Search

Aims Our objective was to compare the efficacy of pre-treatment with different classes of anti-arrhythmic drugs (AADs) in patients with atrial fibrillation (AF) undergoing electrical cardioversion. Methods and results We performed a systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing different AADs in patients with AF undergoing electrical cardioversion. We grouped AADs into five network nodes: no treatment or rate control, Class Ia, Class Ic, Class III, and amiodarone. Outcomes were (i) acute restoration and (ii) maintenance of sinus rhythm. We searched MEDLINE and EMBASE from inception until June 2020. We used Python 3.8.3 and R 3.6.2 for data analysis. We evaluated the overall certainty of evidence with the GRADE framework. We included 28 RCTs. Compared with no treatment or rate control, Class III AADs [odds ratio (OR): 2.41; 95% credible interval (CrI): 1.37 to 4.62, high certainty] and amiodarone (OR: 2.58; 95% CrI: 1.54 to 4.37, high certainty) improved restoration of sinus rhythm. Amiodarone improved long-term maintenance of sinus rhythm when compared with no treatment or rate control (OR: 5.37; 95% CrI: 4.00–7.39, high certainty), Class Ic (OR: 1.89; 95% CrI: 1.05–3.45, moderate certainty) and Class III AADs (OR: 2.19; 95% CrI: 1.39–3.26, high certainty). Conclusion Before electrical cardioversion of AF, treatment with Class III AADs or amiodarone improves the acute restoration of sinus rhythm. Amiodarone is most likely to improve the maintenance of sinus rhythm after electrical cardioversion, but Class Ic and Class III AADs are also effective.

This systematic review aimed to summarize reports of the incidence and long-term recurrence of new-onset atrial fibrillation (AF) associated with non-cardiac surgery. We searched CENTRAL, MEDLINE and EMBASE from inception to November 2019. We included studies that reported on the incidence of new-onset perioperative AF during hospitalization for non-cardiac surgery and/or AF recurrence in such patients following discharge. Reviewers screened articles and abstracted data independently and in duplicate. We assessed study quality by appraising methodology for collecting AF history, incident AF during hospitalization, and AF recurrence after discharge. From 39,233 citations screened, 346 studies that enrolled a total of 5,829,758 patients met eligibility criteria. Only 27 studies used prospective, continuous inpatient electrocardiographic (ECG) monitoring to detect incident AF. Overall, the incidence of postoperative AF during hospitalization ranged from 0.004 to 50.3%, with a median [interquartile range] of 8.7 [3.8–15.0]%. Atrial fibrillation incidence varied with type of surgery. Prospective studies using continuous ECG monitoring reported significantly higher incidences of AF than those that did not (13.9% vs 1.9%, respectively; P < 0.001). A total of 13 studies (25,726 patients) with follow-up up to 5.4 years reported on AF recurrence following hospital discharge; only one study used a prospective systematic monitoring protocol. Recurrence rates ranged from 0 to 37.3%. Rates of AF incidence first detected following non-cardiac surgery and long-term AF recurrence vary markedly. Differences in the intensity of ECG monitoring and type of surgery may account for this variation. PROSPERO (CRD42017068055); registered 1 September 2017.

