Outcomes of Transvenous Lead Extraction in a Referral Center in Northern Israel.

BACKGROUND: Cardiac implantable electronic devices (CIEDs) are increasingly being used; thus, there is an increasing need for transvenous lead extraction (TLE). OBJECTIVES: To summarize our experience with TLE at single referral center in northern Israel. METHODS: The study included all patients who underwent TLE at our center between 2019 and 2022, regardless of the indication. RESULTS: The cohort included 50 patients. The mean age was 69 ± 10.36 years; 78% were males. A total of 99 electrodes were targeted. The mean number of electrodes was 1.96 (range 1-4) per patient. The time between lead implantation and extraction ranged between 1.1 and 34 years with an average of 8.14 ± 5.71 years (median of 7.5 years). Complete lead removal was achieved in 98% of patients and in 98.99% of leads. The complete procedural success rate as well as the clinical procedural success rate was 96%. The procedural failure rate was 4% (1 patient died 2 days after the index procedure and 1 patient remained with large portion of lead). The indication for TLE was infection in 78% of the cohort group. Powered mechanical sheaths were used in 36 patients (72%), laser sheaths in 27 (54%), and a combination of laser and mechanical sheaths in 16 (32%). CONCLUSIONS: The clinical and procedural success rates of TLE, primarily for CEID-related infection, were high. A combination of laser and mechanical sheaths was needed in one-third of patients.

Does the Initial Screening of Syncope in the Emergency Department and During Hospitalization Adhere to ESC Guidelines?

BACKGROUND: The evaluation of syncope in emergency departments (EDs) and during hospitalization can be ineffective. The European Society of Cardiology (ESC) guidelines were established to perform the evaluation based on risk stratification. OBJECTIVES: To investigate whether the initial screening of syncope adheres to the recent ESC guidelines. METHODS: Patients with syncope who were evaluated in our ED were included in the study and retrospectively classified based on whether they were treated according to ESC guidelines. Patients were divided into two groups according to the ESC guideline risk profile: high risk or low risk. RESULTS: The study included 114 patients (age 50.6 ± 21.9 years, 43% females); 74 (64.9%) had neurally mediated syncope, 11 (9.65%) had cardiac syncope, and 29 (25.45%) had an unknown cause. The low-risk group included 70 patients (61.4%), and the high-risk group included 44 (38.6%). Only 48 patients (42.1%) were evaluated according to the ESC guidelines. In fact, 22 (36.7%) of 60 hospitalizations and 41 (53.2%) of 77 head computed tomography (CT) scans were not mandatory according to guidelines. The rate of unnecessary CT scans (67.3% vs. 28.6%, respectively, P = 0.001) and unnecessary hospitalization (66.7% vs. 6.7%, respectively, P < 0.02) were higher among low-risk patients than high-risk patients. Overall, a higher percentage of high-risk patients were treated according to guidelines compared to low-risk patients (68.2% vs. 25.7% respectively, P < 0.0001). CONCLUSIONS: Most syncope patients, particularly those with a low-risk profile, were not evaluated in accordance with the ESC guidelines.

Implantable Loop Recorders in Patients with Unexplained Syncope: Does Ethnic Background Influence Diagnostic Yield?

BACKGROUND: Implantable loop recorders (ILRs) are a central tool in the evaluation of unexplained syncope. These devices record and store electrocardiograms, both automatically and on patient-dependent activation. Therefore, obtaining optimal diagnostic results relies on a patient's comprehension and collaboration. OBJECTIVES: To evaluate the effect of ethnic background and mother-tongue language on the diagnostic yield (DY) of ILRs. METHODS: Patients at two medical centers in Israel, who had ILRs as part of syncope workup were included. Inclusion criteria were age over 18 years and an ILR for at least one year (or less if the cause of syncope was detected). Patient demographics, ethnic background, and previous medical history were recorded. All findings from ILR recordings, activation mode (manual vs. automatic), and treatment decisions (none, ablation, device implantation) were collected. RESULTS: The study comprised 94 patients, 62 Jews (i.e., ethnic majority) and 32 non-Jews (i.e., ethnic minority). While baseline demographic characteristics, medical history, and drug therapy were similar in both groups, Jewish patients were significantly older at the time of device implantation: 64.3 ± 16.0 years of age vs. 50.6 ± 16.9, respectively; (P < 0.001). Arrhythmias recorded in both groups as well as treatment decisions and device activation mode were similar. Total follow-up time from device implantation was longer in the non-Jewish vs. the Jewish group (17.5 ± 12.2 vs. 24.0 ± 12.4 months, respectively; P < 0.017). CONCLUSIONS: The DY of ILR implanted for unexplained syncope did not seem to be influenced by patient's mother-tongue language or ethnicity.

