Cardiology

Lam, P. H., M. Packer, G. S. Gill, W. C. Wu, W. C. Levy, M. R. Zile, V. Brar, C. Arundel, Y. Cheng, S. N. Singh, R. M. Allman, G. C. Fonarow and A. Ahmed (2020). “Digoxin Initiation and Outcomes in Patients with Heart Failure with Preserved Ejection Fraction.” Am J Med Apr 6. pii: S0002-9343(20)30236-9. [Epub ahead of print].

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BACKGROUND: Digoxin reduces the risk of heart failure hospitalization in patients with heart failure with reduced ejection fraction (HFrEF). Less is known about this association in patients with heart failure with preserved ejection fraction (HFpEF), the examination of which was the objective of the current study. METHODS: In the Medicare-linked OPTIMIZE-HF registry, 7374 patients hospitalized for HF had ejection fraction >/=50% who were not receiving digoxin before admission. Of these, 5675 had a heart rate >/=50 beats/minute, an estimated glomerular filtration rate (eGFR) >/=30 mL/min/1.73 m(2) or did not receive inpatient dialysis, and digoxin was initiated in 524 of these patients. Using propensity scores for digoxin initiation, calculated for each of the 5675 patients, we assembled a matched cohort of 513 pairs of patients initiated and not initiated on digoxin, balanced on 58 baseline characteristics (mean age, 80 years; 66% women; 8% African American). Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with digoxin initiation were estimated in the matched cohort. RESULTS: Among the 1026 matched patients with HFpEF, 30-day heart failure readmission occurred in 6% and 9% of patients initiated and not initiated on digoxin, respectively (HR, 0.70; 95% CI, 0.45-1.10; p=0.124). HRs (95% CIs) for 30-day all-cause readmission and all-cause mortality associated with digoxin initiation were 0.95 (0.73-1.23; p=0.689) and 0.93 (0.55-1.56; p=0.773), respectively. Digoxin initiation had no association with 6-year outcomes. CONCLUSION: Digoxin initiation before hospital discharge was not associated with 30-day or 6-year outcomes in older hospitalized patients with HFpEF.

Khan, Z., M. Hamandi, H. Khan, J. M. DiMaio and M. Evans (2020). “Convergent epicardial-endocardial ablation for treatment of long-standing persistent atrial fibrillation: A review of literature.” J Card Surg Apr 25. [Epub ahead of print].

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BACKGROUND AND AIM OF STUDY: The convergent procedure (CVP) is a hybrid ablation technique via a subxiphoid incision that has recently emerged as a treatment option for non-paroxysmal atrial fibrillation (npAF). By combining endocardial and epicardial ablation into a simultaneous or staged procedure, the pulmonary vein and posterior left atrium can be isolated with transmural lesion sets while minimizing the risk of proarrhythmic gaps that are a known limitation with endocardial linear lesion sets. We reviewed the 12-month outcomes in patients who underwent CVP compared to those who underwent endocardial catheter ablation (CA) and surgical ablation (SA). METHODS: A literature search was conducted using the PubMed database for publications related to CVP. Selected studies included detailed 12-month follow-up of patients, patient characteristics, periprocedural complications, use of antiarrhythmic drugs (AADs), and monitoring method. RESULTS: Five studies with 340 patients who underwent CVP between January 2009 and March 2017 were selected for this review. A total of 8.5% of patients had paroxysmal AF (pAF), 42.2% had persistent AF (peAF), and 49.1% had long-standing persistent AF (lspAF). At 12 months, 81.9% of patients were in sinus rhythm, while 54.1% of patients were in sinus rhythm while not taking AADs. The overall complication rate was 10%. CONCLUSION: CVP had better 1-year efficacy in eliminating AF when compared to CA. However, SA, specifically the Cox Maze IV, had lower rates of AF recurrence in the npAF patient population. Despite its promising 1-year efficacy rates, the periprocedural complication rate for CVP was significantly higher than both CA and SA.

Kazory, A., C. Ronco and P. A. McCullough (2020). “SARS-CoV-2 (COVID-19) and intravascular volume management strategies in the critically ill.” Proc (Bayl Univ Med Cent) 0(0): 1-6.

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The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread across the globe, and millions of people may be affected. While knowledge regarding epidemiologic features and diagnostic tools of coronavirus disease 2019 (COVID-19) is rapidly evolving, uncertainties surrounding various aspects of its optimal management strategies persist. A subset of these patients develop a more severe form of the disease characterized by expanding pulmonary lesions, sepsis, acute respiratory distress syndrome, and respiratory failure. Due to lack of data on treatment strategies specific to this subset of patients, currently available evidence on management of the critically ill needs to be extrapolated and customized to their clinical needs. The article calls attention to fluid stewardship in the critically ill with COVID-19 by judiciously applying the evidence-based resuscitation principles to their specific clinical features such as high rates of cardiac injury. As we await more data from treating these patients, this strategy is likely to help reduce potential complications.

Holmes, D. R., Jr. and M. Mack (2020). “The Truly Functional Heart Team: The Devil Is in the Details.” J Am Heart Assoc 9(8): e05035.

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The multidisciplinary team concept for the management of patients with cardiovascular diseases is now well ingrained into the culture of most hospitals and healthcare systems.1, 2, 3, 4, 5, 6, 7, 8 Despite the lack of a robust evidence base demonstrating benefit, the heart team for clinical decision making is a Class I Recommendation in both the US and European guidelines albeit Level of Evidence C.7, 9, 10 Too frequently, however, in practice, the heart team is more virtual than real or worse, it is a perfunctory “check box” at some centers. An ever‐increasing variety of publications relating and attesting to the positives of the heart team while describing the potential nuances, fail to serve as a template for its actual implementation.11, 12, 13 So how then does a center put into practice the concepts of a true heart team approach and demonstrate better patient care? (Excerpt from text; no abstract available.)

Edgerton, J. R. (2020). “Commentary: Ptolemy versus Copernicus: The times they are a-changin’.” J Thorac Cardiovasc Surg Apr 6. pii. [Epub ahead of print].

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As we move to patient-centered medicine, outcomes we track must be those meaningful to patients and their families. To do this, we must transition from proceduralists to practicing disease management. (Excerpt from text; no abstract available.)