BACKGROUND:We present a case of Watchman device extrusion from left atrial appendage (LAA) free wall 6 months after implantation in a patient with longstanding persistent atrial fibrillation. CASE SUMMARY:A 74-year-old male with longstanding persistent atrial fibrillation of 15 years duration was implanted with a Watchman device as he cannot be on long-term oral anticoagulation due to a history of multiple falls. Six months post implantation, repeat transesophageal echocardiogram revealed a thrombus on the epicardial aspect of LAA and a large posterior pericardial effusion. The patient subsequently underwent surgical removal of both the LAA and the protruding Watchman device. DISCUSSION:In the case we present, the patient developed a clinically significant pericardial effusion 6 months after the Watchman device implantation, accompanied by left atrial extrusion, which was not reported to our knowledge. TAKE-HOME MESSAGE:Complications of Watchman devices respect no timeline boundaries and should be kept in mind when evaluating cardiac tamponade in patients with an implanted Watchman device.

Subclinical atrial fibrillation (SCAF) episodes are frequently detected in patients with cardiac implantable electronic devices (CIEDs). These asymptomatic arrhythmias are increasingly recognized as potential harbingers of clinical atrial fibrillation and thromboembolic events. However, the management of SCAF—particularly regarding the use of oral anticoagulation (OAC)—remains controversial. This literature review (Medline, Scopus, Goggle scholar, Embase) focuses on using current literature and clinical studies to guide decision-making regarding anticoagulation therapy and other treatment options that can limit complications for patients with SCAF. The decision to initiate anticoagulation in patients with atrial high-rate episodes (AHREs) should be individualized, balancing stroke risk against bleeding potential. Ongoing research and post hoc analyses will further clarify which subgroups may benefit most from therapy, informing future guideline recommendations.

Bundle branch re-entrant (BBR) tachycardia is an uncommon form of ventricular tachycardia (VT). This arrhythmia typically occurs in patients with a structural heart disease, especially dilated cardiomyopathy, and significant conduction system impairment, although affected patients with a structurally normal heart or normal conduction system have been reported. The QRS morphology during tachycardia can vary; it typically has a left bundle branch block (LBBB) morphology in which the antegrade conduction is over the right bundle and the retrograde limb is over the left bundle. The reverse of this circuit results in a right bundle branch block (RBBB) QRS morphology. A re-entrant circuit also can utilize interfascicular conduction, such as antegrade conduction over the left anterior fascicle and retrograde conduction up the left posterior fascicle or vice versa. Although there are reports of BBR tachycardia and interfascicular VT occurring in the same patient, to our knowledge, there are no prior reports of BBR tachycardia that has both LBBB and RBBB morphologies in the same patient. This case illustrated a BBR tachycardia with both left bundle and right bundle branch morphologies occurring in a patient with a non-dilated left ventricle.

Abstract Background Pericardiocentesis offers a definitive diagnostic and a life-saving therapeutic modality through removal of pericardial fluid and relief of high intrapericardial pressure. Percutaneous pericardiocentesis has been performed via different approaches depending on different institutional experiences. In this paper, we present our institutional experience and review the current literature of the different approaches for performing percutaneous pericardiocentesis. Materials and methods We evaluated consecutive patients who underwent echocardiographic-guided pericardiocentesis via the apical approach for pericardial effusion between the period of April 1st, 2022, and April 1st, 2023, at University of Arkansas for Medical Sciences (UAMS). Health records were reviewed for clinical presentations, available imaging findings, procedural outcomes, and short-term follow up. Results A total of eight consecutive cases of pericardiocentesis via the apical approach were found. Seven were successful. No complications were reported. Six patients had evidence of tamponade physiology on echocardiogram. Conclusion Historically, pericardiocentesis has been most performed via the subxiphoid approach. However, an ultrasound-guided apical approach offers a safe and effective alternative and may be preferable in patients with challenging anatomies.