Background: Atrial fibrillation (AF) is frequently reported as a complication of noncardiac surgery. It is unknown whether new-onset perioperative AF is associated with an increased risk of stroke and death beyond the perioperative period. We performed a systematic review and meta-analysis to assess the long-term risks of stroke and mortality associated with new-onset perioperative AF after noncardiac surgery. Methods: MEDLINE and EMBASE were searched from inception to March 2020 for studies reporting on the association between perioperative AF and the risk of stroke and death occurring beyond 30 days after noncardiac surgery. Reference screening, study selection, data extraction, and quality assessment were performed in duplicate. Data were pooled using inverse variance-weighted random-effects models and presented as risk ratios (RRs). Results: From 7344 citations, we included 31 studies (3,529,493 patients). The weighted mean incidence of perioperative AF was 0.7%. During a mean follow-up of 28.1 ± 9.4 months, perioperative AF was associated with an increased risk of stroke (1.5 vs 0.9 strokes per 100 patient-years; RR: 2.9, 95% confidence interval [CI]: 2.1-3.9, I2 = 78%). Perioperative AF was also associated with a significantly higher risk of all-cause mortality (21.0 vs 7.6 deaths per 100 patient-years; RR: 1.8, 95% CI: 1.5-2.2, I2 = 94%). The pooled adjusted hazard ratios for stroke and all-cause mortality were 1.9 (95% CI: 1.6-2.2, I2 = 31%) and 1.5 (95% CI: 1.3-1.7, I2 = 20%), respectively. Conclusions: Patients who had perioperative AF after noncardiac surgery had a higher long-term risk of stroke and mortality compared with patients who did not. Whether this risk is modifiable with oral anticoagulation therapy should be investigated. Résumé: Contexte: La fibrillation atriale (FA) est une arythmie fréquemment attribuée à une complication d’une chirurgie non cardiaque. On ne sait toutefois pas si l’apparition d’une FA périopératoire est associée à un risque accru d’accident vasculaire cérébral et de décès au-delà de la période périopératoire. Nous avons donc procédé à un examen et à une méta-analyse systématiques dans le but d’évaluer les risques à long terme d’accident vasculaire cérébral et de décès associés à l’apparition d’une FA périopératoire à la suite d’une chirurgie non cardiaque. Méthodologie: Des recherches ont été effectuées dans MEDLINE et EMBASE depuis leur création jusqu’à mars 2020 pour y relever les études signalant l’association entre la FA périopératoire et le risque d’accident vasculaire cérébral et de décès survenant au-delà de 30 jours à la suite d’une chirurgie non cardiaque. Le tri des références, la sélection des études, l’extraction des données et l’évaluation de la qualité ont été effectués en double. Les données ont été regroupées à l’aide de modèles à effets aléatoires pondérés par l’inverse de la variance et présentées sous forme de rapports de risques relatifs (RR). Résultats: Parmi 7 344 références, nous avons inclus 31 études (3 529 493 patients). L’incidence moyenne pondérée de FA périopératoire était de 0,7 %. Dans le cadre d’un suivi moyen de 28,1 ± 9,4 mois, la FA périopératoire était associée à un risque accru d’accident vasculaire cérébral (1,5 vs 0,9 accident vasculaire cérébral par 100 années-patients; RR de 2,9; intervalle de confiance [IC] à 95 %; de 2,1 à 3,9; I2 = 78 %). La FA périopératoire était également associée à un risque considérablement plus élevé de décès toutes causes confondues (21,0 vs 7,6 décès par 100 années-patients; RR de 1,8; IC à 95 %; de 1,5 à 2,2; I2 = 94 %). Les rapports de risques instantanés ajustés regroupés d’accident vasculaire cérébral et de décès toutes causes confondues étaient de 1,9 (IC à 95 %; de 1,6 à 2,2; I2 = 31 %) et de 1,5 (IC à 95 %; de 1,3 à 1,7; I2 = 20 %), respectivement. Conclusions: Les patients qui souffraient de FA périopératoire à la suite d’une chirurgie non cardiaque présentaient un risque accru à long terme d’accident vasculaire cérébral et de décès par rapport aux patients qui n’en souffraient pas. Il serait approprié d’examiner la possibilité de modifier ce risque par une anticoagulothérapie orale.

Background: Left ventricular assist device (LVAD) unloading and hemodynamic support in patients with advanced chronic heart failure can result in significant improvement in cardiac function allowing LVAD removal; however, the rate of this is generally considered to be low. This prospective multicenter nonrandomized study (RESTAGE-HF [Remission from Stage D Heart Failure]) investigated whether a protocol of optimized LVAD mechanical unloading, combined with standardized specific pharmacological therapy to induce reverse remodeling and regular testing of underlying myocardial function, could produce a higher incidence of LVAD explantation. Methods: Forty patients with chronic advanced heart failure from nonischemic cardiomyopathy receiving the Heartmate II LVAD were enrolled from 6 centers. LVAD speed was optimized with an aggressive pharmacological regimen, and regular echocardiograms were performed at reduced LVAD speed (6000 rpm, no net flow) to test underlying myocardial function. The primary end point was the proportion of patients with sufficient improvement of myocardial function to reach criteria for explantation within 18 months with sustained remission from heart failure (freedom from transplant/ventricular assist device/death) at 12 months. Results: Before LVAD, age was 35.1±10.8 years, 67.5% were men, heart failure mean duration was 20.8±20.6 months, 95% required inotropic and 20% temporary mechanical support, left ventricular ejection fraction was 14.5±5.3%, end-diastolic diameter was 7.33±0.89 cm, end-systolic diameter was 6.74±0.88 cm, pulmonary artery saturations were 46.7±9.2%, and pulmonary capillary wedge pressure was 26.2±7.6 mm Hg. Four enrolled patients did not undergo the protocol because of medical complications unrelated to the study procedures. Overall, 40% of all enrolled (16/40) patients achieved the primary end point, P Conclusions: In this multicenter prospective study, this strategy of LVAD support combined with a standardized pharmacological and cardiac function monitoring protocol resulted in a high rate of LVAD explantation and was feasible and reproducible with explants occurring in all 6 participating sites. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01774656.

