Abstract
Introduction
Intracardiac echocardiography (ICE) reveals mobile thrombus on implantable electronic device leads in some patients undergoing electrophysiologic procedures.
Methods
ICE was ...performed in a patient undergoing ventricular tachycardia (VT) ablation.
Results
ICE showed extensive mobile thrombi on the implantable cardioverter defibrillator lead. Radiofrequency catheter ablation of VT from perimitral scar was safely performed via a retrograde aortic approach. After the procedure, chronic anticoagulation was initiated. CT‐angiography of the chest 2 months later showed no pulmonary emboli.
Conclusions
The significance of these thrombi, as related to chronic pulmonary embolization, warrants further study.
Early-onset atrial fibrillation (AF) can be the initial manifestation of a more serious underlying inherited cardiomyopathy or arrhythmia syndrome.
To examine the results of genetic testing for ...early-onset AF.
This prospective, observational cohort study enrolled participants from an academic medical center who had AF diagnosed before 66 years of age and underwent whole genome sequencing through the National Heart, Lung, and Blood Institute's Trans-Omics for Precision Medicine program. Participants were enrolled from November 23, 1999, to June 2, 2015. Data analysis was performed from October 24, 2020, to March 11, 2021.
Rare variants identified in a panel of 145 genes that are included on cardiomyopathy and arrhythmia panels used by commercial clinical genetic testing laboratories.
Sequencing data were analyzed using an automated process followed by manual review by a panel of independent, blinded reviewers. The primary outcome was classification of rare variants using American College of Medical Genetics and Genomics criteria: benign, likely benign, variant of undetermined significance, likely pathogenic, or pathogenic. Disease-associated variants were defined as pathogenic/likely pathogenic variants in genes associated with autosomal dominant or X-linked dominant disorders.
Among 1293 participants (934 72.2% male; median interquartile range age at enrollment, 56 48-61 years; median interquartile range age at AF diagnosis, 50 41-56 years), genetic testing identified 131 participants (10.1%) with a disease-associated variant, 812 (62.8%) with a variant of undetermined significance, 92 (7.1%) as heterozygous carriers for an autosomal recessive disorder, and 258 (20.0%) with no suspicious variant. The likelihood of a disease-associated variant was highest in participants with AF diagnosed before the age of 30 years (20 of 119 16.8%; 95% CI, 10.0%-23.6%) and lowest after the age of 60 years (8 of 112 7.1%; 95% CI, 2.4%-11.9%). Disease-associated variants were more often associated with inherited cardiomyopathy syndromes compared with inherited arrhythmias. The most common genes were TTN (n = 38), MYH7 (n = 18), MYH6 (n = 10), LMNA (n = 9), and KCNQ1 (n = 8).
In this cohort study, genetic testing identified a disease-associated variant in 10% of patients with early-onset AF (the percentage was higher if diagnosed before the age of 30 years and lower if diagnosed after the age of 60 years). Most pathogenic/likely pathogenic variants are in genes associated with cardiomyopathy. These results support the use of genetic testing in early-onset AF.
Abstract
Background
Although catheter ablation is an effective therapy for atrial fibrillation (AF), the most common cardiac arrhythmia encountered in clinical practice, AF ablation generates ...inflammation and oxidative stress in the early postoperative period predisposing to recurrence of AF. Isolevuglandins (IsoLGs) are reactive lipid mediators of oxidative stress injury that rapidly react with endogenous biomolecules to compromise their function. 2-Hydroxybenzylamine (2-HOBA), a potent small molecule scavenger of IsoLGs, sequesters the reactive species as inert adducts. This mechanism, coupled with reported safety in humans, supports the investigation of 2-HOBA as a novel therapeutic to reduce AF caused by oxidative stress, such as that which occurs after catheter ablation. Accordingly, we seek to test the hypothesis that treatment with 2-HOBA will decrease early recurrence of AF and other atrial arrhythmias following AF ablation by decreasing IsoLG adducts with native biomolecules.
Methods
The proposed trial will randomly assign 162 participants undergoing cryo- or radiofrequency catheter ablation for AF to 2-HOBA (
N
= 81) or placebo (
N
= 81). Individuals will begin the study drug 3 days prior to ablation and continue for 28 days. Participants will be given a wearable smartwatch capable of detecting and recording atrial arrhythmias. They will be instructed to record ECGs daily with additional ECGs if they experience symptoms of AF or when alerted by the smartwatch AF detection alarm. The primary clinical endpoint will be an episode of AF, atrial tachycardia, or atrial flutter lasting 30 s or more within 28 days post-AF ablation. Secondary measures will be the change in IsoLG adduct levels from blood samples collected immediately pre-ablation and post-ablation and reduction in AF burden as calculated from the smartwatch.
