Mujeeb Sheikh

Catheter Ablation and Antiarrhythmic Drug Therapy as First- or Second-Line Therapy in the Management of Atrial Fibrillation Systematic Review and Meta-Analysis

Background—The optimal management of atrial fibrillation remains unclear. We performed a meta-analysis of randomized controlled trials to examine the safety and the efficacy of catheter ablation (CA) when compared with antiarrhythmic drug therapy both as first- and second-line therapy for the maintenance of sinus rhythm in atrial fibrillation. Methods and Results—Several databases were searched from inception to March 2014, which yielded 11 studies with 1481 patients with atrial fibrillation. The outcomes measured were recurrence of atrial tachyarrhythmia and the incidence of adverse events. A subgroup analysis was done to evaluate the efficacy of CA as first- or second-line therapy. There was recurrence of atrial tachyarrhythmia in 222 of 785 (28%) patients who underwent CA and in 451 of 696 (65%) patients who were on antiarrhythmic drug therapy (relative risk, 0.40; 95% confidence interval, 0.31−0.52; P=0.00001). Subgroup analysis revealed a beneficial effect of CA both as a first-line (relative risk, 0.52; 95% confidence interval, 0.30−0.91; P=0.02) and as a second-line (relative risk, 0.37; 95% confidence interval, 0.29−0.48; P<0.00001) therapeutic modality. There was a significantly higher incidence of major adverse events in the CA group when compared with those in the antiarrhythmic drug therapy group (relative risk, 2.04; 95% confidence interval, 1.10–3.77; P=0.02, I2=0%). Conclusions—CA seems to be superior to antiarrhythmic drug therapy in drug naïve, resistant, and intolerant patients with atrial fibrillation. However, it should be performed in carefully selected patients after weighing the risks and benefits of the procedure.

Erythropoietin in the treatment of postural orthostatic tachycardia syndrome.

Erythropoietin has been reported to improve symptoms of orthostatic intolerance in patients suffering from orthostatic hypotension. Previous reports on the use of erythropoietin in patients with postural orthostatic tachycardia (POTS) have included only a very small number of patients. In the current study, we report on the use of erythropoietin in patients with refractory POTS. The study was approved by the institutional review board. A retrospective nonrandomized analysis was performed on 39 patients evaluated at our autonomic center for POTS from 2003 to 2010. The diagnosis of POTS was based on patient history, physical examination, and response to head-up tilt-table testing. The mean follow-up period was 6 months. The patients were included in the current study if they had a diagnosis of POTS with severe symptoms of orthostatic intolerance and were refractory to the commonly used medications. All these patients were started on erythropoietin, and the response to therapy was considered successful if it provided symptomatic relief. We screened 200 patients with POTS and found 39 patients (age 33 ± 12, 37 females) to be eligible for inclusion in the current study. The response to the treatment was assessed subjectively in each patient and was obtained in a retrospective fashion from patient charts and physician communications. Eight (21%) patients demonstrated no improvement in symptoms after administration of erythropoietin. Three (8%) patients showed an improvement in symptoms of orthostatic intolerance of <3 months. Twenty-seven (71%) patients demonstrated sustained improvement in their symptoms of orthostatic intolerance at the mean follow-up of 6 months. Erythropoietin significantly improved sitting diastolic blood pressure but had no effect on other hemodynamic parameters. In a select group of POTS patients who are refractory to commonly used medications, erythropoietin may help improve symptoms of orthostatic intolerance.

Multiple coronary to pulmonary artery fistulas: a case report and review of the literature

Coronary to pulmonary artery fistulae (CAF) are rare cardiac anomalies. The majority arise from the right coronary artery, with fistulae originating from the left anterior descending artery or from multiple arteries being less common. CAF are frequently asymptomatic and found incidentally on routine cardiac imaging. We present the case of a 61-year-old woman with multiple CAF who presented with progressive shortness of breath and chest pain and was ultimately treated successfully with trans-catheter coiling with marked improvement in symptoms. We also review the currently available literature regarding advances in diagnosis and treatment of CAF.

Endovascular therapy for radiation-induced pulmonary artery stenosis: A case report and review of the literature

Although pulmonary artery stenosis and its treatment has been well characterized in pediatric populations, its diagnosis and even how to determine the significance of a stenosis can be difficult and optimal management is currently unknown. This case report and review of the literature outlines how we successfully diagnosed, evaluated, and stented a patient with radiation induced pulmonary artery stenosis. This case further adds support to a very limited data pool suggesting that percutaneous angioplasty of pulmonary artery stenosis may be a safe and effective treatment option for this unique patient population.

