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INTRODUCTION: Implantable cardioverter-defibrillator (ICD) in patients with heart failure with reduced ejection fraction reduces mortality secondary to malignant arrhythmias. Whether end-stage heart failure (HF) with continuous-flow left ventricular assist device (cf-LVAD) derive similar benefits remains controversial. METHODS: We performed a systematic literature review and meta-analysis of all published studies that examined the association between active ICDs and survival in advanced HF patients with cfLVAD. We searched PubMed, Medline, Embase, Ovid, and Cochrane for studies reporting the association between ICD and all-cause mortality in advanced HF patients with cfLVAD. Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data. RESULTS: Ten studies (9 retrospective and one prospective) with a total of 7,091 patients met inclusion criteria. There was no difference in all-cause mortality (RR 0.84, 95% CI 0.65–1.10, p=0.20, I(2) =62.40%), likelihood of survival to transplant (RR 1.07, 95% CI 0.98–1.17, p= 0.13, I(2) =0%), RV failure (RR 0.74, 95% CI 0.44–1.25, p = 0.26, I(2) =34%) between Active ICD and inactive/no ICD groups, respectively. Additionally, 27.5% received appropriate ICD shocks, while 9.5% received inappropriate ICD shocks. No significant difference was observed in terms of any complications between the two groups. CONCLUSIONS: All-cause mortality, the likelihood of survival to transplant, and worsening RV failure were not significantly different between active ICD and inactive/no ICD in cf-LVAD recipients. A substantial number of patients received appropriate ICD shocks suggesting a high-arrhythmia burden. The risks and benefits of ICDs must be carefully considered in patients with cf-LVAD.

Subcutaneous loop recorders (SCRMs) are subcutaneous electronic devices which have revolutionized the field of arrhythmia detection. They have become increasingly appealing due to advances such as miniaturization of device, longer battery life, bluetooth capabilities and relatively simple implantation technique without the need for complex surgical suites. They can be implanted in the office, patient bedside without the need to go to the operating room. One of the most common indications for their implantation is detection of atrial fibrillation (AF) after a cryptogenic stroke. They have also been utilized for assessing the success of rhythm control strategies such post pulmonary venous isolation. More recently studies have assessed the utility of SCRMs for detecting silent AF in at risk populations such as patients with sleep apnea or those on hemodialysis. In this paper, we review the evolution of SCRMs, the clinical studies assessing their value for different indications, their role incurrent clinical practice and future avenues in the era of smart wearable devices like apple watch etc.

BACKGROUND: Left atrial appendage occlusion device embolization (LAAODE) is rare but can have substantial implications on patient morbidity and mortality. Hence, we sought to perform an analysis to understand the timing and clinical consequences of LAAODE. METHODS: A comprehensive search of PubMed and Web of Science databases for LAAODE cases was performed from October 2nd, 2014 to November 1st, 2017. Prior to that, we included published LAAODE cases until October 1st, 2014 reported in the systematic review by Aminian et al. RESULTS: 103 LAAODE cases including Amplatzer cardiac plug (N=59), Watchman (N=31), Amulet (N=11), LAmbre (N=1) and Watchman FLX (N=1) were included. The estimated incidence of device embolization was 2% (103/5,000). LAAODE occurred more commonly in the postoperative period compared with intraoperative (61% vs. 39%). The most common location for embolization was the descending aorta 30% (31/103) and left atrium 24% (25/103) followed by left ventricle 20% (21/103). Majority of cases 75% (77/103) were retrieved percutaneously. Surgical retrieval occurred most commonly for devices embolized to the left ventricle, mitral apparatus and descending aorta. Major complications were significantly higher with postoperative LAAODE compared with intraoperative (44.4% vs. 22.5%, p=0.03). CONCLUSIONS: LAAODE is common with a reported incidence of 2% in our study. Post-operative device embolization occurred more frequently and was associated with a higher rate of complications than intraoperative device embolizations. Understanding the timings and clinical sequelae of DE can aid physicians with post procedural follow-up and also in the selection of patients for these procedures.

