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Background: Following cavotricuspid isthmus (CTI) ablation, many patients with atrial flutter (AFL) are diagnosed with atrial fibrillation (AF). The incidence, duration, pattern, and burden of AF remain undefined. These may have implications for the management of these patients. Objective: To classify the incidence, duration, pattern, and burden of AF/AFL using an implantable loop recorder (ILR) after CTI ablation. Methods: We enrolled consecutive patients with CTI-dependent AFL, no known history of AF, and CHA2DS2-VASc ≥ 2. An ILR was implanted before or within 90 days of ablation. The time to first AF/AFL, pattern, duration, and burden of longest AF/AFL were determined. Five distinct AF/AFL cohorts were identified: no AF/AFL and those with recurrences of isolated, clustered, frequent, or persistent AF/AFL. Results: Fifty-two patients (81% male; 73 ± 9 years; CHA2DS2-VASc 3.7 ± 1.2) were followed for 784 (interquartile range [IQR] 263, 1150) days. AF/AFL occurred in 44 (85%) patients at 64 (IQR 8, 189) days post-CTI ablation and was paroxysmal in 31 (70%) patients (burden 0.6% [IQR 0.1, 4.8]). AF/AFL was isolated (n = 5, 11%), clustered (n =7, 16%), frequent (n =19, 43%), and persistent (n =13, 30%). The longest AF episode was

We describe a genetic female living as a transgender male through the use of exogenous testosterone supplementation. He developed Brugada pattern (that was unrecognized) and subsequently had an out-of-hospital cardiac arrest. Sustained ventricular arrhythmias were suppressed through treatment with quinidine; however, this medication could only be administered at very low doses due to the development of angioedema at higher doses. Subsequently, the patient required endocardial ablation for elimination of highly symptomatic, repetitive monomorphic ventricular ectopy. This case highlights the presentation of a unique patient in whom a channelopathy was unmasked by the patient’s lifestyle, suggesting that gender trumps sex when it comes to arrhythmia risk in patients at risk for Brugada syndrome.

Background: Pulmonary vein isolation (PVI) is a cornerstone of atrial fibrillation (AF) ablation procedures to treat symptomatic AF. Ablation success is defined by absence of AF recurrence >30 seconds. However, reduction in AF burden (AFB) is also an important endpoint. Whether patients with paroxysmal (PAF) and persistent AF (PeAF) have similar reduction in AFB post-ablation is unknown. Objective: To compare the decrease in AFB following cryoballoon (CB) PVI in patients with PAF and PeAF. Methods: We enrolled consecutive pts with an implantable loop recorder (ILR) who subsequently underwent CB PVI. All patients were followed prospectively for at least one year, or until repeat ablation; we compared AFB pre and post-ablation. Results: The cohort included had 47 patients (66 ± 10 years; 32 [68%] male; PAF [n=23, 49%]; CHA 2 DS 2 -VASc 2.7 ± 1.7, 34 [72%] on AAD at the time of ablation). A median of 136 days [IQR 280, 73; minimum of 30 days] of ILR data pre-ablation were available. The median AFB for PAF was 4.7% [IQR 0.9, 14.8] and PeAF was 6.8% [IQR 1.1, 40.4]. After excluding a 3-month post-ablation blanking period, recurrent AF occurred in 12 (52%) PAF and 11 (46%) PeAF patients. The median AFB post-ablation for PAF and PeAF cohorts was 0.03%, [IQR 0, 0.3] and 0.04%, [IQR 0, 1.1], respectively. This represents a >99% reduction in AFB. Conclusion: Although 50% of patients undergoing CB PVI for PAF or PeAF had a recurrence of AF, there was >99% reduction in AFB in both groups. These data highlight the importance of using AFB burden as a marker of therapeutic efficacy post-AF ablation.

