Characterization of atrial flutter after pulmonary vein isolation by cryoballoon ablation

PURPOSE

Pulmonary vein isolation (PVI) by cryoballoon ablation (CBA) has emerged as a commonly used technique for the treatment of atrial fibrillation. We sought to explore the incidence, risk factors for, and characterization of post-CBA-PVI atrial flutter.

METHODS

We analyzed a prospective registry of patients who underwent CBA-PVI at a single institution. We included patients with more than 3 months of follow-up data and excluded those with a history of cavotricuspid isthmus (CTI) ablation. Locations of post-CBA-PVI atrial flutters were determined by analysis of intracardiac electrograms and electroanatomic maps.

RESULTS

There were 556 patients included in the analysis. The mean age was 61.0 ± 10.6 years, 67.4% were male, the number of failed anti-arrhythmic medication trials was 1.2 ± 0.8, and the duration of atrial fibrillation pre-CBA was 54.3 ± 69.1 months. The 28-mm second-generation cryoballoon was used almost exclusively. Over a median follow-up time of 22.7 ± 17.9 months, 25 (4.5%) patients developed post-CBA-PVI atrial flutter after the 3-month blanking period. Of those 25 patients, 15 (60%) underwent subsequent ablation to eliminate the atrial flutter circuit, with 60% being CTI-dependent and the remainder left-sided (p value not significant). Risk factors for the development of atrial flutter included NYHA class ≥ 2 (OR 5.02, p < 0.001), presence of baseline bundle branch block (OR 4.33, p = 0.006), and left ventricular ejection fraction < 50% (OR 3.36, p = 0.007).

CONCLUSIONS

The rate of post-CBA-PVI atrial flutter is low after the blanking period even with medium-term follow-up. The origin of atrial flutter is equally divided between the right and left atria.

Decreasing trend of seroprevalence of hepatic amoebiasis in tertiary care hospital of North India: 2010-2015

BACKGROUND:

Globally, amoebic liver abscess, a common extraintestinal complication of intestinal amoebiasis. Diagnosis of hepatic amoebiasis is based on the detection of anti-Entamoeba histolytica immunoglobulin G (IgG) antibody using enzyme-linked immunosorbent assay (ELISA), because of its technique's relatively higher sensitivity and specificity (90%).

AIM:

The aim of the present study was to determine the seroprevalence of hepatic amoebiasis in a referral tertiary care hospital in North India.

MATERIALS AND METHODS:

The blood samples were tested specifically for anti-E. histolytica IgG antibody using commercially available ELISA kit (RIDASCREEN^®E. histolytica IgG [K1721] kit).

RESULTS:

A total of 879 patients (n = 879) were evaluated, of which 78.49% (690/879) were positive for anti-E. histolytica IgG antibody. The seroprevalence rates showed a declining trend from 2010 to 2015 with rates falling from 91.4% to 66.7%. He present a study showed the decreasing trend of seroprevalence of hepatic amoebiasis from 2010 to 2015.

CONCLUSIONS:

This decrease may be attributed to several factors such as increase in awareness, improved hygienic practices, use of safe drinking water, better socioeconomic condition, and perhaps early treatment sought for intestinal amoebiasis.

Prevalence of vitamin D deficiency in childhood acute lymphoblastic leukemia and its association with adverse outcomes during induction phase of treatment

Background: Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. Vitamin D inadequacy is now an internationally recognized health problem. Some relation has been observed between Vitamin D insufficiency and poor outcome in ALL though evidence is limited. Methods: A prospective observational study was done including children (1-15 years) with newly diagnosed ALL. Vitamin D estimation was performed at baseline and at end of induction chemotherapy. Results: Ninety-three patients were recruited in the study. Majority of them belonged to lower socio-economic status (75.3%), and were from rural background (89.2%). Vitamin D deficiency was found in 84.95% of the study population. Seventy-five children (80.6%) completed induction, 9 (9.7%) abandoned treatment and 9 (9.7%) died during induction. Vitamin D levels were significantly low in children with ALL who died (P = 0.016), who had complications (P = 0.002), females (P = 0.036), and those with high risk ALL (P = 0.001). There was a significant drop in the Vitamin D levels (P < 0.001) from pre to post induction phase of chemotherapy. Conclusion: Vitamin D deficiency is prevalent in patients with ALL and is also associated with adverse outcome in these children. Further studies are needed on possible benefits of vitamin D supplementation for preventing complications during treatment of ALL.

