Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Need for a Permanent Pacemaker after Transcatheter Aortic Valve Implantation (TAVI)
Get PDFA permanent pacemaker is commonly required in patients undergoing transcatheter aortic valve implantation (TAVI) at ranges up to 30-50%. In general, the incidence is higher with the self- vs balloon-expandable valves. Several risk factors have been identified. Importantly, pacemaker implantation does not seem to improve prognosis and this needs to be further explored. Finally, new generation valves appear to increase the complication of AV block and need for permanent pacing. These issues are herein briefly reviewed. Rhythmos 2016;11(4):87-89
Cardiology News / Recent Literature Review / First Quarter 2016
Get PDFACC 65th Annual Session: Chicago, 2-4/4/2016HRS 37th Annual Meeting: San Francisco, 4-7/5/16CardioStim/Europace: Nice, 8-11/6/2016Euro PCR: Paris, 17-20/5/2016ESC Meeting: Rome, 27-31/8/2016HCS Panhellenic Congress: Athens, 20-22/10/2016TCT Conference: Washington, DC, 29/10-2/11/2016AHA Scientific Sessions: New Orleans, 12-16/11/2016Exercise-Based Cardiac Rehabilitation Reduces the Risk of Cardiovascular (CV) Mortality and Hospital Admission and Improves Quality of Life in Patients With Coronary Heart Disease Meta-analyses of exercise-based cardiac rehabilitation (CR) studies (n=63) comprising 14,486 participants with median follow-up of 1 year indicated that CR led to a reduction in CV mortality (relative risk - RR: 0.74) and the risk of hospital admissions (RR: 0.82). There was no significant effect on mortality, MI, or revascularization. The majority of studies (14 of 20) showed higher levels of health-related quality of life following exercise-based CR compared with control subjects (Anderson L et al, J Am Coll Cardiol 2016;67:1-12).Coronary CT Angiography (CCTA), Applied Early in Suspected Acute Coronary Syndrome (ACS), is Safe and Associated with Less Outpatient Testing and Lower Costs. However, in the Era of hs-Troponins, it does not Identify more Patients with Significant CAD Requiring Coronary Revascularization, nor does it Shorten Hospital Stay or Allow for More Immediate Discharge from the Emergency Department (ED)Among 500 patients (age 54 ± 10 years, 47% women) with symptoms suggestive of an ACS at the ED, there was no difference in the primary endpoint (22 or 9% patients underwent coronary revascularization within 30 days in the CCTA group and 17 or 7% in the standard care group; p= NS). Discharge from the ED was not more frequent after CCTA (65% vs 59%, p= NS), and length of stay was similar (6.3 h in both groups; p= NS). The CCTA group had lower direct medical costs (€337 vs €511, p< 0.01) and less outpatient testing (10 or 4% vs 26 or 10%, p< 0.01). There was no difference in incidence of undetected ACS (Dedic A et al, J Am Coll Cardiol 2016; 67:16-26).Cost-Effectiveness of Transcatheter Aortic Valve Implantation (TAVI) with a Self-Expanding Prosthesis vs Surgical Aortic Valve Replacement (AVR): TAVI in Patients at High Risk for Complications with AVR Provides Important Incremental Health Benefits at Reasonable Incremental Costs and is an Acceptable Value for the U.S. Health Care SystemRelative to AVR, TAVI reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month quality of life. Index admission and projected lifetime costs were higher with TAVI than with AVR (differences 17,849 per patient, respectively), whereas TAVI was projected to provide a lifetime gain of 0.32 quality-adjusted life-years (QALY; 0.41 LY) with 3% discounting. Lifetime incremental cost-effectiveness ratios were 43,114 per LY gained. N.B.: mean procedure costs: 37,920 for TAVI & 14,258 for AVR (Reynolds MR et al, J Am Coll Cardiol 2016;67:29-38)... (excerpt
Current Data on the Role of Specific Antidotes for the Reversal of Non-Vitamin K Oral Anticoagulant Action
Get PDFThe increasing use of the non-vitamin K oral anticoagulants during the recent years was associated with the need of development of targeted agents that could reverse the anticoagulative activity in cases of severe bleeding episodes or urgent high risk operations. Thus, several reversal agents are currently in development and the early results seem promising. Idarucizumab is a monoclonal antibody that can immediately and specifically reverse dabigatran action. Andexanet alfa is a recombinant modified factor Xa that can bind and reverse factor Xa inhibitors, including rivaroxaban, apixaban and edoxaban, and low molecular weight heparin. Aripazine is a universal reversal agent small molecule that can reverse the action of factor Xa inhibitors, unfractionated and low molecular weight heparin and possibly dabigatran. Currently, only idarucizumab has received approval from the United States Food and drug Administration for the reversal of the dabigatran. Rhythmos 2016;11(3):70-72.