Approximately 10–40% of strokes are cryptogenic (CS). Long-term electrocardiographic (ECG) monitoring has been recommended in these patients to search for atrial fibrillation (AF). An unresolved issue is whether ambulatory ECG (AECG) monitoring should be performed first, followed by an implantable loop recorder (ILR) if AECG monitoring is non-diagnostic, or whether long-term ECG monitoring should be initiated using ILRs from the onset. The purpose of this study was to assess, using an ILR, AF incidence in the first month after CS. We enrolled consecutive CS patients referred for an ILR. All patients were monitored via in-hospital continuous telemetry from admission until the ILR (Medtronic [Minneapolis, MN] LINQ™) was implanted. The duration and overall burden of all AF episodes ≥ 2 min was determined. The cohort included 343 patients (68 ± 11 years, CHA2DS2-VASc 3.5 ± 1.7). The time between stroke and ILR was 3.7 ± 1.5 days. During the first 30 days, only 18 (5%) patients had AF. All episodes were paroxysmal, lasting from 2 min to 67 h and 24 min. The median AF burden was 0.85% (IQR 0.52, 10.75). During 1 year of follow-up, 67 (21%) patients had AF. The likelihood of AF detection by an ILR in the first month post-CS is low. Thus, the diagnostic yield of 30 days of AECG monitoring is likely to be limited. These data suggest a rationale for proceeding directly to ILR implantation prior to hospital discharge in CS patients, as many have AF detected during longer follow-up.

Objectives This study sought to evaluate the clinical and procedural characteristics impacting outcomes during implementation of a His bundle pacing (HBP) program in a real-world setting. Background Right ventricular pacing is associated with an elevated risk of heart failure, but device reprogramming and upgrades have significant challenges. HBP has emerged as an alternative and is reported to be highly successful in the hands of highly experienced centers. Methods All patients referred for permanent pacemaker implantation at the Valley Hospital (Ridgewood, New Jersey) between October 2015 and October 2017 were evaluated; a subset of 24% was selected for HBP. Results Permanent HBP was feasible with an acute implant success rate of 75%. HBP in the presence of bundle branch block (64% vs. 85%, p = 0.05) or complete heart block (56% vs. 83%, p = 0.03) was significantly less successful. The pattern of atrioventricular block in combination with bundle branch block (BBB) further affects outcomes. HBP is highly successful across the spectrum of atrioventricular block pattern severity in the absence of BBB. In the presence of BBB, Mobitz II AV block and complete heart block significantly attenuated HBP success compared with Mobitz I atrioventricular block (62% vs. 100%, p = 0.02). A rising threshold was observed in 30%, and 8% required lead intervention. Conclusions HBP was feasible and readily learned with a high implant success in the hands of experienced electrophysiologists without prior exposure to the technique. BBB and atrioventricular block pattern appears to affect success. The technique is limited by a high rate of rising thresholds and lead intervention. These data have important implications for patient selection.

Author(s): Arshad, Aysha; Johnson, Christopher K; Mittal, Suneet; Buch, Eric; Hamam, Ismail; Tran, Thanh; Shaw, Richard E; Musat, Dan; Preminger, Mark; Sichrovsky, Tina; Herweg, Bengt; Shivkumar, Kalyanam; Hummel, John; Steinberg, Jonathan S | Abstract: BackgroundThere are a variety of periprocedural anticoagulation strategies for atrial fibrillation (AF) ablation, including the use of dabigatran. It is unclear which strategy is superior.ObjectiveTo compare the safety and efficacy of anticoagulation with uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing ablation of AF at four experienced centers.Methods and resultsIn this retrospective analysis, 882 patients (mean age: 61 ± 11 years) underwent ablation of AF using uninterrupted warfarin (n = 276), dabigatran (n = 374), or warfarin with heparin bridging (n = 232) for periprocedural anticoagulation. The rate of total complications was 23/276 (8.3%) in the uninterrupted warfarin group, 30/374 (8.0%) in the dabigatran group, and 29/232 (12.5%) in the bridged group (P = 0.15). Major complications were more frequent in the uninterrupted warfarin group 12/276 (4.3%) compared with 3/374 (0.8%) in dabigatran and 6/232 (2.6%) in the bridged group (P = 0.01). The most common major complication was the need for transfusion or occurrence of major bleeding. Minor complications did not differ among the three groups. On multivariate analysis, female gender (odds ratio [OR] 1.93, confidence interval [CI] 1.16-3.19, P = 0.011), bridging heparin (OR 2.13, CI 1.100-3.941, P = 0.016), use of triple antithrombotic therapy (OR 1.77, CI 1.05-2.98, P = 0.033), and prior myocardial infarction (OR 2.40, CI 1.01-5.67, P = 0.046) independently predicted total complications.ConclusionsWhen comparing the use of uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing catheter ablation of AF, dabigatran was not associated with increased risk, major complications were more common in the uninterrupted warfarin group, and after adjustment, warfarin with bridging increased total complications.