Background Delirium is common after cardiac surgery and is associated with adverse outcomes. Perioperative benzodiazepine use is associated with delirium and is common during cardiac surgery, which may increase the risk of postoperative delirium. We undertook a pilot study to inform the feasibility of a large randomised cluster crossover trial examining whether an institutional policy of restricted benzodiazepine administration during cardiac surgery (compared with liberal administration) would reduce delirium. Methods We conducted a two-centre, pilot, randomised cluster crossover trial with four 4 week crossover periods. Each centre was randomised to a policy of restricted or liberal use, and then alternated between the two policies during the remaining three periods. Our feasibility outcomes were adherence to each policy (goal ≥80%) and outcome assessment (one delirium assessment per day in the ICU in ≥90% of participants). We also evaluated the incidence of intraoperative awareness in one site using serial Brice questionnaires. Results Of 800 patients undergoing cardiac surgery during the trial period, 127/800 (15.9%) had delirium. Of these, 355/389 (91.3%) received benzodiazepines during the liberal benzodiazepine periods and 363/411 (88.3%) did not receive benzodiazepines during the restricted benzodiazepine periods. Amongst the 800 patients, 740 (92.5%) had ≥1 postoperative delirium assessment per day in the ICU. Of 521 patients screened for intraoperative awareness, one patient (0.2%), managed during the restricted benzodiazepine period (but who received benzodiazepine), experienced intraoperative awareness. Conclusions This pilot study demonstrates the feasibility of a large, multicentre, randomised, cluster crossover trial examining whether an institutional policy of restricted vs liberal benzodiazepine use during cardiac surgery will reduce postoperative delirium. Clinical trial registration NCT03053869.

Hemodynamic management of adults with distributive shock often includes the use of catecholamine-based vasoconstricting medications. It is unclear whether adding vasopressin or vasopressin analogues to catecholamine therapy is beneficial in the management of patients with distributive shock. The purpose of this guideline was to develop an evidence-based recommendation regarding the addition of vasopressin to catecholamine vasopressors in the management of adults with distributive shock. We summarized the evidence informing this recommendation by updating a recently published meta-analysis. Then, a multidisciplinary panel from the Canadian Critical Care Society developed the recommendation using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The updated systematic review identified 25 randomized controlled trials including a total of 3,737 patients with distributive shock. Compared with catecholamine therapy alone, the addition of vasopressin or its analogues was associated with a reduced risk of mortality (relative risk [RR], 0.91; 95% confidence interval [CI], 0.85 to 0.99; low certainty), reduced risk of atrial fibrillation (RR, 0.77; 95% CI, 0.67 to 0.88; high certainty), and increased risk of digital ischemia (RR, 2.56; 95% CI, 1.24 to 5.25; moderate certainty). After considering certainty in the evidence, values and preferences, cost, and other factors, the expert guideline panel suggests using vasopressin or vasopressin analogues in addition to catecholamines over catecholamine vasopressors alone for the management of distributive shock (conditional recommendation, low certainty evidence).

The authors aimed to identify risk factors and outcomes associated with new-onset atrial fibrillation (NOAF) after transcatheter aortic valve replacement (TAVR).NOAF is a common complication after TAVR, although estimates of the precise occurrence are variable. This study sought to quantify the occurrence of NOAF after TAVR and to explore the outcomes and predictors associated with this complication.We searched Medline, EMBASE, and the Cochrane database from 2016 to 2020 for articles that reported NOAF after TAVR. We extracted data for studies published before 2016 from a previous systematic review. We pooled data using a random effects model.We identified 179 studies with 241,712 total participants (55,271 participants with pre-existing atrial fibrillation (AF) were excluded) that reported NOAF from 2008 to 2020. The pooled occurrence of NOAF after TAVR was 9.9% (95% CI: 8.1%-12%). NOAF after TAVR was associated with a longer index hospitalization (mean difference = 2.66 days; 95% CI: 1.05-4.27), a higher risk of stroke in the first 30 days (risk ratio [RR]: 2.35; 95% CI: 2.12-2.61), 30-day mortality (RR: 1.76; 95% CI: 1.12-2.76), major or life-threatening bleeding (RR: 1.60; 95% CI: 1.39-1.84), and permanent pacemaker implantation (RR: 1.12; 95% CI: 1.05-1.18). Risk factors for the development of NOAF after TAVR included higher Society of Thoracic Surgeons score, transapical access, pulmonary hypertension, chronic kidney disease, peripheral vascular disease, and severe mitral regurgitation, suggesting that the risk for NOAF is highest in more comorbid TAVR patients.NOAF is common after TAVR. Whether AF after TAVR is a causal factor or a marker of sicker patients remains unclear.