Update in Cardiac Pacing

Initial efforts to artificially stimulate the heart were borne out of a necessity to prevent catastrophic bradycardic events. The initial pacemaker systems were large, bulky external devices. However, advancements in technology allowed for the development of internally powered, fully implantable devices. Further advancements resulted in more complex, programmable devices, but the overall systems have remained largely unchanged for more than 50 years. The most recent advancements in the field have represented fundamental paradigm shifts in both pacemaker design and the approach to cardiac pacing. These efforts have focused on reducing and eliminating hardware to reduce the risk of complications and to focus on improving cardiac efficiency to improve clinical outcomes. In this article, the authors explore these advances including leadless pacemaker systems, permanent His bundle pacing and advances in the field of cardiac resynchronisation therapy.

A randomized controlled study of operative versus nonoperative treatment for large spontaneous supratentorial intracerebral hemorrhage

CONTEXT

Spontaneous intracerebral haemorrhage (ICH) accounts for 4-14% of all strokes and has a high mortality rate of 30-50% during the first month. Management of large hematomas is controversial, with some advocating medical management while others favoring surgical evacuation.

AIM

This study was undertaken to compare the outcome of patients with a spontaneous supratentorial intracerebral hemorrhage (SSICH) managed with or without surgical evacuation.

SETTINGS AND DESIGN

Four hundred and eighty-two SSICH patients admitted from September 2013 to August 2015 were evaluated based on the inclusion and exclusion criteria.

MATERIALS AND METHODS

Among a total of 61 patients with Glasgow Coma Scale (GCS) of 4-14 and hematoma volume of> 30 ml, 27 were randomized to receive medical management (MM) alone and the remaining 34 were randomized to combined surgical as well as medical management (SM). Primary and secondary outcomes were mortality and dependency at 3 months, respectively.

STATISTICAL ANALYSIS USED

Student's t-test and X2 test were used for univariate analysis, and logistic regression analysis was employed for multiple variables.

RESULTS

On univariate analysis, mortality was significantly lower in the SM group (n = 21,61.8%) compared to the MM group (n = 23,85.2%) (P = 0.043); however, the groups showed no significant difference in dependency at 3 months. Further subgroup analysis showed that a hematoma volume of 30-60 ml, a deeply located hematoma, associated intraventricular hemorrhage, and a Glasgow Coma Scale (GCS) of 4-8 had a significantly lesser mortality in the SM group (P < 0.05). On multivariate analysis, a significant association was found between the mortality and the treatment arm (P = 0.006).

CONCLUSIONS

In patients with SSICH, mortality was found to be significantly associated with the treatment arm and the results were in favour of SM among the patients presenting with GCS 4-8, hematoma volume 31-60 ml, midline shift of more than 5 mm, and intraventricular extension of the hematoma.

Inferior right hepatic vein on routine contrast-enhanced CT of the abdomen: prevalence and correlation with right hepatic vein size

AIM

To determine the prevalence of the inferior right hepatic vein (IRHV) in patients undergoing routine contrast-enhanced computed tomography (CECT) of the abdomen and to compare it with the size of the right hepatic vein (RHV).

MATERIALS AND METHODS

Two hundred and twenty-four consecutive patients who underwent routine CECT abdomen, with adequate venous opacification, were included in the study. The number and diameter of IRHVs and the diameter of the RHV was noted in each case.

RESULTS

A total of 214 IRHVs were detected in 126 cases (56.2%) with a mean diameter of 4.15±1.44 mm. The number of IRHVs ranged from one to four (more than one IRHV was present in 39.7% [50/126] of cases). In approximately one-third of cases (46/126), an IRHV ≥5 mm was found. A weak negative correlation was found between size of the RHV and IRHV (Pearson's correlation coefficient -0.222; p=0.01). The RHV was smaller in size in patients with an IRHV (7.34±1.88 mm) than in patients without an IRHV (8.47±1.99 mm) on CECT abdomen. A larger IRHV was associated with a smaller RHV (6.91±2.05 mm).

CONCLUSION

The presence of IRHV on routine CECT abdomen is frequent, and it is not uncommon to encounter more than one IRHV. The diameter of the IRHV has a weak negative correlation with the diameter of the RHV, and a smaller RHV is found in patients with an IRHV.

Patient characteristics as predictors of recurrence of atrial fibrillation following cryoballoon ablation

BACKGROUND

While several studies have evaluated predictors for atrial fibrillation (AF) recurrence following catheter ablation, there are limited data specific to cryoballoon ablation (CBA).