AIMS:While factors associated with adverse events are well elucidated in setting of isolated left ventricular dysfunction, clinical and imaging-based prognosticators of adverse outcomes are lacking in context of biventricular dysfunction. The purpose of this study was to establish role of clinical variables in prognosis of biventricular heart failure (HF), as assessed by cardiac magnetic resonance imaging. METHODS:Study cohort consisted of 840 patients enrolled in DERIVATE registry with coexisting CMR-derived right ventricular (RV) and left ventricular (LV) dysfunction, as defined by RV and LV ejection fractions ≤45 % and ≤ 50 %, respectively. The primary objective was to identify factors associated with adverse long-term outcomes, defined as composite of all-cause death and HF hospitalizations (DHFH). Kaplan-Meir curves were plotted for survival analysis. Cox proportional hazard models were constructed to estimate adjusted hazard ratios (aHRs) and associated 95 % confidence intervals for clinical variables and their correlation with adverse events. RESULTS:Mean age was 61.0 years; 83.1 % were male, 26.6 % had diabetes mellitus (DM), and 45.9 % had non-ischemic cardiomyopathy. At median follow-up of 2 years, DHFH occurred in 32.5 % of the cohort. Kaplan-Meir analysis showed higher rate of DHFH in patients with DM (35.2 % vs. 22.6 %, p < 0.001). Multivariate Cox regression analysis showed that DM was independently associated with DHFH (aHR 1.61 [95 % CI: 1.15-2.25]; p = 0.003). Importantly, ACE-inhibitor/ARB usage in patients with DM was associated with significant reduction in DHFH (aHR 0.53 [95 % CI: 0.31-0.90]; p = 0.02). CONCLUSION:In patients with biventricular HF, DM was a strong predictor of DHFH, with ACE-inhibitor/ARB usage having cardioprotective effect.

Adoption and outcomes for conduction system pacing (CSP), which includes His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), in real-world settings are incompletely understood. We sought to describe real-world adoption of CSP lead implantation and subsequent outcomes. We performed an online cross-sectional survey on the implantation and outcomes associated with CSP, between November 15, 2020, and February 15, 2021. We described survey responses and reported HBP and LBBAP outcomes for bradycardia pacing and cardiac resynchronization CRT indications, separately. The analysis cohort included 140 institutions, located on 5 continents, who contributed data to the worldwide survey on CSP. Of these, 127 institutions (90.7%) reported experience implanting CSP leads. CSP and overall device implantation volumes were reported by 84 institutions. In 2019, the median proportion of device implants with CSP, HBP, and/or LBBAP leads attempted were 4.4% (interquartile range [IQR], 1.9–12.5%; range, 0.4–100%), 3.3% (IQR, 1.3–7.1%; range, 0.2–87.0%), and 2.5% (IQR, 0.5–24.0%; range, 0.1–55.6%), respectively. For bradycardia pacing indications, HBP leads, as compared to LBBAP leads, had higher reported implant threshold (median [IQR]: 1.5 V [1.3–2.0 V] vs 0.8 V [0.6–1.0 V], p = 0.0008) and lower ventricular sensing (median [IQR]: 4.0 mV [3.0–5.0 mV] vs. 10.0 mV [7.0–12.0 mV], p < 0.0001). In conclusion, CSP lead implantation has been broadly adopted but has yet to become the default approach at most surveyed institutions. As the indications and data for CSP continue to evolve, strategies to educate and promote CSP lead implantation at institutions without CSP lead implantation experience would be necessary.

Sudden cardiac death (SCD) caused by ventricular tachyarrhythmias is a significant contributor to cardiovascular deaths worldwide. Implantable cardioverter-defibrillators (ICDs) have shown efficacy in preventing and reducing mortality from SCD, but traditional transvenous ICDs have inherent challenges and drawbacks, such as lead fractures, lead-associated endocarditis, and lead failure. To address these issues, subcutaneous ICDs (S-ICDs) have been developed. S-ICDs lack pacing capacity but are a valid alternative for patients at high risk for infection or with difficult venous access. Pre-implantation screening can help prevent inappropriate device shocks. We present a case in which a patient received inappropriate S-ICD therapy, which was attributed to the triple counting of P-, R-, and T-waves in a patient with sinus rhythm. This is an unusual occurrence, and, to the best of our knowledge, there are only a limited number of case reports documenting inappropriate shocks due to the oversensing of P-waves and T-waves.

