Same-day discharge after cryoballoon ablation of atrial fibrillation: A multicenter experience.

BACKGROUND: It is common practice to observe patients during an overnight stay (ONS) following a catheter ablation procedure for the treatment of atrial fibrillation (AF). OBJECTIVES: To investigate the safety and economic impact of a same-day discharge (SDD) protocol after cryoballoon ablation for treatment of AF in high-volume, geographically diverse US hospitals. METHODS: We retrospectively reviewed 2374 consecutive patients (1119 SDD and 1180 ONS) who underwent cryoballoon ablation for AF at three US centers. Baseline characteristics, acute procedure-related complications, and longer-term evaluations of safety were recorded during routine clinical follow-up. The mean cost of an ONS was used in a one-way sensitivity analysis to evaluate yearly cost savings as a function of the percentage of SDD cases per year. RESULTS: The SDD and ONS cohorts were predominately male (69% vs. 67%; p = .3), but SDD patients were younger (64 ± 11 vs. 66 ± 10; p < .0001) with lower body mass index (30 ± 6 vs. 31 ± 61; p < .0001) and CHA2 DS2 -VASc scores (1.4 ± 1.0 vs. 2.2 ± 1.4; p < .0002). There was no difference between SDD and ONS in the 30-day total complication rate (n = 15 [1.26%] versus n = 24 [2.03%]; p = .136, respectively). The most common complication was hematoma in both the SDD (n = 8; 0.67%) and ONS (n = 11; 0.93%) cohorts. Sensitivity analysis demonstrated that when 50% of every 100 patients treated were discharged the same day, hospital cost savings ranged from $45 825 to $83 813 per year across US hospitals. CONCLUSIONS: SDD following cryoballoon ablation for AF appears to be safe and is associated with cost savings across different US hospitals.

Small Septal Branch Artery Thrombus Inducing Ventricular Fibrillation: To Intervene or Not to Intervene.

A 64-year-old woman presented for chest pain and was diagnosed with anteroseptal ST segment elevation myocardial infarction (STEMI). Emergent angiography showed 95% stenosis at the ostium of the second septal branch, consistent with thrombus, and no other significant lesions. The lesion was not amenable to intervention due to small caliber. Post angiography, the patient's electrical rhythm deteriorated into ventricular fibrillation. Following resuscitation, repeat angiography confirmed same findings. Electrophysiology study at 3 months was positive for inducing fibrillation. Due to patient risk factors, she had placement of a dual chamber defibrillator. A 5-month follow-up echocardiogram showed a small area of ventricular septal wall bowing, consistent with blood supply from septal territory.

Sudden cardiac death in isolated right ventricular hypertrabeculation/noncompaction cardiomyopathy.

Hypertrabeculation/noncompaction of the myocardium is a rare disorder that involves most commonly the left ventricle of the heart and it has been recognized as a distinct cardiomyopathy by the World Health Organization. However, it is extremely rare for this condition to involve exclusively the right ventricle. We report the cases of three patients who presented with ventricular tachyarrhythmia and sudden cardiac death. They were found to have isolated right ventricular hypertrabeculation/noncompaction on echocardiography. This supports the hypothesis that this condition is highly arrhythmogenic and is associated with high mortality similarly to the left ventricular hypertrabeculation/noncompaction cardiomyopathy.

Loperamide cardiotoxicity: "A Brief Review".

Loperamide is a popular antidiarrheal medication that has been used for many years. It is currently gaining more attention among healthcare professionals due to its increasing potential for side effects. At present, it is considered safe enough to be sold over the counter. In contrast with other opioid agonists, loperamide is a peripherally acting µ-receptor agonist exerting its effects mainly on the myenteric plexus of the gastrointestinal longitudinal muscle layer. It decreases peristalsis and fluid secretion resulting in longer gastrointestinal transit time. The bioavailability of the drug is extremely low. Moreover, it is actively excluded from the central nervous system; hence, it lacks the central effects of euphoria and analgesia at the recommended dosages. Loperamide abuse has been steadily increasing in the United States. Abusers typically ingest high doses in desire to achieve a satisfactory central nervous system drug penetration. This has made it a potential over the counter substitute for self-treating opioid withdrawal symptoms and achieving euphoric effects.

