Karim Abdur Rehman

Recurrent Atrial Fibrillation After Initial Long-Term Ablation Success: Electrophysiological Findings and Outcomes of Repeat Ablation Procedures

Background: Atrial fibrillation recurrence after initial long-term success of catheter ablation has been described, yet not well studied. We assessed the electrophysiological findings and outcomes of repeat ablation procedures in this setting. Methods and Results: Between 2000 and 2015, 10 378 patients underwent atrial fibrillation ablation and were enrolled in a prospectively maintained data registry. From this registry, we included all 137 consecutive patients who had initial long-term success, defined as freedom from recurrent arrhythmia for >36 months off antiarrhythmics, then underwent repeat ablation for recurrent atrial fibrillation. The median arrhythmia-free period that defined long-term success was 52 months (41–68 months). In redo ablations, reconnection along at least one of the pulmonary veins (PVs) was found in 111 (81%) patients. Reconnection along a left superior, left inferior, right superior, and right inferior PV was found in 64%, 62%, 50%, and 54% of patients, respectively, and were reisolated. Additional non-PV ablations were performed in 127 (92.7%) patients: posterior wall (46%), septal to right PVs (49%), superior vena cava (35%), roof lines (52%), and cavotricuspid isthmus (33%). After a median follow-up of 17 months (5–36.9 months), 103 patients (75%) were arrhythmia free (79 off antiarrhythmics, 24 on antiarrhythmics). Conclusions: PV reconnection is the most common electrophysiological finding in patients with atrial fibrillation recurrence after long-term success, but with lower rates than what had been reported for early recurrences. In our experience, repeat ablations in this setting involve complex ablation approaches to reisolate the PVs and modify the atrial substrate and are associated with good success rates.

Uremic pericarditis, pericardial effusion, and constrictive pericarditis in end‐stage renal disease: Insights and pathophysiology

A rising prevalence of end‐stage renal disease (ESRD) has led to a rise in ESRD‐related pericardial syndromes, calling for a better understanding of its pathophysiology, diagnoses, and management. Uremic pericarditis, the most common manifestation of uremic pericardial disease, is a contemporary problem that calls for intensive hemodialysis, anti‐inflammatories, and often, drainage of large inflammatory pericardial effusions. Likewise, asymptomatic pericardial effusions can become large and impact the hemodynamics of patients on chronic hemodialysis. Constrictive pericarditis is also well documented in this population, ultimately resulting in pericardiectomy for definitive treatment. The management of pericardial diseases in ESRD patients involves internists, cardiologists, and nephrologists. Current guidelines lack clarity with respect to the management of pericardial processes in the ESRD population. Our review aims to describe the etiology, classification, clinical manifestations, diagnostic imaging tools, and treatment options of pericardial diseases in this population.

Transvenous Lead Extraction in Chronic Kidney Disease and Dialysis Patients With Infected Cardiac Devices

Background: Cardiac implantable electronic device infections have been on the rise. A high-risk population is that with renal disease, especially dialysis. We aimed to assess procedural profiles and clinical outcomes of transvenous lead extraction for cardiac implantable electronic device infection based on renal disease status. Methods and Results: In 1420 consecutive patients undergoing transvenous lead extraction of infected cardiac implantable electronic devices (1996–2012), we assessed procedural profiles and clinical outcomes in 3 groups: normal renal function (group 1, n=1159), renal dysfunction not requiring dialysis (group 2, n=163), and dialysis (group 3, n=98). A total of 3182 infected leads were extracted. Dialysis patients had shorter lead dwell times and were less likely to require transvenous lead extraction tools but as likely to require femoral workstations. There were higher overall rates of procedure-related complications in dialysis patients (12% versus ≈6% in nondialysis) with no difference in the major complication rates (P=not significant). Complete procedural success rates were 94%, 96%, and 94% in groups 1, 2, and 3, respectively (P=not significant). There were 4 intraprocedural deaths in group 1 versus none in groups 2 and 3. Mortality rates were significantly higher in dialysis patients both at 1 and 6 months (P<0.0001 for both). In multivariable analyses, dialysis status was independently associated with increased mortality risk at 1 and 6 months. Other factors associated with mortality were lead material retention, functional (New York Heart Association) class, and occurrence of procedural complications. Conclusions: In patients with cardiac implantable electronic device infection, dialysis status did not seem to add complexity to transvenous lead extraction but was independently associated with increased mortality at 1 and 6 months.

Meta-Analysis of Placebo-Controlled Randomized Controlled Trials on the Prevalence of Statin Intolerance

The prevalence of intolerance varies widely. Stopping statin therapy is associated with worse outcomes in patients with cardiovascular disease. Despite extensive studies, the benefits and risks of statins continue to be debated by clinicians and the lay public. We searched the PubMed, Medline, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for all randomized controlled trials of statins compared with placebo. Studies were included if they had ≥1,000 participants, had patients who were followed up for ≥1 year, and reported rates of drug discontinuation. Studies were pooled as per the random effects model. A total of 22 studies (statins = 66,024, placebo = 63,656) met the inclusion criteria. The pooled analysis showed that, over a mean follow-up of 4.1 years, the rates of discontinuation were 13.3% (8,872 patients) for statin-treated patients and 13.9% (8,898 patients) for placebo-treated patients. The random effects model showed no significant difference between the placebo and statin arms (odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.93 to 1.06). The results were similar for both primary prevention (OR = 0.98, 95% CI = 0.92 to 1.05, p = 0.39) and secondary prevention (OR = 0.92, 95% CI = 0.83 to 1.05, p = 0.43) studies. The pooled analysis suggested that the rates of myopathy were also similar between the statins and placebos (OR = 1.2, 95% CI = 0.88 to 1.62, p = 0.25). In conclusion, this meta-analysis of >125,000 patients suggests that the rate of drug discontinuation and myopathy does not significantly differ between statin- and placebo-treated patients in randomized controlled trials. These findings are limited by the heterogeneity of results, the variable duration of follow-up, and the lower doses of statins compared with contemporary clinical practice.

Repeat ablation or medical management alone for recurrent arrhythmias after ablation of persistent atrial fibrillation

Management of persistent atrial fibrillation (PersAF) remains challenging, and many patients are left on medical therapy after a failed first ablation. In patients with recurrent symptomatic arrhythmias after PersAF ablation, we aimed to compare outcomes of repeat ablation and medical therapy versus medical therapy alone.

A META-ANALYSIS OF CARDIOVASCULAR SAFETY OF FDA APPROVED ANTI OBESITY DRUGS

Introduction: Despite FDA approval, the cardiovascular safety of anti-obesity drugs (naltrexone-bupropion, phenteramine-topiramate, liraglutide, orlistat and lorcaserin) remains unknown. This is important given the withdrawal of historical weight loss agents amidst safety concerns. Methods: Large

Initial Experience With Non-Vitamin K Antagonist Oral Anticoagulants for Short-Term Anticoagulation After Left Atrial Appendage Closure Device

Left atrial appendage closure has been increasingly accepted as an alternative to long-term oral anticoagulation (OAC) for stroke prevention in atrial fibrillation patients who are at increased bleeding risk [(1)][1]. PROTECT-AF (The Watchman Left Atrial Appendage System for Embolic Protection in

Transesophageal Echocardiographic Guidance of Venovenous Extracorporeal Membrane Oxygenation Cannula (Avalon Cannula) Repositioning

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An Unusual Cause of Acute Myocardial Infarction Caused by a Large Pulmonary Artery Intimal Sarcoma

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