INTRODUCTION: Whether cardiac resynchronization therapy (CRT) continues to augment left ventricular remodeling in patients with the continuous-flow left ventricular assist device (cf-LVAD) remains unclear. METHODS: We performed a systematic review and meta-analysis of all clinical studies examining the role of continued CRT in end-stage heart failure patients with cf-LVAD reporting all-cause mortality, ventricular arrhythmias, and ICD shocks. Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data. RESULTS: Eight studies (7 retrospective and 1 randomized) with a total of 1,208 unique patients met inclusion criteria. There was no difference in all-cause mortality (RR 1.08, 95% CI 0.86 – 1.35, p = 0.51, I2=0%), all-cause hospitalization (RR 1.01, 95% CI 0.76-1.34, p = 0.95, I(2)=11%), ventricular arrhythmias (RR 1.08, 95% CI 0.83 – 1.39, p = 0.58, I(2) =50%) and ICD shocks (RR 0.87, 95% CI 0.57 – 1.33, p = 0.52, I(2) =65%) comparing CRT versus non-CRT. Subgroup analysis demonstrated significant reduction in ventricular arrhythmias (RR 0.76, 95% CI 0.64 – 0.90, p = 0.001) and ICD shocks (RR 0.65, 95% CI 0.44 – 0.97, p = 0.04) in “CRT on” group versus “CRT off” group. CONCLUSIONS: CRT was not associated with a reduction in all-cause mortality or increased risk of ventricular arrhythmias and ICD shocks compared to non-CRT in cf-LVAD patients. It remains to be determined which subgroup of cf-LVAD patients benefit from CRT. The findings of our study are intriguing, and therefore, larger studies in a randomized prospective manner should be undertaken to address this specifically.

With the expanding integration of complementary and alternative medicine (CAM) practices in conjunction with modern medicine, yoga has quickly risen to being one of the most common CAM practices across the world. Despite widespread use of yoga, limited studies are available, particularly in the setting of dysrhythmia. Preliminary studies demonstrate promising results from integration of yoga as an adjunct to medical therapy for management of dysrhythmias. In this review, we discuss the role of autonomic nervous system in cardiac arrhythmia,interaction of yoga with autonomic tone and its subsequent impact on these disease states. The role of yoga in specific disease states, and potential future direction for studies assessing the role of yoga in dysrhythmia.

A 65-year-old female who underwent cardioneuroablation for recurrent vasovagal syncope presented for 6 month follow-up visit. She had no further syncope after the procedure. A follow up tilt table testing (TT) demonstrated sinus tachycardia and variable degrees of atrioventricular block (AVB) after sublingual glyceryl trinitrate. She had no syncope during the test. As per existing knowledge, the occurrence of AVB during vasovagal reaction induced by TT should be preceded by sinus rhythm slowing. In this patient, sinus tachycardia during TT demonstrates highly specific denervation of ganglion cells which send postganglionic fibers directly to the sinus node without obvious influence on the atrioventricular node.

Background Manufacturer/federal drug administration (FDA) recommends inpatient initiation of dofetilide with the manufacturer providing an initiation algorithm. The outcomes of algorithm deviation have not been reported outside of clinical trials. Objective We sought to perform a chart review of all the patients admitted for inpatient initiation of dofetilide to report on the incidence of protocol deviations and their implications. Methods We performed a retrospective review of all patients over a 15-month periodwho were initiated on dofetilide for the very first time or reinitiated on dofetilide after a break of three months or more at our institution. We assessed data about patients who were given dofetilide without adherence to the protocol (i.e. protocol deviation). Results A total of 189 patients were included in the study with a median age of 66 ± 9 years. Mean baseline QTc interval was 436 ± 32 msec, and 61% (116/189) were in atrial fibrillation (AF) at the time of dofetilide initiation. In 9% (17/189) of patients, the drug was discontinued due to intolerance or inefficacy. Therapy in 49% (93/189) of patients was noted to deviate from manufacturer recommended protocol with deviations more than once in some patients during the same hospitalization. Baseline QTc exceeding 440 msec(>500msec in conduction abnormalities) was the most frequent deviation (25%; 47/189).Ventricular tachyarrhythmia occurred in 4% (7/189) of patients, did not differ between patients, and occurred with and without protocol deviations (5% vs 2%; p = 0.27). Conclusions In our retrospective study, there were frequent deviations from the manufacturer-recommended algorithm guidelines for dofetilideinitation, primarily due to prolonged baseline QTc interval. The impact of these protocol deviations on drug discontinuation was uncertain; however, significant adverse events were higher in the deviation group compared to the group that fully adhered to the protocol. Further multicenter studies are warranted to clarify our findings.

