Risk of Adverse Outcomes Associated With Cardiac Sarcoidosis Diagnostic Schemes.

BACKGROUND: Multiple cardiac sarcoidosis (CS) diagnostic schemes have been published. OBJECTIVES: This study aims to evaluate the association of different CS diagnostic schemes with adverse outcomes. The diagnostic schemes evaluated were 1993, 2006, and 2017 Japanese criteria and the 2014 Heart Rhythm Society criteria. METHODS: Data were collected from the Cardiac Sarcoidosis Consortium, an international registry of CS patients. Outcome events were any of the following: all-cause mortality, left ventricular assist device placement, heart transplantation, and appropriate implantable cardioverter-defibrillator therapy. Logistic regression analysis evaluated the association of outcomes with each CS diagnostic scheme. RESULTS: A total of 587 subjects met the following criteria: 1993 Japanese (n = 310, 52.8%), 2006 Japanese (n = 312, 53.2%), 2014 Heart Rhythm Society (n = 480, 81.8%), and 2017 Japanese (n = 112, 19.1%). Patients who met the 1993 criteria were more likely to experience an event than patients who did not (n = 109 of 310, 35.2% vs n = 59 of 277, 21.3%; OR: 2.00; 95% CI: 1.38-2.90; P < 0.001). Similarly, patients who met the 2006 criteria were more likely to have an event than patients who did not (n = 116 of 312, 37.2% vs n = 52 of 275, 18.9%; OR: 2.54; 95% CI: 1.74-3.71; P < 0.001). There was no statistically significant association between the occurrence of an event and whether a patient met the 2014 or the 2017 criteria (OR: 1.39; 95% CI: 0.85-2.27; P = 0.18 or OR: 1.51; 95% CI: 0.97-2.33; P = 0.067, respectively). CONCLUSIONS: CS patients who met the 1993 and the 2006 criteria had higher odds of adverse clinical outcomes. Future research is needed to prospectively evaluate existing diagnostic schemes and develop new risk models for this complex disease.

Safety of Diagnostic and Therapeutic Cardiac Catheterization in Cancer Patients With Acute Coronary Syndrome and Chronic Thrombocytopenia.

Little data is available on the bleeding risk and outcomes of cancer patients with chronic thrombocytopenia who underwent cardiac catheterization. We sought to assess the safety of coronary angiography, percutaneous coronary intervention, and antiplatelet therapy in cancer patients with acute coronary syndrome (ACS) and chronic thrombocytopenia. We performed a retrospective study of patients with chronic thrombocytopenia who underwent cardiac catheterization for ACS between November 2009 and November 2015. Preprocedural platelet counts were classified into 3 groups: mild thrombocytopenia (50,000 to 100,000/µL), moderate thrombocytopenia (30,000 to 50,000/µL), and severe thrombocytopenia (<30,000/µL). Postprocedural bleeding complications and overall survival (OS) were recorded. A total of 98 patients were included. Mean platelet count on admission was 47.63 ± 29.85 K/µL. Severe thrombocytopenia was identified in 36 patients (36.7%), moderate thrombocytopenia in 20 patients (20.4%), and mild thrombocytopenia in 42 patients (42.9%). Aspirin therapy (alone or in combination with clopidogrel) was used in 66 patients (67.3%), whereas 27 patients (27.6%) were on dual antiplatelet therapy. One procedure-related retroperitoneal hematoma and 3 procedure-related small hematomas were identified. No cerebrovascular events related to the procedure or the antiplatelet therapy were noted. Moderate thrombocytopenia was associated with decreased OS, whereas aspirin, dual antiplatelet therapy, and statin use showed a trend of improved OS. In conclusion, we suggest that coronary angiography and percutaneous coronary intervention can be performed safely in cancer patients with chronic thrombocytopenia. Aspirin therapy and dual antiplatelet therapy should be considered in cancer patients with chronic thrombocytopenia and ACS.

Outcome of pulmonary vein isolation ablation for paroxysmal atrial fibrillation: predictive role of left atrial mechanical dyssynchrony by speckle tracking echocardiography.

