S-ICD reduced lead-related complications but was similar to TV-ICD with regard to non-lead-related complications, including inappropriate therapy. These results support the concept that S-ICD is a safe and effective alternative to TV-ICD in appropriate patients.

Purpose The most common complications of electrophysiology (EP) procedures are related to vascular access. Our study aims to conduct a meta-analysis comparing ultrasound (US)-guided vs. palpation-based technique for femoral venous access in EP procedures. Methods Electronic databases were searched and systematically reviewed for studies comparing femoral vein puncture with/ without US in EP procedures. The primary outcome was the rate of major vascular complications; secondary outcomes were minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time. Predefined subgroup analysis was conducted separately for patients undergoing pulmonary vein isolation procedure (PVI). A random-effects model was used to derive risk ratios (RR) with 95% confidence interval (CI). Results Nine studies involving 8232 patients met our inclusion criteria. Compared with the standard technique, the use of US reduced major vascular complications (from 2.01 to 0.71%, p < 0.0001). The rate of minor vascular complications (RR = 0.30, 95% CI, 0.14-0.62, p = 0.001) and inadvertent artery puncture were lower with US-guided puncture (RR = 0.31, 95% CI, 0.17-0.58, p = 0.0003). Puncture time was shorter (mean difference = − 92.1 s, 95% CI, − 142.12-− 42.07 s, p = 0.0003) and postprocedural groin pain was less frequent (RR = 0.57, 95% CI, 0.41-0.79, p = 0.0008) in the US group. Subgroup analysis of patients undergoing PVI also showed significant reduction of major vascular complications (RR = 0.27, 95% CI, 0.12-0.64, p = 0.003) and inadvertent artery puncture (RR = 0.35, 95% CI, 0.21-0.59, p < 0.0001). Conclusion Real-time US-guidance of femoral vein puncture in EP procedures is beneficial: it reduces major and minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time.

Atrio-esophageal fistula is an infrequent but devastating complication of catheter-based ablation of atrial fibrillation (AF). Thermal esophageal injury may be the precursor of atrio-esophageal fistula. Here, we evaluated the role of esophageal temperature monitoring in preventing thermal esophageal injury during pulmonary vein isolation for AF with radiofrequency energy. In this meta-analysis, we searched the PubMed, Cochrane, Scopus, Embase, and Refworks databases for all published studies from January 2004 to June 2016 to evaluate the role of esophageal temperature monitoring. We searched for terms esophageal temperature monitoring, AF, radiofrequency ablation, atrio-esophageal fistula, and thermal esophageal injury. We included studies comparing luminal esophageal temperature (LET) monitoring with no LET monitoring during radiofrequency ablation of AF. We excluded studies in which post-ablation esophagogastroduodenoscopy (EGD) was not performed to identify esophageal thermal injuries. To perform the meta-analysis, we used Review Manager statistical software and a fixed-effects modeling to derive the outcomes. Given significant heterogeneity between the studies, we used meta-regression analysis to adjust for age and sex. We identified 4 non-randomized controlled trials that met our search criteria and included a total of 411 patients (n=235 in the LET monitoring group; n=176 in the no LET monitoring group) in the analysis. There were 21 (8.9%) patients with thermal esophageal injury in the LET monitoring group and 12 (6.8%) in the no LET monitoring group. The pooled odds ratio was 0.66 (0.23-1.89), indicating no statistically significant differences between the 2 groups with regard to esophageal injury. Because of the small sample size and the non-randomized nature of the trials, we observed significant heterogeneity in outcomes among the trials. The role of esophageal temperature monitoring in reducing the risk of esophageal thermal lesions during pulmonary vein isolation for AF has not been established, and more studies including randomized controlled trials are needed to assess its true impact.

Introduction Antiretrovirals have immensely increased the average life expectancy of HIV-positive patients. However, the incidence of QT interval prolongation and other arrhythmias has also increased. Methods Pubmed and Google Scholar were searched for relevant literature published between 1990 and 2019. Results and discussion HIV-positive patients with high viral load, low CD4 count, chronic inflammation, and autonomic neuropathy can develop QT interval prolongation. Another factor prolonging QT interval includes exposure to the HIV transactivator protein, which inhibits hERG K (+) channels controlling IKr K (+) currents in cardiomyocytes. Protease inhibitors inhibiting the CYP3A4 enzyme can also lead to QT interval prolongation. QT interval prolongation can potentially be exacerbated by opioids, antipsychotics, antibiotics, and antifungals, the adjunct medications often used in HIV-positive patients. Hepatic insufficiency in seropositive patients on antiretrovirals may also increase the risk of QT interval prolongation. Conclusion Baseline and follow-up EKG in the susceptible population is suggested.

