Nikhil Patel

Diazepam or midazolam for external DC cardioversion (The DORM Study)

AIMS To compare the clinical efficacy and tolerability of two intravenous sedatives for physician-led DC cardioversion of atrial arrhythmias. METHODS AND RESULTS One hundred and forty-one patients attending for elective DC cardioversion of atrial arrhythmias were randomized to intravenous midazolam or diazepam. Sedation was administered using titration protocols. Procedure times, operator satisfaction scores and adverse events were documented. The patients immediate, 24- and 48-h recall and awareness of after-effects were obtained from questionnaires. Seventy-one patients received midazolam (mean 12.5 mg) and 70 patients received diazepam (mean 28.1 mg). There were 16 minor adverse events with midazolam (20% hypotension, 3% oxygen desaturation) and nine with diazepam (7% hypotension, 6% required additional analgesia), P = 0.14. There were no major adverse events. Sedation time was 5.0 +/- 3.4 min for midazolam and 6.5 +/- 3.4 min for diazepam (P = 0.0016). Patients awoke 77 +/- 46 min post-sedation with midazolam and 39 +/- 24 min with diazepam (P < 0.0001). There was no recall of the procedure at 48 h and no difference in awareness of after-effects between the two groups at 24 or 48 h, P = ns. CONCLUSION Physician-led cardioversion of atrial arrhythmias using intravenous sedation is effective and well tolerated. Sedation with diazepam was associated with fewer minor adverse events and a quicker recovery time than midazolam.

The relationship between right ventricular pacing and atrial fibrillation burden and disease progression in patients with paroxysmal atrial fibrillation: the long-MinVPACE study.

AIMS In patients requiring permanent pacemaker implantation for sinus node disease (SND) or atrioventricular (AV) block, right ventricular (RV) pacing has been demonstrated to increase the risk of developing atrial fibrillation (AF). The effects of RV pacing in patients with paroxysmal AF are less well defined. Short- and medium-term studies have suggested no significant correlation between RV pacing and atrial fibrillation burden (AFB) measurement; we sought to assess for an effect in the long-term. METHODS AND RESULTS Sixty-six patients were randomized to receive either conventional dual chamber pacing (DDDR, n = 33), or dual chamber minimal ventricular pacing (MinVP, n = 33), for a period of at least 1 year. Patients were reviewed every 6 months and all pacemaker data were downloaded. The primary outcome measures were device-derived AFB and progression to persistent AF. The mean duration of study follow-up was 1.4 ± 0.6 years. Mean ventricular pacing was less in the MinVP cohort compared with the DDDR cohort (5.8 vs. 74.0%, P < 0.001). At follow-up, the device-derived AFB was significantly lower in the MinVP cohort when compared with the DDDR cohort (12.8 ± 15.3% vs. DDDR 47.6 ± 42.2%, P < 0.001). Kaplan-Meier estimates of time to onset of persistent AF showed significant reductions in the rates of persistent AF for MinVP pacing (9%) when compared with conventional DDDR pacing (42%), P = 0.004. CONCLUSION Right ventricular pacing induces increased AFB in patients with paroxysmal AF in the long term. Dual chamber MinVP algorithms result in reduced AFB and reduced disease progression from paroxysmal to persistent AF in the long term.

A cardiac sonographer led follow up clinic for heart valve disease

INTRODUCTION This study describes the effect of introducing a cardiac sonographer led follow up clinic for patients with stable heart valve disease. The 2 years before and after the instigation of the valve clinic were audited. MATERIALS AND METHODS The clinic was conducted in a single centre and undertaken in the cardiology department of a district general hospital. 382 patients, with 397 clinically significant valve lesions, but for whom surgery was not yet indicated but follow up required, were seen in a cardiac sonographer run clinics. These patients no longer attended a medical follow up clinic unless there was clinical or echocardiographic deterioration. Effectiveness was judged by the percentage treated according to current best practice guidelines, the number of echocardiograms performed and the number of hospital out patient visits attended. In addition mortality data for the subjects in the clinic was collected. RESULTS The proportion followed up according to best practice guidelines rose from 157 (41%) to 354 (92%) (p<0.01). The total number of echocardiograms performed fell from 807 to 550. Total number of out patient visits fell from 998 to 31. 11 patients died in the two year study period, none from progressive valve disease. DISCUSSION This study demonstrates that a protocol driven sonographer led heart valve disease follow up clinic, significantly improved the quality of follow up while bringing about a major reduction in out patients visits, without compromising patient safety.

