BACKGROUND The incidence of atrial fibrillation (AF) is lower in nonwhites than in whites despite a higher burden of AF risk factors. However, the incidence of new AF after cryptogenic stroke in minorities is unknown.OBJECTIVE The purpose of this study was to determine the incidence of AF after cryptogenic stroke in different racial/ethnic groups.METHODS We retrospectively analyzed 416 consecutive patients undergoing insertable cardiac monitor implantation at our hospital from 2014 through 2019. Incidence of AF was identified through the review of device monitoring, including adjudication of AF episodes for accuracy, and compared by race.
RESULTSThe mean follow-up time was 1.5 6 1.1 years. The predominantly nonwhite cohort included 244 (59%) blacks and 109 (26%) Hispanics, and 45% (n5189) were male. The mean age was 62 6 12 years; Blacks and Hispanics had more hypertension, diabetes, and chronic kidney disease and higher body mass index than did whites. In blacks and Hispanics, the cumulative incidences of AF at 1, 2, and 3 years were 14.1%, 19.9%, and 24% and 12.9%, 18.3%, and 20.9%, respectively. By comparison, the incidence in whites was significantly higher: 20.8%, 34.3%, and 40.3%. In a Cox proportional hazards model adjusting for common AF risk factors, blacks (hazard ratio 0.49; confidence interval 0.26-0.82; P 5 .03) and Hispanics (hazard ratio 0.39; confidence interval 0.18-0.83; P 5 .01) were less likely to have incident AF than whites.CONCLUSION In patients with an insertable cardiac monitor after cryptogenic stroke, the incidence of newly detected AF is approximately double in whites compared with both blacks and Hispanics. This has important implications for the investigation and treatment of nonwhites with cryptogenic stroke.
Atrial fibrillation (AF) is a triggered rhythm, and ablation of the trigger is a common strategy for rhythm control. We describe a patient with symptomatic AF who was found to have episodes of AF triggered by premature ventricular complexes, likely by retrograde atrioventricular nodal conduction. (
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Background: Despite increasingly sicker patients and changes in perioperative techniques, the contemporary era of simultaneous heart kidney transplantation (HKT) has not been well described. We report intraoperative characteristics, postoperative medical management and causes of death in patients undergoing HKT at a single center. Methods: Patients undergoing HKT between 2009 and 2015 at Temple University Hospital were identified through review of the electronic medical record and the UNOS registry. Demographics, cause of cardiomyopathy and renal failure, comorbidities and need for preoperative dialysis, mechanical circulatory support (MCS) and inotropes were identified. Cardiac allograft ischemic time and type of immunosuppression therapy were collected. Incidence of treated rejection and death was measured. Results: Six patients underwent HKT, with average age of 61.7 ± 9.1 years. Four were male. Causes of cardiomyopathy included transplant vasculopathy (n = 3), ischemic cardiomyopathy (n = 2) and non ischemic cardiomyopathy (n = 1). Overlapping causes of renal failure were identified, including the cardiorenal syndrome (n = 3), diabetic nephropathy (n = 1), drug toxicity (one calcineurin, one vancomycin), and acute tubular necrosis (n = 2). Prior to HKT, two patients required inotropes, two MCS and two dialysis. All patients received induction immunosuppression (two basiliximab and four alemtuzumab). Average cardiac allograft ischemic and pump times were 157.6 ± 35.5 min and 185.6 ± 58.5 min respectively. One patient was treated for cardiac rejection and one for kidney rejection within the first year. One was initiated on dialysis more than 5 years after HKT. Two patients died within the first year due to sepsis and multiorgan failure. The remaining four were alive at the last clinic visit, median 801 days after HKT. Conclusions: At our center, most patients undergoing HKT required advanced hemodynamic support, with either MCS or inotropes. Causes of cardiomyopathy and renal failure were varied. One year mortality remains high in the first year after transplant and appears related to infectious complications in this sick population. Further research is required to delineate the ideal perioperative strategy regarding immunosuppression and Intraoperative management.
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