Safety And Utility Of Cardiac MRI In A Patient With Pericardial Effusion And A Recently Implanted Conventional Pacemaker

Hussam Ali, Gianluca Epicoco, Antonio Sorgente, Pierpaolo Lupo, Riccardo Cappato

Cardiac MRI is usually not recommended in the acute phase after pacemaker implantation, particularly for conventional devices. This case concerns a 66-year-old patient who developed significant pericardial effusion subacutely after implantation of a dual-chamber, conventional pacemaker. Cardiac MRI was planned to elucidate the characteristics of the pericardial effusion and was performed under controlled conditions without any consequences. Images analysis was very helpful to reveal the non-hemorrhagic nature of the pericardial effusion and correct endocardial position of the leads. In conclusion, cardiac MRI might be feasible and useful, under controlled conditions, in selected non-pacing dependent patients with conventional pacemakers.

Concomitant Left Atrial Appendage Clipping  During Minimally Invasive Mitral Valve Surgery: Technically Feasible and Safe

Ashraf Alqaqa, Shabiah Martin, Aiman Hamdan, Fayez Shamoon, Kourosh T. Asgarian

Background: It is believed that most of thrombi form in the left atrial appendage (LAA)before they emboli. Different surgical and percutaneouse approaches were suggested to manage the LAA. In this study we are evaluating the safety of clipping the LAA via minithoractotomy approach.
Method: All consecutive patients who had minimally invasive mitral valve surgery with concomitant LAA clipping between December 2012 and February 2014 were included in the study. LAA exclusion was performed using AtriClip® LAA Exclusion System (Cincinnati, Ohio, AtriCure®). The patient s’ clinical characteristics, intraoperative complications, and in-hospital coarse were obtained by reviewing the medical records.
Result: Total of 22 patients(50% males) were included in the study. The median ages was 66.0 years (IQR: 50.8 to 81.3). Eight(36%) had mitral valve replacement and the rest had mitral repair surgery. Five(23%) patients needed blood product transfusion during the surgery. No clip related bleeding was observed and no perioperative mortality was recorded.
Conclusion: During minimally invasive mitral valve surgery, Concomitant exclusion of the left atrial appendage using AtriClip® can be performed rapidly and safely.

Assessment Of Sinoatrial Node Function In Patients With Persistent And Long-Standing Persistent Forms Of Atrial Fibrillation After Maze III Procedure Combined With Mitral Valve operation

Dr. Kulikov A.A

Research objective: Assessment of sinoatrial node function after Maze III procedure combined with a mitral valve operation.
Methods: 100 patients were included in the research with persistent and long-standing persistent forms of atrial fibrillation (AF) and need of operative treatment concerning valve disease.
The following preoperative preparation methods were executed to all patients: 1. Electrocardiogram in 12 standard assignments; 2. Two-dimensional echocardiographic with assessment of systolic and diastolic functions of the left ventricle, size of the left atrium and grade of valve disease; 3. Transesophageal echocardiography for exclusion of blood clots in the left atrium and left atrial appendage; 4. Coronary angiography for exclusion of coronary heart disease; 5. Computer tomography for examination of cardiac chambers and anatomic characteristics of pulmonary veins.
Electric cardioversion in X-ray operating room conditions was performed on all patients. After successful restoration of sinus rhythm, electrophysiological examination (EP) of heart was carried out. Then, on the first or second day after EP study, Maze III procedure combined with a mitral valve operation was performed.
Results: Following the results of Maze III procedure combined with correction of valve disease, disposal of AF was observed in 95% of patients. 46% of patients had stable sinus rhythm to the moment of discharge from the hospital. 24% of patients had atrial rhythm with the maximum heart rate of 80-110 bpm (according to results of 24-hour Holter monitoring). For 25% of patients, it was necessary to implant a pacemaker. According to results of EP study, 13% of these patients suffered from sick sinus syndrome before operation. For 9% of the remaining 12% of patients, the indications for pacemaker implantation were atrioventricular nodal rhythm with low heart rate and pauses more than 3 sec long. For 1% of patients the indication was second degree AV block (type 2) and second degree SA block (type 2); for 1% the indication was complete heart block, and for 1% it was atrial rhythm and pauses more than 3 sec long.
13% of patients with an atrial rhythm and normal heart rate developed typical atrial flutter (AFL) in the early postoperative period. For all of them the RF catheter ablation with linear ablation of the right atrial isthmus and creation of isthmus block was effective, and further recurrence of AFL was not observed.
Conclusions: In the early postoperative period Maze III procedure combined with a mitral valve operation proved to be an effective surgical technique of treatment of persistent and long-standing persistent forms of AF. Only 12% of patients had dysfunction of sinus node work due to iatrogenesis.

Myocardial Biopsy In “Idiopathic» Atrial Fibrillation And Other Arrhythmias: Nosological Diagnosis, Clinical And Morphological Parallels, And Treatment

O.V.Blagova, A.V.Nedostup, E.A.Kogan, V.A.Sulimov, S.A.Abugov, A.G.Kupryanova,V.A.Zaydenov, 
A.E.Donnikov, E.V.Zaklyazminskaya, E.A.Okisheva

