Varunsiri Atti

Global rising trends of atrial fibrillation: a major public health concern

Atrial fibrillation (AF) is the most common arrhythmia worldwide and the estimated global age adjusted prevalence was 0.5% in 2010, representing nearly 33.5u2009million individuals.1 The prevalence is likely underestimated as a large proportion of asymptomatic individuals and those having transient symptoms remain undiagnosed. It is recognised as a global public health problem due to its significant burden of morbidity and mortality resulting from embolic stroke, congestive heart failure and acute coronary syndrome. AF may affect functional status and impairs the quality of life. The incremental cost related to AF in the USA is estimated at US

Utilization of the Impella for hemodynamic support during percutaneous intervention and cardiogenic shock: an insight

6–26u2009billion per year.2 Thus, AF already has tremendous implications on the economy and public health.nnNumerous studies have reported AF as a growing epidemic with an expected doubling of its prevalence by 2030.3 However, most of the studies were conducted in the western world and epidemiological studies of AF in the Asian continent are scarce. Furthermore, the healthcare implications of the rapidly changing population dynamics in this region are poorly understood. As the prevalence is expected to rise, it is important to have an updated epidemiology of AF in order to allocate human and economic resources for appropriate healthcare planning. Two thirds of the AF-related healthcare expenses are from direct and indirect inpatient cost. Tremendous regional variation in hospitalisation for AF has been reported. Hence, the analysis of utilisation of hospitalisation is key to allocate resources accordingly.nnIn this context, Kim et al used the National Health Insurance Service (NHIS) database of Korea to describe the temporal trends of hospitalisation, costs, treatment …

Trends in utilization of mechanical circulatory support in patients hospitalized after out-of-hospital cardiac arrest

ABSTRACT Introduction: Impella is a catheter-based micro-axial flow pump placed across the aortic valve, and it is currently the only percutaneous left ventricular assist device approved for high-risk percutaneous coronary intervention and cardiogenic shock. Areas Covered: Even though several studies have repeatedly demonstrated the excellent hemodynamic profile of Impella in high-risk settings, it remains underutilized. Here we aim to provide an up-to-date summary of the available literature on Impellas use in High risk settings as well as the practical aspects of its usage. Expert Commentary: Percutaneous coronary interventions in high rsk settings have always been challenging for a physician. Impella 2.5 and CP, have been proven safe, cost effective and feasible in High Risk Percutaneous coronary Interventions with an excellent hemodynamic profile.

Valve in valve transcatheter aortic valve implantation (ViV-TAVI) versus redo-Surgical aortic valve replacement (redo-SAVR): A systematic review and meta-analysis

OBJECTIVEnThis study sought to examine the trends and predictors of mechanical circulatory support (MCS) use in patients hospitalized after out-of-hospital cardiac arrest (OHCA).nnnBACKGROUNDnThere is a paucity of data regarding MCS use in patients hospitalized after OHCA.nnnMETHODSnWe conducted an observational analysis of MCS use in 960,428 patients hospitalized after OHCA between January 2008 and December 2014 in the Nationwide Inpatient Sample database. On multivariable analysis, we also assessed factors associated with MCS use and survival to discharge.nnnRESULTSnAmong the 960,428 patients, 51,863 (5.4%) had MCS utilized. Intra-aortic balloon pump (IABP) was the most commonly used MCS after OHCA with frequency of 47,061 (4.9%), followed by extracorporeal membrane oxygenation (ECMO) 3650 (0.4%), and percutaneous ventricular assist devices (PVAD) 3265 (0.3%). From 2008 to 2014, there was an increase in the utilization of MCS from 5% in 2008 to 5.7% in 2014 (P trendu202f<u202f0.001). There was a non-significant decline in the use of IABP from 4.9% to 4.7% (P trendu202f=u202f0.95), whereas PVAD use increased from 0.04% to 0.7% (P trendu202f<u202f0.001), and ECMO use increased from 0.1% to 0.7% (P trendu202f<u202f0.001) during the study period. Younger, male patients with myocardial infarction, higher co-morbid conditions, VT/VF as initial rhythm, and presentation to a large urban hospital were more likely to receive percutaneous MCS implantation. Survival to discharge was significantly higher in patients who were selected to receive MCS (56.9% vs. 43.1%, OR: 1.16, 95% CI: (1.11-1.21), pu202f<u202f0.001).nnnCONCLUSIONSnThere is a steady increase in the use of MCS in OHCA, especially PVAD and ECMO, despite lack of randomized clinical trial data supporting an improvement in outcomes. More definitive randomized studies are needed to assess accurately the optimal role of MCS in this patient population.

