Publications by authors named "Danesh Kella"

33 Publications

A Network Meta-Analysis Comparing Osteoporotic Fracture among Different Direct Oral Anticoagulants and Vitamin K Antagonists in Patients with Atrial Fibrillation.

J Bone Metab 2021 May 31;28(2):139-150. Epub 2021 May 31.

Department of Cardiology, Sri Jayadeva Institute of Cardiac Sciences and Research, Bengaluru, India.

Background: There are limited studies comparing the risk of osteoporosis and fractures between different direct oral anticoagulants (DOACs) and vitamin K antagonists (VKA) in non-valvular atrial fibrillation (AF). Using a network meta-analysis (NMA), we compared osteoporotic fractures among 5 different treatment arms, viz. dabigatran, rivaroxaban, apixaban, edoxaban, and VKA.

Methods: Ten studies, including 5 randomized control trials and 5 population-based studies, with a total of 321,844 patients (148,751 and 173,093 in the VKA and DOAC group, respectively) with a median follow-up of 2 years, were included. A Bayesian random-effects NMA model comparing fractures among the treatment arms was performed using MetInsight V3. Sensitivity analysis excluded studies with the highest residual deviances from the NMA model.

Results: The mean age of the patients was 70 years. The meta-analysis favored DOACs over VKA with significantly lower osteoporotic fracture (odds ratio [OR], 0.77; 95% credible interval [CrI], 0.70-0.86). The NMA demonstrated that fractures were significantly lower with apixaban compared with dabigatran (OR, 0.64; 95% CrI, 0.44-0.95); however, fractures were statistically similar between apixaban and rivaroxaban (OR, 0.84; 95% CrI, 0.58-1.24) and dabigatran and rivaroxaban (OR, 1.32; 95% CrI, 0.90-1.87). Based on the Bayesian model of NMA, the probability of osteoporotic fracture was highest with VKA and lowest with apixaban, followed by rivaroxaban, edoxaban, and dabigatran.

Conclusions: The decision to prescribe anticoagulants in elderly patients with AF should be made not only based on thrombotic and bleeding risks but also on the risk of osteoporotic fracture; these factors should be considered and incorporated in contemporary cardiology practice.
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http://dx.doi.org/10.11005/jbm.2021.28.2.139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8206613PMC
May 2021

Subcutaneous implantable cardioverter-defibrillator electrode fracture: Follow-up, troubleshooting, and evaluation.

J Cardiovasc Electrophysiol 2021 May 19;32(5):1452-1457. Epub 2021 Mar 19.

Division of Clinical Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA.

The subcutaneous-implantable cardioverter-defibrillator (S-ICD) and its electrode were developed to avoid long-term complications of transvenous leads in the vasculature. We report a case of unexpected, inappropriate S-ICD shocks due to oversensing of high-amplitude, nonphysiologic, electrical noise artifacts that were not preceded by high-impedance alerts or sensing electrogram noise detections. Following explant, high-magnification X-ray imaging of the S-ICD electrode demonstrated partial fracture of the distal sensing conductor located near a short radius bend in the electrode at the electrode-header interface. Clinicians should be aware of a potential for fatigue failure fracture of the S-ICD electrode. Recommendations for systematic S-ICD follow-up and troubleshooting are discussed.
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http://dx.doi.org/10.1111/jce.14994DOI Listing
May 2021

Renal Dysfunction following Direct Current Cardioversion of Atrial Fibrillation: Incidence and Risk Factors.

Cardiorenal Med 2021 9;11(1):27-32. Epub 2020 Dec 9.

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA,

Introduction: Emerging data suggest that cardioversion for atrial fibrillation (AF) may be associated with acute kidney injury (AKI). However, limited data are available regarding the incidence and risk factors for AKI after direct current cardioversion (DCCV) of AF.

Methods: All patients undergoing DCCV at Mayo Clinic between 2001 and 2012 for AF were prospectively enrolled in a database. All patients with serum creatinine (SCR) values pre- and post-cardioversion were reviewed for AKI, defined as a ≥25% decline in eGFR (estimated glomerular filtration rate) from baseline value within 7 days of the DCCV.

