Continuous Cardiac Monitoring Research Articles

Changes in perfusion can detect changes in the cardiac index in patients with septic shock.

ObjectiveThe perfusion index (PI) is usually used to assess peripheral perfusion, which can be influenced by the cardiac index (CI). CI monitoring is often needed during the treatment of patients with shock. We investigated the relationship between changes in the PI (ΔPI) and changes in the CI (ΔCI) in patients with septic shock.MethodsThis retrospective study included patients with septic shock who underwent pulse-induced continuous cardiac output monitoring. We measured the CI and PI before and after fluid loading during the first 6 hours of intensive care unit admission. Fluid responsiveness was defined as a ≥10% ΔCI after fluid loading. Other hemodynamic and oxygen-derived parameters were also collected at the exact time of each CI measurement.ResultsFifty-five patients were included in the study (29 fluid responders, 26 fluid non-responders). In the univariate analysis, ΔPI was positively correlated with ΔCI. In the multivariable analysis, ΔPI was independently associated with ΔCI. The receiver operating characteristic curve showed that ΔPI was an appropriate marker with which to discriminate a CI increase with an area under the curve of 0.776.ConclusionThis study showed a positive correlation between ΔPI and ΔCI during the early treatment phase of septic shock.

Clinical significance of pulse index contour continuous cardiac output monitoring in patients with constrictive pericarditis undergoing pericardiectomy

The efficacy of pulse index contour continuous cardiac output (PiCCO) monitoring in patients with constrictive pericarditis undergoing pericardiectomy remains unclear. The goal of this study was to explore whether PiCCO monitoring could improve clinical outcomes in these patients. We retrospectively studied 74 patients with constrictive pericarditis undergoing pericardiectomy and assigned them to a PiCCO group and a control group. Postoperative and survival outcomes were compared between the 2 groups. There were 33 (44.6%) cases in the PiCCO group and 41 (55.4%) cases in the control group. The baseline characteristics were comparable between the 2 groups. In comparison to the control group, the PiCCO group showed more intraoperative fluid infusion (P = 0.003), higher postoperative central venous pressure (P = 0.007) and lower levels of postoperative brain natriuretic peptide (P = 0.021). The incidence of postoperative complications (P = 0.004) including cardiac complications (P = 0.033) was also lower in the PiCCO group. Despite no difference in survival outcomes, duration of chest drainage (P = 0.032), length of stay in the intensive care unit (P < 0.001) and the postoperative hospital stay (P = 0.044) were significantly shorter in the PiCCO group. This study confirmed the clinical significance of PiCCO monitoring in the enhanced recovery of patients with constrictive pericarditis undergoing pericardiectomy and provided new evidence for applying PiCCO monitoring in these patients.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)-Induced Cardiovascular Syndrome: Etiology, Outcomes, and Management.

As the coronavirus disease 2019 (COVID-19) pandemic evolves, more complications associated with the disease come to surface. Thus far, there is limited information available on the etiology, clinical outcomes, and management options for cardiovascular complications caused by COVID-19. This review focuses on literature published in year 2020 on the virus-induced cardiovascular damage with intention to better understand pathophysiology of this process, its impact on clinical outcomes, and available therapies. Literature review shows that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) acts through angiotensin-converting enzyme 2 (ACE-2) receptors and causes cardiac injury by direct damage to the cardiomyocytes, systemic inflammation, fibrosis, interferon and cytokine-mediated immune response, coronary plaque destabilization, and hypoxia. Comorbidities, especially underling heart disease, make patients more predisposed to severe cardiovascular damage. COVID-19 patients who develop myocardial injury have a higher mortality rate compared to those who do not. During the pandemic, percutaneous coronary intervention (PCI) should remain the standard of care for patients with ST segment elevation myocardial infarction (STEMI). On the other hand, in order to limit healthcare worker exposure, patients with non-ST segment elevation myocardial infarction (NSTEMI) should be managed with stabilization strategies if hemodynamically stable. Monitoring hospitalized COVID-19 patients with high sensitivity troponin can help screen for severe complications and detect them early. Use of multiple investigational drugs with uncertain cardiac safety profiles in COVID-19 patients requires continuous cardiac monitoring. Notch signaling pathway therapy along with anti-viral agents, interleukin-6 inhibitors, and convalescent serum are possible treatment options to better control the inflammatory state that drives the cardiac damage.

