locations similarly showed significant declines in pressure ( P < 0.001). CONCLUSIONS: This is the first study to demonstrate that the location of the pressure wire can impact the results of both resting and hyperemic pressures, which can cause a false-negative result. This is especially important where the values are near the cutoff.

Very low tidal volume, high-frequency ventilation in atrial fibrillation ablation: a systematic review.

BACKGROUND: Ventilation strategies in atrial fibrillation ablation affect procedure outcomes by influencing catheter stability. Studies have highlighted favorable atrial fibrillation (AF) ablation outcomes with the use of high-frequency jet ventilation (HFJV) which has been shown to improve lesion durability, energy delivery, and tissue contact. However, this mode of ventilation is not readily available. In this systematic review, we highlight the available data on the use of very low tidal volume, high-frequency ventilation using standard ventilators that aim to provide settings similar to HFJV during AF ablations. METHODS: Using a combination of search terms in databases and manual searches in bibliographies of identified articles, we reviewed all published data reported in the English language on the use of very low tidal volume with high-frequency ventilation during atrial fibrillation ablation. RESULTS: A total of 4 manuscripts were identified; 3 cohort studies and 1 case report. The utilization of standard ventilators with a high-frequency, very low tidal volume ventilation strategy appears to closely mimic the catheter stability benefits that HFJV ventilators provide. Across the 3 cohort identified studies, the use of this ventilation strategy was associated with improved catheter stability, tissue contact, and a decrease in radiofrequency time. No increased risk was identified compared to standard ventilation. CONCLUSION: With a purpose of limiting thoracic excursion and cardiac movement, limited and sparse studies have shown improved outcomes with a very low tidal volume, high-frequency ventilation strategy. Additional studies are needed to solidify this easily accessible and widely available mode of ventilation.

In-hospital outcomes of transcatheter versus surgical mitral valve repair in patients with chronic liver disease.

BACKGROUND: Mitral valve transcatheter edge-to-edge repair (TEER) using MitraClip is a treatment option for patients with moderate to severe mitral regurgitation who are not surgical candidate. Liver cirrhosis is associated with higher operative morbidity and mortality; however, it is not part of preoperative risk assessments calculators. We sought to evaluate the in-hospital outcomes in TEER and surgical mitral valve repair (SMVR) in liver cirrhosis. METHODS: National Inpatient Database from 2013 to 2017 was used to obtain all patients with cirrhosis who underwent TEER or SMVR using ICD-9-CM and ICD-10-CM codes. The primary outcome is to compare inpatient mortality between TEER and SMVR. Secondary outcomes were assessed including length of stay (LOS) and rate of complications including cardiogenic shock, blood transfusion and prolonged ventilation. RESULTS: A total of 875 patients with cirrhosis who underwent TEER (n = 123) or SMVR (n = 752) were identified in our analysis. Patients with TEER had significantly higher comorbidities such as congestive heart failure, coronary artery disease and chronic obstructive pulmonary disease. In-hospital mortality was lower in TEER group (8.2% vs 16%, P = .04). TEER was associated with lower rates of blood transfusion (30.3% vs 61.2%, P = .02) and reduced rates of prolonged mechanical ventilation (1.2% vs 17.2%, P = .042). In multivariate regression analysis, both blood transfusion and prolonged mechanical ventilation were significant predictors of mortality in liver cirrhosis. CONCLUSIONS: TEER was associated with lower rate of in-hospital mortality, LOS, blood transfusion and prolonged mechanical ventilation in cirrhosis patients. TEER can be considered as a viable option for cirrhosis patient with severe mitral regurgitation.

Impact of cardiovascular comorbidities on inpatient mortality in patients hospitalized with neutropenic fever.

