Alam, Mustafa

Introduction: Atrial fibrillation (AF) remains a significant cause of morbidity and mortality in the United States. Optimal management of AF in heart failure (HF) patients remains a controversy. Recent studies have demonstrated favorable outcomes of catheter ablation versus medical therapy. The purpose of this meta-analysis is to investigate whether catheter ablation achieves better outcomes as compared to rate control. Methods: A systematic search of MEDLINE was conducted using PRISMA guidelines with the search terms “rate control”, “atrial fibrillation”, and “ablation.” Studies were included if they compared a catheter ablation strategy versus rate control medical therapy in HF patients. Multiple endpoints were extracted from the articles including LVEF, 6MWD, change in BNP, and Quality of Life (QoL) outcomes using the Cochrane manual. Revman 5.4 was used to aggregate the outcomes and compute statistics using a random effects model to create forest plots. Results: A total of 7 studies with 1065 patients were included in this analysis. LVEF increased by 5.69% [4.80, 6.58] p<0.00001, 6MWD increased by 24.82m [2.69, 46.94] p=0.03, BNP decreased -102.54 [-174.68, -30.40] p=0.005, and QoL outcomes using the MLHFQ improved -8.10 [-15.73, -0.48] p=0.04. Conclusions: Catheter ablation improves outcomes in HF patients with atrial fibrillation as compared to a rate control only strategy. Further large-scale randomized studies are needed to quantify improvements in outcomes.

Objectives: To report long-term outcomes of nonmelanoma skin cancer (NMSC) in immunosuppressed cardiac and liver transplant recipients (CLTR). Materials and Methods: The authors reviewed CLTR at the Mayo Clinic in Arizona from 1986 to 2013. Patient and tumor characteristics were recorded. Survival rates were calculated using the Kaplan-Meier method. Patient-specific and lesion-specific analyses were performed. Univariate and multivariate cox regressions were performed for comparisons. Results: Seven-hundred and forty-seven patients underwent cardiac (138) or liver (609) transplantation and of these, 97 patients (13%) developed 382 invasive NMSC. The median follow-up was 11 (range, 3 to 27) years for surviving patients. Primary treatment was mainly surgery alone. At 10 years, the local recurrence (LR) rate was 20% (95% confidence interval, 15%-28%), and 14% of patients had multiple LRs. At 10 years, LR rates were higher for T3/T4 tumors when compared with T1/T2 tumors (32.5% vs. 20%, P=0.05). At 10 years, overall survival was 79% (95% confidence interval, 64%-88%). On multivariate analysis, age 61 years and more demonstrated inferior overall survival (P<0.01). Conclusions: This is the first study describing the AJCC 8th edition stage-based patterns of recurrence and long-term outcomes of surgically managed NMSC in a large cohort of immunosuppressed CLTRs. T3 and T4 tumors recur more often than early stage tumors. Further study is required to identify factors related to recurrence and guide upfront treatment intensification in this high-risk population.