Matthew McKillop

In-Hospital Cerebrovascular Outcomes of Patients With Atrial Fibrillation and Cancer (from the National Inpatient Sample Database)

Limited data are available regarding the impact of cancer on cerebrovascular accidents in patients with atrial fibrillation (AF). We queried the Nationwide Inpatient Survey Database to identify patients who have diagnostic code for AF. We performed a 1:1 propensity matching based on the CHA2DS2VASc score and other risk factors between patients with AF who had lung, breast, colon, and esophageal cancer, and those who did not (control). The final cohort included a total of 31,604 patients. The primary outcome of in-hospital cerebrovascular accidents (CVA) was lower in the cancer group than in the control group (4% vs 7%, p < 0.001), but with only a weak association (ф = -0.067). In-hospital mortality was higher in the cancer group than in the control group (18% vs 11%, p < 0.001; ф = -0.099). A subgroup analysis according to cancer type showed similar results with a weak association with lower CVA in breast cancer (4% vs 7%; ф = -0.066, p < 0.001), lung cancer (4% vs 6%; ф = -0.062, p < 0.001), colon cancer (4% vs 6%; ф = -0.062, p < 0.001), and esophageal cancer (3% vs 7%; ф = -0.095, p < 0.001) compared with the control groups. A weak association with higher in-hospital mortality was demonstrated in lung cancer (20% vs 11%; ф = -0.127, p < 0.001), colon cancer (16% vs 11%; ф = -0.076, p < 0.001), and esophageal cancer (20% vs 12%; ф = -0.111, p < 0.001) compared with the control groups, but no significant difference between breast cancer and control groups in mortality (11% vs 11%; ф = -0.002, p = 0.888). In conclusion, in patients with AF, cancer diagnosis may not add a predictive role for in-hospital CVA beyond the CHADS2VASc score.

Postgraduate Education in Quality Improvement Methods: Initial Results of the Fellows’ Applied Quality Training (faqt) Curriculum

OBJECTIVE Training in quality improvement (QI) is a pillar of the next accreditation system of the Accreditation Committee on Graduate Medical Education and a growing expectation of physicians for maintenance of certification. Despite this, many postgraduate medical trainees are not receiving training in QI methods. We created the Fellows Applied Quality Training (FAQT) curriculum for cardiology fellows using both didactic and applied components with the goal of increasing confidence to participate in future QI projects. METHODS AND RESULTS Fellows completed didactic training from the Institute for Healthcare Improvements Open School and then designed and completed a project to improve quality of care or patient safety. Self-assessments were completed by the fellows before, during, and after the first year of the curriculum. The primary outcome for our curriculum was the median score reported by the fellows regarding their self-confidence to complete QI activities. Self-assessments were completed by 23 fellows. The majority of fellows (15 of 23, 65.2%) reported no prior formal QI training. Median score on baseline self-assessment was 3.0 (range, 1.85-4), which was significantly increased to 3.27 (range, 2.23-4; P = 0.004) on the final assessment. The distribution of scores reported by the fellows indicates that 30% were slightly confident at conducting QI activities on their own, which was reduced to 5% after completing the FAQT curriculum. An interim assessment was conducted after the fellows completed didactic training only; median scores were not different from the baseline (mean, 3.0; P = 0.51). CONCLUSION After completion of the FAQT, cardiology fellows reported higher self-confidence to complete QI activities. The increase in self-confidence seemed to be limited to the applied component of the curriculum, with no significant change after the didactic component.

Iatrogenic Ventricular Fibrillation after Direct-Current Cardioversion of Preexcited Atrial Fibrillation Caused by Inadvertent T-Wave Synchronization

Direct-current cardioversion is an important means of managing arrhythmias. During treatment, carefully synchronizing energy delivery to the QRS complex is necessary to avoid ventricular fibrillation caused by a shock during the vulnerable period of ventricular repolarization, that is, a shock on the T wave. The presence of an accessory pathway and ventricular preexcitation can lead to difficulty in distinguishing the QRS complex from the T wave because of bizarre, wide, irregular QRS complexes and prominent repolarization. We present the cases of 2 patients who had iatrogenic ventricular fibrillation from inappropriate T-wave synchronization during direct-current cardioversion of preexcited atrial fibrillation. Our experience shows that rapidly recognizing the iatrogenic cause of VF and immediate treatment with unsynchronized defibrillation can prevent adverse clinical outcomes.

Meta-Analysis Comparing Catheter-Guided Ablation Versus Conventional Medical Therapy for Patients With Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction

