Riverside Methodist Hospital,OhioHealth

BACKGROUND:Guidelines recommend a trial of antiarrhythmic drugs before catheter ablation for persistent atrial fibrillation. Whether pulsed field ablation (PFA) may be a preferred initial treatment is unclear. METHODS:We conducted an international, randomized trial involving patients with previously untreated persistent atrial fibrillation. The patients were randomly assigned in a 2:1 ratio to receive PFA performed with a pentaspline catheter or to receive antiarrhythmic-drug therapy. An additional group of patients (PFA-assigned) underwent PFA for the analysis of the primary safety end point alone. All the patients received an insertable cardiac monitor. The primary effectiveness end point was the short-term and long-term success of treatment through 12 months. Short-term success was defined as procedural success in the PFA group and the absence of ablation during the blanking period (90 days after treatment initiation) in the antiarrhythmic-drug group. Long-term success was defined as freedom from recurrence of atrial arrhythmias, repeat ablation, or need for antiarrhythmic drugs from 90 days through 12 months (in the PFA group) and freedom from amiodarone use at any time. The primary safety end point was device- and procedure-related serious adverse events. RESULTS:At 12 months, treatment success was observed in 128 of 207 patients (Kaplan-Meier estimate, 56%; 95% confidence interval [CI], 48 to 63) in the PFA group and in 40 of 103 patients (Kaplan-Meier estimate, 30%; 95% CI, 21 to 40) in the antiarrhythmic-drug group (hazard ratio for composite treatment failure [a lack of short- and long-term success], 0.46; 95% CI, 0.33 to 0.65; P<0.001). A primary safety end-point event occurred in 13 of 257 patients (5.1%) in the combined PFA group (both randomized and PFA-assigned groups). At 12 months, serious adverse events had occurred in 45 patients (25%) in the PFA group and in 20 patients (21%) in the antiarrhythmic-drug group. CONCLUSIONS:Among patients with persistent atrial fibrillation, the risk of recurrence of atrial arrhythmia was significantly lower among those who received PFA as first-line treatment than among those who received antiarrhythmic-drug therapy. (Funded by Boston Scientific; AVANT GUARD ClinicalTrials.gov number, NCT06096337.).

Abstract Introduction Chronic cough is defined as a cough lasting longer than 8 weeks and has a prevalence of approximately 8% in the United States. Common causes include upper airway cough syndrome, asthma, and gastroesophageal reflux disorder. These patients typically have concurrent fatigue, disturbed sleep, urinary incontinence, and other complications related to persistent coughing. Rarely, patients with chronic coughs may experience neuronally mediated syncope, which should prompt evaluation and treatment to reduce the risk of further complications. Case A 56-year-old male with a past medical history of tobacco use disorder, chronic cough, and syncopal episodes presented to establish care with a new primary care provider. The patient was recently admitted following a motor vehicle crash secondary to syncope after a large bout of coughing. The hospitalization evaluation consisted of an echocardiogram to ensure no cardiac etiology of the syncope which was unrevealing. Further history obtained by the primary care provider revealed similar syncopal episodes that started 5 years prior to presentation with no formal diagnosis made. Pulmonary function testing was ordered and the patient was noted to have very severe obstruction with reduced diffusing capacity, consistent with emphysema. Partial reversibility was noted post-bronchodilator treatment with improvement of forced expiratory volume in 1 second by 9%. Previous complete blood count was notable for peripheral eosinophilia. Additional workup was also significant for severe obstructive sleep apnea. The patient was subsequently initiated on triple inhaler therapy with tiotropium-budesonide-formoterol as well as nighttime positive pressure therapy, and on reevaluation reported improvement in chronic cough. Since initiation of treatment for the bronchoconstriction and sleep apnea, patient denied any recurrence of syncopal episodes. Discussion This case highlights syncope as a rare, but previously documented complication of chronic cough. While chronic cough may be initially dismissed, it warrants further workup and management of the underlying condition. Often times, underlying causes of chronic cough can be treated, and allow patients to find relief of their symptoms and complications. In this case, workup was initiated early given the patient’s high risk of serious harm in the setting of syncope while operating a vehicle. As such, the patient saw no more episodes requiring medical care evaluation or hospitalization. In addition to improvement in the patient’s symptoms and quality of life, prompt evaluation and treatment of chronic cough may be associated with significant cost-savings for these patients given their high healthcare utilization rates. This abstract is funded by: None