Late Onset of Severe Symptoms in a Patient with Wolff-Parkinson-White Syndrome with Misleading ECG Pattern of the Accessory Pathway Origin Undergoing Successful Ablation
Get PDFThe case of a female patient with symptomatic Wolff-Parkinson-White syndrome is presented with very late onset of symptoms at the age of 65 years, who had an apparent left-sided posteroseptal accessory pathway, which was ablated via a right-sided approach. A subepicardial location was strongly suspected within the coronary sinus ostium at the origin of the middle cardiac vein by applying both ECG and fluoroscopic criteria. Rhythmos 2016;11(3):73-75.
Vieussens’ Arterial Ring Attenuates the Consequences of an Otherwise Large Anterior Myocardial Infarction
Get PDFA 55-year-old patient, with a history of a recent ST-elevation myocardial infarction (STEMI) diagnosed elsewhere but not treated due to patient’s refusal, was urgently admitted to our hospital with symptoms of post-infarction angina over the last 48 hours. The patient, who remained hemodynamically stable, underwent urgent coronary angiography via a transradial access. Total occlusion of the left anterior descending (LAD) coronary artery was visualized right after the first diagonal branch, while the periphery of the LAD was opacified through collaterals from the proximal right coronary artery (RCA), an anatomic variation also knows as the Vieussens’ ring. Decision was taken not to proceed with revascularization, until viability in the territory of the LAD could be documented. Rhythmos 2016;11(4):98-99
Cardiology News / Recent Literature Review / First Quarter 2015
Get PDFHRS Meeting: Boston, 13-16/5/2015EuroPCR: Paris, 19-22/5/2015EHRA Europace-CardioStim: Milan, 21-24/6/2015ESC Congress: London, 29/8-2/9/2015TCT Meeting 2015: San Francisco, 11-15/10/2015HCS Congress: Thessaloniki, 29-31/10/2015AHA Scientific Sessions: Orlando, 7-11/11/2015Low-Level Transcutaneous Electrical Vagus Nerve Stimulation (LLTS) Suppresses Atrial Fibrillation Patients with paroxysmal atrial fibrillation (AF) were randomized to 1 hour of 20 Hz LLTS (n= 20) or sham control (n= 20) by attaching a flat metal clip onto the tragus in the right ear. AF was induced by burst atrial pacing at baseline and after 1 hour of LLTS or sham treatment. Blood samples from the coronary sinus and the femoral vein were collected at those time points and analyzed for inflammatory cytokines, including tumor necrosis factor alpha and C-reactive protein. Pacing-induced AF duration decreased significantly by 6.3 ± 1.9 min compared with baseline in the LLTS but not in the control group (p=0.002). AF cycle length increased significantly from baseline by 28.8 ± 6.5 ms in the LLTS but not in the control group (p= 0.0002). Femoral vein but not coronary sinus tumor necrosis factor (TNF)-alpha and C-reactive protein levels decreased significantly only in the LLTS group. The authors concluded that LLTS suppresses AF and decreases inflammatory cytokines in patients with paroxysmal AF, supporting a role of neuromodulation to treat AF (Stavrakis S et al, J Am Coll Cardiol 2015;65:867-875).Among Patients with Early Repolarization Syndrome, Programmed Stimulation Does not Predict Future Arrhythmic EventsIn a multicenter study, 81 patients, aged 36+13 years, with early repolarization (ER) syndrome and aborted sudden death due to ventricular fibrillation (VF) underwent an electrophysiology study (EPS). VF was inducible in only 18 of 81 (22%) patients. During follow-up of 7.0 ± 4.9 years, 6 of 18 (33%) patients with inducible VF, and 21 of 63 (33%) noninducible patients experienced VF recurrences (p= NS). VF storm occurred in 3 inducible and 4 noninducible patients. VF inducibility was not associated with maximum J-wave amplitude or J-wave distribution (inferior, odds ratio -OR: 0.96; lateral, OR: 1.57; inferior and lateral, OR: 0.83; all p = NS), which have previously been shown to predict outcome in patients with an ER pattern. The authors concluded that EPS did not enhance risk stratification in ER syndrome (Mahida S et al, J Am Coll Cardiol 2015;65:151-159)... (excerpt