The Prognostic Value of Cardiovascular Risk Factors and Laboratory Biomarkers in Predicting 6-Month Outcomes in High-risk Patients with Non-ST Segment Elevation Myocardial Infarction.

BACKGROUND: Acute coronary syndrome (ACS) represents a spectrum of ischemic myocardial disease including unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Various prognostic scores were developed for patients presenting with NSTEMI-ACS. Among these scores, the GRACE risk score offers the best discriminative performance for prediction of in-hospital and 6-month mortality. However, the GRACE score is limited and cannot be used in several ethnic populations. Moreover, it is not predictive of clinical outcomes other than mortality. OBJECTIVES: To assess the prognostic value of traditional cardiovascular risk factors and laboratory biomarkers in predicting 6-month major adverse cardiac and cerebrovascular events (MACCE), including hospitalization, recurrent percutaneous coronary intervention (PCI), stroke, and cardiovascular mortality in patients with NSTEMI treated with PCI. METHODS: This retrospective study included consecutive patients admitted with an initial diagnosis of NSTEMI to the cardiac intensive care unit (CICU) at the Tzafon Medical Center, Israel, between April 2015 and August 2018 and treated by PCI within 48 hours of admission. RESULTS: A total of 223 consecutive patients with NSTEMI treated by PCI were included in the study. Logarithmebrain natriuretic peptide (LogₑBNP), prior MI, and Hb levels were found to be significant predictors of any first MACCE. Only logₑBNP was found to be an independent predictor of a first MACCE event by multivariate logistic regression analysis. CONCLUSIONS: LogₑBNP is an independent predictor of worse prognosis in patients with NSTEMI. Routine evaluation of BNP levels should be considered in patients admitted with NSTEMI.

Left Ventricular "Longitudinal Rotation" and Conduction Abnormalities-A New Outlook on Dyssynchrony.

BACKGROUND: The complete left bundle branch block (CLBBB) results in ventricular dyssynchrony and a reduction in systolic and diastolic efficiency. We noticed a distinct clockwise rotation of the left ventricle (LV) in patients with CLBBB ("longitudinal rotation"). AIM: The aim of this study was to quantify the "longitudinal rotation" of the LV in patients with CLBBB in comparison to patients with normal conduction or complete right bundle branch block (CRBBB). METHODS: Sixty consecutive patients with normal QRS, CRBBB, or CLBBB were included. Stored raw data DICOM 2D apical-4 chambers view images cine clips were analyzed using EchoPac plugin version 203 (GE Vingmed Ultrasound AS, Horten, Norway). In EchoPac-Q-Analysis, 2D strain application was selected. Instead of apical view algorithms, the SAX-MV (short axis-mitral valve level) algorithm was selected for analysis. A closed loop endocardial contour was drawn to initiate the analysis. The "posterior" segment (representing the mitral valve) was excluded before finalizing the analysis. Longitudinal rotation direction, peak angle, and time-to-peak rotation were recorded. RESULTS: All patients with CLBBB (n = 21) had clockwise longitudinal rotation with mean four chamber peak rotation angle of -3.9 ± 2.4°. This rotation is significantly larger than in patients with normal QRS (-1.4 ± 3°, p = 0.005) and CRBBB (0.1 ± 2.2°, p = 0.00001). Clockwise rotation was found to be correlated to QRS duration in patients with the non-RBBB pattern. The angle of rotation was not associated with a lower ejection fraction or the presence of regional wall abnormalities. CONCLUSIONS: Significant clockwise longitudinal rotation was found in CLBBB patients compared to normal QRS or CRBBB patients using speckle-tracking echocardiography.