The prognostic benefit of catheter ablation (CA) for atrial fibrillation in the setting of heart failure (HF) with reduced ejection fraction (EF) is unclear. A systematic search of medical literature was limited to randomized controlled trials. The primary outcome was all-cause mortality, and secondary outcomes were HF hospitalizations, stroke, left ventricular EF improvement, change in 6-minute walk test, and change in Minnesota living with HF questionnaire (Δ MLHFQ). Random effects risk ratios (RR) were calculated for categorical outcomes and standardized mean differences (SMD) for continuous ones, using Der-Simonian and Liard model. A total of 775 ambulatory patients from 6 trials were included. The mean EF was 31% with a mean New York Heart Association classification class 2.5. At a mean follow-up of 26 months, CA was associated with lower incidences of all-cause mortality (RR 0.50, 95% confidence intervals [CI] 0.34 to 0.74, I2 = 0%, p <0.0001), and HF hospitalizations (RR 0.58, 95% CI 0.41 to 0.81, p = 0.002, I2 = 0%), with similar incidences of stroke. Left ventricular EF improvement (SMD = 2.58, 95% CI 0.88 to 4.27), and change in Minnesota living with heart failure HF questionnaire (SMD = -0.40, 95% CI -0.65 to -0.14) were also in favor of CA, with no difference noted in change in 6-minute walk test. The incidence of all reported procedural complications (including major and minor) was 7.3%. In conclusion, CA of atrial fibrillation appears to be associated with improved survival and HF hospitalizations compared with medical therapy, with evidence of low ablation-related complications.

Impact of a Pharmacy-Cardiology Collaborative Practice on Dofetilide Safety Monitoring

Background: Limited studies have been published examining dofetilide’s postmarketing use and its recommended monitoring. Objective: To evaluate the impact of a collaborative pharmacy-cardiology antiarrhythmic drug (AAD) monitoring program on dofetilide monitoring. Methods: This retrospective cohort study was performed to assess if a novel monitoring program improved compliance with dofetilide-specific monitoring parameters based on the Food and Drug Administration’s Risk Evaluation and Mitigation Strategy. Results: A total of 30 patients were included in the analysis. The monitoring parameters evaluated included electrocardiogram, serum potassium, serum magnesium, and kidney function. The primary outcome evaluated was the composite of these dofetilide monitoring parameters obtained in each cohort. In the standard cohort, 245 of 352 (69.6%) monitoring parameters were completed versus 134 of 136 (98.5%) in the intervention group (P < 0.05). Conclusion: A collaborative pharmacy-cardiology AAD monitoring program was associated with a significant improvement in dofetilide monitoring. This improvement could potentially translate into enhanced patient safety outcomes, such as prevention of adverse drug reactions and decreased hospitalizations.

Pitfalls in the Acute Management of Atrial Fibrillation

The evaluation and management of atrial fibrillation is complex, and errors can lead to patient harm. Pitfalls to avoid are numerous—incorrect diagnosis can lead to improper treatment or omission of appropriate therapies, inappropriate management of anticoagulation in atrial fibrillation (AF) places the patient at risk of debilitating stroke or bleeding complications, and injudicious use of antiarrhythmic drug (AAD) therapy can risk dangerous pro-arrhythmic side effects. Furthermore, direct current cardioversion carries its own unique procedural risks. The astute clinician will be aware of potential mistakes and, by avoiding them, will deliver safe and optimal patient care. This chapter will highlight potential errors in AF care.

AVOID THOSE SUTURES: ATRIAL FLUTTER ABLATION AFTER A RECENT HEART TRANSPLANT

There is concern that radiofrequency ablation for atrial flutter after recent heart transplant could potentially disrupt fresh suture lines. A 55 year old man with end stage ischemic cardiomyopathy underwent bicaval orthotopic heart transplant. His postoperative course was complicated by rapid

An Unusual Atrial Tachycardia in a Cardiac Transplant Patient.

A 74-year-old woman with prior history of ischemic cardiomyopathy underwent heart transplant with bi-atrial anastomosis in 1992. She was diagnosed with a supraventricular tachycardia (SVT) in 1995, prompting initiation of flecainide. She later developed recurrent, symptomatic SVT despite drug titration. At electrophysiology study, programmed stimulation induced an atrial tachycardia with gaps in atrial activity. These gaps in atrial activation were approximately twice the atrial tachycardia cycle length (Fig. 1). Based on the initial tracing of atrial tachycardia, why are there gaps in atrial activation? What is the mechanism of the tachycardia?

Subcutaneous ICD implant complicated by an intraperitoneal lead course and device infection

Introduction The subcutaneous implantable cardioverter-defibrillator (S-ICD) is a novel device that demonstrates high efficacy for treatment of ventricular tachycardia and ventricular fibrillation and is an alternative to the transvenous ICD device. The safety and efficacy of the S-ICD has been thoroughly evaluated, and pooled data from the IDE and Effortless studies show only a 0.8% incidence of suboptimal electrode placement. We present a case of extreme lead misplacement that represents how a usually simple implant procedure can result in a serious complication in the hands of an inexperienced implanter.

VIRAL ANTI-INFLAMMATORY PROTEIN TREATMENT SIGNIFICANTLY ALTERS GENE EXPRESSION IN CIRCULATING LEUKOCYTES FROM PATIENTS AFTER ATRIAL FIBRILLATION CRYOBALLOON ABLATION

background: Cryoballoon ablation (CB) for atrial fibrillation (AF) activates inflammation that may lead to increased atrial fibrosis, thrombosis, and recurrent arrhythmia. Two viral anti-inflammatory proteins, M-T7 (a chemokine/glycosaminoglycan inhibitor) and Serp-1 (a serine protease inhibitor) have proven anti-inflammatory activity in animal models. Serp-1 also reduced markers of myocardial damage in patients after coronary stent implant. In this study, we examined the systemic inflammatory response to AF ablation and the potential to modify inflammatory cell activation after ablation using these viral proteins.