Rattanawong, Pattara

Background: Recognition of the causes of early mortality after atrial fibrillation (AF) catheter ablation is essential for the improvement of patient safety. Objective: This study sought to determine the causes of early mortality (≤90-days) after AF ablation and to further understand the circumstances surrounding death after the procedure. Methods: We performed a retrospective analysis of AF ablation from January 1, 2013, to December 1, 2021 at the Mayo Clinic (Rochester, Phoenix, and Jacksonville). Causes of death were identified through a comprehensive chart review of the electronic health record from within the Mayo Clinic system and outside records when available. Results: A total of 6,723 patients were included in the study. The 30-day and 90-day all-cause mortality rates were 0.09% and 0.22%, respectively. Among all 90-day deaths, majority of the deaths (73.3%) did not have a direct relationship with the procedure. Sudden death was the most common cause of early death (20%), followed by peri-procedural stroke (13%), respiratory failure (13%), atrioesophageal fistula (13%), infection (7%), heart failure (7%), and traumatic brain injury (7%). The 90-day mortality rate directly due to AF ablation procedural complications was 0.06%. Most of the early deaths (93.3%) occurred after discharge from index hospitalization, among which 64.3% were readmitted before their death, 14% died at home, and 7% were discharged on comfort care and died in hospice. The main reason for readmission leading to death was respiratory failure (33%). Conclusion: Atrial fibrillation ablation procedure has a 90-day mortality of 0.22% and the most common cause of early mortality was sudden death. The majority (73.3%) of early mortality was not directly associated with a procedural complication, and the mortality rate due to complications associated with the AF ablation procedure was 0.06%.

AbstractBackgroundTransvenous lead extraction (TLE) is increasingly considered in cardiac implantable electronic device management. Heart failure (HF) might be associated with mortality risks after the TLE procedure. This study aims to assess mortality risk in HF patients undergoing TLE.MethodWe searched MEDLINE and Embase databases from inception to June 2022 to identify articles that included patients with and without HF who underwent TLE, which reported mortality in both groups. The pooled effect size was calculated with a random‐effects model and 95% CI to compare post‐TLE mortality between the two groups.ResultsEleven studies were included in the analysis. Each left ventricular ejection fraction (LVEF) increased by 1% was associated with reduced mortality by 2% (HR = 0.98, 95% CI: 0.97–0.99, I2 = 74.9%, p < .01). The presence of HF compared to those without HF was associated with higher mortality rates (OR: 3.04, 95% CI: 2.56–3.61, I2 = 0.0%, p < .531). There was a significant increase in the mortality rates in patients with New York Heart Association (NYHA) function class III (OR: 2.29, 95% CI: 1.29–4.06, I2 = 0.0%, p = .498) and NYHA IV (OR: 8.5, 95% CI: 2.98–24.3, I2 = 0.0%, p = .997).ConclusionsOur study found that post‐TLE mortality decreases by 2% as LVEF increases by 1%, also mortality is higher in patients with NYHA III and IV.

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Idiopathic ventricular fibrillation (IVF) is responsible for 5-7% of sudden cardiac arrests in the absence of substrate for ventricular arrhythmia, structural diseases, or primary arrhythmic syndromes. The characteristics, management, and prognosis of these patients are unclear. Purpose To investigate the clinical features, management, and prognosis of IVF in our hospital healthcare system Methods Mayo Database Explorer software was used to identify IVF patients from our hospital electronic medical records between 1990 to 2022 in 5 states. The medical records were manually reviewed. Results A total of 132 patients were initially diagnosed with IVF. During the 9.2±6.8 years mean follow-up, 36 [27.3%] patients were later diagnosed with structural diseases or primary arrhythmic syndromes (dilated cardiomyopathy [41.7%], Long QT syndrome [27.8%], catecholaminergic polymorphic ventricular tachycardia [8.3%], Brugada syndrome [5.6%], mitral valve-related arrhythmia [5.6%], and short QT syndrome [2.8%]). Among the rest of the 96 patients with true IVF (mean age 38.4±15.7 years, male 59.4%, Caucasian 80.2%, hypertension 28.1%, diabetes 8.3%), 91 (94.8%) patients presented with out-of-hospital cardiac arrest and 88 (91.7%) patients had a history of syncope. Early repolarization and fragmented QRS were noted in 32 (33.3%) and 28 (29.1%) patients, respectively. Defibrillators were implanted in 92 (95.8%) patients. Genetic testing was performed in 35 (36.5%) patients, and possible associated mutations were found in 13 (37.1%) patients. An Electrophysiology study was conducted in 55 (57.3%) patients, and ventricular fibrillation was induced in 17 (30.9%) patients. The medical management with antiarrhythmic drugs was selected in 60 (62.5%) patients, and the catheter ablation ± anti-arrhythmic drugs was selected in 36 (37.5%) patients. The recurrence of ventricular fibrillation during 9.2±6.8 years of mean follow-up was significantly higher in the ablation strategy group (p=0.0003) (Figure 1). Conclusions We reported the largest cohort of IVF patients from a single healthcare system. Early repolarization and fragmented QRS were common in IVF. The possible associated mutations were found in one-third of IVF who underwent genetic testing. The ventricular fibrillation recurrences were significantly higher in the catheter ablation strategy group.

