Development and validation of the Atri-Risk Conduction Index risk score to predict risk of atrial fibrillation after typical atrial flutter ablation.

BACKGROUND: Identification of patients at risk for atrial fibrillation (AF) after typical atrial flutter (tAFL) ablation is important to guide monitoring and treatment. OBJECTIVE: The purpose of this study was to create and validate a risk score to predict AF after tAFL ablation METHODS: We identified patients who underwent tAFL ablation with no AF history between 2017 and 2022 and randomly allocated to derivation and validation cohorts. We collected clinical variables and measured conduction parameters in sinus rhythm on an electrophysiology recording system (CardioLab, GE Healthcare). Univariate and multivariate logistic regressions (LogR) were used to evaluate association with AF development. RESULTS: A total of 242 consecutive patients (81% male; mean age 66 ± 11 years) were divided into derivation (n =142) and validation (n = 100) cohorts. Forty-two percent developed AF over median follow-up of 330 days. In multivariate LogR (derivation cohort), proximal to distal coronary sinus time (pCS-dCS) ≥70 ms (odds ratio [OR] 16.7; 95% confidence interval [CI] 5.6-49), pCS time ≥36 ms (OR 4.5; 95% CI 1.5-13), and CHADS2-VASc score ≥3 (OR 4.3; 95% CI 1.6-11.8) were independently associated with new AF during follow-up. The Atri-Risk Conduction Index (ARCI) score was created with 0 as minimal and 4 as high-risk using pCS-dCS ≥70 ms = 2 points; pCS ≥36 ms = 1 point; and CHADS2-VASc score ≥3 = 1 point. In the validation cohort, 0% of patients with ARCI score = 0 developed AF, whereas 89% of patients with ARCI score = 4 developed AF. CONCLUSION: We developed and validated a risk score using atrial conduction parameters and clinical risk factors to predict AF after tAFL ablation. It stratifies low-, moderate-, and high-risk patients and may be helpful in individualizing approaches to AF monitoring and anticoagulation.

Durability of left bundle branch area pacing.

BACKGROUND: Left bundle branch area pacing (LBBAP) is a form of conduction system pacing. Long-term data on the safety and performance of LBBAP 1 year postdevice implantation has not been well described. METHODS AND RESULTS: Sixty-five patients (49% females) who received LBBAP for bradycardia indications using the SelectSecure 3830 lead (Medtronic) were retrospectively evaluated. Clinical variables were examined. Lead parameters were obtained at implant and during regular follow-up. Mean age of patients was 75.7 ± 10.1 years with left ventricular ejection fraction 59.8 ± 10.4%. Indications for pacing were atrioventricular block 55%, sinus node dysfunction 19%, tachy-brady syndrome 15%, atrioventricular node ablation 8%, and bail out cardiac resynchronization therapy 3%. Mean baseline QRS measured 120 ± 38 ms, paced QRS duration was 138 ± 22ms. Paced QRS narrowed by 24 ms in those with pre-existing left bundle branch block (BBB), increased by 1 ms in those with pre-existing right BBB, and increased by 42 ms in those with no BBB. LBBAP threshold at implant was 0.521 ± 0.153 V at 0.4 ms, and increased to 0.654 ± 0.186 V at 3 months (+26%), 0.707 ± 0.186 V at 6 months (+36%), and 0.772 ± 0.220 V at 12 months (+48%). Patients with left BBB showed the maximum benefit with QRS narrowing 24 ms. Pacing impedance remained unchanged with no procedure-related complications. CONCLUSION: LBBAP is a durable form of conduction system pacing with pacing thresholds remaining relatively stable over 12 months post device implantation. Patients with left BBB display the narrowest paced QRS.

Catastrophic Cardiac Complications of Takayasu's Arteritis.

Takayasu's arteritis (TA) causes inflammation and necrosis of vessel walls, leading to aneurysm formation, extensive coronary damage and valvular abnormalities. We review a case of recurrent coronary, aortic and mitral valve involvement in a patient with TA and discuss the various treatment options available for such patients.