Background: Hemorrhagic pericardial effusion (HPE) is an infrequently encountered entity. We present here a challenging case of HPE. Case: A 67-year-old woman with history of hypothyroidism presented with dyspnea, chest discomfort, chills since 2 weeks. She had received mRNA-1273 vaccine 7 days prior to presentation. Vitals were notable for a heart rate of 136/min, otherwise she was hemodynamically stable. Physical exam was notable for muffled heart sounds. Decision-making: Labs showed a hemoglobin of 9.6 g/dL, C reactive protien(CRP) of 93.80 mg/L, normal thyroid profile and troponin, and a negative COVID-19 PCR. ECG was suggestive of sinus tachycardia. An Echocardiogram showed ejection fraction of 55-60% and large pericardial effusion with tamponade physiology. Emergent pericardiocentesis was done, removing 940 mL of sanguineous fluid. Pericardial fluid showed predominantly red blood cells;cytology was negative for malignant cells. Infectious workup for fungal, viral, tuberculosis and bacterial infections, and antibody testing as a part of rheumatologic workup was negative. A CT of the chest, abdomen and pelvis did not show any evidence of malignancy. She remained hemodynamically stable and was discharged on colchicine and ibuprofen. The patient did well on follow up at one month. Conclusion: Despite extensive workup, underlying etiology of HPE was not identified. As the symptoms preceded vaccination, the likelihood of vaccine-induced pericarditis and HPE was deemed low. [Formula presented]

The outcomes of patients with Wolf Parkinson White (WPW) pattern are usually benign. However, a small subset has atrial fibrillation/flutter (AF), which may progress into ventricular fibrillation leading to cardiac arrest/sudden cardiac death. Data on outcomes among AF patients with WPW is limited to single-center studies.

Atrial fibrillation (AF) is dependent on epicardial fat (EpF) accumulation and infiltration. Complementary therapeutic strategies specifically targeting EpF present an opportunity for slowing progression and reversing the course of AF. A 73-year-old man with a history paroxysmal AF (managed by rate control/anticoagulation), severe aortic valve stenosis (AVS, area 1cm 2 , EF 55%), controlled hypertension, diabetes, and obesity (BMI 37.9) completed a 2-month cardiometabolic health program (CHP). The ‘tech plus touch’ CHP, delivered via a smartphone, utilized a comprehensive approach with physiological, nutritional, and behavioral components. Along with patented dietary regimens and nutritional supplementation implemented with personalized treatment algorithms, the CHP included direct daily engagement (messaging & telehealth) with a staff clinician via the HIPAA compliant mobile app. Patient data visible to both the patient and staff clinician was synced automatically via Bluetooth-linked devices. EpF dropped by 25.5% over 9w (transthoracic echo, Fig1). BMI, visceral adiposity, and body fat were significant reduced, while lean body mass (LBM), muscle mass (MM) and intracellular fluid (ICF, a validated surrogate of chronic inflammation) improved (Fig1). Encouragingly, LBM, MM, and ICF improvements were unusual and particularly large in this older, physically inactive patient. Other clinical risk factors improved including diabetes, kidney function and inflammation. The patient reported resolution of chest pain and dyspnea, improved cardiorespiratory fitness, and began aerobic exercise. Our data demonstrate a nonpharmacologic complementary approach produces significant reductions of EpF and modifiable risk factors linked to hypertension, diabetes, and chronic inflammation in an AF patient with AVS and metabolic syndrome. Whether this will lead to a reduction in AF burden or conversion to persistent AF, remains to be determined.

Anticoagulation to reduce thromboembolic stroke risk due to nonvalvular atrial fibrillation in ESKD is associated with increased bleeding. There is an existing debate in ESKD centers around the pros and cons of anticoagulation. We propose percutaneous left atrial appendage occlusion as a third alternative to balance thrombosis and bleeding risks in this high-risk population.

Implantable cardioverter-defibrillators (ICDs) and CRT-defibrillator (CRT-D) improve survival in indicated patients with left ventricular ejection fraction (LVEF) less than 35%. Approximately 75% of patients with ICD implantation for primary prevention do not experience an appropriate ICD Tachyarrhythmia Therapy (ITT) in the initial generator lifespan. The role of continued arrhythmia monitoring and therapies(and need for generator change) in those with improved left ventricular ejection fraction(LVEF) is not well studied.