Discussion
The proposed trial will test the hypothesis that 2-HOBA reduces post-ablation atrial arrhythmias through sequestration of reactive IsoLG species. The results of this study may improve the understanding of the role of IsoLGs and oxidative stress in AF pathogenesis and provide evidence to advance 2-HOBA and related compounds as a new therapeutic strategy to treat AF.
Trial registration
ClinicalTrials.gov
NCT04433091
. Registered on June 3, 2020.
Abstract
Aims
Failure of radiofrequency (RF) ablation of ventricular arrhythmias is often due to inadequate lesion size. Irrigated RF ablation with half-normal saline (HNS) has the potential to ...increase lesion size and reduce sodium delivery to the patient if the same volume of RF irrigant were used for normal saline (NS) and HNS but could increase risks related to steam pops and lesion size. This study aims to assess periprocedural complications and acute ablation outcome of ventricular arrhythmias ablation with HNS.
Methods and results
Prospective assessment of outcomes was performed in 1024 endocardial and/or epicardial RF ablation procedures in 935 consecutive patients (median age 64 years, 71.2% men, 73.4% cardiomyopathy, 47.2% sustained ventricular tachycardia). Half-normal saline was selected at the discretion of the treating physician. Radiofrequency ablation power was generally titrated to a ≤15 Ω impedance fall with intracardiac echocardiography monitoring. Half-normal saline was used in 900 (87.9%) and NS in 124 (12.1%) procedures. Any adverse event within 30 days occurred in 13.0% of patients treated with HNS RF ablation including 4 (0.4%) strokes/transient ischaemic attacks and 34 (3.8%) pericardial effusions requiring treatment (mostly related to epicardial access). Two steam pops with perforation required surgical repair (0.2%). Patients who received NS irrigation had less severe disease and arrhythmias. In multivariable models, adverse events and acute success of the procedure were not related to the type of irrigation.
Conclusion
Half-normal saline irrigation RF ablation with power guided by impedance fall and intracardiac echocardiography has an acceptable rate of complications and acute ablation success while administering half of the saline load expected for NS irrigation.
Graphical Abstract
Graphical Abstract
To investigate what factors contribute to increased length of stay (LOS) and increased costs in treatment of elderly patients with hip fractures.
Retrospective chart review.
All patients who ...presented to a large tertiary care center between January 2000 and December 31, 2009.
Charts for all patients older than 60 years who presented with isolated low-energy hip fractures were reviewed. Of the 719 patients identified, 660 were included.
Patients who underwent operative fixation or hemiarthroplasty secondary to hip fracture were identified using a search of Current Procedural Terminology (CPT) codes search.
Gender, height, weight, body mass index, length of procedure, American Society of Anesthesiologists (ASA) classification, and medical comorbidities were gathered and compared with LOS and direct daily inpatient hospital cost.
No correlation existed between body mass index or specific comorbidities and LOS, but ASA classification was a predictor. For each ASA increase of 1, average LOS increased 2.053 days (P < 0.001). Given total daily cost to the hospital for these patients was $4530, each increase in ASA classification translated to an increase of $9300.
ASA classification proved useful in estimating LOS and cost for patients undergoing operative fixation of hip fractures. Because ASA classification and cost are universally collected, this method can be employed in almost any hospital. This highlights a role for ASA classification in preoperative estimation of the elderly patient's cost and a potential advantage for incorporating patient factors in the development of tiered reimbursement models.
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Experimental data suggest ryanodine receptor-mediated intracellular calcium leak is a mechanism for atrial fibrillation (AF), but evidence in humans is still needed. Propafenone is composed of two ...enantiomers that are equally potent sodium-channel blockers; however,
)-propafenone is an ryanodine receptor inhibitor whereas
)-propafenone is not. This study tested the hypothesis that ryanodine receptor inhibition with
)-propafenone prevents induction of AF compared to
)-propafenone or placebo in patients referred for AF ablation.
Participants were randomized 4:4:1 to a one-time intravenous dose of
)-propafenone,
)-propafenone, or placebo. The study drug was given at the start of the procedure and an AF induction protocol using rapid atrial pacing was performed before ablation. The primary endpoint was 30 s of AF or atrial flutter.