Background The assessment of aortic stenosis (AS) severity has a major impact on the management of affected patients. Ejection dynamics, including acceleration time (AT), ejection time (ET), and acceleration time/ejection time ratio (AT/ET) measured using doppler echocardiography are established in the evaluation of prosthetic aortic valve stenosis with high sensitivity and specificity. However, their clinical utility in native AS has not been well described. Purpose The aim of this systematic review was to evaluate the diagnostic accuracy of ejection dynamics to identify severe AS and to assess whether ejection dynamics can differentiate low flow, low gradient severe AS from pseudo-severe AS. Methods We conducted a systematic review of Medline, Embase, and Web of Science from database inception until January 2021. We included observational studies and randomized controlled trials (RCTs) in which the diagnostic accuracy of ejection dynamics by doppler echocardiography for severe AS was compared with standard echocardiographic diagnostic criteria including peak velocity, mean pressure gradient, aortic valve area, and dimensionless index. Studies were eligible if they included AS of at least mild severity. Two authors independently screened and extracted data. Results We included 12 studies in the review (RCT=1, observational=11) with a total of 5182 participants. There was significant inconsistency in outcome measurement and reporting of results therefore a meta-analysis was not suitable. We used narrative synthesis to report our results. All included studies used standard echocardiographic criteria to ascertain the presence of severe AS. Mean age was 72 years and 53% of the participants were male. 1983 participants (38.3%) were classified as having severe AS. AT >94–109ms had sensitivity of 74–92% and specificity of 72–89% at identifying severe AS. AT/ET >0.34–0.35 showed sensitivity of 67–77% and specificity of 68–100%. Only one study compared low-flow, low-gradient AS with pseudo-severe AS, showing that an AT >100ms had sensitivity 62%, specificity 76%; and AT/ET >0.33, sensitivity 65%, specificity 84%. Data for ET showed insufficient consistency and diagnostic accuracy. Conclusions AT and AT/ET may be useful to corroborate the presence of severe AS. However, more research is needed to understand whether these parameters add incremental prognostic value to standard echocardiographic measures of AS severity. Funding Acknowledgement Type of funding sources: None. Summary of evidence search and selection

Background Sutureless aortic valve replacement (SuAVR) is an alternative to surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). This study compares the effectiveness of SuAVR to SAVR and TAVR. Methods We searched MEDLINE and EMBASE from inception to July 2021 for studies evaluating SuAVR, SAVR, and TAVR in adults with aortic stenosis. We performed screening, full-text assessment, data collection, and risk of bias evaluation independently and in duplicate. We evaluated risk of bias using by Cochrane and CLARITY's tools, and certainty in evidence using the GRADE framework. Data were pooled using a random-effects model. Results We identified one randomized and 78 observational studies (n = 60,689; SuAVR vs. SAVR = 39,171, vs. TAVR = 21,518). All studies were at high or unclear risk of bias, with very-low certainty in effect estimates. Compared to TAVR, SuAVR demonstrates no significant difference in mortality at 30-days (odds ratio [OR]: 0.52, 95% confidence interval [CI: 0.85, 1.16], I2 = 0%), but decreased odds at 2-years (OR: 0.39, 95% CI [0.17, 0.88], I2 = 0%). SuAVR also reduced odds of mild paravalvular regurgitation (OR: 0.11, 95% CI [0.06, 0.21], I2 = 50%). Compared to SAVR, SuAVR was associated with a similar mortality at 30-days (OR: 0.99, 95% CI [0.85, 1.16], I2 = 0%) and 2-years (OR: 0.99, 95% CI [0.43-2.30], I2 = 7%). SuAVR significantly increased odds of permanent pacemaker implantation (OR: 2.5, 95% CI [2.25, 2.77], I2 = 0%). Pooled effect estimates were consistent with results from the randomized trial comparing SuAVR and SAVR. Conclusion Based on very-low quality evidence, SuAVR is associated with similar short- and midterm outcomes compared to TAVR and SAVR. Comparative randomized data with long-term follow-up are required to clarify the role of SuAVR.

Background Antifibrinolytic agents such as tranexamic acid (TXA) are commonly used as adjunctive therapies to prevent and treat excessive bleeding. In non-surgical settings, TXA is known to reduce bleeding related mortality. However, impact of TXA use on thrombosis is uncertain. Methods We systematically searched the MEDLINE, EMBASE, and CENTRAL databases from January 1985 to August 2018. Studies with the following characteristics were included: (i) RCT design; (ii) compared systemic (oral or intravenous) TXA for prevention or treatment of bleeding for non-surgical indications and placebo or no TXA, and (iii) reported thrombotic events or mortality. A Mantel-Haenzel, random-effects model was used to calculate risk ratios, and risk of bias was assessed using the Cochrane risk of bias tool. Results Our search identified 22 studies representing 49,538 patients. Those receiving TXA had a significantly lower risk of death from any cause (RR = 0.92; 95% CI = 0.87–0.98; I2 = 0%). There was no significant increase in the risk of stroke (RR = 1.10; 95% CI = 0.68–1.78; I2 = 31%), myocardial infarction (RR = 0.88; 95% CI = 0.43–1.84; I2 = 46%), pulmonary embolism (RR = 0.97; 95% CI = 0.75–1.26; I2 = 0%), or deep vein thrombosis (RR = 0.99; 95% CI = 0.70–1.41; I2 = 0%) from use of TXA. The results were similar when restricted to studies at low risk of bias. Conclusions In our systematic review and meta-analysis, the use of tranexamic acid reduced all-cause mortality without increased risk of venous or arterial thrombotic complications.

