Radiofrequency catheter ablation combined with spironolactone in the treatment of atrial fibrillation: A single‐center randomized controlled study

At present, the question of whether radiofrequency ablation (RFA) combined with spironolactone can reduce the levels of plasma angiotensin II (AngII) and aldosterone (ALD) in patients with atrial fibrillation (AF) and reduce the recurrence of AF has not been reported.HypothesisThe present study evaluates the effect of spironolactone as an ALD antagonist on the short‐term and long‐term recurrence of AF after RFA. A total of 203 patients were enrolled in the present study, with 102 patients in the spironolactone therapy group (Group PVI/SP) and 101 patients in the control group (Group PVI alone). The AngII and ALD levels and the size of the left atrium in patients with AF were observed in order to evaluate the relationship between the combination therapy of spironolactone with RFA and the success rate in AF treatment. After therapy, the levels of AngII (52.8 vs. 64.3 pg/ml, p < .001), ALD (45.7 vs. 60.6 pg/ml, p = .016), and N‐terminal of B‐type natriuretic peptide (NT‐proBNP) (73.5 vs. 110 pg/ml, p = .016), along with the size of the left atrium (35.8 vs. 37.2 mm, p = .007), were all significantly lower in Group PVI/SP compared with Group PVI alone. The cumulative AF‐free survival rate was higher in Group PVI/SP than in Group PVI alone after treatment (85.3% vs.73.3%, p = .033). In RFA combined with spironolactone treatment, spironolactone can directly antagonize the effects of ALD and AngII and the recurrence of AF and improve left ventricular function.     

Peripheral artery disease and clinical outcomes in patients with atrial fibrillation: A systematic review and meta‐analysis

BackgroundAtrial fibrillation (AF) is the most common cardiac rhythm disturbance and leads to morbidity and mortality. Peripheral artery disease (PAD) is associated with atherosclerotic risk factors and always classified as a vascular disease and deemed to be a bad complication of AF. In patients with AF, the risk and prognostic value of PAD have not been estimated comprehensively.HypothesisPAD is associated with all‐cause mortality, cardiovascular (CV) mortality, and other outcomes in patients with AF.MethodsWe searched PubMed, Embase, and Cochrane Library databases for prospective studies published before April 2021 that provided outcomes data on PAD in confirmed patients with AF. Heterogeneity was estimated using the I ² statistic. The fixed‐effects model was used for low to moderate heterogeneity studies, and the random‐effects model was used for high heterogeneity studies.ResultsEight prospective studies (Newcastle‐Ottawa score range, 7–8) with 39 654 patients were enrolled. We found a significant association between PAD and all‐cause mortality (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.25–1.62; p < .001), CV mortality (HR, 1.64; 95% CI, 1.32–2.05; p < .001) and MACE (HR, 1.75; 95% CI, 1.38–2.22; p < .001) in patients with AF. No significant relationship was found in major bleeding (HR, 1.22; 95% CI, 0.95–1.57; p = 0.118), myocardial infarction (MI) (HR, 2.07; 95% CI, 1.17–3.67; p = .038), and stroke (HR, 1.14; 95% CI, 0.87–1.50, p = 0.351).ConclusionsPAD is associated with an increased risk of all‐cause mortality, CV mortality, and MACE in patients with AF. However, no significant association was found with major bleeding, MI, and stroke.     

Effect of non‐recommended doses versus recommended doses of direct oral anticoagulants in atrial fibrillation patients: A meta‐analysis