Cardiotoxicity danger in immunotherapy.

Immunotherapy based on immune checkpoint inhibitors (ICIs) is currently broadly used in the treatment of different types of cancer. The treatment targeting programmed cell death protein 1/programmed death-ligand 1 axis is already approved by Food and Drug Administration for numerous cancers. These kinds of therapy brought spectacular results in the treatment of non-small cell lung cancer where systemic therapy was ineffective. However, a wide range of applied therapies based on ICIs in the clinic have led to unexpected side effects, such as severe cardiotoxicity. It needs to be underlined that the molecular mechanism of myocarditis in response to ICIs is still not fully understood. Lack of sufficient knowledge, especially concerning the kind of risk factors increasing probability of myocarditis, poses currently a large clinical problem. Continuous cardiac monitoring of patients who undergo ICI treatment presents another problem as it is cost-ineffective for the healthcare system. Herein, we highlight the risks of use of anticancer therapy based on ICIs. We also stress that detailed monitoring of any event of cardiotoxicity following ICIs treatment should be carefully investigated and registered to give a global overview of the frequency of myocarditis occurrence. Moreover, we propose that the extension of molecular and systemic knowledge of etiology of myocarditis as a side effect, including the role of protein kinases, will be highly beneficial for the medical field. Last but not least, better understanding of mechanisms of cardiotoxicity induction will improve the safety of cancer patients and will help clinicians in prediction of unexpected side effect occurrence.

Heart Rate and Oxygen Saturation Monitoring With a New Wearable Wireless Device in the Intensive Care Unit: Pilot Comparison Trial

Background Continuous cardiac monitoring with wireless sensors is an attractive option for early detection of arrhythmia and conduction disturbances and the prevention of adverse events leading to patient deterioration. We present a new sensor design (SmartCardia), a wearable wireless biosensor patch, for continuous cardiac and oxygen saturation (SpO2) monitoring. Objective This study aimed to test the clinical value of a new wireless sensor device (SmartCardia) and its usefulness in monitoring the heart rate (HR) and SpO2 of patients. Methods We performed an observational study and monitored the HR and SpO2 of patients admitted to the intensive care unit (ICU). We compared the device under test (SmartCardia) with the ICU-grade monitoring system (Dräger-Healthcare). We defined optimal correlation between the gold standard and the wireless system as &lt;10% difference for HR and &lt;4% difference for SpO2. Data loss and discrepancy between the two systems were critically analyzed. Results A total of 58 ICU patients (42 men and 16 women), with a mean age of 71 years (SD 11), were included in this study. A total of 13.49 (SD 5.53) hours per patient were recorded. This represents a total recorded period of 782.3 hours. The mean difference between the HR detected by the SmartCardia patch and the ICU monitor was 5.87 (SD 16.01) beats per minute (bias=–5.66, SD 16.09). For SpO2, the average difference was 3.54% (SD 3.86; bias=2.9, SD 4.36) for interpretable values. SmartCardia’s patch measures SpO2 only under low-to-no activity conditions and otherwise does not report a value. Data loss and noninterpretable values of SpO2 represented 26% (SD 24) of total measurements. Conclusions The SmartCardia device demonstrated clinically acceptable accuracy for HR and SpO2 monitoring in ICU patients.