INTRODUCTION: Although few clinical variables have been associated with recurrence of atrial fibrillation (AF) after pulmonary vein isolation (PVI) the role of left atrial (LA) mechanical function in the outcome of catheter ablation of AF is not adequately defined. The aim of our study was to determine whether LA mechanical dyssynchrony as evaluated by speckle tracking echocardiography can predict outcome of PVI ablation procedure in patients with paroxysmal AF. METHODS: Twenty-five patients (age 58 ± 11 years, [mean ± standard deviation], 17 males) with paroxysmal AF who met specific enrollment criteria pertaining to clinical presentation and follow-up, assessment of LA mechanical dyssynchrony, and strategy of catheter ablation procedure were enrolled. For LA mechanical dyssynchrony assessment, the time to peak longitudinal strain (TPk) in opposing walls in the midportion of the LA walls at peak atrial contraction in standard two- and four-chamber echocardiographic views by vector velocity imaging (VVI) was measured. Outcome of PVI procedure, whether no recurrence (NR) or AF recurrence (AFR) after 3 months of post-procedural blanking period, was evaluated based on AF-related symptoms and documentation of AF by electrocardiogram, continuous 24-h Holter, and intermittent event monitor recordings. RESULTS: During a follow-up period of 20.3 ± 8.6 months, 18 out of 25 (72 %) patients had no recurrence (NR group), and 7 out of 25 (28 %) patients had recurrence of AF (AFR group). Significant gender difference was observed in terms of outcome such that all AFR patients were men and no woman had recurrence of AF. Between the NR and AFR groups, neither the left atrial diameter, 4.0 ± 0.3 and 4.2 ± 0.2 cm, respectively (p = 0.2), nor the left atrial volume indexes, 45 ± 15 and 48 ± 20 ml/m(2), respectively (p = 0.56), were statistically significantly different. For LA mechanical function, compared to the patients in NR group who had maximum opposing wall TPk delay of 39.9 ± 12.0 ms, those in the AFR group demonstrated significantly more LA mechanical dyssynchrony with maximum opposing wall TPk delay of 64.4 ± 17.0 ms prior to ablation (p = 0.007). Using receiver operative characteristic analyses of the data that had an area under the curve of 0.865, we identified a maximum opposing wall delay cutoff value of 51 ms which predicted AF recurrence with sensitivity and specificity values of 89 and 72 %, respectively (p = 0.005). CONCLUSIONS: Speckle tracking strain analysis echocardiography can evaluate the LA mechanical dyssynchrony quantitatively. The severity of LA mechanical dyssynchrony by VVI can predict the outcome of PVI catheter ablation for paroxysmal AF.

Sudden cardiac death of the young in Michigan: development and implementation of a novel mortality review system.

Advances in screening, detection and treatment make Sudden Cardiac Death of the Young (SCDY) a potentially preventable condition. Since hereditary causes account for many deaths, identification of an affected individual has implications for immediate relatives; who should receive targeted screening with the aim of preventing SCDY. To develop a mortality review process for SCDY and to identify potential unmet needs for family-based, medical system and public health interventions. The Michigan Department of Community Health and Michigan State University developed a system for investigating SCDY. Review of medical records and next-of-kin (NOK) interviews were conducted. A de-identified summary of each case was presented to an expert panel. The panel identified factors that contributed to the death and possible actions to prevent future deaths. If the case was deemed to have a likely heritable cause, NOK were notified of a possible increased risk and need for evaluation of immediate family members. Twenty-three deaths aged 1-39 years between 2006 and 2008, were selected for review. Sixteen NOK were interviewed. Several primary and secondary prevention measures were identified, including enhanced pre-participation sports screening; provider education; public awareness of risk factors, symptoms, emergency response training for coaches and the general public; and creation and dissemination of emergency response and medical examiner protocols. Seventeen NOK were notified of the potential heritable cause. Investigation of these deaths has led to identification of individual, family, public and provider needs and motivated policy makers to initiate changes to prevent future SCDY.

Utility of tachycardia cycle length variability in discriminating atrial tachycardia from ventricular tachycardia.

BACKGROUND: Inappropriate implantable cardioverter-defibrillator (ICD) therapy of atrial tachycardia (AT) with 1:1 atrioventricular (AV) conduction is common because it is difficult to discriminate from ventricular tachycardia (VT) with 1:1 retrograde conduction. Tachycardia cycle length (CL) variability and the relationship between atrial and ventricular CLs may be useful in discriminating AT from VT with 1:1 retrograde conduction. OBJECTIVE: The purpose of this study was to evaluate the usefulness of the relationship between the atrial and ventricular CLs in differentiating AT with 1:1 conduction from VT with 1:1 retrograde conduction. METHODS: We studied 71 patients who had a tachycardia with a 1:1 AV relationship and significant CL variability. Thirty-nine patients had AT (21 inducible and 18 simulated), and 32 patients had VT (11 inducible and 21 simulated). The relationship between atrial and ventricular CLs was examined. RESULTS: A change in atrial CL predicted the change in subsequent ventricular CL in 37 (95%) of 39 patients with AT and in none of the patients with VT. A change in preceding ventricular CL predicted the change in atrial CL in 31 (97%) of 32 patients with VT and in only one (3%) of 39 patients with AT. The sensitivity, specificity, and positive and negative predictive values of a change in atrial CL predicting the change in ventricular CL for AT with significant CL variability were 95%, 100%, 100%, and 94%, respectively. The corresponding values for the change in preceding ventricular CL predicting the change in atrial CL for AT with significant CL variability were 97%. CONCLUSION: The relationship between atrial and ventricular CL is useful in differentiating AT from VT with retrograde conduction. A change in atrial CL that predicts the change in subsequent ventricular CL rules in AT and excludes VT.