BackgroundSeveral observational studies have shown that the inappropriate dosing use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) that does not conform to recommendations is becoming a widespread phenomenon. Therefore, we performed a meta‐analysis and systematic review to assess the effect of non‐recommended doses versus recommended doses of DOACs on the effectiveness and safety outcomes among AF patients.MethodsThe PubMed and Ovid databases were systematically searched to identify the relevant studies until December 2020. The effect estimates were hazard ratios (HRs) and 95% confidence intervals (CIs), which were pooled using a fixed‐effects model (I² ≤ 50%) or a random‐effects model (I² > 50%).ResultsA total of 11 studies were included in this meta‐analysis. Compared with recommended dosing of DOACs, non‐recommended low dosing of DOACs was associated with increased risks of stroke or systemic embolism (SSE, HR = 1.29, 95% CI 1.12–1.49) and all‐cause death (HR = 1.37, 95% CI 1.15–1.62), but not the ischemic stroke, myocardial infarction, gastrointestinal bleeding, intracranial bleeding, and major bleeding. Compared with recommended dosing of DOACs, non‐recommended high dosing of DOACs was associated with increased risks of SSE (HR = 1.44, 95% CI 1.01–2.04), major bleeding (HR = 1.99, 95% CI 1.48–2.68), and all‐cause death(HR = 1.38, 95% CI 1.02–1.87).ConclusionCompared with recommended dosing of DOACs, non‐recommended low dosing of DOACs was associated with increased risks of SSE and all‐cause death. Further study should confirm the findings of non‐recommended high dosing versus recommended dosing of DOACs.     

Outcomes of implantable cardioverter‐defibrillator implantation in HIV‐infected patients: A single‐center retrospective cohort study

BackgroundHIV‐infected individuals have a known increased risk of sudden cardiac death (SCD) compared to uninfected individuals. Implantable cardioverter‐defibrillators (ICDs) are standard therapy for preventing SCD; however, there is limited data on the outcomes of ICDs in HIV‐infected individuals.HypothesisHIV‐infected subjects receive a higher number of appropriate ICD therapies than uninfected controls.MethodsThis is a retrospective cohort study of 35 consecutive HIV‐Infected patients and 36 uninfected controls matched by age, race, and gender who were treated at the University of North Carolina Medical Center in the outpatient or inpatient setting from 2014 to the present and had undergone ICD implantation. For HIV‐infected subjects, a multivariate Poisson regression analysis was performed to evaluate the association between covariates and ICD therapies.ResultsAmong HIV‐infected subjects, the mean CD4 count was 582.5 cells/mm³ and 69% had an undetectable viral load. The median follow‐up was 6.4 years. HIV‐infected subjects had both a higher number of appropriate ICD shocks or antitachycardia pacing (ATP) therapy per person‐year as well as a higher number of inappropriate ICD shocks per person‐year than uninfected controls (1.512 vs. 0.590 and 0.122 vs. 0.0166, respectively, p < .001 for both comparisons). After multivariate adjustment, the presence of detectable/unsuppressed viral load at the time of ICD implantation was an independent predictor of both of the following in HIV‐infected subjects: (1) appropriate ICD discharge (p = .004), and (2) appropriate ICD discharge or appropriate ATP therapy (p < .001).ConclusionHIV‐infected subjects had a higher number of appropriate ICD discharge or ATP therapy per person‐year than matched uninfected controls.     

Deterioration of organization in the first minutes of atrial fibrillation: a beat-to-beat analysis of cycle length and wave similarity

Introduction: It has been recently suggested that many episodes of atrial fibrillation (AF) may be partially organized at the onset and thus more suitable for antitachycardia pacing therapy. Nevertheless, the time course of organization in the first minutes of AF has not been quantified yet.
Methods and Results: Twenty episodes of paroxysmal AF were studied. Electrograms were recorded from the right atrium (RA), distal (CSd), and proximal coronary sinus (CSp). The time course of AF cycle length (AFCL) and the regularity of wave morphology (similarity index S) were beat-to-beat measured at each recording site during the first 7 minutes of AF. AFCL and S showed a decreasing trend after the onset of AF. AFCL decreased from 208 ± 31 to 171 ± 21 msec (P < 0.001), from 206 ± 40 to 169 ± 23 msec (P < 0.001) and from 190 ± 42 to 152 ± 18 msec (P < 0.05), respectively, in RA, CSd, and CSp. Similarly, the similarity index decreased in CSd from 0.37 ± 0.27 to 0.12 ± 0.09 (P < 0.01) and in RA from 0.40 ± 0.18 to 0.17 ± 0.16 (P < 0.001). The 80% of the decrease occurred during the first 3 minutes of the arrhythmia, while after this time both cycle length and similarity index did not change significantly anymore. Conversely, the electrical activity in CSp was highly disorganized (S = 0.05 ± 0.03) even in the first minute of AF, and no decreasing temporal trend was observed.
Conclusion: Higher levels of organization and longer fibrillation intervals exist at the onset of AF. The degree of organization of the electrical activity decays within less than 3 minutes. Since antitachycardia pacing success rate increases with high levels of organization, these results suggest an early delivery of pacing treatment.     