This report summarizes the efficacy, safety, and feasibility of intracardiac ultrasound (ICUS) and local electrographic-guided pulmonary vein (PV)-left atrial disconnection, including the isolation of common PV trunks accomplished in 170 consecutive patients with atrial fibrillation (AF). A left common PV was found in 43% of patients with AF. During a follow-up of 549 +/- 330 days after ablation, the AF-free survival rate was 80% and comparable in paroxysmal and persistent AF. PV stenosis was detected in only 1 asymptomatic patient, who required no intervention.

Introduction: Long-term ECG monitoring is often necessary in patients (pts) with unexplained syncope and suspected or known atrial fibrillation (AF). The recently released Medtronic LinQ loop recorder (ILR) accrues ECG data daily; “alert” conditions are wirelessly transmitted to providers. To date, the frequency and characteristics of these alerts are unknown. Hypothesis: We hypothesized that alerts would occur infrequently, thus allowing for remote management of large numbers of pts. Methods: Consecutive pts implanted with the LinQ were assessed. All alerts were collected and analyzed. Alerts ideally reflect a change within the past 24 hours of monitoring. However, some alerts (once triggered) perpetuate daily until cleared by a patient initiating a manual transmission. Results: Our first 100 LinQ pts (mean age 67.5 years; 51% male) implanted within the first 3 months of market release were assessed. The indications for monitoring included suspected AF (cryptogenic stroke, n=10; history of atrial flutter, n=1), known AF (n=61), and unexplained syncope (n=25). During follow-up, an alert occurred in 63 pts; a similar frequency of alerts occurred in AF and syncope pts (Figure). Once present, 29 (46%) alerts perpetuated daily and required manual transmission to clear. Conclusion: We report the initial clinical experience with the LinQ ILR. We found that alerts occurred frequently, irrespective of indication for monitoring. Once present, alerts were frequently perpetuated due to a major design limitation. A more robust system is needed to triage the data being accrued to prevent unnecessary data deluge.

Dexmedetomidine is frequently used for deep sedation during electrophysiology procedures. We report a case where, presumably, the use of dexmedetomidine resulted in a patient's death. The patient developed unexplained and refractory cardiogenic shock and could not be resuscitated. Autopsy failed to demonstrate any abnormality or cause of death. We postulate that, in certain susceptible individuals, dexmedetomidine may lead to terminal complications. We therefore urge caution about using dexmedetomidine in the electrophysiology laboratory.

Objectives The purpose of the study was to define the incidence of systemic embolism after cardioversion in patients with left ventricular (LV) thrombus. Background The risk of systemic embolization after cardioversion in patients with an atrial thrombus is well known. However, data on thromboembolic events after cardioversion in patients with LV thrombus are limited because of hesitance to perform cardioversion in this population. Methods Transthoracic and transesophageal echocardiograms acquired between January 1996 and October 2001 at our institution were reviewed for presence of LV thrombus in two orthogonal apical views. A total of 413 patients had echocardiographic evidence of LV thrombus. Medical records were reviewed for cardioversion performed within 3 weeks of the echocardiogram. Results A total of 21 patients, age 66 ± 10 years and ejection fraction 22 ± 10% were identified. Cardioversion was indicated for atrial fibrillation in 8 (38%) and ventricular tachyarrhythmia in 13 (62%) patients, and was performed emergently in 5 (24%), electively in 8 (38%), and during electrophysiology study in 8 (38%) patients. The time interval between diagnostic echocardiographic study and cardioversion was 6 ± 5 (range 1-18) days. All thrombi were located in the apical LV and were described as laminated (71%) and protruding (29%), and measured 0.7 ± 0.4 × 1.6 ± 0.8 cm. Before cardioversion, 17 (81%) patients were anticoagulated with warfarin or heparin. During clinical follow-up of up to 1 year (153 ± 150 days) anticoagulation with warfarin was given to 15 (71%) patients. No patient had clinically apparent embolic event, including stroke, during hospitalization or during outpatient follow-up. Conclusions Embolism after cardioversion in patients with echocardiographic evidence of LV thrombus was not observed. Cardioversion seems to be safe and further prospective studies are needed to address this.