Cardiovascular complications of the Guillain-Barré syndrome.

The Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis in young adults and the elderly and an important cause of admission to intensive care units. Manifestations of the GBS vary from monoparesis to life-threatening paralysis of the respiratory muscles. The latter is often punctuated by the presence of cardiac involvement. This ranges from variations in blood pressure to involvement of the myocardium and potentially fatal arrhythmias. This review addresses some of the common cardiovascular complications of the GBS, with their myriad presentations and therapeutic options, as well as potential preventive measures that can be helpful in the management of patients admitted to intensive care units. In conclusion, it is necessary to recognize the potentially fatal cardiovascular complications associated with the GBS and treat them accordingly.

Asymptomatic wide complex tachycardia: a case report.

Wide complex tachycardias are a commonly encountered entity in coronary care units, intensive care units and emergency departments. Though, these arrhythmias are potentially fatal, they need to recognized first and treated appropriately. Associated physical signs are helpful in this. We present a case of a 54-year-old-female who recently underwent placement of an implantable cardioverter-defibrillator for cardiomyopathy and developed tachycardia.

Cardiovascular manifestations in human immunodeficiency virus-infected patients.

Human immunodeficiency virus (HIV) is now a pandemic. It afflicts multiple organs, including the cardiovascular system. This occurs by direct invasion as well as opportunistic infections complicating acquired immunodeficiency syndrome. The presence of newer highly active antiretroviral therapy has led to longer survival of patients infected with HIV, but the cardiac abnormalities related to HIV have remained less well characterized. It is now evident that cardiac involvement in patients with acquired immunodeficiency syndrome is relatively common. This includes coronary artery disease, dilated cardiomyopathy, pericardial effusion, pulmonary hypertension, and ill effects of highly active antiretroviral therapy in the form of lipodystrophy, lipoatrophy, and dyslipidemia. In fact, HIV can now be viewed as a potential risk factor for coronary artery disease, and the dilemma facing clinicians is how to quantify this risk. Awareness of accelerated coronary artery disease and dilated cardiomyopathy is critical to implement preventive measures early in the course of HIV. However, better guidelines are still needed on the basis of prospective randomized controlled studies involving large populations. In conclusion, this review describes cardiac abnormalities associated with HIV, including possible molecular mechanisms. The co-morbid sequelae, their presentation, and pharmacologic management are also discussed.

Body mass index, obstructive sleep apnea, and outcomes of catheter ablation of atrial fibrillation.

BACKGROUND: Obesity and obstructive sleep apnea (OSA) are associated with atrial fibrillation (AF). The effects of a large body mass index (BMI) and OSA on the results of radiofrequency catheter ablation (RFA) of AF are unclear. OBJECTIVE: To evaluate the effect of BMI and OSA on the efficacy of RFA for AF. METHODS: RFA was performed in 324 consecutive patients (mean age = 57 +/- 11 years) with paroxysmal (234) or chronic (90) AF. OSA was diagnosed by polysomnography in 32 of 324 patients (10%) prior to ablation. Among the 324 patients, 18% had a normal BMI (<25 kg/m(2)), 39% were overweight (BMI >/= 25 kg/m(2) and <30 kg/m(2)), and 43% were obese (>or=30 kg/m(2)). RFA was performed to eliminate complex fractionated atrial electrograms (CFAE) in the pulmonary vein antrum and left atrium. RESULTS: At 7 +/- 4 months after a single ablation procedure, 63% of patients without OSA and 41% with OSA were free from recurrent AF without antiarrhythmic drug therapy (P = 0.02). Multivariate analysis including variables of age, gender, type and duration of AF, OSA, BMI, left atrial size, ejection fraction, and hypertension demonstrated that OSA was the strongest predictor of recurrent AF (OR = 3.04, 95% CI: 1.11-8.32, P = 0.03). There was no association between BMI and freedom from recurrent AF. A serious complication occurred in 3 of 324 patients, with no relationship to BMI. CONCLUSIONS: OSA is a predictor of recurrent AF after RFA independent of its association with BMI and left atrial size. Obesity does not appear to affect outcomes after radiofrequency catheter ablation of AF.