Robot‐assisted transhiatal esophagectomy: a 3‐year single‐center experience

Minimally invasive esophagectomy has emerged as an important procedure for disease management in esophageal cancer (EC) with clear margin status, less morbidity, and shorter hospital stays compared with open procedures. The experience with transhiatal approach robotic esophagectomy (RE) for dissection of thoracic esophagus and associated morbidity is described here. Between March 2007 and November 2010, 40 patients with resectable esophageal indications underwent transhiatal RE at the institute. Clinical data for all patients were collected prospectively. Of 40 patients undergoing RE, one patient had an extensive benign stricture, one had high‐grade dysplasia, and 38 had EC. Five patients were converted from robotic to open. Median operative time and estimated blood loss were 311 minutes and 97.2 mL, respectively. Median intensive care unit stay was 1 day (range, 0–16), and median length of hospital stay was 9 days (range, 6–36). Postoperative complications frequently observed were anastomotic stricture (n= 27), recurrent laryngeal nerve paresis (n= 14), anastomotic leak (n= 10), pneumonia (n= 8), and pleural effusion (n= 18). Incidence rates of laryngeal nerve paresis (35%) and leak rate (25%) were somewhat higher in comparison with that reported in literature. However, all vocal cord injuries were temporary, and all leaks healed following opening of the cervical incision and drainage. None of the patients died in the hospital, and 30‐day mortality was 2.5% (1/40). Median number of lymph nodes removed was 20 (range, 3–38). In 33 patients with known lymph node locations, median of four (range, 0–12) nodes was obtained from the mediastinum, and median of 15 (range, 1–26) was obtained from the abdomen. R0 resection was achieved in 94.7% of patients. At the end of the follow‐up period, 25 patients were alive, 13 were deceased, and 2 patients were lost to follow‐up. For patients with EC, median disease‐free survival was 20 months (range, 3–45). Transhiatal RE, by experience, is a feasible albeit evolving oncologic operation with low hospital mortality. The benefits include minimally invasive mediastinal dissection without thoracotomy or thoracoscopy. A reasonable operative time with minimal blood loss and postoperative morbidity can be achieved, in spite of the technically demanding nature of the procedure. Broader use of this technology in a setting of high‐volume comprehensive surgical programs will almost certainly reduce the complication rates. Robotic tanshiatal esophagectomy with the elimination of a thoracic approach should be considered an option for the appropriate patient population in a comprehensive esophageal program.     

Safety and efficacy of nonvitamin K antagonist oral anticoagulants versus warfarin in diabetic patients with atrial fibrillation: A study‐level meta‐analysis of phase III randomized trials

In patients with atrial fibrillation (AF), the safety and efficacy of nonvitamin K antagonist oral anticoagulants (NOACs) vs warfarin according to diabetes mellitus (DM) status are not completely characterized. We performed a meta‐analysis to clarify whether in these patients the strategy of oral anticoagulation should be tailored to diabetes status. In this study‐level meta‐analysis, we included 4 randomized phase III trials comparing NOACs and warfarin in patients with nonvalvular AF; a total of 18 134 patients with DM and 40 454 without DM were overall considered. Incidence of the following outcome measures was evaluated during the follow‐up: stroke or systemic embolism, ischemic stroke, major bleeding, intracranial bleeding, and vascular death. Use of NOACs compared with warfarin reduced stroke/systemic embolism in diabetic (Risk Ratios [RR] 0.80, 95% CI 0.68‐0.93; P  = .004) and nondiabetic patients (RR 0.83, 0.73‐0.93; P  = .001) (P for interaction .72). No interaction between diabetes status and benefits of NOACs was found for the occurrence of ischemic stroke, major bleeding, or intracranial bleeding (P for interaction >.05 for each comparison). Reduction of vascular death rates with NOACs was significant in diabetic patients (4.97% vs 5.99% with warfarin; RR 0.83, 0.72‐0.96; P  = .01), in whom absolute the reduction of this outcome measure was higher than in nondiabetics (1.02% vs 0.27%), although no interaction was present (P  = .23). Results of this meta‐analysis support the safety and efficacy of NOACs compared with warfarin in diabetic patients with nonvalvular AF.     

