Bharath Rajagopalan

Cancer Treatment–Induced Arrhythmias: Focus on Chemotherapy and Targeted Therapies

With the development of newer drugs and improvements in established treatment protocols, prognosis for many types of cancer has improved dramatically. Some cancers that were historically associated with high fatality rates now have high cure rates or successful palliation, turning the malignancy into a chronic disease. Given this improved prognosis, more patients will face the adverse effects of cancer treatment. Cancer therapy can result in cardiac toxicity, such as cardiomyopathy. Cardiotoxicity with chemotherapeutic agents in the form of cardiomyopathy was first described in 1966 in patients receiving anthracyclines.1 However, cancer treatment–induced arrhythmia (CTIA) has not attracted specific attention until recently.2 CTIA is a complex entity with multiple factors involved in its pathogenesis. It can be divided into primary CTIA (caused by a drug disrupting specific molecular pathways critical for the development of a specific arrhythmia) and secondary CTIA (caused by damage to the endocardium/myocardium/pericardium through ischemia, inflammation, or radiation therapy (RT), with arrhythmia as a secondary phenomenon). Secondary CTIA is much more common. The distinction between primary and secondary CTIA is not well defined, with many contributing and confounding factors, and the exact mechanisms for many drugs are still to be elucidated (Figure). Figure. Mechanisms of arrhythmias in cancer patients. AC indicates anthracyclines; ATO, arsenic trioxide; HA, histamine; hERG, human Ether-a-go-go -Related Gene; PI3K, phosphotidyl inositol 3–kinase; PKI, protein kinase inhibitors; SB, sinus bradycardia; and 5-FU, 5-fluorouracil. Heart image reprinted with permission from Marieb and Hoehn.3 Copyright

Contemporary Approach to Electrical and Pharmacological Cardioversion of Atrial Fibrillation

Abstract In patients with atrial fibrillation (AF), a rhythm–control strategy may be adopted when there are unacceptable symptoms from AF, failure of rate control, and/or the presence of comorbidities, such as heart failure, that may improve with restoration of sinus rhythm. When a rhythm–control strategy is chosen and the patient is in persistent AF, cardioversion will be necessary to convert the rhythm to sinus. Patients with AF present for > 48 hours must be effectively anticoagulated both prior to and after cardioversion. With newer oral anticoagulants, achieving effective anticoagulation is faster and more reliable, with no requirement for blood test monitoring. Cardioversion can be accomplished either electrically or pharmacologically, and in some cases, electrical cardioversion may be facilitated pharmacologically. Electrical cardioversion has a higher success rate compared with pharmacological cardioversion in the short–term. Pharmacological cardioversion is usually accomplished with intravenous ibutilide, oral flecainide or propafenone, or intravenous amiodarone. Oral amiodarone and dofetilide also result in chemical cardioversion in some patients over a longer period of time. Long–term success in the maintenance of sinus rhythm post–cardioversion can be increased with the use of antiarrhythmic drugs. Alternatively, when AF is recurrent and symptomatic despite the use of antiarrhythmic drugs, catheter ablation is a reasonable option for many patients. Cardioversion may be incorporated into the management approach of persistent AF when the primary therapeutic option chosen is catheter ablation.

State of Structural and Congenital Heart Disease Interventional Training in United States and Canada: An Assessment by the American College of Cardiology Fellows-in-Training Section Leadership Council.

The field of adult and pediatric interventional cardiology (PIC) has expanded considerably over the last decade. Given the recent advances like transcatheter aortic valve replacement, percutaneous mitral valve repair, and left atrial appendage closure, many cardiology training programs are offering

Efficacy of Intravenous Magnesium in Facilitating Cardioversion of Atrial Fibrillation

Background—Low serum magnesium (Mg) levels are associated with an increased risk of atrial fibrillation. Some studies have shown a benefit of Mg in facilitating pharmacological cardioversion. The role of an intravenous infusion of Mg alone in facilitating electric cardioversion is not clear. Methods and Results—In a prospective, randomized, double-blind, placebo-controlled trial, we enrolled patients with atrial fibrillation who were scheduled for electric cardioversion. Patients were randomized to receive Mg or placebo before cardioversion using a step-up protocol with 75, 100, 150, and 200 J biphasic shocks. Patients with hypokalemia, hypermagnesemia, or postcardiac surgery atrial fibrillation were excluded. Patients on antiarrhythmic drugs were included as long as they were at steady state. All patients were monitored for 1 hour post procedure for the maintenance of sinus rhythm. A total of 261 patients (69% male, mean age 65.5±11.1 years) were randomized (132 and 129 patients receiving Mg and placebo, respectively). Baseline characteristics were similar between both the groups. There was no statistically significant difference in the success rate of cardioversion between the 2 groups (86.4% versus 86.0%; P=0.94), cumulative amount of energy required for successful cardioversion (123.3±55.5 versus 129.5±52.6 J; P=0.40), or the number of shocks required to convert to sinus rhythm (2.25±1.24 versus 2.41±1.22, P=0.31). No adverse events were noted in either group. Conclusions—In patients undergoing electric cardioversion for persistent atrial fibrillation, Mg infusion does not increase the rate of successful cardioversion. Clinical Trial Information—URL: https://clinicaltrials.gov. Unique identifier: NCT01597557.