Coronary bypass graft perforation during percutaneous intervention.

INTRODUCTION Coronary artery bypass grafts are prone to accelerated atherosclerosis and as such graft stenosis is frequently encountered in clinical practice. Complications specific to graft- PCI include no-reflow, distal embolization, stent restenosis and thrombosis. Graft perforation during PCI is a rare coomplication of the procedure. Published literature on the predictors of perforation and management strategy remains limited to anecdotal cases. METHOD In this review we collected data on all cases of graft perforations reported in PubMed/Medline from 1987 to 2015. RESULT 37 cases of graft perforation were reported. High risk grafts for perforations included, old grafts (14±7.8years) with more than 80% luminal stenosis. Perforations were noted after use of different cardiac devices and included stent placement (30%, N=11), balloon angioplasty (36%, N=14), post-dilation with non complaint balloon (16%, N=6), guide wire perforation (1 case), post IVUS imaging (1 case) and one case after use of thrombus extraction device. Average stent diameter of 3.7±0.7 mm, average balloon pressure of 15.5±5 atm and 3 or more balloon inflations commonly resulted in graft perforation. 78% of cases reported class III perforation. Covered stent implantation was strongly associated with controlling acute bleed after graft perforation than prolonged balloon inflation (p=0.0001). Majority of cases reported using covered stents (81%). Average stent diameter of 3.9±0.7mm, average stent length of 18.5±6mm and the average deployment pressure of 14±2atm were reported to be effective in controlling the bleed. 95% of the patients did well post procedure and with prolonged hospitalization (8±4days). 24% of cases reported cardiac tamponade causing hemodynamic compromise including 2 peri-procedural deaths. CONCLUSION Graft perforation can be effectively treated with covered stent grafts with good immediate results, short term outcome and acceptable peri-procedural risks.

Transmyocardial Voyage of a Temporary Epicardial Lead: An Unusual Long-Term Complication

Although the majority of temporary epicardial leads used during cardiac surgery are removed in the perioperative period, occasionally, the wires are cut and allowed to retract into the subcutaneous tissue. Complications arising from such retained epicardial wires are rare. We present a case of transmyocardial migration of a retained epicardial wire through the right ventricular myocardium into the pulmonary artery in a patient who had undergone coronary artery bypass graft surgery 13 years ago. We describe the presentation and successful management of this case.(PACE 2011; 1–2)

Simultaneous ST-segment elevation in inferior and precordial leads following ingestion of a lethal dose of desipramine: a novel Brugada-like EKG pattern

The typical Brugada electrocardiographic (EKG) pattern includes ST-segment elevation in the right precordial leads (V1–V3) associated with right bundle branch block (rSR′) like morphology. Recently, a Brugada-like EKG pattern with ST-segment elevation in inferior leads called the “Brugada variant” has been reported. We report a case of simultaneous typical and variant Brugada EKG patterns with ST-segment elevation in the inferior as well as the precordial leads following ingestion of a lethal dose of desipramine.

Coronary stent fracture: a cause of cardiac chest pain?

Inherent risks of coronary artery stenting include restenosis and thrombosis. More recently, stent fractures (SF) have emerged as a complication. Lengthy coronary stents, overlapping stents, saphaneous vein graft stents, and right coronary artery lesions treated with sirolimus-eluting stents (SES; Cypher, Cordis, Miami Lakes, Florida, USA) are some of the predisposing factors that have been linked to fractures. Early detection and management may help alleviate the complications of SF including acute thrombosis and restenosis at the site of fracture. We present an interesting case of a SES fracture in the left main coronary artery.

Rituximab Induced Left Bundle Branch Block

Rituximab (a monoclonal antibody directed against CD 20) therapy can be acutely complicated by infusion reactions and cardiac arrhythmia on rare occasions. We report the first case of a new onset left bundle branch block (LBBB) after rituximab therapy for Wegener′s vasculitis.

Case of Paradoxical Embolic Transient Ischemic Attack from an Unusual Extra Cardiac Shunt Detected on a Contrast-Enhanced Echocardiogram

Paradoxical embolism due to extracardiac right to left shunts (RLSs) manifesting as stroke remains anecdotal. We describe a case of 63‐year‐old female who presented with a transient ischemic attack and at agitated saline contrast echocardiogram was found to have an unusual type of an extracardiac RLS. Further evaluation leads to diagnosis of superior vena cava (SVC) thrombosis from a prior indwelling central venous catheter. The SVC thrombosis induced systemic‐pulmonary venous collaterals were responsible for this unusual extracardiac RLS and paradoxical transient ischemic attack. We discuss the diagnosis and management of this rare clinical case.