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) in pregnancy: a case series of nine patients and review of literature

Background Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic cardiomyopathy characterized by myocardial necrosis and fibrofatty substitution of the myocardium, predominantly of the right ventricle. The evaluation of risk associated with gestation and delivery in patients with ARVC is difficult due to the small number of already reported cases. We present our experience of patients with ARVC who completed a pregnancy and delivery. Methods A case series of nine women in Calgary, Canada, from 2013 to 2018, who were diagnosed with ARVC before or during pregnancy. Patients were identified using our Cardiac-Obstetrics database, and information was collected through electronic charts and patient recollection. Results All pregnancies reported were singleton with an average maternal age of 31 years. Six patients had a related genetic mutation. Beta blockers were being used by eight, and five had an implantable cardioverter-defibrillator (ICD) prior to the pregnancy. None of the patients developed heart failure during pregnancy, but one had a complicated antepartum and postpartum course. All pregnancies delivered at term with eight receiving neuroaxial analgesia. Five patients delivered vaginally. Those without an ICD had continuous cardiac monitoring intrapartum. The incidence of small for gestational age (33%) was higher than the general population. All of the patients breastfed the newborns. Conclusions Pregnancies in these patients with ARVC were generally well tolerated. Given the rarity of the disease and absence of any clinical guidelines, multidisciplinary care is essential in the management of these patients.

Effect of Occupational Exposure to Pesticides on Cardiovascular System among Farmers: A Comparative Study

Background: Agriculturea very complex occupation, apart from increasing productivity also brings huge loss to community in terms of its ill effects on human health,plant and animal life. Adverse effects on cardiovascular system is likely to occur due to aggressive use of agrochemicals such as pesticides. Objectives: To Study Changes in ECG due to pesticide exposure among farmers and to Compare these ECG Changes in those farmers with that of normal non-exposed subjects. Materials and Method: A 12 lead ECG was recorded in apparenty healthy male farmers exposed to pesticides and normal non exposed age matched male control subjects and analysed for parameters such as heart rate, PR interval, QTC interval, QRS axis, ST and T wave changes and compared. Results: This study reports significantly increased heart rate, prolonged QTC interval and non-specific ST and T wave changes among pesticide exposed farmers compared to non-exposed control subjects. Conclusion: The current study concludes that there is a need to detect these ECG changes as early as possible so that future risk of cardiovascular disease can be prevented by adapting precautionary measures during application of pesticides. Some form of continuous cardiac monitoring seems advisable. Farmers can be advised to quit toxic chemical fertilizers & pesticides and opt Organic ones to be safe from the hazardous implications of exposure.

Clinical assessment of AF pattern is poorly correlated with AF burden and post ablation outcomes: A CIRCA-DOSE sub-study

BackgroundContemporary guidelines recommend that atrial fibrillation (AF) be classified into paroxysmal and persistent AF based on clinical assessment, with these categorizations forming the basis of therapeutic recommendations. While pragmatic, clinical assessment may introduce misclassification errors, which may impact treatment decisions. We sought to determine the relationship between AF classification, baseline AF burden, and post-ablation arrhythmia outcomes. DesignThe current study is a sub-analysis of a prospective, parallel-group, multicenter, single-blinded randomized clinical trial. All 346 patients enrolled in CIRCA-DOSE received an implantable cardiac monitor a median of 72 days prior to ablation. AF was classified as low burden paroxysmal, high burden paroxysmal, or persistent based on clinical assessment prior to device implantation. Prior to ablation patients were re-classified using the same definitions based on device monitoring data. Correlation between classifications, AF burden, and post-ablation arrhythmia outcomes were assessed. ResultsThere was poor agreement between clinical and device-based AF classification (Cohen's kappa: 0.192). AF classification derived from pre-ablation continuous monitoring reflected baseline and post-ablation AF burden with greater accuracy and with less overlap between the AF classes (P < 0.01 for all categorical comparisons). Patients objectively classified as “Low Burden” paroxysmal by continuous monitoring data had significantly greater freedom from recurrent AF/AT/AFL compared to those classified as “High Burden” paroxysmal (hazard ratio [HR] 0.57 for AF/AT/AFL recurrence) or persistent AF (HR 0.19 for AF/AT/AFL recurrence). ConclusionsClassification of AF pattern based on pre-ablation continuous cardiac rhythm monitoring better predicted AF burden and freedom from recurrent AF post ablation. Despite the use of standardized definitions, classification of AF based on clinical assessment did not predict baseline AF burden, post ablation AF burden, or freedom from recurrent AF post ablation.Trial registration: ClinicalTrials.govNCT01913522.

