Sandeep Gautam

Management and outcomes of cardiac tamponade during atrial fibrillation ablation in the presence of therapeutic anticoagulation with warfarin

BACKGROUND Cardiac tamponade (CT) is a possible complication of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). Although the incidence of CT is not higher when RFCA is performed with a therapeutic international normalized ratio (INR), outcomes of CT are unclear. OBJECTIVE We compared outcomes among patients with and without a therapeutic INR who developed CT as a complication of RFCA of AF. METHODS The subjects of this retrospective study were 40 consecutive patients who developed CT during RFCA of AF at 3 centers. We divided the patients into 2 groups: RFCA performed with INR < 2 (group 1) and INR ≥ 2 (group 2). There were 23 patients in group 1 and 17 patients in group 2. RESULTS Baseline clinical and procedure characteristics were not different between the 2 groups. Heparin was reversed by protamine in 83% and 94% of patients (P = .37), and warfarin was reversed by fresh frozen plasma or factor VIIa in 17% and 35% of patients (P = .27) in groups 1 and 2, respectively. All patients were successfully treated by percutaneous drainage, and none required surgical intervention. There were no significant differences in the amount of initial pericardial drainage (523 ± 349 ml vs. 409 ± 157 ml, P = .22) or the duration of drainage (P = .14) between the 2 groups. All patients survived to hospital discharge. Median length of hospital stay was 2 days longer in group 1 (P <.01). CONCLUSION Cardiac tamponade is not more severe or difficult to manage in the presence of therapeutic anticoagulation with warfarin in patients undergoing RFCA of AF.

Effect of Hurricane Katrina on the incidence of acute coronary syndrome at a primary angioplasty center in New Orleans.

BACKGROUND In August 2005, New Orleans was hit by Hurricane Katrina, the costliest natural disaster in US history. Previous studies have shown an increase in acute myocardial infarction (AMI) in the immediate hours to weeks after natural disasters. The goals of our study were to detect any long-term increase in the incidence of AMI after Katrina and to investigate any pertinent contributing factors. METHODS This was a single-center retrospective cohort observational study. Patients admitted with AMI to Tulane Health Sciences Center hospital in the 2 years before Katrina and in the 2 years after the hospital reopened (5 months after Katrina) were identified from hospital records. The 2 groups (pre- and post-Katrina) were compared for prespecified demographic and clinical data. RESULTS In the post-Katrina group, there were 246 admissions for AMI, out of a total census of 11,282 patients (2.18%), as compared with 150 AMI admissions out of a total of 21,229 patients (0.71%) in the pre-Katrina group (P < 0.0001). The post-Katrina group had a significantly higher prevalence of unemployment (P = 0.0003), lack of medical insurance (P < 0.0001), medication noncompliance (P = 0.0001), smoking (P = 0.001), substance abuse (P = 0.03), first-time hospitalization (P < 0.001), local residents rather than visitors affected (P < 0.0001), and people living in temporary housing (P = 0.003). DISCUSSION The role of chronic stress in the pathogenesis of AMI is poorly understood, especially in the aftermath of natural disasters. Our data suggest that Katrina was associated with prolonged loss of employment and insurance, decreased access to preventive health services, and an increased incidence of AMI. In addition, it appears that chronic stress after a natural disaster can be associated with tobacco abuse and medication and therapeutic noncompliance. CONCLUSIONS We found a 3-fold increased incidence of AMI more than 2 years after Hurricane Katrina. Even allowing for the loss of some local hospitals after the disaster, this represents a significant change in overall health of the study population and supports the need for further study into the health effects of chronic stress.

Repeat needle biopsies combined with clinical observation are safe and accurate in the management of a solitary pulmonary nodule

Sixty percent of removed solitary pulmonary nodules (SPNs) are benign. An approach that reduces the unnecessary excision of benign nodules is consistent with the oncologic objective of organ preservation.

Interatrial Electrical Dissociation After Catheter-Based Ablation for Atrial Fibrillation and Flutter

A 58-year-old man with hypertension and diabetes with recurrent persistent symptomatic atrial fibrillation resistant to sotalol-facilitated cardioversions was referred for ablation. Catheter-based radiofrequency ablation for persistent atrial fibrillation was performed, which consisted of isolation of all 4 pulmonic veins; linear ablations along the left atrial roof; an ablation line from the lateral mitral annulus to the left inferior vein; and ablation of areas with complex fractionated atrial electrograms along the posterior mitral annulus, anterior septum, and base of left atrial appendage. After these ablation lesions, the atrial fibrillation converted to a focal right atrial tachycardia, which was terminated by ablation in the inferior crista terminalis. The patient remained in sinus rhythm after the procedure for 2 weeks but returned with an incessant atrial tachycardia requiring repeat electrophysiological study. Electroanatomic mapping revealed earliest atrial activation in the proximal coronary sinus. Entrainment from the cavotricuspid isthmus returned long postpacing intervals. Postpacing interval identical to tachycardia cycle length was obtained with entrainment from the ostium of the coronary sinus. A linear ablation from the ostium of the coronary sinus to the inferior vena cava terminated tachycardia and rendered the patient noninducible for atrial arrhythmias. Atrial tachycardia recurred after 3 weeks. The patients antiarrhythmic medication was switched from sotalol to …

Determinants of Heparin Dosing and Complications in Patients Undergoing Left Atrial Ablation on Uninterrupted Rivaroxaban

Patients on rivaroxaban have variable international normalized ratios (INRs) but it is uncertain if INR impacts procedural heparin requirement during left atrial ablation. We sought to examine the determinants of heparin dosing in this patient population.