Catheter ablation (CA) of typical atrial flutter (AFL) is the preferred treatment for typical AFL due to its excellent long-term success rate.However, current guidelines recommend pursuing oral anticoagulation (OAC) based on established indices of stroke regardless of the perceived success of ablation.We conducted a retrospective study of all patients who underwent typical AFL ablation at our institute from 2011 to 2017.All patients continued OAC for at least six weeks post-CA and underwent 24-hour Holter monitoring.OAC was discontinued if there was no evidence of recurrence at six weeks.In patients with low left ventricular ejection fraction or prior atrial fibrillation episodes, OAC was continued for six months with repeat Holter monitoring at six months.A total of 106 patients were included in our analysis, with a mean age of 64 ± 14 years and 78.3% of whom were male.The mean CHA 2 DS 2 -VASc score was 3 ± 1 points.OAC was discontinued by six weeks in 17% and at one year in 55.7% of patients, respectively, but was continued indefinitely in 44.3%.Over a mean follow-up period of 28.6 ± 27.3 months, there was one ischemic stroke in the OAC discontinuation group and no ischemic events in the continued OAC group.There were a total of three major bleeding events, all in the OAC group.In patients undergoing successful AFL ablation, a strategy of OAC discontinuation with close rhythm monitoring appears feasible.The benefit of continued OAC in this cohort may be outweighed by an adverse risk of bleeding.Further studies examining rhythm-guided OAC can minimize unnecessary exposure to long-term anticoagulation.

The incidence of complete heart block (CHB) has been reported to be 1 in 15,000–20,000 live births. According to a study done by Reid and colleagues,1 30% of cases of congenital heart block remain undiscovered until adulthood. Hence, most CHBs found in pregnancy are usually congenital heart blocks that are diagnosed for the first time during the first pregnancy or puerperium. However, acquired CHB usually occurs after 50 years of age.2 Management of maternal CHB requires a multidisciplinary approach involving cardiologists, obstetricians, anesthesiologists, and neonatologists.

Randomized controlled trials (RCTs) of sacubitril/valsartan have suggested possible clinical benefit among patients with heart failure with preserved ejection fraction (HFpEF). The phase II PARAMOUNT (Prospective comparison of ARNI with ARB [angiotensin-receptor blockers] on Management Of HFpEF) trial found sacubitril/valsartan to significantly reduce natriuretic peptide concentrations and left atrial size, compared with valsartan. 1 Solomon SD Zile M Pieske B Voors A Shah A Kraigher-Krainer E Shi V Bransford T Takeuchi M Gong J Lefkowitz M Packer M McMurray JJV The angiotensin receptor neprilysin inhibitor LCZ696 in heart failure with preserved ejection fraction: a phase 2 double-blind randomised controlled trial. Lancet. 2012; 380: 1387-1395 Abstract Full Text Full Text PDF PubMed Scopus (770) Google Scholar In the PARAGON-HF (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in HFpEF) trial, although sacubitril/valsartan did not meet the primary endpoint of a statistically significant reduction in total HF hospitalizations or cardiovascular death, the p-value was marginal and results trended towards benefit. 2 Solomon SD McMurray V, JJ Anand IS Ge J Lam CSP Maggioni AP Martinez F Packer M Pfeffer MA Pieske B Redfield MM Rouleau JL van Veldhuisen DJ Zannad F Zile MR Desai AS Claggett B Jhund PS Boytsov SA Comin-Colet J Cleland J Düngen H Goncalvesova E Katova T Saraiva JFK Lelonek M Merkely B Senni M Shah SJ Zhou J Rizkala AR Gong J Shi VC Lefkowitz MP Angiotensin–Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction. N Engl J Med. 2019; 381: 1609-1620 Crossref PubMed Scopus (624) Google Scholar Most recently, in the PARALLAX-HF (A Randomized, Double-blind Controlled Study Comparing LCZ696 to Medical Therapy for Comorbidities in HFpEF Patients; NCT03066804) trial, 3 Wachter R Shah SJ Cowie MR Szecsödy P Shi V Ibram G Zhao Z Gong J Klebs S Pieske B Angiotensin receptor neprilysin inhibition versus individualized RAAS blockade: design and rationale of the PARALLAX trial. ESC Heart Fail. 2020; 7: 856-864 Crossref PubMed Scopus (19) Google Scholar compared with individualized medical therapy (predominantly valsartan and enalapril), sacubitril/valsartan met the co-primary endpoint of reduction in natriuretic peptide concentration without a benefit on other primary or secondary outcomes. However, post hoc analyses of PARALLAX-HF suggested potential improvement in clinical outcomes. In the context of mixed clinical trial results, the goal of the present meta-analysis was to combine data from existing RCTs to derive a more reliable estimate of the potential benefit of sacubitril/valsartan in HFpEF.