BackgroundIn 2019, the American Society of Extracorporeal Technology (AmSECT) approved the inaugural Standards and Guidelines for Pediatric and Congenital Perfusion Practice. These standards and guidelines were created with the intent of periodic revision to ensure continued alignment with evolving best practices. In 2023, an AmSECT subcommittee initiated this review in consideration of the current literature and contemporary clinical practices.MethodsThe subcommittee, consisting of pediatric and congenital perfusionists, conducted a systematic literature review assessing each standard and guideline to determine if current evidence supports elevation of guidelines to standards, incorporation of new guidelines or standards, or whether existing standards and guidelines should remain unchanged. AmSECT's adult Standards and Guidelines for Perfusion Practice (2023) updates were also considered. Proposed revisions were reviewed by the 2024 AmSECT International conference attendees, AmSECT Pediatric and Congenital Perfusion Committee, AmSECT Fellows of Pediatric Perfusion (FPP), and the AmSECT International Consortium for Evidence-Based Perfusion (ICEBP).ResultsRegarding pediatric and congenital specific changes, 5 guidelines were elevated to standards, and 3 new guidelines and 1 standard were introduced. Additionally, 5 patient safety-related standards and 1 additional guideline were adopted from the Standards for Perfusion Practice (2023) document.ConclusionOver the course of 2 years, consisting of an extensive literature review and feedback from multiple stakeholders, the 2025 update to the Standards and Guidelines for Pediatric and Congenital Perfusion Practice was approved by AmSECT leadership, ratified by an AmSECT membership vote, and subsequently endorsed by the Congenital Heart Surgeons' Society.

Abstract Background and aims Mobile Stroke Units (MSUs) may accelerate enrollment and early trial processes in intracerebral hemorrhage (ICH), but their impact on enrollment efficiency, feasibility, and safety in randomized trials remains incompletely defined. Methods FASTEST was a multicenter randomized trial enrolling patients with spontaneous ICH. In this secondary analysis, patients were categorized as direct MSU enrollment (enrolled entirely on MSU), MSU-facilitated enrollment (identification and initial management on MSU but enrollment in the ED), or non-MSU enrollment. Enrollment efficiency was assessed by time from symptom onset to randomization and by site-level enrollment rates during MSU-available versus MSU-unavailable periods. Issues with MSU enrollment and adverse events were evaluated. Comparisons were conducted using nonparametric tests for continuous variables and χ2 or Fisher's exact tests for categorical variables. Results Among 100 patients enrolled across 13 MSU sites, 38 were enrolled via MSU pathways (17 direct MSU; 21 MSU-facilitated). Median onset-to-randomization time was shorter for MSU-associated enrollments compared with non-MSU enrollments (93 [IQR 26] vs 111.5 [IQR 19] minutes; p<0.001), with a higher proportion enrolled within 90 minutes (36.8% vs 17.7%; p=0.032). Among MSU-associated enrollments, issues were infrequent, with isolated cases of weight estimation error and study kit issues (each 2.6%), with 94.7% having no identified issues. Rates of thromboembolic events did not differ between the two groups. At the site level, enrollment rates during MSU-available periods were higher than during MSU-unavailable periods (0.188 (SD=0.20) vs 0.057 (SD=0.04) enrollments per 10 days), representing a 0.131 relative increase. Conclusions MSUs were associated with faster enrollment, higher enrollment efficiency, and acceptable safety. Conflict of interest