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Markman TM, Peters C, Tate S, Guandalini GS, Hyman MC, Schaller RD, Supple GE, Riley MP, Garcia F, Nazarian S, Lin D, Dixit S, Epstein AE, Callans DJ, Marchlinski FE, Frankel DS. Accuracy of symptoms and pulse checking for detecting atrial fibrillation following catheter ablation. J Interv Card Electrophysiol 2024; 67:617-623. [PMID: 37700118 DOI: 10.1007/s10840-023-01643-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND There is growing interest in the possibility of discontinuing oral anticoagulation following successful catheter ablation of atrial fibrillation (AF). However, it remains unknown whether patients can accurately detect arrhythmia recurrences following ablation. We therefore sought to characterize the accuracy of pulse checking and arrhythmia symptoms for the identification of AF following ablation. METHODS This prospective cohort study included patients at the Hospital of the University of Pennsylvania with an insertable cardiac monitor (ICM) treated with catheter ablation for AF who recorded the results from minimum twice daily pulse checks and additionally with arrhythmia symptoms into a diary for 2 months following their procedure. Accuracy of this self-assessment protocol was determined by comparison to ICM-detected AF. RESULTS A total of 55 patients (age 69 ± 8 years, 30 (55%) male, CHA2DS2VASc score 3.2 ± 1. 5) were included. Patients recorded a total of 5911 pulse checks, and there were 280 episodes of ICM-documented AF among 26 patients with an average duration of 2.5 ± 3.3 h. Among 362 episodes of patient-suspected AF, 134 correlated with ICM-identified AF (37% true positive rate). Of the 5549 pulse checks that did not identify AF, 196 correlated with ICM-identified AF (4% false negative rate). Twice daily pulse checking had a sensitivity of 47% and a specificity of 96% for identifying each episode of AF. CONCLUSIONS Our data indicate that a strategy of pulse checks and symptom assessment is insufficient to identify all episodes of AF in many patients following catheter ablation.
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Affiliation(s)
- Timothy M Markman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Carli Peters
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Simone Tate
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gustavo S Guandalini
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew C Hyman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert D Schaller
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory E Supple
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael P Riley
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Fermin Garcia
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Saman Nazarian
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David Lin
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sanjay Dixit
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew E Epstein
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David J Callans
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Petzl AM, Epstein AE, Guandalini GS. Less Obvious Than One Might Think: Why Is There Grouped Beating? Circulation 2024; 149:481-483. [PMID: 38315765 DOI: 10.1161/circulationaha.123.068252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Affiliation(s)
- Adrian M Petzl
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Andrew E Epstein
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Gustavo S Guandalini
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia
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3
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Thind M, Oraii A, Chaumont C, Arceluz MR, Sekigawa M, Yogasundaram H, Sugrue A, Mirwais M, AlSalem AB, Zado ES, Guandalini GS, Markman TM, Deo R, Schaller RD, Dixit S, Epstein AE, Supple GE, Tschabrunn CM, Santangeli P, Callans DJ, Hyman MC, Nazarian S, Frankel DS, Marchlinski FE. Predictors of nonpulmonary vein triggers for atrial fibrillation: A clinical risk score. Heart Rhythm 2024:S1547-5271(24)00102-4. [PMID: 38296010 DOI: 10.1016/j.hrthm.2024.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/21/2023] [Accepted: 01/24/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Targeting nonpulmonary vein triggers (NPVTs) after pulmonary vein isolation may reduce atrial fibrillation (AF) recurrence. Isoproterenol infusion and cardioversion of spontaneous or induced AF can provoke NPVTs but typically require vasopressor support and increased procedural time. OBJECTIVE The purpose of this study was to identify risk factors for the presence of NPVTs and create a risk score to identify higher-risk subgroups. METHODS Using the AF ablation registry at the Hospital of the University of Pennsylvania, we included consecutive patients who underwent AF ablation between January 2021 and December 2022. We excluded patients who did not receive NPVT provocation testing after failing to demonstrate spontaneous NPVTs. NPVTs were defined as nonpulmonary vein ectopic beats triggering AF or focal atrial tachycardia. We used risk factors associated with NPVTs with P <.1 in multivariable logistic regression model to create a risk score in a randomly split derivation set (80%) and tested its predictive accuracy in the validation set (20%). RESULTS In 1530 AF ablations included, NPVTs were observed in 235 (15.4%). In the derivation set, female sex (odds ratio [OR] 1.40; 95% confidence interval [CI] 0.96-2.03; P = .080), sinus node dysfunction (OR 1.67; 95% CI 0.98-2.87; P = .060), previous AF ablation (OR 2.50; 95% CI 1.70-3.65; P <.001), and left atrial scar (OR 2.90; 95% CI 1.94-4.36; P <.001) were risk factors associated with NPVTs. The risk score created from these risk factors (PRE2SSS2 score; [PRE]vious ablation: 2 points, female [S]ex: 1 point, [S]inus node dysfunction: 1 point, left atrial [S]car: 2 points) had good predictive accuracy in the validation cohort (area under the receiver operating characteristic curve 0.728; 95% CI 0.648-0.807). CONCLUSION A risk score incorporating predictors for NPVTs may allow provocation of triggers to be performed in patients with greatest expected yield.
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Affiliation(s)
- Munveer Thind
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alireza Oraii
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corentin Chaumont
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Martín R Arceluz
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Masahiro Sekigawa
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Haran Yogasundaram
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan Sugrue
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maiwand Mirwais
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahmed B AlSalem
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica S Zado
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gustavo S Guandalini
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy M Markman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajat Deo
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D Schaller
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew E Epstein
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cory M Tschabrunn
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C Hyman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Chaumont C, Oraii A, Markman TM, Garcia FC, Lin D, Supple GE, Zado ES, Epstein AE, Callans DJ, Frankel DS, Anselme F, Santangeli P, Marchlinski FE, Hyman MC. Epicardial carbon dioxide insufflation is a novel technique for the identification of epicardial adhesions and targeting epicardial access. Heart Rhythm 2024:S1547-5271(24)00088-2. [PMID: 38280620 DOI: 10.1016/j.hrthm.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 01/29/2024]
Affiliation(s)
- Corentin Chaumont
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Cardiology Department, Rouen University Hospital, Rouen, France
| | - Alireza Oraii
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy M Markman
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica S Zado
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew E Epstein
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Ohio
| | - Francis E Marchlinski
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C Hyman
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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5
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Pothineni NVK, Batnyam U, Schwennesen H, Tierney A, Messé SR, Cucchiara B, Mendelson TB, Luebbert JJ, Yang W, Kumareswaran R, Hyman MC, Lin D, Dixit S, Epstein AE, Arkles JS, Nazarian S, Schaller RD, Supple GE, Callans D, Yaeger A, Frankel DS, Santangeli P, Kasner SE, Marchlinski FE, Deo R. Evaluation of organized atrial arrhythmias after cryptogenic stroke. Heart Rhythm O2 2024; 5:34-40. [PMID: 38312199 PMCID: PMC10837165 DOI: 10.1016/j.hroo.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Long-term rhythm monitoring to detect atrial fibrillation (AF) following a cryptogenic stroke (CS) is well established. However, the burden of organized atrial arrhythmias in this population is not well defined. Objective The purpose of this study was to assess the incidence and risk factors for organized atrial arrhythmias in patients with CS. Methods We evaluated all patients with CS who received an insertable cardiac monitor (ICM) between October 2014 and April 2020. All ICM transmissions categorized as AF, tachycardia, or bradycardia were reviewed. We evaluated the time to detection of organized AF and the combination of either organized atrial arrhythmia or AF. Results A total of 195 CS patients with ICMs were included (51% men; mean age 66 ± 12 years; mean CHA2DS2-VASC score 4.6). Over mean follow-up of 18.9 ± 11.2 months, organized atrial arrhythmias lasting ≥30 seconds were detected in 45 patients (23%), of whom 62% did not have AF. Seventeen patients had both organized atrial arrhythmia and AF, and another 21 patients had AF only. Compared to those with normal left atrial size, patients with left atrial enlargement had a higher adjusted risk for development of atrial arrhythmias (mild left atrial enlargement: hazard ratio 1.99; 95% confidence interval 1.06-3.75; moderate/severe left atrial enlargement: hazard ratio 3.06; 95% confidence interval 1.58-5.92). Conclusion Organized atrial arrhythmias lasting ≥30 seconds are detected in nearly one-fourth of CS patients. Two-thirds of these patients did not have AF. Further studies are required to evaluate the impact of organized atrial arrhythmias on recurrent stroke risk.
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Affiliation(s)
- Naga Venkata K. Pothineni
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Uyanga Batnyam
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah Schwennesen
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann Tierney
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven R. Messé
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brett Cucchiara
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Todd B. Mendelson
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey J. Luebbert
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramanan Kumareswaran
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C. Hyman
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew E. Epstein
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S. Arkles
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D. Schaller
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E. Supple
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Callans
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amaryah Yaeger
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S. Frankel
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott E. Kasner
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E. Marchlinski
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajat Deo
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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6
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Patel NA, Lin D, Ha B, Hyman MC, Nazarian S, Frankel DS, Epstein AE, Marchlinski FE, Markman TM. Intraoperative ultrasound-guided pectoral nerve blocks for cardiac implantable device procedures. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01724-4. [PMID: 38105353 DOI: 10.1007/s10840-023-01724-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/08/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Pectoral nerve (PECs) blocks are established regional anesthesia techniques that can provide analgesia to the anterior chest wall. Although commonly performed preoperatively by anesthesiologists, the feasibility of electrophysiologist-performed PECs blocks from within cardiac implantable electronic device (CIED) pockets at the time of implantation has not been established. The objective of this study is to assess the feasibility of routine PECs blocks performed by the electrophysiologist from within the exposed device pocket at the time of CIED procedures. METHODS Patients undergoing CIED procedures underwent a PECs I block (15 cc of 1% lidocaine/0.25% bupivacaine) injected between the pectoralis major and minor muscles guided by ultrasound placed in the device pocket, or PECs II block, which included a second injection (15 cc) between pectoralis minor and serratus anterior muscles. Postoperatively, pain was assessed on a numeric scale (0-10) at 1, 2, 4, and 24 h, and 2 weeks after the procedure. RESULTS Among 20 patients (age 65 ± 16 years, 70% male, 55% with history of chronic pain), PECs I (75%) and PECs II (25%) blocks were performed. The procedures were de novo implantation (n = 17) or device revision (n = 3). The average pain score in the first 4 h was 0.4 ± 0.8 and 0.3 ± 0.6 at 24 h after the procedure. During the 24-h postoperative period, 4 patients received opioids. Two patients were discharged with opioids for pain unrelated to the procedure. CONCLUSIONS Intraoperative PECs blocks can be feasibly performed from within an exposed pocket at the time of CIED procedures with minimal postoperative pain.
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Affiliation(s)
- Neel A Patel
- Cardiac Electrophysiology, University of Pennsylvania, Philadelphia, PA, USA
| | - David Lin
- Cardiac Electrophysiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Bao Ha
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew C Hyman
- Cardiac Electrophysiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Saman Nazarian
- Cardiac Electrophysiology, University of Pennsylvania, Philadelphia, PA, USA
| | - David S Frankel
- Cardiac Electrophysiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew E Epstein
- Cardiac Electrophysiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Timothy M Markman
- Cardiac Electrophysiology, University of Pennsylvania, Philadelphia, PA, USA.
