Ajay Vallakati

Feasibility and Safety of Uninterrupted Rivaroxaban for Periprocedural Anticoagulation in Patients Undergoing Radiofrequency Ablation for Atrial Fibrillation

OBJECTIVES The purpose of this study was to evaluate the feasibility and safety of uninterrupted rivaroxaban therapy during atrial fibrillation (AF) ablation. BACKGROUND Optimal periprocedural anticoagulation strategy is essential for minimizing bleeding and thromboembolic complications during and after AF ablation. The safety and efficacy of uninterrupted rivaroxaban therapy as a periprocedural anticoagulant for AF ablation are unknown. METHODS We performed a multicenter, observational, prospective study of a registry of patients undergoing AF ablation in 8 centers in North America. Patients taking uninterrupted periprocedural rivaroxaban were matched by age, sex, and type of AF with an equal number of patients taking uninterrupted warfarin therapy who were undergoing AF ablation during the same period. RESULTS A total of 642 patients were included in the study, with 321 in each group. Mean age was 63 ± 10 years, with 442 (69%) males and 328 (51%) patients with paroxysmal AF equally distributed between the 2 groups. Patients in the warfarin group had a slightly higher mean HAS- BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly) score (1.70 ± 1.0 vs. 1.47 ± 0.9, respectively; p = 0.032). Bleeding and embolic complications occurred in 47 (7.3%) and 2 (0.3%) patients (both had transient ischemic attacks) respectively. There were no differences in the number of major bleeding complications (5 [1.6%] vs. 7 [1.9%], respectively; p = 0.772), minor bleeding complications (16 [5.0%] vs. 19 [5.9%], respectively; p = 0.602), or embolic complications (1 [0.3%] vs. 1 [0.3%], respectively; p = 1.0) between the rivaroxaban and warfarin groups in the first 30 days. CONCLUSIONS Uninterrupted rivaroxaban therapy appears to be as safe and efficacious in preventing bleeding and thromboembolic events in patients undergoing AF ablation as uninterrupted warfarin therapy.

Initial experience with post Lariat left atrial appendage leak closure with Amplatzer septal occluder device and repeat Lariat application

BACKGROUND Left atrial appendage (LAA) ligation with the Lariat device is a therapeutic option to prevent thromboembolic stoke in patients with nonvalvular atrial fibrillation (AF) at high risk for systemic thromboembolization and bleeding related to use of anticoagulation. In rare cases, this procedure could leave the LAA incompletely ligated with continued risk of stroke. OBJECTIVE The purpose of this study was to investigate the incidence and characteristics of LAA leak following ligation using the Lariat device and the feasibility of leak closure with the Amplatzer septal occluder device or a repeat Lariat application. METHODS Seventy-one consecutive patients who underwent LAA ligation by the Lariat device were followed-up with transesophageal echocardiography to evaluate for the presence of appendage leaks, characterization of the leaks, and the presence of any thrombus. Patients with LAA leaks underwent definite closure of the leak. RESULTS Six patients had LAA leaks with a mean leak size of 4.3 ± 0.6 mm. All leaks were concentric in nature. None of the patients had LAA thrombus. Leaks in 5 of these patients were successfully closed using an Amplatzer septal occluder device (St. Jude Medical); the leak in the sixth patient was closed using a repeat Lariat procedure. CONCLUSION LAA leaks from incomplete ligation of the LAA following the Lariat procedure are not uncommon and could be successfully closed with an Amplatzer septal occluder device or a repeat Lariat procedure.

Risk of Atrial Fibrillation With Use of Oral and Intravenous Bisphosphonates

Clinical studies suggest an association between bisphosphonate use and new-onset atrial fibrillation (AF). Intravenous bisphosphonates more potently increase the release of inflammatory cytokines than do oral bisphosphonates; thus, the risk of developing AF may be greater with intravenous preparations. We have evaluated incidence of new-onset AF with use of oral and intravenous bisphosphonates through a systematic review and meta-analysis of the literature. We searched PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Scopus, and EMBASE databases for observational studies and randomized controlled trials (RCTs) published from 1966 to April 2013 that reported the number of patients developing AF with use of oral or intravenous bisphosphonates. The random-effects Mantel-Haenszel test was used to evaluate the relative risk of AF with use of oral and intravenous bisphosphonates. Nine studies (5 RCTs and 4 observational studies) were included in the final analysis. Pooled data from RCTs and observational studies (n = 135,347) showed a statistically significantly increased risk of new-onset AF with both intravenous (relative risk 1.40, 95% confidence interval 1.32 to 1.49) and oral (relative risk 1.22, 95% confidence interval 1.14 to 1.31) bisphosphonates. The z statistic, which assesses the difference between the 2 risk ratios, indicated higher risk of AF with intravenous bisphosphonates versus oral bisphosphonates (p = 0.03). In conclusion, pooled data from RCTs and observational studies suggest that risk of AF is increased by use of oral or intravenous bisphosphonates but further suggest that risk is relatively greater with intravenous preparations.