A Rare Case of Rectus Muscle Twitching Due to Abandoned Uncapped Pacemaker Leads.

Extra-cardiac stimulation after cardiac pacemaker implantation is seldom seen in the cardiac field. However, this case report demonstrates an unusual symptom of persistent abdominal twitching in a 42-year-old male patient who underwent pacemaker replacement, lasting for 15 years. Initially, it was attributed to diaphragmatic pacing by the new pacemaker. Despite several attempts to replace the endocardial leads, the patient's symptoms did not improve. Finally, he was referred to our hospital, where our team conducted further investigations and discovered that the old pacemaker lead was exposed, leading to excitation of the rectus muscle.

Left atrial appendage exclusion in atrial fibrillation.

Although oral anticoagulants (OACs) are first-line therapy for stroke prevention in patients with atrial fibrillation (AF), some patients cannot be treated with OACs due to absolute or relative contraindications. Left atrial appendage (LAA) exclusion techniques have been developed over the years as a therapeutic alternative for stroke prevention. In this paper, we review the evolution of surgical techniques, employed as an adjunct to cardiac surgery or as a stand-alone procedure, as well as the recently introduced and widely utilized percutaneous LAA occlusion techniques. Until recently, data on surgical LAAO were limited and based on non-randomized studies. We focus on recently published randomized data which strongly support an add-on surgical LAAO in eligible patients during cardiac surgery and could potentially change current practice guidelines. In recent years, the trans-catheter techniques for LAA occlusion have emerged as another, less invasive alternative for patients who cannot tolerate oral anticoagulation. We review the growing body of evidence from prospective studies and registries, focusing on the two systems which are in widespread clinical use nowadays: the Watchman and Amulet type devices. These data show favorable results for both Watchman and Amulet devices, setting them as an important tool in our arsenal for stroke reduction in AF patients, especially in those who have contraindications for OACs. A better understanding of the different therapeutic alternatives, their specific benefits, and downfalls in different patient populations can guide us in tailoring the optimal therapeutic approach for stroke reduction in our AF patients.

Detection of Common Arrhythmias by the Watch-PAT: Expression of Electrical Arrhythmias by Pulse Recording.

Background: The WatchPAT (WP) device was shown to be accurate for the diagnosis of sleep apnea and is widely used worldwide as an ambulatory diagnostic tool. While it records peripheral arterial tone (PAT) and not electrocardiogram (ECG), the ability of it to detect arrhythmias is unknown and was not studied previously. Common arrhythmias such as atrial fibrillation (AF) or premature beats may be uniquely presented while recording PAT/pulse wave. Purpose: To examine the potential detection of common arrhythmias by analyzing the PAT amplitude and pulse rate/volume changes. Patients and Methods: Patients with suspected sleep disordered breathing (SDB) were recruited with preference for patients with previously diagnosed AF or congestive heart failure (CHF). They underwent simultaneous WP and PSG studies in 11 sleep centers. A novel algorithm was developed to detect arrhythmias while measuring PAT and was tested on these patients. Manual scoring of ECG channel (recorded as part of the PSG) was blinded to the automatically analyzed WP data. Results: A total of 84 patients aged 57±16 (54 males) participated in this study. Their BMI was 30±5.7Kg/m2. Of them, 41 had heart failure (49%) and 17 (20%) had AF. The sensitivity and specificity of the WP to detect AF segments (of at least 60 seconds) were 0.77 and 0.99, respectively. The correlation between the WP derived detection of premature beats (events/min) to that of the PSG one was 0.98 (p<0.001). Conclusion: The novel automatic algorithm of the WP can reasonably detect AF and premature beats. We suggest that when the algorithm raises a flag for arrhythmia, the patients should shortly undergo ECG and/or Holter ECG study.

Acute Kidney Injury Following Transcatheter Aortic Valve Implantation: Association with Contrast Media Dosage and Contrast Media Based Risk Predication Models.