Abstract Funding Acknowledgements Type of funding sources: Private hospital(s). Main funding source(s): Mayo Clinic Background/Introduction Syncope is a common presentation in heart failure (HF) patients. However, the associations between syncope and prognosis in HF patients with the cardiac implantable electronic device (CIED) have not been demonstrated. It is unclear whether syncope increases all-cause mortality in HF patients with CIED. Purpose We aimed to examine the association between syncope and all-cause mortality in the largest cohort of HF with reduced ejection fraction (HFrEF), mid-ranged ejection fraction (HFmEF), and preserved ejection fraction (HFpEF) patients with and without CIED. Methods A retrospective cohort of patients with HF and syncope at our hospital between 2010 and 2015 were identified, and 1:1 propensity was matched with a control group of HF patients without syncope. A chart review was conducted. The multivariate Cox regression model was applied to estimate the association between syncope and the all-cause mortality endpoint. Results 3,449 HF patients were diagnosed with syncope (mean age, 72.8±14.5 years; 41.5% women), and the propensity-matched control HF patients without syncope (n=3,449) aged 72.8±14.3 years, and 42.5% women were selected. Cardiac implantable electronic devices were implanted more in HF patients with syncope (32.5% versus 13.7%, p&lt;0.001). Implantable cardioverter defibrillators were implanted more in HF patients with syncope (15.6% versus 8.3%, p&lt;0.001) as well as pacemakers (16.9% versus 7.5%, p&lt;0.001) and cardiac resynchronization therapy devices (6.9% versus 4.8%, p=0.015). Among HF patients with CIED, syncope significantly increased the risk of all-cause mortality in HFrEF patients (hazard ratio [HR]=1.479, 95% confidence interval [CI]: 1.197-1.828, p&lt;0.001) but not in HFpEF (HR=0.980, 95%CI: 0.793-1.210, p=0.849)(Figure 1). Syncope also tended to increase the risk of all-cause mortality in HFmEF patients with CIED but was not significant (HR=1.193, 95%CI: 0.762-1.865, p=0.762)(Figure 1). Among HF patients without CIED, syncope did not increase the risk of all-cause mortality in HFrEF (HR=0.923, 95%CI: 0.806-1.057, p=0.247), HFmEF (HR=1.074, 95%CI: 0.848-1.360, p=0.554), or HFpEF (HR=0.964, 95%CI: 0.883-1.052, p=0.406). Conclusions Syncope significantly increased the risk of all-cause mortality in HFrEF patients but not in HFmEF or HFpEF patients with CIED. The association of syncope and increased mortality in HFrEF patients with CIED suggests that syncope may be a marker and a factor of mortality and warrants further investigation.

Background: Recognition of the causes of early mortality after atrial fibrillation (AF) catheter ablation is essential for the improvement of patient safety. This study sought to determine the causes of early mortality (≤90 days) after AF ablation. Methods: We performed a retrospective analysis of AF ablation from January 1, 2013, to December 1, 2021 at the Mayo Clinic (Rochester, Phoenix, and Jacksonville). Causes of death were identified through a comprehensive chart review of the electronic health record from within the Mayo Clinic system and outside records when available. Results: A total of 6723 patients were included in the study. The 90-day all-cause mortality rate was 0.22% (n=15). Among all 90-day deaths, majority of the deaths (73.3%) did not have a direct relationship with the procedure. Sudden death was the most common cause of early death (20%), followed by peri-procedural stroke (13%), respiratory failure (13%), atrioesophageal fistula (13%), infection (7%), heart failure (7%), and traumatic brain injury (7%). The 90-day mortality rate directly due to AF ablation procedural complications was 0.06% (n=4). Conclusions: AF ablation procedure has a 90-day mortality of 0.22%, and the most common cause of early mortality was sudden death. The majority (73.3%) of early mortality was not directly associated with a procedural complication, and the mortality rate due to complications associated with the AF ablation procedure was low at 0.06%. Further studies are required to investigate causes and risk factors associated with sudden death in this patient population.