Results: Of the 6,427 eligible patients, 1,256 (19.5%) patients had pre- and post-DCCV SCR available and formed the cohort under study. The mean age was 70.4 (SD 11.7) years, and 67.3% were male. During the study period, 131 (10.4%) patients suffered from AKI following DCCV. AKI was independently associated with inpatient status (OR 26.79; 95% CI 3.69-194.52), CHA2DS2-VASc score (OR 1.25; 95% CI 1.11-1.41), prior use of diuretics (OR 1.59; 95% CI 1.03-2.46), and absence of CKD (OR 1.61; 95% CI 1.04-2.49), and was independent of the success of the DCCV. None of the patients required acute dialysis during the study outcome period.

Conclusion: AKI following DCCV of AF is common, self-limited, and without the need for replacement therapies.
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http://dx.doi.org/10.1159/000507566DOI Listing
December 2020

MRI in patients with cardiac implantable electronic devices: A comprehensive review.

Pacing Clin Electrophysiol 2021 02 9;44(2):360-372. Epub 2021 Jan 9.

Department of Cardiac Electrophysiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India.

Magnetic resonance imaging (MRI) has become a commonly used non-ionizing radiation dependent imaging modality which has an excellent spatial resolution with the capability to provide physiological information. Cardiac implantable electronic devices (CIEDs) are used in modern cardiology with a frequency of 1:50 over 75 years of age and nearly one in three people in this population required MRI during their lifetime. Changes in the CIED structure, electronics, and algorithms paired with changes in the protocol design of MRI have created a relatively safe environment for performing MRI in patients with CIED. Despite their documentation in literature and a guideline document from a professional society, significant skepticism exists in doing MRI in patients with CIEDs. We intend to give an overview of interactions between MRI and CIEDs, including the evidence available in this regard and conclude with the suggestion of a protocol for safely carrying out an MRI in patients with CIEDs.
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http://dx.doi.org/10.1111/pace.14141DOI Listing
February 2021

Prospective evaluation of the utility of magnetic resonance imaging in patients with non-MRI-conditional pacemakers and defibrillators.

J Cardiovasc Electrophysiol 2020 11 31;31(11):2931-2939. Epub 2020 Aug 31.

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.

Background: Magnetic resonance imaging (MRI) in patients with legacy cardiovascular implantable electronic devices (CIEDs) in situ is likely underutilized. We hypothesized the clinical benefit of MRI would outweigh the risks in legacy CIED patients.

Methods: This is a single-center retrospective study that evaluated and classified the utility of MRI using a prospectively maintained database. The outcomes were classified as aiding in diagnosis, treatment, or both for the patients attributable to the MRI. We then assessed the incidence of adverse effects (AE) when the MRI was performed.

Results: In 668, MRIs performed on 479 patients, only 13 (1.9%) MRIs did not aid in the diagnosis or treatment of the patient. Power-on reset events without clinical sequelae in three scans (0.45%) were the only AE. The probability of an adverse event happening without any benefit from the MRI scan was 1.1 × 10 . A maximum benefit in diagnosis using MRI was obtained in ruling out space-occupying lesions (121/185 scans, 65.4%). Scans performed in patients for elucidating answers to queries in treatment were most frequently done for disease staging at long term follow-up (167/470 scans, 35.5%). Conservative treatment (184/470 scans, 39%) followed by medication changes (153/470 scans, 28.7%) were the most common treatment decisions made.

Conclusions: The utility of MRI in patients with non-MRI-conditional CIEDs far outweighs the risk of adverse events when imaging is done in the context of a multidisciplinary program that oversees patient safety.
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http://dx.doi.org/10.1111/jce.14705DOI Listing
November 2020

LV only pacing-mediated electrical storm with cardiac resynchronization therapy managed by simultaneous biventricular pacing.

J Cardiovasc Electrophysiol 2020 09 8;31(9):2539-2543. Epub 2020 Aug 8.

Clinical Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA.