Utility of atrial and ventricular cycle length variability in determining the mechanism of paroxysmal supraventricular tachycardia.

INTRODUCTION: No prior studies have systematically investigated the diagnostic value of cycle length (CL) variability in differentiating the mechanism of paroxysmal supraventricular tachycardia (PSVT). METHODS AND RESULTS: We studied 173 consecutive patients with PSVT; 86 typical atrioventricular nodal reentrant tachycardia (AVNRT), 11 atypical AVNRT, 47 orthodromic reciprocating tachycardia (ORT), and 29 with atrial tachycardia (AT). Two consecutive atrial cycles that displayed the most CL variability were selected for analysis. One hundred and twenty-six patients (73%) had > or = 15 msec variability in tachycardia CL. The change in atrial CL predicted the change in subsequent ventricular CL in six of eight patients (75%) with atypical AVNRT, 18 of 21 patients (86%) with AT, in none of 66 patients with typical AVNRT, and in 32 patients with ORT. The change in atrial CL was predicted by the change in preceding ventricular CL in 55 of 66 patients (83%) with typical AVNRT, no patient with atypical AVNRT, 27 of 31 patients (87%) with ORT, and one of 21 patients (5%) with AT. The sensitivity, specificity, and positive and negative predictive values of a change in atrial CL predicting the change in ventricular CL for AT or atypical AVNRT were 83%, 100%, 100%, and 95%, respectively. The corresponding values for the change in atrial CL being predicted by the change in the preceding ventricular CL for typical AVNRT or ORT were 85%, 97%, 99%, and 65%, respectively. CONCLUSION: Tachycardia CL variability > or = 15 msec is common in PSVT. A change in atrial CL that predicts the change in subsequent ventricular CL strongly favors AT or atypical AVNRT. A change in atrial CL that is predicted by the change in the preceding ventricular CL favors typical AVNRT or ORT.

Unusual complications of coronary artery bypass graft surgery.

Complications after coronary artery bypass grafting are myriad and are to a certain extent operator dependent. The investigators report 2 unusual cases of inadvertent aortocoronary fistula after coronary artery bypass grafting that escaped routine detection. In conclusion, the development of heart failure led to the detection of this rare complication.

Recurrent syncope following radiation therapy.

This case report describes a 51-year-old man who presented with syncope. His electrocardiogram showed an abnormally long pause and the electrophysiology study revealed a prolonged H-V interval. This was attributed to the radiation therapy he received to the chest. He was successfully treated with implantation of a permanent pacemaker. This case highlights this rare complication of radiation-induced conduction system disease and management of this potentially life-threatening condition.

3-dimensional mapping and radiofrequency ablation of atrial flutter in a patient with interrupted inferior vena cava.

The presence of isolated interrupted inferior vena cava (IVC) is very rare. Though the occurrence of typical atrial flutter in this setting has recently been described, the use of 3-dimensional activation mapping to aid the management of such patients has not yet been described. We report the successful ablation of this arrhythmia in a 63-year-old woman using the superior route through the internal jugular vein with the help of a mapping system.

Echocardiography induced tachycardia in a patient with a minute ventilation rate responsive pacemaker.

We report a case of a 57 year-old man with a minute ventilation rate-response pacemaker and an inappropriate increase in his heart rate during a transthoracic echocardiography study. The increase in heart rate was due to interference between echocardiography and minute ventilation sensor. This was confirmed by a repeat echocardiogram, which reproduced the same effect and turning off the minute ventilation sensor stopped the tachycardia. We suggest that deactivating the minute ventilation sensor would avoid this interaction and electrophysiologists should be aware of this unusual electromagnetic interference phenomenon.

Dieulafoy lesion in mid-esophagus with esophageal varices.

Dieulafoy lesion is an uncommon cause of gastrointestinal (GI) bleeding. Most such lesions are reported in the stomach, though a few have been reported in the distal esophagus. We report a 54-year-old man who presented with upper GI bleeding and had esophageal varices but bled from a Dieulafoy lesion 5 cm above the proximal end of the varices.