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Introduction The reuse of cardiac implantable electronic devices may help increase access to these therapies in low- and middle-income countries (LMICs). No published data exist regarding the views of patients and family members in LMICs regarding this practice. Methods and Results A paper questionnaire eliciting attitudes regarding pacemaker reuse was administered to ambulatory adult patients and patients’ family members at outpatient clinics at Centro Nacional Cardiologia in Managua, Nicaragua, Indus Hospital in Karachi, Pakistan, Hospital Carlos Andrade Marín and Hospital Eugenio Espejo in Quito, Ecuador, and American University of Beirut Medical Center in Beirut, Lebanon. There were 945 responses (Nicaragua – 100; Pakistan – 493; Ecuador – 252; Lebanon – 100). A majority of respondents agreed or strongly agreed that they would be willing to accept a reused pacemaker if risks were similar to a new device (707, 75%), if there were a higher risk of device failure compared to a new device (584, 70%), or if there were a higher risk of infection compared to a new device (458, 56%). A large majority would be willing to donate their own pacemaker at the time of their death (884, 96%) or the device of a family member (805, 93%). Respondents who were unable to afford a new device were more likely to be willing to accept a reused device (79% vs. 63%, P

The American College of Cardiology/American Heart Association guidelines recommend a wearable cardioverter defibrillator (WCD) for certain conditions or scenarios. WCD is felt to provide adequate protection against ventricular arrhythmias. This case highlights failure of a WCD to detect and deliver life-saving therapy and the need for improved detection algorithms. (Level of Difficulty: Beginner.), Graphical abstract

As the severe acute respiratory syndrome coronavirus 2 virus pandemic continues to grow globally, an association is apparent between patients with underlying cardiovascular disease comorbidities and the risk of developing severe COVID-19. Furthermore, there are potential cardiac manifestations of severe acute respiratory syndrome coronavirus 2 including myocyte injury, ventricular dysfunction, coagulopathy, and electrophysiologic abnormalities. Balancing management of the infection and treatment of underlying cardiovascular disease requires further study. Addressing the increasing reports of health care worker exposure and deaths remains paramount. This review summarizes the most contemporary literature on the relationship of the cardiovascular system and COVID-19 and society statements with relevance to protection of health care workers, and provides illustrative case reports in this context.

Introduction: Liraglutide, a glucagon-like peptide 1 receptor agonist (GLP-1) utilized for management of type 2 diabetes mellitus, has been associated with reduced risk of cardiovascular events. However, it is also associated with increased heart rate and reduced heart rate variability. In this study, we investigate the effect of liraglutide in patients with atrial fibrillation (AF). Methods: TriNetX global research network provided aggregate data for this retrospective cohort study of AF patients on liraglutide that were matched to AF patients not on liraglutide from January 1, 2016, through November 13, 2021. Primary outcomes were all-cause mortality, ischemic stroke, hemorrhagic stroke, acute heart failure episode, and acute coronary syndrome episode. Results: 16,214 AF patients on liraglutide were propensity score matched to AF patients not on liraglutide. They were matched for demographics, cardiovascular procedures, cardiovascular medications, hypertension, diabetes, heart failure, ischemic heart disease, and diabetic medications. AF patients on liraglutide were found to have a significantly lower risk of all-cause mortality (HR 0.67, 95% CI 0.631 – 0.711, p < 0.001). There was a tendency toward lower risk of stroke, acute heart failure, and acute coronary syndrome but was not statistically significant. Conclusion: Liraglutide is associated with lower risk of all-cause mortality in AF patients. These findings are limited due to the retrospective nature of the study. Further examination is needed of liraglutide effect on mortality in AF patients.