A total of 193 participants were enrolled and 165 (85%) completed the study protocol (median age: 63 years, 58% male, 95% paroxysmal AF). Sustained AF and/or atrial flutter was induced in 60 participants (84.5%) receiving
)-propafenone, 60 (80.0%) receiving
)-propafenone group, and 12 (63.2%) receiving placebo. Atrial flutter occurred significantly more often in the
)-propafenone (N=23, 32.4%) and
)-propafenone (N=26, 34.7%) groups compared to placebo (N=1, 5.3%,
=0.029). There was no significant difference between
)-propafenone and
)-propafenone for the primary outcome of AF and/or atrial flutter induction in univariable (
=0.522) or multivariable analysis (
=0.199, adjusted for age and serum drug level).
There is no difference in AF inducibility between
)-propafenone and
)-propafenone at clinically relevant concentrations. These results are confounded by a high rate of inducible atrial flutter due to sodium-channel blockade.
https://clinicaltrials.gov; Unique Identifier: NCT02710669.
To identify the impact of the American Society of Anesthesiologists (ASA) physical status on postoperative length of stay (LOS) and to document the cost due to LOS after surgical management of the 8 ...most common lower extremity and 2 most common upper extremity isolated orthopaedic fractures.
Retrospective chart review.
All patients who presented and underwent one of the 10 selected isolated orthopaedic surgical procedures at a large tertiary care center between January 1, 2000, and December 31, 2010.
Charts for patients undergoing the 10 selected isolated orthopaedic surgical fracture procedures more than 10 years were reviewed. Thirteen thousand seven hundred seventy-six distinct operations were identified. One thousand three hundred ninety-eight distinct operations were included in analysis after selection.
This was an observational study. Patients who received operative management for isolated orthopaedic fractures were identified utilizing a CPT code search for analysis in a retrospective chart review.
LOS and cost secondary to LOS.
ASA physical status proved the strongest predictor of postoperative LOS for the 8 most common lower extremity and 2 most common upper extremity isolated orthopaedic procedures. ASA was also a significant predictor of inpatient cost for all isolated orthopaedic procedures included in the study with the exception of CPT code 27536.
ASA classification is an indicator for variance in LOS and total inpatient cost for hospitalized patients. Given that ASA classification is a universally collected data point, this method can be used in almost any hospital system and for any operative service. In addition, this study provides a foundation for many other studies to be conducted which will include multiple institutions and fracture types, such that ASA can be used as a more generalizable predictor of LOS and inpatient cost in orthopaedic trauma patients. This model may be used to accurately predict a patient's postoperative course and the expected cost to the health care system of a given procedure.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Recurrence after atrial fibrillation (AF) ablation remains common. We evaluated the association between recurrence and levels of biomarkers of cardiac remodeling, and their ability to improve ...recurrence prediction when added to a clinical prediction model.
Blood samples collected before de novo catheter ablation were analyzed. Levels of bone morphogenetic protein-10, angiopoietin-2, fibroblast growth factor-23, insulin-like growth factor-binding protein-7, myosin-binding protein C3, growth differentiation factor-15, interleukin-6, N-terminal pro-brain natriuretic peptide, and high-sensitivity troponin T were measured. Recurrence was defined as ≥30 seconds of an atrial arrhythmia 3 to 12 months postablation. Multivariable logistic regression was performed using biomarker levels along with clinical covariates: APPLE score (Age >65 years, Persistent AF, imPaired eGFR <60 ml/min/1.73m
, LA diameter ≥43 mm, EF <50%; which includes age, left atrial diameter, left ventricular ejection fraction, persistent atrial fibrillation, and estimated glomerular filtration rate), preablation rhythm, sex, height, body mass index, presence of an implanted continuous monitor, year of ablation, and additional linear ablation. A total of 1873 participants were included. A multivariable logistic regression showed an association between recurrence and levels of angiopoietin-2 (odds ratio, 1.08 95% CI, 1.02-1.15,
=0.007) and interleukin-6 (odds ratio, 1.02 95% CI, 1.003-1.03;
=0.02). The area under the receiver operating characteristic curve of a model that only contained clinical predictors was 0.711. The addition of any of the 9 studied biomarkers to the predictive model did not result in a statistically significant improvement in the area under the receiver operating characteristic curve.
Higher angiopoietin-2 and interleukin-6 levels were associated with recurrence after atrial fibrillation ablation in multivariable modeling. However, the addition of biomarkers to a clinical prediction model did not significantly improve recurrence prediction.
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