METHODS

We analyzed a prospective registry of patients at a single institution who underwent CBA. Recurrence of AF (RAF) was defined as recurrence of AF by 12-month follow-up, excluding the 3-month blanking period. Univariate analysis was performed to evaluate predictors of RAF. Receiver operating characteristic analysis was used to compare and evaluate the performance of various risk scores for discriminating risk of RAF.

RESULTS

There were 542 patients included in the analysis with mean age 61.3 ± 10.6 years, 67.9% male, and 51.6% paroxysmal AF (PAF). Overall, only left atrial diameter (LAD) > 40 mm and ERAF (early recurrence of AF within 0-3 month blanking period) were significant predictors of RAF. In the PAF specific subgroup, LAD > 40 mm, AF duration > 12 months, prior stroke or transient ischemic attack, ERAF, and having previously failed an antiarrhythmic drug were significant predictors of RAF. In persistent AF (PeAF) subgroup, obstructive sleep apnea (OSA) and ERAF were significant predictors of RAF. Out of clinical risk scores tested, BASEAF2 had the highest performance with area under the curve of 0.646 (95% confidence interval [0.548, 0.708]; P < .01).

CONCLUSIONS

In this single-center retrospective study of CBA, we found only LAD > 40 mm and ERAF to be predictors of RAF. We identified OSA as a potential targetable risk factor in PeAF patients undergoing CBA. Out of risk scores tested for discriminating risk of RAF, BASEAF2 had the best performance.

Hodgkin Lymphoma Presenting as Immune Thrombocytopenia

Immune thrombocytopenia (ITP) in lymphoid malignancies has been observed primarily in relation to chronic lymphoproliferative disorders. ITP in Hodgkin lymphoma (HL) is a rare presentation, most often reported at follow-up. We report a case of a 12-year-old female presenting with symptomatic thrombocytopenia at the time of diagnosis of HL. The patient had stage III B bulky disease with HL mixed cellularity subtype on histology. The patient was treated with adriamycin, bleomycin, vinblastine, and dacarbazine regime along with local radiation therapy and is in complete remission at 18 months of follow-up. The treatment of underlying lymphoma in such cases resolves thrombocytopenia.

Correlation of Foot Bimalleolar Angle and Ultrasonography in Assessing the Severity of Club Foot in Neonates Treated by the Ponseti Method

Introduction: Correlation of Pirani score and foot bimalleolar (FBM) angle has been used in few studies but correlation of FBM angle with ultrasonography has never been evaluated so they are being correlated in assessing the severity of clubfoot in neonates treated by Ponseti method. Material and Methods: Thirty-two feet with congenital talipes equinovarus (CTEV) deformity in neonates were prospectively treated by the Ponseti method. FBM angle and ultrasound parameters were measured three times i.e. at the time of initial presentation, at four weeks of treatment and at completion of treatment. The feet were divided according to the Pirani score in groups: one (0-2.0), two (2.5-4) and three (4.5-6). Correlation between FBM angle and ultrasound parameters were evaluated using Pearson correlation/regression. Results: Correlation between FBM angle and ultrasound parameters were statistically significant (p-value < 0.05). Conclusion: Ultrasound has the potential to accurately depict the pathoanatomy in clubfoot. FBM angle and ultrasound are objective methods to assess the severity of clubfoot. FBM angle and ultrasonography correlated in severity of deformity and correction achieved along the course of treatment.

Atypical cases of filariasis from a non-endemic area

Filariasis can present in many different ways and pose significant dilemma to the clinician. We report four atypical cases of filariasis which presented as abdominal mass, cervical lymph node enlargement, fever in pregnancy and nosocomial febrile illness respectively. All the four cases were treated successfully with oral antifilarial agents. It is essential to be aware of such atypical presentations of filariasis so that prompt therapy can be initiated.

Incidence of atrial fibrillation among patients with an embolic stroke of undetermined source: Insights from insertable cardiac monitors

Background

Prophylactic use of direct oral anticoagulants for recurrent stroke prevention in patients with embolic strokes of undetermined source is currently being investigated. It is uncertain whether the bleeding risks associated with prophylactic direct oral anticoagulants use will outweigh any stroke prevention benefit in embolic strokes of undetermined source patients who lack underlying atrial fibrillation.

Methods

We determined the proportion of cryptogenic stroke patients in the CRYSTAL atrial fibrillation trial who met inclusion criteria for the NAVIGATE embolic stroke of undetermined source and RE-SPECT embolic stroke of undetermined source trials and their atrial fibrillation incidence. Both embolic strokes of undetermined source trials impose requirements on age, modified Rankin Score, antiplatelet use, and type of infarction. Insertable cardiac monitors were used to determine the atrial fibrillation detection rates at 30 days and 3 years using Kaplan–Meier’s estimates.