The ablation of atrial fibrillation (AF) using pulmonary vein isolation is indicated when patients do not respond favorably to medical therapy. Successful procedures are accomplished in the majority of patients, but the outcome after many years of follow-up after ablation is unknown.To describe the long-term recurrence rate and pattern of AF after successful ablation.A prospectively identified cohort of 445 patients who demonstrated freedom from AF for at least 1 year postablation (single procedure in 391 [87.9%]) was followed for 66.0 ± 34.0 months. Patients were seen at least annually as outpatients and underwent regular electrocardiographic monitoring.At 40.7 ± 27.0 months postablation, 97 (21.8%) patients experienced at least 1 episode of recurrent AF. The vast majority of events were symptomatic, and no serious clinical events were associated with AF recurrence (eg, stroke). There was a steady attrition rate reaching 16.3% and 29.8% at 5 and 10 years, respectively. In 29 patients (29.5%) of the patients, recurrences were self-limited; the remainder required either medical therapy or repeat ablation. By multivariate analysis, persistent AF (hazard ratio 3.08; P.0001) and hypertension (hazard ratio 1.08; P = .009) were independent risk factors for the recurrence of AF. The presence of both factors placed the patient at high risk of recurrence: 37.6% at 5 years and 68.8% at 10 years.Over the decade after a successful ablation of AF, most patients continue to demonstrate freedom from AF. At the highest risk of very late recurrence is the subset of patients with hypertension and prior persistent AF.

There are a variety of periprocedural anticoagulation strategies for atrial fibrillation (AF) ablation, including the use of dabigatran. It is unclear which strategy is superior.To compare the safety and efficacy of anticoagulation with uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing ablation of AF at four experienced centers.In this retrospective analysis, 882 patients (mean age: 61 ± 11 years) underwent ablation of AF using uninterrupted warfarin (n = 276), dabigatran (n = 374), or warfarin with heparin bridging (n = 232) for periprocedural anticoagulation. The rate of total complications was 23/276 (8.3%) in the uninterrupted warfarin group, 30/374 (8.0%) in the dabigatran group, and 29/232 (12.5%) in the bridged group (P = 0.15). Major complications were more frequent in the uninterrupted warfarin group 12/276 (4.3%) compared with 3/374 (0.8%) in dabigatran and 6/232 (2.6%) in the bridged group (P = 0.01). The most common major complication was the need for transfusion or occurrence of major bleeding. Minor complications did not differ among the three groups. On multivariate analysis, female gender (odds ratio [OR] 1.93, confidence interval [CI] 1.16-3.19, P = 0.011), bridging heparin (OR 2.13, CI 1.100-3.941, P = 0.016), use of triple antithrombotic therapy (OR 1.77, CI 1.05-2.98, P = 0.033), and prior myocardial infarction (OR 2.40, CI 1.01-5.67, P = 0.046) independently predicted total complications.When comparing the use of uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing catheter ablation of AF, dabigatran was not associated with increased risk, major complications were more common in the uninterrupted warfarin group, and after adjustment, warfarin with bridging increased total complications.

Cardiac implantable electronic device (CIED) infection is associated with morbidity and mortality.To determine the incidence and risk factors for CIED infection, to develop a scoring index for risk stratification, and to analyze the effect of the AIGISRx envelope on infection rates.Consecutive patients who underwent a CIED procedure were identified and surveyed for 6 months for the development of an infection necessitating removal of all implanted hardware.In the pre-envelope era, an infection occurred in 25 (1.5%) of 1651 patients. After its availability, an envelope was used in 275 (22%) of 1240 patients; an infection occurred in 8 (0.6%) patients in this era (P = .029 vs pre-envelope). In the overall cohort of 2891 patients, the infection rate was 1.2% and 3.5% in patients with an implantable cardioverter-defibrillator device and those with a cardiac resynchronization therapy defibrillator device, respectively (P = .018); in these patients, 7 independent risk factors predicted infection: early pocket re-exploration, male sex, diabetes, upgrade procedure, heart failure, hypertension, and glomerular filtration rate60 mL/min. A composite risk score (0-25; C index 0.72; 95% confidence interval 0.61-0.83) was created by weight, adjusting these 7 factors: 3 groups emerged-low risk (score 0-7; 1% infection), medium risk (score 8-14; 3.4% infection), and high risk (score ≥15; 11.1% infection). The envelope reduced infections by 79% and 100% in the medium- and high-risk groups, respectively.CIED infection most commonly occurred in patients with an implantable cardioverter-defibrillator device and those with a cardiac resynchronization therapy defibrillator device. A composite score based on clinical variables appeared feasible for infection risk stratification. The AIGISRx envelope significantly lowered the risk of CIED infection. Randomized clinical data are warranted.

