Cardiovascular Implications of Epilepsy: Unraveling the Elevated Risk of Mortality.

Introduction Epilepsy is a complex prevalent seizure disorder impacting a significant number of individuals worldwide. Those with epilepsy face the possibility of experiencing sudden unexpected death in epilepsy (SUDEP). When examining the relationship between epilepsy and SUDEP, cardiac-related deaths (CRD) may be considered a driving force. We hypothesize that patients with epilepsy are at higher risk of CRD than those without epilepsy. While utilizing the National Institutes of Health (NIH) All of Us Researcher Program (AoU) database, we also explored the relationship between epilepsy and cardiac-related deaths and propose potential connective mechanisms between the two conditions. Methods Baseline data from the National Institutes of Health All of Us Researcher Program was used to evaluate the relationship between cardiac-related deaths and epilepsy. A retrospective cohort study was conducted where individuals with epilepsy and without epilepsy were matched by inclusion and exclusion criteria including death, cardiac-related death, and epilepsy. Additionally, the prevalence of cardiac-related deaths was compared to neurological, respiratory, and hepatic-related deaths for patients with epilepsy to identify emerging causes of SUDEP. Results Among patients with a history of epilepsy, the prevalence of CRD was 45 (17.3%) compared to 305 (11%) in the control group. This difference was statistically significant by p<0.0042 with an odds ratio (OR)=1.698, 95%CI 1.214-2.379. Additionally, there was the highest number of significant cardiac-related deaths amongst patients with epilepsy compared to patients without epilepsy as opposed to different mechanisms of death such as acute respiratory failure, acute hepatic failure, and hypoxic brain injury. Conclusion This study indicates that epileptic patients have a statistically significant higher prevalence of cardiac-related deaths. Additionally, cardiac-related deaths constitute a significantly higher proportion of fatalities amongst patients with epilepsy compared to other causes of SUDEP. Potential mechanisms for these findings may include seizure-induced arrhythmias, hypoxia-induced cardiac arrest, autonomic dysregulation, and neurotransmitter disequilibrium. The results of our study suggest promising directions for future research in identifying predictors of cardiac-related deaths with proposed cardiac monitoring protocols as preventative strategies for epileptic patients in efforts to reduce the prevalence of SUDEP.

The White Coat Ceremony: Welcome to the Medical Profession.

We have written about a number of the transitions, or 'lurches,' that most of us in medicine encounter as we move through the various stages of education and training in our profession. Some of our prior musings have addressed the transition into a Surgery Clerkship or a Surgery externship in the third or fourth years of medical school, respectively, as well as transitions into internship, the senior years of a Surgery residency, and a new job after completing Thoracic Surgery training. [Tribble: 2019, 2021, 2018, 2021, 2022].

Accuracy of Detecting Atrial Fibrillation: A Systematic Review and Meta-Analysis of Wrist-Worn Wearable Technology.

Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia, and ECG remains the gold standard for diagnosing AF. Wrist-worn technologies are appealing for their ability to passively process near-continuous pulse signals. The clinical application of wearable devices is controversial. Our systematic review and meta-analysis qualitatively and quantitatively analyze available literature on wrist-worn wearable devices (Apple Watch, Samsung, and KardiaBand) and their sensitivity and specificity in detecting AF compared to conventional methods. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, yielding nine studies (n = 1,581). Observational studies assessing the sensitivity and specificity of wrist-worn wearables in detecting AF in patients with and without a history of AF were included and analyzed using a fixed-effect model with an inverse-variance method. In patients with a history of AF, the overall sensitivity between device groups did not significantly differ (96.83%; P = 0.207). Specificity significantly differed between Apple, Samsung, and KardiaBand (99.61%, 81.13%, and 97.98%, respectively; P<0.001). The effect size for this analysis was highest in the Samsung device group. Two studies (n = 796) differentiated cohorts to assess device sensitivity in patients with known AF and device specificity in patients with normal sinus rhythm (NSR) (sensitivity: 96.02%; confidence intervals (CI) 93.85%-97.59% and specificity: 98.82%; CI:97.46%-99.57%). Wrist-worn wearable devices demonstrate promising results in detecting AF in patients with paroxysmal AF. However, more rigorous prospective data is needed to understand the limitations of these devices in regard to varying specificities which may lead to unintended downstream medical testing and costs.

Is Surgical Intervention the Optimal Therapy for the Treatment of Aortic Valve Stenosis for Patients With Intermediate Society of Thoracic Surgeons Risk Score?