The effect of contrast media (CM), delivered prior to- and during transcatheter aortic valve implantation (TAVI), on kidney function, following the procedure, is debatable. Consequently, the performance of CM-based, acute kidney injury (AKI) risk prediction models is also questionable. We retrospectively studied 210 patients that underwent TAVI. We recorded the dose of CM used prior and during TAVI, calculated the results of different AKI risk assessment models containing a CM module, and tested their association with AKI after the procedure. AKI was diagnosed in 38 patients (18.1%). The baseline estimated glomerular filtration rate (eGFR) was lower in the AKI+ group compared to AKI- group (51 ± 19.3 versus 64.5 ± 19 mL/min/1.73 mr2, respectively). While the dose of CM delivered prior to TAVI, during TAVI or the cumulative amount of both did not differ between the groups, the results of all tested risk models were higher in AKI+ patients. However, by multivariable analysis, only eGFR had a consistent independent association with AKI. We suggest that the dose of CM delivered prior or during TAVI is not associated with AKI and that the predictive power of CM based AKI risk models is, in all probability, limited to eGFR alone.

The Obesity Paradox in Real-World Nation-Wide Cohort of Patients Admitted for a Stroke in the U.S.

Background: Obesity has been associated with increased incidence and severity of various cardiovascular risk factors and increased risk for stroke. However, the evidence of its effect on outcomes in stroke victims have been equivocal. We aimed to investigate the distribution of BMI in a nation-wide cohort of individuals, admitted for a stroke, and the relationship between BMI and in-hospital mortality. Methods: Data from the U.S. National Inpatient Sample (NIS) was collected, to identify hospitalizations for stroke, between October 2015 and December 2016. The patients were sub-divided into six groups based on their BMI: underweight, normal weight, overweight, obese I, obese II and extremely obese groups. Various sociodemographic and clinical parameters were gathered, and incidence of mortality and the length of hospital stay were analyzed. Multivariable analysis was performed to identify independent predictors of in-hospital mortality. Results: A weighted total of 84,185 hospitalizations for stroke were included in the analysis. The approximate mean patients aged was 65.5 ± 31 years, the majority being female (55.3%) and white (63.1%). The overall in-hospital mortality during the study period was 3.6%. A reverse J-shaped relationship between the body mass index and in-hospital mortality was documented, while patients with elevated BMI showed significantly lower in-hospital mortality compared to the underweight and normal weight study participants, 2.8% vs. 7.4%, respectively, p < 0.001. Age and several comorbidities, as well as the Deyo Comorbidity Index, were found to predict mortality in a multivariable analysis. Conclusion: A reverse J-shaped relationship between body mass index and in-hospital mortality was documented in patients admitted for a stroke in the U.S. during the study period. The above findings support the existence of an "obesity paradox" in patients hospitalized following a stroke, similar to that described in other cardiovascular conditions.

Safety of catheter ablation for atrial fibrillation in patients with mechanical prosthetic valves.

BACKGROUND: Catheter ablation (CA) for atrial fibrillation (AF) is increasingly utilized in recent years, with promising results. We aimed to investigate the nationwide trends in utilization and procedural complications of CA for AF in patients with mechanical prosthetic valves (MPVs). METHODS AND RESULTS: We drew data from the US National Inpatient Sample (NIS) database to identify cases of AF ablations in patients with MPVs, between 2003 and 2015. Sociodemographic and clinical data were collected, and incidence of procedural complications, mortality, and length of stay were analyzed. We compared the outcomes to a propensity-matched cohort of patients without MPVs. The study included a weighted total of 1898 CA for AF cases in patients with MPVs. The median age of the study population was 67 (61-75) years and 53% were males. Despite the increasing age and significant uptrend in the prevalence of individual comorbidities and Deyo-Charlson Comorbidity Index (CCI) over the years, the risk of peri-procedural complications and mortality in the study group did not change between the early (2003-2008) and late (2009-2015) study years. The peri-procedural complication rate (8.4% vs. 10.4%, p = .33) and in-hospital mortality (0.2% vs. 0.2%, p = .9) did not differ significantly between patients with MPVs and 1901 matched patients without MPVs. Length of stay was higher among patients with prior MPVs compared to the controls (4.0 ± 0.2 vs. 3.3 ± 0.2 days, p = .011). CONCLUSION: This nationwide analysis shows that AF ablation in patients with mechanical valve prothesis bares a similar risk of periprocedural complications and mortality as in patients without prosthetic valves.