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7
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Thind M, Arceluz MR, Lucena-Padros I, Kubala M, Mirwais M, Bode W, Cerantola M, Sugrue A, Van Niekerk C, Vigdor A, Patel NA, AlSalem AB, Zado ES, Kumareswaran R, Lin D, Arkles JS, Garcia FC, Guandalini GS, Markman TM, Riley MP, Deo R, Schaller RD, Nazarian S, Dixit S, Epstein AE, Supple GE, Frankel DS, Tschabrunn CM, Santangeli P, Callans DJ, Hyman MC, Marchlinski FE. Identifying Origin of Nonpulmonary Vein Triggers Using 2 Stationary Linear Decapolar Catheters: A Novel Algorithm. JACC Clin Electrophysiol 2023; 9:2275-2287. [PMID: 37737775 DOI: 10.1016/j.jacep.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/06/2023] [Accepted: 07/15/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Targeting nonpulmonary vein triggers (NPVTs) of atrial fibrillation (AF) after pulmonary vein isolation can be challenging. NPVTs are often single ectopic beats with a surface P-wave obscured by a QRS or T-wave. OBJECTIVES The goal of this study was to construct an algorithm to regionalize the site of origin of NPVTs using only intracardiac bipolar electrograms from 2 linear decapolar catheters positioned in the posterolateral right atrium (along the crista terminalis with the distal bipole pair in the superior vena cava) and in the proximal coronary sinus (CS). METHODS After pulmonary vein isolation in 42 patients with AF, pacing from 15 typical anatomic NPVT sites was conducted. For each pacing site, the electrogram activation sequence was analyzed from the CS catheter (simultaneous/chevron/inverse chevron/distal-proximal/proximal-distal) and activation time (ie, CSCTAT) between the earliest electrograms from the 2 decapolar catheters was measured referencing the earliest CS electrogram; a negative CSCTAT value indicates the crista terminalis catheter electrogram was earlier, and a positive CSCTAT value indicates the CS catheter electrogram was earlier. A regionalization algorithm with high predictive value was defined and tested in a validation cohort with AF NPVTs localized with electroanatomic mapping. RESULTS In the study patient cohort (71% male; 43% with persistent AF, 52% with left atrial dilation), the algorithm grouped with high precision (positive predictive value 81%-99%, specificity 94%-100%, and sensitivity 30%-94%) the 15 distinct pacing sites into 9 clinically useful regions. Algorithm testing in a 98 patient validation cohort showed predictive accuracy of 91%. CONCLUSIONS An algorithm defined by the activation sequence and timing of electrograms from 2 linear multipolar catheters provided accurate regionalization of AF NPVTs to guide focused detailed mapping.
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Affiliation(s)
- Munveer Thind
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Martín R Arceluz
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Irene Lucena-Padros
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maciej Kubala
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maiwand Mirwais
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Weeranun Bode
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maxime Cerantola
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alan Sugrue
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christoffel Van Niekerk
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aaron Vigdor
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neel A Patel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ahmed B AlSalem
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica S Zado
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramanan Kumareswaran
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Arkles
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin C Garcia
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustavo S Guandalini
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Timothy M Markman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rajat Deo
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cory M Tschabrunn
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Kay GN, Okumura K, Mackall JA, Epstein AE. In Memoriam: Albert L. Waldo, MD, PhD (Hon) (1936-2023). Heart Rhythm 2023; 20:1602-1603. [PMID: 37914499 DOI: 10.1016/j.hrthm.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 11/03/2023]
Affiliation(s)
- G Neal Kay
- Electrophysiology Section, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Judith A Mackall
- Electrophysiology Section, University Hospitals of Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Andrew E Epstein
- Electrophysiology Section, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania.
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9
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Epstein AE. When Flatliners Meet the Wearable Cardioverter-Defibrillator. JACC Clin Electrophysiol 2023; 9:1340-1343. [PMID: 37558290 DOI: 10.1016/j.jacep.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/18/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Andrew E Epstein
- Electrophysiology Section, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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10
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Markman TM, Marchlinski FE, Epstein AE, Nazarian S. Physiologic Effects of Right-Sided Intravascular Cervical Sympathetic Nerve Stimulation. Circ Arrhythm Electrophysiol 2023:e012063. [PMID: 37357770 DOI: 10.1161/circep.123.012063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Affiliation(s)
- Timothy M Markman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Francis E Marchlinski
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew E Epstein
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Saman Nazarian
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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11
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Garg L, Moss J, Hyman MC, Arkles J, Callans DJ, Dixit S, Epstein AE, Frankel DS, Garcia FC, Kumareswaran R, Sharkoski T, Markman TM, Nazarian S, Riley MP, Santangeli P, Schaller RD, Supple GE, Marchlinski F, Deo R. Simultaneous comparison of patch versus multi-electrode cardiac monitoring for the detection of arrhythmias: The COMPARE study. Heart Rhythm 2023:S1547-5271(23)02118-5. [PMID: 37085025 DOI: 10.1016/j.hrthm.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/09/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Affiliation(s)
- Lohit Garg
- Division of Cardiovascular Medicine, Electrophysiology Section, University of Colorado, Denver, Colorado
| | - Juwann Moss
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C Hyman
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey Arkles
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew E Epstein
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramanan Kumareswaran
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tiffany Sharkoski
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy M Markman
- Division of Cardiovascular Medicine, Electrophysiology Section, University of Colorado, Denver, Colorado
| | - Saman Nazarian
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Riley
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Robert D Schaller
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis Marchlinski
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajat Deo
- Division of Cardiovascular Medicine, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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12
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Markman TM, Marchlinski FE, Epstein AE, Nazarian S. Feasibility of Intravascular Cervical Sympathetic Nerve Stimulation. JACC Clin Electrophysiol 2023:S2405-500X(23)00202-5. [PMID: 37227347 DOI: 10.1016/j.jacep.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/03/2023] [Accepted: 03/10/2023] [Indexed: 05/26/2023]
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13
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Garg L, Schaller R, Kumareswaran R, Santangeli P, Frankel DS, Guandalini G, Riley MP, Hyman MC, Nazarian S, Dixit S, Epstein AE, Callans DJ, Marchlinski FE, Deo R. COMPARISON OF PATCH VERSUS MULTI-ELECTRODE CARDIAC MONITORING FOR THE DETECTION OF ARRHYTHMIAS: THE COMPARE STUDY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00705-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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14
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Markman TM, Gugger D, Arkles J, Riley MP, Dixit S, Guandalini GS, Frankel DS, Epstein AE, Callans DJ, Singhal S, Marchlinski FE, Nazarian S. Neuromodulation for the Treatment of Refractory Ventricular Arrhythmias. JACC Clin Electrophysiol 2023; 9:161-169. [PMID: 36858681 DOI: 10.1016/j.jacep.2022.08.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Neuromodulation is increasingly recognized as a therapeutic strategy for patients with refractory ventricular arrhythmias (VAs). Percutaneous stellate ganglion blockade (SGB), transcutaneous magnetic stimulation (TcMS), and surgical cardiac sympathetic denervation (CSD) have all been utilized in this setting. OBJECTIVES This study sought to characterize contemporary use and outcomes of these neuromodulation techniques for patients with refractory VA. METHODS This retrospective cohort study included all patients at the Hospital of the University of Pennsylvania with antiarrhythmic drug (AAD)-refractory VA from 2019 to 2021 who were treated with SGB, TcMS, or CSD. RESULTS A total of 34 patients (age 61 ± 14 years, 15 polymorphic VAs [44%], refractory to 1.8 ± 0.8 AADs) met inclusion criteria. SGB was performed on 11 patients (32%), TcMS on 19 (56%), and CSD on 7 (21%). Neuromodulation was associated with a reduction in the number of episodes of sustained VAs from 7 [IQR: 4-12] episodes in the 24 hours before the initial neuromodulation strategy to 0 [IQR: 0-1] episodes in the subsequent 24 hours (P < 0.001). During 1.2 ± 1.1 years of follow-up, 21 (62%) experienced recurrent VAs, and among those patients, the median time to recurrence was 3 [IQR: 1-25] days. Outcomes were similar among patients with monomorphic and polymorphic VAs. Among patients who had an acute myocardial infarction within 30 days before neuromodulation, the burden of VAs decreased from 11 [IQR: 7-12] episodes to 0 episodes in the 24 hours after treatment. CONCLUSIONS Autonomic neuromodulation with SGB, TcMS, or CSD in patients with AAD-refractory VAs is safe and results in substantial acute reduction of VA although recurrent arrhythmias are common, and not all patients experience a reduction in arrhythmia burden.
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Affiliation(s)
- Timothy M Markman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Douglas Gugger
- Department of Anesthesia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustavo S Guandalini
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sunil Singhal
- Thoracic Surgery Division, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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15
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Markman TM, Jarrah AA, Tian Y, Mustin E, Guandalini GS, Lin D, Epstein AE, Hyman MC, Deo R, Supple GE, Arkles JS, Dixit S, Schaller RD, Santangeli P, Nazarian S, Riley M, Callans DJ, Marchlinski FE, Frankel DS. Safety of Pill-in-the-Pocket Class 1C Antiarrhythmic Drugs for Atrial Fibrillation. JACC Clin Electrophysiol 2022; 8:1515-1520. [PMID: 36543501 DOI: 10.1016/j.jacep.2022.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Guidelines recommend that initial trial of a "pill-in-the-pocket" (PIP) Class 1C antiarrhythmic drug (AAD) for cardioversion of atrial fibrillation (AF) be performed in a monitored setting because of the potential for adverse reactions. OBJECTIVES This study sought to characterize real-world, contemporary use of the PIP approach, including the setting of initiation and incidence of adverse events. METHODS This retrospective cohort study included all patients at the Hospital of the University of Pennsylvania treated with a PIP approach for AF between 2007 and 2020. RESULTS A total of 273 patients (age 56 ± 13 years; 182 [67%] male; CHA2DS2VASc score 1.1 ± 1.2) took a first dose of PIP AAD. Flecainide was used in 151 (55%) and propafenone in 122 (45%). The first dose of PIP AAD was taken in a monitored setting in 167 (62%). Significant adverse events occurred in 7 patients (3%), 2 of whom had taken the dose in a monitored setting. Significant adverse events included unexplained syncope (1 of 7), symptomatic bradycardia/hypotension (4 of 7), and 1:1 atrial flutter (2 of 7). All occurred in patients taking 300 mg of flecainide (n = 4) or 600 mg of propafenone (n = 3). Electrical cardioversion was performed in 29 (11%) patients because of failure of the AAD to terminate AF. One patient required intravenous fluids and vasopressors for 2 hours because of persistent hypotension and bradycardia. Two patients required permanent pacemakers for bradycardia. The remaining patients required no intervention. CONCLUSIONS Our data support the current recommendation to initiate PIP AAD in a monitored setting because of rare significant adverse reactions that can require urgent intervention.