Background: The nosological nature of “idiopathic” arrhythmias and the effect of etiotropic and pathogenetic treatment are often unknown.
Methods And Results: 19 patients (42.6±11.3 years, 9 women) with atrial fibrillation (n = 16), supraventricular (n = 10) and ventricular (n = 4) premature beats, supraventricular (n = 2) and ventricular tachycardia (n = 1), left bundle branch block (n= 2), AV block (n = 2) without structural heart changes. Viruses were identified (polymerase chain reaction, PCR) along with measurement of anti-heart antibodies (AHA) and endomyocardial biopsy (EMB).
EMB allowed to establish diagnosis in all patients: 1) infectious-immune myocarditis (n = 11, parvovirus-positive in 1), 2) parvovirus-positive endomyocarditis (n = 1), 3) systemic (n = 2) and myocardial (n = 1) vasculitis, 4) Fabry’s disease (n = 1), 5) arrhythmogenic right ventricular dysplasia (n = 1), 6) unspecified genetic cardiomyopathy (n = 2, herpes virus 6 one positive). Level of AHA had the greatest significance for myocarditis diagnostics. All patients with myocarditis/vasculitis had background therapy: acyclovir (n = 10), IV immunoglobulin (n = 2), meloxicam (n = 12), hydroxychloroquine (n = 15), steroids (n = 14, 31.1±12.5 mg/day), azathioprine 150 mg/day (n = 2). Median follow-up was 4 years. Treatment significantly reduced the rate of arrhythmias (8 [5;8] to 3 [1.25;7.75] points); disappearance of bundle branch block was noted.
Conclusion: EMB allowed to diagnose immune-mediated inflammatory diseases in 78.9% patients with ‘idiopathic’ arrhythmias and genetic diseases in 21.1%. Background therapy of myocarditis improved the antiarrhythmic efficiency, and allowed the best premed for interventional treatment.

The Role of NOACs in Atrial Fibrillation Management: A Qualitative Study

Katherine Kirley, Goutham Rao, Victoria Bauer, Christopher Masi

Patients with atrial fibrillation (AF) benefit from anticoagulation to reduce stroke risk. However, 30-60% of patients with AF are not anticoagulated. This study explored physicians’ reasons for under-treatment of AF, focusing on the role of the novel oral anticoagulants (NOACs). We interviewed primary care physicians and cardiologists involved in AF management in a variety of practice settings. We conducted interviews using a semi-structured format and analyzed the data using the Framework Method. Four themes emerged. First, the likelihood of physicians to prescribe NOACs depends upon their willingness to try new medications and their successful experience with them.  Second, physicians typically balance the benefits and risks of anticoagulation in AF patients, although not always accurately. Third, patient convenience and preferences, as well as physician convenience, are important when considering anticoagulation. Finally, concerns regarding the out-of-pocket cost of NOACs deter many physicians from prescribing them. The persistence of under-treatment in AF despite the availability of effective therapies suggests that new strategies are needed to improve physician knowledge and practice. These strategies should enhance physician awareness of AF under-treatment, emphasize accurate assessment of bleeding risk among AF patients, compare the safety, efficacy, and convenience of NOACs relative to warfarin, and address physician concerns regarding the out-of-pocket cost of NOACs. Guidelines and decision supports which promote physician knowledge in these areas have the potential to increase oral anticoagulant use and reduce preventable morbidity and mortality.

Comparison of the Influence of Right Atrial Septal Pacing and Appendage Pacing on an Atrial Function and Atrial Fibrillation in the Clinical Situation

Mariko Tanaka, Kanae Su, Maki Oi, Yasuyo Motohashi, Kousuke Takahashi, Euihong Ko, Koji Hanazawa, Mamoru Toyofuku, Masahiko Kitada, Yousuke Yuzuki, Takashi Tamura

BACKBROUND Radiofrequency ablation is extensively used to achieve pulmonary veins isolation for the cure of atrial fibrillation. Luminal esophageal temperature can be monitored by means of suitable probes to prevent the onset of lesions.
OBJECTIVE To compute the thermal field generated by the ablation, to investigate the interaction between the electromagnetic field and the probe sensors, and to provide a safe interpretation of the temperature detected by the probe, supported by clinical data.
METHODS A mathematical model is formulated and the is computed. Experiments have been performed to assess the solution energy deposition rate on the probe sensors. Clinical data have been collected during RF isolation of pulmonary veins in patients with atrial fibrillation.
RESULTS The direct interaction between the radiofrequency source and the probe sensors is found to be negligible. Numerical simulations show that the outer esophageal wall can be much warmer than the lumen. Theoretical heating curves are compared with the clinical data selecting the maximal slope as the reference quantity. The clinical values range between 0.01�C/s and 0.15�C/s agree with the computed predictions and demonstrate that reducing the esophagus-atrium distance by 1mm causes a slope increase of 0.06�C/s.
CONCLUSION The use of esophageal thermal probes is absolutely safe and necessary in order to prevent the occurrence of thermal lesions. The model is reliable, and describes effectively the generated thermal field. The external esophageal temperature can be considerably higher than the luminal one.

Quality measures in Atrial Fibrillation therapy – AF ablation and Get with the Guidelines AFIB registries

Dhanunjaya (DJ) Lakkireddy, Andrea Natale

Dear Colleagues Welcome to the summer issue of JAFIB. Hope everyone had a chance to enjoy the season and related travels. As MACRA and Pay for Performance continue to evolve to be the guiding force on physician reimbursement, quality becomes an important piece we need to focus on. It doesn't mean that we are not providing quality care to our patients now, but we need a special effort to document our quality work through various registries and quality bench marks. AF ablation has become an important area of focus for all the professional societies including HRS, ACC and AHA. One such effort is the recently released NCDR�s AFib registry. It's relatively comprehensive dataset that attempts to track outcomes and quality in a systematic way. Eventhough, it may not be very extensive and lead to long term follow up, it is a good start.