Improved Cardiac Output with Right Ventricular Septal Pacing in a Patient with Right Bundle Branch Block and Left Ventricular Dysfunction
Get PDFAlternate site pacing improved the left ventricular outflow tract velocity time integral (surrogate of cardiac output) compared to native rhythm in a patient with ischemic cardiomyopathy and severe left ventricular dysfunction with underlying right bundle branch block
Atrial Flutter Mimicking Acute Myocardial Infarction
Get PDFA case of ST-elevation myocardial infarction (STEMI) mimic produced by prominent atrial flutter waves is being presented and discussed
The Current Role of Glycoprotein IIb/IIIa Inhibitors in Percutaneous Coronary Intervention
Get PDFThe central role of platelets in acute coronary syndromes (ACS) and percutaneous coronary interventions (PCI) is well appreciated. The various platelet activation mechanisms finally lead to expression and activation of surface glycoprotein IIb/IIIa receptors that mediate platelet aggregation and thrombus formation. Glycoprotein IIb/IIIa inhibitors (GPIs) are the most potent antiplatelent agents and their role in ACS treatment and PCI has been dominant in the recent past. The advent of stents and thienopyridines minimized ischemic complications and in parallel the role of GPIs in low risk PCI. Despite being effective in decreasing PCI-related ischemic complications, the major drawback of GPI use is a relative increase of bleeding that can adversely affect prognosis. The availability of bivalirudin, which is regarded as an equally effective but safer antithrombotic agent when compared to the combination of heparin and GPIs, despite an ongoing controversy, has also led to a decrease of GPI use in PCI for ACS. Finally the advent of novel potent antiplatelet agents (prasugrel, ticagrelor and soon cangrelor) further contained GPI use in patients with ischemic – thrombotic risk that clearly exceeds bleeding risk and mainly for bail-out in case of a thrombotic event during PCI. A concise overview of accumulated data regarding optimal use of GPIs as determined by large clinical trials and recent guidelines is herein attempted
Should All Patients With Atrial Fibrillation Receive an Oral Anticoagulant in the Era of Non-Vitamin K Anticoagulants?
Get PDFOral anticoagulants (OAC) decrease the thromboembolic risk of non-valvular atrial fibrillation (AF) at the expense of increased bleeding. Over the years, several risk stratification schemes for both stroke and bleeding risk have been devised, among which lately the respective CHA2DS2-VASc and HAS-BLED scores predominate. However, even when the bleeding risk score is high, the guidelines recommend not to withhold OAC at least for patients with high stroke risk, but to attempt to concomitantly modify the conditions contributing to the high bleeding risk. The CHA2DS2-VASc score has been considered more reliable than other scores in identifying “truly low-risk” patients who do not require OAC, in whom the risk of bleeding may negate the protective effect of OAC. Some have suggested more complex schemes to better identify very low risk patients, but these schemes may lead to more extensive and costly assessments to decide on a relatively simple question, i.e. the need or not for anticoagulation therapy. In the era of non-vitamin K oral anticoagulants (NOACs), this may not be necessary any more, and a simple recommendation of providing every AF patient with OAC therapy may turn out to be a more practical and realistic approach, as long as these newer agents remain safe and effective. Rhythmos 2016;11(3):63-69.