The Effect of Bipole Tip‐to‐Ring Distance in Atrial Electrodes upon Atrial Tachyarrhythmia Sensing Capability in Modern Dual‐Chamber Pacemakers

Introduction: Accurate atrial arrhythmia discrimination is important for dual chamber pacemakers and defibrillators. The aim was to assess the accuracy of atrial arrhythmia recording using modern devices and relate this to atrial tip‐to‐ring (TTR) distance.

Aortic valve calcification – a commonly observed but frequently ignored finding during CT scanning of the chest

Aim:  To describe the frequency and severity of Aortic valve calcification (AVC) in an unselected cohort of patients undergoing chest CT scanning and to assess the frequency with which AVC was being reported in the radiology reports.

It’s good to talk! Changes in coronary revascularisation practice in PCI centres without onsite surgical cover and the impact of an angiography video conferencing system

Introduction:  Percutaneous coronary intervention (PCI) activity has increased more than 6 fold in the last 15 years. Increased demand has been met by PCI centres without on‐site surgical facilities. To improve communication between cardiologists and surgeons at a remote centre, we have developed a video conferencing system using standard internet links. The effect of this video data link (VDL) on referral pattern and patient selection for revascularisation was assessed prospectively after introduction of a joint cardiology conference (JCC) using the system.

DOES ALCOHOL USE INCREASE THE RISK OF ATRIAL FIBRILLATION RECURRENCE AFTER RADIOFREQUENCY ABLATION

Alcohol is the most widely consumed drug in the world. Binge drinking has been associated with the “holiday heart syndrome”. However, it is unclear whether alcohol use post ablation increases the risk of Atrial Fibrillation (AF) recurrence. One hundred sixty-five patients underwent

First time and repeat cardioversion of atrial tachyarrhythmias – a comparison of outcomes

Introduction:  Repeat cardioversion may be necessary in over 50% of patients with persistent atrial fibrillation (AF), but identifying responders remains challenging. This study evaluates the long‐term success of direct current cardioversion (DCCV) and the clinical and echocardiographical parameters that influence them, in over 1000 sedation‐cardioversion procedures undertaken at Eastbourne General Hospital between 1996 and 2006.

Implantable cardioverter defibrillator shocks induced by showering

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40 Right ventricular high septal pacing vs. right ventricular apical pacing following av node ablation: 20 years follow up

Introduction Right ventricular septal (RVS) pacing is often recommended as a more physiological alternative to right ventricular apical (RVA) pacing. Most comparisons between the two sites have had short follow up and few trials have assessed the different pacing sites following atrioventricular node (AVN) ablation. We analysed 200 consecutive patients (pts) aged 66–96 (51% male) who underwent implantation of a pacemaker prior to AVN ablation with either RVA- or RVS-pacing between 1996 to 2016. Methods All hospital notes were retrieved and reviewed. Radiographic data for the site of V lead, all hospitalisations, change in echocardiography ejection fraction (EF), QRS width trend and lead parameters were collated. All pts additionally underwent dyssynchrony echocardiography. Results See tables 1 and 2. Conclusions (i) EF of less than 40%; (ii) prior diagnosis of IHD and (iii) dilated cardiomyopathy independently predict HF admission following AVN ablation. However, there was no decrease in EF and no difference in inter-ventricular or intra-ventricular dyssynchrony with either pacing site after up to 20 year follow up. There was a decreased mortality rate with RVA pacing following AVN ablation after longterm follow up. We now prophylactically use CRT pacing in all pts with EF 40% and known IHD. Their outcome is part of ongoing follow up.Abstract 40 Table 1 Baseline characteristicsAbstract 40 Table 2 Patient characteristics with and without left ventricular decompensation