Epicardial mapping and ablation of ventricular tachycardia from the coronary venous system in post-coronary bypass patients

BACKGROUND

Ventricular tachycardia (VT) ablation of mid- or epicardial substrate is difficult and requires a creative approach in patients with a history of coronary bypass that precludes percutaneous epicardial catheter manipulation. The coronary venous system (CVS) provides limited access to the epicardial surface of the heart. The objective of this study is to assess the feasibility, safety, and efficacy of epicardial mapping and ablation of VT substrates from the CVS in patients with history of coronary bypass.

METHODS

Patients undergoing VT ablation at our institution were retrospectively reviewed. Those who had basal to mid ventricular substrate based on computed tomography imaging and history of coronary bypass were included. Endocardial and CVS mapping and ablation was performed in standard fashion using 3D electroanatomic mapping. The primary endpoint was defined as VT circuit elimination, termination, non-inducibility, or perturbation of the circuit.

RESULTS

Of 192 consecutive VT ablations from 2017 to 2020, 35 (18%) had a history of coronary bypass and basal to the mid-ventricular substrate by imaging. There were no significant characteristic differences between the endocardial only (n = 19) vs endocardial + CVS (n = 16) groups. In 14 (88%) of patients undergoing CVS mapping, the VT circuit was identified to be within access from the epicardial surface. Ablation was attempted in 8 (57%) of these patients, and the primary endpoint was reached in 88% of those undergoing CVS ablation. There were no complications related to CVS ablation.

CONCLUSION

Mapping and ablation of mid- or epicardial VT circuits from the CVS branches are feasible and safe and may be helpful in the treatment of VT in patients who are otherwise not candidates for percutaneous epicardial ablation.

Prevalence of modifiable risk factors and related poor cardiovascular outcomes following atrial fibrillation ablation

Background

Atrial fibrillation (AF) has become a global epidemic. Early catheter ablation and therapies modifying risk factors (RF) have been shown to improve outcomes of AF ablation. However, the time invested in pursuing risk factor modification may delay ablation, which could negate the procedural benefit.

Purpose

This study sought to investigate the prevalence and impact of potentially modifiable RF among AF patients undergoing catheter ablation in clinical practice.

Methods

This retrospective study included 724 consecutive patients undergoing AF ablation at a tertiary care center from 2012–2019. Pre-specified modifiable risks were examined, including the time from AF diagnosis to ablation, fluctuation/increase in BMI >5% prior to ablation, mean systolic/diastolic blood pressure >125/80 mmHg, obstructive sleep apnea with CPAP noncompliance, hyperlipidemia without statin therapy, tobacco use, excessive alcohol use, and diabetes mellitus with hemoglobin A1c (HbA1c) >6.5%. The primary outcome was a composite of recurrent atrial arrhythmias, cardiovascular (CV) hospitalizations and mortality following AF ablation. A multivariate analysis was performed.

Results

The mean age was 61±10 years old, 32.5% were female and 72.2% had persistent AF. Many study patients had modifiable RF, ranging from 4.7% with excessive alcohol use to 64.0% experiencing delayed AF ablation. The mean time from AF diagnosis to ablation was 4.7 years. During a mean follow-up of 1.6 years after ablation, 467 (64.5%) patients met the primary outcome. Independent RF for the primary outcome were an increase/fluctuation in BMI >5% (adjusted hazard ratio [AHR] 1.31, 95% confidence interval [CI] 1.07–1.60; P=0.008), diabetes with HbA1c >6.5% (AHR 1.50, 95% CI 1.09–2.03; P=0.014) and hyperlipidemia without statin therapy (AHR 1.30, 95% CI 1.08–1.57; P=0.005). Delayed AF ablation over 1.5 years did not alter the outcome, Figure 1.

Conclusion

Substantial portions of patients undergoing AF ablation have potentially modifiable RF. Increased or fluctuating BMI, diabetes with HbA1c >6.5%, and hyperlipidemia not treated with statin therapy portend an increased risk of recurrent atrial arrhythmia, CV hospitalizations and mortality. These findings underscore an importance pursuing RF management in patients with AF to reduce adverse outcomes after ablation.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Jensen Family Research Sponsorship at the University of Nebraska Medical Center