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Affiliation(s)
- Timothy M Markman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew A Jarrah
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ye Tian
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Evan Mustin
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustavo S Guandalini
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rajat Deo
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Arkles
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Riley
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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16
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Markman TM, Epstein AE, Frankel DS. Reply: Pill-in-the-Pocket Therapy for Atrial Fibrillation: Is There More to Say? JACC Clin Electrophysiol 2022; 8:1586. [PMID: 36543513 DOI: 10.1016/j.jacep.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/12/2022] [Indexed: 12/23/2022]
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17
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Chee J, Lin AN, Julien H, Lin D, Schaller RD, Frankel DS, Supple GE, Santangeli P, Riley MP, Nazarian S, Deo R, Arkles J, Kumareswaran R, Hyman MC, Guandalini G, Epstein AE, Zado ES, Callans DJ, Marchlinski FE, Dixit S. Impact of Left Ventricular Papillary Muscle Ventricular Arrhythmia Ablation on Mitral Valve Function. JACC Clin Electrophysiol 2022; 8:1475-1483. [PMID: 36543496 DOI: 10.1016/j.jacep.2022.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Although efficacious, catheter ablation (CA) of ventricular arrhythmias (VAs) originating from left ventricular (LV) papillary muscles (PAPs) has the potential to affect mitral valve (MV) function. OBJECTIVES The aim of this study was to determine whether lesions delivered during CA of VAs from LV PAPs affected MV function. METHODS Consecutive patients undergoing CA of LV PAP VAs from January 2015 to December 2020 in whom both preprocedural and postprocedural transthoracic echocardiography was performed were included. Radiofrequency ablation was performed with an irrigated-tip catheter with or without contact force sensing and intracardiac echocardiographic guidance. The PAPs were delineated into segments: tip, body, and base. Pre- and post-CA transthoracic echocardiograms were reviewed to assess MV regurgitation, which was graded 0 (none), 1 (mild), 2 (moderate), or 3 (severe). A change of ≥2 grades from baseline was considered significant. RESULTS A total of 103 patients (mean age 63 ± 15 years, 78% men) were included. VAs were ablated from the anterolateral PAP in 35% (n = 36), posteromedial PAP in 55% (n = 57), and both PAPs in 10% (n = 10). Lesion distribution was as follows: PAP tip in 52 (50%), PAP base in 34 (33%), PAP body in 13 (13%), and entire PAP in 4 (4%). The mean number of lesions delivered was 16 ± 13 (median 14). Of 103 patients, 102 (99%) showed no change in MV function. CONCLUSIONS Using intracardiac echocardiographic guidance, lesions can be safely delivered on various aspects of this structure without adverse impact on MV function.
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Affiliation(s)
- Jennifer Chee
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aung N Lin
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Howard Julien
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rajat Deo
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramanan Kumareswaran
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustavo Guandalini
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica S Zado
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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18
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Carrington M, Providência R, Chahal CAA, Ricci F, Epstein AE, Gallina S, Fedorowski A, Sutton R, Khanji MY. Clinical applications of heart rhythm monitoring tools in symptomatic patients and for screening in high-risk groups. Europace 2022; 24:1721-1729. [PMID: 35983729 DOI: 10.1093/europace/euac088] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/12/2022] [Indexed: 12/15/2022] Open
Abstract
Recent technological advances have facilitated and diversified the options available for the diagnosis of cardiac arrhythmias. Ranging from simple resting or exercise electrocardiograms to more sophisticated and expensive smartphones and implantable cardiac monitors. These tests and devices may be used for varying periods of time depending on symptom frequency. The choice of the most appropriate heart rhythm test should be guided by clinical evaluation and optimized following accurate characterization of underlying symptoms, 'red flags', risk factors, and consideration of cost-effectiveness of the different tests. This review provides evidence-based guidance for assessing suspected arrhythmia in patients who present with symptoms or in the context of screening, such as atrial fibrillation or advanced conduction disturbances following transcatheter aortic valve implantation in high-risk groups. This is intended to help clinicians choose the most appropriate diagnostic tool to facilitate the management of patients with suspected arrhythmias.
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Affiliation(s)
- Mafalda Carrington
- Department of Cardiology, Hospital do Espírito Santo de Évora, Évora, Portugal
| | - Rui Providência
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Department of Cardiology, Newham University Hospital, BartsHealth NHS Trust, London, UK.,Institute of Health Informatics Research, University College London, London, UK
| | - C Anwar A Chahal
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Cardiovascular Division, University of Pennsylvania, Philadelphia, PA, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy.,Department of Cardiology, Casa di Cura Villa Serena, Città Sant'Angelo, Italy.,Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden
| | - Andrew E Epstein
- Cardiovascular Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Artur Fedorowski
- Department of Cardiology, Casa di Cura Villa Serena, Città Sant'Angelo, Italy.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden.,Department of Cardiology, Hammersmith Hospital Campus, Imperial College, London, UK
| | - Mohammed Y Khanji
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Department of Cardiology, Newham University Hospital, BartsHealth NHS Trust, London, UK.,NIHR Biomedical Research Unit, William Harvey Research Institute, Queen Mary University of London, London, UK
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19
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Carrington M, Providência R, Chahal CAA, Ricci F, Epstein AE, Gallina S, Fedorowski A, Sutton R, Khanji MY. Monitoring and diagnosis of intermittent arrhythmias: evidence-based guidance and role of novel monitoring strategies. Eur Heart J Open 2022; 2:oeac072. [PMID: 36440351 PMCID: PMC9683599 DOI: 10.1093/ehjopen/oeac072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/13/2022] [Accepted: 10/26/2022] [Indexed: 11/14/2022]
Abstract
Technological advances have made diagnosis of heart rhythm disturbances much easier, with a wide variety of options, including single-lead portable devices, smartphones/watches to sophisticated implantable cardiac monitors, allowing accurate data to be collected over different time periods depending on symptoms frequency. This review provides an overview of the novel and existing heart rhythm testing options, including a description of the supporting evidence for their use. A description of each of the tests is provided, along with discussion of their advantages and limitations. This is intended to help clinicians towards choosing the most appropriate test, thus improving diagnostic yield management of patients with suspected arrhythmias.
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Affiliation(s)
- Mafalda Carrington
- Cardiology Department, Hospital do Espírito Santo de Évora, Largo do Sr. da Pobreza, 7000-811 Évora, Portugal
| | - Rui Providência
- Barts Heart Centre, Barts Health NHS Trust, W Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
- Institute of Health Informatics Research, University College London, 222 Euston Road London, NW1 2DA, UK
| | - C Anwar A Chahal
- Barts Heart Centre, Barts Health NHS Trust, W Smithfield, London EC1A 7BE, UK
- Cardiovascular Division, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
- Department of Cardiology, Fondazione Villaserena per la Ricerca, Viale L. Petruzzi n. 42, 65013, Città S. Angelo, Italy
- Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden
| | - Andrew E Epstein
- Cardiovascular Division, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, 171 64 Solna, Stockholm, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital Campus, Imperial College, Du Cane Road, London W12 0HS, England, United Kingdom of Great Britain and Northern Ireland
| | - Mohammed Y Khanji
- Barts Heart Centre, Barts Health NHS Trust, W Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
- NIHR Biomedical Research Unit, William Harvey Research Institute, Queen Mary University of London, Mile End Road, London E1 4NS, UK
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Amankwah NA, Pothineni NVK, Guandalini G, Santangeli P, Schaller R, Supple GE, Deo R, Nazarian S, Lin D, Epstein AE, Dixit S, Callans DJ, Marchlinski FE, Frankel DS. Impact of atrial fibrillation recurrences during the blanking period following catheter ablation on long-term arrhythmia-free survival: a prospective study with continuous monitoring. J Interv Card Electrophysiol 2022; 65:519-525. [PMID: 35794440 DOI: 10.1007/s10840-022-01291-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/21/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND The significance of atrial fibrillation (AF) recurrences during the 90-day blanking period following catheter ablation is controversial. Studies to date examining the impact of AF recurrences during the blanking period have been limited by intermittent monitoring. We sought to test whether AF recurrences during the blanking period are associated with long-term recurrences using continuous monitoring. METHODS Patients undergoing AF ablation by a single operator at an academic medical center between 2015 and 2019, who either already had a cardiac implantable electronic device (CIED) with an atrial lead or received an insertable cardiac monitor (ICM), were followed for long-term AF recurrence. Recurrence was defined as > 30 s by CIED and > 2 min by ICM. All device-reported AF episodes were adjudicated by a physician. RESULTS Of 196 consecutive patients, 51 (26%) had AF recurrence in the blanking period and 145 (74%) did not. Over the year following ablation, those who had an AF recurrence in the blanking period were significantly more likely to have long-term AF recurrences than those without AF in the blanking period (log rank p < 0.001). The higher the burden of AF recurrences during the blanking period, the more likely AF was to recur long-term (hazard ratio 1.04 [CI 1.01-1.06] per 1% increase in burden, p = 0.002). CONCLUSION Using continuous monitoring of a sizable population, we confirmed that AF recurrences in the blanking period following ablation are in fact associated with long-term AF recurrences. The higher the burden of recurrence, the more likely AF is to recur long-term.
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Affiliation(s)
- Nigel Adjei Amankwah
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Naga Venkata K Pothineni
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gustavo Guandalini
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Pasquale Santangeli
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Schaller
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory E Supple
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rajat Deo
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Saman Nazarian
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David Lin
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew E Epstein
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sanjay Dixit
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David J Callans
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David S Frankel
- Cardiovascular Division, Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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21
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Alsalem A, Judy R, Zado ES, Guandalini GS, Deo R, Arkles J, Schaller RD, Santangeli P, Nazarian S, Frankel DS, Riley MP, Dixit S, Garcia FC, Epstein AE, Callans DJ, Marchlinski FE, Damrauer S, Hyman MC. HF-566-03 EMD MISSENSE VARIANTS ARE ASSOCIATED WITH A DILATED CARDIOMYOPATHY AND CONDUCTION SYSTEM DISEASE/ATL. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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22
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Markman T, Hyman MC, Deo R, Epstein AE, Frankel DS, Guandalini GS, Dixit S, Riley MP, Callans DJ, Marchlinski FE, Nazarian S. PO-698-06 NEUROMODULATION FOR THE TREATMENT OF REFRACTORY VENTRICULAR ARRHYTHMIAS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.1015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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23
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Pothineni NVK, Cherian T, Patel N, Smietana J, Frankel DS, Deo R, Epstein AE, Marchlinski FE, Schaller RD. Subcutaneous Implantable Cardioverter-defibrillator Explantation-A Single Tertiary Center Experience. J Innov Card Rhythm Manag 2022; 13:4947-4953. [PMID: 35474857 PMCID: PMC9023024 DOI: 10.19102/icrm.2022.130407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022] Open
Abstract
The subcutaneous implantable cardioverter-defibrillator (S-ICD) is an appealing alternative to transvenous ICD systems. However, data on indications for S-ICD explantations are sparse. The objective of this study was to assess the incidence and indications for S-ICD explantation at a large tertiary referral center. We conducted a retrospective study of all S-ICD explantations performed from 2014–2020. Data on demographics, comorbidities, implantation characteristics, and indications for explantation were collected. A total of 64 patients underwent S-ICD explantation during the study period. During that time, there were 410 S-ICD implantations at our institution, of which 53 (12.9%) were explanted with a mean duration from implant to explant of 19.7 ± 20.1 months. The mean age of the patients at explantation was 44.8 ± 15.3 years, and 42% (n = 27) were women. The indication for S-ICD implantation was primary prevention in 58% and secondary prevention in 42% of patients, respectively. The most common reason for explantation was infection (32.8%), followed by abnormal sensing (25%) and the need for pacing (18.8%). Those who underwent S-ICD explantation for pacing indications were significantly older (55.7 ± 13.6 vs. 42.3 ± 14.6 years, P = 0.005) with a wider QRS duration (111 ± 19 vs. 98 ± 19 ms, P = 0.03) at device implantation compared to patients who underwent explantation for other indications. The incidence of S-ICD explantation in a large tertiary practice was 12.9%. While infection was the indication for one-third of the explantations, a significant number of explantations were due to sensing abnormalities and the need for pacing. These data may have implications for patient selection for S-ICD implantation.
