Erin A. Fender

Severe Pulmonary Vein Stenosis Resulting From Ablation for Atrial Fibrillation: Presentation, Management, and Clinical Outcomes.

Background: The frequency of pulmonary vein stenosis (PVS) after ablation for atrial fibrillation has decreased, but it remains a highly morbid condition. Although treatment strategies including pulmonary vein dilation and stenting have been described, the long-term impacts of these interventions are unknown. We evaluated the presentation of severe PVS, and examined the risk for restenosis after intervention using either balloon angioplasty (BA) alone or BA with stenting. Methods: This was a prospective, observational study of 124 patients with severe PVS evaluated between 2000 and 2014. Results: All 124 patients were identified as having severe PVS by computed tomography in 219 veins. One hundred two patients (82%) were symptomatic at diagnosis. The most common symptoms were dyspnea (67%), cough (45%), fatigue (45%), and decreased exercise tolerance (45%). Twenty-seven percent of patients experienced hemoptysis. Ninety-two veins were treated with BA, 86 were treated with stenting, and 41 veins were not treated. A 94% acute procedural success rate was observed and did not differ by initial management. Major procedural complications occurred in 4 of the 113 patients (3.5%) who underwent invasive assessment, and minor complications occurred in 15 patients (13.3%). Overall, 42% of veins developed restenosis including 27% of veins (n=23) treated with stenting and 57% of veins (n=52) treated with BA. The 3-year overall rate of restenosis was 37%, with 49% of BA-treated veins and 25% of stented veins developing restenosis (hazard ratio, 2.77; 95% confidence interval, 1.72–4.45; P<0.001). After adjustment for age, CHA2DS2-VASc score, hypertension, and the time period of the study, there was still a significant difference in the risk of restenosis for BA versus stenting (hazard ratio, 2.46; 95% confidence interval, 1.47–4.12; P<0.001). Conclusions: The diagnosis of PVS is challenging because of nonspecific symptoms and the need for dedicated pulmonary vein imaging. There is no difference in acute success by type of initial intervention; however, stenting significantly reduces the risk of subsequent pulmonary vein restenosis in comparison with BA.

Pulmonary vein stenosis after atrial fibrillation ablation.

Pulmonary vein stenosis (PVS) is an uncommon but devastating complication of atrial fibrillation (AF) ablation. Patients are often misdiagnosed due to non-specific symptoms and the challenges of visualising the pulmonary veins on standard chest imaging. Delays in treatment result in worsening symptoms and pulmonary venous occlusion. The optimal method of intervening for PVS has not been well established. Restenosis after successful intervention is common, warrants active surveillance, and is the focus of research into prevention and management strategies. In this article we review the existing literature on PVS, and discuss our own experience in managing patients with severe PVS.

Isolated tricuspid regurgitation: outcomes and therapeutic interventions

Isolated tricuspid regurgitation (TR) can be caused by primary valvular abnormalities such as flail leaflet or secondary annular dilation as is seen in atrial fibrillation, pulmonary hypertension and left heart disease. There is an increasing recognition of a subgroup of patients with isolated TR in the absence of other associated cardiac abnormalities. Left untreated isolated TR significantly worsens survival. Stand-alone surgery for isolated TR is rarely performed due to an average operative mortality of 8%–10% and a paucity of data demonstrating improved survival. When surgery is performed, valve repair may be preferred over replacement; however, there is a risk of significant recurrent regurgitation after repair. Existing society guidelines do not fully address the management of isolated TR. We propose that patients at low operative risk with symptomatic severe isolated TR and no reversible cause undergo surgery prior to the onset of right ventricular dysfunction and end-organ damage. For patients at increased surgical risk novel percutaneous interventions may offer an alternative treatment but further research is needed. Significant knowledge gaps remain and future research is needed to define operative outcomes and provide comparative data for medical and surgical therapy.

Long-Term Outcomes in Survivors of Early Ventricular Arrhythmias After Acute ST-Elevation and Non–ST-Elevation Myocardial Infarction Treated With Percutaneous Coronary Intervention

Guidelines do not recommend an implantable cardioverter defibrillator (ICD) for prevention of sudden death in patients who develop ventricular arrhythmia (VA) within 48 hours of acute myocardial infarction (AMI) if they are successfully revascularized. We aimed to determine long-term survival in a cohort of early VA survivors treated with percutaneous coronary intervention (PCI) and to determine whether certain high-risk characteristics predicted worse outcomes. This retrospective study included all patients with early VA after AMI treated with PCI at our institution from 2002 to 2012 who survived to hospital discharge. Patients who had an ICD before their index AMI and those who received ICD before hospital discharge were excluded. Overall survival in the early VA survivors was analyzed based on post-MI left ventricular ejection fraction (LVEF) (≥50% vs <50%), MI type (ST-segment elevation myocardial infarction [STEMI] vs non-ST-segment elevation myocardial infarction [NSTEMI]), and single-vessel versus multivessel disease. Baseline presenting clinical and PCI characteristics plus outcomes were compared with matched controls with PCI-treated AMI but no early VA. Of the 79 early VA survivors treated with PCI, there were no significant differences in long-term overall survival between AMI type (STEMI vs NSTEMI), single-vessel versus multivessel disease, and LVEF at time of MI (>50% vs <50%). Despite having lower presenting LVEF (46% vs 55%, p <0.001) and higher rates of cardiogenic shock (28% vs 4%; p <0.001), survivors of early VA had similar overall survival compared with PCI-treated controls whose post-AMI hospital course was not complicated by early VA (p = 0.61). In conclusion, patients with early VA treated with PCI who survive to discharge were more likely to have STEMI, lower LVEF, and cardiogenic shock. Type of AMI or the presence of systolic dysfunction or multivessel disease did not predict long-term mortality. With early PCI, early VA survivors have similar long-term prognosis compared with those without early VA.

