Deshmukh, Abhishek

Background: Recent case series and smaller registries from around the world have reported higher frequency of Takotsubo Cardiomyopathy (TTC) in females.The aim of this study was to look for gender difference and age - gender interactions for TTC across the nation. Methods: This was a cross sectional study using the Nationwide Inpatient Sample (NIS) 2007 database. TTC or Broken heart syndrome or Reversible left ventricular dysfunction following sudden emotional stress or Stress induced Cardiomyopathy or Transient left ventricular apical ballooning syndrome was defined as patients discharged with any ICD code of 429.83 ( http://www.cdc.gov/nchs/data/icd9/agendasept05.pdf ). Multivariate logistic regression with interaction variable between age and sex was performed. Results: There were 6229 estimated discharges in 2007 NIS. Of these, 5558 (89.2 %) were females and 671 (10.8%) were males. 11.1 % were between 18-50 years, 32% between 50-65 years,58% were more than 65 years. Overall females had significantly higher odds of developing TTC (OR, 7.5; 95% CI, 6.31-9.13). In age group > 55yrs, the odds of developing TTC was 9.5 times higher in females than in males, while in age 55yrs had 2.9 times higher odds of developing TTC while there was no such age difference in males. Conclusions: We conclude that women have 7.5 times higher odds of developing TTC than males. Females with age > 55 years have 2.9 times higher odds of developing TTC than females with age < 55 years. Further research needs to be done on hormonal influence and its effect on TTC.

Background: Takotsubo cardiomyopathy (TTC) has emerged as a new clinical entity which has not been fully understood. Numerous case reports exist regarding association of TTC with high adrenergic state conditions like Pheochromocytoma. Our aim was to explore the association of common medical conditions with TTC. Methods: This was a cross sectional study using the National Inpatient Sample (NIS) 2007 database.TTC or Broken heart syndrome or Reversible left ventricular dysfunction following sudden emotional stress or Stress induced cardiomyopathy or Transient left ventricular apical ballooning syndrome was defined as patients discharged with any ICD code of 429.83 ( http://www.cdc.gov/nchs/data/icd9/agendasept05.pdf ). The common medical conditions were identified by appropriate ICD 9 codes Results: We indentified total 6229 discharges with any discharge diagnosis of TTC. The likelihood of common medical conditions with TTC is shown in Table 1. Conclusions: This is the first study to explore the association of common medical conditions associated with TTC on a nationwide basis. We conclude that the patient with hyperlipidemia, smoking, pulmonary hypertension, sub arachnoid hemorrhage, migraine, hyperthyroidism, collagen vascular diseases, anxiety state, and stress have higher odds of developing TTC. Further research needs to be done for better understanding the causes and pathophysiology of TTC which in turn will help risk stratification and define optimal therapy.

AbstractIntroductionVentricular tachycardia storm or electrical storm (ES) is a common complication following left ventricular assist device (LVAD) implantation. The factors contributing to ES and outcomes are less studied. The study aimed to determine the factors associated with ES and the probability of survival in patients undergoing LVAD in three tertiary centers over a span of 15 years.MethodsWe performed a retrospective cohort study on all patients who underwent LVAD implantation at the Mayo Clinic (Rochester, Phoenix, and Jacksonville) from January 1, 2006 to December 31, 2020. ES was defined as ≥3 episodes of sustained ventricular tachycardia over a period of 24 h with no identifiable reversible cause. Detailed chart reviews of the electronic health records within the Mayo Clinic and outside medical records were performed.ResultsA total of 883 patients who underwent LVAD implantation were included in our study. ES occurred in 7% (n = 61) of patients with a median of 13 days (interquartile range [IQR]: 5–297 days) following surgery. We found 57% of patients (n = 35) developed ES within 30 days, while 43% (n = 26) patients developed ES at a median of 545 (IQR 152–1032) days after surgery. Following ES, 26% of patients died within 1 year. Patients with ES had a significant association with a history of ventricular arrhythmias and implantable cardioverter defibrillator (ICD) shocks before the procedure. ES was significantly associated with reduced survival compared to patients without ES (hazards ratio [HR]: 1.92, 95% CI: 1.39–2.64, p < .001).ConclusionFollowing LVAD implantation, the rate of ES was 7% with majority of ES occurring within 30 days of LVAD. Risk factors for ES included pre‐implant history of ventricular arrhythmias and ICD shock. ES was significantly associated with reduced survival compared to patients without ES.