Prophylactic catheter ablation of ventricular tachycardia in ischemic cardiomyopathy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUNDnBioprosthetic (BP) valves have been increasingly used for aortic valve replacement over the last decade. Due to their limited durability, patients presenting with failed BP valves are rising. Valve in Valve - Transcatheter Aortic Valve Implantation (ViV-TAVI) emerged as an alternative to the gold standard redo-Surgical Aortic Valve Replacement (redo-SAVR). However, the utility of ViV-TAVI is poorly understood.nnnMETHODSnA systematic electronic search of the scientific literature was done in PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov. Only studies which compared the safety and efficacy of ViV-TAVI and redo-SAVR head to head in failed BP valves were included.nnnRESULTSnSix observational studies were eligible and included 594 patients, of whom 255 underwent ViV- TAVI and 339 underwent redo-SAVR. There was no significant difference between ViV-TAVI and redo- SAVR for procedural, 30 day and 1 year mortality rates. ViV-TAVI was associated with lower risk of permanent pacemaker implantation (PPI) (OR: 0.43, CI: 0.21-0.89; Pu2009=u20090.02) and a trend toward increased risk of paravalvular leak (PVL) (OR: 5.45, CI: 0.94-31.58; Pu2009=u20090.06). There was no significant difference for stroke, major bleeding, vascular complications and postprocedural aortic valvular gradients more than 20u2009mm-hg.nnnCONCLUSIONnOur results reiterate the safety and feasibility of ViV-TAVI for failed aortic BP valves in patients deemed to be at high risk for surgery. VIV-TAVI was associated with lower risk of permanent pacemaker implantation with a trend toward increased risk of paravalvular leak.

Outcomes of patients admitted with ventricular arrhythmias and sudden cardiac death in the United States

BackgroundCatheter ablation is proven to be an effective strategy for drug refractory ventricular tachycardia (VT) in ischemic cardiomyopathy. However, the appropriate timing of VT ablation and identifying the group of patients that may receive the greatest benefit remains uncertain. There is limited data on the effect on prophylactic catheter ablation (PCA) in the prevention of implantable cardioverter defibrillator (ICD) therapy, electrical storm, and mortality.MethodsWe performed a comprehensive literature search through November 1, 2017, for all eligible studies comparing PCA + ICD versus ICD only in eligible patients with ischemic cardiomyopathy. Clinical outcomes included all ICD therapies including ICD shocks and electrical storm. Additional outcomes included all-cause mortality, cardiovascular mortality, and complications.ResultsThree randomized controlled trials (RCTs) (Nu2009=u2009346) met inclusion criteria. PCA was associated with a significantly lower ICD therapies (OR 0.49; CI 0.28 to 0.87; pu2009=u20090.01) including ICD shocks [OR 0.38; CI 0.22 to 0.64; pu2009=u20090.0003) and electrical storm (OR 0.55; CI 0.30 to 1.01; pu2009=u20090.05) when compared with ICD only. There was no significant difference in all-cause mortality (OR 0.77; CI 0.41 to 1.46; pu2009=u20090.42), cardiovascular mortality (OR 0.49; CI 0.16 to 1.50; pu2009=u20090.21), and major adverse events (OR 1.45; CI 0.52 to 4.01; pu2009=u20090.47) between two groups.ConclusionThese results suggest prophylactic catheter ablation decreases ICD therapies, including shocks and electrical storm with no improvement in overall mortality. There is a need for future carefully designed randomized clinical trials.