The Impact of Atrial Fibrillation and Its Treatment on Dementia

Atrial fibrillation (AF) is a very common tachyarrhythmia and is becoming increasingly prevalent, while dementia is a neurological condition manifested as loss of memory and cognitive ability. Both these conditions share several common risk factors. It is becoming increasingly evident that AF increases the risk of dementia. There are several pathophysiological mechanisms by which AF can cause dementia. AF increases the stroke risk and strokes are strongly associated with dementia. Besides stroke, altered cerebral blood flow in AF and cerebral microbleeds from anticoagulation may enhance the risk of dementia. Maintaining sinus rhythm may therefore decrease this risk. Catheter ablation is emerging as an effective alternative to maintain patients in sinus rhythm. This procedure has also shown promise in decreasing the risk of all types of dementia. Besides maintaining sinus rhythm and oral anticoagulation, aggressive risk factor modification may reduce the likelihood or delay the onset of dementia.

Dronedarone-induced digoxin toxicity: new drug, new interactions.

Dronedarone is a relatively new antiarrhythmic drug approved for paroxysmal or persistent atrial fibrillation. Dronedarone can inhibit P-glycoprotein-mediated digoxin clearance and increase steady-state digoxin level 2.5 times. It is important to closely monitor plasma digoxin levels or administer a lower loading dose of digoxin in patients taking dronedarone concomitantly. We report a case of digoxin toxicity in a patient taking concomitant dronedarone as a result of interaction between digoxin and dronedarone.

Intra-atrial tumor thrombi secondary to hepatocellular carcinoma responding to chemotherapy

Context: Hepatocellular carcinoma accounts for 1-2.5% of all cancer in America with extension to inferior vena cava and right atrium in 1-4% of the cases. Patients with advanced hepatocellular carcinoma invading the right heart are considered poor candidates for surgery. In the past, such patients had dismal prognosis due to complications like pulmonary embolism and sudden death. Case Report: Our patient was admitted with worsening jaundice, abdominal pain and significant weight loss. Abdominal ultrasound, elevated alfa feto-protein levels and computerized tomography pointed to the diagnosis of hepatocellular carcinoma. Transthoracic echocardiography demonstrated two masses in the right atrium with the base of masses extending from inferior vena cava into right atrium. The patient was diagnosed to have stage IV heptaocellular carcinoma. This is associated with dismal prognosis. But after being started on sorafenib, the tumor regressed considerably and was barely discernable on echocardiography performed a month later. Conclusion: Though aggressive surgical resection is the best therapeutic approach for hepatocellular carcinoma, it may not always be possible and in such cases combination of different therapeutic approaches such as chemotherapeutic agents, radiotherapy and chemoembolization may improve survival.

Left atrial thrombus formation after successful left atrial appendage ligation: case series from a nationwide survey.