Takotsubo Cardiomyopathy precipitated by opiate withdrawal.

INTRODUCTION: Takotsubo Cardiomyopathy is a transient non-ischemic cardiomyopathy usually characterized by apical ballooning of the left ventricle, with electrocardiographic changes and enzyme release, without evidence of obstructive coronary artery disease. Typically seen in stress induced situations, in post-menopausal females, this condition may have a predilection for patients with dependency disorders. CASE: The following is a case in which Takotsubo Cardiomyopathy was induced by withdrawal from opiate medications. Followed by resolution of symptoms after restarting maintenance opioid therapy. DISCUSSION: We feel health care professionals should be aware of this possibility in such a patient population especially when they have demonstrated cardiovascular symptomatology. Given the prevalence of opiate use both recreational and iatrogenic, the index of suspicion for opiate-withdrawal induced cardiomyopathy should be high in the presence of cardiac symptomatology.

Asystole caused by Hydroxycut Hardcore: A case report and literature review.

Obesity is a rising epidemic worldwide driving people to search for remedy through nonconventional therapies. Hydroxycut products are popular supplements used as weight loss aids. Many reports revealed serious adverse effects related to their ingestion. We report the case of a 37-year-old healthy male patient who presented following an episode of syncope. On telemetry, he manifested recurrent sinus node arrests, including a symptomatic 24 s sinus pause. The patient admitted to taking Hydroxycut Hardcore for 10 days previously. After discontinuation of the drug, his symptoms completely resolved. This is the first case of Hydroxycut-associated syncope secondary to bradyarrhythmia.

Safety and efficacy of second-generation versus first-generation cryoballoons for treatment of atrial fibrillation: a meta-analysis of current evidence.

BACKGROUND: The newer second-generation cryoballoons (CB-2 or Arc-Adv-CB) have been shown to achieve significantly lower temperature and faster pulmonary vein isolation (PVI) time in comparison with first-generation cryoballoons (CB-1 or Arc-CB). To test the premise that second-generation cryoballoons can improve clinical outcomes in comparison to first-generation cryoballoons in terms of safety and efficacy, we pooled data for systemic review and meta-analyses from all available literature comparing their clinical performance. METHODS: The Cochrane Library, PubMed, Google Scholar, and studies presented at various meetings were searched for any published literature comparing safety and efficacy of the second-generation cryoballoons (Arctic Front Advance cryoballoons) with first-generation cryoballoons (Arctic Front Cryoballoons). A total of ten published studies, with 2310 patients, were included in this meta-analysis with 957 patients in second-generation cryoballoon group and 1237 patients in first-generation cryoballoon group. RESULTS: The pooled analysis showed significant superiority of second-generation cryoballoons in terms of less procedure time, less fluoroscopic time, and fewer incidences of arrhythmia recurrences compared to first-generation cryoballoons at the cost of higher incidence of persistent and transient phrenic nerve palsy. The differences in the rate of pericardial effusion and incidence of access site complications were not statistically significant. CONCLUSIONS: Second-generation cryoballoons are associated with a shorter procedure time and fluoroscopy time, along with lower arrhythmia recurrence rates, reflecting higher procedure efficacy when compared to first-generation cryoballoons. However, they are also associated with a higher incidence of transient and persistent phrenic nerve palsies with a non-significant difference in rates of access site complications and pericardial effusion.

Recordings of diaphragmatic electromyograms during cryoballoon ablation for atrial fibrillation accurately predict phrenic nerve injury.