Background: Inflammation is integral in the pathogenesis and propagation of atrial fibrillation (AF). Peri-ablation administration of steroids has been shown to significantly reduce AF recurrence at 3 months. We sought to determine the effect of intraoperative dexamethasone on early recurrence at both 3 months and 12 months post-ablation. Methods: A cohort of 94 adult patients (>18 years) underwent catheter ablation at Mayo Clinic Rochester from January to March 2019. Only first-time ablation patients were included, with all re-do ablations excluded to minimize heterogeneity. Administration of intraoperative dexamethasone 4 mg or 8 mg was determined by chart review from the procedure. At our institution, intraoperative intravenous steroids are administered for postoperative nausea and vomiting (PONV) prophylaxis at the discretion of the anesthesiologist. AF recurrence was determined by ECG or cardiac monitoring at less than 3 months or between 3 months and 1 year with an in-person follow-up visit. Results: A total of 36.2% of patients received intravenous dexamethasone compared to 63.8% who did not (providing a 2:1 comparison group). The incidence of documented AF or flutter lasting greater than 30 seconds was 20.6% in the dexamethasone group versus 21.7% in the non-dexamethasone group, p value 1.00. AF or atrial flutter recurrence from 3 months to 1 year was 20.6% in the dexamethasone group compared to 21.7% in the non-dexamethasone group, p value 1.00. Conclusion: These data suggest that intraoperative intravenous dexamethasone administered during AF ablation for postoperative nausea and vomiting prophylaxis does not have a significant effect on AF recurrence rates.

BACKGROUND: The incidence and prognosis of right bundle branch block (RBBB) following transcatheter aortic valve replacement (TAVR) are unknown. Hence, we sought to characterize the incidence of post-TAVR RBBB and determine associated risks of permanent pacemaker (PPM) implantation and mortality. METHODS: All patients 18 years and above without preexisting RBBB or PPM who underwent TAVR at US Mayo Clinic sites and Mayo Clinic Health Systems from June 2010 to May 2021 were evaluated. Post-TAVR RBBB was defined as new-onset RBBB in the postimplantation period. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. RESULTS: Of 1992 patients, 15 (0.75%) experienced new RBBB post-TAVR. There was a higher degree of valve oversizing among patients with new RBBB post-TAVR versus those without (17.9% versus 10.0%; P =0.034). Ten patients (66.7%) with post-TAVR RBBB experienced high-grade atrioventricular block and underwent PPM implantation (median 1 day; Q1, 0.2 and Q3, 4), compared with 268/1977 (13.6%) without RBBB. Following propensity score adjustment for covariates (age, sex, balloon-expandable valve, annulus diameter, and valve oversizing), post-TAVR RBBB was significantly associated with PPM implantation (hazard ratio, 8.36 [95% CI, 4.19–16.7]; P <0.001). No statistically significant increase in mortality was seen with post-TAVR RBBB (hazard ratio, 0.83 [95% CI, 0.33–2.11]; P =0.69), adjusting for age and sex. CONCLUSIONS: Although infrequent, post-TAVR RBBB was associated with elevated PPM implantation risk. The mechanisms for its development and its clinical prognosis require further study.

AbstractNew‐onset atrial fibrillation (NOAF) in COVID‐19 raises significant clinical and public health issues. This systematic review and meta‐analysis aims to compile and analyze the current literature on NOAF in COVID‐19 and give a more comprehensive understanding of the prevalence and outcomes of NOAF in COVID‐19. A comprehensive literature search was carried out using several databases. The random effect model using inverse variance method and DerSimonian and Laird estimator of Tua2 was used to calculate the pooled prevalence and associated 95% confidence interval (CI). Results for outcome analysis were presented as odds ratios (ORs) with 95% CI and pooled using the Mantel‐Haenszel random‐effects model. The pooled prevalence of NOAF in COVID‐19 was 7.8% (95% CI: 6.54%–9.32%),a pooled estimate from 30 articles (81 929 COVID‐19 patients). Furthermore, our analysis reported that COVID‐19 patients with NOAF had a higher risk of developing severe disease compared with COVID‐19 patients without a history of atrial fibrillation (OR = 4.78, 95% CI: 3.75–6.09) and COVID‐19 patients with a history of pre‐existing atrial fibrillation (OR = 2.75, 95% CI: 2.10–3.59). Similarly, our analysis also indicated that COVID‐19 patients with NOAF had a higher risk of all‐cause mortality compared with, COVID‐19 patients without a history of atrial fibrillation (OR = 3.83, 95% CI: 2.99–4.92) and COVID‐19 patients with a history of pre‐existing atrial fibrillation (OR = 2.32, 95% CI: 1.35–3.96). The meta‐analysis did not reveal any significant publication bias. The results indicate a strong correlation between NOAF and a higher risk of severe illness and mortality. These results emphasize the importance of careful surveillance, early detection, and customized NOAF management strategies to improve clinical outcomes for COVID‐19 patients.