Cardiogenic Shock Due to Atrial Myxoma With Mitral Valve Involvement

Despite being the most common primary cardiac neoplasm, the incidence of cardiac myxomas remains low. The majority of myxomas usually have a nonspecific presentation often leading to symptoms such as cough, dyspnea, and weakness. Larger tumors may cause arrhythmia, syncope, or cerebrovascular events due to embolization. Rarely, patients with myxomas may present with signs and symptoms of cardiogenic shock. A 50-year-old female presented to our Emergency Department with an altered mental status and hypotension. Initial imaging of the patient’s head showed an embolic infarction. Subsequent investigations revealed a large atrial mass protruding through the mitral valve. The patient was initially resuscitated and then taken to the operating room emergently where the mass was removed. Postoperatively, she was observed in the intensive care unit and eventually transferred to a step-down unit. Her pathology report confirmed that the mass was a cardiac myxoma. Here, we report the case of a patient with an atrial myxoma protruding through the mitral valve who presented in cardiogenic shock. The etiologies of cardiogenic shock and atrial myxomas are explored. The medical and surgical management of a patient with an atrial myxoma presenting in cardiogenic shock is reviewed. We reflect on our diagnostic evaluation, determining that patients who present in undifferentiated cardiogenic shock should be approached with a broad differential diagnosis.

Pre-ablation interatrial conduction delay or block predicts atrial fibrillation recurrence after ablation among obese patients

Funding Acknowledgements

Type of funding sources: None.

Background

Obesity is associated with greater risk of atrial fibrillation (AF) recurrence post-ablation and higher incidence of conduction delay compared to non-obese patients. Pre-ablation P-wave duration (PWD) and morphology (PWM) indicating interatrial delay are easily assessed in the clinic and may predict AF recurrence post-ablation in these patients.

Purpose

Evaluate the predictive value of PWD and PWM on AF recurrence post-ablation in obese patients.

Methods

Pre-ablation PWD and PWM (negative P-wave in lead II or III) were analyzed on consecutive patients with BMI ≥30 kg/m2 who underwent initial AF ablation from 2012–19. The primary outcome was recurrent AF after a 3-month post-ablation blanking period. Multivariate analysis adjusted for baseline characteristics was performed.

Results

For 205 patients (61.0±9.5 years old, 39.0% female), mean BMI was 36.9±5.7 kg/m2 and 71.7% had persistent AF pre-ablation. Recurrent AF post-ablation occurred in 115 (56.1%) during a median follow up of 491 (270, 1001) days. PWD >130 ms was significantly associated with higher AF recurrence (AHR of 1.62, 95%CI 1.04-2.57, p=0.03) after adjusting for age, persistent AF and left atrial volume index (LAVI). In a subgroup with LAVI <42 mL/m2 (n=112), PWD >130 ms and negative P-waves in lead II or III were independently associated with increased risk of recurrent AF (AHR 2.06, 95%CI 1.12-3.91; p=0.019 and AHR 1.94, 95% CI 1.00-3.56; p=0.05, respectively) (Figure 1).

Conclusion

AF recurred in >50% of obese patients within 1.5 years of ablation. Pre-ablation PWD >130 ms and negative P-waves in lead II or III independently predicted recurrent AF post-ablation in this cohort of obese patients. These easily assessed findings add predictive value to other risk factors.

Poor glycemic control in diabetic patients increases the risk of recurrent atrial arrhythmia and cardiovascular hospitalizations among morbidly obese patients undergoing atrial fibrillation ablation

Background/Introduction

Obesity and atrial fibrillation (AF) coexist and share multiple cardiovascular risk factors. Lifestyle modifications can reduce AF burden in obese patients. However, the time invested in pursing lifestyle changes may delay AF ablation, which could negate the procedural benefit.

Purpose

To examine the effects of lifestyle modifications and the timing of catheter ablation on morbidly obese patients with AF.

Methods

This retrospective study included 217 consecutive AF patients with a body mass index (BMI) ≥35 kg/m2 undergoing AF ablation at a tertiary care center from 2012 to 2019. Modifiable risks were examined, including the time from AF diagnosis to ablation, fluctuation of BMI >5% or an increase in BMI >3% prior to ablation, mean systolic blood pressure >130 mmHg or diastolic blood pressure >80 mmHg, obstructive sleep apnea with CPAP noncompliance, hyperlipidemia without statin therapy, tobacco use, excessive alcohol use, and diabetes mellitus with hemoglobin A1c (HbA1c) ≥6.5%. The primary outcome was a composite of recurrent atrial arrhythmias and cardiovascular (CV) hospitalizations following AF ablation. A multivariate analysis adjusting for age, gender and modifiable risks was performed.

Results

The mean age was 61±9 years old, 58% were female and 45% had persistent AF. A substantial portion of the study patients had modifiable risk factors, ranging from 2.7% with excessive alcohol use to 67.3% experiencing delayed AF ablation, Figure 1. The median time from diagnosed AF to ablation was 1.3 years. During a mean follow-up of 2.9 years after AF ablation, 136 (62.7%) patients met the primary outcome. Only HbA1c ≥6.5% was an independent risk factor with adjusted hazard ratio of 1.57, 95% confidence interval 1.02–2.36, P=0.0412, Figure 2A. Delayed AF ablation did not alter the outcome, Figure 2B. There was no interaction between time of ablation and HbA1c ≥6.5% (P=0.67).