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Affiliation(s)
- Naga Venkata K Pothineni
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tharian Cherian
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Neel Patel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Smietana
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David S Frankel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rajat Deo
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew E Epstein
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Francis E Marchlinski
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert D Schaller
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
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24
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Markman TM, Pothineni NVK, Zghaib T, Smietana J, McBride D, Amankwah NA, Linn KA, Kumareswaran R, Hyman M, Arkles J, Santangeli P, Schaller RD, Supple GE, Frankel DS, Deo R, Lin D, Riley MP, Epstein AE, Callans DJ, Marchlinski FE, Hamilton R, Nazarian S. Effect of Transcutaneous Magnetic Stimulation in Patients With Ventricular Tachycardia Storm: A Randomized Clinical Trial. JAMA Cardiol 2022; 7:445-449. [PMID: 35171197 PMCID: PMC8851364 DOI: 10.1001/jamacardio.2021.6000] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Autonomic neuromodulation provides therapeutic benefit in ventricular tachycardia (VT) storm. Transcutaneous magnetic stimulation (TcMS) can noninvasively and nondestructively modulate a patient's nervous system activity and may reduce VT burden in patients with VT storm. OBJECTIVE To evaluate the safety and efficacy of TcMS of the left stellate ganglion for patients with VT storm. DESIGN, SETTING, AND PARTICIPANTS This double-blind, sham-controlled randomized clinical trial took place at a single tertiary referral center between August 2019 and July 2021. The study included 26 adult patients with 3 or more episodes of VT in 24 hours. INTERVENTIONS Patients were randomly assigned to receive a single session of either TcMS that targeted the left stellate ganglion (n = 14) or sham stimulation (n = 12). MAIN OUTCOMES AND MEASURES The primary outcome was freedom from VT in the 24-hour period following randomization. Key secondary outcomes included safety of TcMS on cardiac implantable electronic devices, as well as burden of VT in the 72-hour period following randomization. RESULTS Among 26 patients (mean [SD] age, 64 [13] years; 20 [77%] male), a mean (SD) of 12.7 (10.3) episodes of VT occurred within the 24 hours preceding randomization. Patients had recurrent VT despite taking a mean (SD) of 2.0 (0.6) antiarrhythmic drugs (AADs), and 11 patients (42%) required mechanical hemodynamic support at the time of randomization. In the 24-hour period after randomization, VT recurred in 4 of 14 patients (29% [SD 47%]) in the TcMS group vs 7 of 12 patients (58% [SD 51%]) in the sham group (P = .20). In the 72-hour period after randomization, patients in the TcMS group had a mean (SD) of 4.5 (7.2) episodes of VT vs 10.7 (13.8) in the sham group (incidence rate ratio, 0.42; P < .001). Patients in the TcMS group were taking fewer AADs 24 hours after randomization compared with baseline (mean [SD], 0.9 [0.8] vs 1.8 [0.4]; P = .001), whereas there was no difference in the number of AADs taken for the sham group (mean [SD], 2.3 [0.8] vs 1.9 [0.5]; P = .20). None of the 7 patients in the TcMS group with a cardiac implantable electronic device had clinically significant effects on device function. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, findings support the potential for TcMS to safely reduce the burden of VT in the setting of VT storm in patients with and without cardiac implantable electronic devices and inform the design of future trials to further investigate this novel treatment approach. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04043312.
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Affiliation(s)
- Timothy M. Markman
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia,Penn Brain Science, Translation, Innovation, and Modulation Center, University of Pennsylvania, Philadelphia
| | - Naga Venkata K. Pothineni
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Tarek Zghaib
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Jeffrey Smietana
- Division of Cardiology, Temple University, Temple University Hospital, Philadelphia, Pennsylvania
| | - Daniel McBride
- Division of Cardiology, University of Michigan, Ann Arbor
| | - Nigel A. Amankwah
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Kristin A. Linn
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - Ramanan Kumareswaran
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Matthew Hyman
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Jeffrey Arkles
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Pasquale Santangeli
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Robert D. Schaller
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Gregory E. Supple
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - David S. Frankel
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Rajat Deo
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - David Lin
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Michael P. Riley
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Andrew E. Epstein
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia,Cardiology Division, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - David J. Callans
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Francis E. Marchlinski
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Roy Hamilton
- Penn Brain Science, Translation, Innovation, and Modulation Center, University of Pennsylvania, Philadelphia,Department of Neurology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Saman Nazarian
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
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25
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Daw JM, Chahal CAA, Arkles JS, Callans DJ, Dixit S, Epstein AE, Frankel DS, Garcia FC, Hyman MC, Kumareswaran R, Lin D, Nazarian S, Riley MP, Santangeli P, Schaller RD, Supple GE, Tschabrunn C, Marchlinski FE, Deo R. Longitudinal Electrocardiographic Assessment in the Brugada Syndrome. Heart Rhythm O2 2022; 3:233-240. [PMID: 35734292 PMCID: PMC9207730 DOI: 10.1016/j.hroo.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The type 1 electrocardiographic (ECG) pattern diagnostic of Brugada syndrome (BrS) can be dynamic. Limited studies have rigorously evaluated the temporal stability of the Brugada ECG pattern. Objective We sought to evaluate fluctuations of the Brugada pattern in serial resting ECGs from BrS patients managed within a large health care system. Methods In our cohort of BrS patients with at least 2 standard, resting ECGs recorded on separate clinical encounters, we evaluated serial changes in the Brugada pattern and categorized patients into 1 of 3 groups: dynamic was defined as the presence of both type 1 and non–type 1 patterns in available ECGs; the provoked-only group was defined as having a non–type 1 Brugada pattern across resting ECGs; and the persistent group was defined as having a type 1 pattern on all ECGs. We also evaluated the clinical risk in this cohort according to the Shanghai risk score. Results In 72 patients with BrS (mean age 46 ± 15 years, 69% male), 828 standard, resting ECGs were recorded over a median duration of 30.2 (interquartile range 6.3–68.1) months. The dynamic group comprised 50 (69% of the cohort) patients, the provoked-only group consisted of 17 patients (24% of the cohort), and the persistent group included 5 patients. No significant differences were detected in the total number of ECGs evaluated during the follow-up period between any of the groups. Only sinus node dysfunction and a prior cardiac arrest were associated with the persistent type 1 group. The majority of patients had a low annualized risk of lethal arrhythmic events. Conclusion Most BrS patients have a dynamic Brugada pattern noted on longitudinal, resting ECGs. Expert consensus statements should provide clarity on the frequency of obtaining resting ECGs in patients suspected of having BrS during follow-up.
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26
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Steinberg JS, Gorcsan J, Mazur A, Jain SK, Rashtian M, Greer GS, Zarraga I, Vloka M, Cook MM, Salam T, Mountantonakis S, Beck H, Silver J, Aktas M, Henrikson C, Schaller RD, Epstein AE, McNitt S, Schleede S, Peterson D, Goldenberg I, Zareba W. Junctional AV ablation in patients with atrial fibrillation undergoing cardiac resynchronization therapy (JAVA-CRT): results of a multicenter randomized clinical trial pilot program. J Interv Card Electrophysiol 2022; 64:519-530. [PMID: 35043250 PMCID: PMC8765764 DOI: 10.1007/s10840-021-01116-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022]
Abstract
Introduction Cardiac resynchronization therapy (CRT) improves outcomes in sinus rhythm, but the data in atrial fibrillation (AF) is limited. Atrio-ventricular junctional ablation (AVJA) has been proposed as a remedy. The objective was to test if AVJA results in LV end-systolic volume (ESV) reduction ≥ 15% from baseline to 6 months. Methods The trial was a prospective multicenter randomized trial in 26 patients with permanent AF who were randomized 1:1 to CRT-D with or without AVJA. Results LVESV improved similarly by at least 15% in 5/10 (50%) in the CRT-D-only arm and in 6/12 (50%) in the AVJA + CRT-D arm (OR = 1.00 [0.14, 7.21], p = 1.00). In the CRT-D-only arm, the median 6-month improvement in LVEF was 9.2%, not different from the AVJA + CRT-D arm, 8.2%. When both groups were combined, a significant increase in LVEF was observed (25.4% at baseline vs 36.2% at 6 months, p = 0.002). NYHA class from baseline to 6 months for all patients combined improved 1 class in 15 of 24 (62.5%), whereas 9 remained in the same class and 0 degraded to a worse class. Conclusion In patients with permanent AF, reduced LVEF, and broad QRS who were eligible for CRT, there was insufficient evidence that AVJA improved echocardiographic or clinical outcomes; the results should be interpreted in light of a smaller than planned sample size. CRT, however, seemed to be effective in the combined study cohort overall, suggesting that CRT can be reasonably deployed in patients with AF. Trial registration ClinicalTrials.gov Identifier: NCT02946853.
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Affiliation(s)
- Jonathan S Steinberg
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA. .,Summit Medical Group, 85 Woodland Road, Short Hills, NJ, 07078, USA.
| | - John Gorcsan
- Penn State University College of Medicine, Hershey, PA, USA
| | - Alexander Mazur
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sandeep K Jain
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | - Margot Vloka
- Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | | | - Tariq Salam
- Multicare Institute for Research and Innovation, Tacoma, WA, USA
| | | | - Hiroko Beck
- SUNY Buffalo Medical Center, Buffalo, NY, USA
| | | | - Mehmet Aktas
- University of Rochester Medical Center, Rochester, NY, USA
| | | | | | - Andrew E Epstein
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott McNitt
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Susan Schleede
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Derick Peterson
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, USA
| | - Ilan Goldenberg
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Wojciech Zareba
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
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27
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Cairns JA, Healey JS, Epstein AE, Themeles E, Balasubramanian K, Connolly SJ. Prospective long-term follow-up of silicone-polyurethane–insulated implantable cardioverter-defibrillator leads. Heart Rhythm O2 2021; 3:57-64. [PMID: 35243436 PMCID: PMC8859782 DOI: 10.1016/j.hroo.2021.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Objective Methods Results Conclusion
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Affiliation(s)
- John A. Cairns
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Address reprint requests and correspondence: Dr John A. Cairns, UBC Division of Cardiology, Rm 9113, GLD Health Care Centre, 2775 Laurel St, Vancouver, BC V5Z 1M9 Canada.
