Treatment of Obstructive Sleep Apnea Reduces the Risk of Atrial Fibrillation Recurrence After Catheter Ablation

ObjectivesThe aim of this study was to examine the effect of continuous positive airway pressure (CPAP) therapy on atrial fibrillation (AF) recurrence in patients with obstructive sleep apnea (OSA) undergoing pulmonary vein isolation (PVI).BackgroundOSA is a predictor of AF recurrence following PVI. However, the impact of CPAP therapy on PVI outcome in patients with OSA is poorly known.MethodsAmong 426 patients who underwent PVI between 2007 and 2010, 62 patients had a polysomnography-confirmed diagnosis of OSA. While 32 patients were “CPAP users” the remaining 30 patients were “CPAP nonusers.” The recurrence of any atrial tachyarrhythmia, use of antiarrhythmic drugs, and need for repeat ablations were compared between the groups during a follow-up period of 12 months. Additionally, the outcome of patients with OSA was compared to a group of patients from the same PVI cohort without OSA.ResultsCPAP therapy resulted in higher AF-free survival rate (71.9% vs. 36.7%; p = 0.01) and AF-free survival off antiarrhythmic drugs or repeat ablation following PVI (65.6% vs. 33.3%; p = 0.02). AF recurrence rate of CPAP-treated patients was similar to a group of patients without OSA (HR: 0.7, p = 0.46). AF recurrence following PVI in CPAP nonuser patients was significantly higher (HR: 2.4, p < 0.02) and similar to that of OSA patients managed medically without ablation (HR: 2.1, p = 0.68).ConclusionsCPAP is an important therapy in OSA patients undergoing PVI that improves arrhythmia free survival. PVI offers limited value to OSA patients not treated with CPAP

Cardiogenic shock due to right ventricular infarction

Case report on the findings in a patient in whom clinical suspicion and hemodynamic monitoring made possible the recognition and successful treatment of shock due to acute right ventricular infarction

Prevention of AV Nodal Reentry Tachycardia by Oral Amiodarone: An Alternative Mechanism of Action

A 73-year-old man was noted to have atrioventricular (AV) nodal reentry tachycardia, which was induced during programmed electrical stimulation. After 1 month of oral amiodarone therapy, AV nodal reentry tachycardia was prevented by the prolongation of atrial refractoriness and not by direct action on the AV node itself. (Texas Heart Institute Journal 1987; 14:99-101

Outcome after cardiac arrest during acute myocardial infarction

A community-wide study of acute myocardial infarction (AMI) was conducted in all 16 acute-care general hospitals in the Worcester, Massachusetts, metropolitan area during the years 1975, 1978, 1981 and 1984. The in-hospital and long-term prognoses of 667 patients with AMI complicated by cardiac arrest (CA) was compared with that of 2,596 AMI patients without CA. The incidence of CA complicating AMI was similar (21%) during each of the 4 study years. Among patients with AMI who had CA, 36% had CA within the first day of hospitalization and 48% within the first 2 days. The in-hospital case-fatality rate was much higher for AMI patients with CA (78%) than for those without CA (4%) (p less than 0.001). For patients discharged alive from the hospital, a trend toward a higher mortality rate was seen at 1 and 2 years after hospital discharge for patients with CA; however, long-term survival rates were not significantly different between AMI patients with and without CA. When time of occurrence of CA relative to in-hospital survival was examined, patients with early CA (within 1 day or within 2 days of hospital admission) had a significantly greater in-hospital survival (39% and 34%) than did those with late CA (after 1 day or after 2 days) (13% and 12%). Similarly, patients discharged from the hospital after early CA had a significantly better chance of long-term survival than patients discharged after late CA

Amiodarone for refractory atrial fibrillation

Atrial fibrillation (AF) is a difficult arrhythmia to manage with antiarrhythmic agents. Amiodarone is highly effective in restoring and maintaining normal sinus rhythm in patients with AF. However, the mechanism and predictors of efficacy for amiodarone in treating AF have not been adequately addressed. Various measures of success or failure of amiodarone therapy were examined in 68 patients who had paroxysmal or chronic, established AF refractory to conventional antiarrhythmic agents. The patients were 25 to 75 years old (mean 59) and mean follow-up was 21 months (range 3 to 56). Maintenance amiodarone dosages were 200 to 400 mg/day. Overall, amiodarone therapy was effective long term in 54 of the 68 patients (79%). Left atrial diameter, age, gender and origin of AF were not helpful in predicting success or failure of amiodarone therapy. The presence of chronic AF for longer than 1 year was an adverse factor in maintaining normal sinus rhythm (p = 0.007), although the success rate even in this group was relatively high (57%). Thirty-five percent of the patients had adverse effects, which precluded long-term therapy with amiodarone in 10%