Conclusion

Substantial portions of morbidly obese patients undergoing AF ablation have potentially modifiable risk factors. Poor glycemic control with HbA1c ≥6.5% predicts an increased risk of recurrent atrial arrhythmias and CV hospitalizations, while delayed AF ablation does not. This finding underscores an importance of optimizing HbA1c in morbidly obese patients with AF to reduce adverse outcomes after ablation.

Funding Acknowledgement

Type of funding sources: None.

Impact of age on catheter ablation of premature ventricular contractions

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation (CA) of frequent premature ventricular contractions (PVC) is increasingly performed in older patients as the population ages.

Purpose

The purpose of this study was to assess the impact of age on procedural characteristics, safety and efficacy on PVC ablations.

Methods

Consecutive patients with symptomatic PVCs undergoing CA between 2015 and 2020 were evaluated. Acute ablation success was defined as the elimination of PVCs at the end of the procedure. Sustained success was defined as an elimination of symptoms, and  ≥80% reduction of PVC burden determined by Holter-ECG during long-term follow. Patients were sub-grouped based on age (< 65 years vs. ≥ 65 years).

Results

A total of 114 patients were enrolled (median age 64 years, 71% males) and followed up for a median duration of 228 days. Baseline and procedural data were similar in both age groups. A left-sided origin of PVCs was more frequently observed in the elderly patient group compared to younger patients (83% vs. 67%, p = 0.04, Figure 1). The median procedure time was significantly shorter in elderly patients (160 min vs. 193 min, p = 0.02). The rates of both acute (86% vs. 92%, p = 0.32) and sustained success (70% vs. 71%, p = 0.90) were similar between groups. Complications rates (3.7%) did not differ between the two groups.

Conclusion

In a large series of patients with a variety of underlying arrhythmia substrates, similar rates of acute procedural success, complications, and ventricular arrhythmia-free-survival were observed after CA of PVCs. Older age alone should not be a reason to withhold CA of PVCs. Abstract Figure 1

Cardioneuroablation for cardioinhibitory vasovagal syncope

BACKGROUND

Cardioneuroablation (CNA) is an emerging technique being used to treat patients with cardioinhibitory vasovagal syncope (VVS). We describe a case of CNA in targeting atrial ganglionated plexi (GP) based upon anatomical landmarks and fractionated electrogram (EGM) localization in a patient with cardioinhibitory syncope.

CASE PRESENTATION

A 20-year-old healthy female presented with malignant VVS and symptomatic sinus pauses, with the longest detected at 10 s. She underwent acutely successful CNA with demonstration of vagal response (VR) noted after ablation of left sided GP, and tachycardia noted with right sided GP ablation. All GP sites were defined by anatomical landmarks and EGM analysis. By using the fractionation mapping software of Ensite Precision mapping system with high density mapping, fragmented EGMs were successfully detected in each GP site. One month after vagal denervation, there were no recurrent syncopal episodes or sinus pauses. Longer term follow-up with implantable loop recorder is planned.

CONCLUSION

We performed CNA in a patient with VVS by utilizing a novel approach of combined use of high density mapping and fractionation mapping software. With this approach, we were able to detect fractionation in all GP sites and demonstrate acute VR. This workflow may allow for a new, standardized technique suitable for widespread use.

Fractionation Mapping of the Ganglionated Plexi for Cardioneuroablation

Cardioneuroablation (CNA) is an emerging technique used to treat patients with vasovagal syncope (VVS). We herein describe a case of CNA targeting the atrial ganglionated plexi (GPs) based upon anatomical landmarks and fractionated electrogram (EGM) localization in a 20-year-old healthy female who presented to our center with malignant VVS and symptomatic sinus pauses, the longest of which measured 10 seconds. She underwent acutely successful CNA with a demonstration of vagal response noted following ablation of the left-sided GPs, and tachycardia was noted with right-sided GP ablation. All GP sites were defined by anatomical landmarks and EGM analysis. By using the fractionation mapping software of the EnSite Precision™ cardiac mapping system (Abbott, Chicago, IL, USA) with high-density mapping, fragmented EGMs were successfully detected in each GP site. One month after vagal denervation, no recurrent syncopal episodes or sinus pauses had been recorded. Longer-term follow-up with an implantable loop recorder is planned. Broadly, we performed CNA in a patient with VVS by combining high-density mapping and fractionation mapping software in a novel approach, which allowed us to detect fractionation in all GP sites and demonstrate an acute vagal response. This workflow may facilitate the introduction of a standardized technique suitable for widespread use.

Impact of age on catheter ablation of premature ventricular contractions

INTRODUCTION

Catheter ablation (CA) of frequent premature ventricular contractions (PVC) is increasingly performed in older patients as the population ages. The aim of this study was to assess the impact of age on procedural characteristics, safety and efficacy on PVC ablations.