Results

Among 441 patients enrolled in the CRYSTAL atrial fibrillation trial, 189 (42.9%) and 236 (53.5%) met the inclusion criteria of the NAVIGATE embolic stroke of undetermined source and RE-SPECT embolic stroke of undetermined source trials, respectively. Atrial fibrillation detection rates at 3 years among insertable cardiac monitors patients eligible for the NAVIGATE embolic stroke of undetermined source and RE-SPECT embolic stroke of undetermined source trials were 35.8% and 33.6% while detection rates at 30 days were 5.6% and 3.5%, respectively.

Conclusion

Only half of cryptogenic stroke patients in CRYSTAL atrial fibrillation met the inclusion criteria for the ongoing embolic strokes of undetermined source trials. Approximately, two-thirds of patients with embolic strokes of undetermined source do not have any atrial fibrillation despite continuous rhythm monitoring for up to three years. The benefits of prophylactic use of direct oral anticoagulants in the absence of atrial fibrillation is unknown and therefore embolic strokes of undetermined source patients could benefit from prolonged atrial fibrillation monitoring until more robust data are available.

ClinicalTrials.gov Registration

NCT00924638. https://clinicaltrials.gov/ct2/show/NCT00924638 .

Gallbladder empyema complicating acute myeloid leukaemia in an adolescent boy

Gallbladder (GB) empyema is an uncommon complication in acute myeloid leukaemia (AML). Non-specific signs and symptoms and rarity of disease in AML make it difficult to diagnose early. We report a case of 13-year-old boy who had AML and developed GB empyema in the neutropaenic period. The patient was managed with antibiotics, ultrasound-guided tapping and interval cholecystectomy and recovered well. GB empyema is a life-threatening complication which should be kept as a possibility while evaluating patients with neutropaenia with pain abdomen localised to right hypochondrium as early diagnosis and treatment can lead to better outcomes.

Hypertriglyceridemia thalassemia syndrome

Background Hypertriglyceridemia thalassemia syndrome is a rare entity with an unknown pathogenetic link. Case presentation We report a case of an 8-month-old female with thalassemia major and increased triglyceride (TG) levels. The clinical features were as in classical thalassemia except for a white discoloration of the plasma. After exclusion of familial triglyceridemia and secondary causes (hypothyroidism, nephrotic syndrome, drugs etc.), a diagnosis of hypertriglyceridemia thalassemia syndrome was made. Conclusions The high levels of TG in these patients are associated with oxidative stress and higher risk of acute pancreatitis and coronary diseases. An early recognition is thus essential. In our patient, the levels reduced after a transfusion therapy similar to previous reports.

Permanent His-Bundle pacing in a patient with advanced conduction system disease: What is the mechanism of QRS narrowing?

QRS narrowing during permanent His-bundle pacing is primarily thought to result from longitudinal dissociation within the His bundle. We present a case with an alternative mechanism, highlighting the likelihood that there are actually multiple explanations for this phenomenon. In addition, this case highlights the utility of His-bundle pacing even in the face of a wide QRS.

A Biomarker Combining Imaging and Neuropsychological Assessment for Tracking Early Alzheimer's Disease in Clinical Trials

Background:

Combining optimized cognitive (Alzheimer's Disease Assessment Scale- Cognitive subscale, ADAS-Cog) and atrophy markers of Alzheimer's disease for tracking progression in clinical trials may provide greater sensitivity than currently used methods, which have yielded negative results in multiple recent trials. Furthermore, it is critical to clarify the relationship among the subcomponents yielded by cognitive and imaging testing, to address the symptomatic and anatomical variability of Alzheimer's disease.

Method:

Using latent variable analysis, we thoroughly investigated the relationship between cognitive impairment, as assessed on the ADAS-Cog, and cerebral atrophy. A biomarker was developed for Alzheimer's clinical trials that combines cognitive and atrophy markers.

Results:

Atrophy within specific brain regions was found to be closely related with impairment in cognitive domains of memory, language, and praxis. The proposed biomarker showed significantly better sensitivity in tracking progression of cognitive impairment than the ADAS-Cog in simulated trials and a real world problem. The biomarker also improved the selection of MCI patients (78.8±4.9% specificity at 80% sensitivity) that will evolve to Alzheimer's disease for clinical trials.