The debate in this issue of Kidney360 addresses the question of oral anticoagulation for stroke prevention in patients with atrial fibrillation (AF) and ESKD on hemodialysis. This is an important topic that remains a considerable source of debate. AF is highly prevalent among patients on hemodialysis. The annual incidence of subclinical new-onset AF is 19%, whereas the annual incidence of new-onset or recurrent AF may be as high as 26% in this population (1). In addition, AF is associated with higher morbidity and mortality in patients with advanced CKD, compared with patients with preserved kidney function, with an overall mortality rate up to 40% at 2 years (2). Although use of oral anticoagulants is highly beneficial for stroke prevention in the general population or patients with moderate CKD and AF, there is a lack of high-quality randomized data in patients with advanced CKD or ESKD. Therefore, available evidence comes from retrospective observational studies that are notoriously unreliable to estimate treatment effects. Let us see what our debaters have to say about one of the most difficult conundrums for the experts. On the pro side of the debate, Devabhaktuni and Mounsey highlight the results from a nationwide registry in Denmark, including 907 patients on maintenance hemodialysis. In this study, published in the New England Journal, patients treated with warfarin had a lower risk of stroke or systemic embolism, compared with patients who did not receive any antithrombotic therapy (3). In addition, Devabhaktuni and Mounsey discuss observational data from a prevalent dialysis population with AF from the United States Renal Data system, showing apixaban may be associated with a lower incidence of major bleeding compared with warfarin, and may therefore constitute a reasonable alternative in this population (4). They also highlight a potential mortality benefit from apixaban compared with no anticoagulation identified in a retrospective cohort study from the United States Renal Data system with an incident dialysis population with new-onset AF (5). On the con side of the debate, Bansal and Lidgard discuss the important limitations of observational studies due to selection bias and confounding by indication. They present results from a meta-analysis including 20 observational studies, showing that patients treated with oral anticoagulation have a higher incidence of any stroke and major bleeding compared with no anticoagulation (6). Bansal and Lidgard also highlight how challenging it is to achieve adequate time in the therapeutic range for patients on hemodialysis treated with warfarin. Indeed, according to preliminary results from the RENAL-AF trial (Renal Hemodialysis Patients Allocated Apixaban Versus Warfarin in Atrial Fibrillation) presented at the American Heart Association 2019 meeting, time in therapeutic range was only 44% with a significant proportion of patients in the subtherapeutic range. The reason for this variability in the intensity of anticoagulation is not entirely clear, and it might be due, at least in part, to kidney disease–specific dietary restrictions. So, what should nephrologists caring for patients with AF on maintenance dialysis take away from this debate? In my opinion, use of warfarin for stroke prevention in this setting is hard to justify for most patients, unless another compelling indication exists, such as venous thromboembolism or a metallic valve. Although available observational studies may have underestimated treatment effects, there is accumulating evidence that warfarin may be harmful in this setting. In addition to a higher incidence of bleeding complications, of particular importance is calciphylaxis, a life-threatening syndrome of vascular calcification that is 3–13 times as common among warfarin users, probably due to the warfarin-induced deficiency of vitamin K–dependent calcification inhibitors (7). Moreover, any potential benefit may be hard to obtain because it proves very difficult to achieve adequate time in the therapeutic range for most patients, even in the well-monitored setting of a randomized trial, as mentioned above. If warfarin is not an option for patients on hemodialysis with AF, should direct oral anticoagulants (DOACs) be considered in this setting? There are several important points that have to be discussed with respect to use of these agents in patients with severely impaired kidney function. First, all DOACs are not the same. These agents have different mechanisms of action or different degrees of renal elimination, and they should not be grouped together in observational