METHODS

Consecutive patients with symptomatic PVCs undergoing CA between 2015 and 2020 were evaluated. Acute ablation success was defined as the elimination of PVCs at the end of the procedure. Sustained success was defined as an elimination of symptoms, and ≥80% reduction of PVC burden determined by Holter-electrocardiogram during long-term follow. Patients were sub-grouped based on age (<65 vs. ≥65 years).

RESULTS

A total of 114 patients were enrolled (median age 64 years, 71% males) and followed up for a median duration of 228 days. Baseline and procedural data were similar in both age groups. A left-sided origin of PVCs was more frequently observed in the elderly patient group compared to younger patients (83% vs. 67%; p = .04). The median procedure time was significantly shorter in elderly patients (160 vs. 193 min; p = .02). The rates of both acute (86% vs. 92%; p = .32) and sustained success (70% vs. 71%; p = .90) were similar between groups. Complications rates (3.7%) did not differ between the two groups.

CONCLUSION

In a large series of patients with a variety of underlying arrhythmia substrates, similar rates of acute procedural success, complications, and ventricular arrhythmia-free-survival were observed after CA of PVCs. Older age alone should not be a reason to withhold CA of PVCs.

The broken circle method: a novel technique that enhances detection of Hill-Sachs lesions on internal rotation shoulder radiographs

AIM

To describe and test a new method that increases the conspicuity of a Hill-Sachs lesion on internal rotation (IR) radiographs.

MATERIALS AND METHODS

This study had institutional review board approval. A retrospective search for patients with a prior shoulder dislocation and a Hill-Sachs lesion documented on magnetic resonance imaging (MRI) was performed over a 10-year period identifying 256 test patients. In Part 1, the IR radiographs from test cases were randomised with controls, and three readers scored them independently for the defect. The readers were then taught the Broken Circle (BC) method and re-scored the radiographs. In Part 2, 15 cases of Hill-Sachs lesions that were missed by all readers in Part 1 were randomised with controls, and were shown to 25 radiology residents before (pre-test) and after (post-test) learning the BC method. A paired t-test was used to compare the differences in sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

In Part 1, the sensitivity increased 19.7% (54.1%-73.8%; p<0.05) and NPV increased 10.8% (62.5%-73.3%; p<0.01). In Part 2, post-test sensitivity for residents increased 16.3% (55.2%-71.5%; p<0.0001), accuracy increased 13.4% (64%-77.4%; p<0.0001), and NPV increased 13.3% (40.8%-54.1%; p<0.0001) independent of the level of training. The change in accuracy was also statistically significant for every individual class.

CONCLUSION

The BC method was an effective technique that facilitated detection of a Hill-Sachs lesion at all levels of training, and was useful as a teaching tool.

P1127Occurrence, management and outcomes of iatrogenic aortic dissections as a complication of catheter ablation. A multicenter study

Background

Data on occurrence, management and outcomes of iatrogenic aortic dissections (IAD) as a complication of catheter ablation (CA) do not exist.

Purpose

To evaluate multicenter data on occurrence, management and outcomes of IAD as a complication of CA.

Methods

Data on occurrence, management and outcomes of documented vascular dissections from 10 centers were evaluated.

Results

IADs occurred in 7 patients (2 females, age 63 ± 8 years). Indications for CA were frequent premature ventricular complexes (PVC)/ventricular tachycardia (VT) in 6 patients (86%) and left-sided accessory pathway in the remaining one (14%). Hypertension was most frequent comorbidity (4 pts, 57%).  All IADs occurred during retrograde advancement of ablation catheter. In the vast majority of patients creation of IAD during catheter advancement was not associated with any symptoms (6 pts, 86%). IAD was initially detected using trans-luminal angiogram in 5 (71%) and further confirmed using computed tomography (CT) (5 pts, 71%), conventional angiography (2 pts, 28%) and ultrasound (2 pts, 28%). One IAD was detected during CT scan performed for other indication after CA. There was one IAD-related death and IAD was evaluated post-mortem. Follow-up lasted 10 ± 19 months. Four patients were treated conservatively, one patient underwent descending aorta stenting and one femoral artery stenting.

Conclusions

IAD during CA is a rare but can be devastating. Early recognition can be difficult. Conservative management of IAD is an option of treatment.

P1652Limited correlation of calculated plasma volume status with invasive right heart pressures in patients with heart failure

Background

Estimated plasma volume (ePV) can be calculated from haematocrit and body weight, and has been shown to correlate with PV measured using 125Iodine labelled human serum albumin. Comparing a patient's ePV to ideal PV (iPV), an estimate of a patient's relative congestion, called PV status (PVS), is possible. Higher PVS is associated with increased mortality in patients with heart failure (HF), and has been proposed as a simple, cheap, and non-invasive way of assessing congestion.

