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Stroke is a leading cause of morbidity and mortality across the world and a significant portion of ischemic strokes have a cardiac source. We report a case of a 55‐year‐old male who presented with an ischemic stroke and bilateral pulmonary emboli secondary to an intra‐cardiac thrombus straddling a patent foramen ovale, which was clearly seen using transesophageal echocardiography. We discuss the management dilemma associated with this clinical picture given the risk of hemorrhagic transformation in the acute phase of an ischemic stroke. Our case demonstrates the need for a multidisciplinary approach in an area of medicine that lacks clear guidelines. [ABSTRACT FROM AUTHOR]

We report the first leadless pacemaker (L-PM) providing atrioventricular synchronous pacing implanted into a heart transplant patient receiving chronic immunosuppressive therapy. The patient presented with syncope corresponding to sinus rhythm with high-grade atrioventricular block. Previously, L-PMs provided only single-chamber ventricular sensing and pacing. A Micra AV lL-PM provides atrioventricular synchronous pacing by tracking mechanical atrial contraction. L-PMs, which now support broader indications, should be considered in patients at greater risk of infection. [ABSTRACT FROM AUTHOR]

As the population ages and cardiovascular disease becomes more prevalent, an increasing number of patients are receiving implantable cardioverter-defibrillators (ICDs). When these patients present to the emergency department, it is imperative that physicians are not only aware of the possible underlying medical issues that may have precipitated their admission but should also have a good understanding of the potential interactions that any medical intervention may have on the patient's device. We discuss a case in which a patient known to have an ICD in situ was transcutaneously paced for the management of bradycardia, leading to an unnecessary shock. [ABSTRACT FROM AUTHOR]

Background: Provocative testing with sodium channel blockers is advocated for the evaluation of unexplained cardiac arrest (UCA) with the primary purpose of unmasking the typical ECG features of Brugada syndrome. The Cardiac Arrest Survivors with Preserved Ejection Fraction Registry (CASPER) systematically assesses subjects with UCA or a family history of sudden death (FHSD). Objective: The purpose of this study was to determine the clinical yield of procainamide infusion in a national registry of subjects with either UCA or a FHSD. Methods: Subjects with either UCA or a FHSD without evidence of a Brugada pattern at baseline underwent procainamide testing (15 mg/kg to a maximum of 1 g at 50 mg/min). A test was considered positive for Brugada pattern if there was an increase in ST elevation >1 mm or if there was >1 mm of new ST elevation in leads V1 and/or V2. Genetic testing was performed on the basis of phenotype detection. Results: Procainamide testing was performed in 174 subjects (age 46.8 ± 15.4 years, 47% female). Testing provoked a Brugada pattern in 12 subjects (6.9%), 5 of whom had no ST abnormalities at baseline. No subjects with a negative procainamide challenge were subsequently diagnosed with Brugada syndrome. Genetic testing was conducted in 10 of the 12 subjects with a provoked Brugada pattern and was positive for a mutation in the SCN5A gene in 1. Conclusion: Irrespective of the baseline ECG, procainamide testing provoked a Brugada pattern in a significant proportion of subjects with UCA or a FHSD, thereby facilitating a diagnosis of Brugada syndrome, and is recommended in the workup of UCA. [Copyright &y& Elsevier]

Atrial fibrillation (AF) is the most common arrhythmia worldwide. Data regarding readmission for new congestive heart failure (CHF) following index admission for AF in the developing world are poorly described.The study aimed to assess the rate, predictors, and outcomes of 120-day CHF readmission after index admission for AF in Syria.This retrospective cohort study collected all adult patients without known CHF who had an index admission with AF to Latakia’s tertiary center between June 2021-December 2023. Data were taken from patients’ medical notes. The primary outcome included readmission with incident CHF within 120 of index discharge, and secondary outcomes included predictors and outcomes of these CHF readmissions.A total of 660 patients were included in the final analysis, of which 69 (11.7%) were readmitted with new CHF within 120 days of index discharge. Readmitted patients had higher median age (58 vs 70 years, p < .001). Factors that independently increased 120-day CHF incidence were age ≥60 years (HR: 9.8, 95% CI: 4.8-23.6, p < .001), diabetes mellitus (DM) (HR:2.9, 95% CI:1.7-4.9, p < .001), valvular heart disease (VHD) (HR:1.7, 95% CI:1.04-2.78, p = .047), and hypertension (HR:2.5, 95% CI:1.5-4, p < .001). Inpatient mortality occurred in six readmitted patients (9%). LVEF <40% (HR:6.7, 95% CI: 24.31, p = .01) and DM (HR:7.2, 95% CI: 1.9-33, p = .004) were independently associated with inpatient mortality.Hospitalization for new CHF was common in Syrian patients discharged with AF. The clinical predictors of incident CHF emphasize the importance of integrated management of lifestyle risk factors and common comorbidities in AF patients to optimize outcomes in resource-depleted communities. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. However, there is no data on AF inpatient management strategies and clinical outcomes in Syria.The study aims were to review the inpatient management of patients with AF and assess cardiovascular (CV) mortality in a tertiary cardiology centre in Latakia, Syria.A single-centre retrospective observational cohort study was conducted at Tishreen’s University Hospital, Latakia, Syria, from June 2021 to June 2023. Patients ≥16 years of age presenting and being treated for AF as the primary diagnosis with or without a thromboembolic event were included. Medical records were examined for patients’ demographics, laboratory results, treatment plans and inpatient details. Studied outcomes include inpatient all-cause and CV mortality, ischemic and bleeding events, and conversion to sinus rhythm (SR).The study included 596 patients. The median age was 58, and 61% were males. 121 patients (20.3%) were known to have AF. A rhythm control strategy was pursued in 39% of patients. Ischemic and bleeding events occurred in 62 (11%) and 12 (2%), respectively. CV and all-cause mortality occurred in 28 (4.7%) and 31 patients (5%), respectively. The presence of valvular heart disease (VHD) (adjusted odds ratio (aOR) = 9.1, 95% confidence interval (CI): 1.7 to 55.1, p < .001), thyroid disease (aOR: 9.7, 95% CI = 1.2 to 91.6, p < .001) and chronic obstructive pulmonary disease (COPD) (aOR: 82, 95% CI: 12.7 to 71, p < .001) were independent risk factors of increased CV inpatient mortality.Syrian inpatients admitted with AF in Latakia are relatively younger than those in other countries. Active thyroid disease, COPD and VHD were independent risk factors of inpatient CV mortality with AF. [ABSTRACT FROM AUTHOR]

