Raed H. Abdelhadi

Design, Challenges, and Implications of Quality Improvement Projects Using the Electronic Medical Record

Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery, which results in increased morbidity, mortality, length of stay, and hospital costs. We developed and followed a process map to implement a protocol to decrease POAF: (1) identify stakeholders and form a working committee, (2) formal literature and guideline review, (3) retrospective analysis of current institutional data, (4) data modeling to determine expected effects of change, (4) protocol development and implementation into the electronic medical record, and (5) ongoing review of data and protocol adjustment. Retrospective analysis demonstrated that POAF occurred in 29.8% of all cardiovascular surgery cases. Median length of stay was 2 days longer (P<0.001), and median total variable costs

Autosomal-dominant biventricular arrhythmogenic cardiomyopathy in a large family with a novel in-frame DSP nonsense mutation

2495 higher (P<0.001) in POAF patients. Modeling predicted that up to 60 cases of POAF and >

Design and Initial Results of the Minneapolis Heart Institute TeleHeart Program

200 000 annually could be saved. A clinically based electronic medical record tool was implemented into the electronic medical record to aid preoperative clinic providers in identifying patients eligible for prophylactic amiodarone. Initial results during the 9-month period after implementation demonstrated a reduction in POAF in patients using the protocol, compared with those who qualified but did not receive amiodarone and those not evaluated (11.1% versus 38.7% and 38.8%; P=0.022); however, only 17.3% of patients used the protocol. A standardized methodological approach to quality improvement and electronic medical record integration has potential to significantly decrease the incidence of POAF, length of stay, and total variable cost in patients undergoing elective coronary artery bypass graft and valve surgeries. This framework for quality improvement interventions may be adapted to similar clinical problems beyond POAF.

OUTCOMES OF PERIPROCEDURAL ANTICOAGULATION THERAPY WITH WARFARIN VERSUS NEW ORAL ANTICOAGULANTS IN PATIENTS UNDERGOING CARDIAC IMPLANTABLE ELECTRONIC DEVICE PLACEMENT

A novel autosomal‐dominant in‐frame deletion resulting in a nonsense mutation in the desmoplakin (DSP) gene was identified in association with biventricular arrhythmogenic cardiomyopathy across three generations of a large Caucasian family. Mutations that disrupt the function and structure of desmosomal proteins, including desmoplakin, have been extensively linked to familial arrhythmogenic right ventricular cardiomyopathy (ARVC). Analysis of data from 51 individuals demonstrated the previously undescribed variant p.Cys81Stop (c.243_251delCTTGATGCG) in DSP segregates with a pathogenic phenotype exhibiting variable penetrance and expressivity. The mutations pathogenicity was first established due to two sudden cardiac deaths (SCDs), each with a biventricular cardiomyopathy identified on autopsy. Of the individuals who underwent genetic screening, 27 of 51 were heterozygous for the DSP mutation (29 total with two obligate carriers). Six of these were subsequently diagnosed with arrhythmogenic cardiomyopathy. An additional nine family members have a conduction disorder and/or myocardial structural changes characteristic of an evolving condition. Previous reports from both human patients and mouse studies proposed DSP mutations with a premature stop codon impart mild to no clinical symptoms. Loss of expression from the abnormal allele via the nonsense‐mediated mRNA decay pathway has been implicated to explain these findings. We identified an autosomal‐dominant DSP nonsense mutation in a large family that led to SCD and phenotypic expression of arrhythmogenic cardiomyopathy involving both ventricles. This evidence demonstrates the pathogenic significance of this type of desmosomal mutation and provides insight into potential clinical manifestations.

STANDARDIZED NURSE-DRIVEN PROTOCOL FOR POSTOPERATIVE ATRIAL FIBRILLATION REDUCES LENGTH OF STAY AND HOSPITAL COSTS

Telehealth is an emerging care delivery method that is defined by the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health.1 Telehealth is emerging into chronic condition management and settings outside of the acute care hospital.2 The American Heart Association has recognized telehealth as critically important in the future of cardiac care—both to reduce the burden of disease and costs.3 However, there are limited reports of successful implementation of cardiac telehealth programs beyond heart failure monitoring and acute care settings.4 We report the design and initial results of a regional cardiac telehealth system, the Minneapolis Heart Institute (MHI) TeleHeart program. The MHI has 36 clinic outreach sites across Minnesota and Wisconsin, ranging from 8 to 129 miles from the primary hospital, Abbott Northwestern Hospital in Minneapolis, MN (Figure). Many outreach sites have cardiology presence once a week or more, but more distant and rural sites may have on-site cardiologist presence only once or twice a month. These more distant rural sites were experiencing significant delays to cardiology appointments (range, 2.5 to 7.5 weeks) or challenging travel requirements for timely access to outpatient cardiology consultation, particularly in inclement weather. Figure. Minnesota map depicting Minneapolis Heart Institute (MHI) outreach sites and TeleHeart sites (green TH labels). Sites depicted in red are sites with services 5 d/wk. Therefore, the MHI TeleHeart program was designed to improve patient access to care in rural Minnesota by decreasing wait times and travel for specialty cardiovascular care. The program was also designed to enhance regional partnerships and increase cardiovascular subspecialty availability at rural locations. There were several barriers to program development and implementation.