BACKGROUND: Patients at intermediate risk (IR) according to The Society of Thoracic Surgeons risk score are today frequently oriented toward the transfemoral aortic valve replacement (TAVR) option. Our goal was to evaluate the best treatment strategies for IR patients with severe aortic stenosis. METHODS: Of a consecutive series of 1,144 surgical aortic valve replacements (AVRs) performed in our institution between 2008 and 2014, we reviewed the early and late outcomes of two different groups: a low-risk (LR) group of 470 patients, and an IR group of 620. We eliminated from the analysis 54 high-risk patients who were currently candidates for TAVR. All patients underwent surgical AVR with or without concomitant coronary artery bypass grafting. Social Security database interrogation provided long-term information. RESULTS: The early mortality rate (30 days) between LR and IR patients was similar (1.70% vs 2.74%, p = 0.25) and both lower than predicted mortality rates. However, cumulative 5-year survival was significantly higher in LR patients (86.3%) than in IR patients (75.4%; p = 0.0007 by log-rank test), although excellent in IR group. Comparing IR survivors and nonsurvivors, ages at operation were 69.5 ± 12.7 years for survivors vs 75.4 ± 9.6 years for those experiencing late deaths (p = 0.002). Risk factors for late deaths after multivariate analysis were age, hemodialysis, and chronic lung disease. CONCLUSIONS: Most IR patients today should undergo surgical AVR, but because of survival rates combined with still unavailable late structural deterioration rates in TAVR valves, patients in the IR group with high Society of Thoracic Surgeons scores and known risk factors may be better served with TAVR as data regarding late percutaneous valve function accrue.

Epicardial ultrasonic ablation of atrial fibrillation during concomitant cardiac surgery is a valid option in patients with ischemic heart disease.

BACKGROUND: Surgical therapy of atrial fibrillation concomitant to coronary bypass grafting using epicardial Ultrasound technology was assessed after a minimum 6-month follow-up. METHODS AND RESULTS: A cohort of 98 consecutive patients with a mean age of 72+/-7.58 years and a primary diagnosis of ischemic heart disease had surgery for structural disease. Coronary artery bypass grafting was isolated (n=51) or associated (n=47) with various combinations of aortic, mitral, tricuspid, and left ventricular restoration surgery. Atrial fibrillation duration ranged from 6 to 360 months (mean 71 months) and was permanent in 47 patients, paroxysmal in 34, and persistent in 17. Left atrial mean diameter was 48+/-6.71 mm. A circumferential ablation was performed off-pump, before the concomitant procedure, and was always associated with an epicardial mitral line lesion using the same technology. At 3-, 6-, and 12-month visits, patients were routinely evaluated by physical examination, ECG, chest X-ray, and 24-hour Holter. There were 1 early death (1%) and 4 extracardiac late deaths. A pacemaker was implanted in 4 patients. Mean follow-up time was 325 days, 2 patients being lost to follow-up. Freedom from atrial fibrillation and flutter at the 6-month visit was 84% for the entire population, 76% in patients with permanent, and 91% in patients with paroxysmal atrial fibrillation. At the 1-year visit, 85% were free from atrial fibrillation or flutter. CONCLUSIONS: Epicardial beating heart ablation using therapeutic ultrasound is safe, reliable, and can easily treat atrial fibrillation in a difficult surgical population of patients with primary ischemic heart disease.

Ultrasonic cardiac ablation for atrial fibrillation during concomitant cardiac surgery: long-term clinical outcomes.

BACKGROUND: Therapeutic ultrasound as an alternative to the maze procedure was evaluated in this large US experience. Safety and efficacy were assessed at 6-, 12-, and 18-month visits with systematic 24-hour Holter monitoring. METHODS: From February 2005 to February 2007, 220 patients were prospectively enrolled in a single center study, and among them 129 patients with concomitant cardiac surgery and at least 6-month follow-up were reviewed. Primary procedures were mitral surgery in 50% of the cases, coronary bypass in 32%, and aortic surgery in 16%. Atrial fibrillation was permanent in 66 (51.1%), paroxysmal in 43 (33.3%), and persistent in 20 (15.5%) patients. An epicardial and circumferential left atrial encircling line was created on the beating heart. Routinely a mitral isthmus line was also created from the left atrium epicardium using an ultrasonic handheld device. RESULTS: No morbidity or mortality was device-related. There were four (2.33%) early deaths and six late extra-cardiac deaths. Follow-up ranged from 6 to 670 days with a mean follow-up of 358.5 days, median 340 days with two patients lost to follow-up. Freedom from atrial fibrillation or left-sided flutter was 83.2%, 84.4%, and 86.2% at 6, 12, and 18 months, respectively. A pacemaker was implanted in seven patients (5.4%). Male gender and left atrial dimension were significant risk factors for failure. CONCLUSIONS: The study confirms the excellent safety record of the technology, and the efficacy at the level reported in a previous European multicenter study. Efficacy is also maintained at longer (12 and 18 months) follow-up.