Background: Patients with true paroxysmal supraventricular tachycardia (SVT) are frequently misdiagnosed with panic or anxiety disorders due to similar symptoms of palpitations, light-headedness, dyspnea, or chest discomfort. Unrecognized SVT can lead to unnecessary management with anxiety medications. Treatment of SVT with catheter ablation may lead to reduction in anxiety medications. Methods: A total of 175 patients underwent successful SVT ablation between January 1, 2010 and December 31, 2020. We examined symptoms at presentation, psychiatric medications prior to SVT ablation, comorbidities, and psychiatric medications at 3 months post-ablation. Results: 15% of patients who underwent successful SVT ablation were being treated with psychiatric medications and were included in the final study population. The most common symptoms were palpitations (80.77%), followed by dizziness (42.31%), and shortness of breath (34.62%). The average number of medications prior to ablation was 1.42 and decreased down to 1.08 at 3 months post-ablation (p = 0.04). The average number of SSRIs, SNRIs, and other anxiolytics were also decreased but were not statistically significant. Conclusion: In patients with anxiety and paroxysmal supraventricular tachycardia, catheter ablation is associated with reduced average number of psychiatric medications.

Coronavirus disease-2019 (COVID-19) has been associated with pre-existing cardiac conditions as well as cardiovascular complications. The incidence rates of cardiac complications, age, and gender differences in this population are unknown.We wanted to study the incidence of cardiac complications and mortality in patients with COVID-19.Data from the TriNetX COVID-19 global research network platform was used to identify COVID-19 patients. We compared patients with and without cardiac complications in patients with COVID-19 and obtained survival data.The final cohort was composed of 81,844 patients with COVID-19. Cardiac complications occurred in 9.3% of patients as follows: acute coronary syndromes in 1.3%, heart failure in 4.4%, atrial fibrillation in 4.5%, sinus bradycardia 1.9%, ventricular tachycardia in 0.5% and complete heart block in 0.01%. Mortality was significantly higher in patients with the cardiac complications mentioned (20%) than in those without them (2.9%) (odds ratio 7.2, 95% CI, 6.7-7.7; p 0.0001). Older males seem to have higher incidence of cardiac complications and mortality.Patients with COVID-19 who have cardiac complications have a higher risk of mortality when compared to those without cardiac complications.

BACKGROUND: Sodium glucose cotransporter 2 (SGLT2) inhibitors have been associated with various cardiovascular benefits. There is limited data examining the effect of these medications on atrial fibrillation (AF) associated clinical outcomes. We compared ischemic stroke, acute coronary syndrome (ACS), cardioversion, and all-cause mortality outcomes in AF patients on SGLT2 inhibitors to propensity matched controls. MATERIALS AND METHODS: We conducted a retrospective study with a global medical research network database. AF patients were identified via ICD codes that must have been present for at least one month. Patients on SGLT2 inhibitors were identified as those on dapagliflozin, empagliflozin, or canagliflozin for at least one month. AF patients on SGLT2 inhibitors were propensity matched to those not on SGLT2 inhibitors based on age, race, ethnicity, cardiovascular comorbidities, valvular disease, pulmonary disease, urinary diseases, cardiovascular procedures, cardiovascular medications, and anticoagulants. We examined incidence of ischemic stroke, at least one ACS episode, cardioversion, and all-cause mortality. RESULTS: In 26,269 AF patients, SGLT2 inhibitors were associated with lower risk of cardioversion (HR 0.921, 95% CI 0.841 - 0.999, p = 0.0245) and all-cause mortality (HR 0.676, 95% CI 0.635 - 0.721, p < 0.0001). However, there was an association with increased risk for ischemic stroke (HR 1.081, 95% CI 1.012 - 1.154, p 0.0201). There was no clear association with ACS events. CONCLUSIONS: In patients with AF, use of SGLT2 inhibitors was associated with a lower risk of cardioversion and all-cause mortality and higher probability of survival based on Kaplan-Meier analysis.