Purpose

Whether PVS is associated with invasively measured markers of congestion is unknown. We calculated PVS in patients with HF who had right heart catheterisation (RHC), and assessed any correlation between PVS and invasive measures of congestion.

Methods

We calculated PVS in consecutive patients who had RHC performed as part of transplant assessment. iPV was calculated as: iPV = c × weight (kg) where c=39 in males and c=40 in females. ePV was calculated using subjects' haematocrit and weight as follows: ePV = (1 − haematocrit) × [a + (b × weight in kg)], where haematocrit is a fraction, a=1530 in males and a=864 in females, and b=41 in males and b=47.9 in females. PVS was calculated as: PVS = PVS = (ePV − iPV) /iPV × 100%. Correlation between PVS and invasive wedge pressure, mean right atrial (RA) pressure, and NTproBNP were made using Pearson correlation.

Results

PV indices and RHC data were available for 61 patients, 43 (71%) were male. Median age was 55 [IQR 48, 58] years. 20 (33%), 24 (39%), and 15 (25%) were NYHA association class II, III, and IV respectively. The median NTproBNP was 1390 [IQR 512, 3612] pg/ml and median ejection fraction was 29 [IQR 20, 35] %. The median PVS was −5.9% (IQR −12.5, −1.6]. Median wedge and mean-RA pressures were 14 [7, 21] and 4 [1, 8] mmHg, respectively. Correlation between mean RA pressure and PVS is shown in the figure. There was no correlation between PVS and mean RA pressure (r=0.12, p=0.34) or wedge pressure (r=0.01, p=0.92). There was a weak correlation between NTproBNP and PVS (r=0.31, p=0.01)

Correlation mean RA pressure and PVS

Conclusion

PVS did not correlate with the invasive measures of congestion, mean RA and wedge pressure, but was weakly correlated with NTproBNP. Although there were limited number of patients in this study, we question the conclusion that PVS is a marker of congestion, and whether it can be used clinically for this purpose.

The safety of morphine use in acute coronary syndrome: a meta-analysis

Background

Morphine is widely used for pain control in patients with acute coronary syndrome (ACS). Several studies have questioned the safety of morphine in this setting with a concern of interaction with and reduced efficacy of antiplatelet agents.

Objective

This study aims to systematically review the safety of morphine use in ACS.

Methods

MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were queried from inception through April 2018. Studies comparing morphine to nonmorphine use in ACS were included. Study endpoints included: in-hospital myocardial infarction (MI), all-cause mortality, stroke, major bleeding, minor bleeding and dyspnoea.

Results

A total of 64 323 patients with ACS were included from eight studies, seven of which were observational studies and one was a randomised controlled trial. The use of morphine was associated with increased risk of in-hospital recurrent MI (OR 1.30, 95% CI 1.18 to 1.43, p < 0.00001). There was, however, no significant difference in terms of all-cause mortality (OR 0.87, 95% CI 0.62 to 1.22, p = 0.44), stroke (OR 0.81, 95% CI 0.39 to 1.66, p = 0.57), major bleeding (OR 0.49, 95% CI 0.24 to 1.00, p = 0.05), minor bleeding (OR 0.98, 95% CI 0.41 to 2.34, p = 0.97), or dyspnoea (OR 0.55, 95% CI 0.16 to 1.83, p = 0.33).

Conclusion

The use of morphine for pain control in ACS was associated with an increased risk of in-hospital recurrent MI. Randomised clinical trials are needed to further investigate the safety of morphine in ACS.

Noninvasive tissue adhesive for cardiac implantable electronic device pocket closure: the TAPE pilot study

PURPOSE

Device infection is a serious complication of cardiac implantable electronic devices (CIED). Ensuring complete pocket closure can be time consuming, but remains vital to prevent infection. The Zip® Surgical Skin Closure (ZIP) is a noninvasive adhesive device applied to the skin as an alternative to subcuticular sutures for skin closure. We hypothesized that using this device would decrease pocket closure times without increasing the risk of pocket infections. This is a single center, retrospective cohort study to compare pocket closure times and infection rates between ZIP and standard suture for CIED pocket closure.

METHODS

Two separate groups of consecutive new intravenous implants, upgrades, and pulse generator replacements from October 2015 to April 2017 were included. A total of 175 patients were included, using either ZIP (n = 80) or suture (n = 95). Total procedure time (local anesthetic to dressing application) and pocket closure time (fascial suture to dressing application) were compared. Pocket infections were defined as infections leading to CIED extraction or wound dehiscence requiring repeat procedure. Statistical analysis was performed using chi square test and Student's t test.