Ventricular arrhythmia (VA) is a rare complication of cardiac resynchronization therapy (CRT). Little is known about ventricular proarrhythmia related to the pacing vector of CRT. This case report describes the elimination of ventricular arrythmia using biventricular pacing in a patient with VT-storm related to LV only pacing as part of the AdaptivCRT algorithm (Medtronic Inc). Simultaneous biventricular pacing was effective in eliminating polymorphic ventricular tachycardia. Changing the pacing vector is a noninvasive treatment strategy that should be considered to manage VA due to CRT.
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http://dx.doi.org/10.1111/jce.14697DOI Listing
September 2020

Fibroplasty (venoplasty) to facilitate transvenous lead placement: A single-center experience.

J Cardiovasc Electrophysiol 2020 09 20;31(9):2425-2430. Epub 2020 Jul 20.

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: Venous stenosis is a well-recognized complication of transvenous leads (TVLs) that is encountered during lead revisions or device upgrades. We here report the outcomes of TVL placement facilitated by fibroplasty or tunneling (TUN) procedure.

Methods: We conducted a single-center retrospective cohort study of all patients undergoing TVL implantation requiring fibroplasty or TUN from 2005 to 2017. Medical records and procedure reports were reviewed for relevant data. Outcomes for fibroplasty and TUN to facilitate TVL placement were compared.

Results: Sixty patients had fibroplasty and thirty-five patients had a TUN procedure. There was no difference in procedure success rates between the two groups (97% fibroplasty vs. 100% TUN; p = .98). The fluoroscopy time was longer (fibroplasty = 39.7 ± 21.5 min vs. TUN = 29.2 ± 21.3 min; p = .01) and the total procedural time was shorter in the fibroplasty group (fibroplasty = 247 ± 77.8 min vs. TUN = 287 ± 77.1 min; p = .01). TUN was associated with a significantly higher incidence of acute complications (fibroplasty = 0 vs. TUN = 8; p = .002) most requiring invasive intervention and/or transfusion with blood products. Long-term complications requiring additional device-related procedures were comparable between the two groups (fibroplasty = 6 vs. TUN = 6; logrank p = .21).

Conclusions: For patients with venous stenosis requiring additional TVL, balloon fibroplasty is associated with similar rates of success and a significantly decreased incidence of acute complications when compared with subcutaneous TUN.
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http://dx.doi.org/10.1111/jce.14655DOI Listing
September 2020

Defining the substrate for ventricular tachycardia ablation: The impact of rhythm at the time of mapping.

Indian Pacing Electrophysiol J 2020 Jul - Aug;20(4):147-153. Epub 2020 Mar 7.

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA. Electronic address:

Background: Voltage mapping is critical to define substrate during ablation. In ventricular tachycardia, abnormal potentials may be targets. However, wavefront of activation could impact local signal characteristics. This may be particularly true when comparing sinus rhythm versus paced rhythms. We sought to determine how activation wavefront impacts electrogram characteristics.

Methods: Patients with ischemic cardiomyopathy, ventricular tachycardia, and without fascicular or bundle branch block were included. Point by point mapping was done and at each point, one was obtained during an atrial paced rhythm and one during a right ventricular paced rhythm. Signals were adjudicated after ablation to define late potentials, fractionated potentials, and quantify local voltage. Areas of abnormal voltage (defined as <1.5 mV) were also determined.

Results: 9 patients were included (age 61.3 ± 9.2 years, 56% male, mean LVEF 34.9 ± 8.6%). LV endocardium was mapped with an average 375 ± 53 points/rhythm. Late potentials were more frequent during right ventricular pacing (51 ± 21 versus 32 ± 15, p < 0.01) while overall scar area was higher during atrial pacing (22 ± 11% vs 13 ± 7%, p < 0.05). In 1/9 patients, abnormal potentials were seen during a right ventricular paced rhythm that were not apparent in an atrial paced rhythm, ablation of which resulted in non-inducibility.