Conclusion:

The proposed biomarker provides a boost to the efficacy of clinical trials focused in the mild cognitive impairment (MCI) stage by significantly improving the sensitivity to detect treatment effects and improving the selection of MCI patients that will evolve to Alzheimer’s disease.

Bronchial effects of cryoballoon ablation for atrial fibrillation

BACKGROUND

Damage to extracardiac structures, including the esophagus and phrenic nerve, is a known complication of cryoballoon ablation (CBA) during pulmonary vein (PV) isolation for atrial fibrillation (AF). Other adjacent structures, including the pulmonary bronchi and lung parenchyma, may be affected during CBA at the PV ostia.

OBJECTIVE

The purpose of this study was to prospectively study the bronchial effects of CBA in humans undergoing CBA for PV isolation.

METHODS

Ten patients undergoing CBA for AF under general anesthesia were enrolled in an institutional review board-approved prospective observational study. Real-time bronchoscopy was performed during cryoablation of PVs adjacent to pulmonary bronchi to monitor for thermal injury. Patients were followed for the development of respiratory complaints postprocedure.

RESULTS

In 7 of 10 patients (70%) and in 13 of 22 freezes (59%), ice formation was visualized in the left mainstem bronchus during CBA in the left upper PV. Ice formation was not seen in the right mainstem bronchus during right upper PV CBA. The average time to ice formation was 89 seconds. There was no significant difference (P = -.45) in average minimum balloon temperature during freezes with ice formation (-48.5°C) and freezes without ice formation (-46.3°C). No patients went on to develop respiratory complications.

CONCLUSION

Unrecognized ice formation occurs frequently in the left mainstem bronchus during CBA for AF. This information helps explain the source of cough and hemoptysis in some patients who undergo CBA. The long-term consequences of this novel finding and the implications for procedural safety are unknown.

Reconnection Rate and Long-Term Outcome with Adenosine Provocation During Cryoballoon Ablation for Pulmonary Vein Isolation

Background

Adenosine can unmask dormant conduction during pulmonary vein isolation (PVI) for atrial fibrillation (AF). Studies of adenosine use in radiofrequency PVI show high reconnection rates and conflicting results for long-term success, however there is limited data with cryoballoon ablation (CBA).

Methods

A prospectively maintained database of patients undergoing first CBA at a single institution was analyzed. Adenosine use was at the discretion of the primary operator. Additional freezes were delivered for reconnected veins until dormant conduction was eliminated. The primary endpoint, time to AF recurrence defined as any episode < 30 seconds after a 3-month blanking period, was assessed by Kaplan-Meier analysis.

Results

From 2011 to 2015, 406 patients underwent CBA, 361 of whom had > 3 months follow-up. The mean age was 61.7 years, 69% were male, and the prevalence of paroxysmal AF was 79% with no significant difference between those that did and did not receive adenosine (77% vs 86%, respectively, p = 0.23). Adenosine testing was performed in 78 patients (21.6%) with a mean dose of 10.6 mg/vein. Of the 306 veins evaluated, 17 (6%) demonstrated dormant conduction. Over a median 14.4 months follow-up, there was no significant difference in freedom from AF with adenosine use (p= 0.86).

Conclusions

Dormant conduction with adenosine is uncommon following CBA and its use does not improve long-term success rates.

Outcome of extraocular retinoblastoma in a resource limited center from low middle income country

Retinoblastoma (RB) is the most common ocular malignancy in children, and is managed by multimodal treatment. There is a paucity of data regarding the clinical profile and outcome of children with extraocular retinoblastoma from Low Middle Income Countries (LMIC) including India. Case records of children with newly diagnosed extraocular RB from January 2013 to August 2016 treated at our unit were analysed for clinical profile, treatment, and outcome. Over the 44 month study period, 91 children were diagnosed with RB, out of which 41 had extraocular disease. While 26 children had extraocular spread limited to orbit (IRSS stage III), 15 had a distant spread to brain (IRSS stage IV). Median lag period for diagnosis was eight months. Treatment abandonment rates were 38.5% and 46.6% in International Retinoblastoma Staging System (IRSS) stage III and IV respectively. With a median follow up of 31.5 months, the projected overall survival for IRSS III at one, two, and three years was 87.5%, 55.6%, and 39.7%. All patients with stage IV disease died after a median follow up duration of three months. High treatment abandonment rates and limited availability of resources lead to suboptimal survival in children with extraocular RB from LMIC. Initiatives aimed at improving early diagnosis, so that the disease is detected in the intraocular stage, are critical to improve the survival in children with RB.