Mouhannad M. Sadek

Corticosteroid therapy for cardiac sarcoidosis: a systematic review.

BACKGROUND There are no published clinical consensus guidelines or systematic evaluation supporting the use of corticosteroids for the treatment of cardiac sarcoidosis. The purpose of this study was to systematically review the published data on corticosteroid treatment of cardiac sarcoidosis. METHODS Studies were identified from MEDLINE, EMBASE, Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, and National Institutes of Health Clinical Trials.gov database. The quality of included articles was rated using Scottish Intercollegiate Guidelines Network 50. Outcomes examined were atrioventricular (AV) conduction, left ventricular function, ventricular arrhythmias, and mortality. RESULTS A total of 1491 references were retrieved and 10 publications met the inclusion criteria. There were no randomized trials and all publications were of poor to fair quality. In the 10 reports, 257 patients received corticosteroids and 42 patients did not. There were 57 patients with AV conduction disease treated with corticosteroids, with 27/57 (47.4%) improving. In contrast, 16 patients were not treated with corticosteroids and 0/16 improved. Four publications reported on left ventricular function recovery, 2 reported on ventricular arrhythmia burden, and 9 reported on mortality. However, the data quality were too limited to draw conclusions for any of these outcomes. CONCLUSIONS Our systematic review identified 10 publications reporting outcomes after corticosteroid therapy. The best data relates to AV conduction recovery and corticosteroids appeared to be beneficial. It is not possible to draw clear conclusions about the utility of corticosteroids for the other outcomes. There is a clear need for large multicentre prospective registries and trials in this patient population.

Idiopathic ventricular arrhythmias originating from the moderator band: Electrocardiographic characteristics and treatment by catheter ablation

BACKGROUND The moderator band (MB) can be a source of premature ventricular contractions (PVCs), monomorphic ventricular tachycardia (VT), and idiopathic ventricular fibrillation (IVF). OBJECTIVE The purpose of this study was to define the electrocardiographic (ECG) characteristics and procedural techniques to successfully identify and ablate MB PVCs/VT. METHODS In 10 patients with left bundle branch block morphology PVCs/VT, electroanatomic mapping in conjunction with intracardiac echocardiography (ICE) localized the site of origin of the PVCs to the MB. Clinical characteristics of the patients, ECG features, and procedural data were collected and analyzed. RESULTS Seven patients presented with IVF and 3 presented with monomorphic VT. In all patients, the ventricular arrhythmias (VAs) had a left bundle branch block QRS with a late precordial transition (>V4), a rapid downstroke of the QRS in the precordial leads, and a left superior frontal plane axis. Mean QRS duration was 152.7 ± 15.2 ms. Six patients required a repeat procedure. After mean follow-up of 21.5 ± 11.6 months, all patients were free of sustained VAs, with only 1 patient requiring antiarrhythmic drug therapy and 1 patient having isolated PVCs no longer inducing VF. There were no procedural complications. CONCLUSION VAs originating from the MB have a distinctive morphology and often are associated with PVC-induced ventricular fibrillation. Catheter ablation can be safely performed and is facilitated by ICE imaging.

Aortitis and Spondyloarthritis—An Unusual Presentation: Case Report and Review of the Literature

OBJECTIVES To report a patient with aortic regurgitation (AR) and aortitis, who failed to respond to multiple attempts at surgical replacement of the affected valve and adjacent aorta, and in whom a late diagnosis of spondyloarthritis (SpA) was made. The relevant literature on the association of SpA and aortitis is reviewed. METHODS Descriptive case report of a patient with AR secondary to aortic dilation and aortitis with a late diagnosis of SpA, and a review of the relevant literature (PubMed search 1956 through April 2008). RESULTS A 36-year-old man was admitted to the hospital for replacement of his aortic valve and aortic valve root as a result of AR after a dehiscence of a mechanical prosthetic valve and subsequent aortic pseudoaneurysm. His past medical history included 2 prior aortic valve replacements that failed due to late postoperative dehiscence. Histological findings from the aortic wall after the third operation showed signs of aortitis. A rheumatologic workup revealed a 6-year history of mild low back pain, radiological evidence of bilateral sacroiliitis, and presence of HLA-B27. A diagnosis of SpA, most likely ankylosing spondylitis (AS), was made. On reviewing the literature, AR has been diagnosed in 2 to 12% of the patients with AS, most of whom had long-lasting disease. There have been several reports of uncommon presentations of acute AR in young patients with juvenile AS; however, no similar adult case was found. CONCLUSION This unusual case emphasizes the importance of early and adequate workup for SpA in young patients with lone AR or aortic dilation.