Racial differences in sudden cardiac death

There is an increased risk of sudden cardiac death (SCD) and sudden cardiac arrest (SCA), in African Americans, the basis of which is likely multifactorial. African Americans have higher rates of traditional cardiac risk factors including hypertension, left ventricular hypertrophy, diabetes, coronary heart disease, and heart failure. There are also significant disparities in health care delivery. While these factors undoubtedly affect health outcomes, there is also growing evidence that genetics may have a significant impact as well. In this paper, we discuss data and hypotheses in support of both sides of the controversy around racial differences in SCD/SCA.

Percutaneous therapies for tricuspid regurgitation

ABSTRACT Introduction: Chronic tricuspid valve regurgitation is usually associated with left-sided heart disease or pulmonary hypertension. Although severe tricuspid valve regurgitation carries a poor prognosis, isolated surgery is rarely performed due to high in-hospital mortality and an unclear impact on long term survival. The lack of adequate surgical treatment has resulted in a large population of patients with an unmet clinical need. Areas covered: Transcatheter therapies have revolutionized the management of high risk patients with left-sided valvular disease, and have sparked interest in translating minimally invasive therapies to the tricuspid valve. Here we will discuss some of the challenges of percutaneous tricuspid interventions, and review the novel therapies which are in early development. Expert commentary: Transcatheter therapies for the tricuspid valve are in early development, and are not yet appropriate for clinical use. In select non-surgical patients transcatheter devices may ultimately provide a therapeutic approach to palliate symptoms. However, further studies are needed to demonstrate both efficacy and safety before these devices are introduced to clinical practice.

Acute Sinus Node Dysfunction after Atrial Ablation: Incidence, Risk Factors, and Management

Many patients with atrial fibrillation (AF) or atrial flutter (Aflutter) have concomitant sinus node dysfunction (SND). Ablation may result in injury to the sinus node complex or its blood supply resulting in sinus arrest and need for temporary pacing. We sought to characterize patients who develop acute SND (ASND) during/immediately after AF/Aflutter ablation.

Lead extraction outcomes in patients with congenital heart disease

Aims Patients with congenital heart disease (CHD) are at increased risk for intracardiac device malfunction and infection that may necessitate extraction; however, the risk of extraction is poorly understood. This study addresses the safety of extraction in patients with structural heart disease and previous cardiac surgery. Methods and results This retrospective study included 40 CHD and 80 matched control patients, who underwent transvenous lead extractions between 2001 and 2014. Only leads >12 months were included. There were 77 leads in CHD patients and 146 in controls. The mean age was 38 ± 16 years in CHD patients. Ninety per cent of CHD patients had ≥1 cardiac surgeries when compared with 21% of controls (P < 0.001). The number of abandoned leads was significantly different (17 vs. 3, P < 0.001). Lead age was similar with an average duration of 83 ± 87 months in CHD patients and 62 ± 65 months in controls (P = 0.24). There was no significant difference in extraction techniques. Manual traction was successful in 40% of CHD patients and 47% of controls, and advanced techniques were used in 60 and 53% of CHD patients and controls, respectively. Complete extraction was achieved in 94% of the patients in both groups. There was no significant difference in complications. Conclusion Lead extraction can be safely performed in patients with CHD. Despite anatomic abnormalities and longer implantation times, the difficulty of lead extraction in patients with CHD is comparable with controls.

Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation

Purpose of ReviewAnticoagulant therapy effectively reduces the incidence of stroke in patients with atrial fibrillation (AF) but is underutilized and frequently contraindicated. The left atrial appendage (LAA) is the primary site of thrombus formation in AF patients. Surgical and percutaneous appendage closure has been evaluated as a site-specific therapy to reduce systemic thromboembolism.Recent FindingsWe will review LAA closure techniques, examine recent outcome data, and discuss the indications for, and potential complications of, each approach.SummaryRandomized data examining surgical LAA closure and epicardial closure with the LARIAT device are lacking. High quality, randomized data supports the efficacy of the WATCHMAN device for stroke prevention in patients with AF.

Percutaneous revascularization in patients treated with thoracic radiation for cancer

Objectives To assess coronary revascularization outcomes in patients with previous thoracic radiation therapy (XRT). Background Previous chest radiation has been reported to adversely affect long term survival in patients with coronary disease treated with percutaneous coronary interventions (PCI). Methods Retrospective, single center cohort study of patients previously treated with thoracic radiation and PCI. Patients were propensity matched against control patients without radiation undergoing revascularization during the same time period. Results We identified 116 patients with radiation followed by PCI (XRT‐PCI group) and 408 controls. Acute procedural complications were similar between groups. There were no differences in all‐cause and cardiac mortality between groups (all‐cause mortality HR 1.31, P = .078; cardiac mortality 0.78, P = .49). Conclusion Patients with prior thoracic radiation and coronary disease treated with PCI have similar procedural complications and long term mortality when compared to control subjects.