Pulmonary embolism, pulmonary hemorrhage and pulmonary infarction

We compared 41 patients with angiographic proof of pulmonary embolism and clinical signs of pulmonary infarction (as evidenced by an infiltrate on x-ray study and pleuritic pain in the area of the embolus) with 24 patients with pulmonary embolism but without infarction. Only 18 of the 41 patients with pulmonary infarction had associated heart disease. Pulmonary infarction was uncommon when emboli obstructed central arteries but frequent when distal arteries were occluded. Follow-up x-ray examination showed that the infiltrates resolved in the patients with pulmonary infarction without heart disease, but persisted when heart disease was present. We suggest that obstruction of distal arteries results in pulmonary hemorrhage owing to an influx of bronchial arterial blood at systemic pressure. Hemorrhage causes symptoms and x-ray changes usually attributed to pulmonary infarction. However, hemorrhage resolves without infarction in patients without, but progresses to infarction in those with, heart disease

Chronic tocainide therapy for refractory high-grade ventricular arrhythmias

Tocainide, an oral analog of lidocaine, was evaluated as a long-term antiarrhythmic agent in 21 patients with symptomatic complex ventricular ectopic activity (10 with hemodynamically significant ventricular tachycardia) refractory to currently available antiarrhythmics singly, and in combination for periods of 3 days to 35 months (mean 13.6 months). Tocainide appeared to be an effective and safe agent for the control of these refractory symptomatic ventricular arrhythmias in 14 of the 21 patients (66%). Minor central nervous system and gastrointestinal side effects were present in most of the patients, usually early on in therapy, and only precluded long-term use in 2 patients. Furthermore, lidocaine responsiveness was a good predictor of tocainide effectiveness in this group of patients. Tocainide precipitated atrioventricular (A-V) block in one patient with pre-existing A-V nodal disease; two patients developed a skin rash while on tocainide therapy. These two patients had previously developed lupus-like syndromes and skin rashes while on procainamide. The ANA titers had been falling in these two patients while on tocainide, and in one of these patients with true systemic lupus erythematosus, rechallenge with tocainide failed to produce skin rash. Tocainide\u27s long plasma half-life and high oral bioavailability permit an 8-h regime. We conclude that tocainide is an effective, safe antiarrhythmic agent with tolerable side effects

Fatal pulmonary hemorrhage after use of the flow-directed balloon-tipped catheter

The flow-directed balloon-tipped catheter is extensively used in intensive care units, catheterization laboratories, operating rooms, and emergency wards. Major complications associated with its use have not been frequently reported. In a recent 2-year period in four hospitals, we identified five cases of fatal pulmonary hemorrhage resulting from balloon-tipped catheters. We review here four additional cases previously cited in the literature and discuss possible mechanisms and predisposing factors associated with this complication and guidelines for safe use of these catheters. Pulmonary artery rupture is probably commoner than previously reported

Use of ergonovine to identify esophageal spasm in patients with chest pain

We administered intravenous ergonovine maleate to 14 patients with chest pain resembling angina pectoris and to four healthy volunteers. Five of the patients experienced their typical chest pain after ergonovine, and manometric signs of esophageal spasm also developed. The remaining nine patients and the four volunteers did not experience chest pain, but all subjects except one had some symptomatic response to ergonovine, including chest warmth or heaviness, headache, mild choking sensation, facial numbness, flushing, or nausea. Two of the nine patients and one of the four volunteers developed manometric signs of esophageal spasm after ergonovine but experienced no chest pain. Intravenous ergonovine may be useful to identify esophageal spasm in selected patients with chest pain who have normal coronary arteries or in whom coronary artery disease is insufficient to explain symptoms. However, we believe that the potential risks of ergonovine do not justify its routine use as a provocative agent for esophageal spasm

Evaluation of an emergency cardiac transport system

A university-based cardiac transport system was developed for the safe transfer of critically ill cardiac patients from community hospitals to a tertiary care facility. During the first year of operation, 50 patients were transported, 41 (82%) by ambulance and 9 (18%) by helicopter, from 24 hospitals in four New England states. The average response time from hospital request to transport team arrival was 75 minutes. Seventy-eight percent of these patients were unstable at the time of transfer. Hypotension or cardiogenic shock (39%), ventricular tachycardia or fibrillation (16%), and severe and recurrent chest pain (12%) were the most common conditions for which the team was summoned. Forty-six percent required invasive procedures for stabilization prior to transport, and one-third of patients required active intervention, including defibrillation, during transfer to the tertiary care facility. The majority (62%) of transferred patients underwent significant hospital procedures, and 75% of admitted patients were discharged from the hospital. Our initial experience indicates that transport of critically ill cardiac patients in need of advanced care can be accomplished in a rapid and efficient manner with a relatively good short-term prognosis