Conclusion: Rhythm in which mapping is performed has an impact on electrogram characteristics. Whether one rhythm is preferable to map in remains to be determined. However, it is possible defining local signals during normal conduction as well as variable paced rhythms may impart a greater likelihood of elucidating arrhythmogenic substrate.
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http://dx.doi.org/10.1016/j.ipej.2020.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371953PMC
March 2020

Sudden cardiac arrest and ventricular arrhythmias following first type I myocardial infarction in the contemporary era.

J Cardiovasc Electrophysiol 2019 12 17;30(12):2869-2876. Epub 2019 Oct 17.

Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona.

Introduction: Myocardial infarction (MI) is associated with an increase in subsequent heart failure (HF), recurrent ischemic events, sudden cardiac arrest, and ventricular arrhythmias (SCA-VA). The primary objective of the study to determine the role of intercurrent HF and ischemic events on the development of SCA-VA following first type I MI.

Methods And Results: A retrospective cohort study of patients experiencing first type 1 MI in Olmsted County, Minnesota (2002-2012) was conducted by identifying patients using the medical records linkage system (Rochester epidemiology project). Patients aged ≥18 years were followed from the time of MI till death or 31 July, 2017. Intercurrent HF and ischemic events were the primary exposures following MI and their association with outcome SCA-VA was assessed. Eight hundred and sixty-seven patients (mean age was 63 ± 14.5 years; 69% male; 49.8% ST-elevation myocardial infarction) who had their first type I MI during the study period were included. Majority of acute MI patients were revascularized using percutaneous coronary intervention and bypass surgery (628 [72.43%] and 87 [10.03%] respectively). During a mean follow-up of 7.69 ± 4.17 years, HF, recurrent ischemic events and SCA-VA occurred in 155 (17.9%), 245 (28.3%), and 40 (4.61%) patients respectively. Low ejection fraction (adjusted hazard ratio [HR] 0.95; 95% confidence interval [CI], 0.93-0.98; P < .001), intercurrent HF (adjusted HR 3.11; 95% CI, 1.39-6.95; P = .006) and recurrent ischemic events (adjusted HR 3.47; 95% CI, 1.68-7.18; P < .001) were associated with subsequent SCA-VA.

Conclusion: SCA-VA occurred in a small proportion of patients after MI and is associated with intercurrent HF and recurrent ischemic events.
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http://dx.doi.org/10.1111/jce.14218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276850PMC
December 2019

Lyme carditis atrioventricular block: management strategies-Authors' reply.

Europace 2019 08;21(8):1282

Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN, USA.

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http://dx.doi.org/10.1093/europace/euz111DOI Listing
August 2019

Safety of thoracic magnetic resonance imaging for patients with pacemakers and defibrillators.

Heart Rhythm 2019 11 29;16(11):1645-1651. Epub 2019 May 29.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: During magnetic resonance imaging (MRI), cardiac implantable electronic device (CIED) leads can be antennae to focus energy onto myocardium, leading to heating and arrhythmias. Clinical data on thoracic MRI safety for patients with legacy devices are limited.

Objective: The purpose of this study was to identify patients undergoing thoracic MRI with legacy devices, compare the incidence of adverse events of those patients with control patients undergoing brain MRI with legacy devices, and compare paired cardiac troponin T (cTnT) values.

Methods: In this single-center study, we reviewed a prospectively collected database of patients with CIED undergoing MRI from January 25, 2008, through February 28, 2017.

Results: Of 952 patients (1290 scans), 120 patients (12.6%) underwent 134 thoracic MRI scans with legacy CIEDs (median [range] age 61.98 [21.24-86.96] years; male 71.1%). Median (range; interquartile range [IQR]) age of leads across devices was 3.5 (1.6-7.1; 5.5) years; implantable cardioverter-defibrillators (ICDs) were oldest (median [range; IQR], 3.7 [1.1-8.0; 6.9] years). No difference was observed in incidence of adverse events between groups. Paired cTnT values were compared for 19 patients (19 scans) with no difference between pre- and postimaging values. No significant difference was present in device setting values before and after MRI (mean follow-up 72.5 days). Incidence of adverse events was no different after adjustment for ICD coil number.