Comparison of efficacy and safety between VKAs and DOACs in patients with atrial fibrillation after transcatheter aortic valve replacement: A systematic review and meta‐analysis

In the past decade, direct oral anticoagulants (DOACs) have proven to be the best option for patients with nonvalvular atrial fibrillation. Nevertheless, evidence for the use of DOACs for anticoagulation in valvular atrial fibrillation, particularly after aortic valve replacement, remains inadequate. Thus, we conducted a meta‐analysis to compare the efficacy and safety of vitamin K antagonists (VKAs) and DOACs in patients with atrial fibrillation after transcatheter aortic valve replacement (TAVR). We conducted a comprehensive search of online databases, and 11 studies were included in the final analysis. The primary endpoint was all‐cause mortality. Secondary endpoints included stroke and cardiovascular death. The safe endpoint is major and/or life‐threatening bleeding. Subgroup analysis was conducted according to the different follow‐up time of each study. Random‐effects models were used for all outcomes. Statistical heterogeneity was assessed using χ ² tests and quantified using I ² statistics. Patients in the DOACs group had a significantly lower risk of all‐cause mortality compared with patients in the VKAs group (relative risk [RR]: 1.20, 95% confidence interval [CI]: 1.01–1.43, p = .04). This benefit may be greater with longer follow‐up. In a subgroup analysis based on the length of follow‐up, a significantly lower risk of all‐cause mortality was found in the DOACs group in the subgroup with a follow‐up time of >12 months (RR: 1.50, 95% CI: 1.07–2.09, p = .001). There were no significant differences between the two groups in cardiovascular death, stroke, and major and/or life‐threatening bleeding. For patients with atrial fibrillation after TAVR, the use of DOACs may be superior to VKAs, and the benefit may be greater with longer follow‐up. The anticoagulant strategy for atrial fibrillation after TAVR is a valuable direction for future research.     

Premere occlusion system for transcatheter patent foramen ovale closure: Mid‐term results of a single‐center registry

Background: Transcatheter closure of patent foramen ovale (PFO) with rigid devices may be problematic in patients with long channel PFO: alternative devices with asymmetrical opening and more physiological positioning may be preferable in such cases. We present the mid‐term results of transcatheter closure of PFO with Premere Occlusion System, a device studied for this specific anatomy, in a single‐center registry of adults with previous cerebral ischemia. Methods: During a 53‐months period (July 1, 2005 to December 1, 2009) 70 patients (48 females and 22 males, mean age 38 ± 6.7 years) with previous stroke were admitted in our center for transcatheter closure of PFO with Premere Occlusion System on the basis of absence of moderate or severe atrial septal aneurysm (ASA) on Transesophageal echocardiography and intracardiac echocardiography (< 3RL or 3LR ASA and length of PFO channel >10 mm). Results: The procedure was successful in all of the patients with no peri‐operative and in‐hospital complications. Forty‐six 20 mm and twenty‐four 25 mm Premere devices were implanted. Rates of procedural success, predischarge occlusion, and complication were: 100%, 95.7% and 0%, respectively. On mean follow‐up of 40 ± 10.9 months (range 6–54), the follow‐up occlusion rate was 98.5%. During follow‐up, no cases of permanent atrial fibrillation, aortic/atrial erosion, device thrombosis, or atrioventricular valve inferences were noted. Conclusion: The mid‐term outcomes of our registry suggests that the Premere Occlusion System may be an excellent device for patients with long‐channel PFO and absence of moderate/severe ASA, offering a physiological and anatomically respective closure of PFO also in patients with hypertrophic rims. © 2010 Wiley‐Liss, Inc.     