Background The optimal antithrombotic therapy after surgical bioprosthetic aortic valve replacement (BAVR) is uncertain. We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) comparing antiplatelet therapy and anticoagulation in patients with surgical BAVR. Methods We searched Cochrane CENTRAL, MEDLINE and EMBASE from inception to 3 November 2017 for studies evaluating antiplatelet therapy versus anticoagulation early after surgical BAVR. We performed title and abstract screening, full-text review, risk of bias evaluation and data collection independently and in duplicate. We evaluated overall quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework, and pooled data using a random effects model. Results We identified 2 RCTs (n = 397) and 5 observational studies (n = 2,012) meeting our eligibility criteria. The mean follow-up for all outcomes was 3 months in RCTs, and 10 months for observational studies. Antiplatelet compared with anticoagulant therapy demonstrated a trend towards fewer major bleeds in RCTs (relative risk [RR], 0.34; 95% confidence interval [CI], 0.11–1.04, p = 0.06, I 2 = 0%, low quality evidence), and significantly fewer major bleeds in observational studies (RR, 0.34; 95% CI, 0.20–0.58, p ≤ 0.0001, I 2 = 0%, very low quality evidence), but stroke, thromboembolism and mortality did not show a significant difference in either RCTs or observational studies. Conclusion Antiplatelet therapy demonstrated reduced bleeding risk with no negative effects on stroke, thromboembolism or mortality compared with anticoagulation therapy after surgical BAVR. Our confidence in the results is reduced by the low quality of the available evidence.

This systematic review aimed to summarize reports of the incidence and long-term recurrence of new-onset atrial fibrillation (AF) associated with non-cardiac surgery.We searched CENTRAL, MEDLINE and EMBASE from inception to November 2019. We included studies that reported on the incidence of new-onset perioperative AF during hospitalization for non-cardiac surgery and/or AF recurrence in such patients following discharge. Reviewers screened articles and abstracted data independently and in duplicate. We assessed study quality by appraising methodology for collecting AF history, incident AF during hospitalization, and AF recurrence after discharge.From 39,233 citations screened, 346 studies that enrolled a total of 5,829,758 patients met eligibility criteria. Only 27 studies used prospective, continuous inpatient electrocardiographic (ECG) monitoring to detect incident AF. Overall, the incidence of postoperative AF during hospitalization ranged from 0.004 to 50.3%, with a median [interquartile range] of 8.7 [3.8-15.0]%. Atrial fibrillation incidence varied with type of surgery. Prospective studies using continuous ECG monitoring reported significantly higher incidences of AF than those that did not (13.9% vs 1.9%, respectively; P0.001). A total of 13 studies (25,726 patients) with follow-up up to 5.4 years reported on AF recurrence following hospital discharge; only one study used a prospective systematic monitoring protocol. Recurrence rates ranged from 0 to 37.3%.Rates of AF incidence first detected following non-cardiac surgery and long-term AF recurrence vary markedly. Differences in the intensity of ECG monitoring and type of surgery may account for this variation.PROSPERO (CRD42017068055); registered 1 September 2017.RéSUMé: OBJECTIF: Cette revue systématique visait à résumer les comptes rendus sur l’incidence et la récurrence à long terme de la fibrillation auriculaire (FA) de novo associée à une chirurgie non cardiaque.Nous avons effectué des recherches dans les bases de données CENTRAL, MEDLINE et EMBASE de leur création à novembre 2019. Nous avons inclus les études ayant examiné l’incidence de nouvelle FA périopératoire pendant l’hospitalisation pour une chirurgie non cardiaque et/ou la récurrence de la FA chez de tels patients après leur congé. Les chercheurs ont passé en revue les articles et les données extraites de manière indépendante et en double. Nous avons estimé la qualité des études en évaluant la méthodologie de collecte des antécédents de FA, de l’incident de FA pendant l’hospitalisation et de la récurrence de FA après le congé.Sur les 39 233 citations examinées, 346 études portant sur un total de 5 829 758 patients ont répondu à nos critères d’admissibilité. Seulement 27 études ont utilisé un monitorage électrocardiographique (ECG) continu prospectif et des patients hospitalisés pour détecter les incidents de FA. Dans l’ensemble, l’incidence de FA postopératoire pendant l’hospitalisation allait de 0,004 à 50,3 %, avec une médiane [écart interquartile] de 8,7 [3,8-15,0] %. L’incidence de fibrillation auriculaire variait en fonction du type de chirurgie. Des études prospectives utilisant un monitorage continu par ECG ont fait état d’incidences significativement plus élevées de FA que celles sans monitorage continu (13,9 % vs 1,9 %, respectivement; P0,001). Au total, 13 études (25 726 patients) avec un suivi allant jusqu’à 5,4 ans ont rapporté leurs données sur la récurrence de FA après le congé de l’hôpital; seule une étude a utilisé un protocole de monitorage prospectif systématique. Les taux de récurrence allaient de 0 à 37,3 %.Les taux d’incidence de nouvelle FA détectés après une chirurgie non cardiaque et la récurrence à long terme de FA varient considérablement. Les différences du degré de monitorage par ECG et le type de chirurgie pourraient expliquer cette variation. ENREGISTREMENT DE L’éTUDE: PROSPERO (CRD42017068055); enregistrée le 1er septembre 2017.