Conclusion: Thoracic MRI is relatively safe in an institutional multidisciplinary program. It does not represent greater risk than brain MRI for patients with legacy CIEDs.
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http://dx.doi.org/10.1016/j.hrthm.2019.05.031DOI Listing
November 2019

Radiofrequency ablation of the cavotricuspid isthmus for management of atrial flutter in patients with congenital heart disease after tricuspid valve surgery: A single-center experience.

Heart Rhythm 2019 11 29;16(11):1621-1628. Epub 2019 Apr 29.

Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: Typical atrial flutter involving the cavotricuspid isthmus (CTI) is the most common reentrant arrhythmia in congenital heart disease and ablation is effective in its management. However, congenital heart disease patients often require surgical interventions on their tricuspid valve that utilize prosthetic material, making CTI ablation technically challenging.

Objective: To describe the techniques and outcomes of CTI ablation in the presence of prior tricuspid valve repair or replacement.

Methods: We included all patients who had undergone tricuspid valve repair utilizing an annuloplasty ring or tricuspid valve replacement who underwent CTI ablation for treatment of atrial arrhythmias between 2005 and 2017. Acute procedural success was defined as demonstration of bidirectional conduction block across the CTI. Long-term success was defined as lack of arrhythmia recurrence on monitoring or related symptoms.

Results: Sixteen patients met the inclusion criteria. Twelve (75%) patients had Ebstein's anomaly, 14 (88%) patients had a prosthetic tricuspid valve, and 2 (12%) patients had annuloplasty ring. Acute success was achieved in all cases, with no complications. Radiofrequency ablation was required on the ventricular side in 9 (56%) patients. In 1 case, ablation in the small cardiac vein was required. All patients remained free from atrial flutter during 18 months follow-up (range, 1-101 months).

Conclusion: Our study demonstrates the safety and efficacy of catheter ablation of the CTI in the presence of a tricuspid annuloplasty ring or a prosthetic tricuspid valve. This may require ablation from the ventricular side of the valve to target atrial tissue rendered inaccessible as a result of tricuspid valve surgery.
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http://dx.doi.org/10.1016/j.hrthm.2019.04.045DOI Listing
November 2019

Potentially modifiable factors of dofetilide-associated risk of torsades de pointes among hospitalized patients with atrial fibrillation.

J Interv Card Electrophysiol 2019 Mar 23;54(2):189-196. Epub 2018 Oct 23.

Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.

Purpose: There is a significant variation in the clinical approach of initiation and dose adjustment of dofetilide in atrial fibrillation (AF). Excessive QT prolongation could predispose patients to torsades de pointes (TdP), which can be fatal.

Methods: We performed a retrospective case-control study at Mayo Clinic Rochester (January 1, 2003 to December 31, 2016). "TdP risk" cases were defined as patients on dofetilide therapy for AF with subsequent TdP or excessive QTc prolongation requiring dose reduction or discontinuation (N = 31). A control group was matched 1:1 with cases by age, gender, year of admission, and dofetilide dose (N = 31).

Results: Using multivariate regression analysis, independent predictors of TdP risk included baseline QTc exceeding recommendations (adjusted odd ratio [AOR] 4.57; P = 0.023); underlying AF with rapid ventricular rate (AOR 16.95; P = 0.004); and diuretic therapy for acute heart failure (AOR 8.42; P = 0.007). Poor inter-observer agreement was identified among QT interval measurement in patients with AF and rapid ventricular rate compared to those in rate controlled AF or sinus rhythm. TdP risk cases receiving diuretics for acute heart failure had a significant decline in creatinine clearance than controls, although serum electrolytes and replacement did not differ among the two groups.

Conclusions: Excessive QTc prolongation and AF with rapid ventricular rate at time of dofetilide initiation (likely due to difficulty in measuring QT intervals), and diuretic therapy for acute heart failure were independent factors for dofetilide-related TdP risk. Based on these data, possible preventive strategies could be adapted for safety protocols among hospitalized patients.
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http://dx.doi.org/10.1007/s10840-018-0476-2DOI Listing
March 2019

Feasibility and safety of percutaneous epicardial access for mapping and ablation for ventricular arrhythmias in patients on oral anticoagulants.