Current status of low‐density lipoprotein cholesterol for primary prevention of coronary artery disease in late‐stage elderly persons with type 2 diabetes mellitus: A retrospective,single‐center study

Aims/IntroductionThe importance of low‐density lipoprotein cholesterol (LDL‐C) in the primary prevention of cardiovascular disease has recently been reported in the population aged ≥75 years with hypercholesterolemia. Therefore, the current status of LDL‐C management for primary prevention of coronary artery disease in patients aged ≥75 years with type 2 diabetes mellitus was investigated.Materials and MethodsA total of 124 patients aged ≥75 years who had type 2 diabetes mellitus, but no coronary artery disease, were investigated. The patients'' background characteristics, LDL‐C, glycemic status, ankle‐brachial index and cardio‐ankle vascular index were compared between patients taking and not taking LDL‐C‐lowering agents, such as hydroxymethylglutaryl‐CoA reductase inhibitors (statins) and ezetimibe. The details of the antihyperlipidemic and antidiabetic agents used in the present study were also examined.ResultsLDL‐C was significantly lower in patients taking LDL‐C‐lowering agents (LDLCLT[+]) than in patients not taking them (LDLCLT[−]), although LDL‐C was maintained <120 mg/dL in both groups (93.0 mg/dL vs 102.1 mg/dL). Approximately half of the cases in the LDLCLT(+) group received moderate‐intensity statins, with pitavastatin being the most prescribed statin. Glycated hemoglobin was significantly lower in the LDLCLT(+) group than in the LDLCLT(−) group (6.9% vs 7.3%). Sodium‐glucose transporter 2 inhibitors were more frequently used in the LDLCLT(+) group than in the LDLCLT(−) group. The ankle‐brachial index/cardio‐ankle vascular index did not differ between the groups.ConclusionLow‐density lipoprotein cholesterol was properly managed for primary prevention of coronary artery disease in patients aged ≥75 years with type 2 diabetes mellitus regardless of the presence or absence of LDL‐C‐lowering agents.     

Off‐pump versus on‐pump coronary artery bypass grafting for octogenarians: A meta‐analysis involving 146 372 patients

There is an ongoing debate concerning the optimal surgical option of myocardial revascularization for octogenarians. The current meta‐analysis aimed to compare clinical outcomes following off‐pump coronary artery bypass grafting (OPCABG) or conventional coronary artery bypass grafting (CCABG) in octogenarians. PubMed, Cochrane, Web of Science, and EMBASE databases were searched to identify eligible studies from inception to March 2021. The analysis was performed using STATA 15.1. A literature search yielded 18 retrospective studies involving 146 372 patients (OPCABG = 44 522 vs. CCABG = 101 850). Pooled analysis showed a strong trend toward reducing mortality risk in the OPCABG group (odds ratio: 0.75, 95% confidence interval: 0.56–1.00, p = .05). However, it did not reach statistical significance. The sensitive analysis demonstrated that OPCABG was less likely to cause death than CCABG. There were comparable data in myocardial infarction, renal failure, deep sternal wound infection, and hospital stays between the two groups, although the incidence of stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding was significantly lower in the OPCAGB group. OPCABG may be an effective surgical strategy for myocardial revascularization, especially in reducing the incidence of postoperative stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding.     

Etiology,risk factors,and prognosis of patients with syncope: A single‐center analysis

ObjectiveTo investigate the main causes, risk factors, and prognosis of patients hospitalized with syncope.MethodsThe patients admitted due to syncope were included. We analyzed the etiology, risk factors, and prognosis of patients with an average follow‐up of 15.3 months.ResultsHigh‐risk factors for cardiogenic syncope included age ≥60, male, hypertension, palpitation, troponin T‐positive, abnormal ECG, CHD history, and syncope‐related trauma. Mortality rate was 4.6%, recurrence rate of syncope was 10.5%, and the rehospitalization rate was 8.5%. Univariate analysis showed that prognosis of syncope was related to age ≥60 years old, hypertension, positive troponin T, abnormal electrocardiogram, and coronary heart disease (p < .05). Multivariate Cox proportional hazard analysis showed that age ≥60 years old (p = .021) and high‐sensitivity troponin‐positive (p = .024) were strongly related to the prognosis of syncope. Kaplan–Meier curve showed statistical difference in the survival rate between the groups divided by age ≥60 years (p = .028), hs‐TnT‐positive (p < .001), abnormal ECG (p = .027), and history of CHD (p = .020).ConclusionHigh‐risk factors for cardiogenic syncope included age ≥60, male, hypertension, palpitation, troponin T‐positive, abnormal ECG, CHD family history, and syncope‐related trauma. Age, hypertension, troponin T‐positive, abnormal ECG, and CHD history were associated with the prognosis of syncope.     

