Improvement of Early Outcomes in Type A Acute Aortic Syndrome After an Aorta Code Implementation.

BACKGROUND: Reduction of variability through process reengineering can improve surgical results for patients with type A acute aortic syndrome. We compare short-term results before and after implementation of an Aorta Code for patients with type A acute aortic syndrome who underwent surgery. METHODS: The Aorta Code was implemented in a 5-hospital healthcare network in 2019. This critical pathway was based on a simple diagnostic algorithm, ongoing training, immediate patient transfer, and treatment by an expert multidisciplinary team. We retrospectively compared all patients operated on in our center before (2005-2018) and after (January 2019 to February 2023) its implementation. RESULTS: One hundred two and 70 patients underwent surgery in the precode and code periods, respectively. In the code period the number of patients operated on per year increased (from 7.3 to 16.8), and the median elapsed time until diagnosis (6.5 hours vs 4.2 hours), transfer (4 hours vs 2.2 hours), and operating room (2.7 hours vs 1.8 hours) were significantly shorter (P < .05). Aortic root repair and total arch replacement were more frequent (66.7% vs 82.9% [P = .003] and 20.6% vs 40% [P = .001]). Cardiopulmonary bypass and ischemia times were also shorter (179.7 minutes vs 148.2 minutes [P = .001] and 105 minutes vs 91.2 minutes [P = .022]). Incidence of prolonged mechanical ventilation (53.9% vs 34.3%, P = .011), major stroke (17.7% vs 7.1%, P = .047), and 30-day mortality (27.5% vs 7.1%, P = .001) decreased significantly. CONCLUSIONS: An Aorta Code can be successfully implemented by using a standardized protocol within a hospital network. The number of cases increased; time to diagnosis, transfer, and operating room were reduced; and 30- day mortality significantly decreased.

Incidence of Atrial Fibrillation in Elite Athletes.

Importance: Vigorous exercise (particularly endurance sports) might increase the risk of atrial fibrillation (AF), but there is variability in the reported frequency of this condition among elite athletes. The underlying pathophysiologic source remains unclear. Objective: To determine AF incidence in a large cohort of elite athletes and its association with potential risk factors. Design, Setting, and Participants: Retrospective observational cohort of all Spanish athletes (N = 6813) referred to a single center was used to determine AF incidence from January 1, 1997, to December 31, 2017, and cross-sectional analysis was conducted to compare athletes with and without reported AF. The cohort covered most sports disciplines, and the studied athletes were on national teams and competed in major international events. Cardiologists responsible for echocardiographic assessment were not blinded to the condition (AF or no AF) of the athletes. Exposures: All participants underwent at least 1 cardiologic evaluation, including assessment at time of AF diagnosis in those with this condition. Main Outcomes and Measures: Diagnosis of AF based on resting and/or exercise electrocardiogram, and/or 24-hour Holter monitoring and echocardiography-assessed atrial dimensions. Results: A total of 6813 Spanish elite athletes (2385 [35.0%] women) were referred for cardiac evaluation during the study period. Mean (SD) age was 22 (7) years, and mean (SD) time of competition was 8 (5) years. Only 21 athletes (1 woman), participating in different types of sports, had AF (ie, paroxysmal [n = 18], persistent [n = 1], or long-standing persistent [n = 2]) during the 20-year study. In multivariate analysis, increasing values of age (odds ratio [OR], 1.07; 95% CI, 1.00-1.14), years of competition (OR, 1.14; 95% CI, 1.07-1.22), and left atrial anteroposterior diameter (OR, 1.21; 95% CI, 1.10-1.32) were associated with higher AF risk. Conclusions and Relevance: The incidence of AF is low among young Spanish elite athletes, even when considering only endurance athletes. Yet, potential contributors (particularly atrial remodeling) need to be monitored.

Activation of inward rectifier potassium channels accelerates atrial fibrillation in humans: evidence for a reentrant mechanism.

BACKGROUND: It is unclear whether atrial fibrillation (AF) drivers in humans are focal or reentrant. To test the hypothesis that functional reentry is involved in human AF maintenance, we determined the effects of adenosine infusion on local dominant frequency (DF) at different atrial sites. By increasing inward rectifier potassium channel conductance, adenosine would increase DF of reentrant drivers but decrease it in the case of a focal mechanism. METHODS AND RESULTS: Thirty-three patients were studied during AF (21 paroxysmal, 12 persistent) using recordings from each pulmonary vein-left atrial junction (PV-LAJ), high right atrium, and coronary sinus. DFs were determined during baseline and peak adenosine effect. In paroxysmal AF, adenosine increased maximal DF at each region compared with baseline (PV-LAJ, 8.03+/-2.2 versus 5.7+/-0.8; high right atrium, 7+/-2.2 versus 5.4+/-0.7; coronary sinus, 6.6+/-1.1 versus 5.3+/-0.7 Hz; P=0.001) and increased the left-to-right DF gradient (P=0.007). In contrast, in persistent AF, adenosine increased DF only in the high right atrium (8.33+/-1.1 versus 6.8+/-1.2 Hz; P=0.004). In 4 paroxysmal AF patients, real-time DF mapping of the left atrium identified the highest DF sites near the PV-LAJ, where adenosine induced an increase in DF (6.7+/-0.29 versus 4.96+/-0.26 Hz; P=0.008). Finally, simulations demonstrate that the frequency of reentrant drivers accelerates proportionally to the adenosine-modulated inward rectifier potassium current. CONCLUSIONS: Adenosine accelerates drivers and increases frequency differently in paroxysmal compared with persistent human AF. The results strongly suggest that AF is maintained by reentrant sources, most likely located at the PV-LAJ in paroxysmal AF, whereas non-PV locations are more likely in persistent AF.