J Interv Card Electrophysiol 2019 Jan 19;54(1):81-89. Epub 2018 Sep 19.

Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Purpose: This study aimed to assess the risk of procedure-related complications of percutaneous epicardial access (EpiAcc) for radiofrequency catheter ablation (RFA) of ventricular arrhythmias (VAs) in patients chronically treated oral anticoagulants (OACs) with warfarin compared to those not on OACs.

Methods: We analyzed 205 patients (53 ± 16 years, 155 males) undergoing percutaneous EpiAcc as part of an RFA for VAs, and compared the outcome between patients chronically on OACs with warfarin (OAC group) and those without (non-OAC group).

Results: Forty-seven patients (23%) were chronically treated on OACs before their procedure. EpiAcc in patients on OAC (OAC group) was not associated with an increased risk of cardiac tamponade (11% vs. 6%, p = 0.238) compared to non-OAC group, but a higher risk of need for blood transfusion (17% vs. 6%; p = 0.013). With respect to the OAC group, the international normalized ratio (INR) on the day of the RFA was ≥ 2.0 in 9 patients (19%) and < 2.0 in the remaining 38 patients (81%). The rate of all complication and blood transfusion were similar between them (11% vs. 21%; p = 0.496, 11% vs. 18%; p = 0.600).

Conclusion: Percutaneous EpiAcc in patients on chronic OAC with warfarin did not significantly increase the risk of cardiac tamponade, but was associated with a higher risk of need for blood transfusion. EpiACC in patients with an INR > 2.0 is reasonable in experienced hands when clinical indications are strong.
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http://dx.doi.org/10.1007/s10840-018-0441-0DOI Listing
January 2019

A case of paroxysmal atrioventricular block-induced cardiac arrest.

HeartRhythm Case Rep 2018 Sep 1;4(9):383-385. Epub 2018 Mar 1.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.1016/j.hrcr.2018.02.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140407PMC
September 2018

Sleep Duration and Risk of Fatal Coronary Heart Disease, Sudden Cardiac Death, Cancer Death, and All-Cause Mortality.

Am J Med 2018 12 1;131(12):1499-1505.e2. Epub 2018 Aug 1.

Institute of Public Health and Clinical Nutrition, Department of Medicine, University of Eastern Finland, Kuopio; Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland and Central Finland Hospital District, Department of Medicine, Jyväskylä.

Background: Sleep duration has been shown to be associated with all-cause mortality; however, its relationship with cause-specific fatal events remains uncertain. We examined the relationship between sleep duration and risk of fatal coronary heart disease, sudden cardiac death, cancer-related death, and all-cause mortality.

Methods: Sleep duration was self-reported at baseline examinations performed between March 20, 1984, and December 5, 1989, in 2361 men aged 42-61 years from the Kuopio Ischemic Heart Disease study. Of these, 1734 (73.4%) men were free from coronary heart disease and cancer at baseline.

Results: A total of 802 all-cause deaths, 202 fatal coronary heart disease events, 141 sudden cardiac events, and 229 cancer-related deaths were reported during a median follow-up of 25.9 (interquartile range, 20.6-28.2) years. Multivariable adjusted hazard ratios comparing the top quartile (>10 hours) of sleep duration vs the bottom quartile (<8 hours) was 1.19 (95% confidence interval [CI], 1.01-1.43) for all-cause mortality, 1.27 (95% CI, 0.88-1.84) for fatal coronary heart disease, 1.20 (95% CI, 0.78-1.86) for sudden cardiac death, and 1.29 (95% CI, 0.92-1.80) for cancer death. No differences in association of sleep duration with outcomes were found in clinically relevant subgroups, including age, history of coronary heart disease, body mass index, physical activity, and C-reactive protein levels.