Percutaneous left atrial appendage (LAA) exclusion can be performed using endocardial occlusion devices or an endoepicardially placed suture delivery device (1-3). Thrombus formation on endocardial occlusion devices (Watchman, Boston Scientific, Marlborough, Massachusetts; or Amplatzer Cardiac Plug [ACP], St. Jude Medical, St. Paul, Minnesota) (1,2) has been attributed to platelet aggregation in the setting of a foreign body in the left atrium (LA). With the percutaneous endoepicardial ligation technique (Lariat, SentreHEART, Redwood City, California), there is no foreign body left behind, and the risk of thrombus formation should be insignificant. This study describes the clinical course of LA thrombi after the Lariat procedure in 19 patients. We conducted a nationwide survey of physicians performing procedures with the Lariat device in the United States to identify patients who developed LA thrombus after the procedure. Our study cohort comprised patients found to have LA thrombus post-procedure. Post-procedure surveillance imaging was not uniform across centers. Most patients underwent transesophageal echocardiogram (TEE)/computed tomography at 1 to 3 months post-procedure. Anticoagulation/antiplatelet therapy was initiated immediately after detection of LA thrombus. We collected demographic, clinical, and pre-procedural imaging characteristics of patients. Procedural variables and clinical course of patients after thrombus detection were recorded. Statistical analyses were performed using SPSS version 19.0 for Windows (SPSS, Inc., Chicago, Illinois). A total of 47 operators participated in the survey. Routine post-procedure imaging was performed by 44 (93.6%) operators. Three (6.4%) operators performed imaging only if clinically indicated. Routine post-procedure follow-up imaging was performed at 1 to 3 months and 3 to 6 months by 80% and 40% of the operators, respectively. Of the 964 patients who underwent the procedure, 19 (2%) had an LA thrombus. Table 1 lists some patient characteristics and includes follow-up data of the 19 patients. TABLE 1 Patient Characteristics and Follow-Up (n = 19) LA thrombus was detected within 90 days in 15 (79%) patients. TEEs performed in the first 6 months were negative for thrombi in 2 patients with clots discovered >200 days after the procedure. Eighteen patients received oral anticoagulants after detection of LA thrombus, whereas 1 patient received antiplatelet therapy. Thrombus remained unchanged at 90 days in the latter patient, requiring a switch to rivaroxaban. Serial TEEs were performed until thrombus resolution. Oral anticoagulation was discontinued in 16 patients after clot resolution, whereas 3 patients with unresolved thrombi remained on anticoagulation (30, 58, and 80 days, respectively). None of the patients had clinical evidence of stroke or peripheral embolism during follow-up. Our study highlights that the risk of LA thrombus formation with the device is low (2%). Most (79%) cases were detected within the first 90 days. Prompt initiation of anticoagulation can lead to thrombus resolution. This is the first investigation to describe the clinical course of LA thrombus post-procedure in a large cohort of patients receiving the Lariat device. In a clinical study involving 89 patients, no case of LA thrombus was detected on the 30-day post-procedure TEE. However, 1 patient had an LA thrombus away from the site of occlusion at 1-year follow-up (3). Our study is consistent in that, although uncommon, an LA thrombus can develop after the procedure. The pathophysiology of LA thrombus formation after the Lariat procedure remains unclear. Focal endocardial damage and inflammation around the LAA orifice secondary to tissue compression from the Lariat suture, causing edema and ischemic necrosis around the ligation site, can increase the propensity for LA thrombus formation. In our study, 17 of 19 (89%) patients developed a thrombus at the ligation site. Currently, there are no clear guidelines on LA thrombus surveillance after LAA ligation. We strongly support a follow-up TEE 30 to 90 days post-procedure. Given that the risk of thrombus formation is greatest during the first 3 months post-procedure, it may be appropriate for patients to receive antiplatelet or anticoagulant therapy during this period. The risk of LA thrombus in the absence of anticoagulation use post-procedure is low and is more frequently seen during the first 3 months after LAA ligation. Periodic imaging studies are essential for early detection of an LA thrombus. With prompt initiation of anticoagulation and close supervision, an LA thrombus can be managed safely.

Impact of gender on outcomes after atrial fibrillation ablation

a Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, United States b Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid-America Cardiology, University of Kansas Hospital & Medical Center, Kansas City, KS, United States c Division of Cardiovascular Medicine, State University of New York Downstate Medical Center, NY, United States d Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, United States e Texas Cardiac Arrhythmia Institute, Austin, TX, United States f Department of Biomedical Engineering, University of Texas, Austin, TX, United States g Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States

Impact of haematoma after pacemaker and CRT device implantation on hospitalization costs, length of stay, and mortality: a population-based study

AIMS Pocket haematoma is a common complication following pacemaker implantation. Impact of this complication on post-procedural outcomes has previously not been systematically studied. We sought to identify the incidence of pocket haematoma after a de novo pacemaker and cardiac resynchronization therapy (CRT) device implantation and evaluate its impact on the hospital outcomes using a large all-payer national inpatient database. METHODS AND RESULTS Data from Nationwide Inpatient Sample 2010 was queried to identify all primary implantations of single chamber, dual chamber pacemakers, and biventricular devices during the year 2010 using the appropriate ICD-9 codes. Patients who experienced a procedure-related haematoma during the hospital stay were identified. Of a total of 78,751 primary pacemaker implantations in the year 2010, 1677 (2.1%) of the implantations were complicated by a pocket haematoma. Higher age groups, more complex pacemaker types (BiV > dual chamber > single chamber), and comorbidities such as congestive heart failure and coagulopathy were associated with an increased risk of pocket haematoma formation post-pacemaker implantation. Patients who developed a pocket haematoma had a longer length of stay (8.7 vs. 4.8 days, P < 0.001), higher hospitalization costs (

EFFECT OF ENDOEPICARDIAL PERCUTANEOUS LEFT ATRIAL APPENDAGE LIGATION (LARIAT) ON ARRHYTHMIA BURDEN IN PATIENTS WITH ATRIAL FIBRILLATION

48,815 vs.