| | - Jeff S. Healey
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
| | - Andrew E. Epstein
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ellison Themeles
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
| | - Kumar Balasubramanian
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
| | - Stuart J. Connolly
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
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28
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Markman TM, Brown CR, Yang L, Guandalini GS, Hyman MC, Arkles JS, Santangeli P, Schaller RD, Supple GE, Deo R, Nazarian S, Dixit S, Callans DJ, Epstein AE, Marchlinski FE, Groeneveld PW, Frankel DS. Persistent Opioid Use After Cardiac Implantable Electronic Device Procedures. Circulation 2021; 144:1590-1597. [PMID: 34780252 DOI: 10.1161/circulationaha.121.055524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prescription opioids are a major contributor to the ongoing epidemic of persistent opioid use (POU). The incidence of POU among opioid-naïve patients after cardiac implantable electronic device (CIED) procedures is unknown. METHODS This retrospective cohort study used data from a national administrative claims database from 2004 to 2018 of patients undergoing CIED procedures. Adult patients were included if they were opioid-naïve during the 180-day period before the procedure and did not undergo another procedure with anesthesia in the next 180 days. POU was defined by filling an additional opioid prescription >30 days after the CIED procedure. RESULTS Of the 143 400 patients who met the inclusion criteria, 15 316 (11%) filled an opioid prescription within 14 days of surgery. Among these patients, POU occurred in 1901 (12.4%) patients 30 to 180 days after surgery. The likelihood of developing POU was increased for patients who had a history of drug abuse (odds ratio, 1.52; P=0.005), preoperative muscle relaxant (odds ratio, 1.52; P<0.001) or benzodiazepine (odds ratio, 1.23; P=0.001) use, or opioid use in the previous 5 years (OR, 1.76; P<0.0001). POU did not differ after subcutaneous implantable cardioverter defibrillator or other CIED procedures (11.1 versus 12.4%; P=0.5). In a sensitivity analysis excluding high-risk patients who were discharged to a facility or who had a history of drug abuse or previous opioid, benzodiazepine, or muscle relaxant use, 8.9% of the remaining cohort had POU. Patients prescribed >135 mg of oral morphine equivalents had a significantly increased risk of POU. CONCLUSIONS POU is common after CIED procedures, and 12% of patients continued to use opioids >30 days after surgery. Higher initially prescribed oral morphine equivalent doses were associated with developing POU.
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Affiliation(s)
- Timothy M Markman
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Chase R Brown
- Division of Cardiovascular Surgery (C.R.B.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Lin Yang
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia (L.Y., P.W.G., D.S.F.)
| | - Gustavo S Guandalini
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Matthew C Hyman
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeffrey S Arkles
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Pasquale Santangeli
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert D Schaller
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Gregory E Supple
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rajat Deo
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia (R.D., S.D., A.E.E., P.W.G.)
| | - Saman Nazarian
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Sanjay Dixit
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia (R.D., S.D., A.E.E., P.W.G.)
| | - David J Callans
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Andrew E Epstein
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia (R.D., S.D., A.E.E., P.W.G.)
| | - Francis E Marchlinski
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Peter W Groeneveld
- Division of General Internal Medicine (P.W.G.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia (L.Y., P.W.G., D.S.F.).,Corporal Michael J. Crescenz VA Medical Center, Philadelphia (R.D., S.D., A.E.E., P.W.G.)
| | - David S Frankel
- Cardiovascular Division (T.M.M., G.S.G., M.C.H., J.S.A., P.S., R.D.S., G.E.S., R.D., S.N., S.D., D.J.C., A.E.E., F.E.M., D.S.F.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia (L.Y., P.W.G., D.S.F.)
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Schaller RD, Giri J, Epstein AE. Entrapped Leads After Transcatheter Tricuspid Valve Replacement. JACC Cardiovasc Interv 2021; 14:715-716. [PMID: 33736785 DOI: 10.1016/j.jcin.2021.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/19/2021] [Indexed: 10/21/2022]
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Peng G, Lin AN, Obeng-Gyimah E, Hall SN, Yang YW, Chen S, Riley M, Deo R, Ali A, Arkles J, Epstein AE, Dixit S. Implantable loop recorder for augmenting detection of new-onset atrial fibrillation after typical atrial flutter ablation. Heart Rhythm O2 2021; 2:255-261. [PMID: 34337576 PMCID: PMC8322804 DOI: 10.1016/j.hroo.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Patients with typical atrial flutter (AFL) undergoing successful cavotricuspid isthmus ablation remain at risk for future development of new-onset atrial fibrillation (AF). Conventional monitoring (CM) techniques have shown AF incidence rates of 18%–50% in these patients. Objectives To evaluate whether continuous monitoring using implantable loop recorders (ILRs) would enhance AF detection in this patient population. Methods Veteran patients undergoing AFL ablation between 2002 and 2019 who completed at least 6 months of follow-up after the ablation procedure were included. We compared new-onset AF detection between those who underwent CM and those who received ILRs immediately following AFL ablation. Results A total of 217 patients (age: 66 ± 9 years; all male) participated. CM was used in 172 (79%) and ILR in 45 (21%) patients. Median follow-up duration after ablation was 4.1 years. Seventy-nine patients (36%) developed new-onset AF, which was detected by CM in 51 and ILR in 28 (30% vs 62%, respectively, P < .001). AF detection occurred at 7.7 months (IQR: 4.7–17.5) after AFL ablation in the ILR group vs 41 months (IQR: 23–72) in the CM group (P < .001). Eleven patients (5%) experienced cerebrovascular events (all in the CM group) and only 4 of these patients (36%) were on long-term anticoagulation. Conclusion Patients undergoing AFL ablation remain at an increased risk of developing new-onset AF, which is detected sooner and more frequently by ILR than by CM. Improving AF detection may allow optimization of rhythm management strategies and anticoagulation in this patient population.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Sanjay Dixit
- Address reprint requests and correspondence: Dr Sanjay Dixit, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce St, Philadelphia, PA 19104.
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Guandalini GS, Riley MP, Supple GE, Hyman MC, Lin D, Walsh K, Kumareswaran R, Arkles J, Santangeli P, Schaller RD, Deo R, Frankel DS, Nazarian S, Tschabrunn CM, Garcia FC, Dixit S, Epstein AE, Callans DJ, Marchlinski FE. B-PO03-216 VENTRICULAR TACHYCARDIA SECONDARY TO CORONARY VASOSPASM: A CASE SERIES. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Chee J, Lin AN, Julien H, Epstein AE, Callans DJ, Riley MP, Santangeli P, Nazarian S, Garcia FC, Lin D, Schaller RD, Frankel DS, Supple GE, Deo R, Arkles J, Kumareswaran R, Hyman MC, Walsh K, Guandalini GS, Zado ES, Marchlinski FE, Sanjay Dixit. B-PO04-125 IMPACT OF LEFT VENTRICULAR PAPILLARY MUSCLE VENTRICULAR ARRHYTHMIA ABLATION ON MITRAL VALVE FUNCTION. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lin AN, Peng G, Pothineni NK, Winn SP, Hall SN, Deo R, Riley M, Epstein AE, Arkles J, Dixit S. Race Does Not Provide Protection From New-Onset Atrial Fibrillation After Typical Flutter Ablation in Male Veteran Patients. JACC Clin Electrophysiol 2021; 7:1312-1314. [PMID: 34332878 DOI: 10.1016/j.jacep.2021.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/26/2021] [Accepted: 05/29/2021] [Indexed: 11/25/2022]
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Varma N, Love CJ, Michalski J, Epstein AE. Alert-Based ICD Follow-Up: A Model of Digitally Driven Remote Patient Monitoring. JACC Clin Electrophysiol 2021; 7:976-987. [PMID: 33640345 DOI: 10.1016/j.jacep.2021.01.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/04/2021] [Accepted: 01/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The goal of this study was to test whether continuous automatic remote patient monitoring (RPM) linked to centralized analytics reduces nonactionable in-person patient evaluation (IPE) but maintains detection of at-risk patients and provides actionable notifications. BACKGROUND Conventional ambulatory care requires frequent IPEs. Many encounters are nonactionable, and additional unscheduled IPEs occur. METHODS Patients receiving implantable cardioverter-defibrillators for Class I/IIa indications were randomized (2:1) to RPM or conventional follow-up, and they were followed up for 15 months. IPEs were conducted every 3 months in the conventional care group but at 3 and 15 months with RPM. Groups were compared for patient retention, nonactionable IPEs, and discovery of at-risk patients during 1 year of exclusive RPM. Frequency and value of RPM alerts were assessed. RESULTS Patients enrolled (mean age 63.5 ± 12.8 years; male 71.9%; left ventricular ejection fraction 29.0 ± 10.7%; primary prevention 72.3%; n = 1450) were similar between groups (977 RPM vs. 473 conventional care). Mean follow-up durations were 407 ± 103 days for the RPM group versus 399 ± 111 days for the conventional care group (p = 0.165). Patient attrition to follow-up was 42% greater with conventional care (20.1% [87 of 431]) versus RPM (14.2% [129 of 908]; p = 0.007). Nonactionable IPEs were reduced 81% by RPM (0.7 per patient year) compared with conventional care (3.6 per patient year; p < 0.001) but event discoveries remained similar (2.9 per patient year). In RPM, alert rate was median 1 per patient (interquartile range: 0 to 3) with >50% actionability, indicating low volume but high clinical value. Unscheduled IPE was the basis for discovery of 100% of intercurrent problems in RPM and also 75% in conventional care, indicating limited value of appointment-based follow-up for problem discovery. The number of IPEs needed to discover an actionable event was 8.2 in Conventional, 4.9 in RPM, and 2.1 when alert driven (p < 0.001). CONCLUSIONS RPM transformed ambulatory care to IPE directed to those patients with clinically actionable events when required. Filtering patient information by digitally driven remote monitoring expends fewer clinic resources while providing a greater yield of actionable interventions. (Lumos-T Safely Reduces Routine Office Device Follow-up [TRUST]; NCT00336284).
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Affiliation(s)
- Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Charles J Love
- Department of Cardiology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Andrew E Epstein
- Department of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Bhatla A, Borovskiy Y, Katz R, Hyman MC, Patel PJ, Arkles J, Callans DJ, Chokshi N, Dixit S, Epstein AE, Frankel DS, Garcia FC, Kumareswaran R, Liang JJ, Lin D, Messé SR, Nazarian S, Riley MP, Santangeli P, Schaller RD, Supple GE, Kasner SE, Marchlinski F, Deo R. Stroke, Timing of Atrial Fibrillation Diagnosis, and Risk of Death. Neurology 2021; 96:e1655-e1662. [PMID: 33536273 DOI: 10.1212/wnl.0000000000011633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/18/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the prognosis of patients with ischemic stroke according to the timing of an atrial fibrillation (AF) diagnosis, we created an inception cohort of incident stroke events and compared the risk of death between patients with stroke with (1) sinus rhythm, (2) known AF (KAF), and (3) AF diagnosed after stroke (AFDAS). METHODS We used the Penn AF Free study to create an inception cohort of patients with incident stroke. Mortality events were identified after linkage with the National Death Index through June 30, 2017. We also evaluated initiation of anticoagulants and antiplatelets across the study duration. Cox proportional hazards models evaluated associations between stroke subtypes and death. RESULTS We identified 1,489 individuals who developed an incident ischemic stroke event: 985 did not develop AF at any point during the study period, 215 had KAF before stroke, 160 had AF detected ≤6 months after stroke, and 129 had AF detected >6 months after stroke. After a median follow-up of 4.9 years (interquartile range 1.9-6.8), 686 deaths occurred. The annualized mortality rate was 8.8% in the stroke, no AF group; 12.2% in the KAF group; 15.8% in the AFDAS ≤6 months group; and 12.7% in the AFDAS >6 months group. Patients in the AFDAS ≤6 months group had the highest independent risk of all-cause mortality even after multivariable adjustment for demographics, clinical risk factors, and the use of antithrombotic therapies (hazard ratio 1.62 [1.22-2.14]). Compared to the stroke, no AF group, those with KAF had a higher mortality risk that was rendered nonsignificant after adjustment. CONCLUSIONS The AFDAS group had the highest risk of death, which was not explained by comorbidities or use of antithrombotic therapies.