BACKGROUND: Cryoballoon ablation has been associated with a significant incidence of phrenic nerve injury (PNI). OBJECTIVE: The purpose of this study was to evaluate whether recordings of diaphragmatic compound motor action potentials (CMAP) on a modified lead I during cryoballoon ablation can predict PNI. METHODS: Cryoballoon ablation was performed in 109 patients with atrial fibrillation (AF). During ablation of the right-sided pulmonary veins, the phrenic nerve was paced from the superior vena cava. The right and left arm electrodes from a 12-lead ECG were positioned 5 cm above the xiphoid process and 16 cm along the right costal margin. The amplitude of CMAP was recorded on lead I during ablation. RESULTS: Cryoballoon was applied 424 times in 211 right-sided veins. PNI occurred in 7 (6.4%) patients. The average CMAP amplitude did not significantly change in patients without PNI from the initial average CMAP amplitude of 0.34 ± 0.18 mV to 0.32 ± 0.17 mV (P = .58). In patients who developed PNI, there was a significant decrease in the initial average CMAP amplitude during the ablation from 0.33 ± 0.14 mV to 0.09 ± 0.05 mV (P <.001). The maximal percent change in the average CMAP amplitude in patients with PNI was higher (70% ± 10%) than in patients without PNI (7.6% ± 7%; P <.001). In any patient without PNI, the CMAP amplitude did not decrease more than 35% from baseline. CONCLUSION: Recording of CMAP amplitude on a modified lead I is reliable and could be early and sensitive method for predicting PNI in patients undergoing cryoballoon ablation for AF.

The Rate Of Complications Associated With Concomitant Use Of Dabigatran With Cryoballoon Ablation For Atrial Fibrillation.

INTRODUCTION: Catheter ablation is an evolving therapeutic strategy for the management of atrial fibrillation (AF). It is associated with a risk of thromboembolic events. The peri-procedural anticoagulation management with warfarin has been successful in mitigating this risk. However, introduction of novel oral anticoagulants like dabigatran offers more flexibility in anticoagulation approaches. Previous studies had evaluated the safety and efficacy of dabigatran in the radiofrequency ablation, but data related to cryoballoon ablation is lacking. METHODS AND RESULTS: We performed a retrospective observational study involving patients who underwent cryoballoon ablation for drug-refractory, symptomatic AF while on dabigatran in periprocedural period. Thromboembolic, hemorrhagic or other complications occurring within the first 30 days after the ablation procedure were analyzed. Our study population comprised of 50 patients with mean age of 58.96 ± 3.54 years with 76% (n=38) being male. We found 3 (6%) minor complications in peri-procedural period including 2 groin hematomas and 1 trace asymptomatic pericardial effusion. There were no major intraprocedural or post procedural hemorrhagic or thromboembolic events. None of patients with the minor complications required significant additional workup or extended hospital stay. All the patients were able to continue dabigatran for 30 days without any additional side effects or complications. CONCLUSION: Dabigatran is a safe and efficacious agent in patients undergoing cryoballoon AF ablation.

Do omega-3 polyunsaturated fatty acids reduce risk of sudden cardiac death and ventricular arrhythmias? A meta-analysis of randomized trials.

INTRODUCTION: Omega-3 polyunsaturated fatty acids (PUFA) have demonstrated to have antiarrhythmic properties. However, randomized studies have shown inconsistent results. OBJECTIVE: We aimed to analyze the effect of omega-3 PUFA on preventing potentially fatal ventricular arrhythmias and sudden cardiac death. METHODS: Randomized trials comparing omega-3 PUFA to placebo and reporting sudden cardiac death (SCD) or first implanted cardioverter-defibrillator (ICD) event for ventricular tachycardia or fibrillation were included in this study. A meta-analysis using a random effects model was performed and results were expressed in terms of Odds Ratio (OR) and 95% Confidence Interval (CI) after evaluating for interstudy heterogeneity using I(2). The reported data were extracted on the basis of the intention-to-treat principle. RESULTS: A total of 32,919 patients were included in nine trials; 16,465 patients received omega-3 PUFA and 16,454 received placebo. When comparing omega-3 PUFA to placebo, there was nonsignificant risk reduction of SCD or ventricular arrhythmias (OR = 0.82 [95% CI: 0.60-1.21], p = 0.21 I(2) = 49.7%). CONCLUSION: Dietary supplementation with omega-3 PUFA does not affect the risk of SCD or ventricular arrhythmias.

Use of intracardiac echocardiography for early detection of phrenic nerve injury during cryoballoon pulmonary vein isolation.