Conclusions: Longer duration of sleep was associated with significantly increased all-cause mortality. The mechanistic link between these findings remains to be explored further.
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http://dx.doi.org/10.1016/j.amjmed.2018.07.010DOI Listing
December 2018

Leadless pacemaker used as long-term temporary therapy in Lyme carditis with high-grade atrioventricular block.

Europace 2019 Jan;21(1)

Division of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, USA.

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http://dx.doi.org/10.1093/europace/euy175DOI Listing
January 2019

Fast and the Furious: Electrogram Drift: Dynamic Analysis of Acquired Electrograms to Optimize Discrimination of Ventricular Tachycardia Substrate.

Circ Arrhythm Electrophysiol 2018 04;11(4):e006391

Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN.

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http://dx.doi.org/10.1161/CIRCEP.118.006391DOI Listing
April 2018

Safety of magnetic resonance imaging in patients with legacy pacemakers and defibrillators and abandoned leads.

Heart Rhythm 2018 02 16;15(2):228-233. Epub 2017 Oct 16.

Division of Cardiovascular Diseases, Rochester, Minnesota. Electronic address:

Background: During magnetic resonance imaging (MRI), abandoned leads may act as antennae that result in tissue heating and arrhythmia induction.

Objective: The purpose of this study was to assess the safety of MRI in patients with abandoned leads, with the addition of cardiac troponin T (cTnT) assessment to screen for myocardial damage.

Methods: We reviewed our prospectively collected database of patients with cardiovascular implantable electronic devices (CIEDs) undergoing MRI between 2008 and 2017 at Mayo Clinic, Rochester, MN, and selected patients who had abandoned leads. We compared the adverse events in this population with an age, sex, and site of MRI-matched cohort of patients selected from this database. We evaluated paired (before/after) cTnT values using MRI in these patients.

Results: Of 952 patients, 80 (8.4%) underwent 97 MRI scans with CIEDs in situ with 90 abandoned leads in place during the scans. The median age was 66 years (interquartile range 22.3 years) 66.1 years (interquartile range, Q1,Q3: 53.6, 75.9) with 66.3% (53 patients) men. There was no clinical or electrical evidence of CIED dysfunction, arrhythmias, or pain. Paired samples for the measurement of cTnT values were available in 40 patients undergoing 44 MRI examinations. The mean difference between the pre- and postimaging values was -0.002 ± 0.006 ng/mL (interquartile range 0). There was no difference after adjustment for total number of leads per patient and total number of implantable cardioverter-defibrillator coils.

Conclusion: There was no evidence of myocardial injury as measured by paired cTnT. The risk of MRI with abandoned leads appears low, suggesting a favorable risk-benefit profile in patients with CIEDs and abandoned leads who are considered for MRI.
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http://dx.doi.org/10.1016/j.hrthm.2017.10.022DOI Listing
February 2018

An Incidentaloma in the Cardiology Clinic.

Am J Med 2017 Apr;130(4):e149-e150

Department of Medicine, Emory University School of Medicine, Atlanta, Ga.

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http://dx.doi.org/10.1016/j.amjmed.2016.10.033DOI Listing
April 2017

False alarm reduction in critical care.

Physiol Meas 2016 08 25;37(8):E5-E23. Epub 2016 Jul 25.

Department of Biomedical Informatics, Emory University, Atlanta GA, USA. Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta GA, USA.

High false alarm rates in the ICU decrease quality of care by slowing staff response times while increasing patient delirium through noise pollution. The 2015 PhysioNet/Computing in Cardiology Challenge provides a set of 1250 multi-parameter ICU data segments associated with critical arrhythmia alarms, and challenges the general research community to address the issue of false alarm suppression using all available signals. Each data segment was 5 minutes long (for real time analysis), ending at the time of the alarm. For retrospective analysis, we provided a further 30 seconds of data after the alarm was triggered. A total of 750 data segments were made available for training and 500 were held back for testing. Each alarm was reviewed by expert annotators, at least two of whom agreed that the alarm was either true or false. Challenge participants were invited to submit a complete, working algorithm to distinguish true from false alarms, and received a score based on their program's performance on the hidden test set. This score was based on the percentage of alarms correct, but with a penalty that weights the suppression of true alarms five times more heavily than acceptance of false alarms. We provided three example entries based on well-known, open source signal processing algorithms, to serve as a basis for comparison and as a starting point for participants to develop their own code. A total of 38 teams submitted a total of 215 entries in this year's Challenge. This editorial reviews the background issues for this challenge, the design of the challenge itself, the key achievements, and the follow-up research generated as a result of the Challenge, published in the concurrent special issue of Physiological Measurement. Additionally we make some recommendations for future changes in the field of patient monitoring as a result of the Challenge.
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http://dx.doi.org/10.1088/0967-3334/37/8/E5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5017205PMC
August 2016