Sudden cardiac death (SCD) in competitive athletes, though relatively uncommon, invariably leads to controversy. Specific limitations of an extensive screening process include lack of robust evidence to support prevention of SCD, poor cost-effectiveness and uncertain downstream implications of a positive screening test. An emerging body of evidence points to enhanced neurologically intact survival to hospital discharge when automated external defibrillators (AEDs) are used in a timely manner following sudden cardiac arrest (SCA). A viable alternative to an expansive screening process could be a robust secondary prevention system comprising of improvements in AED availability, stringent enforcement of CPR training in athletes and trainers to provide timely and effective resuscitation to reduce death following SCA. This strategy could widen the window to diagnose and treat the underlying etiology and prevent recurrence of SCA while also offering financial feasibility. Restricting athletes from competitive sports is a difficult decision for physicians owing to a lack of well-defined cutoffs for acceptable and prohibitive risk from pathology predisposing to SCD, especially in the absence of a protective medico-legal framework. In this review, we highlight a few cases that generated intense scrutiny by the public, media and medical professionals about the efficacy, feasibility and pitfalls of the existing screening process to diagnose cardiovascular pathology predisposing to SCD. Furthermore, contrasting approaches to screening, diagnosis and downstream workup protocols between the European Society of Cardiology and the American Heart Association are analyzed.

Ventricular free wall rupture (VFWR) is a rare entity and is mostly related to post myocardial infarction (MI) complications usually involving left ventricle. In traumatic chest injuries, the right ventricle (RV) is more commonly involved due to its anatomic and structural vulnerability, as in our case. Survival, although rare, has almost always been secondary to urgent surgical repair, which is the current standard of care for such cases. However, extremely tenuous hemodynamic parameters preclude urgent surgical interventions in most of these cases. Surgical repair was considered to have prohibitive risk in our case also due to multiple comorbidities. Our case offers a unique perspective into the feasibility and safety of percutaneous closure of VFWR with devices such as Amplatzer Vascular Plug (AVP) II under transesophageal echocardiography (TEE) and angiographic guidance in patients who survive VFWR. The lack of randomized evidence to standardize the duration and regimen of antiplatelet therapy following placement of these devices is to be noted.

Catheter based left atrial appendage (LAA) closure techniques are emerging as a promising alternative for stroke prevention in patients who cannot tolerate oral anticoagulation. Lariat procedure involves percutaneous catheter based epicardial ligation of the LAA with a suture via an endo-epicardial hybrid approach. It offers the advantage of not leaving behind a focus for thrombus formation or embolization. Similar to surgical ligation of the left atrial appendage, Lariat ligation is limited by leaks in a small percentage of patients. The incidence of leaks is variable and can be seen in the immediate post procedure period or during follow up. The electrical and mechanical implications of leaks are still under debate. In this review, we discuss the incidence, pathophysiology, clinical implications and methods of closure of leaks after Lariat. In the end, we present a case of a Lariat leak closed with an Amplatzer septal occluder.