RESULTS

Pocket closure time and procedure time were significantly shorter for the ZIP group (14.9 ± 6.8 vs 20.1 ± 11.09 min, p = 0.0003) and (65.02 ± 30.4 vs 83.83 ± 40.3 min, p = 0.0008), respectively. No pocket infections occurred in the Zip group, while the suture group had 2:1 wound dehiscence and 1 pocket infection.

CONCLUSION

The ZIP device resulted in significantly shorter pocket closure and procedure times without increasing device pocket infections.

Three-way stopcock suture technique for hemostasis after ablation for atrial fibrillation

BACKGROUND

Figure-of-eight sutures (F8S) have emerged as an alternative to the standard practice of manual compression to achieve venous hemostasis after catheter ablation for atrial fibrillation (AF). In lieu of a knot to secure the sutures in place, a three-way stopcock can be used, which can be loosened or tightened as needed to achieve hemostasis and is easier to remove. The safety and effectiveness of this technique, when compared to traditional F8S, are unknown. In this case series, we sought to describe this stopcock closure (SC) technique and compare procedural characteristics and outcomes to the traditional F8S.

METHODS

Charts of consecutive patients who underwent AF radiofrequency at two centers were reviewed for the type of hemostasis (SC or F8S), demographics, periprocedural anticoagulation, groin complications, and procedural duration.

RESULTS

A total of 100 patients were included (50 in the F8S group and 50 in the SC group). The two groups were similar in terms of mean age, gender, weight, renal function, oral anticoagulant use, and procedural heparin dosing. There was one groin bleeding complication in each group. The procedural time was shortened in the SC group (220 ± 8 minutes vs 313 ± 8 minutes), and there was more protamine use (25 vs 3 patients) owing to the differences in preferences among two operators.

CONCLUSION

In this proof-of-concept study, a simple stopcock device provided comparable hemostasis to standard F8S after radiofrequency catheter ablation of AF.

Figure-of-eight sutures for hemostasis result in shorter lab recovery time after ablation for atrial fibrillation

BACKGROUND

Ablation for atrial fibrillation (AF) requires multiple venous sheaths and anticoagulation with heparin, both risk factors for bleeding complications. Manual compression (MC) with heparin reversal is the standard method to achieve venous hemostasis postablation; however, temporary figure-of-eight sutures (F8S) are an alternative. While this technique has been shown to be safe and effective, little is known about its effect on postprocedural recovery time.

METHODS

In this retrospective cohort study, consecutive patients who underwent AF radiofrequency ablation over a 23-month period were reviewed for type of hemostasis (manual compression or figure-of-eight suture), demographics, periprocedural anticoagulation, groin complications, and procedural duration.

RESULTS

A total of 104 patients were included (42 in the MC group and 62 in the F8S group). The two groups were similar for mean age, gender, weight, oral anticoagulant use, and procedural heparin dosing. Access site complications were 4.76% versus 3.23% (P = 0.68). Time from procedure end to sheath removal was lower in the F8S group (16.2 ± 8.47 vs 4.25 ± 4.14 min, P < 0.0001). Overall time from procedure end to hemostasis was 36.1 ± 10.1 min in the MC group versus 7.9 ± 5.6 in the F8S group (P < 0.0001). Times to extubation and transport out of the lab were both significantly lower in the F8S group (34.1 ± 14.6 vs 13.5 ± 5.4 min, and 44 ± 14.6 vs 21.9 ± 6.7 min, respectively, P < 0.0001).

CONCLUSION

Figure-of-eight sutures provided efficient hemostasis following AF ablation, with significantly reduced postprocedure recovery time including time to hemostasis, extubation, and transport out of the lab.

Intracranial haemorrhage in children with inherited bleeding disorders in the UK 2003-2015: A national cohort study

INTRODUCTION

Intracranial haemorrhage in children with inherited bleeding disorders is a potentially life-threatening complication and presents a significant therapeutic challenge.

AIM

To define the characteristics, management and outcomes of intracranial haemorrhage presenting in UK children ≤16 years of age with inherited bleeding disorders from 2003 to 2015.

METHOD

Retrospective analysis of children treated at UK haemophilia centres.

RESULTS

Of 66 children presenting with Intracranial haemorrhage (ICH), 82% had haemophilia A or B, 3% VWD and 15% a rare IBD. The IBD was a severe phenotype in 91%. The rates of ICH were 6.4 and 4.2 per 1000 patient years for haemophilia A and B, respectively. Median age at presentation was 4 months (33% neonates; 91% children <2 years of age). In neonates, delivery was spontaneous vaginal (SV) in 11, instrumental in 6, caesarean in 4 and unknown in 1. In children with haemophilia, the risk of ICH after instrumental delivery was 10.6 times greater than after SV delivery. Trauma was more common in children >2 years (67%) than in children 1 month to 2 years (18%; P = .027). Prior to ICH, only 4.5% of children were on prophylaxis. 6% of haemophiliacs had an inhibitor. The median duration of initial replacement therapy was 15 days. Mortality was 13.5%. Neurological sequelae occurred in 39% of survivors, being more common following intracerebral bleeding. In haemophilia survivors, 52% subsequently developed a FVIII inhibitor.