BACKGROUND Cardiac implantable electronic device (CIED) infections associated with large, mobile vegetation adds to the complexity of lead extraction and is associated with significant patient morbidity and mortality. OBJECTIVE To show the feasibility of concomitant cardiovascular implantable electronic device extraction and vacuum-assisted removal of lead-related vegetations. METHODS This is a single-center retrospective case series of consecutive patients with persistent bacteremia, sepsis, or endocarditis despite medical therapy who have vegetations >2 cm and subsequently underwent immediate CIED lead extraction after debulking with vacuum-assisted suction. RESULTS Eight patients underwent successful removal of 17 leads immediately after debulking of vegetations with vacuum-assisted device suction. Debulking procedure was not successful in 1 patient due to inability to direct the vacuum suction device into proper position. There were no intraprocedure complications related to the vacuum-assisted debulking. One patient required open sternotomy for tear of the coronary sinus ostium related to extraction of a left ventricular pacing electrode. There was no mortality within 30 days of the procedure. CONCLUSIONS Based upon these clinical results, it is feasible for patients with infected CIED systems that have large right-sided vegetations to undergo vacuum-assisted debulking then immediately followed by percutaneous CIED removal in whom surgical removal is considered high risk.

Background: Expert opinion recommends performing exercise testing with initiation of Class Ic antiarrhythmic medication. Objective: To evaluate the rate and reason for discontinuation of Ic agent within the first year of follow up, with particular attention to rate of proarrhythmia and the value of routine treadmill testing. Methods: This is a single center retrospective cohort study including consecutive patients with atrial arrhythmias who were initiated on a Class Ic agent from 2011 to 2016. Data was collated from chart review and pharmacy database. Results: The study population included 300 patients (55% male, mean age 61; mean ejection fraction, 56%) started on flecainide (n = 153; 51%) and propafenone (n = 147; 49%). Drug initiation was completed while hospitalized on telemetry and the staff electrophysiologists directed dosing. There was one proarrhythmic event during initiation (0.3%). The primary reason for not being discharged on Ic agent was due to detection of proarrhythmia (n = 15) or ischemia (n = 1) with treadmill testing (5.3%). Exercise testing was the single significant variable to affect the decision to discontinue Ic drug, p

During early experience with subcutaneous implantable cardioverter-defibrillators (S-ICD), several patients had inappropriate shocks from T-wave oversensing (TWOS) during exercise. This prompted some operators to perform routine treadmill exercise tests after implantation of S-ICD to screen for TWOS. Meanwhile, improvements have been made in the detection algorithms by the manufacturer.To assess whether routine treadmill exercise post S-ICD implantation is warranted.Patients undergoing S-ICD implantation from October 2012 to December 2016 who were able to complete a treadmill exercise were included in the study. The amplitude of R and T waves as assessed by the device programmer at rest and peak exercise was calculated and incidence of TWOS recorded.Eighty-seven patients with complete treadmill exercise test data were included in the final analysis. The majority of the patients received S-ICD for primary prevention. Nine percent of the included patients had hypertrophic obstructive cardiomyopathy. During treadmill exercise, there was significant increase in the heart rate from rest (77 ± 14 beats per minute) to peak exercise (133 ± 14 beats per minute; P.0001). There was no significant difference between R-wave amplitude at rest (2 ± 0.77 mV) and peak exercise (1.88 ± 0.94 mV; P = .36). Similarly, there was no significant difference between T-wave amplitude at rest (0.27 ± 0.19 mV) and peak exercise (0.33 ± 0.23 mV; P = .06). The incidence of TWOS during exercise was zero.With current screening and detection algorithms for S-ICD, routine treadmill exercise does not result in additional discrimination of patients susceptible to TWOS.