In patients with atrial flutter who undergo cavotricuspid isthmus ablation, long-term electrocardiographic (ECG) monitoring may identify new onset of atrial fibrillation (AF).To ascertain, through the use of an implantable loop recorder (ILR) with a dedicated AF detection algorithm, the incidence, duration, and burden of new AF in these patients and to develop an optimal postablation ECG monitoring strategy.We enrolled 20 patients with flutter, a CHADS2 score of 2-3, and no prior episode of AF. After cavotricuspid isthmus ablation, we implanted an ILR, which was interrogated routinely; all stored ECGs were adjudicated.During a mean follow-up of 382 ± 218 days, 3 patterns were observed. First, in 11 (55%) patients, stored ECGs confirmed AF at 62 ± 38 days after ablation. Second, in 4 (20%) patients, although the ILR suggested AF, episodes actually represented sinus rhythm with frequent premature atrial contractions and/or oversensing. Third, in 5 (25%) patients, no AF was observed. Episodes4 hours were associated with low AF burden (1%) or false detections. The 1-year freedom from any episode of AF4 and12 hours was 52% and 83%, respectively.Our data show that many (but not all) patients develop new AF within the first 4 months of flutter ablation. Since external ECG monitoring for this duration is impractical, the ILR has an important role for long-term AF surveillance. Future research should be directed toward identifying the relationship between duration/burden of AF and stroke and improving existing ILR technology.

The calculation of the corrected QT interval (QTc) is particularly problematic in patients during atrial fibrillation (AF). The aims of this study were to compare the QTc calculated using Bazett's formula in AF and sinus rhythm (SR) and determine whether alternative methods for QT correction were superior to Bazett's, in an effort to define the optimal method for QT correction in patients with AF. We evaluated consecutive patients with persistent AF admitted for initiation of dofetilide. The QT interval was corrected according to the following formulas: Bazett's, Fridericia, and Framingham. We compared the QTc interval on the last electrocardiogram in AF to the first electrocardiogram in SR. The cohort included 54 patients (age 60 ± 10 years, 80% men) with persistent AF for a median of 36 months. Bazett's overestimated QTc during AF compared with SR (464 ± 34 vs 445 ± 38 ms, p = 0.008); in contrast, Framingham underestimated it (385 ± 48 vs 431 ± 40 ms, p0.001, respectively). However, there was no significant difference between the QTc interval in AF and SR when assessed by Fridericia (435 ± 33 vs 440 ± 35 ms, p = 0.46). There were 24 dofetilide dose reductions based on Bazett's QTc; this would have been avoided in 33% of patients had Fridericia been used. In conclusion, the commonly used Bazett's formula leads to an overestimation of the QTc during AF. This may result in unnecessary reduction in antiarrhythmic doses and thus drug efficacy. These data suggest that the Fridericia most closely approximates the QTc during AF to QTc during SR.

Background: Despite encouraging results of pulmonary vein isolation (PVI) ablation for atrial fibrillation (AF), it is unclear whether there is genuine cure or there is an important attrition rate. We sought to determine the long-term outcome of the initial responders who experienced a prolonged AF-free complete response. Methods: From a series of 350 consecutive patients who underwent PVI for AF, 264 patients (75%) (males 71%, age 57 ± 12 years, paroxysmal AF 87%) who demonstrated ≥1 year AF-free follow-up on no antiarrhythmic drugs were followed for 1–5 years. Results: During 28 ± 12 months follow-up, 23 of 264 (8.7%) patients had recurrence of AF. The actuarial recurrence at 2 years postablation was 5.8% and increased to 25.5% at 5 years. Compared with long-term responders, more patients with late recurrence had hypertension (HR = 2.18, P = 0.009) and hyperlipidemia (HR = 4.01, P = 0.0005). Among 18 patients with recurrent AF necessitating repeat PVI, 15 (83%) required re-isolation of > 1 PV and 28 of 45 (58%) PVs showed reconnection. All PVs were re-isolated and five (28%) patients had additional linear ablation. All 15 patients became AF-free again. Conclusions: Although most patients following PVI remain AF-free, some patients develop “late” recurrence of AF. The “late” recurrence patients are more likely to have hypertension and hyperlipidemia. Most late recurrences are associated with PV reconnections. Our observations emphasize the importance of continued long-term vigilance for AF recurrence, and also raise concerns regarding the need for long-term anticoagulation therapy.

