Kewcharoen, Jakrin

AbstractBackgroundIn the modern era, atrial fibrillation (AF) ablation trend has been shifted toward same‐day discharge (SDD), from a traditional overnight stay. Yet, recent studies have not well stated the safety profiles which remained poor‐understood and dispersed. We hence performed systematic review and meta‐analysis to assess the adverse outcomes of SDD in comparison with an overnight stay.MethodsDatabases were searched through January 2021. Effect estimates from the individual studies were extracted and combined using random‐effects, generic inverse variance method of der Simonian and Laird. The primary outcomes included total cumulative complications and immediate complications following AF ablation.ResultsTen observational studies were met our inclusion criteria, comprising of total population of 11,660 patients, with SDD 51.3%. For total cumulative complications, there were no differences observed between SDD and overnight stay (5.2% vs. 6.2%: pooled OR 0.77: 95% CI 0.55–1.08, p = .13 with I2 = 27.1%). In addition, comparable immediate complications were also demonstrated (5.2 % vs. 4.3: pooled OR 1.08: 95% CI 0.72–1.62, p = .718, with I2 = 37.3 %).ConclusionOur study suggested that SDD had similar complication rates, both total cumulative and immediate outcomes, compared with overnight stay in selected patients following AF ablation. Nevertheless, randomized control trials are warranted to validate the findings.

Background The presence of atrial fibrillation (AF) in patients with heart failure with preserved ejection fraction (HFpEF) dramatically increases higher morbidity and mortality. Recent studies have suggested that early rhythm control may alleviate the burden of poor outcomes. Currently, there remain limited data on whether rhythm or rate control has better efficacy. This study sought to compare both strategies in HFpEF patients with AF. Methods Databases were searched throughout 2020. Studies that reported cardiovascular outcomes amongst HFpEF patients with AF who received either rhythm or rate control were included. Estimates of the effects from the individual studies were extracted and combined using random-effects, a generic inverse variance method of DerSimonian and Laird. Results Five observational studies were included in the analysis, consisting of 16,953 patients, 13.8% of whom were receiving rhythm control. In comparison with rate control, rhythm control was associated with decreased overall mortality rates (pooled RR 0.85, 95% CI 0.75–0.95, with I2 = 0%, p value = 0.009). Conclusions In HFpEF patients with AF, rhythm control was associated with lower mortality, compared to rate control. Further studies are warranted to validate our observation.

AbstractBackgroundRadiofrequency catheter ablation for cardiac arrhythmias has traditionally been guided by fluoroscopy. Fluoroscopy exposes the patient, operator, and staff to ionizing radiation which has no safe dose void of stochastic and deterministic biologic risks. Zero fluoroscopy (ZF) approaches for catheter ablation have been advocated to eliminate these risks. We conducted a meta‐analysis comparing acute procedure success, recurrence‐free survival, complications, and procedure times between the approaches.MethodsWe conducted a literature search from inception through December 2020 in the databases of EMBASE and MEDLINE. We included randomized controlled trials and cohorts that compared the outcomes of interest in ZF and conventional/low fluoroscopy (CF/LF) approaches. The outcomes sought were acute procedure success, recurrence‐free survival, complications, and procedure times. Effect estimates were combined, using the random‐effects, generic inverse variance method of DerSimonian and Laird.ResultsSixteen studies from 2013 to 2020, including 6052 patients (2219 ZF, 3833 CF/LF) were included. There were no significant differences in acute procedure success rate (odds ratio [OR]: 1.10, 95% confidence interval [CI]: 0.75–1.59), recurrence‐free survival (OR: 1.08, 95% CI: 0.78–1.49), periprocedural complication rate (OR: 0.72, 95% CI: 0.45–1.16), or total procedure time (weighted mean difference 2.32 min, 95% CI: −2.85–7.50) between ZF and CF/LF approaches, respectively. Overall, only 1.26% of patients crossed over from ZF to CF/LF arm.ConclusionsPeriprocedural and postprocedural outcomes with a ZF approach compared favorably with traditional fluoroscopic guidance without increasing procedural times. As comfort with ZF grows, coupled with evolving mapping technologies, this method has potential to become the standard approach for catheter ablation.