Abstract P113: Increased Incidence of Atrial Fibrillation During Periods of High Influenza Activity

Introduction: Influenza is an important inflammatory illness which results in 3 to 5 million cases of severe illness, and 290,000 to 650,000 deaths per year, worldwide. Influenza’s role in triggering acute coronary syndromes is well established, but influenza’s impact on cardiac arrhythmias has yet to be investigated. Hypothesis: We investigated the effect of influenza on triggering atrial fibrillation (AFib) episodes. Methods: This retrospective observational study included de-identified data from patients who had a Zio patch (iRhythm Technologies, San Francisco), a wearable continuous cardiac monitoring device. Data were available from October 2012 to September 2017. The “influenza activity” was defined as the percentage of positive respiratory specimens that tested for influenza virus during each influenza season reported by the Centers for Disease Control and Prevention (CDC). We included all cases with AFib burden &lt;=90% from the weeks with the highest and lowest influenza activity up to two consecutive weeks after them. An independent-samples t-test was used to compare the burden of AFib in weeks with the highest and lowest influenza activity. Results: We reviewed the records of 825,869 patients (mean age= 61.1 ± 15.3 years; 48.8% male) who had a Zio patch from October 2012 to September 2017. Of these patients, 47,106 met the pre-defined inclusion criteria for our study. There was a significant difference in the AFib burden in high influenza activity (Mean=1.19, SD=0.69) and low influenza activity (Mean=1.03, SD=0.63) conditions; t (47104) = -2.6, p =0.009. The incidence of AFib was 15% higher in high influenzas activity weeks (OR=1.15, 95%CI, 1.03-1.19, p=0.009). The higher burden of AFib in high influenza activity weeks was significant for each influenza season and a similar trend was observed consistently in each individual influenza season. Conclusions: High seasonal influenza activity is associated with increased odds of AFib. Prospective studies are needed to determine the clinical implications of this finding.

Evaluation of pulse wave transit time analysis for non-invasive cardiac output quantification in pregnant patients

Pregnant patients undergoing minimally-invasive foetoscopic surgery for foetal spina bifida have a need to be subjected to advanced haemodynamic monitoring. This observational study compares cardiac output as measured by transpulmonary thermodilution monitoring with the results of non-invasive estimated continuous cardiac output monitoring. Transpulmonary thermodilution-based pulse contour analysis was performed for usual anaesthetic care, while non-invasive estimated continuous cardiac output monitoring data were additionally recorded. Thirty-five patients were enrolled, resulting in 199 measurement time points. Cardiac output measurements of the non-invasive estimated continuous cardiac output monitoring showed a weak correlation with the corresponding thermodilution measurements (correlation coefficient: 0.44, R2: 0.19; non-invasive estimated continuous cardiac output: 7.4 [6.2–8.1]; thermodilution cardiac output: 8.9 [7.8–9.8]; p ≤ 0.001), while cardiac index experienced no such correlation. Furthermore, neither stroke volume nor stroke volume index correlated with the corresponding thermodilution-based data. Even though non-invasive estimated continuous cardiac output monitoring consistently underestimated the corresponding thermodilution parameters, no trend analysis was achievable. Summarizing, we cannot suggest the use of non-invasive estimated continuous cardiac output monitoring as an alternative to transpulmonary thermodilution for cardiac output monitoring in pregnant patients undergoing minimally-invasive foetoscopic surgery for spina bifida.