Importance: Ischemic strokes pose a significant health burden. However, the etiology of between 20 and 40% of these events remains unknown. Left atrial appendage morphology may influence the occurrence of thromboembolic events.Design: A retrospective cross-sectional study was conducted to investigate the role of LAA morphology in patients with atrial fibrillation (AF) and cardioembolic-associated stroke and patients with cryptogenic stroke without atrial fibrillation. LAA morphology is classified into two groups: (1) simple (chicken-wing) vs. (2) complex (non-chicken wing) based on transesophageal echocardiography (TEE) findings. In addition to the LAA morphology, left atrial parameters, including orifice diameter, depth, emptying velocity, and filling velocity, were collected for both groups. Mathematical, computational models were constructed to investigate flow velocities in chicken-wing and non-chicken wing morphological patterns to assess LAA function further.Findings: TEE values for volume, size, emptying, and filling velocities were similar between simple and complex LAA morphology groups. Patients with cryptogenic stroke without coexisting AF were noted to have significantly higher rates of complex LAA morphology. Chicken-wing LAA morphology was associated with four-fold higher flow rate (kg/s) in computational simulations.Conclusions: Complex LAA morphology may be an independent contributing factor for cryptogenic strokes. Further studies are warranted to investigate the mechanism involved in LAA morphology and thromboembolic events.

Objective: High power short duration (HPSD) ablation strategy is proposed to be more effective than low power long duration (LPLD) for radiofrequency ablation of atrial fibrillation. Although small trials abound, data from a large cohort are lacking. This meta-analysis compares all the existing studies comparing these two approaches to evaluate perceived advantages of one over the other. Methods: A systematic search of PubMed, EMBASE, and Cochrane databases identified studies comparing HPSD to LPLD ablation. All the analyses used the random-effects model. Results: Ablation settings varied widely across 20 studies comprising 2,136 patients who underwent HPSD and 1,753 patients who underwent LPLD. The pooled incidence of atrial arrhythmia recurrence after HPSD ablation was 20% [95% confidence interval (CI): 0.16-0.25; I 2 =88%]. Atrial arrhythmia recurrences were significantly less frequent with HPSD ablation (incidence risk ratio=0.66; 95% CI: 0.49-0.88; I 2 =72%; p=0.004). Procedural, fluoroscopy, and ablation times were significantly shorter with HPSD ablation. First-pass pulmonary vein isolations (PVIs) were significantly more [odds ratio (OR)=2.94; 95% CI: 1.50-5.77; I 2 =89%; p=0.002), and acute pulmonary vein reconnections (PVRs) were significantly lesser (OR=0.41; 95% CI: 0.28-0.62; I 2 =62%; p<0.001) in the HPSD group. Although radiofrequency energy was significantly higher, esophageal thermal injuries (ETI) were lower with HPSD ablation. Acute complications, including steam-pops, were rare and statistically similar in both the groups. Conclusion: HPSD ablation enables faster first-pass PVI with fewer PVRs, similar ETI rates, rare collateral damage, and lower recurrence of atrial arrhythmia in the long term than LPLD. Randomized controlled studies with a larger cohort are indicated both to confirm the benefit of HPSD ablation and standardize the ablation protocol.

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Background Studies indicate that uninterrupted anticoagulation (UA) is superior to interrupted anticoagulation (IA) in the periprocedural period during catheter ablation of atrial fibrillation. Still IA is followed in many centers considering the bleeding risk. This meta‐analysis compares interrupted and uninterrupted direct oral anticoagulation during catheter ablation of atrial fibrillation. Methods A systematic search into PubMed, EMBASE, and the Cochrane databases was performed and five studies were selected that directly compared IA vs UA before ablation and reported procedural outcomes, embolic, and bleeding events. The primary outcome of the study was major adverse cerebro‐cardiovascular events. Results The meta‐analysis included 840 patients with UA and 938 patients with IA. Median follow‐up was 30 days. Activated clotting time (ACT) before first heparin bolus was significantly longer with UA (P = .006), whereas mean ACT was similar between the two groups (P = .19). Total heparin dose needed was significantly higher with IA (mean, ‒1.61; 95% CI, ‒2.67 to ‒0.55; P = .003). Mean procedure time did not vary between groups (P = .81). Overall complication rates were low, with similar major adverse cerebro‐cardiovascular event (P = .40) and total bleeding (P = .55) rates between groups. Silent cerebral events (SCEs) were significantly more frequent with IA (log odds ratio, ‒0.90; 95% CI, ‒1.59 to ‒0.22; P < .01; I2, 33%). Rates of major bleeding, minor bleeding, pericardial effusion, cardiac tamponade, and puncture complications were similar between groups. Conclusions UA during atrial fibrillation ablation has similar bleeding event rates, procedural times, and mean ACTs as IA, with fewer SCEs.