Parijat S. Joy

Antiarrhythmics After Ablation of Atrial Fibrillation (5A Study)

Background— Atrial arrhythmias are common early after atrial fibrillation (AF) ablation. We hypothesized that empirical antiarrhythmic drug (AAD) therapy for 6 weeks after AF ablation would reduce the occurrence of atrial arrhythmias. Methods and Results— We randomized consecutive patients with paroxysmal AF undergoing ablation to empirical antiarrhythmic therapy (AAD group) or no antiarrhythmic therapy (no-AAD group) for the first 6 weeks after ablation. In the no-AAD group, only atrioventricular nodal blocking agents were prescribed. All patients wore a transtelephonic monitor for 4 weeks after discharge and were reevaluated at 6 weeks. The primary end point of the study was a composite of (1) atrial arrhythmias lasting more than 24 hours; (2) atrial arrhythmias associated with severe symptoms requiring hospital admission, cardioversion, or initiation/change of antiarrhythmic drug therapy; and (3) intolerance to antiarrhythmic agent requiring drug cessation. Of 110 enrolled patients (age 55±9 years, 71% male), 53 were randomized to AAD and 57 to no-AAD. There was no difference in baseline characteristics between groups. During the 6 weeks after ablation, fewer patients reached the primary end point in the AAD compared with the no-AAD group (19% versus 42%; P=0.005). There remained fewer events in the AAD group (13% versus 28%; P=0.05) when only end points of AF >24 hours, arrhythmia-related hospitalization, or electrical cardioversion were compared. Conclusions— AAD treatment during the first 6 weeks after AF ablation is well tolerated and reduces the incidence of clinically significant atrial arrhythmias and need for cardioversion/hospitalization for arrhythmia management.

Comparison of Bleeding Complications With Omega-3 Fatty Acids + Aspirin + Clopidogrel—Versus—Aspirin + Clopidogrel in Patients With Cardiovascular Disease

Fish oil is used to lower triglycerides and for the secondary prevention of cardiovascular events in patients with coronary artery disease. Many of these patients will also be taking aspirin and clopidogrel. Any of these medications alone can increase the risk of bleeding; however, the risk of bleeding in patients taking all 3 of these medications has not been studied. We retrospectively reviewed the medical records for bleeding complications in 182 patients, most with coronary artery disease (mean age 61 +/- 11 years, 82% men) and being treated with high-dose fish oil (mean dose 3 +/- 1.25 g), aspirin (mean dose 161 +/- 115 mg), and clopidogrel (mean dose 75 mg), and in 182 age- and gender-matched controls treated with aspirin and clopidogrel alone. During a mean follow-up period of 33 months, 1 major bleeding episode occurred in the treatment group and no major bleeding episodes occurred in the control group (p = 1.0). During follow-up, 4 minor bleeding episodes (2.2%) occurred in the treatment group and 7 (3.9%) in the control group. More patients had minor bleeding complications in the control group than in the treatment group; however, the difference was not statistically significant (p = 0.5). In conclusion, high-dose fish oil is safe in combination with aspirin and clopidogrel and does not increase the risk of bleeding compared with that seen with aspirin and clopidogrel alone.

Risk Factors and Outcomes of Gastrointestinal Bleeding in Left Ventricular Assist Device Recipients

Increasing use of left ventricular assist devices (LVADs) has been accompanied by rising incidence of gastrointestinal bleeding (GIB). Objectives of this study were to determine the yearly incidence of GIB in LVAD recipients, compare outcomes of continuous-flow (CF) and pulsatile-flow LVAD eras, and investigate for risk factors. The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database from 2005 to 2010 was analyzed. Primary outcome of interest was incidence of GIB in LVAD recipients. Multivariate logistic regression model was used to examine independent associations of GIB with risk factors and outcomes. An estimated 8,879 LVAD index admissions and 8,722 readmissions in LVAD recipients over 6 years were analyzed. The yearly incidence of GIB after LVAD implantation increased from 5% in 2005 to 10% in 2010. On multivariate regression analysis, the odds of GIB was 3.24 times greater (95% confidence interval 1.53 to 6.89) in the era of CF LVADs than in the era of pulsatile-flow LVADs. Compared to their younger counterparts, in LVAD recipients aged >65 years, the adjusted odds of GIB was 20.5 times greater (95% confidence interval 2.24 to 188). GIB did not significantly increase the inhospital mortality but increased the inpatient length of stay. In conclusion, the incidence of GIB in LVAD recipients has increased since the use of CF LVADs has increased, leading to greater inpatient lengths of stay and hospital charges. Older recipients of CF LVADs appear to be at a greater risk of GIB.

Principles of Physics in Surgery: The Laws of Mechanics and Vectors Physics for Surgeons—Part 2

In this sequel, to an earlier article, we discuss the laws of Mechanics, Thermodynamics and Vectors as they apply to soft and bony tissues. These include the Laplace’s Law as applied to colonic perforation, compression therapy, parturition, variceal rupture, disc herniations etc. The Pascal’s Law finds use in hernia repair and the Heimlich maneuver. Trigonometrically derived components of forces, acting after suturing, show ways to reduce cut-through; the thickness and the bite of suture determines the extent of tissue reaction. The heating effect of current explains the optimum gap between the prongs of a bipolar cautery and the use of law of transfer of heat in determining relation between healthy wound healing and ambient temperature.

