BACKGROUND Many of the drugs being used in the treatment of the ongoing pandemic coronavirus disease 2019 (COVID-19) are associated with QT prolongation. Expert guidance supports electrocardiographic (ECG) monitoring to optimize patient safety.OBJECTIVE The purpose of this study was to establish an enhanced process for ECG monitoring of patients being treated for COVID-19.METHODS We created a Situation Background Assessment Recommendation tool identifying the indication for ECGs in patients with COVID-19 and tagged these ECGs to ensure prompt over reading and identification of those with QT prolongation (corrected QT interval . 470 ms for QRS duration 120 ms; corrected QT interval . 500 ms for QRS duration . 120 ms). This triggered a phone call from the electrophysiology service to the primary team to provide management guidance and a formal consultation if requested.RESULTS During a 2-week period, we reviewed 2006 ECGs, corresponding to 524 unique patients, of whom 103 (19.7%) met the Situation Background Assessment Recommendation tool-defined criteria for QT prolongation. Compared with those without QT prolongation, these patients were more often in the intensive care unit (60 [58.3%] vs 149 [35.4%]) and more likely to be intubated (32 [31.1%] vs 76 [18.1%]). Fifty patients with QT prolongation (48.5%) had electrolyte abnormalities, 98 (95.1%) were on COVID-19-related QT-prolonging medications, and 62 (60.2%) were on 1-4 additional non-COVID-19-related QT-prolonging drugs. Electrophysiology recommendations were given to limit modifiable risk factors. No patient developed torsades de pointes.CONCLUSION This process functioned efficiently, identified a high percentage of patients with QT prolongation, and led to relevant interventions. Arrhythmias were rare. No patient developed torsades de pointes.
Accurate assessment of the left atrial appendage (LAA) is important for pre-procedure planning when utilizing device closure for stroke reduction. Sizing is traditionally done with transesophageal echocardiography (TEE) but this is not always precise. Three-dimensional (3D) printing of the LAA may be more accurate. 24 patients underwent Watchman device (WD) implantation (71 ± 11 years, 42% female). All had complete 2-dimensional TEE. Fourteen also had cardiac computed tomography (CCT) with 3D printing to produce a latex model of the LAA for pre-procedure planning. Device implantation was unsuccessful in 2 cases (one with and one without a 3D model). The model correlated perfectly with implanted device size (R = 1; p < 0.001), while TEE-predicted size showed inferior correlation (R = 0.34; 95% CI 0.23-0.98, p = 0.03). Fisher's exact test showed the model better predicted final WD size than TEE (100 vs. 60%, p = 0.02). Use of the model was associated with reduced procedure time (70 ± 20 vs. 107 ± 53 min, p = 0.03), anesthesia time (134 ± 31 vs. 182 ± 61 min, p = 0.03), and fluoroscopy time (11 ± 4 vs. 20 ± 13 min, p = 0.02). Absence of peri-device leak was also more likely when the model was used (92 vs. 56%, p = 0.04). There were trends towards reduced trans-septal puncture to catheter removal time (50 ± 20 vs. 73 ± 36 min, p = 0.07), number of device deployments (1.3 ± 0.5 vs. 2.0 ± 1.2, p = 0.08), and number of devices used (1.3 ± 0.5 vs. 1.9 ± 0.9, p = 0.07). Patient specific models of the LAA improve precision in closure device sizing. Use of the printed model allowed rapid and intuitive location of the best landing zone for the device.
IntroductionThe wearable cardioverter-defibrillator (WCD) is used in patients at risk for sudden cardiac death (SCD) but not immediate candidates for intracardiac defibrillator (ICD) implantation.MethodsWe performed a single center retrospective study of patients prescribed WCD upon hospital discharge from January 2002 to October 2015. Clinical characteristics were obtained from the hospital electronic database and device data from Zoll LifeVest database.ResultsOf 140 patients, 62% were men, 85.9% were African-American and mean age was 58.2 ± 15.5 years. Ischemic cardiomyopathy was present in 45 (32%) and non-ischemic cardiomyopathy in 64 patients (46%). Mean left ventricular ejection fraction (EF) was 0.28 ± 0.4. WCD was worn for 7657 patient-days (21 patient-years), with each patient using WCD for median of 43 days (IQR: 7–83 days), and daily mean use 17.3 ± 7.5 h. There were a total of 6 (4.2%) WCD shocks of which 2 (1.4%) were appropriate (one for VT, one for VF) and 4 (2.8%) were inappropriate (2 had supraventricular tachycardia, 2 had artifact). Two patients who received appropriate shocks were African-American with non-ischemic cardiomyopathy (EF<20%), non-sustained VT and wide QRS duration. Upon termination of WCD use, 45 (32%) received ICD while EF improved in 34 patients (32%).ConclusionsIn a predominantly minority, community setting, WCD compliance is high and use is effective in aborting SCD. However, inappropriate shocks do occur. A significant proportion of patients did not ultimately require ICD implantation suggesting this may be a cost-effective strategy in patients at risk of SCD.
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