Tushar Tuliani

In-Hospital Complications Associated With Catheter Ablation of Atrial Fibrillation in the United States Between 2000 and 2010 Analysis of 93 801 Procedures

Background— Atrial fibrillation ablation has made tremendous progress with respect to innovation, efficacy, and safety. However, limited data exist regarding the burden and trends in adverse outcomes arising from this procedure. The aim of our study was to examine the frequency of adverse events attributable to atrial fibrillation (AF) ablation and the influence of operator and hospital volume on outcomes. Methods and Results— With the use of the Nationwide Inpatient Sample, we identified AF patients treated with catheter ablation. We investigated common complications including cardiac perforation and tamponade, pneumothorax, stroke, transient ischemic attack, vascular access complications (hemorrhage/hematoma, vascular complications requiring surgical repair, and accidental arterial puncture), and in-hospital death described with AF ablation, and we defined these complications by using validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. An estimated 93 801 AF ablations were performed from 2000 to 2010. The overall frequency of complications was 6.29% with combined cardiac complications (2.54%) being the most frequent. Cardiac complications were followed by vascular complications (1.53%), respiratory complications (1.3%), and neurological complications (1.02%). The in-hospital mortality was 0.46%. Annual operator (<25 procedures) and hospital volume (<50 procedures) were significantly associated with adverse outcomes. There was a small (nonsignificant) rise in overall complication rates. Conclusions— The overall complication rate was 6.29% in patients undergoing AF ablation. There was a significant association between operator and hospital volume and adverse outcomes. This suggests a need for future research into identifying the safety measures in AF ablations and instituting appropriate interventions to improve overall AF ablation outcomes.

Burden of arrhythmias in patients with Takotsubo Cardiomyopathy (Apical Ballooning Syndrome)

INTRODUCTION The objective of our study was to assess the burden of arrhythmias, the gender differences in occurrence of arrhythmias and the impact of these arrhythmias on hospitalization outcomes in patients with Takotsubo Cardiomyopathy (TTC). METHODS TTC and various arrhythmias were identified using appropriate ICD-9-CM codes from Nationwide Inpatient Sample (NIS) discharge records 2006-2010. Length of hospital stay (LOS), in-hospital mortality and total charges were used to assess the impact of the arrhythmias on TTC hospitalization. All analyses were performed using SASv9.2 (Cary Institute Inc., Cary, NC). RESULTS A total of 16,450 patients were included in the study and 26% (n=4296) of patients had cardiac arrhythmias. Following arrhythmias were present in the descending order of frequency: atrial fibrillation (Afib) 6.9%, ventricular tachycardia (VT) 3.2%, atrial flutter (Afl) 1.9%, ventricular fibrillation and flutter 1%, paroxysmal supraventricular tachycardia (PSVT) 0.8%. Nearly two percent of the patients had sudden cardiac arrest (SCA). Males were more likely to have cardiac arrhythmias in general compared to females (OR: 1.5, 95% CI: 1.3-1.7, p-value 0.001). Occurrence of ventricular tachycardia (OR: 1.7, 95% CI: 1.3-2.2, p-value<0.001) and sudden cardiac arrest OR: 1.6, 95% CI: 1.1-2.2, p<0.001) were significantly higher in males. In contrast, Afib was significantly less in males compared to females (OR:0.8, 95% CI:0.6-0.9). Patients with arrhythmias had significantly longer length of stay, and increased cost of hospitalization and mortality. CONCLUSIONS Arrhythmias are present in nearly one-quarter of patients with TTC and worsen the outcome. While TTC has been established as a disease mainly of females, life threatening arrhythmias like VT and SCA are more common in males.

Atrial fibrillation post cardiac bypass surgery

Atrial fibrillation occurs in 5-40% patients after coronary artery bypass graft surgery. Atrial fibrillation increases mortality and morbidity in the post-operative period. We sought to conduct a comprehensive review of literature focusing on pathophysiology, risk factors, prevention and treatment of post coronary artery bypass graft atrial fibrillation.

Electrocardiographic Abnormalities and Reclassification of Cardiovascular Risk: Insights from NHANES-III

BACKGROUND We aimed to assess the additive value of electrocardiogram (ECG) findings to risk prediction models for cardiovascular disease. METHODS Our dataset consisted of 6025 individuals with ECG data available from the National Health and Nutrition Examination Survey-III. This is a self-weighting sample with a follow-up of 79,046.84 person-years. The primary outcomes were cardiovascular mortality and all-cause mortality. We compared 2 models: Framingham Risk Score (FRS) covariates (Model A) and ECG abnormalities added to Model A (Model B), and calculated the net reclassification improvement index (NRI). RESULTS Mean age of our study population was 58.7 years; 45.6% were male and 91.7% were white. At baseline, 54.6% of individuals had ECG abnormalities, of which 545 (9%) died secondary to a cardiovascular event, compared with 194 individuals (3.2%) (P <.01) without ECG abnormalities. ECG abnormalities were significant predictors of cardiovascular mortality after adjusting for traditional cardiovascular risk factors (hazard ratio 1.44; 95% confidence interval, 1.13-1.83). Addition of ECG abnormalities led to an overall NRI of 3.6% subjects (P <.001) and 13.24% in the intermediate risk category. The absolute integrated discrimination index was 0.0001 (P <.001). CONCLUSION Electrocardiographic abnormalities are independent predictors of cardiovascular mortality, and their addition to the FRS improves model discrimination and calibration. Further studies are needed to assess the prospective application of ECG abnormalities in cardiovascular risk prediction in individual subjects.