The Role of Affect as a Mediator between Coping Resources and Heart Rate Variability among Older Adults.

BACKGROUND: Heart rate variability (HRV) has been suggested as an indicator of capacity to adapt effectively to physiological or environmental challenges and of physical and psychological health in old age. AIMS: The study assessed levels of high-frequency HRV (HF-HRV) among older adults in relation to positive and negative affect and the mediating role of positive and negative affect in the association between coping resources (perceived social support and sense of mastery) and HF-HRV. METHOD: Participants were 187 men and women in three assisted-living residences who were independent in activities of daily living (93.4% participation rate). The participants completed sense of mastery, multidimensional scale of perceived social support, and positive and negative affect questionnaires. HF-HRV was derived from electrocardiography data measured by a Holter monitoring device for 15 minutes. RESULTS: The empirical model showed good fit indices indicating that higher HF-HRV was associated with lower negative affect, and negative affect mediated the association between perceived social support and HF-HRV. In addition, perceived social support and sense of mastery were associated with higher positive affect and lower negative affect. CONCLUSIONS: Although this was a cross-sectional study, it suggests that HF-HRV may be a link between affect and health in old age. It also suggests the importance of identification and intervention with older adults and their support systems to reduce negative affect.

Left atrial function analysis in patients in sinus rhythm, normal left ventricular function and indeterminate diastolic function.

Assessment of diastolic function by echocardiography may be indeterminate as demonstrated in previous studies where diastolic measurement is a discrepant. We aimed to assess whether left atrial (LA) function may contribute to left ventricle filling evaluation in patients with indeterminate diastolic function (IndtDFx). This retrospective study included 3 groups of patients based on diastolic function: normal diastolic function (NDFx), definite diastolic dysfunction (DDFx) and IndtDFx. All patients had sinus rhythm with left ventricular ejection fraction ≥ 45%. Diastolic function was determined according to the following echocardiographic parameters: mitral E', mitral E/E' ratio, LA maximal volume index, and pulmonary pressure. NDFx was defined as having less than 2 abnormal parameters, DDFx as more than 2 abnormal parameters, and IndtDFx as 2 abnormal parameters. LA function analysis was performed in all patients using echocardiographic 2D speckle tracking. Sixty seven patients were included in strain analysis. The DDFx group (n = 21) and IndtDFx (n = 19) were significantly different from NDFx (27) in some demographics, cardiovascular risk factors, presentation and echocardiographic parameters. Some of the phasic LA function (phasic LA volumes and strains) parameters in the IndtDFx group were similar to DDFx and significantly different from the NDFx group, while other parameters fell in between the two groups. Phasic LA minimal volume index was found to be associated with heart failure symptoms. The IndtDFx group is a heterogeneous group demonstrating clinical and echocardiographic profiles that closely resemble that of DDFx group. LA phasic function analysis may help in re-classification of patients with IndtDFx as actual DDFx or as NDFx.

The Mechanical Cost of Decreasing Conduction Velocity: A Mathematical Model of Pacing-Induced Lower Strain.

PURPOSE: To simulate the effect of decreasing conduction velocity (Cvel) on average segmental myocardial strain using mathematical modeling. METHODS: The simulation was run using MatLab version 7.4 (The MathWorks, Inc. Natick, Massachusetts). A normal strain-time curve pattern was sampled from a normal human echo study using the 2D strain imaging software (GE Healthcare, Milwaukee, Wisconsin). Contraction was simulated from simultaneous segmental activation (Cvel=∞) through normal activation (Cvel=400cm/sec) to pacing Cvel (100 to 10cm/sec). The simulation generated average segmental strain-time waveforms for each velocity and peak strain as a function of Cvel and time to peak strain as a function of Cvel curves. RESULTS: With decreasing Cvel, average peak segmental strain was found to be decreased and delayed. The following correlation equation represents the correlation betweenpeak strain and Cvel : strain= -20.12+27.65 x e (-0.29 x Cvel). At the highest pacing Cvel (100cm/sec) average peak segmental strain dropped by 10%, at 50cm/sec by 30% and at the lowest pacing Cvel (10cm/sec) peak strain dropped by >90%. Time to peak segmental strain was minimally longer with decreasing Cvel down to 70cm/sec (pacing velocity range). Further decreased velocity dramatically increased time to peak strain of the simulated segment. CONCLUSIONS: The simulation yielded a predictive correlation between slower conduction velocities and decreased and delayed segmental strain.