INTRODUCTION: Concomitant cardiovascular comorbidities in patients with cancer are not uncommon. There is limited data on the impact of cardiovascular comorbidities on in-hospital mortality in patients admitted with neutropenic fever. METHODS: This is a retrospective cohort study using the 2016 NIS database of adults (> 18 years old) hospitalized for neutropenic fever as the primary diagnosis. The primary outcome studied is all-cause mortality in patients with neutropenic fever. ICD-10-CM codes were used to identify cardiovascular risk factors including smoking; hyperlipidemia; peripheral vascular diseases; hypertension; history of cerebrovascular disease or transient ischemic attack; and cardiovascular morbidities including atrial fibrillation, coronary artery disease, and congestive heart failure. Multivariate linear regression analysis was used to adjust for cofounders. RESULTS: A total of 28,060 patients were admitted with neutropenic fever in 2016. Average age was 43.9 ± 1.7 years, and 49.3% were females. Among the cases identified, 205 patients died during hospitalization with an overall in-hospital mortality of 0.7%. Atrial fibrillation was independently associated with higher in-hospital mortality (odds ratio [OR] 3.01; CI 1.38 to 6.57; p = 0.005) as was congestive heart failure (OR 3.15; CI 1.08 to 10.14; p = 0.049). CONCLUSION: Atrial fibrillation and congestive heart failure were associated with higher inpatient mortality in patients with neutropenic fever. Identifying the risk factors for increased mortality in patients with neutropenic fever is important for risk stratification and guiding clinicians in taking therapeutic decisions in this set of patients.

Concurring hypertrophic cardiomyopathy and takotsubo cardiomyopathy: Assessment and management.

The prevalence of takotsubo cardiomyopathy (TCM) has been on the rise, but co-occurrence with hypertrophic cardiomyopathy (HOCM) remains rare. Although presenting patient demographics were similar to those in TCM, the potential for hemodynamic compromise was significantly compounded by the presence of underlying HOCM. Management was similar to standalone TCM, although use of inotropic agents and mechanical support appears to be more prevalent. Despite the increased potential for complications and the paucity of data regarding management, outcomes appear to be mostly favorable in both the hospitalization period and at follow-up. Interestingly, despite a new diagnosis of HOCM in about half the cases described, which signifies no significant left ventricular outflow tract (LVOT) gradient prior to TCM, half of those patients had a persistently elevated LVOT gradient after resolution of TCM. This poses a question of whether or not TCM can predispose to LVOT obstruction in HOCM patients even after its resolution.

Outcomes of MitraClip Placement in Patients With Liver Cirrhosis.

INTRODUCTION: Liver cirrhosis is associated with increased morbidity and mortality. Many preoperative risk assessment tools do not take into account the presence or degree of liver cirrhosis prior to surgery. Over recent years, percutaneous mitral valve repair using MitraClip has emerged as an option for patients at high risk of surgical intervention. However, the safety, efficacy and outcomes of this procedure in patients with liver cirrhosis have not yet been evaluated. METHODS: This is a retrospective cohort study using the 2013-2017 National Inpatient Sample database of adults who were hospitalized for MitraClip repair of mitral valve. All patients were divided into patients with cirrhosis and those without cirrhosis. The primary outcome was all-cause mortality in patient with cirrhosis who underwent MitraClip. The secondary outcomes were to assess length of stay (LOS) and total hospital cost per year in cirrhotic patients compared to non-cirrhotic patients. RESULTS: In-hospital mortality was higher in cirrhosis group compared to non-cirrhosis however not statistically significant (8.1% vs 3.2%, OR: 2.59 [95% CI: 0.47-14.28, p-value 0.27). Additionally, neither of the secondary outcomes, LOS and total cost, were found to be statistically significant. However, the incidence of cardiogenic shock was significantly higher in the cirrhosis group 13.3% versus 3.9% (p-value 0.032). CONCLUSION: Patients with liver cirrhosis who underwent MitraClip repair of MV were at higher risk of developing cardiogenic shock, without any significant increase in in-hospital mortality, LOS or total cost. However, this study showed a trend toward higher rates of mortality, requirement of blood transfusion, mechanical ventilation, length of stay, and cost of care in cirrhosis patients.

