Transcatheter Mitral Valve Repair for Severe,Symptomatic Mitral Regurgitation in Patients with Left Ventricular Assist Devices.

Patients with symptomatic stage D heart failure who require left ventricular assist device (LVAD) support and suffer concomitant severe mitral regurgitation are often difficult to manage. One reason is due to cardiac anatomic constraints that limit optimization of the mechanical assist device. Typically, these patients are not candidates for repeat sternotomy with surgical mitral valve repair, and heart transplantation may not be feasible or timely. This case describes two patients with LVAD support who received transcatheter edge-to-edge mitral valve repair for severe, symptomatic mitral regurgitation. We believe this procedure may be a therapeutic option in stable patients with severe mitral regurgitation who require mechanical support.

Post-Myocardial Infarction Complications During the COVID-19 Pandemic - A Case Series.

We report 4 cases of post myocardial infarction complications due to the delay in presentation during COVID-19 era. We highlighted the need for auscultating the chest for early diagnosis. Through this case series, we urge to raise awareness among cardiac patients to access healthcare despite the fear of COVID-19.

Mechanical Circulatory Support in High-Risk Percutaneous Coronary Intervention.

Due to advancing age and increasing comorbidities, the current population has a higher incidence of complex coronary artery disease, often without surgical options for revascularization. In this setting, hemodynamic support devices are an important adjunct in the interventionist's toolbox as they allow for a safer, more effective procedure. The following paper reviews the indications of various available mechanical support devices, highlights their clinical data and technical parameters, and offers a practical approach towards appropriate patient and device selection.

Randomized Study of Persistent Atrial Fibrillation Ablation: Ablate in Sinus Rhythm Versus Ablate Complex-Fractionated Atrial Electrograms in Atrial Fibrillation.

BACKGROUND: Achieving long-term successful outcomes with ablation of persistent atrial fibrillation (AF) remains a clinical and procedural challenge. We aimed to assess 2 ablation strategies for persistent AF: pulmonary vein antral isolation (PVAI) in sinus rhythm after direct current cardioversion versus PVAI and ablation targeting complex-fractionated atrial electrograms while in AF. METHODS AND RESULTS: Between June 2009 and July 2013, patients with continuous persistent AF for ≥3 months were prospectively randomized to either direct current cardioversion before PVAI and posterior wall/septum ablation while in sinus rhythm (group 1), versus same ablation in group 1 in addition to complex-fractionated atrial electrogram ablation while in AF (group 2). The procedural profiles and clinical outcomes of the 2 strategies were compared. Ninety patients were randomized to group 1 (n=46) or group 2 (n=44). There were no differences in baseline characteristics between groups. Over 365 days of follow-up after the index procedure, 16 patients (35%) in group 1 and 13 patients (30%) in group 2 remained arrhythmia-free off antiarrhythmic medications. Over long-term follow-up (median, 867 days), arrhythmia-free survival off antiarrhythmic medications was more likely in group 1 than in group 2 in Kaplan-Meier analysis (Log Rank P=0.04). Group 1 ablation was associated with significantly shorter procedural duration and fluoroscopy time (231±72 versus 273±76 min; P=0.008 and 54 [Q1-Q3: 46-67] versus 66 (Q1-Q3: 53-83] min; P=0.018, respectively). CONCLUSIONS: In patients with persistent AF, PVAI in sinus rhythm after direct current cardioversion is associated with higher success and shorter procedural and fluoroscopy times compared with PVAI in AF with additional complex-fractionated atrial electrogram ablation. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02429648.

Hiatal Hernia Is Associated With an Increased Prevalence of Atrial Fibrillation in Young Patients.

Purpose: Hiatal hernia (HH) causes protrusion of the stomach into the chest cavity, directly impinging on the left atrium and possibly increasing predisposition to atrial arrhythmogenesis. However, such association has not been fully explored. The objective was to determine if an association between HH and atrial fibrillation (AF) exists and whether there are age- and sex-related differences. Methods: Adult patients diagnosed with HH from 1976 to 2006 at Mayo Clinic Rochester, Minnesota, were evaluated for AF. The number of patients with AF and HH was compared to age- and sex-matched patients with AF reported in the general population. Long-term outcomes were compared to corresponding county and state populations. Results: During the 30-year period, 111,429 patients were diagnosed with HH (mean age 61.4 ± 13.8 years, 47.9% male) and 7,865 patients (7.1%) also had a diagnosis of AF (mean age 73.1 ± 10.5 years; 55% male). In younger patients (<55 years), the occurrence of AF was 17.5-fold higher in men with HH and 19-fold higher in women with HH compared to the frequency of AF reported in the general population. Incidence of heart failure for patients with AF and HH was worse compared to the overall county population, but better than for those with AF. Similarly, mortality was worse in patients with AF and HH compared to the overall state population, but better than for those with AF in the county. Conclusion: Hiatal hernia appears to be associated with increased frequency of AF in both men and women of all age groups, but particularly in young patients. Further studies are needed to investigate this possible association and underlying mechanism.

Knowledge of asthma management by general practitioners in Karachi, Pakistan: comparison with international guidelines.

BACKGROUND: Suboptimal management of asthma by general practitioners (GPs) can lead to poor health outcomes AIMS: To assess the management of common asthma presentations by GPs using the Global Initiative for Asthma (GINA) guidelines as a comparative tool. METHODS: A cross-sectional survey was conducted in Karachi, Pakistan. Of 250 GPs approached, 192 completed a self-administered questionnaire regarding pathology, key history points, risk factors, diagnosis, and management of asthma. RESULTS: Overall, 28.6% of GPs had adequate knowledge of the core concepts of asthma, while only 10.4% had adequate practice in asthma management. About 78% of GPs had inadequate knowledge of pathology, about 90% had inadequate knowledge of medications to be used, and 63% had inadequate knowledge regarding diet restrictions. Knowledge regarding symptoms not usually associated with asthma was adequate, as was knowledge regarding non-pharmacological management (79% each). Practices regarding asthma diagnosis were good (99.0%). However, practices regarding acute exacerbations and patients who wish to exercise were inadequate in 85.9% and 82.8% of GPs, respectively. CONCLUSIONS: The majority of GPs had poor knowledge and practice of asthma. We recommend initiation of programmes to improve their knowledge and practices.