studies or meta-analyses. Second, if these agents were ever to be widely used in patients on hemodialysis, some degree of dose adjustment would probably prove to be necessary, as suggested by pharmacokinetic studies with repeated administration of rivaroxaban and apixaban in this population (8–9). Dose adjustment is also supported by differential treatment effect with standard and reduced doses of rivaroxaban and apixaban in this setting (5,10), and by a recently published randomized trial comparing rivaroxaban at the dose of 10 mg daily with warfarin (11). Unfortunately, results from single-dose pharmacokinetic studies have been widely diffused and cited, despite the fact that these studies are unable to account for drug accumulation occurring with repeated administration. Third, mortality benefit with apixaban in observational studies has to be interpreted with caution. This is most likely due to selection bias not accounted for by propensity score matching. This was acknowledged by the authors of the study showing this finding, who also report a numerically lower risk for outcomes that should not be influenced by anticoagulation, such as hospital admission for pneumonia or hip fracture, with apixaban compared with no anticoagulation (5). Fourth, careful selection of patients that may benefit from anticoagulation is necessary and requires more accurate prognostic scores for stroke and bleeding risk than we currently have (12). Fifth, relevant outcomes have to be carefully selected. If any benefit from ischemic stroke reduction is offset by a higher incidence of intracranial or fatal bleeding in this population, a composite outcome of ischemic or hemorrhagic stroke may be more relevant than the traditionally selected outcome of ischemic stroke or thromboembolism. It does not really matter to our patients if their hemiplegia or aphasia is due to a blood clot or an intraparenchymal hematoma. In addition, dialysis access bleeding is a clinically relevant complication that has not been adequately studied. Sixth, antiplatelet agents may have to be discontinued in patients who will be started on oral anticoagulation (12). Last, but not least, rivaroxaban or apixaban have to be compared in a randomized trial with no anticoagulation, and not with warfarin. Warfarin may significantly increase bleeding in the control arm and mask potential harm with DOACs in this setting. In a recently published observational study, apixaban was not associated with a lower incidence of stroke, but was associated with a higher incidence of fatal or intracranial bleeding compared with no anticoagulation (5). For all reasons mentioned above, in my view, it is also hard to justify use of rivaroxaban or apixaban for stroke prevention for the majority of patients on hemodialysis with AF. Randomized data are necessary before such a recommendation can be made. However, if this approach is selected for a patient on hemodialysis because they are considered to be at very high risk of stroke, I would suggest using the reduced dose of 2.5 mg twice a day for apixaban or 10 mg daily for rivaroxaban, and consider obtaining a factor Xa trough level a couple of weeks after drug initiation. Although the target range remains largely unknown for these agents, overtly subtherapeutic or supratherapeutic levels would probably be identified. A thrombosis specialist might be involved for the interpretation of drug trough levels. This strategy should not be widely implemented, at least for now, and may be considered only in selected patients after careful assessment of risks and benefits. The SAFE-D trial (Strategies for the Management of Atrial Fibrillation in Patients Receiving Dialysis) (NCT03987711) is a randomized study that will compare different anticoagulation strategies (apixaban, warfarin, and no anticoagulation) in patients with AF on maintenance dialysis. Although at a pilot stage for now, this trial shows the way to proceed, and the investigators should be complimented for their effort. A phase 3 trial will ultimately be needed to answer this critical question, and such a study will have to be investigator initiated and will require international collaboration to be completed. The need for randomized trials of anticoagulation in end-stage kidney disease has been highlighted, at least since 2014 (13). Almost a decade later, the challenge for the nephrology community is still ahead. Disclosures T.A. Mavrakanas reports receiving honoraria from Daiichi Sankyo and BMS Canada, outside the submitted work. Funding This work was supported by the Department of Medicine, McGill University.