Systematic Review of COVID-19 Related Myocarditis: Insights on Management and Outcome.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also referred to as COVID-19, was declared a pandemic by the World Health Organization in March 2020. The manifestations of COVID-19 are widely variable and range from asymptomatic infection to multi-organ failure and death. Like other viral illnesses, acute myocarditis has been reported to be associated with COVID-19 infection. However, guidelines for the diagnosis of COVID-19 myocarditis have not been established. METHODS: Using a combination of search terms in the PubMed/Medline, Ovid Medline and the Cochrane Library databases and manual searches on Google Scholar and the bibliographies of articles identified, we reviewed all cases reported in the English language citing myocarditis associated with COVID-19 infection. RESULTS: Fourteen records comprising a total of fourteen cases that report myocarditis/myopericarditis secondary to COVID-19 infection were identified. There was a male predominance (58%), with the median age of the cases described being 50.4 years. The majority of patients did not have a previously identified comorbid condition (50%), but of those with a past medical history, hypertension was most prevalent (33%). Electrocardiogram findings were variable, and troponin was elevated in 91% of cases. Echocardiography was performed in 83% of cases reduced function was identified in 60%. Endotracheal intubation was performed in the majority of cases. Glucocorticoids were most commonly used in treatment of myocarditis (58%). Majority of patients survived to discharge (81%) and 85% of those that received steroids survived to discharge. CONCLUSION: Guidelines for diagnosis and management of COVID-19 myocarditis have not been established and our knowledge on management is rapidly changing. The use of glucocorticoids and other agents including IL-6 inhibitors, IVIG and colchicine in COVID-19 myocarditis is debatable. In our review, there appears to be favorable outcomes related to myocarditis treated with steroid therapy. However, until larger scale studies are conducted, treatment approaches have to be made on an individualized case-by-case basis.

Iatrogenic atrial septal defect following the MitraClip procedure: A state-of-the-art review.

With an increase in number of patients undergoing percutaneous treatment of severe mitral regurgitation with MitraClip placement, the consequences of transseptal puncture resulting in iatrogenic atrial septal defects (iASDs) are being increasingly realized. Closure of iASDs following MitraClip therapy is not routinely performed, and no guidelines currently exist in managing this condition. While immediate hemodynamic and clinical compromise secondary to acute hypoxemia related to iASDs should be acutely managed with defect closure, the prevalence and consequences of long-term iASDs are still unclear. Some studies have cited a potential improvement in hemodynamic outcomes as a result of iASDs; while others report potential inferior and even fatal outcomes. In this state-of-the-art clinical review, we present the readers with the current data on the prevalence, outcomes, and potential management options of iASDs after MitraClip placement.

An observational study of the management practices and outcomes of patients with new onset atrial fibrillation in non-cardiothoracic surgeries.

BACKGROUND AND OBJECTIVE: Limited data exist on characteristics and management of patients with postoperative atrial fibrillation (POAF) after noncardiothoracic surgeries and on the relationship between symptoms and outcomes. We sought to describe clinical features, in-hospital practices and outcomes in patients with new POAF by the presence or absence of clinical symptoms. METHODS: Retrospective cohort study of adults with POAF in one tertiary center. RESULTS: Among the 99 patients who fulfilled the eligibility criteria, median age was 75 years (IQR 64-83) and 57.6% were male. Only thirty percent of patients with POAF were symptomatic. Rate control/conversion to sinus rhythm was achieved in ≤ 4 h in 56% of the patients and in 80% was maintained for ≥ 24 h. Anticoagulation was prescribed in 50% of those discharged in AF; the CHADS2-VASc score was not associated with anticoagulation prescribed. One third of patients were readmitted and half of them were in AF. Asymptomatic patients had lower median heart rate than symptomatic patients but no other clinical characteristics, or outcomes were different. CONCLUSIONS: Most patients with POAF were asymptomatic but their presentation or outcomes were similar with symptomatic patients. One in four discharged patients was prescribed anticoagulation and the CHADS2-VASC score was not associated with this decision. These findings have important implications for practice and future research. There is a need to better delineate the risk associated with transient versus persistent POAF, symptomatic versus asymptomatic POAF, as well as for clinical trials to determine optimal strategies to improve their outcomes.

Age associated non-linear regulation of redox homeostasis in the anucleate platelet: Implications for CVD risk patients.

BACKGROUND: Aging is a complex physiological phenomenon, intricately associated with cardiovascular pathologies, where platelets play a central pathophysiological role. Although antiplatelets are commonly employed to prevent and treat major adverse cardiovascular events, aging associated intraplatelet changes remain largely unexplored. METHODS: Platelets were studied in high cardiovascular risk patients (aged 40-100 years) comparing them to younger healthy subjects. This was followed by cross sectional and longitudinal mice studies. Flow cytometry, biochemical and molecular assays were used to study platelets comprehensively. FINDINGS: CVD Patients were categorized in the age groups 40-59, 60-79, and 80-100 years. Progressive decline in platelet health was observed in the 40-79 years age cohort, marked by increase in oxidative stress, hyperactivation and apoptotic markers. Paradoxically, this was reversed in patients aged above 79 years and the improved platelet phenotype was associated with lower oxidative damage. The platelets from the very old (80-100 year) group were found to be preloaded with increased antioxidants, which also contributed to higher resistance against induced redox insults. Cross sectional mouse studies excluded the effect of comorbidities and medications. Longitudinal mouse studies implicate an adaptive increase in antioxidant levels as the mechanism. INTERPRETATION: We report a novel age associated, non-linear redox regulation in platelets in both humans and mice. In advanced age, there occurs an adaptive increase in platelet antioxidants, reducing the intracellular ROS and leading to a healthier platelet phenotype. Clinically, our results advocate the use of less aggressive antiplatelet therapies for CVD in the elderly population. FUND: Study funded by NIH-NHLBI, RO1-HL122815 and RO1-HL115247.