Pacemakers are a key technology in the treatment of bradyarrhythmias. Leadless pacemakers (LP) were introduced to address limitations of transvenous devices. However, guidelines and other restrictions have led to LPs becoming niche products. The aim of this consensus statement was to determine the strength of opinion of UK implantation experts as to how LPs can be more optimally used. Using a modified Delphi approach, a panel of LP experts developed 36 statements that were used to form a survey that was distributed to LP implanters in the UK. Stopping criteria included a 3-month window for response, a minimum 25% response rate and at least 75% of statements achieving the threshold for consensus (agreed at 66%). In all, 31 of 36 statements reached consensus, and 23 of these achieved ≥90% agreement. Five statements did not achieve consensus. On the basis of these results, seven recommendations were proposed. The implementation of these recommendations may increase the use of LPs, with the aim of improving patient outcomes., Competing Interests: Disclosure: PRR has received honoraria from Medtronic, Boston Scientific and EBR Systems. ME has received research funding from Boston Scientific. AR has received honoraria from Medtronic, Boston Scientific and Phillips. SS has received honoraria from Medtronic, Boston Scientific and Biotronik. PF, DS, RS, GW, AZ, CP have received honoraria from Medtronic. Funding: This study was managed and facilitated on behalf of the authors by Triducive Partners Limited, who received funding from Medtronic. The authors did not receive any funding from Medtronic for their involvement in this study., (Copyright © 2022, Radcliffe Cardiology.)

Cavotricuspid isthmus (CTI) ablation is a current first-line management method for typical atrial flutter. A voltage-directed technique that systematically targets points of maximal voltage has be found to reduce procedure and fluoroscopy times without increasing recurrence. We hypothesized that this technique's efficiency would be enhanced by using signals from radial minielectrodes of a novel catheter (IntellaTip MiFi™; Boston Scientific, Natick, MA, USA). Prospectively, atrial flutter patients underwent voltage-directed ablation with a nonirrigated 8-mm-tip catheter. Ablation was either directed by conventional bipolar electrodes (group A, n = 13) or mini-electrodes (group B, n = 17) with the goal of achieving bidirectional block at the CTI and a subsequent observation time of 30 minutes. Total radiofrequency application time and lesion numbers were not significantly different. Group B had a lower mean power [38.7 watts (W) ± 2.0 W versus 44.8 W ± 1.9 W; p < 0.05] and a tendency for longer fluoroscopy and procedure times. In three of the cases in group B, a switch to an irrigated catheter was required in order to achieve bidirectional block. In group A, bidirectional block was obtained in all patients using the nonirrigated catheter with no significant increase in reconnection. Differences in the catheter performance between the two groups were driven by poorer performance of the MiFi™ catheter (Boston Scientific, Natick, MA, USA) in patients presenting in atrial flutter. Electroanatomical mapping revealed a more proximal localization of the maximal voltage by the minielectrodes as compared with the conventional bipolar electrodes, resulting in less efficient identification and ablation of the conducting muscle bundles. Final results indicated CTI ablation using minielectrodes is not superior to conventional bipolar electrodes in the use of 8-mm, nonirrigated electrodes., Competing Interests: The authors report no conflicts of interest for the published content. This study was reviewed by a local ethics group., (Copyright: © 2018 Innovations in Cardiac Rhythm Management.)