Cryoballoon catheter ablation has recently emerged as an effective tool to achieve pulmonary vein isolation (PVI). Right-sided PVI with cryoballoon ablation has been associated with a significant incidence of phrenic nerve palsy. Multiple modalities are currently utilized to monitor phrenic nerve function during ablation. We describe a novel approach toward monitoring and diagnosing phrenic nerve palsy using intracardiac echocardiography (ICE) during cryoballoon ablation of the right pulmonary veins. This technique of monitoring has the advantage of continuous direct diaphragmatic visualization without the use of fluoroscopy, hence significantly minimizing radiation to both the patient and the operator. In addition, this technique does not require extra personnel to monitor the diaphragm using manual palpation. Further prospective studies of our and other methods for prevention of phrenic nerve palsy are required.

Ryanodine calcium channel: a novel channelopathy for seizures.

INTRODUCTION: Catecholamine-induced polymorphic ventricular tachycardia (CPVT) is one of the most severe inherited arrhythmogenic disorders, where patients clinically present with syncope or seizures. CASE: An 18-year-old white male with a history of mild developmental delay and CPVT, was brought to the ED after an episode of unresponsiveness for several minutes. The EMS documented a rhythm strip showing sinus tachycardia. The patient was awake and alert with no clinical evidence of any focal neurologic deficits, but unable to recall the event. Initial blood works including cardiac enzymes were normal. EKG showed sinus rhythm at 86 bpm, along with bigeminy and couplets of bidirectional QRS morphology with a QT interval of 0.3 seconds. Imaging studies including computed tomography scans of head, magnetic resonance imaging of brain, and 2D cardiac echo were normal. A routine EEG revealed abnormal bursts of spike and aftergoing slow wave complexes, highly suggestive of a potential for seizure activity. A 24-hour video EEG-EKG confirmed abnormal brain activity in the presence of normal sinus rhythm. A recent experimental study showed that knock in models of mice mutated with leaky calcium channels in the heart and brain exhibited seizures independent of arrhythmias. CONCLUSIONS: Our patient is probably the clinical paradigm of this study. This episode of unresponsiveness, most probably a complex partial seizure, may have been caused by the same mutations known to precipitate CPVT.

Inadvertent malposition of a permanent pacemaker ventricular lead into the left ventricle which was initially missed and diagnosed two years later: a case report.

INTRODUCTION: Inadvertent malposition of a pacemaker ventricular lead into the left ventricle is an uncommon event, and its actual incidence is probably unknown. It may be underestimated and underreported because of a possible asymptomatic course. A 12-lead electrocardiogram is important to confirm proper placement. CASE PRESENTATION: We report a case of a 60-year-old Caucasian man with a malpositioned transvenous permanent pacing lead into the left ventricle via a patent foramen ovale that was not suspected during implantation and went undiagnosed for two years without complications. The patient remained asymptomatic as he was being treated with oral anticoagulation therapy for atrial fibrillation. The decision was made to leave the pacing lead in place and continue lifelong warfarin therapy. CONCLUSIONS: Inadvertent insertion of pacing wires into the left ventricle is a potentially dangerous complication that may happen under fluoroscopic guidance and may be overlooked by routine pacemaker interrogation. It is advisable to obtain a 12-lead electrocardiogram during or immediately after transvenous pacemaker implantation rather than use a routine pacemaker interrogation or a limited electrocardiogram.

Ginseng: a potential cause of long QT.

Ginseng is a frequently used food additive and considered to be relatively safe. Long QT syndrome can be hereditary or acquired. It presents as syncope, sudden cardiac death, or seizures. We report the novel case of a female patient without cardiovascular risk factors who developed prolonged QT with subsequent torsades de pointes during periods in which she was drinking large amounts of ginseng.

THE VALUE OF ECHOCARDIOGRAPHY IN THE MANAGEMENT OF ACUTE AORTIC INSUFFICIENCY.

Three cases of acute rupture of the aortic cusp complicating bacterial endocarditis are described. Special emphasis is placed on the value of serial echocardiography as a means of identifying progressive changes in aortic valve anatomy during the destructive process of the disease. Prior to the results of blood cultures, an echocardiogram confirmed a diagnosis of vegetations on the valve cusps. It also demonstrated flailing of the aortic cusp, which was confirmed at operation. Echocardiographic findings of flailing aortic valves in these patients coincided with the onset of acute aortic insufficiency and contributed to the timing of surgical intervention for replacement of the affected valves.