Jayasree Pillarisetti

Effect of Yoga on Arrhythmia Burden, Anxiety, Depression, and Quality of Life in Paroxysmal Atrial Fibrillation: The YOGA My Heart Study

OBJECTIVES The purpose of this study was to examine the impact of yoga on atrial fibrillation (AF) burden, quality of life (QoL), depression, and anxiety scores. BACKGROUND Yoga is known to have significant benefit on cardiovascular health. The effect of yoga in reducing AF burden is unknown. METHODS This single-center, pre-post study enrolled patients with symptomatic paroxysmal AF with an initial 3-month noninterventional observation period followed by twice-weekly 60-min yoga training for next 3 months. AF episodes during the control and study periods as well as SF-36, Zung self-rated anxiety, and Zung self-rated depression scores at baseline, before, and after the study phase were assessed. RESULTS Yoga training reduced symptomatic AF episodes (3.8 ± 3 vs. 2.1 ± 2.6, p < 0.001), symptomatic non-AF episodes (2.9 ± 3.4 vs. 1.4 ± 2.0; p < 0.001), asymptomatic AF episodes (0.12 ± 0.44 vs. 0.04 ± 0.20; p < 0.001), and depression and anxiety (p < 0.001), and improved the QoL parameters of physical functioning, general health, vitality, social functioning, and mental health domains on SF-36 (p = 0.017, p < 0.001, p < 0.001, p = 0.019, and p < 0.001, respectively). There was significant decrease in heart rate, and systolic and diastolic blood pressure before and after yoga (p < 0.001). CONCLUSIONS In patients with paroxysmal AF, yoga improves symptoms, arrhythmia burden, heart rate, blood pressure, anxiety and depression scores, and several domains of QoL.

Relationship between complex fractionated electrograms (CFE) and dominant frequency (DF) sites and prospective assessment of adding DF-guided ablation to pulmonary vein isolation in persistent atrial fibrillation (AF).

Dominant Frequency Mapping and Ablation. Background: Sites of high DF are potential targets for AF ablation, but it is unknown if addition of DF ablation can improve procedural outcome.

Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications

BACKGROUND Watchman and Lariat left atrial appendage (LAA) occlusion devices are associated with LAA leaks postdeployment. OBJECTIVE The purpose of this study was to compare the incidence, characteristics, and clinical significance of these leaks. METHODS We performed a multicenter prospective observational study of all patients who underwent LAA closure. Baseline, procedural, and imaging variables along with LAA occlusion rates at 30-90 days and 1-year postprocedure were compared. RESULTS A total of 478 patients (219 with the Watchman device and 259 with the Lariat device) with successful implants were included. Patients in the Lariat group had a higher CHADS2 (congestive heart failure, hypertension, age >74 years, diabetes, stroke) score and a larger left atrium and LAA. A total of 79 patients (17%) had a detectable leak at 1 year. More patients in the Watchman group had a leak compared with those in the Lariat group (46 [21%] vs 33 [14%]; P = .019). All the leaks were eccentric (edge effect) in the Watchman group and concentric (gunny sack effect) in the Lariat group. The size of the leak was larger in the Watchman group than in the Lariat group (3.10 ± 1.5 mm vs 2.15 ± 1.3 mm; P = .001). The Watchman group had 1 device embolization requiring surgery and 2 pericardial effusions requiring pericardiocentesis. In the Lariat group, 4 patients had cardiac tamponade requiring urgent surgical repair. Three patients in each group had a cerebrovascular accident and were not associated with device leaks. CONCLUSION The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.

Radiofrequency catheter ablation of ventricular arrhythmias in patients with hypertrophic cardiomyopathy: safety and feasibility

BACKGROUND Management of ventricular tachycardia (VT) in patients with hypertrophic cardiomyopathy (HCM) is challenging. OBJECTIVE The purpose of this study is to assess the value of radiofrequency catheter ablation (RFCA) for the treatment of the VTs in the setting of HCM. METHODS Twenty-two patients (18 with ICD) with HCM and multiple episodes of VTs resistant to medical therapy underwent RFCA with an open irrigation catheter. Epicardial access was obtained if required. All patients were followed for at least 1 year after RFCA. RESULTS Mean age was 50.4 +/- 15.3, and mean ejection fraction was 34.3% +/- 9.8%. RFCA was performed endocardially in all patients, while epicardial radiofrequency applications were needed in 13 patients. A previous endocardial ablation was unsuccessful in six patients. At 20 +/- 9 months of follow-up, elimination of VTs reached 73%. No major complication was observed during and after the procedures in all patients. CONCLUSION Catheter ablation of VTs in patients with hypertrophic cardiomyopathy refractory to medical therapy is safe, feasible, and successful in eliminating VT. Epicardial VT mapping and ablation should be considered as an important access option for the treatment of these patients to increase the success rate.

Differences in complication rates between large bore needle and a long micropuncture needle during epicardial access: time to change clinical practice?