Isolated Insular Stroke: Clinical Presentation

The symptoms related to insular ischemia have been the object of several studies in patients affected by stroke, although they are often accompanied by other ischemic alteration of adjacent brain structures supplied by the middle cerebral artery (MCA). The insula is vulnerable because of an ischemia due to thromboembolic vascular occlusion of the M1 MCA segment and the 2 main MCA branches (M2), mainly when they abruptly arise from the principal stem at a right angle. This topographical and anatomical peculiarity could enable an embolic formation, especially due to atrial fibrillation (AF), to occlude the transition pathway between M1 and M2, while the proximal origin of vascular supply protects the insula from ischemia due to hemodynamic factors. The aim of the study is to characterize the clinical aspects of acute ischemic strokes as a first event in the insular territory with specific attention to atypical manifestation. We have considered 233 patients with a first event stroke involving the insular territory and 13 cases of isolated insular stroke (IIS), from the stroke registry of the Policlinico “G.Martino”, University of Messina, between the February 10, 2014 and the February 7, 2018. IIS patients showed CT/MRI lesions restricted to the insular region. Exclusion criteria were coexisting neurological diseases, structural brain lesions, extension to the subinsular area >50% of the total infarct volume. We identified 13 IIS patients (mean age 74 years), with an isolated symptom or a combination of typical and atypical aspects. Furthermore, we observed high frequency detection of cardiac disturbances. To our knowledge, just a few previous studies have described IIS; their incidence is still not well defined. IIS manifested with a combination of deficits including motor, somatosensory, speaking, coordination, autonomic and cognitive disturbances. After an ischemic stroke, AF manifestation could follow briefly the major event and its duration could be very short, as an autonomic dysfunction due to an insular infarction. This clinical condition requires a continuous cardiac monitoring for this dangerous occurrence.

Abstract TP377: Nurse Entered Stroke Order Sets Improve Emergency Department Metrics at a Comprehensive Stroke Center

Introduction: The Joint Commission has established time sensitive metrics for stroke care in the Emergency Department (ED) including door to initial physician evaluation, door to lab and CT order placement, door to lab resulted and door to CT interpretation. Purpose: The purpose of this quality improvement project was to assess if nurse entered protocolized order sets for stroke patients would help to improve these metrics. Methods: A code stroke order set was initiated independently by nursing staff upon symptom recognition in the ED. The order set included CBC, electrolyte panel, BUN, creatinine, glucose, troponin, PT/INR, aPTT, non-contrast CT head, EKG, swallow screen and continuous cardiac monitoring. Data was collected for 3 months pre and post intervention. All ED nurses were trained on order set entry and their skills were validated. Data was analyzed using a T-Test. Results: 60 patient pre and 52 post-implementation were evaluated. Door to initial physician evaluation was faster (7 mins pre vs. 5 mins post; p=0.029). Door to lab order placement was faster (8 mins pre vs. 3 mins post; p=0.038). Door to CT ordered was faster (8 mins pre vs. 6 mins post; p&lt;0.01). Door to labs resulted was faster (32 mins pre vs. 27 mins post; p=0.01). Door to CT interpretation was faster (19 mins pre vs. 18 mins post; p=0.04). Conclusion: Implementation of nurse entered order sets can improve ED metrics for door to initial physician evaluation, door to lab and CT order placement. This subsequently led to faster interpretation of the CT scan and lab results.

The Pattern of Cardiac Arrhythmias in Acute ST Elevated Myocardial Infarction and their in-hospital Outcome

Background: Acute myocardial infarction (AMI) is a major cause of death worldwide with arrhythmia being the most common determinant in the post-infarction period. Identification and management of arrhythmias at an early period of acute MI has both short term and long term significance.&#x0D; Objective: The aim of the study is to evaluate the pattern of arrhythmias in acute STEMI in the first 48 hours of hospitalization and their inhospital outcome.&#x0D; Methods: A total of 50 patients with acute STEMI were included in the study after considering the inclusion and exclusion criteria. The patients were observed for the first 48 hours of hospitalization for detection of arrhythmia with baseline ECG at admission and continuous cardiac monitoring in the CCU. The pattern of the arrhythmias during this period &amp; their in-hospital outcome were recorded in predesigned structured data collection sheet.&#x0D; Result: The mean age was 53.38 ± 10.22 years ranging from 29 to 70 years. Most of the patients were male 42(84%). Majority of the patients had anterior wall ( anterior, antero-septal &amp; extensive anterior) myocardial infarction (54%). Sinus tachycardia in isolation was the most common arrhythmia observed in 36.8% of patients followed by sinus bradycardia (22.8%), ventricular tachycardia (19.3%), ventricular ectopic (12.3%),first degree AV block (5.3%), complete heart block and atrial ectopic 1.7% each. Tachyarrhythmias were more common in anterior wall myocardial infarction, whereas bradyarrhythmias were more common in inferior wall myocardial infarction. Among studied patients, 72% had favourable outcome , followed by acute left ventricular failure 10%, cardiogenic shock &amp; lengthening of hospital stay 8% each and death 2%.&#x0D; Conclusion: The commonest arrhythmias encountered were sinus tachycardia followed by sinus bradycardia, ventricular tachycardia, ventricular ectopic, AV block and atrial ectopic. The incidence of mortality was 2%.&#x0D; University Heart Journal Vol. 16, No. 1, Jan 2020; 16-21