CONCLUSION

Intracranial haemorrhage occurs most frequently in children with severe IBDs, during the first 2 years of life and in children not receiving prophylaxis. Intracranial haemorrhage often occurs without documented trauma.

The impact of education, country, race and ethnicity on the self-report of postpartum depression using the Edinburgh Postnatal Depression Scale

BACKGROUND

Universal screening for postpartum depression is recommended in many countries. Knowledge of whether the disclosure of depressive symptoms in the postpartum period differs across cultures could improve detection and provide new insights into the pathogenesis. Moreover, it is a necessary step to evaluate the universal use of screening instruments in research and clinical practice. In the current study we sought to assess whether the Edinburgh Postnatal Depression Scale (EPDS), the most widely used screening tool for postpartum depression, measures the same underlying construct across cultural groups in a large international dataset.

METHOD

Ordinal regression and measurement invariance were used to explore the association between culture, operationalized as education, ethnicity/race and continent, and endorsement of depressive symptoms using the EPDS on 8209 new mothers from Europe and the USA.

RESULTS

Education, but not ethnicity/race, influenced the reporting of postpartum depression [difference between robust comparative fit indexes (∆*CFI) 0.01), but not between European countries (∆*CFI < 0.01).

CONCLUSIONS

Investigators and clinicians should be aware of the potential differences in expression of phenotype of postpartum depression that women of different educational backgrounds may manifest. The increasing cultural heterogeneity of societies together with the tendency towards globalization requires a culturally sensitive approach to patients, research and policies, that takes into account, beyond rhetoric, the context of a person's experiences and the context in which the research is conducted.

Highly Pathogenic Avian Influenza (H5N1) Virus in Feathers

H5N1 highly pathogenic avian influenza (HPAI) virus causes high mortality of infected birds, with infection in multiple organs, including in feathers. Feathers have been proposed as samples for diagnosis of HPAI infection in birds, and this study is part of a broader investigation validating the use of feathers for diagnostic purposes. To understand and characterize the morphological basis for feather infection, sections from 7 different skin tracts of ducks and chickens infected with 3 different clades of H5N1 HPAI virus from Indonesia and Vietnam were examined histologically. Results showed that in ducks, lesions and viral antigen were mainly detected in the epidermis of feathers and follicles, whereas in chickens, they were mostly found in the dermis of these structures. Abundant viral antigen was found in nearly all the feathers examined from chickens, and there was no apparent difference between virus isolates or skin tracts in the proportion of feathers that were antigen positive. By immunohistochemistry, the majority of feathers from most skin tracts from ducks infected with a Vietnamese H5N1 HPAI virus contained abundant levels of viral antigen, while few feathers were antigen positive from ducks infected with 2 Indonesian viruses. These results support and inform the use of feathers for diagnostic detection of H5N1 HPAI virus in birds.

Quantification of sodium pentobarbital residues from equine mortality compost piles

Sodium pentobarbital, a euthanasia drug, can persist in animal carcasses following euthanasia and can cause secondary toxicosis to animals that consume the remains. This experiment was conducted to observe the effects of composting on euthanized horse carcass degradation and sodium pentobarbital residues in compost material up to 367 d. Six separate compost bins were constructed on pastureland. Three bins served as the control while 3 served as the treatment. The carbonaceous material, or bulking agent, consisted of hardwood chips mixed with yard waste wetted to approximately 50% moisture content. Bulking agent was added to each bin at a depth of 0.46 m, creating the pad. A licensed veterinarian provided 6 horse carcasses for use in the experiment. These horses had required euthanasia for health reasons. All horses were weighed and then sedated with an intravenous injection of 8 mL of xylazine. After sedation the 3 horses in the treatment group were euthanized by intravenous injection of 60 mL of sodium pentobarbital. The 3 control group horses were anesthetized by intravenous injection of 15 mL of ketamine hydrochloride and then humanely euthanized by precise gunshot to the temporal lobe. Following euthanasia, each carcass was placed on the center of the pad and surrounded with 0.6 m of additional bulking agent. Serum and liver samples were obtained immediately following death. Compost samples were obtained on d 7, 14, 28, 56, 84, 129, 233, and 367 while soil samples were obtained on d -1 and 367. Each sample was analyzed for sodium pentobarbital concentration. Compost pile and ambient temperatures were also recorded. Composting successfully degraded soft tissue with only large bones remaining. Data illustrate that sodium pentobarbital was detectable up to 367 d in compost piles with no clear trend of concentration reduction. Drug residues were detected in soil samples indicating that sodium pentobarbital leached from the carcass and through the pad. These findings confirm the persistence of sodium pentobarbital from equine mortality compost piles and emphasize the importance of proper carcass management of animals euthanized with a barbiturate to reduce environmental impact and secondary toxicosis.