Diffuse Alveolar Hemorrhage due to Acute Mitral Valve Regurgitation

Diffuse alveolar hemorrhage (DAH) can be caused by several etiologies including vasculitis, drug exposure, anticoagulants, infections, mitral valve stenosis, and regurgitation. Chronic mitral valve regurgitation (MR) has been well documented as an etiological factor for DAH, but there have been only a few cases which have reported acute mitral valve regurgitation as an etiology of DAH. Acute mitral valve regurgitation can be a life-threatening condition and often requires urgent intervention. In rare cases, acute mitral regurgitation may result in a regurgitant jet which is directed towards the right upper pulmonary vein and may specifically cause right-sided pulmonary edema and right-sided DAH. Surgical repair of the mitral valve results in rapid resolution of DAH. Acute MR should be considered as a possible etiology in patients presenting with unilateral pulmonary edema, hemoptysis, and DAH.

Identifying oncological emergencies

Prompt identification and treatment of life-threatening oncological conditions is of utmost importance and should always be included in the differential diagnosis. Oncological emergencies can have a myriad of presentations ranging from mechanical obstruction due to tumor growth to metabolic conditions due to abnormal secretions from the tumor. Notably, hematologic and infectious conditions may complicate the presentation of oncological emergencies. Advanced testing and imaging is generally required to recognize these serious presentations of common malignancies. Early diagnosis and treatment of these conditions can significantly affect the patient’s clinical outcome.

Renal Medullary Cancer in a Patient with Sickle Cell Trait

Renal medullary cancer is a rare malignancy almost exclusively seen in young patients of African ethnicity. These patients often present with the cardinal symptoms of hematuria, flank pain, and an abdominal mass, and this malignancy has been associated with patients carrying sickle cell trait. It is estimated that 300 million people worldwide carry sickle cell trait, and the presence of hematuria in these patients should be treated as a harbinger of a possible malignancy. Notably, this tumor mostly develops on the right side of the body. Patients often present with it at an advanced stage and the prognosis is poor. Therefore, a high index of suspicion in a patient of African descent presenting with a right sided abdominal mass and hematuria may assist in an early diagnosis. Current chemotherapy options are very limited, and early detection may provide a chance for surgical resection. It may also provide a bigger time frame for the initiation of novel chemotherapy regimens in patients who fail current chemotherapy regimens.

Delirium Tremens Leads to Poor Outcomes for Acute Coronary Syndrome.

Objectives: The mortality rate for patients with delirium tremens (DT) is 5%. As these patients present with elevated cardiac indices, coexisting DT in acute coronary syndrome (ACS) likely worsens outcomes. Our aim was to examine the outcomes of alcohol withdrawal syndrome (AWS) and DT in patients with ACS. Methods: We used the Nationwide Inpatient Sample (2000-2009) for our study. A multivariable logistic regression model was used to examine the independent association of AWS on inhospital mortality and a multivariable linear regression was used to examine the effect of AWS on inpatient length of stay (LOS). Results: An estimated 2,465,852 admissions with a primary diagnosis of ACS were analyzed. Of these, 4,499 patients had AWS and 3,460 patients had DT. Adjusting for age, gender, race, insurance, hospital characteristics, Charlsons comorbidity index, stent placement and year, the inhospital mortality was significant only for DT (OR 1.56; 95% CI 1.21-2.04). Inpatient LOS was 1.64 (95% CI 1.58-1.73) times higher in those with AWS and 2.33 (95% CI 2.22-2.43) times higher in DT when compared to nonalcoholics. Total hospital charges were higher for patients with AWS and DT when compared to nonalcoholics. Conclusions: Coexisting DT in ACS admissions is associated with increased mortality along with longer inpatient LOS and higher hospital costs.

Giant Adrenal Myelolipoma Masquerading as Heart Failure

Adrenal myelolipomas are rare benign tumors of the adrenal cortex composed of adipose and hematopoietic cells. They have been postulated to arise from repeated stimulation by stress, inflammation and ACTH oversecretion. Myelolipomas are usually detected incidentally on imaging and do not require any active intervention besides regular follow-up by imaging. However, myelolipomas may insidiously grow to large sizes and cause mass effects and hemorrhage. Timely diagnosis and surgical resection are curative and lifesaving.

Effect of Ablation for Atrial Fibrillation on Heart Failure Readmission Rates

Atrial fibrillation (AF) and heart failure (HF) cause numerous hospital admissions. We investigated if AF increases readmissions in patients with HF and whether AF ablation alters readmissions for HF exacerbations. The 2013 Nationwide Readmissions Database was analyzed for all-cause 90-day readmissions, after discharge for HF exacerbation. Kaplan-Meier analysis was used to compare hazard rates for readmissions due to HF exacerbation, after recent ablation versus no ablation. There were 885,270 admissions for HF exacerbation of which 364,447 had coexisting AF. All-cause 90-day readmission rates were higher in patients with HF with coexisting AF versus those without AF (41.4% vs 37.6%, p <0.0001). Associated factors increasing all-cause 90-day readmissions after ablation in patients without HF were female (odds ratio [OR] 1.44, p <0.001), complication of ablation (OR 1.44, p = 0.022), coronary artery disease (OR 1.56, p <0.001), chronic lung disease (OR 1.74, p <0.001), and malnutrition (OR 10.33, p <0.001). These factors were not significant for patients with HF. HF was not a significant risk factor for complications of ablation (adjusted OR 0.82, 95% confidence interval 0.57 to 1.18). Patients who underwent ablation versus patients who were discharged after HF exacerbation without ablation had a lower rate and length of stay for the 90-day readmission episode, due to HF exacerbation (27.5% vs 41.4%, p <0.0001, and 5.58 days vs 6.60 days, p = 0.031, respectively). In conclusion, AF increased 90-day readmissions in patients with HF, and ablation for AF in patients with HF was associated with reduced frequency, length of stay, and readmissions without an increase in complication rates.