265 The Timing of Arrhythmia Post-STEMI: A Retrospective Audit

Little is known about the detection of significant arrhythmias post-STEMI in contemporary populations with high rates of reperfusion therapy. We sought to determine the type and timing of arrhythmias in continuously monitored STEMI patients. A retrospective audit of the Electronic Medical Record of STEMI patients presenting to Concord Hospital from August 6th 2018 to August 4th 2019 was performed. The type and timing of significant arrhythmias and cause of death were reported. 64 patients were included; the mean age±SD was 65±15 years, with male predominance (89%). The culprit lesions were predominantly RCA(48%) and LAD(34%). The majority(88%) received primary PCI, 12% were thrombolysed. 19/64[30%] had clinically significant arrhythmias, 16/64[25%] had LVEF <40% and 11/64[17%] had ongoing pain post reperfusion. The incidence of significant arrhythmias was: sustained VT 9%, recurrent non-sustained VT 6%, VF 5%, accelerated idioventricular rhythm 2%, complete heart block(CHB) 6%, new atrial arrhythmias 8%. All sustained VT and VF occurred prior to reperfusion(D1). No significant ventricular arrhythmias or CHB occurred after day 3. Only 16% of arrhythmias occurred beyond day 2 and 75% of these were atrial. Four patients died during admission; two from primary ischaemic or arrhythmic causes within the first 48hours; two from secondary multi-organ dysfunction beyond 48hours. Most significant arrhythmias occur prior to reperfusion or within the first 48hours, suggesting there is minimal yield arising from monitoring beyond this point. Reducing cardiac monitoring to 48hours in patients without clinical indication may safely reduce costs associated with continuous cardiac monitoring.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Effectiveness of magnesium sulphate for prevention of atrial fibrillation after coronary artery bypass grafting

Introduction and background: Postoperative atrial fibrillation is the most common complication that develops after cardiovascular surgery and is associated with adverse outcomes. Magnesium is an essential element in the body, which is required as a cofactor for over 300 enzymatic reactions and reduced levels of magnesium in the blood have been found related with an increased risk of AF, both in ambulatory setting and after cardiac surgeries. Our study was aimed at determining role of prophylactic magnesium sulphate in preventing postoperative AF in subjects undergoing CABG. This would eventually improve the overall outcome of patients undergoing cardiovascular surgeries. Objective: To compare efficacy of magnesium sulphate with control group for prevention of atrial fibrillation after coronary artery bypass surgery. Study duration and setting: 6 months from November 2019 to April 2020 at Department of Cardiac surgery, Cardiac Center PIMS Islamabad. Materials and methods: In the present study, enrolled a total of one hundred and twenty eight (n=128) patients of both gender between age 50-70 year who were planned for coronary artery bypass surgery. The trial was conducted in compliance with the international on Harmonization guidelines for good clinical practices and according to the declarations of Helsinki. All the patients were randomized by lottery method into group A, who were given intravenous injection of 200 mEq MgSO4 in 100 ml of normal saline/day for 03 days and group B, who were given intravenous injection of 100 ml of normal saline only for 03 days. All the patients had continuous cardiac monitoring performed for 72 hours to observe for occurrence of AF. Occurrence of postoperative AF was compared in both groups by applying chi-square test, a p-value of <0.05 was considered as significant. Results: There were 93.8% (n=60/64) males and 6.3% (n=4/64) females in group A and 90.6% (n=58/64) males and 9.4% (n=6/64) females in group B. Mean age of subjects in group A was 59.9 years ± 6.7 SD while it was 58.6 years ± 6.3 SD in group B. Mean baseline LVEF was 52.7% ± 8.1 SD in group A while it was 53.4% ± 5.9 SD in group B. Postoperative AF was observed in 12.5% (n=8/64) patients in group A while it was observed in 45.3% (n=29/64) patients in group B (p=0.001). When stratified for age and gender magnesium sulphate was found more effective in preventing postoperative AF in younger males (p=0.001). Conclusion: In the present study, postoperative AF was developed in significantly lesser number of patients who received prophylactic magnesium sulphate as compared to placebo group. Magnesium sulphate was found more effective in preventing postoperative AF among younger males. Significance of the study: AF was most commonly assessed post-operatively after cardiac surgery. Findings of our study suggest that Magnesium sulphate administration during CABG serves a prevelantive strategy for post-op AF.