The ASCOT-LLA and ALLHAT-LLT trials provide conflicting evidence of the efficacy of statins in decreasing cardiovascular (CV) morbidity and mortality in hypertensive patients. We performed a meta-analysis to compare the overall efficacy of statins in hypertensive and nonhypertensive patients enrolled in major randomized clinical trials. We systematically reviewed PubMed publications from 1985 onward for placebo-controlled randomized trials that examined the effect of statins on cardiac morbidity and mortality. Only trials that followed ≥1,000 patients for ≥2 years were included in the meta-analysis. Outcomes included cardiac or CV death, major coronary events, or major CV events. Pooled estimates of relative risk (RR) were calculated separately for hypertensive and nonhypertensive patients. The moderating effect of the percentage of hypertensive patients at baseline was tested using meta-regression. Besides the ASCOT-LLA and ALLHAT-LLT, 12 trials enrolling 69,984 patients met inclusion criteria. Overall, in these 12 trials, statin therapy decreased cardiac death by 24% (RR 0.76, 95% confidence interval [CI] 0.71 to 0.82). There was no evidence of difference in RR estimates for hypertensive (RR 0.78, 95% CI 0.72 to 0.84) and nonhypertensive (RR 0.76, 95% CI 0.72 to 0.80) patients. Similarly, meta-regression showed that the efficacy of statins was not moderated by the percentage of hypertensive patients at baseline (Q estimate 1.51, p = 0.22). In conclusion, statin therapy effectively decreases CV morbidity and mortality to the same extent in hypertensive and nonhypertensive patients.

Hypertension and Pulmonary Vein Dilation. Introduction: Atrial fibrillation (AF) is associated with increased ostial pulmonary vein (PV) diameter and commonly with hypertension. We sought to investigate ostial PV anatomy in patients with and without AF with the goal of characterizing the relationship to hypertension and cardiovascular disease. Methods and Results: Ostial PV diameter was assessed by preprocedural spiral computed tomography in 100 AF patients undergoing a PV isolation procedure and in 24 age- and sex-matched non-AF control patients. Ostial diameter of 392 PVs in 100 AF patients was increased compared to 106 PVs in 24 non-AF controls (1.50 ′ 0.31 vs 1.20 ′ 0.31 cm, P < 0.001) and diameters of individual PVs were uniformly affected (r = 0.45-0.62, P < 0.001). Left atrial dilation was associated with a larger PV diameter (1.56 ′ 0.32 vs 1.44 ′ 0.29 cm, P < 0.01). PV diameter in AF patients with hypertension (1.55 ′ 0.32 cm), particularly if associated with left ventricular hypertrophy (1.66 ′ 0.37 cm), was larger compared to AF patients without hypertension (1.43 ′ 0.26 cm, P < 0.01). PV diameter in control patients with hypertension (n = 14) was larger than in those without hypertension (n = 10, P < 0.01). Patients with persistent AF had larger PV diameters (1.61 ′ 0.34 cm) than patients with paroxysmal AF (1.47 ′ 0.30 cm, P < 0.01). Male gender (P < 0.01), history of hypertension (P < 0.01), and persistent AF (P < 0.05) were identified as independent cofactors of increased ostial PV diameter. Conclusion: PV dilation affects all PVs uniformly in AF patients. Hypertension and hypertensive heart disease in patients with and without AF are associated with PV dilation, supporting theories that impaired left ventricular diastolic function is associated with a stretch-induced PV arrhythmia mechanism.