BACKGROUND It is unclear whether patients and physicians understand that atrial fibrillation ablation (AFA) has been shown to only improve symptomology and not reduce morbidity or mortality. METHODS Note that 177 of 445 (40%) consecutive patients referred to an electrophysiology clinic for atrial fibrillation (AF) management responded anonymously to our survey via mail. Note that 105 of 656 (15%) physicians responded to our survey via email. Comparisons among groups were conducted using χ2 test for categorical variables. Odds ratios and 95% confidence intervals were estimated by using a multivariate logistic regression model. RESULTS Almost half of patients and physicians believed AF ablation (AFA) would eliminate the need for anticoagulation (43% vs. 44%, P > 0.05) while the majority of both groups believed AFA would improve survival (58% vs. 67%, P = 0.308). The great majority of both groups believed AFA would decrease stroke rates (89% vs. 80%, P = 0.106). When comparing noncardiologists (n = 86) to cardiologists (n = 19), noncardiologists were more likely to believe that an AFA would eliminate the need for anticoagulation 49% vs. 21% (X = 4.9, P = 0.04), improve survival 80% vs. 11% (X = 30.2, P < 0.001), and decrease stroke 87% vs. 44% (X = 15.6, P < 0.001), respectively. CONCLUSIONS The perceived benefit of AFA by patients and physicians is not supported by the medical literature. It is the responsibility of the electrophysiology community to educate patients and referring physicians regarding the true benefits of AFA. In addition, our study displays the great need for long-term clinical trials examining the impact AFA has on morbidity and mortality.

Background Previous studies have shown underutilization of anticoagulation therapy in patients with atrial fibrillation and a CHA 2 DS 2 -VASc score ≥2; however there exists little data regarding the inappropriate use of anticoagulation in patients with a CHA 2 DS 2 -VASc score of 0. We aimed to determine the true prevalence and predictors of inappropriate anticoagulation therapy in patients with atrial fibrillation and a CHA 2 DS 2 -VASc score of 0. Methods A retrospective chart review was performed on all patients with atrial fibrillation and a CHA2DS2-VASc score of 0 in our institution from January 2009 to January 2016. Demographic and clinical data were collected from the electronic medical record. We utilized multivariable logistic regression analysis to determine independent clinical predictors of inappropriate anticoagulation administration. Results 512 patients were identified with a CHA 2 DS 2 -VASc score of 0 and a diagnosis of atrial fibrillation. Of the 137 patients prescribed anticoagulation, 64 patients were identified as inappropriately treated with anticoagulation therapy after assessing for other indications of warfarin or novel anticoagulant therapy. Independent variables associated with inappropriate anticoagulation administration were age (OR 1.07; 95% CI 1.03–1.10), body mass index (OR 1.06; 95% CI 1.01–1.10), absence of current aspirin use (OR 13.50; 95% CI 6.00–30.54) and persistent atrial fibrillation (OR 2.34; 95% CI 1.11–4.94). Conclusions Our study shows that 12% of patients with a CHA 2 DS 2 -VASc score of 0 were inappropriately prescribed anticoagulant therapy. Independent predictors of unnecessary anticoagulation were age, body mass index, absence of current aspirin use and persistent atrial fibrillation.

Background Rate-related left bundle branch block (LBBB) has not been well implicated as a cause of cardiomyopathy and its management remains controversial. Case presentation 52-year-old female presented with acute heart failure; EKG showed sinus tachycardia at 115 bpm with LBBB; an echocardiogram revealed left ventricle ejection fraction (LVEF) of 20%. Her cardiac catheterization showed no coronary disease, cardiac magnetic Resonance showed no late-gadolinium scaring or active inflammation. Heart Failure guideline directed medical therapy was started, including metoprolol succinate, Lisinopril and spironolactone. Follow-up echocardiogram at 4 months showed LVEF 25%. Clinical decision making Plan was to implant cardiac resynchronization therapy (CRT) with defibrillator (ICD); however, at time of implant, EKG showed sinus rhythm at 80 bpm with resolution of LBBB, hence, she underwent an ICD implantation instead. At 6 months, her symptoms improved and her LVEF noted to be 50%. We suspected rate-related LBBB as a cause for her cardiomyopathy. Serial EKGs while using her ICD atrial lead to pace at incremental rates, showed a predictable and reproducible LBBB at a ventricular rate of 110 bpm (Figure 1). ICD histogram showed her heart rate with current dose of metoprolol was predominantly under 110 bpm, which means minimal time in LBBB, which in turn likely resulted in resolution of cardiomyopathy. Conclusion Rate-related LBBB should be recognized as a potential cause of cardiomyopathy; management is to decrease the “time spent” in LBBB; if this is achieved by rate control alone, CRT can be avoided.

