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Background: Thromboembolic (TE) events are among the most common and devastating adverse events in patients with continuous-flow left ventricular assist device (cf-LVAD). Given the high burden of AF among cf-LVAD patients, we sought to evaluate the effect of concomitant surgical LAAO in patients receiving cf-LVAD., Methods: A systematic search using electronic databases was performed using the keywords: "left atrial appendage occlusion" and "left ventricular assist device." Statistical analysis was performed using metapackage for R version 4.0 and Rstudio version 1.2. Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data between two groups. The primary outcomes included: (a) stroke; (b) LVAD pump thrombosis; (c) all-cause mortality RESULTS: Three studies with a total of 305 patients (LAAO = 68 and No-LAAO = 237) were included in the analysis. HeartMate II (39%) and Heartware (27.5%) were the two most common cf-LVADs utilized, while only 5% received HeartMate III. At a mean follow up of 1.47 years, LAAO group had a lower risk of stroke (8.8% vs. 15.2%, RR 0.64; 95% CI 0.28-1.49), LVAD pump thrombosis (1.5% vs. 3.8%, RR 0.28; 95% CI 0.05-1.55) and all-cause mortality (5.9% vs. 20.2%, RR 0.69; 95% CI 0.19-2.52) when compared with no-LAAO group, but the difference did not reach statistical significance., Conclusion: Concomitant surgical LAAO at the time of cf-LVAD implantation demonstrated a trend toward positive outcomes and was not associated with adverse outcomes during the follow-up period, though the results were not statistically significant., (© 2022 Wiley Periodicals LLC.)

The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion., (© 2021 Wiley Periodicals LLC.)

Introduction: Renal sympathetic denervation (RSDN) is an alternate management approach for refractory ventricular arrhythmias (VAs). We aimed to perform a systematic review of clinical outcomes on the impact of RSDN on refractory VA patients., Methods: A systematic search without language restriction, using PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov from inception to August 18, 2020, was performed for the studies that reported outcomes in patients who underwent RSDN for VA. The outcomes studied were-(1) recurrent VA; and (2) all-cause mortality., Results: Five studies (from 2014 to 2018) with a total of 51 VA patients met study inclusion criteria. The mean age was 61.92 ± 11.76 years, and 78.4% were men. The pooled incidence of short-term (3 months or less) and long-term (more than 3 months) VA recurrence was 63.85% (95% CI 16.75 to 99.32) and 10.52% (95% CI 0.14 to 28.75), respectively. When stratified by the number of VA episodes, there was a significant reduction in mean VA episodes (SMD -3.79, 95% CI -6.59 to -0.98, p < .01), ICD shocks (SMD -1.71, 95% CI -3.0 to -0.42, p < .01) and anti-tachycardia pacing (SMD -1.21, 95% CI -1.98 to -0.44, p < .01) following RSDN denervation. The pooled incidence of all-cause mortality after RSDN was 10.16% (95% CI 1.08 to 24.12). There were no major vascular complications, one minor vascular complication-small non-flow limiting renal artery dissection (no intervention needed)., Conclusion: RSDN appears to be a safe and effective treatment strategy in patients with prior failed antiarrhythmic drugs and catheter ablation for recurrent ventricular arrhythmia and electrical storm., (© 2021 Wiley Periodicals LLC.)

Background: Same-day discharge (SDD) after atrial fibrillation (AF) ablation is increasingly being considered. This study examined the barriers and financial impact associated with SDD in a contemporary cohort of patients undergoing elective AF ablation., Methods: A single center retrospective review was conducted of the 249 first case-of-the-day outpatient AF ablations performed in 2019 to evaluate the proportion of patients that could have undergone SDD. Barriers to SDD were defined as any intervention that prevented SDD by 8 p.m. The financial impact of SDD was based on savings from avoidance of the overnight hospital stay and revenue related to management of chest pain facilitated by a vacant hospital bed., Results: SDD could have occurred in 157 patients (63%) without change in management and in up to 200 patients (80%) if avoidable barriers were addressed. Barriers to SDD included non-clinical logistical issues (43%), prolonged post-procedure recovery (42%) and minor procedural complications (15%). On multivariate analysis, factors associated with barriers to SDD included increasing age (P = .01), left ventricular ejection fraction ≤ 35% (P = .04), and severely dilated left atrium (P = .04). The financial gain from SDD would have ranged from $1,110,096 (assuming discharge of 63% of eligible patients) to $1,480,128 (assuming 80% discharge) over the course of a year., Conclusions: Up to 80% of patients undergoing outpatient AF ablation were amenable to SDD if avoidable delays in care had been anticipated. Based on reduced hospital operating expenses and increased revenue from management of individuals with chest pain, this would translate to a financial savings of ∼$1.5 million., (© 2021 Wiley Periodicals LLC.)

Introduction: Implantable cardioverter-defibrillator (ICD) in patients with heart failure with reduced ejection fraction reduces mortality secondary to malignant arrhythmias. Whether cardiac transplant patients considered high risk for sudden death (SD) derive similar benefits remains controversial., Methods: Systematic search, without language restriction, using PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov was performed from inception to June 4, 2020, for studies that had reported outcomes in patients who had ICD implanted after cardiac transplant. The outcomes studied were as follows: (a) SD and (b) appropriate and inappropriate ICD therapies., Results: Seven studies (from 1983 through 2018) with a total of 338 cardiac transplant patients who received ICD met study inclusion criteria. The mean age was 48.37 ± 14.85 years, and 70.4% were men. The pooled incidence of SD was 16.3% (95% CI 6.2-29.0%; I 2   = 66%). Appropriate and inappropriate ICD therapies were observed in 12.1% (95% CI 5.3-20.4; I 2   = 0%) and 3.5% (95% CI 0.11-9.58%; I 2   = 0%), respectively during the follow-up period (27.48 ± 24.27 months). The most common cause for SD was heart failure (15.6%), followed by electromechanical disassociation, malignant ventricular arrhythmias (4.7% each, respectively), and cardiac allograft vasculopathy (CAV) (3.1%). Furthermore, approximately 60% (10/17) of patients with appropriate ICD shocks had CAV., Conclusion: Despite, low incidence of arrhythmic mortality, there remains an increased burden of ventricular arrhythmias, as evident by a 12% appropriate ICD shock rates, suggesting ICD might be a practical decision in selected cardiac transplant patients deemed high risk of SD (i.e., patients with advanced CAV and left ventricular systolic dysfunction)., (© 2020 Wiley Periodicals LLC.)