Background Bleeding complications especially gastrointestinal bleeding remains a major challenge associated with oral anticoagulation therapy (OAT) and often leads clinicians to withdraw oral anticoagulation therapy (OAT) . This exposes patients to risk of stroke and systemic thromboembolism (STE). Novel oral anticoagulants (NOACs) have proved no better when it comes to bleeding events and in fact studies have shown that overall NOACs are associated with higher incidence of gastrointestinal (GI) bleeding compared to warfarin . Objectives In this review, we describe the difficulties encountered in managing OAT in patients with bleeding and strategies to maneuver around these bleeding complications particularly gastrointestinal bleeding secondary to arteriovenous malformations (AVM) and other vascular abnormalities. Findings Left atrial appendage closure (LAAC) has emerged as a very elegant and promising tool for stroke prevention in non-valvular atrial fibrillation (AF) patients who are intolerant to OAT. But the need for OAT post procedure for a brief period is becoming a major hurdle for clinicians to pursue in this direction in patients with recurrent gastrointestinal bleeds. And in majority of cases, recurrent or refractory gastrointestinal bleeds are usually secondary to arteriovenous malformations/angiodysplasias (AVM/AD). We suggest that the problem has to be approached by decreasing or eliminating the acute bleeding risk and closing the LAA in the long term, to enable the patients to come off of OAT and minimize the risk of recurrent bleeding.

Background Catheter ablation is an effective strategy for treatment of drug-refractory atrial fibrillation (AF). Continuation of oral anticoagulation (OAC) beyond 3 months after an apparently successful ablation of AF remains controversial. Methods A systematic electronic search of the scientific literature was performed in PubMed, EMBASE, SCOPUS and Google Scholar. Studies comparing continuation vs discontinuation of OACs after an apparent successful ablation of AF among patients with CHA2DS2VASC or CHADS2 score ≥2were included. Clinical outcomes included cerebrovascular events, systemic thromboembolism and major bleeding. Risk ratios (RR) and 95% confidence intervals for above outcomes were calculated. Results Nine observational studies were eligible and included 3,436patients of whom 1,815 continued OACs and1,621 discontinued OAC post -AF ablation. There was no significant difference in risk of cerebrovascular events (RR: 0.85, 95%CI: 0.42 to 1.70, p= 0.64)and systemic thromboembolism (RR: 1.21, 95%CI: 0.66 to 2.23, p= 0.54)between the two groups. Continuation of OACs was associated with an increased risk of major bleeding (RR: 6.50, 95% CI: 2.53 to 16.74, p= 0.0001). Conclusion In conclusion, discontinuation of oral anticoagulation 3 months after a successful AF ablation appears to be safe in highly selected closely monitored patients. Further randomized trials are warranted to assess the safety of discontinuing OACs after AF ablation.

Introduction: Restoration of normal sinus rhythm by radiofrequency ablation (RFA) in atrial fibrillation (AF) patients can result in a reduction of left atrial (LA) volume and pulmonary vein (PV) dimensions. It is not clear if this PV size reduction represents a secondary effect of overall LA volume reduction or true PV stenosis. We assessed the relationship between LA volume reduction and PV orifice area pre- and post-RFA. Methods: A retrospective cohort study was conducted at a tertiary care academic hospital. Pre- and post-RFA cardiac computed tomography (CT) studies of 100 consecutive AF patients were reviewed. Studies identifying obvious segmental PV narrowing were excluded. Left atrial volumes and PV orifice cross-sectional areas (PVOCA) were measured using proprietary software from the CT scanner vendor (GE Healthcare, Waukesha, WI). Results: The cohort had a mean age of 60 ± 8 years, 73% were male, and 90% were Caucasian. Non-paroxysmal AF was present in 76% of patients with a mean duration from diagnosis to RFA of 55 ± 54 months. Mean procedural time was 244 ± 70 min. AF recurred in 27% at 3 month follow-up. Pre-RFA LA volumes were 132 ± 60 ml and mean PVOCA was 2.89 ± 2.32 cm2. In patients with successful ablation, mean LA volume decreased by 10% and PVOCA decreased by 21%. PVOCA was significantly reduced in patients with successful RFA compared to those who had recurrence (2.18 ± 1.12 vs. 2.8 ± 1.9 cm2, p = 0.04) but reduction in LA volume between groups was not significant (118 ± 42 vs. 133 ± 54 ml, p=0.15). Conclusions: The study demonstrates that both PV orifice dimensions and LA volume are reduced after successful AF ablation. These data warrant a reassessment of criteria for diagnosing PV stenosis based on changes in PV caliber alone, ideally incorporating LA volume changes.