Flecainide can reduce the rate of Atrial Flutter (AFL) which allows for 1:1 conduction through the AtrioVentricular (AV) node. A 57-year-old male with a history of atrial fibrillation (AF) on flecainide, presented with narrow complex tachycardia. He received adenosine 12 mg IV which resulted in

Previous studies have shown underutilization of anticoagulation therapy in patients with atrial fibrillation and a CHAA retrospective chart review was performed on all patients with atrial fibrillation and a CHA2DS2-VASc score of 0 in our institution from January 2009 to January 2016. Demographic and clinical data were collected from the electronic medical record. We utilized multivariable logistic regression analysis to determine independent clinical predictors of inappropriate anticoagulation administration.512 patients were identified with a CHAOur study shows that 12% of patients with a CHA

Short QT syndrome (SQTS) is a rare genetic channelopathy that affects the repolarization of cardiac cells and is associated with cardiac arrhythmia and sudden cardiac death (SCD). “Abbreviated repolarization” is the hallmark of the disease, which is secondary to genetic defects; mutations in several genes that encode different cardiac ion channels have been identified in individuals with the disease. Presentations of the disease include syncope, atrial or ventricular arrhythmia and SCD. SQTS is diagnosed with a corrected-QT (QTc) interval of

Local anesthetics have a theoretical risk of inducing cardiac arrhythmias secondary to their inhibition of sodium channels. Concomitant sinus pauses and high degree atrioventricular (AV) blocks have not been described in patients undergoing bupivacaine treatment. A 45 year old white male was

A great disparity exists in the utilization of pacemakers between the developed world and the low- and middle-income countries where healthcare resources are limited. Worldwide, it is estimated that more than 1 million individuals are in need of pacemakers to treat life-threatening bradyarrhythmias. Pacemaker reutilization is a promising solution to overcome the cost barrier of treating highly symptomatic bradyarrhythmias in these countries. Thus far, this initiative has gained the support of physicians, patients and funeral directors who have proven that a feasible model to deliver these devices to underserved nations is achievable. Many challenges still exist regarding pacemaker reutilization, however, Project My Heart Your Heart is working with the US FDA to overcome many of these obstacles with the goal of alleviating the associated morbidity and mortality of this otherwise treatable epidemic.

It is unclear whether patients and physicians understand that atrial fibrillation ablation (AFA) has been shown to only improve symptomology and not reduce morbidity or mortality.Note that 177 of 445 (40%) consecutive patients referred to an electrophysiology clinic for atrial fibrillation (AF) management responded anonymously to our survey via mail. Note that 105 of 656 (15%) physicians responded to our survey via email. Comparisons among groups were conducted using χAlmost half of patients and physicians believed AF ablation (AFA) would eliminate the need for anticoagulation (43% vs. 44%, P0.05) while the majority of both groups believed AFA would improve survival (58% vs. 67%, P = 0.308). The great majority of both groups believed AFA would decrease stroke rates (89% vs. 80%, P = 0.106). When comparing noncardiologists (n = 86) to cardiologists (n = 19), noncardiologists were more likely to believe that an AFA would eliminate the need for anticoagulation 49% vs. 21% (X = 4.9, P = 0.04), improve survival 80% vs. 11% (X = 30.2, P0.001), and decrease stroke 87% vs. 44% (X = 15.6, P0.001), respectively.The perceived benefit of AFA by patients and physicians is not supported by the medical literature. It is the responsibility of the electrophysiology community to educate patients and referring physicians regarding the true benefits of AFA. In addition, our study displays the great need for long-term clinical trials examining the impact AFA has on morbidity and mortality.

Cardiovascular (CV) disease is the leading cause of mortality among women in the US. Despite targeted public health initiatives, many women remain unaware of and undertreated for their CV risk factors. We surveyed women presenting to obstetrics and gynecology (OB/GYN) clinics for the presence of