Introduction: Recent studies have described several cardiovascular manifestations of COVID-19 including myocardial ischemia, myocarditis, thromboembolism, and malignant arrhythmias. However, to our knowledge, syncope in COVID-19 patients has not been systematically evaluated. We sought to characterize syncope and/or presyncope in COVID-19., Methods: This is a retrospective analysis of consecutive patients hospitalized with laboratory-confirmed COVID-19 with either syncope or presyncope. This "study" group (n = 37) was compared with an age and gender-matched cohort of patients without syncope ("control") (n = 40). Syncope was attributed to various categories. We compared telemetry data, treatments received, and clinical outcomes between the two groups., Results: Among 1000 COVID-19 patients admitted to the Mount Sinai Hospital, the incidence of syncope/presyncope was 3.7%. The median age of the entire cohort was 69 years (range 26-89+ years) and 55% were men. Major comorbidities included hypertension, diabetes, and coronary artery disease. Syncopal episodes were categorized as (a) unspecified in 59.4% patients, (b) neurocardiogenic in 15.6% patients, (c) hypotensive in 12.5% patients, and (d) cardiopulmonary in 3.1% patients with fall versus syncope and seizure versus syncope in 2 of 32 (6.3%) and 1 of 33 (3.1%) patients, respectively. Compared with the "control" group, there were no significant differences in both admission and peak blood levels of d-dimer, troponin-I, and CRP in the "study" group. Additionally, there were no differences in arrhythmias or death between both groups., Conclusions: Syncope/presyncope in patients hospitalized with COVID-19 is uncommon and is infrequently associated with a cardiac etiology or associated with adverse outcomes compared to those who do not present with these symptoms., (© 2020 Wiley Periodicals LLC.)

Background: Cardiac sympathetic denervation (CSD) is being used in the management of refractory ventricular tachycardia (VT) and electrical storm. However, data on the role of CSD in the management of ventricular arrhythmia is limited., Methods: We performed a meta-analysis of retrospective studies to calculate the pooled rate of freedom from VT and the standard mean difference of ICD shocks before and after CSD., Results: 14 nonrandomized studies with a total of 311 patients with refractory VT or electrical storm were included. At a mean follow up of 15 ± 10.7 months, the pooled rate of freedom from VT (VT nonrecurrence rate) after CSD in all causes of arrhythmia was 60% (range 48.8% to 70%, I 2   = 43%). When analysis was restricted to only arrhythmias caused by conditions other than catecholaminergic polymorphic ventricular tachycardia (CPVT) and long QT syndrome (LQTS), the pooled VT non-recurrence rate was 50% (range 41% to 58%, I 2   = 5%). After CSD, mean total number of ICD shocks per person diminished by 3.01 (95% CI 1.09-4.94, P = .002, I 2  = 96%) in overall analysis and by 0.97(95% CI 0.41-1.5, P = .001, I 2  = 45%) when CPVT and LQTS were excluded., Conclusion: In patients with refractory VT or electrical storm, CSD is associated with pooled VT nonrecurrence rate of 60% at a mean follow-up of 15 ± 10.7 months. CSD was also associated with significantly lower mean number ICD shocks per person. Further studies are needed to validate this finding in a prospective setting., (© 2020 Wiley Periodicals LLC.)

Background: Atrial arrhythmias (AA), including atrial fibrillation (AF), have been reported in patients after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFL). Several studies have examined the effect of performing concomitant pulmonary vein isolation (PVI) with CTI on recurrent AA. These studies were analyzed to determine the overall effect of this approach on recurrent AA., Methods: PubMed and Google Scholar were searched for randomized trials comparing the incidence of AA after CTI versus CTI + PVI until June 2018. Only patients without prior history of AF were included in the recurrent AA analysis. All patients were included in the analyses of other clinical outcomes., Results: Four randomized control trials were included in the meta-analysis. In the recurrent AA analysis, a total of 314 patients were randomized in the studies (n = 158 CTI, n = 156 CTI + PVI). Freedom from AA at 1 year was significantly higher in the CTI + PVI group versus CTI alone (odds ratio [OR] 0.25 [0.14, 0.44] 95% confidence interval [CI], P < 0.00001). A total of 550 patients (n = 336 CTI, n = 214 CTI + PVI) were included in analyses for procedure time, fluoroscopy time, and complications rates. Procedure time and fluoroscopy time were significantly longer in the CTI + PVI group (mean difference [MD]: 103.31 min [94.40, 112.23] 95% CI, P < 0.00001) and (MD: 16.47 min [14.89, 18.05] 95% CI, P < 0.00001), respectively. Total complications were statistically similar between groups., Conclusion: This meta-analysis shows addition of a prophylactic PVI during CTI ablation significantly reduces recurrent AA at 1 year without significantly increasing major complications., (© 2019 Wiley Periodicals, Inc.)