New Model of Automated Patient-Reported Outcomes Applied in Atrial Fibrillation.

Background The value of patient-reported outcomes (PRO) is increasingly recognized in patient-centered care. Longitudinal data collection may be challenging and cost prohibitive. Automation of PRO collection may complement routine clinical follow-up, especially for procedures aiming to improve quality of life, such as atrial fibrillation (AF) ablation. Methods We aimed to develop a fully automated platform to collect PRO and evaluate its first clinical application in a prospective cohort of AF ablation. The duration of follow-up and data availability were assessed with automated PRO and routine follow-up versus routine follow-up alone (primary outcome). Quality of life and healthcare utilization (secondary outcomes) by PRO were assessed. Results Between 2013 and 2016, 2175 patients were eligible to receive 10 903 PRO assessment invitations, and the automated platform sent all invitations as programmed. More follow-up assessments were obtained with automated PRO and routine follow-up compared with routine follow-up alone (12 859 versus 10 248; P<0.0001) which allowed longer duration of follow-up (378 versus 217 days, 74% increase; P<0.0001). By automated PRO, a large number of disease-specific variables were collected and showed improvement in quality of life (baseline median AF symptom severity score AFSSS of 12 [6-18] and ranged between 2 and 3 on subsequent assessments; P<0.0001). This improvement was also true for each of the AFSSS individual components ( P<0.0001). In PRO, there was a significant reduction in AF burden (such as frequency and duration of episodes; P<0.0001) and associated healthcare utilization (including emergency visits and hospitalizations; P<0.0001) after the ablation procedures. Conclusions A fully automated system for PRO collection enhanced clinical follow-up and allowed collection of disease-specific data when applied in a prospective cohort of AF ablation.

Coronary Artery Aneurysm Presenting as Non-ST Elevation Myocardial Infarction.

Coronary artery aneurysms are rare in the general population. There are no randomized control trials to guide the therapy at this moment. We present a case of a 52-year-old male who was recovering from addiction and was sober for past five years. He came to the hospital with typical chest pain. There were ST segment depressions in leads III and AVF. The second troponin was found to be elevated. The impression was non-ST-segment elevation myocardial infarction. He was started on subcutaneous enoxaparin and underwent left heart catheterization which revealed dilated ectatic coronary arteries with aneurysmal dilatation. In addition, there was sluggish blood flow and several blood clots mainly in the left circumflex artery. No intervention was performed and the patient was started on heparin drip which was transitioned to warfarin on discharge. The echocardiogram revealed an ejection fraction of 35% with anterior and inferoseptal wall dyskinesia. Echocardiogram at one-year follow-up showed improved ejection fraction of 50% with similar wall dyskinesia. Coronary artery aneurysms are treated with medical management with or without invasive approach. Invasive management is conducted in people with stenosis and can be achieved by coronary artery bypass graft or covered stents.

Pacemaker Placement in Persistent Left Superior Vena Cava.

Persistent left superior vena cava (PLSVC) is a rare disorder which is asymptomatic and hence is usually discovered while performing interventions through the left subclavian vein. We present a case of a 78-year-old male who was undergoing elective placement of a permanent pacemaker for tachycardia - bradycardia syndrome with post-conversion pauses of up to nine seconds. After achieving access through the left subclavian vein the wire kept on going on the left side of the chest instead of crossing the midline to the right side. The wire was removed and contrast venography was done, PLSVC with dilated coronary sinus emptying into the right atrium was confirmed. There was some difficulty in passing the lead to the right ventricle even with the acute curve in the stylet. The sheath size was increased and a longer deflectable sheath was used and with the tip of the lead anteriorly the right ventricle was cannulated and the lead was affixed. There were good sensing and pacing parameters. Post procedure chest x-ray was done and the patient was discharged without any complications.