Clinical characteristics of patients with chronic eosinophilic pneumonia in a Chinese tertiary‐care hospital: A 6‐year retrospective study

IntroductionChronic eosinophilic pneumonia (CEP) is a rare disease with unknown etiology. Due to lack of specificity of CEP symptoms, clinicians are not experienced in establishing its diagnosis.ObjectivesTo summarize the clinical data of CEP patients to improve the understanding of CEP and reduce misdiagnosis.MethodsData of patients pathologically diagnosed with CEP in the PLA General Hospital between May 2013 and May 2019 were collected, and clinical manifestations, imaging characteristics, pathological features, and treatment were retrospectively analyzed.ResultsTwenty patients, including 6 males and 14 females, were diagnosed with CEP. The average age was 47.0 ± 10.2 years. The main clinical manifestations were cough and dyspnea. The average duration of CEP was 15.5 ± 11.5 months. The average proportion of eosinophils in the peripheral blood was 18.9 ± 17.8%, and the average proportion of eosinophils in the bronchoalveolar lavage fluid was 41.5 ± 19.4%. The main imaging features were patchy shadows and consolidation shadows. The most common manifestations on bronchoscopic examination were congestion and edema of the bronchial mucosa. Two patients had granular protrusions of the endotracheal membrane. Histological examination indicated infiltration of numerous eosinophils. All patients improved after prednisone therapy.ConclusionCEP onset is insidious, and clinical manifestations lack specificity. Typical imaging features are peripheral and subpleural distribution of lung infiltrates. Some patients have a normal proportion of eosinophils in the peripheral blood, but most have an increased number of eosinophils in the BALF, which contributes to CEP diagnosis. A biopsy is necessary when differential diagnosis is difficult. A systemic glucocorticoid is effective.     

Efficacy and safety of same‐day discharge after atrial fibrillation ablation: A systematic review and meta‐analysis

Conventionally, patients have been admitted overnight after atrial fibrillation (AF) catheter ablation. Several centers have recently adopted a same‐day discharge (SDD) protocol for patients undergoing AF catheter ablation. We aimed to systematically review the current evidence for the safety and efficacy of SDD after AF catheter ablation. A systematic search was performed in PubMed, Embase, Scopus, Web of Science, and the Cochrane library until August 21, 2021. The risk of bias was assessed with the “Methodological Index for Non‐Randomized Studies” (MINORS). The pooled efficacy rate of SDD protocol (defined as the proportion of patients discharged the same day of ablation among the patients who were planned for SDD) was calculated. Meanwhile, pooled major complication rates and early readmission or emergency department (ED) visit rates were evaluated in successful and planned SDD groups separately. Overall, 12 observational studies consisting of 18,065 catheter ablations were included, among which 7320 (40.52%) were discharged the same‐day after ablation. The pooled efficacy was 90.3% (95% confidence interval [CI] [82.7–96.0]). The major complication rates were 1.1% (95%CI [0.5–1.9]), and 0.7% (95% CI [0.0–3.1]) in planned SDD and successful SDD groups, respectively. In addition, readmission/ED visit rate were 3.0% (95%CI [0.9–6.1]), and 3.1% (95% CI [0.8–6.5]) in the same groups. There were no significant differences between planned SDD and overnight groups with respect to major complication rate (risk ratio = 0.70, 95%CI [0.35–1.42], p‐value = .369). The available data indicates that SDD after AF ablation is safe and efficient. Further prospective and randomized studies are warranted to elucidate the safety of SDD after AF ablation and develop a standardized SDD protocol.