Atrial Fibrillation-Mediated Cardiomyopathy.

AF-mediated cardiomyopathy (AMC) is an important reversible cause of heart failure that is likely underdiagnosed in today's clinical practice. AMC describes AF either as the sole cause for ventricular dysfunction or exacerbating ventricular dysfunction in patients with existing cardiomyopathy or heart failure. Studies suggest that irreversible ventricular and atrial remodeling can occur in AMC, making timely diagnosis and intervention critical to optimize clinical outcome. Clinical correlation between AF onset/burden and progression of cardiomyopathy/heart failure symptoms provides strong evidence for the diagnosis of AMC. Cardiac MRI, continuous cardiac monitoring, and biomarkers are important diagnostic tools. From the therapeutic standpoint, early data suggest that AF ablation may improve long-term outcomes in AMC patients compared with medical rate and rhythm control. Patients with more AF burden and less severe underlying structural heart disease are more likely to experience left ventricle function recovery with successful AF ablation. Despite recent advances, significant knowledge gaps exist in our understanding of the epidemiology, mechanisms, diagnosis, management strategies, and prognosis of AMC.

Wireless, Skin-Like Membrane Electronics With Multifunctional Ergonomic Sensors for Enhanced Pediatric Care.

Continuous cardiac monitoring using electrocardiograms (ECG) provides a range of patient information, essential for making clinical decisions, to healthcare providers. Unfortunately, the clinical standard of ECG recording requires the use of rigid metal electrodes, conductive gels, and wired electronic devices, which often cause skin injuries and health risks for pediatric patients with underdeveloped, fragile skin. Here, we introduce a wireless, soft, comfortable electronic system that obviates the need for skin preparation, electrolyte gels, or aggressive tapes. The low-profile device incorporates a thin-film circuit and nanomembrane sensors, encapsulated in a hyperelastic elastomer. The soft elastomeric membrane offers an optimized adhesion that ensures a conformal lamination of stretchable electrodes on the skin for recording of high-fidelity biopotentials. The combined set of on-board Bluetooth module, front-end amplifier, and voltage regulator enables a real-time, long-range, wireless monitoring of physiological data, including ECG, heart rate (HR) and respiratory rate (RR). A pilot study with pediatric patients demonstrates the clinical feasibility of the device as a comfortable, reliable biopotential monitor, suggesting a new standard for safe and effective pediatric care.

Continuous Cardiac Monitoring Policy Implementation: Three-year Sustained Decrease of Hospital Resource Utilization.

