Background: Little is known about the frequency of, risk factors predisposing to, and long-term impact of post-operative atrial fibrillation (AF) after lung transplantation. Methods: A prospectively collected registry of 167 consecutive patients who underwent single or bilateral lung transplantation at the University of Minnesota Medical Center from January 1st, 2004 to December 30th, 2008 was reviewed. Post-operative AF was confirmed by review of electrocardiograms by two cardiologists. Kaplan-Meier survival curves were constructed to determine the impact of new onset AF on long-term survival. Results: The mean age (±SD) of the population was 55 ± 11 years and 52% were male. A total of 48 patients (28%) developed AF in the postoperative period. Predictors of postoperative AF in multivariate analysis included: age (per decade) Odds Ratio (OR): 1.61, 95% confidence interval (CI) 1.10-2.34, p=0.01, postoperative thromboembolic disease OR: 9.73 (95% CI: 2.16-43.81, p<0.01, and postoperative pericarditis OR: 3.57, (95% CI: 1.38-9.22, p < 0.01). Of the 48 patients who developed post-operative AF, 41 were discharged in sinus rhythm (SR). Survival among patients who were discharged in AF was significantly lower when compared to patients discharged in SR (HR: 0.08; 0.01-0.43, p<0.05). Conclusions: Postoperative AF is common after lung transplant. Increased age, postoperative thromboembolic disease, and pericarditis are independent predictors of postoperative AF. Persistence of AF at the time of discharge is an identifier of decreased survival.
Successful antitachycardia pacing (ATP) terminates ventricular tachycardia (VT) up to 250 bpm without the need for painful shocks in implantable cardioverter-defibrillator (ICD) patients. Fast VT (FVT) >200 bpm is often treated by shock because of safety concerns, however. This prospective, randomized, multicenter trial compares the safety and utility of empirical ATP with shocks for FVT in a broad ICD population.We randomized 634 ICD patients to 2 arms-standardized empirical ATP (n=313) or shock (n=321)-for initial therapy of spontaneous FVT. ICDs were programmed to detect FVT when 18 of 24 intervals were 188 to 250 bpm and 0 of the last 8 intervals were >250 bpm. Initial FVT therapy was ATP (8 pulses, 88% of FVT cycle length) or shock at 10 J above the defibrillation threshold. Syncope and arrhythmic symptoms were collected through patient diaries and interviews. In 11+/-3 months of follow-up, 431 episodes of FVT occurred in 98 patients, representing 32% of ventricular tachyarrhythmias and 76% of those that would be detected as ventricular fibrillation and shocked with traditional ICD programming. ATP was effective in 229 of 284 episodes in the ATP arm (81%, 72% adjusted). Acceleration, episode duration, syncope, and sudden death were similar between arms. Quality of life, measured with the SF-36, improved in patients with FVT in both arms but more so in the ATP arm.Compared with shocks, empirical ATP for FVT is highly effective, is equally safe, and improves quality of life. ATP may be the preferred FVT therapy in most ICD patients.
Background: Syncope/collapse accounts for approximately 3% of total Emergency Department (ED) visits, and available published literature indicates that about 30-40% of these individuals are admitted to hospital. To ascertain whether these hospitalization rates remain current, this study examined USA national 2006-13 trends in ED visits and hospitalizations for syncope/collapse. Methods: We used Nationwide Emergency Department Sample (NEDS) from 2006 through 2013 to identify syncope/collapse related ED visits using Clinical Classifications Software code 102 (includes ICD 9 codes 780.2) as the first-listed diagnosis. NEDS is the largest all-payer ED-based database with discharge data from 947 hospitals located in 30 States. NEDS includes a 20% stratified sample of U.S. hospital-based EDs, comprising nearly 134 million visits per year. Results: From 2006 to 2013, there was a 21% increase in ED visits with a principal discharge diagnosis of syncope/collapse (990,497 vs. 1,199,890, p Females presented more commonly to ED with syncope/collapse than males (58% vs. 42%, p Conclusions: From 2006 to 2013, ED visits for syncope/collapse increased 21% in the US, but the percentage of these patients admitted to hospital after an ED visit decreased significantly. These observations may reflect the results of education designed to improve syncope/collapse risk stratification in US Emergency Departments and switch to observation status for many of these patients. Figure 1: Total number of ED visits and admission to the same hospital, from 2006 to 2013
Abstract Introduction Diagnostic ambulatory electrocardiogram (AECG) monitoring is widely used for evaluating syncope and collapse, and practice guidelines provide recommendations regarding optimal AECG device selection. However, whether physicians utilize AECGs in accordance with the pertinent guidelines is unclear. This study assessed utilization of AECG monitoring systems for syncope and collapse diagnosis by physicians in the United States. Methods and results A quantitative survey was undertaken of physicians comprising multiple specialties (emergency department, n = 35; primary care, n = 35; hospitalists, n = 30; neurologists, n = 30; nonimplanting, n = 34, and implanting‐cardiologists, n = 35). Depending on specialty, respondents reported that neural‐reflex and orthostatic causes accounted for 17–23%, cardiac causes for 12–20%, and “neurological causes” (specifically psychogenic pseudo‐syncope/pseudo‐seizures and acute cerebrovascular conditions) for 7–12% of their syncope/collapse cases. The choice of AECG technology varied by specialty. Thus, despite patients having daily symptoms, 25% of respondents chose an AECG technology other than a Holter‐type monitor. Conversely, when monitoring for infrequent events (e.g., less than monthly), 12–18% indicated that they would choose a 24‐ to 48‐hour Holter, 20–34% would choose either a conventional event recorder or a mobile cardiac telemetry system, and only 53–65% would select an insertable cardiac monitor. Conclusions In evaluation of syncope/collapse, most U.S. clinicians across specialties use AECGs appropriately, but in a substantial minority there remains discordance between choice of AECG technology and guideline‐based recommendations.
As part of a new effort to develop an implantable drug infusion pacing system to treat atrial fibrillation, this study examined the effects of rapid intracardiac procainamide infusion in humans with pacing‐induced atrial fibrillation. Twenty patients with atrial fibrillation for >5 minutes during an EP study received 500mg of procainamide either via a peripheral venotis infusion (n=5) or directly in the right atrium (n=15). Peak coronary simis and femoral vein procainamide blood levels (mean ± SEM) during 10, 5, and 3.3 minute central infusions were 17.0 ± 4.1, 25.1 ± 4.5, 45.6 ± 5.1 and 11.3 ± 3.2, 17.1 ± 6.4, 18.7 ± 5.0, respectively. In contrast, peak coronary sinus and femoral procainamide levels following the 5 minute intravenous infusion were 17.7 ± 5.1 and 9.3 ± 2.1. Changes in QT, QTc, QRS, and RI intervals were similar at each infiision rate. Systolic blood pressures (BP) decreased more with higher procainamide infusion rates but similar when comparing intravenous versus central drug administration at the same rate. The mean ± SEM decreases in blood pressure with the 10, 5, and 3.3 min procainamide infusions were 12f5, 20f11, and 39f14, respectively. Conversion to sinus rhythm was not a primary endpoint given the often transient nature of acute atrial fibrillation in this setting. We conclude that significantly higher femoral vein and coronary sinus procainamide levels can be achieved by central rather than peripheral drug infusion. These data support that concept that rapid central infitsion of anti‐arrhythmic therapy can result in high intracardiac levels of antifibrillatory agents for the treatment of paroxysmal atrial fibrillation.