AbstractIntroductionBrugada syndrome is an inherited arrhythmic disease associated with major arrhythmic events (MAE). The importance of primary prevention of sudden cardiac death (SCD) in Brugada syndrome is well recognized; however, ventricular arrhythmia risk stratification remains challenging and controversial. We aimed to assess the association of type of syncope with MAE via systematic review and meta‐analysis.MethodsWe comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2021. Included studies were cohort (prospective or retrospective) studies that reported the types of syncope (cardiac, unexplained, vasovagal, and undifferentiated) and MAE. Data from each study were combined using the random‐effects, generic inverse variance method of DerSimonian and Laird to calculate the odds ratio (OR) and 95% confidence intervals (CIs).ResultsSeventeen studies from 2005 to 2019 were included in this meta‐analysis involving 4355 Brugada syndrome patients. Overall, syncope was significantly associated with an increased risk of MAE in Brugada syndrome (OR = 3.90, 95% CI: 2.22–6.85, p < .001, I2 = 76.0%). By syncope type, cardiac (OR = 4.48, 95% CI: 2.87–7.01, p < .001, I2 = 0.0%) and unexplained (OR = 4.71, 95% CI: 1.34–16.57, p = .016, I2 = 37.3%) syncope was significantly associated with increased risk of MAE in Brugada syndrome. Vasovagal (OR = 2.90, 95% CI: 0.09–98.45, p = .554, I2 = 70.9%) and undifferentiated syncope (OR = 2.01, 95% CI: 1.00–4.03, p = .050, I2 = 64.6%, respectively) were not.ConclusionOur study demonstrated that cardiac and unexplained syncope was associated with MAE risk in Brugada syndrome populations but not in vasovagal syncope and undifferentiated syncope. Unexplained syncope is associated with a similar increased risk of MAE compared to cardiac syncope.

AbstractBackgroundThe impact of chronic kidney disease (CKD) or end‐stage renal disease (ESRD) on patients receiving transvenous lead extraction (TLE) is not well‐established. We performed a systematic review and meta‐analysis to explore the association between CKD and all‐cause mortality in TLE.MethodsWe searched the databases of PubMed and EMBASE from inception to April 2022. Included studies were published TLE studies that compared the risk of mortality in CKD patients compared to control patients. Data from each study were combined using the random‐effects model.ResultsEight studies (5,013 patients) were included. Compared with controls, CKD patients had a significantly higher risk of overall all‐cause mortality (hazard ratio [HR] = 2.14, 95% confidence interval [CI]: 1.65–2.77, I2 = 51.1%, p < .001). The risk of overall all‐cause mortality increased with the severity of CKD for nonspecific CKD (HR = 2.01, 95% CI: 1.49–2.69, I2 = 53.4, p < .001) and ESRD (HR = 2.79, 95% CI: 1.85–4.23, I2 = 0%, p < .001). The risk of all‐cause mortality in CKD is double at follow‐up ≤1 year (HR = 1.99, 95% CI: 1.29–3.09, I2 = 50.9%, p = .002) and higher at follow‐up >1 year (HR = 2.36, 95% CI: 1.63–3.42, I2 = 59.7%, p < .001).ConclusionsOur meta‐analysis demonstrates a significantly increased risk of overall all‐cause mortality in patients with CKD who underwent TLE compared to controls.