Background Brugada syndrome is an inherited cardiac channelopathy associated with major arrhythmic events (MAEs). The presence of a positive family history of sudden cardiac death (SCD) as a risk predictor of MAE remains controversial. We aimed to examine the association between family history of SCD and MAEs stratified by age of SCD with a systematic review and meta‐analysis. Methods and Results We searched the databases of MEDLINE and EMBASE from January 1992 to January 2020. Data from each study were combined using the random‐effects model. Fitted metaregression was performed to evaluate the association between the age of SCD in families and the risk of MAE. Twenty‐two studies from 2004 to 2019 were included in this meta‐analysis involving 3386 patients with Brugada syndrome. The overall family history of SCD was not associated with increased risk of MAE in Brugada syndrome (pooled odds ratio [OR], 1.11; 95% CI, 0.82–1.51; P =0.489, I 2 =45.0%). However, a history of SCD in family members of age younger than 40 years of age did increase the risk of MAE by ≈2‐fold (pooled OR, 2.03; 95% CI, 1.11–3.73; P =0.022, I 2 =0.0%). When stratified by the age of cut point at 50, 45, 40, and 35 years old, a history of SCD in younger family member was significantly associated with a higher risk of MAE (pooled OR, 0.49, 1.30, 1.51, and 2.97, respectively; P =0.046). Conclusions A history of SCD among family members of age younger than 40 years was associated with a higher risk of MAE.

Introduction: Drug challenge testing is performed to unmask Type-1 Brugada pattern. The safety and prevalence of its complications during the test are unclear. We aimed to assess the relation of complications in patients with positive and negative results by a systematic review and meta-analysis. Hypothesis: The prevalence of arrhythmic complications is higher in patients with positive drug challenge testing. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to June 2020. Included studies were cohort studies that reported ventricular arrhythmia that required interventions (VAI) (sustained ventricular tachycardia [VT], polymorphic VT, ventricular fibrillation, appropriate implantable cardioverter defibrillator [ICD] shock, or sudden cardiac arrest) and ventricular arrhythmias that did not required interventions (VANI) (premature ventricular complexes and non-sustained VT) during drug challenge testing. Data were combined using the random-effects model. Results: Thirteen studies involving 2,688 patients (62.7% positive) were included. The overall prevalence of VAI and VANI were 3.7% (95% confidence interval [CI]: 1.8-5.7) and 0.5% (95% CI: 0.1-0.9), respectively. VAI were more common in positive when compared to negative test result patients (1.5% [95% CI: 0.6-2.4] and 0%, respectively) but the prevalence of VANI were similar (2.7% [95% CI: 0.8-4.6] and 2.6% [95% CI: 0.8-4.6], respectively). VAI in positive result patients were more common with flecainide followed by pilsicainide and ajmaline (2.4% [95% CI: -4.3 to 9.2], 2.2% [95% CI: 0.5-4.0], and 1.5% [95% CI: 0.6 to 2.4], respectively). Most of patients with VAI during drug challenge testing underwent ICD implantation (94%). VAI during drug challenge testing in positive result patients carries an increased risk of VAI during 8.6 ± 4.9 years follow-up (odds ratio 3.73, 95% CI: 1.77-7.86, p=0.001). Conclusions: VAI were more common in patients with positive drug challenge testing, more often occurring with positive flecainide challenge, and carries an increased risk of VAI over long-term follow-up in patients with positive drug challenge testing.

Background: Although high power, shorter duration (HPSD) ablation and low power, longer duration (LPLD) ablation strategies for atrial fibrillation (AF) are frequently advocated to enhance safety and efficacy, there exists a need for comparative data from large populations. We performed a meta-analysis to compare arrhythmia-free survival, procedure time and complications rates between the two strategies. Methods: We searched the databases of MEDLINE and EMBASE from inception to April 2020. Included studies were case-control studies, cohort studies, or randomized controlled trials that compared patients undergoing HPSD and LPLD strategies for AF ablation and reported either of the following outcomes: freedom from atrial tachyarrhythmia (AT) including AF and atrial flutter, procedure time, or periprocedural complications. Data from each study were combined using the random-effects model to calculate odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI). Results: Ten studies from 2006 to 2020 involving 2,189 patients were included (1,350 patients underwent HPSD strategy and 839 patients underwent LPLD strategy). Both HPSD and LPLD strategies resulted in a similar freedom from AT at 12-month follow-up (OR=1.36, 95% CI:0.91-2.04, p=0.13, Figure 1A). HPSD strategy did result in a significant reduction in total procedure time (WMD=47.34, 95% CI:29.47-65.21, p<0.001, Figure 1B) compared to LPSD. HPSD wasn’t associated with reduction in esophageal ulcer/arterioesophageal fistula (OR=0.35, 95%CI=0.12-1.06, p=0.06) or pericardial effusion/cardiac tamponade (OR=0.96, 95%CI: 0.24-3.79, p=0.95) Conclusions: In this large meta-analysis both LPLD and HPSD are equally effective and safe. Although HPSD is often advocated to reduce esophageal injury, risk was similar between approaches. However, HPSD strategy significantly lowers procedure times.