Immune checkpoint inhibitor therapy and myocarditis: a systematic review of reported cases.

INTRODUCTION: The advent of immune checkpoint inhibitors in the treatment of certain types of cancers has revolutionized cancer therapy. In general, these novel agents are more tolerable and have better safety profiles than conventional chemotherapy agents. Although a low incidence of myocarditis was noted as a side effect of immune checkpoint inhibitors in clinical trials, it is being increasingly cited in the literature as their use also increases. METHODS: Using a combination of search terms in the PubMed/Medline database and manual searches on Google Scholar and the bibliographies of articles identified, we reviewed all cases reported in the English language citing myocarditis associated with either pembrolizumab, nivolumab, ipilimumab, or any combination of these agents. RESULTS: A total of 42 cases were included in the study. Mean age was 65.5 years; 64% were male, 36% were female. One or two doses preceded the onset of myocarditis in 33% and 29% of cases, respectively. Steroids were used as the first-line therapy in 90% of cases. Complete heart block occurred in 36% of cases. Fourteen (33%) deaths were reported, with 64% and 29% of deaths occurring after one or two doses, respectively. CONCLUSION: Most cases and fatalities of myocarditis occurred shortly after initiation of immune checkpoint inhibitor therapy. Arrhythmias, particularly complete heart block, appear to be related to the occurrence of more severe and fatal cases. The use of serial electrocardiograms or biomarkers of myocardial injury may be crucial in detecting early stages of the disease process. Further research establishing more specific guidelines is necessary in dealing with this potentially fatal side effect.

Pericardial effusion due to pembrolizumab-induced immunotoxicity: A case report and literature review.

The advent of immune checkpoint inhibitors has revolutionized cancer treatment. These novel agents have provided promising treatment options in patients with different types of cancers. One of these agents is pembrolizumab, which works by blocking the binding of T-lymphocytes to programmed cell death ligand 1 receptors on tumor cells, thus enabling immune activation of T-lymphocytes against tumor cells. Pembrolizumab is commonly used in metastatic nonsmall cell lung cancer and melanoma. However, despite the remarkable efficacy this agent has achieved, multiple immune-related adverse events have been reported including hepatitis, colitis, thyroid dysfunction, and pneumonitis. Only 2 other cases of pericardial effusion as a side effect of pembrolizumab have been cited in the literature; however, its incidence may be on the rise. Despite the rarity of this side effect, its complications are potentially life threatening and no clear platform currently exists to help guide healthcare professionals in the management of these adverse events. Herein we present the case of a 66-year-old female who developed pericardial effusion as a side effect of pembrolizumab and review the data currently available to assist in the management of this life-threatening condition.

Luminal esophageal temperature monitoring to reduce esophageal thermal injury during catheter ablation for atrial fibrillation: A review.

Over the past decade, catheter ablation for atrial fibrillation has emerged as an important rhythm control strategy. One of the most dreaded complications of this procedure is atrio-esophageal (AE) fistula formation, which is relatively rare but usually fatal. Esophageal tissue injury during ablation appears to be a precursor to the formation of AE fistulae. Luminal esophageal temperature (LET) monitoring is one of the most commonly utilized strategies to mitigate this risk, despite little evidence that it reduces esophageal injury. The incidence of AE fistulae appears to be on the rise, despite the widespread use of LET monitoring. This may be due to the advent of improved large lesion technology including force-sensing catheters and the use of high power, although AE fistulae have also been observed with the use of low power along the left atrial posterior wall. Currently available discrete sensors probes, whether single or multiple, do not appear to significantly reduce injury rates. The purpose of this manuscript is to systematically review the incidence of esophageal thermal injury with and without LET monitoring and review the factors that may be associated with increased risk of injury.