Objective: Atrio-esophageal fistula is an infrequent but devastating complication of catheter-based ablation of atrial fibrillation (AF). Thermal esophageal injury may be the precursor of atrio-esophageal fistula. Here, we evaluated the role of esophageal temperature monitoring in preventing thermal esophageal injury during pulmonary vein isolation for AF with radiofrequency energy. Methods: In this meta-analysis, we searched the PubMed, Cochrane, Scopus, Embase, and Refworks databases for all published studies from January 2004 to June 2016 to evaluate the role of esophageal temperature monitoring. We searched for terms esophageal temperature monitoring, AF, radiofrequency ablation, atrio-esophageal fistula, and thermal esophageal injury. We included studies comparing luminal esophageal temperature (LET) monitoring with no LET monitoring during radiofrequency ablation of AF. We excluded studies in which post-ablation esophagogastroduodenoscopy (EGD) was not performed to identify esophageal thermal injuries. To perform the meta-analysis, we used Review Manager statistical software and a fixed-effects modeling to derive the outcomes. Given significant heterogeneity between the studies, we used meta-regression analysis to adjust for age and sex. Results: We identified 4 non-randomized controlled trials that met our search criteria and included a total of 411 patients (n=235 in the LET monitoring group; n=176 in the no LET monitoring group) in the analysis. There were 21 (8.9%) patients with thermal esophageal injury in the LET monitoring group and 12 (6.8%) in the no LET monitoring group. The pooled odds ratio was 0.66 (0.23-1.89), indicating no statistically significant differences between the 2 groups with regard to esophageal injury. Because of the small sample size and the non-randomized nature of the trials, we observed significant heterogeneity in outcomes among the trials. Conclusion: The role of esophageal temperature monitoring in reducing the risk of esophageal thermal lesions during pulmonary vein isolation for AF has not been established, and more studies including randomized controlled trials are needed to assess its true impact.

Objective: We aimed to perform a meta-analysis from eligible studies to analyze the true impact of QL when compared with BL with regard to post-procedural outcomes including lead deactivation, revision or replacement.

Percutaneous left atrial appendage ligation (LAA) techniques have come to the forefront of management of atrial fibrillation (AF) patients who are at high risk of stroke and are unsuitable for oral anticoagulation therapy. LARIAT is a novel percutaneous endo-epicardial ligation technique for LAA exclusion. This technique is increasingly becoming popular for LAA exclusion in AF patients. A few studies have validated the efficacy of LARIAT in mitigating stroke risk in AF patients with contraindications to anticoagulation. Additionally a few studies have suggested that AF burden decreases after the LARIAT procedure. In this review paper we discuss the indications, technique and the latest advances in the LAA exclusion using the LARIAT system.

Background: Fluoroscopic radiation has been implicated in reducing the sex ratio (M:F) by potentially damaging the Y chromosome. We examined the effects of exposure to fluoroscopic radiation on gender of offspring of cardiologists across the world.

Atrial fibrillation (AF) is a common complication in patients with atrial septal defects (ASDs). The link between AF and ASD is fairly complex and entails modifications in electrophysiologic, contractile and structural properties, at the cellular and tissue level, of both atria, mainly due to chronic atrial stretch and dilation. Surgical repair or percutaneous closure of ASDs are equally effective in reducing mortality and symptoms but limited in preventing or curbing AF, unless combined with an arrhythmia-specific procedure. Transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) have improved the safety and success of the above procedures. Finally, clearer understanding of the pathophysiology of AF in patients with ASD (and CHF, in general) has led to target-specific advances in medical management.