Jared D. Miller

Diagnostic Utility of a Novel Leadless Arrhythmia Monitoring Device

Although extending the duration of ambulatory electrocardiographic monitoring beyond 24 to 48 hours can improve the detection of arrhythmias, lead-based (Holter) monitors might be limited by patient compliance and other factors. We, therefore, evaluated compliance, analyzable signal time, interval to arrhythmia detection, and diagnostic yield of the Zio Patch, a novel leadless, electrocardiographic monitoring device in 26,751 consecutive patients. The mean wear time was 7.6 ± 3.6 days, and the median analyzable time was 99% of the total wear time. Among the patients with detected arrhythmias (60.3% of all patients), 29.9% had their first arrhythmia and 51.1% had their first symptom-triggered arrhythmia occur after the initial 48-hour period. Compared with the first 48 hours of monitoring, the overall diagnostic yield was greater when data from the entire Zio Patch wear duration were included for any arrhythmia (62.2% vs 43.9%, p <0.0001) and for any symptomatic arrhythmia (9.7% vs 4.4%, p <0.0001). For paroxysmal atrial fibrillation (AF), the mean interval to the first detection of AF was inversely proportional to the total AF burden, with an increasing proportion occurring after 48 hours (11.2%, 10.5%, 20.8%, and 38.0% for an AF burden of 51% to 75%, 26% to 50%, 1% to 25%, and <1%, respectively). In conclusion, extended monitoring with the Zio Patch for ≤14 days is feasible, with high patient compliance, a high analyzable signal time, and an incremental diagnostic yield beyond 48 hours for all arrhythmia types. These findings could have significant implications for device selection, monitoring duration, and care pathways for arrhythmia evaluation and AF surveillance.

Feasibility of Extended Ambulatory Electrocardiogram Monitoring to Identify Silent Atrial Fibrillation in High‐risk Patients: The Screening Study for Undiagnosed Atrial Fibrillation (STUDY‐AF)

Identification of silent atrial fibrillation (AF) could prevent stroke and other sequelae.

An updated meta-analysis of novel oral anticoagulants versus vitamin K antagonists for uninterrupted anticoagulation in atrial fibrillation catheter ablation

BACKGROUND Catheter ablation is recommended as a first- or second-line rhythm control therapy for selected patients with atrial fibrillation (AF). There is a wide variability in the periprocedural management of oral anticoagulation in patients undergoing AF ablation. OBJECTIVE We aimed to perform an updated meta-analysis of novel oral anticoagulants (NOACs) vs vitamin K antagonists (VKAs) as uninterrupted anticoagulation in patients undergoing AF ablation. METHODS Databases and conference abstracts were searched. Studies were excluded if oral anticoagulants were held at any periprocedural period. The primary outcomes were stroke or transient ischemic attack (TIA) and major bleeding. RESULTS Twelve studies and 4962 patients were included. Stroke or TIA was rare (NOAC, 0.08%; VKA, 0.16%) and not different between groups (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.19-2.30). The incidence of silent cerebral embolic events was also not significantly different between NOACs (8%) and VKAs (9.6%) (OR 0.86; 95% CI 0.42-1.76). Major bleeding was significantly reduced in the NOAC group (0.9%) as compared with VKA-treated patients (2%) (OR 0.50; 95% CI 0.30-0.84; P < .01). This finding was confirmed in a subgroup analysis of randomized and cohort studies with matched controls (OR 0.45; 95% CI 0.24-0.83; P = .01). There was no significant difference in the outcomes of individual NOACs and VKAs, although these analyses may have been underpowered to detect minor differences in such rare outcomes. CONCLUSION In patients undergoing AF ablation, uninterrupted periprocedural NOACs are associated with a low incidence of stroke or TIA and a significant reduction in major bleeding as compared with uninterrupted VKAs.

The implantable cardioverter–defibrillator: An update

The implantable cardioverter-defibrillator (ICD) provides life-saving therapy to prevent sudden cardiac death. ICDs have been implanted in millions of patients worldwide since the first human implant in 1980. Clinical trials have helped establish guidelines for ICD implantation in primary and secondary prevention of sudden cardiac death. Recent trials have also tested and compared various programing strategies to avoid unnecessary shocks and improve survival among ICD recipients. ICDs may also assist with monitoring for heart failure management. In this review, we discuss the clinical science to date that has helped define the role of ICDs in current practice.

Giant left atrium in rheumatic heart disease: the classic signs of left atrial enlargement.

*Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, †Department of Medicine, Stanford University Hospital andClinics, Stanford University School of Medicine, Stanford, California, and ‡Department of Radiation andCellular Oncology, University of Chicago Medical Center, Pritzker School of Medicine, Chicago, Illinois Reprint Address: Jeffrey F. B. Chick, MD, Department of Radiology, Brigham andWomen’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115

The many faces of Behçet's disease.

A 23-year-old man with fevers, night sweats, lymphadenopathy, worsening vision, and aphthous ulcers was diagnosed with Behçets disease. Multiple diagnostic imaging modalities were used to identify various multisystem complications associated with Behçets disease including vascular thomboses, mediastinal fibrosis, chylothoraces, chylopericardium and coronary artery aneurysms.

First report of dabigatran reversal in iatrogenic pericardial tamponade during catheter ablation of atrial fibrillation

Introduction Catheter ablation of atrial fibrillation (AF) is recommended for the management of symptomatic paroxysmal or persistent AF. Iatrogenic pericardial tamponade is a well-described potential complication of AF ablation. Pericardial tamponade has been reported to be a complication of 1%–2% of AF ablation procedures. The recently published RE-CIRCUIT study supports the value of performing AF ablation on uninterrupted dabigatran to minimize bleeding and stroke risk. Idaracizumab is an approved and widely available monoclonal antibody fragment that has been shown to bind dabigatran and reverse its anticoagulant effect. Herein, we report the first use of idaracizumab to reverse the anticoagulant effect of dabigatran in the management of iatrogenic pericardial tamponade during AF ablation.

Extracorporeal membrane oxygenation for profound cardiogenic shock due to cocaine toxicity

Cocaine toxicity can result in myocardial infarction from coronary vasospasm. The current treatment algorithm includes intravenous and/or intracoronary vasodilator administration with an expectantly quick resolution of symptoms and signs of ischemia. However, in situations in which myocardial injury persists, the optimal management is uncertain. We present a case in which extracorporeal membrane oxygenation effectively stabilized a patient with ongoing hemodynamic instability who experienced repeated episodes of myocardial injury and ventricular tachyarrhythmias due to cocaine toxicity. <Learning objective: In many urban settings, cocaine-induced angina is not uncommon. The pathogenesis of its manifestation includes coronary artery vasospasm and decreased left ventricular function. Treatment typically involves systemic vasodilators, such as nitrates and calcium channel blockers. However, in patients with substantial hemodynamic instability, these agents might result in a worsening of systemic perfusion. Accordingly, extracorporeal membrane oxygenation should be considered in such cases to promote myocardial recovery.>.