Background: Antidepressants are one of the most prescribed medications, particularly for patients with mental disorders. Nevertheless, there are still limited data regarding the risk of ventricular arrhythmia (VA) and sudden cardiac death (SCD) associated with these medications. Thus, we performed systemic review and meta-analysis to characterize the risks of VA and SCD among patients who used common antidepressants. Methods: A literature search for studies that reported risk of ventricular arrhythmias and sudden cardiac death in antidepressant use from MEDLINE, EMBASE, and Cochrane Database from inception through September 2020. A random-effects model network meta-analysis model was used to analyze the relation between antidepressants and VA/SCD. Surface Under Cumulative Ranking Curve (SUCRA) was used to rank the treatment for each outcome. Results: The mean study sample size was 355,158 subjects. Tricyclic antidepressant (TCA) patients were the least likely to develop ventricular arrhythmia events/sudden cardiac deaths at OR 0.24, 0.028–1.2, OR 0.32 (95% CI 0.038–1.6) for serotonin and norepinephrine reuptake inhibitors (SNRI), and OR 0.36 (95% CI 0.043, 1.8) for selective serotonin reuptake inhibitors (SSRI), respectively. According to SUCRA analysis, TCA was on a higher rank compared to SNRI and SSRI considering the risk of VA/SCD. Conclusion: Our network meta-analysis demonstrated the low risk of VA/SCD among patients using antidepressants for SNRI, SSRI and especially, TCA. Despite the relatively lowest VA/SCD in TCA, drug efficacy and other adverse effects should be taken into account in patients with mental disorders.

Introduction As percutaneous coronary intervention (PCI) technologies have been far improved, we hence conducted an updated systemic review and meta-analysis to determine the comparability between coronary artery bypass graft (CABG) and PCI with drug-eluting stent (DES) in ESRD patients. Methods We comprehensively searched the databases of MEDLINE, EMBASE, PUBMED and the Cochrane from inception to January 2020. Included studies were published observational studies that compared the risk of cardiovascular outcomes among dialysis patients with CABG and DES. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. Subgroup analyses and meta-regression were performed to explore heterogeneity. Results Thirteen studies were included in this analysis, involving total 56 422 (CABG 21 740 and PCI 34 682). Compared with DES, our study demonstrated CABG had higher 30-day mortality [odds ratio (OR) 3.85, P = 0.009] but lower cardiac mortality (OR 0.78, P < 0.001), myocardial infarction (OR 0.5, P < 0.001) and repeat revascularization (OR 0.35, P < 0.001). No statistical differences were found between CABG and DES for long-term mortality (OR 0.92, P = 0.055), composite outcomes (OR 0.88, P = 0.112) and stroke (OR 1.49, P = 0.457). Meta-regression suggested diabetes and the presence of left main coronary artery disease as an effect modifier of long-term mortality. Conclusion PCI with DES shared similar long-term mortality, composite outcomes and stroke outcomes to CABG among dialysis patients but still was associated with an improved 30-day survival . However, CABG had better rates of myocardial infarction, repeat revascularization and cardiac mortality.

Gastrointestinal bleeding (GIB) especially from arteriovenous malformations (AVM) remains one of the devastating complications following continuous-flow left ventricular device (CF-LVAD) implantation. Blockade of angiotensin II pathway using angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) was reported to mitigate the risk of GIB and AVM-related GIB by suppressing angiogenesis. We performed a systematic review and meta-analysis to evaluate the association between ACEI/ARB treatment and GIB in CF-LVAD population. Comprehensive literature search was performed through December 2019. We included studies reporting risk of GIB and/or AVM-related GIB events in LVAD patients who received ACEI/ARB with those who did not. Data from each study were combined using the random-effects to calculate odd ratios and 95% confidence intervals. Three retrospective cohort studies were included in this meta-analysis involving 619 LVADs patients (467 patients receiving ACEI/ARB). The use of ACEI/ARB was statistically associated with decreased incidence of overall GIB (pooled OR 0.35, 95% CI 0.22–0.56, I 2 = 0.0%, p < 0.001). There was a non-significant trend toward lower risk for AVM-related GIB in patients who received ACEI/ARB (pooled OR 0.46, 95% CI 0.19–1.07, I 2 = 51%, p = 0.07). Larger studies with specific definitions of ACEI/ARB use and GIB are warranted to accurately determine the potential non-hemodynamic benefits of ACEI/ARB in CF-LVAD patients.