Management of atrial fibrillation: What is new in the 2014 ACC/AHA/HRS guideline?

Abstract Recently, the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society published an updated guideline on the management of atrial fibrillation (AF). This document is a complete revision of the 2006 guideline. Prominent changes in the 2014 guideline include the use of the CHA2DS2-VASc score for risk stratification of stroke, recommendations on when and how to use newer oral anticoagulants for thromboprophylaxis, downgrading of the use of aspirin for thromboprophylaxis of moderate-risk patients, and the use of catheter ablation in selected patients as first-line therapy for paroxysmal AF. In regard to rate control, the 2014 guideline reverts back to a previous recommendation for stricter targets for mean and maximum heart rate on therapy. The current guideline incorporates many recent trials in updating existing recommendations from the 2006 guideline. The 2014 guideline will be a vital tool in guiding physicians in the management of AF.

A New Educational Framework to Improve Lifelong Learning for Cardiologists

Lifelong learning is essential for the practicing cardiologist. Present lifelong learning mechanisms are stagnant and at risk for not meeting the needs of currently practicing cardiologists. With the increasing burden of cardiovascular disease, growing complexity of patient care, and ongoing pressures of nonclinical responsibilities, educational programming must evolve to meet the demands of the contemporary cardiovascular professional. A paradigm shift, replete with modern and practical educational tools, is needed in the lifelong learning armamentarium. Emerging evidence of novel educational strategies in graduate medical education supports the promise of broader application of these tools to different stages of professional life. In this commentary from the Fellows-in-Training Section Leadership Council, the authors propose 3 novel educational tools-personalized learning, adaptive learning, and the flipped classroom-to improve lifelong learning to meet the educational needs of fellows-in-training to practicing cardiologists alike.

TCT-334 Predictors of Outcomes Among Nonagenarians Undergoing Percutaneous Coronary Intervention: A National Veterans Affairs Database Study

TCT-334 Predictors of Outcomes Among Nonagenarians Undergoing Percutaneous Coronary Intervention: A National Veterans Affairs Database Study Abhishek Sawant, Vasvi Singh, Kevin Josey, Meg Plomondon, Thomas Maddox, Ali Sheikh, Zaid Said, Bharath Rajagopalan, Deepak Bhatt, John Corbelli State University of New York at Buffalo, Buffalo, New York, United States; Clinical centre of Serbia; Clinical centre of Serbia; Niguarda Hospital; Kurume-univaersity; Kurume-univaersity; University of Glasgow; Golden Jubilee National Hospital; Brigham and Women’s Hospital, Boston, Massachusetts, United States; School of Medicine, University of California, Irvine

PROPHYLACTIC IMPLANTABLE CARDIOVERTER DEFIBRILLATOR IN CARDIAC SARCOIDOSIS: SAVE A LIFE, COST A JOB?

Cardiac sarcoidosis (CS) is a granulomatous disease that could result in life threatening arrhythmias. Recent HRS expert consensus statement recommends prophylactic ICD implantation in patients with CS who requires a pacemaker implantation for high degree AV block. A 55-year-old Caucasian

TOO MUCH CALCIUM, TOO LITTLE GRADIENT: AN UNUSUAL CASE OF LOW GRADIENT AORTIC STENOSIS

case: 89 year old female with hypertension and hyperlipidemia presented with new onset severe limiting fatigue and an elevated troponin. A grade 3/6 late peaking systolic murmur and 2/6 diastolic rumble were found on cardiac auscultation. The patient had an echocardiogram which demonstrated mild left ventricular hypertrophy, hyperdynamic left ventricular systolic function with an ejection fraction > 75%, low gradient severe AS (mean gradient 23 mmHg, indexed aortic valve area 0.5 cm2/m2) and functional mitral stenosis (MS) secondary to significant mitral annular calcification with restricted posterior leaflet motion (mean gradient 11 mmHg). Paradoxical low gradient severe AS was suspected and the patient went for cardiac catheterization. She was found to have anomalous coronary circulation with all three coronary arteries arising from the right coronary cusp, and non-obstructive disease. The left ventricular end diastolic pressure was 12 mmHg, and cardiac output by both estimated Fick and thermodilution method was 4.1 L/min. The mean gradient across the aortic valve was 30 mmHg with a calculated area of 0.7 cm2 and an indexed stroke volume of 30 ml/m2 confirming low flow, low gradient severe AS with preserved ejection fraction.

MECHANICAL COMPLICATIONS OF ROBOTIC MITRAL VALVE REPAIR: VIRTUOUS INTENTIONS, MALIGN CONSEQUENCES?

The use of robotic valve surgery for mitral valve repair is steadily increasing. The complication rate is 1-2% in experienced centers, and much higher in less experienced centers. 73 year old Caucasian woman with a history of diabetes, hypertension, and severe mitral regurgitation underwent, what