Aims Single oral dose anti-arrhythmic drugs (AADs) are used to cardiovert recent-onset atrial fibrillation (AF); however, the optimal agent is uncertain. Methods We performed a systematic review and network meta-analysis of randomized trials testing single oral dose AADs vs. any comparator to cardiovert AF Results From 12 712 citations, 22 trials (2320 patients) were included. Thirteen trials included patients with some degree of heart failure; 19 included patients with some degree of ischaemic heart disease vs. placebo or rate-control (32% success) at 8 h, flecainide [73%, network odds ratio (OR) 7.6, 95% credible interval (CrI) 4.4–14.0], propafenone (70%, OR 4.6, CrI 2.9–7.3), and pilsicainide (59%, OR 10.0, CrI 1.8–69.0), but not amiodarone (28%, OR 1.0, CrI 0.4–2.8) were superior. Flecainide (OR 7.5, CrI 2.6–24.0) and propafenone (OR 4.5, CrI 1.6–13.0) were superior to amiodarone; propafenone vs. flecainide did not statistically differ (OR 0.6, CrI 0.3–1.1). At longest follow-up, amiodarone was superior to placebo (OR 11.0, CrI 3.2–41.0), flecainide vs. amiodarone (OR 0.79, CrI 0.19–3.1), and propafenone vs. amiodarone (OR 0.36, CrI 0.092–1.4) were not statistically different, and flecainide was superior to propafenone (OR 2.2, CrI 1.1–4.8). Atrial and ventricular tachyarrhythmias, bradyarrhythmias, and hypotension were rare with PO AADs. Conclusion Single oral dose Class 1C AADs are effective and safe for cardioversion of recent-onset AF. Flecainide may be superior to propafenone. Amiodarone is a slower acting alternative.

Objective: There is uncertainty about the incidence of and prognosis associated with atrial fibrillation that is documented for the first time in the setting of an acute stressor, such as surgery or medical illness. Our objective was to perform a systematic review of the incidence and long-term recurrence rates for atrial fibrillation occurring transiently with stress in the setting of acute medical illness. Data sources: Medline, Embase and Cochrane Central to September 2017. Study selection: We included retrospective and prospective observational studies, and randomised controlled trials. The population of interest included patients hospitalised for medical (i.e. non-surgical) illness who developed newly diagnosed atrial fibrillation. Studies were included if they included data on either the incidence of atrial fibrillation or the rate of atrial fibrillation recurrence in atrial fibrillation occurring transiently with stress patients following hospital discharge. Data extraction: Two reviewers collected data independently and in duplicate. We characterised each study’s methodology for ascertainment of prior atrial fibrillation history, atrial fibrillation during hospitalisation and atrial fibrillation recurrence after hospital discharge. Data synthesis: Thirty-six studies reported the incidence of atrial fibrillation. Ten used a prospective design and included a period of continuous electrocardiographic (ECG) monitoring. Atrial fibrillation incidence ranged from 1% to 44%, which was too heterogeneous to justify meta-analysis ( I2=99%). In post-hoc meta-regression models, the use of continuous ECG monitoring explained 13% of the variance in atrial fibrillation incidence, while care in an intensive care unit explained none. Two studies reported the long-term rate of atrial fibrillation recurrence following atrial fibrillation occurring transiently with stress. Neither of these studies used prospective, systematic monitoring. Recurrence rates at 5 years ranged from 42% to 68%. Conclusions: The incidence of atrial fibrillation with medical illness may be as high as 44%, with higher estimates in reports using continuous ECG monitoring. Within 5 years following hospital discharge, atrial fibrillation recurrence is documented in approximately half of patients; however, the true rate may be higher. Protocol registration PROSPERO CRD42016043240

Atrial fibrillation occurring transiently with stress (AFOTS) describes the first detection of AF in a patient who is hospitalized for a non-cardiac medical illness or following non-cardiac surgery. Uncertainty exists whether episodes of AFOTS are due to reversible precipitants and will not recur after recovery, or if they are paroxysmal atrial fibrillation (AF) that is detected during inpatient cardiac monitoring. Previous studies have used retrospective, non-systematic and ultimately low-sensitivity protocols to investigate the recurrence of AF in patients with AFOTS. The prospective, multi-center, investigator-initiated AFOTS Follow-Up Cohort Study will enroll 138 case patients with AFOTS in the setting of non-cardiac surgery or medical illness, matched 1:1 with control patients for age, sex, stressor, and hospital unit. Participants will wear a 14-day ECG heart monitor at 1 and 6 months after hospital discharge. Over 12 months of follow-up, we will collect data regarding participant's medications, and clinical events. The primary endpoint is detection of 30 or more seconds of AF after hospital discharge. To date, 50% of the target sample has been enrolled. The study is expected to complete enrolment in mid-2019 and conclude 1 year later. The AFOTS follow-up study will employ a systematic protocol to detect AF and will provide a precise and valid estimate of AF recurrence following AFOTS. This study will establish whether patients with AFOTS have an increased propensity to AF after hospitalization as compared to matched controls and may inform the management of this population.