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Affiliation(s)
- Anjali Bhatla
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Yuliya Borovskiy
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Ronit Katz
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Matthew C Hyman
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Parin J Patel
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Jeffrey Arkles
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - David J Callans
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Neel Chokshi
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Sanjay Dixit
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Andrew E Epstein
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - David S Frankel
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Fermin C Garcia
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Ramanan Kumareswaran
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Jackson J Liang
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - David Lin
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Steven R Messé
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Saman Nazarian
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Michael P Riley
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Pasquale Santangeli
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Robert D Schaller
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Gregory E Supple
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Scott E Kasner
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Francis Marchlinski
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN
| | - Rajat Deo
- From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN.
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Pothineni NVK, Bonilla CA, Ebrahim MA, Epstein AE, Garcia-Fernandez FJ, Guzman CE, Joshi H, Nasir JM, Singh A, Supple GE, Schaller RD. Chronic Swelling Over Cardiac Implantable Electronic Device Sites: A Multicenter Case Series. Circ Arrhythm Electrophysiol 2020; 13:e009253. [PMID: 33320698 DOI: 10.1161/circep.120.009253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Naga Venkata K Pothineni
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia (N.V.K.P., A.E.E., G.E.S., R.D.S.)
| | - Cesar A Bonilla
- Cardiac Electrophysiology, AdventHealth Medical Group, Orlando, FL (C.A.B.)
| | - Mohammad A Ebrahim
- Pediatric Department, Kuwait University, Chest Diseases Hospital, Kuwait (M.A.E.)
| | - Andrew E Epstein
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia (N.V.K.P., A.E.E., G.E.S., R.D.S.)
| | - F Javier Garcia-Fernandez
- Section of Cardiac Electrophysiology, Department of Cardiology, Hospital Universitario de Burgos, Spain (F.J.G.-F.)
| | - Carlos E Guzman
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia (N.V.K.P., A.E.E., G.E.S., R.D.S.).,Hospital Christus Muguerza Alta Especialidad, Monterrey, Mexico (C.E.G.)
| | - Hari Joshi
- Cardiac Electrophysiology, Lehigh Valley Heart Institute, Bethlehem, PA (H.J.)
| | | | | | | | - Robert D Schaller
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia (N.V.K.P., A.E.E., G.E.S., R.D.S.)
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Mariani MV, Pothineni NVK, Arkles J, Deo R, Frankel D, Supple G, Garcia F, Lin D, Hyman MC, Kumareswaran R, Riley M, Nazarian S, Schaller RD, Epstein AE, Bermudez C, Dixit S, Callans D, Marchlinski FE, Santangeli P. Catheter ablation of atrial arrhythmias following lung transplant: Electrophysiological findings and outcomes. J Cardiovasc Electrophysiol 2020; 32:49-57. [PMID: 33205513 DOI: 10.1111/jce.14816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/20/2020] [Accepted: 10/19/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Data on the mechanisms of atrial arrhythmias (AAs) and outcomes of catheter ablation (CA) in lung transplantation (LT) patients are insufficient. We evaluated the electrophysiologic features and outcomes of CA of AAs in LT patients. METHODS AND RESULTS: We conducted a retrospective study of all the LT patients who underwent CA for AAs at our institution between 2004 and 2019. A total of 15 patients (43% males, age: 61 ± 10 years) with a history of LT (60% bilateral and 40% unilateral) were identified. All patients had documented organized AA on surface electrocardiogram and seven patients also had atrial fibrillation (AF; 47% with >1 clinical arrhythmia). At electrophysiological study, 19 organized AAs were documented (48% focal and 52% macro-re-entrant). Focal atrial tachycardias/flutters were targeted along the pulmonary vein (PV) anastomotic site at the left inferior PV (n = 2), ridge and carina of the left superior PV (n = 2), left atrium (LA) posterior wall (n = 3), LA roof (n = 1), and tricuspid annulus (n = 1). Macro-re-entrant AAs included cavotricuspid isthmus-dependent flutter (n = 2), incisional LA flutter (n = 4), LA roof-dependent flutter (n = 1), and mitral annular flutter (n = 3). In patients with LA mapping (n = 13), PV reconnection on the side of the LT was found in six patients (40%, all with clinically documented AF), with a mean of 2.1 ± 0.9 PVs reconnected per patient. Patients with AF underwent successful PV isolation. After a median follow-up of 19 months (range: 6-86 months), 75% of patients remained free from recurrent AAs. No procedural major complications occurred. CONCLUSION In patients with prior LT, recurrent AAs are typically associated with substrate surrounding the surgical anastomotic lines and/or chronically reconnected PVs. CA of AAs in this population is safe and effective to achieve long-term arrhythmia control.
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Affiliation(s)
- Marco V Mariani
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Naga Venkata K Pothineni
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rajat Deo
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Frankel
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory Supple
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin Garcia
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramanan Kumareswaran
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Riley
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian Bermudez
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Callans
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Lilly SM, Deshmukh AJ, Epstein AE, Ricciardi MJ, Shreenivas S, Velagapudi P, Wyman JF. 2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2020; 76:2391-2411. [DOI: 10.1016/j.jacc.2020.08.050] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Markman TM, Kuo L, Mustin E, Amankwah NA, Supple GE, Dixit S, Nazarian S, Arkles J, Hyman M, Lin D, Epstein AE, Santangeli P, Deo R, Schaller RD, Frankel DS. Time Course and Predictors of Worsening Tricuspid Regurgitation Following Right Ventricular Lead Implantation. Circ Arrhythm Electrophysiol 2020; 13:e009177. [PMID: 33035081 DOI: 10.1161/circep.120.009177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Timothy M Markman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Ling Kuo
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Evan Mustin
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Nigel A Amankwah
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Gregory E Supple
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Sanjay Dixit
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Saman Nazarian
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeffery Arkles
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Matthew Hyman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - David Lin
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Andrew E Epstein
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Pasquale Santangeli
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rajat Deo
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert D Schaller
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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40
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Walsh KA, Supple GE, Garcia FC, Frankel DS, Lin D, Kumareswaran R, Hyman M, Arkles JS, Deo R, Riley MP, Schaller RD, Nazarian S, Santangeli P, Dixit S, Epstein AE, Callans DJ, Marchlinski FE. Ablation of Ventricular Arrhythmias From the Left Ventricular Apex in Patients Without Ischemic Heart Disease. JACC Clin Electrophysiol 2020; 6:1089-1102. [PMID: 32972543 DOI: 10.1016/j.jacep.2020.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/19/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This study aimed to characterize the incidence, clinical characteristics, and electrocardiographic and electrophysiologic features of LVA VA in the absence of CAD and to describe the experience with catheter ablation (CA) in this group. BACKGROUND The left ventricular apex (LVA) is a well-described source of ventricular arrhythmias (VAs) in patients with coronary artery disease (CAD) and history of apical infarction but is a rare source of VA in the absence of CAD. METHODS Patients referred for CA of VA at our institution were retrospectively reviewed, and those with LVA VA in the absence of CAD were identified. RESULTS Of 3,710 consecutive patients undergoing VA ablation, CA of LVA VA was performed in 24 patients (20 with monomorphic ventricular tachycardia, 4 with premature ventricular contractions or nonsustained ventricular tachycardia; 18 men; mean age: 54 ± 15 years). These cases comprised 10 of 35 (29%) hypertrophic cardiomyopathy, 9 of 789 (1.2%) nonischemic cardiomyopathy, and 5 of 1,432 (0.4%) idiopathic VA ablation procedures. VA QRS morphology was predominantly right bundle with slurred upstroke and right superior frontal plane axis with precordial transition ≤V3. Epicardial ablation was performed in 14 of 24 (58%). After a median of 1 procedure (range 1 to 4) at this institution and median follow-up of 47 months (range 0-176), VA recurred in 1 patient (4%). CONCLUSIONS LVA VA in the absence of CAD is unusual and may occur in patients with hypertrophic cardiomyopathy or nonischemic cardiomyopathy or, rarely, in the absence of structural heart disease. It can be recognized by characteristic ECG features. CA of LVA VA is challenging; multiple procedures, including epicardial approaches, may be required to achieve VA control over long-term follow-up.
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Affiliation(s)
- Katie A Walsh
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Gregory E Supple
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin C Garcia
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramanan Kumareswaran
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew Hyman
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Arkles
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rajat Deo
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Bhatla A, Mayer MM, Adusumalli S, Hyman MC, Oh E, Tierney A, Moss J, Chahal AA, Anesi G, Denduluri S, Domenico CM, Arkles J, Abella BS, Bullinga JR, Callans DJ, Dixit S, Epstein AE, Frankel DS, Garcia FC, Kumareswaram R, Nazarian S, Riley MP, Santangeli P, Schaller RD, Supple GE, Lin D, Marchlinski F, Deo R. COVID-19 and cardiac arrhythmias. Heart Rhythm 2020; 17:1439-1444. [PMID: 32585191 PMCID: PMC7307518 DOI: 10.1016/j.hrthm.2020.06.016] [Citation(s) in RCA: 265] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early studies suggest that coronavirus disease 2019 (COVID-19) is associated with a high incidence of cardiac arrhythmias. Severe acute respiratory syndrome coronavirus 2 infection may cause injury to cardiac myocytes and increase arrhythmia risk. OBJECTIVES The purpose of this study was to evaluate the risk of cardiac arrest and arrhythmias including incident atrial fibrillation (AF), bradyarrhythmias, and nonsustained ventricular tachycardia (NSVT) in a large urban population hospitalized for COVID-19. We also evaluated correlations between the presence of these arrhythmias and mortality. METHODS We reviewed the characteristics of all patients with COVID-19 admitted to our center over a 9-week period. Throughout hospitalization, we evaluated the incidence of cardiac arrests, arrhythmias, and inpatient mortality. We also used logistic regression to evaluate age, sex, race, body mass index, prevalent cardiovascular disease, diabetes, hypertension, chronic kidney disease, and intensive care unit (ICU) status as potential risk factors for each arrhythmia. RESULTS Among 700 patients (mean age 50 ± 18 years; 45% men; 71% African American; 11% received ICU care), there were 9 cardiac arrests, 25 incident AF events, 9 clinically significant bradyarrhythmias, and 10 NSVTs. All cardiac arrests occurred in patients admitted to the ICU. In addition, admission to the ICU was associated with incident AF (odds ratio [OR] 4.68; 95% confidence interval [CI] 1.66-13.18) and NSVT (OR 8.92; 95% CI 1.73-46.06) after multivariable adjustment. Also, age and incident AF (OR 1.05; 95% CI 1.02-1.09) and prevalent heart failure and bradyarrhythmias (OR 9.75; 95% CI 1.95-48.65) were independently associated. Only cardiac arrests were associated with acute in-hospital mortality. CONCLUSION Cardiac arrests and arrhythmias are likely the consequence of systemic illness and not solely the direct effects of COVID-19 infection.