Does Duration of Symptoms Reliably Predict Detection of Left Atrial Thrombus in Newly Diagnosed Atrial Fibrillation.

BACKGROUND: Large prospective trials attribute minimal thromboembolic risk for cardioversion of atrial fibrillation (AF) when duration of symptoms is shorter than 48 hours. Our goal is to compare the prevalence of left atrial appendage (LAA) thrombus as demonstrated by a Trans esophageal echocardiography (TEE) exam between patients presenting with less or more than 48 hours of AF symptoms. METHODS: Observational cohort study including consecutive patients hospitalized with primary diagnosis of new onset AF, not previously treated with oral anticoagulation. All patients underwent TEE to exclude LAA thrombus, regardless of symptoms duration. Patients were divided into two groups based on AF duration: 1) early presenters: up to 48 hours, 2) later presenters: longer than 48 hours. RESULTS: The study included 122 patients mean age 65.8 years). The "early presenters" were younger, with less co-morbidities. LAA thrombus was detected in 13(21%) of 62 early presenters, compared to 20 (33%) of 60 patients of the second group (P=0.12). Significant predictors of LAA thrombus in the whole cohort by univariate analysis were ≥65 years of age (1.051, P=0.017), acute heart failure (2.394, P=0.038), and history of coronary artery/ peripheral vascular disease (2.7, P= 0.019). Notably neither duration of symptoms nor CHA2DS2-VASc score significantly predicted LAA thrombus. Inmultivariate analysis, only age ≥65 was found to be a significant predictor of LAA thrombus. CONCLUSIONS: LAA thrombus in patients presenting within 48 hours of AF symptoms onset is not uncommon. Duration of symptoms is not reliable for excluding LAA thrombus.

The relationship between the body mass index and in-hospital mortality in patients admitted for sudden cardiac death in the United States.

While obesity has been shown to be associated with elevated risk for Sudden Cardiac Death (SCD), studies examining its effect on outcomes in SCD victims have shown conflicting results. We aimed to describe the body mass index (BMI) distribution in a nationwide cohort of patients admitted for an out of hospital SCD (OHSCD), and the relationship between BMI and in-hospital mortality. We drew data from the U.S. National Inpatient Sample (NIS), to identify cases of OHSCD. Patients were divided into six groups based on their BMI (underweight, normal weight, overweight, obese I, obese II, extremely obese). Socio-demographic and clinical data were collected, mortality and length of stay were analyzed. Multivariate analysis was performed to identify predictors of mortality. Among a weighted total of 2330 hospitalizations for OHSCD in patients with documented BMI, the mean age was 62.3 ± 29 years, 52.4% were male and 62% were white. The overall rate of in-hospital mortality was 69.3%. A U-shaped relationship between the BMI and mortality was documented, as patients with 25 < BMI < 40 exhibited significantly lower mortality (60.7%) compared to the other BMI groups (75.2%), p < .001. BMI of 25 kg/m2 and below or 40 kg/m2 and above, were independent predictors of in-hospital mortality in a multivariate analysis along with prior history of congestive heart failure and Deyo Comorbidity Index of ≥2. A U-shaped relationship between the BMI and in-hospital mortality was documented in patients hospitalized for an out of hospital sudden cardiac death in the United States in the recent years.

The Relationship Between Body Mass Index and In-Hospital Mortality in Patients Following Coronary Artery Bypass Grafting Surgery.