Propensity matched comparison of in-hospital outcomes of TAVR vs. SAVR in patients with previous history of CABG: Insights from the Nationwide inpatient sample

BACKGROUNDnMortality caused by ventricular arrhythmias (VAs) remains a problem of epidemic proportions. Understanding current trends on admission of VA, patient characteristics, morbidity, mortality, and health care utilization could help us improve allocation of health care resources and risk prediction.nnnOBJECTIVEnThe purpose of this study was to investigate clinical outcomes of VA, including ventricular tachycardia (VT), implantable cardioverter-defibrillator (ICD) shocks, and sudden cardiac death (SCD); and to identify predictors of morbidity and mortality, patterns of utilization of ICD and VT ablation, and the impact of such metrics on overall health care utilization.nnnMETHODSnFrom 2010-2015, we identified 290,998 VA hospitalizations, which were stratified into group 1: normal heart; group 2: ischemic heart disease (IHD); group 3: nonischemic heart disease (non-IHD); group 4: ICD shocks; and group 5: SCD (cardiac arrest without ICD shock).nnnRESULTSnThe number of admissions for VA decreased during the study period (except for patients with SCD and ICD shock, which increased); in-hospital mortality in patients admitted with VA and SCD increased; utilization of VT ablation in patients with ICD shocks and IHD increased; ICD implantation decreased in non-IHD patients and IHD patients; and admission for SCD was the strongest predictor of in-hospital mortality, followed by patients with non-IHD, patients with ICD shocks, and all patients with a Charlson comorbidity index ≥2.nnnCONCLUSIONnWe report a decrease in admissions for VA, decreased ICD utilization, a change in pattern of VT ablation utilization, and an increase of in-hospital mortality in SCD patients. Predictors of adverse outcomes identified in our study should be considered when developing risk models for patients undergoing risk assessment for SCD.

Spontaneous rupture of a pancreatic pseudocyst

The incidence of patients with previous history of coronary artery bypass grafting (CABG) presenting for aortic valvular replacement has been consistently on the rise. Repeat sternotomy for surgical aortic valve replacement (SAVR) carries an inherent risk of morbidity and mortality when compared to Transcatheter aortic valve replacement (TAVR).

Sarcomatoid carcinoma of the duodenum

This is a case of a 50-year-old woman with medical history significant for chronic pancreatitis secondary to alcohol abuse who initially presented with a 3-week history of progressively worsening epigastric pain. The patient described the pain as sharp, radiating to the back, worsened with intake of both solid foods and liquids and relieved with self-induced emesis. On admission, the patient was hypertensive, but other vitals were within normal limits. The abdomen was soft; however, there isxa0a firm palpable mass extending from the epigastric to the right and left upper quadrants. Labs were remarkable for hypokalaemia with potassium (K) 3 meq/L (normal range 3.5–4.9 meq/L), mildly elevated lipase 132u2009U/L (7–60u2009U/L) and an elevated alkaline phosphatase of 164u2009U/L (41–108u2009U/L). CT of the abdomen with contrast (figures 1 and 2) showed a large cystic structure measuring 12.9×21.2u2009cm directly adjacent to the body of the pancreas and a fluid collection with enhancing rim measuring 4.8×6.6u2009cm near the pancreatic tail with subsequent displacement of the stomach. Gastroenterology recommended cyst-gastrostomy at a tertiary care centre. However, surgery recommended surgical cyst-gastrostomy in the facility. The patient was made nil per os …

Temporal Trends in Utilization of Right-Sided Heart Catheterization Among Percutaneous Ventricular Assist Device Recipients in Acute Myocardial Infarction Complicated by Cardiogenic Shock

A 69-year-old Caucasian man presented to the gastroenterology clinic with complaints of nausea, abdominal pain and more than 100-pound unintentional weight loss over the past 1u2009year. He had a history of colon polyps and was overdue for surveillance colonoscopy. He was subsequently scheduled for an outpatient oesophagogastroduodenoscopy (EGD) and colonoscopy as initial work-up for his symptoms. One week later, the patient underwent endoscopy. EGD showed an ulcerated mass in the second portion of the duodenum (figure 1). Biopsy of the lesion showed features of pleomorphic cells without glandular differentiation (figures 2 and 3). Immunohistochemical studies revealed pleomorphic cells positive for cytokeratin AE1/AE3 (figure 4), CAM 5.2 …