In cardiac transplant recipients the release of soluble cellular adhesion molecules intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and E-Selectin into serum is pronounced during immune activation. It is uncertain whether there is a specific pattern of release during infection or cardiac allograft rejection. In a prospective study, 30 consecutive cardiac allograft recipients were followed for a median period of 11.4 months (range 1–34). Soluble ICAM-1 (sICAM-1), soluble VCAM-1 (sVCAM-1) and soluble E-Selectin (sE-Selectin) were measured in addition to acute phase proteins (C-reactive protein, α1-antitrypsin), complement factors (C3, C4) and β2-microglobulin. The measured serum levels were correlated with the clinical status of the transplant recipient: 1) uneventful clinical status; 2) asymptomatic infection; 3) symptomatic infection and 4) rejection. Forty age-matched healthy subjects served as controls. Six days before biopsy-proven cardiac allograft rejection sICAM-1-release started to increase (p < 0.05) as compared to uneventful clinical status. The peak concentration of sICAM-1 was measured three days before rejection. On the day of rejection, serum concentrations of sICAM-1 (p < 0.001) and sVCAM-1 (p < 0.05) were increased, whereas sE-Selectin was not markedly elevated. In symptomatic infections, the serum concentrations of sICAM-1 (p < 0.001) and sVCAM-1 (p < 0.05) were elevated at the day of diagnosis and both parameters reached peak levels three days after onset of chemotherapy. In multivariate analysis soluble adhesion molecules only weakly discriminated between rejection and infection (sensitivity: 13%, specificity: 95%). Although, in combination with routine blood parameters the discriminatory power could be improved (sensitivity: 85%, specificity: 85%) the clinical utility of these markers in non-invasive monitoring is limited.

o t e c b c H f r m l m d e A d r a t w d Ever since its beginning 4 years ago,1 the cyclooxyenase-2 (COX-2) inhibitor controversy has created considrably more heat than light. Not only have the news media yped the controversy and thereby scared patients and frusrated practicing physicians, but even reputable medical ournals have used phraseology that seems much more suitble for the tabloid press than contemporary science. This is nfortunate, because as Sir George Pickering2 stated, conroversy is the lifeblood of science and should be welcomed. ery often, it is only through controversy that science adances. Regrettably however, the COX-2 inhibitor controersy has become first and foremost the lifeblood for litiating trial lawyers. The recent thorough article of Sowers t al3 elucidates some pathophysiologic aspects of this issue. he investigators conducted a prospective, randomized trial valuating, with ambulatory blood pressure (BP) monitorng, the effects of celecoxib, rofecoxib, and naproxen in pproximately 400 patients with type 2 diabetes mellitus, ypertension, and osteoarthritis and showed that at equally ffective doses for osteoarthritis symptoms, patients treated ith rofecoxib, but not with celecoxib or naproxen, exhibted significant increases in 24-hour systolic BP of 3 to 4 m Hg. The destabilization of hypertension control ocurred, to some extent, in all 3 treatment groups but signifcantly more often in patients who were receiving rofecoxib. he recent meta-analysis of Aw et al4 corroborates and mplifies these findings. Clearly, the differences in BP beween the 2 COX-2 inhibitors, which support previous findngs,5 seem small, and many clinicians will consider them of uestionable clinical significance. However, the 1 million– atient meta-analysis of the BP trialists allows one to calulate that a mere 2 mm Hg decrease in the usual systolic P would involve an approximately 10% lower stroke morality rate and an approximately 7% lower mortality rate rom ischemic heart disease.6 The BP difference in the study f Sowers et al3 between celecoxib and rofecoxib was about wice as much, and it is important that the study is unique in hat it was performed in patients with type 2 diabetes. In ypertensive diabetic patients, the risks for heart attack and troke have been shown to be much more dependent on BP han in nondiabetic patients. The Systolic Hypertension in urope study7 allows one to estimate that for a similar ecrease in systolic BP, the risk for stroke and cardiovas

ContextEarly mechanical revascularization in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock is a therapeutic strategy that reduces mortality. It has been a class I recommendation in guidelines from the American College of Cardiology and the American Heart Association since 1999 for patients younger than 75 years. However, little is known about implementation of these guidelines in practice.ObjectivesTo assess trends in early revascularization and mortality for patients with cardiogenic shock complicating AMI and to determine whether the national guidelines affect revascularization rates.Design, Setting, and PatientsProspective, observational study of 293 633 patients with ST-elevation myocardial infarction (25 311 [8.6%] had cardiogenic shock; 7356 [29%] had cardiogenic shock at hospital presentation) enrolled in the National Registry of Myocardial Infarction (NRMI) from January 1995 to May 2004 at 775 US hospitals with revascularization capability (defined as the capability to perform cardiac catheterization, percutaneous coronary intervention [PCI], and open-heart surgery).Main Outcome MeasuresManagement patterns and in-hospital mortality rates.ResultsThere was an increase in primary PCI rates from 27.4% to 54.4% (P