AbstractIntroductionAtrial fibrillation (AF) is the most common cardiac arrhythmia with a high stroke and mortality rate. The video‐assisted thoracoscopic radiofrequency pulmonary vein ablation is a treatment option for patients who fail catheter ablation. Randomized data comparing surgical versus catheter ablation are limited. We performed a meta‐analysis of randomized control trials to explore the outcome efficacy between surgical and catheter radiofrequency pulmonary vein ablation in patients with AF.MethodsWe comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2020. Included studies were published randomized control trials that compared video‐assisted thoracoscopic and catheter radiofrequency pulmonary vein ablation. Data from each study were combined using the fixed‐effects, generic inverse variance method of DerSimonian, and Laird to calculate odds ratios and 95% confidence intervals.ResultsSix studies from November 2013 to 2020 were included in this meta‐analysis involving 511 AF patients (79% paroxysmal) with 263 catheter ablation (mean age 56 ± 3 years) and 248 surgical ablations (mean age 52 ± 4 years). Catheter ablation was associated with increased atrial arrhythmias recurrence when compared to surgical ablation (pooled relative risk = 1.85, 95% confidence interval: 1.44−2.39, p < .001, I2 = 0.0%) but associated with less total major adverse events (pooled relative risk = 0.29, 95% confidence interval: 0.16−0.53, p < .001, I2 = 0.0%). In subgroup analysis, catheter ablation was associated with increased AF recurrence in refractory paroxysmal AF when compared to surgical ablation (pooled relative risk = 2.47, 95% confidence interval: 1.31−4.65, p = .005, I2 = 0.0%) but not in persistent AF (relative risk = 1.09, 95% confidence interval: 0.60−2.0, p = .773).ConclusionCatheter ablation was associated with higher atrial arrhythmia recurrence when compared with surgical ablation. However, our study suggests that the benefit of surgical ablation in patients with persistent AF is unclear. More studies and alternative ablation strategies investigation in persistent AF are warranted.

Abstract Background Fever, alcohol, and sodium channel blockers can unmask Brugada pattern and may also induce arrhythmias in Brugada syndrome. We report a case of unmasked Type-1 Brugada pattern presenting with ventricular fibrillation that was induced by a tetrahydrocannabinol vaping. Case summary A 48-year-old male with a past medical history of hypertension treated with hydrochlorothiazide and back pain controlled with tetrahydrocannabinol vaping presented with sudden cardiac arrest from ventricular fibrillation, which was terminated with defibrillation. Electrocardiogram after resuscitation showed a new Type-1 Brugada pattern compared to a previous normal baseline electrocardiogram. Echocardiography and coronary angiogram were unremarkable. Complete blood count and chemistries were unremarkable except for mild hypokalaemia (K = 3.3 mmol/L). After correction of the hypokalaemia, the Type-1 Brugada pattern persisted. Urine drug screen was positive for tetrahydrocannabinol (60 ng/mL). Genetic testing was negative for inherited arrhythmic disease and cardiomyopathy gene panels. Discussion The patient’s type-1 Brugada pattern and ventricular fibrillation were likely induced by vaping tetrahydrocannabinol. He underwent secondary prevention with an implantable cardioverter-defibrillator. He abstains from cannabis and Type-1 Brugada pattern is normalized. There was no arrhythmic event at his 18-month follow-up appointment with abstinence from tetrahydrocannabinol.

Abstract Funding Acknowledgements Type of funding sources: None. Background The prevalence of Type-1 Brugada pattern in Caucasians and Asians have been estimated to be 20 and 180 per 100,000. However, the prevalence of Type-1 Brugada pattern in African Americans has never been studied. Purpose This study aims to identify the prevalence of Type-1 Brugada pattern in African Americans. Methods Medical records of African American patients ages 18 years old or older with at least one 12-lead electrocardiogram (ECG) performed at 16 hospitals from 5 states in a single healthcare system between January 1, 2011 to December 31, 2020 were included. The search engine software was used to identify patients with keywords (Brugada pattern, Brugada ECG, Brugada Type-1, or Brugada syndrome) documented in the electronic medical record. The 12-lead ECGs were retrospectively analyzed by 2 cardiologists. Any inconsistencies were reviewed by a third cardiac electrophysiologist. Type-1 Brugada pattern was diagnosed according to the recent Heart Rhythm Society Expert Consensus Statement. Results Among 43,116 African American patients, (46.9% males), 6 patients (mean age 44.8±13.9 years, 100% males) had Type-1 Brugada pattern documented on at least one 12-lead ECG. The prevalence of Type-1 Brugada pattern in this large patient population of African American was 13.9 per 100,000. None of the patients had major arrhythmic event at 6.7±4.7 years follow-up. Conclusions The prevalence of Type-1 Brugada pattern in African American is lower than Caucasian and Asian populations. The risk of major arrhythmic event of Type-1 Brugada pattern in African American appears to be low; however longer follow-up data is needed.