Figure-of-eight sutures for hemostasis result in shorter lab recovery time after ablation for atrial fibrillation

Ablation for atrial fibrillation (AF) requires multiple venous sheaths and anticoagulation with heparin, both risk factors for bleeding complications. Manual compression (MC) with heparin reversal is the standard method to achieve venous hemostasis postablation; however, temporary figure‐of‐eight sutures (F8S) are an alternative. While this technique has been shown to be safe and effective, little is known about its effect on postprocedural recovery time.

Successful Percutaneous Retrieval of Embolized Septal Occluder Device from Aortic Arch and Placement of a Newer Septal Occluder Device in Combined Procedure

Embolization of the Amplatzer Septal Occluder (ASO) device (St. Jude Medical, Minnesota) after percutaneous closure of atrial septal defect (ASD) is a rare and potentially catastrophic complication. Percutaneous retrieval of the embolized device is gaining ground as an acceptable method, although these patients are usually subsequently referred for open surgical closure of the ASD. We present a unique case of percutaneous retrieval embolized ASO device and placement of newer larger ASO device in a single procedure.

TRAF3IP2 mediates TWEAK/TWEAKR-induced pro-fibrotic responses in cultured cardiac fibroblasts and the heart

Persistent inflammation promotes development and progression of heart failure (HF). TWEAK (TNF-Related WEAK Inducer Of Apoptosis), a NF-κB- and/or AP-1-responsive proinflammatory cytokine that signals via TWEAK receptor (TWEAKR), is expressed at high levels in human and preclinical models of HF. Since the adapter molecule TRAF3IP2 (TRAF3 Interacting Protein 2) is an upstream regulator of various proinflammatory pathways, including those activated by NF-κB and AP-1, we hypothesized that targeting TRAF3IP2 inhibits TWEAK-induced proinflammatory and pro-fibrotic responses in vitro and in vivo. Consistent with the hypothesis, forced expression of TRAF3IP2 upregulated TWEAK and its receptor expression in cultured adult mouse cardiac fibroblasts (CF). Further, exogenous TWEAK upregulated TRAF3IP2 expression in a time- and dose-dependent manner, suggesting a positive-feedback regulation of TRAF3IP2 and TWEAK. TWEAK also promoted TRAF3IP2 nuclear translocation. Confirming its critical role in TWEAK signaling, silencing TRAF3IP2 inhibited TWEAK autoregulation, TWEAKR upregulation, p38 MAPK, NF-κB and AP-1 activation, inflammatory cytokine expression, MMP and TIMP1 activation, collagen expression and secretion, and importantly, proliferation and migration. Recapitulating these in vitro results, continuous infusion of TWEAK for 7 days increased systolic blood pressure (SBP), upregulated TRAF3IP2 expression, activated p38 MAPK, NF-κB and AP-1, induced the expression of multiple proinflammatory and pro-fibrotic mediators, and interstitial fibrosis in hearts of wild type mice. These proinflammatory and pro-fibrotic changes occurred in conjunction with myocardial hypertrophy and contractile dysfunction. Importantly, genetic ablation of TRAF3IP2 inhibited these TWEAK-induced adverse cardiac changes independent of increases in SBP, indicating that TRAF3IP2 plays a causal role, and thus a therapeutic target, in chronic inflammatory and fibro-proliferative diseases.

Use of antibiotic envelopes to prevent cardiac implantable electronic device infections: A meta-analysis

The rates of cardiac implantable electronic device (CIED) infections have risen over the past decade and are associated with increased hospitalizations and mortality. A number of preventative strategies have been developed including an antibiotic coated envelope, but it has yet to gain widespread use.

Three-way stopcock suture technique for hemostasis after ablation for atrial fibrillation: PAYNE et al.

Figure‐of‐eight sutures (F8S) have emerged as an alternative to the standard practice of manual compression to achieve venous hemostasis after catheter ablation for atrial fibrillation (AF). In lieu of a knot to secure the sutures in place, a three‐way stopcock can be used, which can be loosened or tightened as needed to achieve hemostasis and is easier to remove. The safety and effectiveness of this technique, when compared to traditional F8S, are unknown. In this case series, we sought to describe this stopcock closure (SC) technique and compare procedural characteristics and outcomes to the traditional F8S.