Inappropriate cardiac monitoring leads to increased hospital resource utilization and alarm fatigue, which is ultimately detrimental to patient safety. Our institution implemented a continuous cardiac monitoring (CCM) policy that focused on selective monitoring for patients based on the American Heart Association (AHA) guidelines. The primary goal of this study was to perform a three-year median follow-up review on the longitudinal impact of a selective CCM policy on usage rates, length of stay (LOS), and mortality rates across the medical center. A secondary goal was to determine the effect of smaller-scale interventions focused on reeducating the nursing population on the importance of cardiac alarms. A system-wide policy was developed at The Ohio State University in December 2013 based on guidelines for selective CCM in all patient populations. Patients were stratified into Critical Class I, II, and III with 72 hours, 48 hours, or 36 hours of CCM, respectively. Pre- and post-implementation measures included average cardiac monitoring days (CMD), emergency department (ED) boarding rate, mortality rates, and LOS. A 12-week evaluation period was analyzed prior to, directly after, and three years after implementation. There was an overall decrease of 53.5% CMDs directly after implementation of selective CCM. This had remained stable at the three-year follow-up with slight increase of 0.5% (p = 0.2764). Subsequent analysis by hospital type revealed that the largest and most stable reductions in CMD were in noncardiac hospitals. The cardiac hospital CMD reduction was stable for roughly one year, then dipped into a lower stable level for nine months, then returned to the previous post-implementation levels. This change coincided with a smaller intervention to further reduce CMD in the cardiac hospital. There was no significant change in mortality rates with a slight decrease of 3.1% at follow-up (p = 0.781). Furthermore, there was no significant difference in LOS with a slight increase of 1.1% on follow-up (p = 0.649). However, there was a significant increase in ED boarding rate of 7.7% (p < 0.001) likely due to other hospital factors altering boarding times. Implementing selective CCM decreases average cardiac monitoring rate without affecting LOS or overall mortality rate. Selective cardiac monitoring is also a sustainable way to decrease overall hospital resource utilization and more appropriately focus on patient care.

Cryoballoon or Radiofrequency Ablation for Atrial Fibrillation Assessed by Continuous Monitoring: A Randomized Clinical Trial.

Advanced generation ablation technologies have been developed to achieve more effective pulmonary vein isolation (PVI) and minimize arrhythmia recurrence after atrial fibrillation (AF) ablation. We randomly assigned 346 patients with drug-refractory paroxysmal AF to contact force-guided radiofrequency ablation (CF-RF; n=115), 4-minute cryoballoon ablation (Cryo-4; n=115), or 2-minute cryoballoon ablation (Cryo-2; n=116). Follow-up was 12 months. The primary outcome was time to first documented recurrence of symptomatic or asymptomatic atrial tachyarrhythmia (AF, atrial flutter, or atrial tachycardia) between days 91 and 365 after ablation or a repeat ablation procedure at any time. Secondary end points included freedom from symptomatic arrhythmia and AF burden. All patients received an implantable loop recorder. One-year freedom from atrial tachyarrhythmia defined by continuous rhythm monitoring was 53.9%, 52.2%, and 51.7% with CF-RF, Cryo-4, and Cryo-2, respectively (P=0.87). One-year freedom from symptomatic atrial tachyarrhythmia defined by continuous rhythm monitoring was 79.1%, 78.2%, and 73.3% with CF-RF, Cryo-4, and Cryo-2, respectively (P=0.26). Compared with the monitoring period before ablation, AF burden was reduced by a median of 99.3% (interquartile range, 67.8%-100.0%) with CF-RF, 99.9% (interquartile range, 65.3%-100.0%) with Cryo-4, and 98.4% (interquartile range, 56.2%-100.0%) with Cryo-2 (P=0.36). Serious adverse events occurred in 3 patients (2.6%) in the CF-RF group, 6 patients (5.3%) in the Cryo-4 group, and 7 patients (6.0%) in the Cryo-2 group, with no significant difference between groups (P=0.24). The CF-RF group had a significantly longer procedure duration but significantly shorter fluoroscopy exposure (P<0.001 vs cryoballoon groups). In this multicenter, randomized, single-blinded trial, CF-RF and 2 different regimens of cryoballoon ablation resulted in no difference in 1-year efficacy, which was 53% by time to first recurrence but >98% burden reduction as assessed by continuous cardiac rhythm monitoring. URL: https://www.clinicaltrials.gov. Unique identifier: NCT01913522.