ICD LEAD MALFUNCTION DUE TO FAILURE AT THE DEVICE-TISSUE INTERFACE

With increasing utilization of new oral anticoagulants (NOACs), data are needed to guide therapy in patients anticipating procedures such as Cardiac Implantable Electronic Device (CIED) placement. There are limited data comparing outcomes with warfarin and NOACs apixaban, dabigatran, and rivaroxaban

“SILENT” ATRIAL FIBRILLATION BURDEN IN PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY

Postoperative atrial fibrillation (POAF) is common following cardiovascular (CV) surgery and is associated with an increase in complications. Significant variation in the management of POAF exists, which can cause increased hospital costs and length of stay (LOS). Prospective use of a real-time,

1166-212 Pulmonary vein isolation in patients with prior cardiac surgery

Background: ICD lead malfunction (MAL) may result in morbidity and surgical revision. While MAL due to conductor and insulation defects are well known, there are little data for MAL caused by failure at the device-tissue interface. Accordingly we assessed MAL for contemporary ICD leads at our center and compared MAL caused by conductor and insulation defects (ELEC) to MAL due to device-tissue interface failure (DTF). Methods: This is a retrospective single center observational study that includes all Sprint Quattro (SQ), Endotak Reliance (ER), and Durata (DU) leads followed in our clinic. ELEC were MAL in the presence of electrical failure, mainly impedance and/or noise; DTF were high threshold/exit block and/or undersensing/low R-wave in the presence of electrically intact leads and absence of radiographic lead dislodgement. Kaplan-Meier estimates were calculated to assess lead survivals (SURV). Results: Of 2,268 ICD leads, 29 MAL were due to ELEC and 31 MAL were caused by DTF; the overall mean implant time was 3.8±3.0 SD yrs. The SURV for ELEC vs DTF are shown in the graph (log rank p=0.90). No significant differences in ELEC or DTF MAL were found for SQ (n=1706), ER (n=363) or DU (n=199). Mean time to failure was significantly shorter for DTF (1.9±2.1 SD yrs) than ELEC (4.9±2.6 SD yrs; p<0.001). Conclusions: DTF MAL is as common as ELEC MAL in contemporary ICD leads and they occur much earlier. This observation should encourage leadless ICD development and efforts to improve electrodes, fixation mechanisms, and implant techniques. CONTACT Robert Hauser MD FACC, Raed Abdelhadi MD FACC, Ross Garberich MS, William Katsiyiannis MD FACC Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA

Relation of an exaggerated rise in white blood cells after coronary bypass or cardiac valve surgery to development of atrial fibrillation postoperatively

Symptomatic atrial fibrillation (AF) is thought to occur in at least 20% of patients with hypertrophic cardiomyopathy (HCM), however, the burden and clinical significance created by asymptomatic and “silent” AF in HCM is unknown. Asymptomatic AF is often detected at routine device follow-up, and

New hope for the prevention of recurrent atrial fibrillation

Background: The short-term reliability of patient reported symptoms as a marker of atrial tachyarrhythmia or atrial fibrillation (AT/AF) recurrence has been studied. However, the long-term correlation of symptoms with continuous monitoring of AT/AF episodes during pacing is unknown. Methods: This prospective multicenter trial assessed the development of AT/AF in paced patients by examining the correlation of patient-reported symptoms with device-detected AT/AF event data in patients with bradyarrhythmias and > 1 episode of AT/AF in the prior year. Full disclosure device datalogs with electrogram (EGM) validation of AT/AF events were obtained from a pacemaker (AT500, Medtronic) that records the daily frequency, atrial and ventricular cycle length, EGM, and duration of AT/AF episodes. Patients logged symptomatic events into the device memory via an external manual activator. Following a one-month lead-in period, patients were followed for an additional 12 months and were contacted weekly to ensure compliance with activator usage. Episodes were classified as symptomatic AT/AF, asymptomatic AT/AF, or symptomatic “non-AT/AF” depending on concordance between patient-indicated symptoms and device-detected AT/AF. Results: 48 patients (28 M, 76±10 yr) were implanted and followed for 12±2 months. Arrhythmia-related symptoms were noted in 8% of all device-detected AT/AF episodes (sensitivity).Only 19% of all patient symptoms were associated with device documented AT/AF events (positive predictive value). A paired analysis in a subset of patients (n=15) with both symptomatic and asymptomatic stored episodes indicated no difference (p=NS) with respect to median ventricular rate (94 vs 94 bpm), atrial cycle length (230 vs 235 ms), or episode duration (103 vs 75 s). Conclusion: Over a long-term follow-up, the vast majority of AT/AF episodes are asymptomatic and patient symptoms are seldom associated with AT/AF episodes. Hence, patient symptoms are an unreliable index of recurrent AF in clinical studies of AF therapies and in management of anticoagulation therapy. Continuous monitoring via implantable device datalogs provides objective early and reliable detection of AF during followup.