Washington Adventist Hospital

Rhythm control is challenging in patients with extended atrial fibrillation (AF) duration and persistent/long-standing persistent AF. Among surgical approaches to treat AF, the Cox maze procedure performed using alternative energy sources remains superior to other beating heart techniques. We examined permanence of safety and success for the on-pump, minimally invasive, stand-alone Cox maze procedure 5 years after surgery. Stand-alone, right 5 cm minithoracotomy, Cox maze III/IV procedure for nonparoxysmal AF was conducted in 133 patients (mean follow-up=65±34 months). Data collected prospectively at 3, 6, 9, 12, 18, 24 months and yearly thereafter and reported per Heart Rhythm Society Guidelines. Paired-samples t tests evaluated quality of life changes. Mean age was 57.3±9.2 years, mean LA size was 4.9±1.1 cm, median AF duration was 51 months, and 78% had long-standing persistent AF. All procedures performed with no conversion to midsternotomy, no renal failure, strokes, or operative mortality (<30 days), transient ischemic attack in 1 patient, reoperation for bleeding in 2 patients, and median length of stay was 4 days [3-5.5 days]. At 5 years, 73% were in sinus rhythm off antiarrhythmic medications after single intervention, 1 stroke (718 patient-years) with 81% off anticoagulation, catheter ablation reinterventions in 13 patients for atrial arrhythmia, and cardioversions in 15 patients. Quality of life scores improved significantly by 12 months after surgery. Successful ablation for nonparoxysmal AF is challenging. Therefore, periprocedural safety and long-term efficacy of minimally invasive Cox maze procedures should be noted. Continued refinement of decision-making techniques is warranted to improve patient selection for the appropriate intervention to treat AF.

To compare bivalirudin to heparin during non-primary percutaneous coronary intervention (PCI). The optimal anticoagulant to support PCI remains uncertain. We performed a propensity score-based analysis comparing clinical outcomes of patients receiving heparin to those receiving bivalirudin during non-primary PCI. Of 18,867 patients in the Cardiovascular Patient Outcomes Research Team Non-Primary PCI (CPORT-E) trial, we selected 7,913 patients undergoing non-staged PCI of whom 57.3% received heparin and 42.7% received bivalirudin. In-hospital myocardial infarction occurred in 4.4% of patients receiving bivalirudin and 3.0% of patients receiving heparin (relative risk [RR] 1.5, 95% confidence interval [CI] 1.1-2.1, P = 0.022); this difference persisted at 6 weeks (5.0% vs. 3.6%, RR 1.4, 95% CI 1.0-1.8, P = 0.041). There was no difference in all-cause mortality either in-hospital (0.2% vs. 0.1% for heparin vs. bivalirudin, P = 0.887) or at 6 weeks (0.5% vs. 0.7%, P = 0.567). In-hospital bleeding requiring transfusion occurred in 0.9% of patients receiving bivalirudin and 1.9% of patients receiving heparin (RR 0.4, 95% CI 0.3-0.7, P <0.001), but there was no difference at 6 weeks (2.7% for heparin vs. 1.9% for bivalirudin, RR 0.7, 95% CI 0.5-1.0, P = 0.062). In patients undergoing non-primary PCI at hospitals without on-site cardiac surgery, bivalirudin was associated with a decreased risk of in-hospital bleeding requiring transfusion and an increased risk of in-hospital MI compared to heparin. © 2017 Wiley Periodicals, Inc.

The use of prophylactic antibiotics during insertable cardiac monitor (ICM) procedures is a carryover of the common practice used with therapeutic cardiac implantable electronic devices. We sought to characterize the current practice of ICM insertion procedures to evaluate the influence of prophylactic antibiotic administration on the occurrence of infections. We characterized insertion procedures and procedure-related infections from an ongoing multicenter registry (Reveal LINQ(TM) Registry). In order to accurately capture infections, only patients enrolled before or the day of insertion who also had a record of whether or not preoperative antibiotics were used were included in this analysis. Infections were defined based on the physician's assessment and reported upon occurrence. Patients were categorized into two analysis cohorts based on prophylactic antibiotic use. We analyzed 375 patients from 14 U.S. centers (age 63.1 ± 15.6 years; male 54.1%). Approximately two-thirds of patients (66.4%) did not receive any preprocedural antibiotics. The overall infection rate was 1.1% (0.3-2.7% confidence interval [CI]) and corresponded to four events. In the group that did not receive preprocedural antibiotics, there were two minor infections (0.8%, [0.1-2.9% CI]), whereas in the group receiving preprocedural antibiotics a serious and a minor infection occurred (1.6%, [0.2-5.6% CI]); this serious infection resulted in an explant. Current real-world practice shows that ICM insertions are increasingly performed without the use of prophylactic antibiotics, which is associated with a very low infection rate.