Major Electrocardiographic Abnormalities and 25-Hydroxy Vitamin D Deficiency: Insights from National Health and Nutrition Examination Survey-III

We explored the relationship between major electrocardiogram (ECG) abnormalities (mECG) and 25‐hydroxy (25‐OH) vitamin D deficiency (VDD) and the effect of mECG abnormalities on all‐cause and cardiovascular mortality in a healthy cohort with 25‐OH vitamin D insufficiency and deficiency.

Persistent Left Superior Vena Cava with Absent Right Superior Vena Cava: Out of Mind is Out of Sight?

Persistent Left Superior Vena cava (LSVC) is the most common venous cardiac anomaly found in 0.3 0.5% [1-4] and in 4.3% of those with congenital cardiac anomaly. However, its association with absent Right Superior Vena Cava (RSVC) is rare (0.09 0.13%) [5]. It can be associated with situs inversus. It gives rise to increased risk of paradoxical embolism since it is associated with interatrial septal defect, unroofed coronary sinus or direct communication of the vein to left atrium [2]. A genetic culprit may be genes for leftright signaling [6]. Since it is a rare anomaly, the key is to keep it ‘in mind’ so that when we see it, we recognize it. We report a case of Persistent LSVC with absent RSVC discovered during pacemaker implantation.

Combined use of direct renin inhibitor and carvedilol in heart failure with preserved systolic function

HYPOTHESES Heart failure with preserved systolic function (HFPSF) has attained epidemic proportions; however evidence-based therapeutic interventions have not advanced despite continued research over the past three decades. We propose the combined use of direct renin inhibitor and carvedilol for this condition. RATIONALE The Renin Angiotensin Aldosterone System (RAAS) plays a central role in myocyte hypertrophy, fibrosis and ventricular remodeling which is responsible for the diastolic dysfunction in HFPSF. Rising serum aldosterone levels with age have been implicated as a cause of myocardial fibrosis in the elderly. The sole use of Angiotensin Converting Enzyme Inhibitors or Angiotensin Receptor Blockers is associated with angiotensin-II and aldosterone escape and increased plasma renin activity. Carvedilol is a novel third generation non-selective β-blocker. The use of combination therapy will facilitate in better blood pressure control, reduce afterload, improve ventricular relaxation, cause regression of ventricular remodeling/fibrosis, maintain atrioventricular synchrony and enhance cardio-metabolic profile. The individual benefits of direct renin inhibitor and carvedilol could plausibly have a supra-additive effect when used in combination. Besides this, carvedilol can further reduce generation of free radicals, decrease LDL oxidation, improve Doppler echo diastolic parameters and decrease cardiac norepinephrine and density of cardiac β-receptors. CONCLUSION Evidence suggests that patients with HFPSF are treated less aggressively as compared to patients with heart failure with systolic dysfunction. Aggressive therapy with concurrent use of direct renin inhibitor and carvedilol will help in improving outcomes in this vulnerable patient sub-population. No prior trial has evaluated the combined use of these drugs for the treatment of HFPSF.

VARIATION IN GEOGRAPHIC DISTRIBUTION OF IN-HOSPITAL MORTALITY ASSOCIATED WITH ACUTE MYOCARDIAL INFARCTION: A NATIONWIDE ANALYSIS

Mortality from acute myocardial infarction (AMI) has significantly declined nationwide due to various reasons. Data regarding geographic variation in mortality is however limited. Using the Nationwide Inpatient Sample (NIS) between the years 2000-2010, patients with primary diagnosis of AMI was

SUBCLINICAL HYPOTHYROIDISM AND MICROALBUMINURIA: INSIGHTS FROM NHANES-III

Studies suggest sub clinical hypothyroidism (SCH) is related to cardiovascular mortality (CVM). We explored the relationship of SCH on the prevalence of microalbuminuria (MIA) which is a strong marker for CV disease. We explored the NHANES-III database (n=6812). We excluded individuals <40 years,

In-Hospital Complications Associated With Catheter Ablation of Atrial Fibrillation in the United States Between 2000 and 2010Clinical Perspective: Analysis of 93 801 Procedures

Background— Atrial fibrillation ablation has made tremendous progress with respect to innovation, efficacy, and safety. However, limited data exist regarding the burden and trends in adverse outcomes arising from this procedure. The aim of our study was to examine the frequency of adverse events attributable to atrial fibrillation (AF) ablation and the influence of operator and hospital volume on outcomes. Methods and Results— With the use of the Nationwide Inpatient Sample, we identified AF patients treated with catheter ablation. We investigated common complications including cardiac perforation and tamponade, pneumothorax, stroke, transient ischemic attack, vascular access complications (hemorrhage/hematoma, vascular complications requiring surgical repair, and accidental arterial puncture), and in-hospital death described with AF ablation, and we defined these complications by using validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. An estimated 93 801 AF ablations were performed from 2000 to 2010. The overall frequency of complications was 6.29% with combined cardiac complications (2.54%) being the most frequent. Cardiac complications were followed by vascular complications (1.53%), respiratory complications (1.3%), and neurological complications (1.02%). The in-hospital mortality was 0.46%. Annual operator (<25 procedures) and hospital volume (<50 procedures) were significantly associated with adverse outcomes. There was a small (nonsignificant) rise in overall complication rates. Conclusions— The overall complication rate was 6.29% in patients undergoing AF ablation. There was a significant association between operator and hospital volume and adverse outcomes. This suggests a need for future research into identifying the safety measures in AF ablations and instituting appropriate interventions to improve overall AF ablation outcomes.