Benzodiazepines are commonly administered during cardiac surgery because of their limited effect on hemodynamics and presumed role in preventing intraoperative awareness. Recent concerns about an increased risk of delirium with benzodiazepines have resulted in decreased usage in the intensive care unit and in geriatric perioperative practice. Little is known, however, about current benzodiazepine usage in the setting of adult cardiac surgery. We contacted all academic anesthesia departments in Canada to identify practicing attending cardiac anesthesiologists; this group constituted our sampling frame. Information regarding participant demographics, benzodiazepine usage, type, dose, and other administration details were obtained by electronic survey. Responses were analyzed descriptively. The survey was completed by 243/346 (70%) of cardiac anesthesiologists. Eleven percent of respondents do not administer benzodiazepines. Midazolam was the most commonly used benzodiazepine, with a mean (standard deviation) dose of 4.9 (3.8) mg given to an average patient. When respondents were asked the proportion of patients that they gave benzodiazepines, the response was bimodal. The most common considerations that influenced benzodiazepine use were patient age (73%), patient anxiety (63%), history of alcohol/drug/benzodiazepine use (60%), and the presence of risk factors for intraoperative awareness (44%). Benzodiazepine use is common among academic cardiac anesthesiologists in Canada. Nonetheless, heterogeneity exists between individual practices, suggesting clinical equipoise between restrictive and liberal administration of benzodiazepines for cardiac anesthesia. L’administration de benzodiazepines pendant la chirurgie cardiaque chez l’adulte: evaluation de la pratique actuelle des anesthesiologistes canadiens exercant en milieu universitaire

Objective We conducted a meta-analysis to estimate the risk of adverse events, life expectancy, and event-free life expectancy after the Ross procedure in adults. Methods We searched databases for reports evaluating the Ross procedure in patients aged more than or equal to 16 years of age. A microsimulation model was used to evaluate age- and gender-specific life expectancy for patients undergoing the Ross procedure. Results Data were pooled from 63 articles totaling 19 155 patients from 20 countries. Perioperative mortality was 2.5% (95% confidence interval [CI]: 1.9-3.1; N = 9978). We found a mortality risk of 5.9% (95% CI: 4.8-7.2) at a mean follow-up of 7.2 years (N = 7573). The rate of perioperative clinically significant bleeding was 1.0% (95% CI: 0.1-3.0); re-exploration for bleeding 4.6% (95% CI: 3.1-6.3); postoperative clinically significant bleeding from 30 days until a mean of 7.1 years was 0.5% (95% CI: 0.2-1.0). At a mean of 6.9 years of follow-up, reintervention rate of any operated valve was 7.9% (95% CI: 5.7-10.3). The risk of valve thrombosis was 0.3% (95% CI: 0.2-0.5) at 7.6 years; peripheral embolism 0.3% (95% CI: 0.2-0.4) at 6.4 years; stroke 0.9% (95% CI: 0.7-1.2) at 6.5 years; and endocarditis 2.1% (95% CI: 1.6-2.6) at 8.0 years. Microsimulation reported a 40-year-old undergoing the Ross procedure to have a life expectancy of 35.4 years and event-free life expectancy of 26.6 years. Conclusions Ross procedure in nonelderly adults is associated with low mortality and low risk of adverse events both at short- and long-term follow-up. The surgical community must prioritize a large, expertize-based randomized controlled trial to definitively address the risks and benefits of the Ross procedure compared to conventional aortic valve replacement.

Clinical guidelines recommend peri-cardioversion anticoagulation in patients with atrial fibrillation (AF). We performed a systematic review and meta-analysis to compare the safety and efficacy of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients with AF undergoing cardioversion. We searched CENTRAL, MEDLINE, and EMBASE for randomized controlled trials (RCTs) and observational studies comparing DOACs to VKAs in patients undergoing cardioversion for AF. We performed title, abstract, and full-text screening, data extraction, and risk of bias evaluation independently and in duplicate. We pooled data using a random effects model and evaluated the overall quality of evidence using Grading of Recommendations Assessment, Development and Evaluation. We identified three eligible RCTs (n = 5203) and 21 observational studies (n = 11,855). The three RCTs and four observational studies were at low risk of bias. In RCTs (mean follow-up, 30 days), thromboembolic events occurred in 0.18% of patients receiving DOACs, as compared with 0.55% receiving VKAs (relative risk [RR] 0.40, 95% CI [0.13, 1.24], moderate quality). Major bleeding occurred in 0.42% of patients receiving DOACs as compared with 0.64% receiving VKAs (RR 0.62, 95% CI [0.28, 1.35], moderate quality), and death occurred in 0.28% of patients receiving DOACs as compared with 0.38% receiving VKAs (RR 0.70, 95% CI [0.23, 2.10], low quality). Confidence in the estimates of effect for observational studies was very low. DOACs peri-cardioversion in patients with AF appears safe from both a bleeding and thromboembolic risk perspective. Available evidence supports the use of DOACs as standard of care peri-cardioversion in patients with AF.