Restless leg syndrome, more recently renamed Willis-Ekbom disease, is a condition that disrupts sleep and occurs more frequently in the pregnant population. We present a 39-year-old woman with restless legs syndrome in the third trimester and discuss the epidemiology, pathophysiology and therapeutic options in the pregnant population while highlighting the challenges posed by the lack of safety data of approved drugs.

The provisional approach for bifurcation stenting with side-branch balloon angioplasty is associated with dissections and suboptimal results requiring kissing balloon techniques or bailout stenting. We hypothesized that using a scoring balloon for the side branch and a drug-eluting stent for the main vessel might improve outcomes of true bifurcation lesions. A total of 93 patients with complex bifurcations were enrolled in a multicenter, single-arm, prospective clinical trial. A drug-eluting stent was deployed in the main vessel following dilatation of the side-branch stenosis with a scoring balloon. The overall angiographic success rate was 93.5%, and procedural success rate was 91.4%. The final diameter stenosis was 13.9% ± 7.2% for the main vessel and 33.3% ± 22.9% for the side branch. Crossover to stent deployment in the side branch was required in 10.8%. The postscoring balloon dissection rate was 8.2% and 6% (all ≤ class C) for the main vessel and side branch respectively, which was reduced to 1.1 and 2.1% poststenting. At 9-month follow-up, the composite MACE rate [cardiac death, myocardial infarction, or target lesion revascularization (TLR)] was 5.4%, including a TLR rate of 3.3% (1.1% from hospital discharge to 9 months). The 9-month results of the AGILITY trial support a simple provisional strategy for treating complex true bifurcation lesions with deployment of a drug-eluting stent in the main vessel after dilatation of the side-branch vessel with a scoring balloon. This strategy was associated with excellent and safe procedural results, a low rate of crossover to side-branch stenting, and favorable outcomes.

Introduction. While recent studies have highlighted the clinical importance of minor, or “nuisance” bleeding, the predictors of all bleeding complications including minor bleeding events have not been examined in detail. Methods. The PARIS registry was a multicenter, international, all-comers registry of patients who had undergone successful PCI in 2009-2010 for stable angina, acute coronary syndrome (ACS) or documented silent ischemia. All bleeding events were adjudicated by a Clinical Events Committee according to the Bleeding Academic Research Consortium (BARC) criteria from source documents. We compared baseline clinical and treatment variables in patients who had any versus no bleeding at 6-months. Results. Of 5,033 patients, 235 (4.7%) had a bleeding event in the first 6-months. Of these, 27.7% had BARC type 1 bleeding, 40.4% had BARC type 2 bleeding, 30.2% had type 3, 0.4% had type 4 (CABG-related), and 1.3% had type 5 (fatal) bleeding. Compared to patients with no bleeding, patients who had bleeding were more likely to be older, female, non-smokers, and to be prescribed on warfarin on discharge (Table). After multivariable analysis, independent predictors of 6-month bleeding were age (OR 1.02, 95% CI 1.002 - 1.03), female gender (OR 1.9, 95% CI 1.3 - 2.9), and warfarin therapy (OR 2.6, 95% CI 1.7 - 3.7, all p&lt;0.05), whereas hypertension was associated with reduced risk of bleeding (OR 0.7, 95% CI 0.52 - 0.98, p=0.04). Treatment with prasugrel (vs. clopidogrel) was not a predictor. Conclusion. In this real world, contemporary PCI registry with close evaluation of bleeding events, the 6-month rate of any bleeding was 4.7%. Almost 70% of these bleeding incidents were BARC type 1 and 2, which may be classified as minor or “nuisance” bleeds. Age, female gender, and warfarin were independent predictors of bleeding events. Table.