The Incidence of Complications of Tibial Tubercle Osteotomy: A Systematic Review

PURPOSE

The goal of this review was to quantify the risk of perioperative and early postoperative complications of tibial tubercle osteotomy (TTO) with different techniques.

METHODS

A systematic review of multiple databases was performed to identify studies that reported complications of TTO. Complications were defined as any adverse outcome, including osteotomy site nonunion, fracture, infection, wound complications, neurovascular complications, deep vein thrombosis (DVT), and pulmonary embolism (PE). Major complications were defined as nonunion, fracture, infections/wound complications requiring return to the operating room, and DVT or PE. The risk of subsequent hardware removal was also quantified.

RESULTS

The 19 identified studies included a total of 787 TTOs: 472 direct medialization procedures (Elmslie-Trillat technique), 193 anteromedialization procedures (Fulkerson technique), and 102 procedures in which the tibial tubercle was completely detached for medialization or distalization, or a combination. The overall complication risk was 4.6%. The risk of complications was higher when the tibial tubercle was completely detached (10.7%) than with Elmslie-Trillat (3.3%) or Fulkerson (3.7%) procedures (P = .004). The overall risk of major complications was 3.0%. Hardware removal was performed in 36.7% of osteotomies and was less frequent with the Elmslie-Trillat technique (26.8%) than with the Fulkerson technique (49.0%) or complete tubercle detachment (48.3%) (P < .001).

CONCLUSIONS

Tibial tubercle osteotomy is a complex surgical procedure with a significant risk of complications. Osteotomies that involve complete detachment of the tubercle have an increased risk of complications compared with those in which a distal cortical hinge is maintained.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Recent trends in breast, cervical, and colorectal cancer screening test utilization in Canada, using self-reported data from 2008 and 2012

In Canada, self-reported data from the Canadian Community Health Survey 2008 and 2012 provide an opportunity to examine overall utilization of breast, cervical, and colorectal cancer screening tests for both programmatic and opportunistic screening. Among women 50-74 years of age, utilization of screening mammography was stable (62.0% in 2008 and 63.0% in 2012). Pap test utilization for women 25-69 years of age remained high and stable across Canada in 2008 and 2012 (78.9% in 2012). The percentage of individuals 50-74 years of age who reporting having at least 1 fecal test within the preceding 2 years increased in 2012 (to 23.0% from 16.9% in 2008), but remains low. Stable rates of screening mammography utilization (about 30%) were reported in 2008 and 2012 among women 40-49 years of age, a group for which population-based screening is not recommended. Although declining over time, cervical cancer screening rates were high for women less than 25 years of age (for whom screening is not recommended). Interestingly, an increased percentage of women 70-74 years of age reported having a Pap test. In 2012, a smaller percentage of women 50-69 years of age reported having no screening test (5.9% vs. 8.5% in 2008), and more women reported having the three types of cancer screening tests (19.0% vs. 13.2%). Efforts to encourage use of screening within the recommended average-risk age groups are needed, and education for stakeholders about the possible harms of screening outside those age groups has to continue.

Functional profiling in Streptococcus mutans: construction and examination of a genomic collection of gene deletion mutants

A collection of tagged deletion mutant strains was created in Streptococcus mutans UA159 to facilitate investigation of the aciduric capability of this oral pathogen. Gene-specific barcoded deletions were attempted in 1432 open reading frames (representing 73% of the genome), and resulted in the isolation of 1112 strains (56% coverage) carrying deletions in distinct non-essential genes. As S. mutans virulence is predicated upon the ability of the organism to survive an acidic pH environment, form biofilms on tooth surfaces, and out-compete other oral microflora, we assayed individual mutant strains for the relative fitness of the deletion strain, compared with the parent strain, under acidic and oxidative stress conditions, as well as for their ability to form biofilms in glucose- or sucrose-containing medium. Our studies revealed a total of 51 deletion strains with defects in both aciduricity and biofilm formation. We have also identified 49 strains whose gene deletion confers sensitivity to oxidative damage and deficiencies in biofilm formation. We demonstrate the ability to examine competitive fitness of mutant organisms using the barcode tags incorporated into each deletion strain to examine the representation of a particular strain in a population. Co-cultures of deletion strains were grown either in vitro in a chemostat to steady-state values of pH 7 and pH 5 or in vivo in an animal model for oral infection. Taken together, these data represent a mechanism for assessing the virulence capacity of this pathogenic microorganism and a resource for identifying future targets for drug intervention to promote healthy oral microflora.