Optimal postprocedural antithrombotic regimen is uncertain after transcatheter aortic valve replacement (TAVR). We developed an online questionnaire on post-TAVR antithrombotic management. After research ethics board approval, we distributed the survey to TAVR implanters across Canada. A total of 24 TAVR implanters from 17 centres responded to the survey for a response rate of 75%. Dual antiplatelet therapy for variable durations was the preferred initial treatment for patients in sinus rhythm after isolated TAVR, TAVR with a recent stent (≤ 1 month), and valve-in-valve procedures (71%, 96%, and 65%, respectively). Most respondents continued patients on acetylsalicylic acid indefinitely after these procedures (100%, 92%, 90%, respectively). In patients with atrial fibrillation, the CHA2DS2-VASC score was the preferred stroke risk score for 57% of respondents, the CHADS2 score was the preferred stroke risk score for 22% of respondents, and the CHADS65 score was the preferred stroke risk score for 17% of respondents. To determine the risk of bleeding, the HASBLED score was most often used (52%), but 48% of respondents indicated that they did not use a bleeding risk score. In the presence of atrial fibrillation, antithrombotic therapy choice varied widely. Our survey shows that dual antiplatelet therapy is the most common discharge regimen after TAVR in current practice. However, the choice and duration of antithrombotic regimen vary in patients requiring anticoagulation.

Purpose The RESTAGE-HF multicenter study demonstrated high rates of myocardial recovery after combining LVAD support with HF pharmacological therapy and regular cardiac function monitoring protocol. We sought to investigate whether the time course of LVAD-mediated reverse remodeling impacts the post-explantation long-term sustainability of myocardial recovery. Methods We studied 36 HeartMate II LVAD patients with advanced non-ischemic dilated cardiomyopathy who completed the study protocol. LVAD explantations occurred when patients met the reverse remodeling criteria with the LVADs turned-down to minimum speed: LVEF >45%, left ventricular end diastolic diameter (LVEDD) 2.4 L/min/m2. We investigated whether meeting these criteria 12 months post-LVAD support impacted long-term sustainability of the myocardial structural and functional response or long-term survival free of Transplant (Tx) or LVAD. Results Nineteen patients (53%) met criteria and underwent LVAD explantation. Patients explanted at 12 months post-LVAD were 2 (10.5%), 9 (47.4%) and 8 (42.1%), respectively. There were no significant differences (p=0.80) in the survival free of Tx or LVAD at 1, 3, and 5 years post-LVAD removal between patients explanted at Conclusion In RESTAGE-HF multicenter study the time course of reverse remodeling during LVAD support did not appear to impact the long-term sustainability of the post-explantation favorable clinical response either in terms of long-term survival free of HF recurrence or stability of the improved cardiac structure and function.

Supplemental Digital Content is available in the text., Objective: To estimate the incidence of new-onset atrial fibrillation in critically ill patients. Design: Prospective cohort. Setting: Medical-surgical ICU. Subjects: Consecutive patients without a history of atrial fibrillation but with atrial fibrillation risk factors. Interventions: Electrocardiogram patch monitor until discharge from hospital or up to 14 days. Measurements and Main Results: A total of 249 participants (median age of 71 yr [interquartile range] 64–78 yr; 35% female) completed the study protocol of which 158 (64%) were admitted to ICU for medical illness, 78 (31%) following noncardiac surgery, and 13 (5%) with trauma. Median Acute Physiology and Chronic Health Evaluation II score was 16 (interquartile range, 12–22). Median duration of patch electrocardiogram monitoring, ICU, and hospital lengths of stay were 6 (interquartile range, 3–12), 4 (interquartile range, 2–8), and 11 days (interquartile range, 5–23 d), respectively. Atrial fibrillation ≥ 30 seconds was detected by the patch in 44 participants (17.7%), and three participants (1.2%) had atrial fibrillation detected clinically after patch removal, resulting in an overall atrial fibrillation incidence of 18.9% (95% CI, 14.2–24.3%). Total duration of atrial fibrillation ranged from 53 seconds to the entire monitoring time. The proportion of participants with ≥1 episode(s) of ≥6 minute, ≥1 hour, ≥12 hour and ≥24 hour duration was 14.8%, 13.2%, 7.0%, and 5.3%, respectively. The clinical team recognized only 70% of atrial fibrillation cases that were detected by the electrocardiogram patch. Conclusions: Among patients admitted to an ICU, the incidence of new-onset atrial fibrillation is approximately one in five, although approximately one-third of cases are not recognized by the clinical team.