Background: Catheter ablation is an effective tool to reduce ventricular tachycardia (VT) burden. There is a lack of robust data studying the characteristics and outcomes of VT ablation in patients with ischemic (ICM) versus non-ischemic cardiomyopathy (NICM). Aims: The aim of this study was to assess the impact of ICM vs NICM on outcomes of VT ablation. Methods: A single-center, retrospective study of patients undergoing catheter ablation for VT was conducted. Results: A total of 168 patients, undergoing 200 VT ablation procedures, were included in this study. NICM group (112 procedures) was compared to ICM group (88 procedures). Patients in the ICM group were older (66.6 ± 13.4 vs 58.9 ± 14.4 years) and had higher rates of prior myocardial infarction (65.9% vs 3.6) and coronary artery bypass graft surgery (40.9% vs 1.8%). Overall, ICM group had more comorbidities like hypertension (80.7% vs 52.7%), diabetes mellitus (23.9% vs 12.5%), chronic kidney disease (45.5% vs 35.7%), stroke (17% vs 7.1%), and lower left ventricular ejection fraction (36.8 ± 13.2% vs 43.1 ± 14.7%). The ICM group had lower incidence of prior cardiac valvular surgery (9.1% vs 29.5%). The inducibility of VT (93% vs 93.5%; p= 1.0) and the number of different VT morphologies induced during the case (1.9 ± 1.5 vs 2.3 ± 2.5; p=0.19) was similar between the two groups. There was no acute mortality in either group. There was a non-significant trend towards greater VT recurrence in the NICM group (43.2% vs 33.3%, p= 0.19). However, patients with NICM had a lower VT-free survival as determined by Kaplan-Meier analysis (p=0.05) [Figure]. Long term mortality was higher in ICM group when compared to NICM group (18.2% vs 8.9%, p<0.01). Conclusion: Patients undergoing VT ablation in the NICM group when compared to the ICM group were noted to be younger, had fewer comorbidities, and lower long-term mortality. However, they had significantly less VT-free survival, likely owing to more challenging substrate responsible for VT.

Introduction: Accurate pre-procedure localization of the premature ventricular contractions (PVCs) is critical in preparing for the ablation. So far, no tools exist for artificial intelligence guided PVC-localization. Hypothesis: Trained deep learning model will be able to predict the site of origin (SOO) of PVCs using 12 lead electrocardiogram (ECG). Methods: We analyzed 707 ECG-ablation pairs from 2403 patients who had at least one ECG flagged for PVCs in the 6 months prior to their procedure. First, we used a cohort of 100,000 ECGs without PVCs and 10,000 ECGs with PVCs to train a convolutional neural network (CNN) to isolate the ECG segments with PVCs in them from a 12-lead ECG (Figure 1). We then trained two models, one utilizing a 10-second 12-lead ECG, and the other with just the isolated PVC beats as input. The models were trained using the Keras framework with TensorFlow (Google). Results: The mean age of the patients in the cohort was 61.2 ± 15.0 years. 66.3 percent of patients underwent left ventricle ablation, 54.6 percent had outflow ablation, and 55.3 percent had ablation of sites with leftward axis (septal location for midline and left ventricle PVCs). The model trained on 10-second ECGs yielded validation and test AUCs of 0.941 and 0.931 for outflow, 0.898 and 0.891 for ventricle, and 0.863 and 0.846 for leftward axis (Figure 1A). The model trained on isolated segments containing PVC beats yielded validation and test AUCs of 0.966 and 0.957 for outflow, 0.879 and 0.907 for ventricle, and 0.846 and 0.829 for SOO for leftward axis (Figure 1B). Conclusions: We have trained an accurate convolutional neural network that can predict SOO using the surface ECG. Further fine-tuning would be needed to refine the model and develop prediction of specific sites.

Introduction: Atrial fibrillation (AF) is a common arrhythmia that can impair quality of life and increase cardiovascular mortality. Previous studies have shown potentially better outcomes with rate-control agents in patients with coronary artery disease (CAD). Yet, optimal treatment of AF is not yet known. Methods: Leveraging data from the AFFIRM trial, we performed a post-hoc analysis examining outcome differences in patients on rate vs. rhythm-control agents, based on CAD status. The primary outcome was defined as death from any cause; secondary outcomes included ischemic stroke, major bleeding, and hospitalization after baseline. Univariate and multivariate modeling were used to determine risk factors associated with designated outcomes. Results: Of 4060 patients enrolled, 1551 patients had CAD at baseline. There were no differences in treatment randomization based on CAD status; however, more patients with CAD had worse heart function and comorbid CHF. More patients with CAD ultimately used some form of rate-control compared to those without. Overall, CAD patients were more likely to experience death (HR 2.08 [1.79-2.42], P<0.001), specifically those on rhythm-control (HR 1.24 [1.01-1.52], P=0.04, Figure). CAD patients were also more likely to have ischemic stroke (HR 1.24 [1.00-1.53], P=0.05). When comparing CVD vs. non-CVD death, only CAD patients on rhythm-control exhibited a significantly higher rate of CVD death (HR 1.39 [1.03-1.89], P=0.03), while no differences in primary outcomes were noted for all other groups (P>0.05, Figure). In multivariate modeling, the effect of treatment arm on risk of CVD death in CAD patients diminished upon accounting for age, smoking, rhythm at randomization, first episode of AF, CHF, and LVEF<50% (HR 1.18 [0.93-1.50], P=0.17). Conclusions: AF patients with CAD on rhythm-control agents exhibited worse CVD outcomes, which may be more reflective of heart disease severity rather than treatment effects.