Myocardial Injury Secondary to ICD Shocks: Insights from Patients with Lead Fracture

Patients who receive appropriate implantable cardioverter defibrillator (ICD) shocks have a subsequent adverse prognosis. Most data suggest that patients with inappropriate ICD shocks also have a subsequent adverse prognosis, although this is more controversial. The shocks may be an epiphenomenon, that is, a marker of underlying disease progression; however, it cannot be excluded that shocks cause direct myocardial damage. This latter question is difficult to clarify as the arrhythmia provoking the shock can also cause troponin release. Inappropriate shocks secondary to lead fracture are an ideal situation to examine this question; any troponin release in an otherwise well and hemodynamically stable patient, is likely due directly to the shocks.

Recurrent atrial arrhythmias in the setting of chronic pulmonary vein isolation

BACKGROUND Atrial arrhythmias may still occur in patients after durable pulmonary vein isolation (PVI). OBJECTIVE The purpose of this study was to examine the incidence of patients undergoing ablation for recurrent arrhythmia despite chronic PVI and their clinical outcomes. METHODS Patients undergoing repeat left atrial ablation procedures were selected from a prospective registry. From this population, we identified patients with chronic PVI. Clinical characteristics, ablation strategies, and outcomes were analyzed. RESULTS Between January 2003 and December 2013, 1045 patients underwent 1298 repeat left atrial procedures. Of these, 900 patients had atrial fibrillation (AF) and 145 had atrial flutter (AFL)/atrial tachycardia (AT). Fifty-two patients (5.0%; 27 with AF and 25 with AFL/AT) had chronic PVI and were included in the study. Patients were followed for 19.7 ± 5.6 months. In patients with AF, 11 (41%) had a non-PV trigger identified. Ablation strategies included non-PV trigger ablation (n = 11), empiric trigger-site ablation (n = 3), provoked arrhythmia ablation (n = 9), complex fractionated atrial electrogram ablation (n = 2), and linear ablation (n = 2). During follow-up, 9 (33%) had no recurrence, 7 (26%) had rare AF (≤2 episodes during follow-up ≥1 year), and 11 (41%) had AF recurrence. In patients with AFL/AT, 12 (48%) had no recurrence, 4 (16%) had rare recurrence (≤2 episodes during follow-up ≥1 year), and 9 (36%) had recurrence. CONCLUSION In patients with PVI undergoing a repeat procedure during the time period studied, only a small portion had chronic PVI. A strategy of targeting non-PV triggers for AF and linear/focal ablation for AFL/AT may achieve long-term arrhythmia control in the majority of patients.

Complete occlusion of the proximal subclavian artery post-CABG : Presentation and treatment

Atherosclerotic disease of the proximal left subclavian artery is an uncommon cause of angina in the post-coronary artery bypass graft patient, and is termed coronary-subclavian steal syndrome. Typical manifestations include cardiac symptoms of angina and noncardiac symptoms of lightheadedness, left arm numbness or weakness, and a difference in blood pressure of more than 20 mmHg between both arms. A case of complete proximal occlusion of the subclavian artery is reported. The clinical picture, investigations and treatment are described. Historical treatments of occlusive disease include surgical bypass graft and, more recently, percutaneous transluminal angioplasty. The patient underwent percutaneous transluminal angioplasty with stenting by a retrograde approach, with an excellent short-term response, but ultimately required a carotid subclavian bypass due to restenosis.