Background: The association between Body Mass Index (BMI) and clinical outcomes following coronary artery bypass grafting (CABG) remains controversial. Our objective was to investigate the real-world relationship between BMI and in-hospital clinical course and mortality, in patients who underwent CABG. Methods: A sampled cohort of patients who underwent CABG between October 2015 and December 2016 was identified in the National Inpatient Sample (NIS) database. Outcomes of interest included in-hospital mortality, peri-procedural complications and length of stay. Patients were divided into 6 BMI (kg/m2) subgroups; (1) under-weight ≤19, (2) normal-weight 20-25, (3) over-weight 26-30, (4) obese I 31-35, (5) obese II 36-39, and (6) extremely obese ≥40. Multivariable logistic regression model was used to identify predictors of in-hospital mortality. Linear regression model was used to identify predictors of length of stay (LOS). Results: An estimated total of 48,710 hospitalizations for CABG across the U.S. were analyzed. The crude data showed a U-shaped relationship between BMI and study population outcomes with higher mortality and longer LOS in patients with BMI ≤ 19 kg/m2 and in patients with BMI ≥40 kg/m2 compared to patients with BMI 20-39 kg/m2. In the multivariable regression model, BMI subgroups of ≤19 kg/m2 and ≥40 kg/m2 were found to be independent predictors of mortality. Conclusions: A complex, U-shaped relationship between BMI and mortality was documented, confirming the "obesity paradox" in the real-world setting, in patients hospitalized for CABG.

Ventricular arrhythmia ablation in the presence of mechanical valve utilization and complications of catheter ablation for ventricular arrhythmia in patients with mechanical prosthetic valves.

BACKGROUND: Catheter ablation (CA) for ventricular arrhythmias (VAs) is increasingly utilized in recent years. We aimed to investigate the nationwide trends in utilization and procedural complications of CA for VAs in patients with mechanical valve (MV) prosthesis. METHODS: We drew data from the US National Inpatient Sample database to identify cases of VA ablations, including premature ventricular contraction and ventricular tachycardia, in patients with MVs, between 2003 and 2015. Sociodemographic and clinical data were collected and the incidence of catheter ablation complications, mortality, and length of stay were analyzed. We compared the outcomes to a propensity-matched cohort of patients without prior valve surgery. RESULTS: The study population included a weighted total of 647 CA cases in patients with prior MVs. The annual number of ablations almost doubled, from 34 ablations on average during the "early years" (2003-2008) to 64 on average during the "late years" (2009-2015) of the study (p = .001). Length of stay at the hospital did not differ significantly between patients with MVs and 649 matched patients without prior MVs (5.4 ± 0.4, 4.7 ± 0.3 days, respectively, p = .12). The data revealed a trend toward a higher incidence of complications (12.6% vs. 7.5% respectively, p = .14) and mortality (3.7% vs. 0.7%, respectively, p = .087) among patients with MVs compared to the matched control group, not reaching statistical significance. CONCLUSION: The data show increased utilization of VA ablations in patients with MVs and a trend toward a higher incidence of in-hospital mortality and complications compared to the propensity-matched control group without MVs.

The Relationship Between Body Mass Index and In-Hospital Mortality in the Contemporary Era of an Acute Myocardial Infarction Management.

BACKGROUND: The association between body mass index (BMI) and clinical outcomes following an acute myocardial infarction (AMI) remains controversial. Our objective was to investigate the relationship between BMI and AMI presentation, in-hospital clinical course and mortality in the contemporary era of AMI management. METHODS: Patients, hospitalized for an AMI between October 2015 and December 2016, were identified in the National Inpatient Sample (NIS) database. Socio-demographic and clinical data, including BMI, were collected and outcomes, including length of stay and mortality, were analyzed. Patients were divided into 6 BMI (kg/m2) subgroups; under-weight (≤19), normal-weight (20-25), over-weight (26-30), obese I (31-35), obese II (36-39) and extremely obese (≥40). Multivariable logistic regression model was used to identify predictors of in-hospital mortality. Linear regression model was used to identify predictors of length of stay (LOS). RESULTS: An estimated total of 125,405 hospitalizations for an AMI across the US were analyzed. Compared to the other BMI subgroups, the under-weight, normal-weight and extremely obese groups presented with a non-ST segment elevation AMI (NSTEMI) more frequently and were less likely to undergo coronary revascularization. The data show a J-shaped relationship between BMI and study outcomes with lower mortality in patients with BMI over 25 compared to normal- and low-weight patients. In the multivariate regression model, BMI group was found to be an independent predictor of mortality. CONCLUSION: J-shaped relationship between BMI and mortality was documented in patients hospitalized for an AMI in the recent years. These findings confirm that the "obesity paradox" persists during the contemporary era of an AMI management.