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Affiliation(s)
- Anjali Bhatla
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael M Mayer
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Srinath Adusumalli
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C Hyman
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric Oh
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann Tierney
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Juwann Moss
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anwar A Chahal
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - George Anesi
- Division of Pulmonary and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Srinivas Denduluri
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher M Domenico
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey Arkles
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin S Abella
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John R Bullinga
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew E Epstein
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramanan Kumareswaram
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Riley
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D Schaller
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis Marchlinski
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajat Deo
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Saxon LA, Varma N, Epstein LM, Ganz LI, Epstein AE. Rates of Adoption and Outcomes After Firmware Updates for Food and Drug Administration Cybersecurity Safety Advisories. Circ Arrhythm Electrophysiol 2020; 13:e008364. [DOI: 10.1161/circep.120.008364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Leslie A. Saxon
- Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles (L.A.S.)
| | - Niraj Varma
- Department of Medicine, Cleveland Clinic, OH (N.V.)
| | | | | | - Andrew E. Epstein
- Department of Medicine, University of Pennsylvania, Philadelphia (A.E.E.)
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Schaller RD, Epstein AE. Debulking Infection: Do What's Right, Save What's Left. JACC Clin Electrophysiol 2020; 6:681-683. [PMID: 32553218 DOI: 10.1016/j.jacep.2020.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Robert D Schaller
- Electrophysiology Section, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Electrophysiology Section, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Healey JS, Gladstone DJ, Swaminathan B, Eckstein J, Mundl H, Epstein AE, Haeusler KG, Mikulik R, Kasner SE, Toni D, Arauz A, Ntaios G, Hankey GJ, Perera K, Pagola J, Shuaib A, Lutsep H, Yang X, Uchiyama S, Endres M, Coutts SB, Karlinski M, Czlonkowska A, Molina CA, Santo G, Berkowitz SD, Hart RG, Connolly SJ. Recurrent Stroke With Rivaroxaban Compared With Aspirin According to Predictors of Atrial Fibrillation: Secondary Analysis of the NAVIGATE ESUS Randomized Clinical Trial. JAMA Neurol 2020; 76:764-773. [PMID: 30958508 DOI: 10.1001/jamaneurol.2019.0617] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance The NAVIGATE ESUS randomized clinical trial found that 15 mg of rivaroxaban per day does not reduce stroke compared with aspirin in patients with embolic stroke of undetermined source (ESUS); however, it substantially reduces stroke risk in patients with atrial fibrillation (AF). Objective To analyze whether rivaroxaban is associated with a reduction of recurrent stroke among patients with ESUS who have an increased risk of AF. Design, Setting, and Participants Participants were stratified by predictors of AF, including left atrial diameter, frequency of premature atrial contractions, and HAVOC score, a validated scheme using clinical features. Treatment interactions with these predictors were assessed. Participants were enrolled between December 2014 and September 2017, and analysis began March 2018. Intervention Rivaroxaban treatment vs aspirin. Main Outcomes and Measures Risk of ischemic stroke. Results Among 7112 patients with a mean (SD) age of 67 (9.8) years, the mean (SD) HAVOC score was 2.6 (1.8), the mean (SD) left atrial diameter was 3.8 (1.4) cm (n = 4022), and the median (interquartile range) daily frequency of premature atrial contractions was 48 (13-222). Detection of AF during follow-up increased for each tertile of HAVOC score: 2.3% (score, 0-2), 3.0% (score, 3), and 5.8% (score, >3); however, neither tertiles of the HAVOC score nor premature atrial contractions frequency impacted the association of rivaroxaban with recurrent ischemic stroke (P for interaction = .67 and .96, respectively). Atrial fibrillation annual incidence increased for each tertile of left atrial diameter (2.0%, 3.6%, and 5.2%) and for each tertile of premature atrial contractions frequency (1.3%, 2.9%, and 7.0%). Among the predefined subgroup of patients with a left atrial diameter of more than 4.6 cm (9% of overall population), the risk of ischemic stroke was lower among the rivaroxaban group (1.7% per year) compared with the aspirin group (6.5% per year) (hazard ratio, 0.26; 95% CI, 0.07-0.94; P for interaction = .02). Conclusions and Relevance The HAVOC score, left atrial diameter, and premature atrial contraction frequency predicted subsequent clinical AF. Rivaroxaban was associated with a reduced risk of recurrent stroke among patients with ESUS and moderate or severe left atrial enlargement; however, this needs to be independently confirmed before influencing clinical practice.
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Affiliation(s)
- Jeff S Healey
- Division of Cardiology, Hamilton Health Sciences, Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David J Gladstone
- Division of Neurology and Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Balakumar Swaminathan
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jens Eckstein
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | | | - Andrew E Epstein
- Electrophysiology Section, Cardiovascular Division University of Pennsylvania, Cardiology Section, Philadelphia VA Medical Center, Philadelphia
| | | | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St. Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Danilo Toni
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia, Mexico D.F., Mexico City, Mexico
| | - George Ntaios
- Department of Medicine, University of Thesally, Larissa, Greece
| | - Graeme J Hankey
- UWA Medical School, University of Western Australia, Sir Charles Gairdner Hospital, Perth, Australia
| | - Kanjana Perera
- McMaster University/Population Health Research Institute, Department of Medicine (Neurology), Hamilton, Ontario, Canada
| | - Jorge Pagola
- Unitat d'Ictus, Servei de Neurologia, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Helmi Lutsep
- Department of Neurology, OHSU, VA Portland Health Care System, Portland, Oregon
| | - Xiaomeng Yang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shinichiro Uchiyama
- International University of Health and Welfare, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Matthias Endres
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Michal Karlinski
- Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.,Department of Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Carlos A Molina
- Department of Pharmacology, Medical University of Warsaw, Warsaw, Poland.,Vall d'Hebron Stroke Unit. Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Gustavo Santo
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Scott D Berkowitz
- Bayer US LLC, Pharmaceuticals Clinical Development Thrombosis, Whippany, New Jersey
| | - Robert G Hart
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Division of Cardiology, Hamilton Health Sciences, Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Tschabrunn CM, Pothineni NVK, Sauer WH, Doynow D, Salas J, Liao TW, Santangeli P, Arkles J, Hyman MC, Frankel DS, Supple GE, Garcia FC, Nazarian S, Dixit S, Epstein AE, Schaller RD, Callans DJ, Marchlinski FE. Evaluation of Radiofrequency Ablation Irrigation Type: In Vivo Comparison of Normal Versus Half-Normal Saline Lesion Characteristics. JACC Clin Electrophysiol 2020; 6:684-692. [PMID: 32553219 DOI: 10.1016/j.jacep.2020.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/23/2020] [Accepted: 02/20/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study investigated the impact of the type of catheter irrigant used during delivery of radiofrequency ablation. BACKGROUND The use of half-normal saline (HNS) as an irrigant has been suggested as a method for increasing ablation lesion size but has not been rigorously studied in the beating heart or the use of a low-flow irrigation catheter. METHODS Sixteen swine underwent left ventricular mapping and ablation using either normal saline (NS) (group 1: n = 9) or half-normal saline (HNS) (group 2: n = 7). All lesions were delivered using identical parameters (40 W with 10-second ramp, 30-second duration, 15 ml/min flow, and 8- to14-g target contact force). An occurrence of steam pop, catheter char, or thrombus was assessed using intracardiac echocardiography and catheter inspection following each application. Lesion depth, width, and area were measured using electronic calibers. RESULTS A total of 109 lesions were delivered in group 1 and 77 in group 2. There were significantly more steam pops in group 2 (32 of 77 [42%] vs. 24 of 109 [22%], respectively). The frequencies of catheter tip char were similar (group 1: 9 of 109 [8%] vs. group 2: 10 of 77 [13%]; p = 0.29). Lesion depths, widths, and areas also were similar in both groups. CONCLUSIONS The use of an HNS irrigant using a low-flow open irrigated ablation catheter platform results in more tissue heating due to higher radiofrequency current delivery directed to tissue, but this can lead to higher rate of steam pops. In this in vivo porcine beating-heart model, the use of HNS does not appear to significantly increase lesion size in normal myocardium despite evidence of increased radiofrequency heating.
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Affiliation(s)
- Cory M Tschabrunn
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Naga Venkata K Pothineni
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Doynow
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan Salas
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ting-Wei Liao
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin C Garcia
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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46
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Briceño DF, Santangeli P, Frankel DS, Liang JJ, Shirai Y, Markman T, Enriquez A, Walsh K, Riley MP, Nazarian S, Lin D, Kumareswaran R, Arkles JS, Hyman MC, Deo R, Supple GE, Garcia FC, Dixit S, Epstein AE, Callans DJ, Marchlinski FE, Schaller RD. QRS morphology in lead V 1 for the rapid localization of idiopathic ventricular arrhythmias originating from the left ventricular papillary muscles: A novel electrocardiographic criterion. Heart Rhythm 2020; 17:1711-1718. [PMID: 32454219 DOI: 10.1016/j.hrthm.2020.05.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/30/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Twelve-lead electrocardiogram (ECG) criteria have been developed to identify idiopathic ventricular arrhythmias (VAs) from the left ventricular (LV) papillary muscles (PAPs), but accurate localization remains a challenge. OBJECTIVE The purpose of this study was to develop ECG criteria for accurate localization of LV PAP VAs using lead V1 exclusively. METHODS Consecutive patients undergoing mapping and ablation of VAs from the LV PAPs guided by intracardiac echocardiography from 2007 to 2018 were reviewed (study group). The QRS morphology in lead V1 was compared to patients with VAs with a "right bundle branch block" morphology from other LV locations (reference group). Patients with structural heart disease were excluded. RESULTS One hundred eleven patients with LV PAP VAs (mean age 54 ± 16 years; 65% men) were identified, including 64 (55%) from the posteromedial PAP and 47 (42%) from the anterolateral PAP. The reference group included patients with VAs from the following LV locations: fascicles (n = 21), outflow tract (n = 36), ostium (n = 37), inferobasal segment (n = 12), and apex (5). PAP VAs showed 3 distinct QRS morphologies in lead V1 93% of the time: Rr (53%), R with a slurred downslope (29%), and RR (11%). Sensitivity, specificity, positive predictive value, and negative predictive value for the 3 morphologies combined are 93%, 98%, 98%, and 93%, respectively. The intrinsicoid deflection of PAP VAs in lead V1 was shorter than that of the reference group (63 ± 13 ms vs 79 ± 24 ms; P < .001). An intrinsicoid deflection time of <74 ms best differentiated the 2 groups (sensitivity 79%; specificity 87%). CONCLUSION VAs originating from the LV PAPs manifest unique QRS morphologies in lead V1, which can aid in rapid and accurate localization.