Background—A dry epicardial access (EA) is increasingly used for advanced cardiovascular procedures. Conventionally used large bore needles (Tuohy or Pajunk needle; LBN) have been associated with low but definite incidence of major complications with EA. Use of micropuncture needle (MPN) may decrease the risk of complications. We intended to compare the outcomes of LBN with MPN for EA. Methods and Results—We report a multicenter observational study of consecutive patients who underwent EA for ventricular tachycardia ablation or Lariat procedure using the LBN or MPN. Oral anticoagulation was stopped before the procedure. Baseline characteristics and procedure-related complications were collected and compared. Of the 404 patients, LBN and MPN were used in 46% and 54% of patients, respectively. There was no significant difference in the incidence of inadvertent puncture of myocardium between LBN and MPN (7.6% versus 6.8%, P=0.76). However, there was a significantly higher rate of large pericardial effusions with LBN compared with MPN (8.1% versus 0.9%; P<0.001). The incidence of pleural effusions were not significantly different between both (1.6% versus 2.3%; P=0.64). LBN group had an increase in other complications compared with MPN (open heart surgery to repair cardiac laceration [6 versus 0], injury to liver [1 versus 0], coronaries [1 versus 0], and superior epigastric artery requiring surgical exploration [0 versus 1]). Conclusions—The use of MPN is associated with decreased incidence of major complications, and the need for surgical repair and routine use should be considered for EA.

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.

Cardiac catheterization in patients with end-stage liver disease: Safety and outcomes†

Introduction: Patients with end‐stage liver disease (ESLD) awaiting transplant are at increased risk of bleeding. Nevertheless, these patients routinely undergo cardiac catheterization for various indications. Safety and outcomes of cardiac catheterization in these patients are not well reported. Methods: In a case–control study 43 patients with ESLD who underwent angiography for liver transplant work‐up were compared to 43 age and gender‐matched controls with no liver dysfunction. In‐hospital outcomes and procedural variables were compared. Results: Patients with ESLD had a lower baseline hemoglobin (12.1 ± 2.1 vs. 13.7 ± 1.8, P < 0.0005), lower platelet counts (86.8 ± 66 vs. 247 ± 80, P < 0.0001) and higher international normalized ratio (INR) (1.4 ± 0.2 vs. 1.1 ± 0.2, P < 0.0001) than controls. Among ESLD group, five (11.6%) patients received platelet transfusions, one received blood transfusion, and three patients (7%) with INR > 1.6 received fresh frozen plasma (FFP) compared with none in the control group. Smaller size (four French) vascular sheaths were used more frequently in the group with ESLD (16% vs. 4%, P = 0.04). There were no significant vascular or bleeding complications in either group. Conclusions: Elective cardiac catheterization can be safely performed in patients with ESLD with outcomes (vascular and bleeding complications, length of hospital stay and in‐hospital mortality) similar to patients without liver disease despite significant thrombocytopenia and elevated INR in patients with ESLD. Practices such as platelet transfusion for platelets <60,000 μL, prophylactic FFP transfusion for INR ≥≥ 1.6, less frequent use of antiplatelet therapy and more frequent use of smaller vascular sheaths may have contributed to the safety of cardiac catheterization in ESLD patients.

Mortality Rates and Clinical Predictors of Reduced Survival After Cardioverter Defibrillator Implantation

We aimed to identify mortality rates and clinical predictors of reduced survival in a large cohort of patients after implantation of an implantable cardioverter-defibrillator (ICD). Although existing data from clinical trials report annual mortality after ICD implantation from 2% to 9%, there are few data available on mortality rates or predictors of reduced survival in this patient population in clinical practice. In this single-center, retrospective analysis of 286 patients who underwent ICD implantation between June 1, 2000 and December 30, 2003, candidate predictors of mortality were assessed and subjected to multivariable analysis. Outcomes were documented using the Social Security Death Master File and hospital medical records. Overall annualized mortality was 11.3% after ICD implantation. Mortality rates in patients with left ventricular ejection fraction (LVEF) <25% were 27.2% at 1 year and 50.5% at 3 years. Digoxin (hazard ratio 1.86, 95% confidence interval [CI] 1.21 to 2.86, p = 0.0046) and loop diuretics (hazard ratio 1.59, 95% CI 1.06 to 2.38, p = 0.024) were associated with reduced survival. Angiotensin-converting enzyme inhibitor or aldosterone receptor blocker use was associated with reduced mortality (hazard ratio 0.50, 95% CI 0.31 to 0.80, p = 0.0038). In conclusion, mortality after ICD implantation is higher than demonstrated in primary or secondary prevention ICD trials; LVEF remains a potent predictor of mortality after ICD implantation, particularly in patients with an LVEF <25%; loop diuretic and digoxin use is associated with an approximate twofold increase in mortality in this population; and angiotensin-converting enzyme inhibitor or aldosterone receptor blocker use is associated with improved survival after ICD implantation.

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.

Clinical Utility and Prognostic Significance of Measuring Troponin I Levels in Patients Presenting to the Emergency Room With Atrial Fibrillation

The clinical significance of mildly elevated troponins in patients presenting to the emergency room (ER) with atrial fibrillation (AF) is not well understood.