Atrial fibrillation incidence after coronary artery bypass graft surgery and percutaneous coronary intervention: the prospective AFAF cohort study.

Objectives. Atrial fibrillation is a common arrhythmia in patients with ischemic heart disease. This study aimed to determine the cumulative incidence of new-onset atrial fibrillation after percutaneous coronary intervention or coronary artery bypass grafting surgery during 30 days of follow-up. Design. This was a prospective multi-center cohort study on atrial fibrillation incidence following percutaneous coronary intervention or coronary artery bypass grafting for stable angina or non-ST-elevation acute coronary syndrome. Heart rhythm was monitored for 30 days postoperatively by in-hospital telemetry and handheld thumb ECG recordings after discharge were performed. The primary endpoint was the cumulative incidence of atrial fibrillation 30 days after the index procedure. Results. In-hospital atrial fibrillation occurred in 60/123 (49%) coronary artery bypass graft and 0/123 percutaneous coronary intervention patients (p < .001). The cumulative incidence of atrial fibrillation after 30 days was 56% (69/123) of patients undergoing coronary artery bypass grafting and 2% (3/123) of patients undergoing percutaneous coronary intervention (p < .001). CABG was a strong predictor for atrial fibrillation compared to PCI (OR 80.2, 95% CI 18.1-354.9, p < .001). Thromboembolic stroke occurred in-hospital in one coronary artery bypass graft patient unrelated to atrial fibrillation, and at 30 days in two additional patients, one in each group. There was no mortality. Conclusion. New-onset atrial fibrillation during 30 days of follow-up was rare after percutaneous coronary intervention but common after coronary artery bypass grafting. A prolonged uninterrupted heart rhythm monitoring strategy identified additional patients in both groups with new-onset atrial fibrillation after discharge.

Right ventricular lead perforation with iatrogenic injury to an intercostal artery causing haemothorax after pacemaker implant.

A woman in her 80s experienced a life-threatening complication of pacemaker implant consisting of subacute right ventricular lead perforation causing iatrogenic injury to an intercostal artery, resulting in a large haemothorax. A CT scan confirmed active bleeding from the fourth intercostal artery. The patient underwent cardiothoracic surgery via a median sternotomy approach, during which the source of the bleeding was sealed, a new epicardial lead was positioned, and the original lead was extracted. This case emphasises the potentially severe consequences of pacemaker lead perforation and secondary injury to adjacent structures. It underscores the importance of early recognition and timely intervention, preferably in a tertiary specialist unit equipped for cardiothoracic surgery and confirms the value of pacemaker interrogation and CT scans for diagnosis.

The contribution of intermittent handheld electrocardiogram and continuous electrocardiogram monitoring with an implantable loop recorder to detect incident and recurrent atrial fibrillation during 1 year after coronary artery bypass graft surgery: A prospective cohort study.

BACKGROUND: Atrial fibrillation (AF) is common after coronary artery bypass graft (CABG) surgery. OBJECTIVE: To evaluate the incidence and recurrence rate of AF during 1 year after CABG surgery. We also aimed at calculating the AF burden and compare long-term intermittent vs continuous electrocardiogram (ECG) monitoring. METHODS: Forty patients scheduled for CABG surgery were equipped with an implantable loop recorder (ILR). After discharge, they carried out handheld ECG 3 times daily during the first 30 postoperative days and during 2 weeks at 3 and 12 months. During hospital stay they were monitored with telemetry. RESULTS: Altogether 27 of 40 (68%) patients were diagnosed with AF, 24 during the first month (21 in-hospital and 3 after discharge) and 3 during months 2-12. Three patients progressed into persistent AF. In addition, 17 patients had AF recurrence, 9 of them after the first 30 days. In patients with paroxysmal AF, the AF burden was low, 0.1% (interquartile range [IQR] 0.02%-0.3%). Patients with AF had higher CHA2DS2-VASc scores than non-AF patients: median 4 (IQR 3-4) and 3 (IQR 2-3.5), respectively, P = .006. The handheld ECG identified 45% (9/20) of the patients with AF episodes identified with continuous ECG monitoring with the ILR after discharge from hospital, P = .001. CONCLUSIONS: Patients with AF during the postoperative hospitalization showed a high likelihood of recurrent AF, usually within 30 days. Continuous ECG monitoring with an ILR was superior to the handheld ECG for detecting patients with AF. The AF burden was low.

[Platypnea-orthodeoxia syndrome: a neglected cause of dyspnea?] / Platypné­ortodeoxisyndrom ­ förbisedd orsak till dyspné.

A 68-year-old woman presented with progressive and severe effort-related dyspnea. Her history included an ischemic stroke at age 43. Routine exams were normal. Cardiopulmonary exercise testing (CPET) showed a reduction in PaO2 from 11.8 kPa to 4.8 kPa. Repeated CPET with 100 % inhaled O2 improved the drop in PaO2 marginally. Transesophageal echocardiography revealed a shunt from right to left through a patent foramen ovale (PFO). A right heart catheterization showed normal pressures and no signs of intrapulmonary shunting. The PFO was closed percutaneously and the patient's symptoms resolved almost completely. Platypnea-orthodeoxia syndrome is an uncommon disorder where the pathophysiological mechanisms include a right-to-left shunt, either intracardiac or pulmonary. The most common intracardiac shunt related to the syndrome is a PFO. Platypnea-orthodeoxia syndrome, although rare, merits our attention, since it is often easily treatable. The key finding is desaturation on standing up.

Clinical risk profile score predicts all cause mortality but not implantable cardioverter defibrillator intervention rate in a large unselected cohort of patients with congestive heart failure.

BACKGROUND: Primary prophylactic implantable cardioverter defibrillator (ICD) therapy is indicated for patients with reduced left ventricular ejection fraction (LVEF). We aimed to determine if preoperative clinical risk profiling can predict long-term benefit, and if clinical risk scores can be applied and improved in a patient cohort outside the clinical trial setting. METHODS: Using registry data, 789 patients with reduced LVEF who received ICDs for primary prevention during 2006-2011 were identified (age 64 ± 11 years, 82% men, 63% ischemic etiology, 52% cardiac resynchronization therapy with defibrillator). The patients were divided into three risk groups, based on the presence of baseline clinical risk factors (age >70, QRS duration >120 ms, New York Heart Association class III-IV, atrial fibrillation history, or creatinine >106 µmol/L). Endpoints were all-cause mortality and survival free of adequate ICD therapy. RESULTS: Mean follow-up was 39 ± 18 months. Annual mortality was 7.6%, and increased with risk group (p < .001). Rates of appropriate antitachycardia pacing and shock therapy were not statistically different between the groups, and ranged from 11%-16% and 6%-14%, respectively. By combining the previous risk score with data on diabetes, a better independent prediction of mortality was achieved; mortality rates then ranged from 11% (low-risk) to 46% (high-risk) (p < .0001). CONCLUSIONS: Implantable cardioverter defibrillator therapies occur across the spectrum of comorbidities in a population with systolic heart failure. However, all-cause mortality is considerably higher in the group of patients with accumulated risk factors, and using the proposed scoring system can be helpful for the evaluation and risk stratification of the patient prior to making a decision for a primary prophylactic ICD implantation.