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Affiliation(s)
- David F Briceño
- Electrophysiology Section, Division of Cardiology, Albert Einstein College of Medicine, Montefiore Hospital, New York, New York
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jackson J Liang
- Division of Cardiovascular Medicine, Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, Michigan
| | - Yasuhiro Shirai
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy Markman
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andres Enriquez
- Division of Cardiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Katie Walsh
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Riley
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramanan Kumareswaran
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Arkles
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C Hyman
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajat Deo
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew E Epstein
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D Schaller
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Markman TM, Geng Z, Epstein AE, Nazarian S, Deo R, Marchlinski FE, Groeneveld PW, Frankel DS. Trends in Antiarrhythmic Drug Use Among Patients in the United States Between 2004 and 2016. Circulation 2020; 141:937-939. [DOI: 10.1161/circulationaha.119.044109] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Timothy M. Markman
- Cardiovascular Division (T.M.M., A.E.E., S.N., R.D., F.E.M., D.S.F.), Perelman School of Medicine
| | - Zhi Geng
- Division of General Internal Medicine (Z.G., P.W.G.), Perelman School of Medicine
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research (Z.G., P.W.G.), University of Pennsylvania, Philadelphia
| | - Andrew E. Epstein
- Cardiovascular Division (T.M.M., A.E.E., S.N., R.D., F.E.M., D.S.F.), Perelman School of Medicine
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (A.E.E., P.W.G.)
| | - Saman Nazarian
- Cardiovascular Division (T.M.M., A.E.E., S.N., R.D., F.E.M., D.S.F.), Perelman School of Medicine
| | - Rajat Deo
- Cardiovascular Division (T.M.M., A.E.E., S.N., R.D., F.E.M., D.S.F.), Perelman School of Medicine
| | - Francis E. Marchlinski
- Cardiovascular Division (T.M.M., A.E.E., S.N., R.D., F.E.M., D.S.F.), Perelman School of Medicine
| | - Peter W. Groeneveld
- Division of General Internal Medicine (Z.G., P.W.G.), Perelman School of Medicine
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research (Z.G., P.W.G.), University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (A.E.E., P.W.G.)
| | - David S. Frankel
- Cardiovascular Division (T.M.M., A.E.E., S.N., R.D., F.E.M., D.S.F.), Perelman School of Medicine
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Yaeger A, Keenan BT, Cash NR, Parham T, Deo R, Frankel DS, Schaller RD, Santangeli P, Nazarian S, Supple GE, Arkles J, Kumareswaran R, Hyman MC, Riley MP, Garcia FC, Lin D, Epstein AE, Callans DJ, Mora JI, Amaro A, Schwab R, Pack A, Marchlinski FE, Dixit S. Impact of a nurse-led limited risk factor modification program on arrhythmia outcomes in patients with atrial fibrillation undergoing catheter ablation. J Cardiovasc Electrophysiol 2020; 31:423-431. [PMID: 31916273 DOI: 10.1111/jce.14336] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/03/2019] [Accepted: 12/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND We have previously demonstrated the feasibility of a nurse-led risk factor modification (RFM) program for improving weight loss and obstructive sleep apnea (OSA) care among patients with atrial fibrillation (AF). OBJECTIVE We now report its impact on arrhythmia outcomes in a subgroup of patients undergoing catheter ablation. METHODS Participating patients with obesity and/or need for OSA management (high risk per Berlin Questionnaire or untreated OSA) underwent in-person consultation and monthly telephone calls with the nurse for up to 1 year. Arrhythmias were assessed by office ECGs and ≥2 wearable monitors. Outcomes, defined as Arrhythmia control (0-6 self-terminating recurrences, with ≤1 cardioversion for nonparoxysmal AF) and Freedom from arrhythmias (no recurrences on or off antiarrhythmic drugs), were compared at 1 year between patients undergoing catheter ablation who enrolled and declined RFM. RESULTS Between 1 November 2016 and 1 April 2018, 195 patients enrolled and 196 declined RFM (body mass index, 35.1 ± 6.7 vs 34.3 ± 6.3 kg/m2 ; 50% vs 50% paroxysmal AF; P = NS). At 1 year, enrolled patients demonstrated significant weight loss (4.7% ± 5.3% vs 0.3% ± 4.4% in declined patients; P < .0001) and improved OSA care (78% [n = 43] of patients diagnosed with OSA began treatment). However, outcomes were similar between enrolled and declined patients undergoing ablation (arrhythmia control in 80% [n = 48] vs 79% [n = 38]; freedom from arrhythmia in 58% [n = 35] vs 71% [n = 34]; P = NS). CONCLUSION Despite improving weight loss and OSA care, our nurse-led RFM program did not impact 1-year arrhythmia outcomes in patients with AF undergoing catheter ablation.
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Affiliation(s)
- Amaryah Yaeger
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brendan T Keenan
- Sleep Medicine Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy R Cash
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tara Parham
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajat Deo
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D Schaller
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey Arkles
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramanan Kumareswaran
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C Hyman
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Riley
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew E Epstein
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jorge I Mora
- Sleep Medicine Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anastassia Amaro
- Endocrinology Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Schwab
- Sleep Medicine Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Allan Pack
- Sleep Medicine Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
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Briceño DF, Liang JJ, Shirai Y, Markman TM, Chahal A, Tschabrunn C, Zado E, Hyman MC, Kumareswaran R, Arkles JS, Santangeli P, Schaller RD, Supple GE, Frankel DS, Deo R, Riley MP, Nazarian S, Lin D, Epstein AE, Garcia FC, Dixit S, Callans DJ, Marchlinski FE. Characterization of Structural Changes in Arrhythmogenic Right Ventricular Cardiomyopathy With Recurrent Ventricular Tachycardia After Ablation: Insights From Repeat Electroanatomic Voltage Mapping. Circ Arrhythm Electrophysiol 2020; 13:e007611. [PMID: 31922914 DOI: 10.1161/circep.119.007611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data characterizing structural changes of arrhythmogenic right ventricular (RV) cardiomyopathy are limited. METHODS Patients presenting with left bundle branch block ventricular tachycardia in the setting of arrhythmogenic RV cardiomyopathy with procedures separated by at least 9 months were included. RESULTS Nineteen consecutive patients (84% males; mean age 39±15 years [range, 20-76 years]) were included. All 19 patients underwent 2 detailed sinus rhythm electroanatomic endocardial voltage maps (average 385±177 points per map; range, 93-847 points). Time interval between the initial and repeat ablation procedures was mean 50±37 months (range, 9-162). No significant progression of voltage was observed (bipolar: 38 cm2 [interquartile range (IQR), 25-54] versus 53 cm2 [IQR, 25-65], P=0.09; unipolar: 116 cm2 [IQR, 61-209] versus 159 cm2 [IQR, 73-204], P=0.36) for the entire study group. There was a significant increase in RV volumes (percentage increase, 28%; 206 mL [IQR, 170-253] versus 263 mL [IQR, 204-294], P<0.001) for the entire study population. Larger scars at baseline but not changes over time were associated with a significant increase in RV volume (bipolar: Spearman ρ, 0.6965, P=0.006; unipolar: Spearman ρ, 0.5743, P=0.03). Most patients with progressive RV dilatation (8/14, 57%) had moderate (2 patients) or severe (6 patients) tricuspid regurgitation recorded at either initial or repeat ablation procedure. CONCLUSIONS In patients with arrhythmogenic RV cardiomyopathy presenting with recurrent ventricular tachycardia, >10% increase in RV endocardial surface area of bipolar voltage consistent with scar is uncommon during the intermediate term. Most recurrent ventricular tachycardias are localized to regions of prior defined scar. Voltage indexed scar area at baseline but not changes in scar over time is associated with progressive increase in RV size and is consistent with adverse remodeling but not scar progression. Marked tricuspid regurgitation is frequently present in patients with arrhythmogenic RV cardiomyopathy who have progressive RV dilation.
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Affiliation(s)
- David F Briceño
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Jackson J Liang
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Yasuhiro Shirai
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Timothy M Markman
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Anwar Chahal
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Cory Tschabrunn
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Erica Zado
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Mathew C Hyman
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Ramanan Kumareswaran
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Jeffery S Arkles
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Robert D Schaller
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Gregory E Supple
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David S Frankel
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Rajat Deo
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Michael P Riley
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Saman Nazarian
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David Lin
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Andrew E Epstein
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Fermin C Garcia
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Sanjay Dixit
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David J Callans
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
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Yaeger A, Cash NR, Parham T, Frankel DS, Deo R, Schaller RD, Santangeli P, Nazarian S, Supple GE, Arkles J, Riley MP, Garcia FC, Lin D, Epstein AE, Callans DJ, Marchlinski FE, Kolansky DM, Mora JI, Amaro A, Schwab R, Pack A, Dixit S. A Nurse-Led Limited Risk Factor Modification Program to Address Obesity and Obstructive Sleep Apnea in Atrial Fibrillation Patients. J Am Heart Assoc 2019; 7:e010414. [PMID: 30571593 PMCID: PMC6405543 DOI: 10.1161/jaha.118.010414] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Obesity and obstructive sleep apnea (OSA) are associated with atrial fibrillation (AF), yet these conditions remain inadequately treated. We report on the feasibility and efficacy of a nurse‐led risk factor modification program utilizing a pragmatic approach to address obesity and OSA in AF patients. Methods and Results AF patients with obesity (body mass index ≥30 kg/m2) and/or the need for OSA management (high risk per Berlin Questionnaire or untreated OSA) were voluntarily enrolled for risk factor modification, which comprised patient education, lifestyle modification, coordination with specialists, and longitudinal management. Weight loss and OSA treatment were monitored by monthly follow‐up calls and/or continuous positive airway pressure (CPAP) unit downloads. Quality of life and arrhythmia symptoms were assessed with the SF‐36 and AF Severity Scale at baseline and at 6 months. From November 1, 2016 to October 31, 2017, 252 patients (age 63±11 years; 71% male; 57% paroxysmal AF) were enrolled, 189 for obesity and 93 for OSA. Obese patients who enrolled lost significantly greater percent body weight than those who declined (3% versus 0.3%; P<0.05). Among 93 patients enrolled for OSA, 70 completed sleep studies, OSA was confirmed in 50, and the majority (76%) started CPAP therapy. All components of quality of life and arrhythmia symptoms improved significantly from baseline to 6 months among enrolled patients. Conclusions A nurse‐led risk factor modification program is a potentially sustainable and generalizable model that can improve weight loss and OSA in AF patients, translating into improved quality of life and arrhythmia symptoms.
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Affiliation(s)
- Amaryah Yaeger
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Nancy R Cash
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Tara Parham
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - David S Frankel
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Rajat Deo
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Robert D Schaller
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Pasquale Santangeli
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Saman Nazarian
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Gregory E Supple
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Jeffrey Arkles
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Michael P Riley
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Fermin C Garcia
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - David Lin
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Andrew E Epstein
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - David J Callans
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Francis E Marchlinski
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Daniel M Kolansky
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
| | - Jorge I Mora
- 2 Division of Sleep Medicine Hospital of The University of Pennsylvania Philadelphia PA
| | - Anastassia Amaro
- 3 Division of Endocrinology Hospital of The University of Pennsylvania Philadelphia PA
| | - Richard Schwab
- 2 Division of Sleep Medicine Hospital of The University of Pennsylvania Philadelphia PA
| | - Allan Pack
- 2 Division of Sleep Medicine Hospital of The University of Pennsylvania Philadelphia PA
| | - Sanjay Dixit
- 1 Division of Cardiovascular Hospital of The University of Pennsylvania Philadelphia PA
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