Patient Outcomes From a Specialized Inherited Arrhythmia Clinic

Background—Patients with inherited arrhythmia syndromes are at an increased risk of sudden cardiac death (SCD). Specialized inherited arrhythmia clinics were founded to optimize management and prevention of SCD in this population. However, the clinical effectiveness of these clinics has never been evaluated. Methods and Results—Clinical outcome data of patients referred to a specialized inherited arrhythmia clinic between 2005 and 2014 for a possible primary electric syndrome or arrhythmogenic right ventricular cardiomyopathy were analyzed. Of 720 patients evaluated, 278 received a definite or probable diagnosis and received long-term management in the inherited arrhythmia clinic. All patients diagnosed with long QT syndrome and catecholaminergic polymorphic ventricular tachycardia received routine &bgr;-blocker therapy and demonstrated >90% long-term compliance. In patients with arrhythmogenic right ventricular cardiomyopathy, those demonstrating an arrhythmia burden on Holter or treadmill testing received &bgr;-blocker therapy (17%). In diagnosed channelopathy or arrhythmogenic right ventricular cardiomyopathy index cases, 44 patients received secondary prevention implantable cardioverter-defibrillators (long QT syndrome, 9; Brugada syndrome, 8; catecholaminergic polymorphic ventricular tachycardia, 3; short QT syndrome, 1; and arrhythmogenic right ventricular cardiomyopathy, 23). Median follow-up was 4.1 years with 43% having a follow-up period of >5 years. SCD occurred in a single patient (annualized risk of SCD, 0.1% per year). In individuals determined to have clinical or genetic disease by cascade screening, no SCD has occurred over a median follow-up of 5.6 years (55%, >5 years). Low event rates occurred despite a low rate (4.0%) of primary prevention implantable cardioverter-defibrillator utilization. Conclusions—Longitudinal care in a specialized inherited arrhythmia clinic is associated with a low incidence of SCD and a low rate of primary implantable cardioverter-defibrillator utilization in patients with inherited arrhythmia syndromes.

Efficacy and safety of driver-guided catheter ablation for atrial fibrillation: A systematic review and meta-analysis

Targeting localized drivers (electrical rotors or focal impulses) during catheter ablation for atrial fibrillation (AF) has been proposed as a strategy to improve procedural success. However, the strength and quality of the evidence to support this approach is unclear.

Effects of Age‐Related Aortic Root Anatomic Changes on Left Ventricular Outflow Tract Pace‐Mapping Morphologies: A Cardiac Magnetic Resonance Imaging Validation Study

Outflow tract ventricular arrhythmias (OT VAs) are common and catheter ablation is an effective treatment option. We sought to investigate the relationship between age‐related anatomic aortic root changes and QRS morphology during left ventricular outflow tract (LVOT) pace‐mapping using cardiac magnetic resonance (CMR) imaging.

Radiation safety and ergonomics in the electrophysiology laboratory: update on recent advances.

Purpose of review Risks associated with exposure to ionizing radiation in patients undergoing electrophysiology procedures and interventional cardiac electrophysiologists performing these procedures are a serious concern. Strategies to reduce radiation exposure are of obvious importance. In addition, interventional cardiac electrophysiologists have to perform procedures wearing heavy lead protection for prolonged periods, making them prone to cervical and lumbar spinal injuries. Recent findings Recently developed technologies, such as low-exposure radiographic imaging, novel radiographic imaging protection systems, nonfluoroscopic mapping systems using image integration, and remote catheter manipulation systems have been successful in reducing ionizing radiation exposure in the electrophysiology laboratory. The efficacy and safety of these technologies are being evaluated in clinical trials. In addition, economic analyses are being performed to evaluate these novel systems. The use of nonweight-bearing radiation protection devices and ergonomic design of the electrophysiology laboratory aim to reduce the incidence of occupational injuries in interventional cardiac electrophysiologists. Summary There is need for ongoing development and evaluation of new technologies to minimize exposure to ionizing radiation during electrophysiologic procedures. In addition, ergonomic planning of the electrophysiology laboratory and training of interventional cardiac electrophysiologists are crucial to occupational injury prevention.