The PhysioNet/Computing in Cardiology Challenge 2015: Reducing False Arrhythmia Alarms in the ICU.

Comput Cardiol (2010) 2015 Sep;2015:273-276

Institute for Medical Engineering & Science, Massachusetts Institute of Technology, USA.

High false alarm rates in the ICU decrease quality of care by slowing staff response times while increasing patient delirium through noise pollution. The 2015 Physio-Net/Computing in Cardiology Challenge provides a set of 1,250 multi-parameter ICU data segments associated with critical arrhythmia alarms, and challenges the general research community to address the issue of false alarm suppression using all available signals. Each data segment was 5 minutes long (for real time analysis), ending at the time of the alarm. For retrospective analysis, we provided a further 30 seconds of data after the alarm was triggered. A collection of 750 data segments was made available for training and a set of 500 was held back for testing. Each alarm was reviewed by expert annotators, at least two of whom agreed that the alarm was either true or false. Challenge participants were invited to submit a complete, working algorithm to distinguish true from false alarms, and received a score based on their program's performance on the hidden test set. This score was based on the percentage of alarms correct, but with a penalty that weights the suppression of true alarms five times more heavily than acceptance of false alarms. We provided three example entries based on well-known, open source signal processing algorithms, to serve as a basis for comparison and as a starting point for participants to develop their own code. A total of 38 teams submitted a total of 215 entries in this year's Challenge.
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http://dx.doi.org/10.1109/CIC.2015.7408639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910643PMC
September 2015

EFFECTS OF RAMADAN FASTING ON BLOOD PRESSURE IN NORMOTENSIVE MALES.

J Ayub Med Coll Abbottabad 2015 Apr-Jun;27(2):338-42

Background: Research has been done to investigate the effect of intermittent complete fasting on human physiological parameters but the effect of fasting on blood pressure remains relatively unexplored. Research in animal models suggests a hypotensive effect with an undetermined mechanism. Muslims worldwide fast daily from dawn to dusk throughout the Islamic month of Ramadan. This study was to investigate the proposed hypotensive effect of Ramadan fasting in males over A period of 20 days and to study the relationship of the pattern of blood pressure variation with body mass index change.

Methods: A repeated measures observational study design was implemented with convenient sampling. Study group included 40 normotensive, non-smoker males with no known comorbidities between the ages of 18-40 who fasted daily in the month of Ramadan. One set of BP readings, each, was taken one week before the start of Ramadan and on the 7th, 14th and 21st day of Ramadan which included pre and post Iftar measurements along with other variables. Data was analysed by repeated measures ANOVA using SPSS. The differences were compared with critical values generated by Tukey's Method.

Results: There was a significant drop in systolic BP of 7.61 mmHg before Iftar, 2.72 mm-Hg after Iftar (p<0.005). There was a significant effect of Ramadan on diastolic BP (p<0.005), the drop being 3.19 mmHg. The drop in body mass index was significant only before Iftar at 0.3 kg/m2 (p<0.005). Pulse rate showed a significant drop of 7.79 bpm before Iftar and a significant rise of 3.96 bpm (p<0.005).

Conclusions: Intermittent fasting causes a drop in both systolic and diastolic blood pressure in normotensive males.
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October 2015

Cardiorespiratory fitness and atrial fibrillation: A population-based follow-up study.

Heart Rhythm 2015 Jul 14;12(7):1424-30. Epub 2015 Mar 14.

Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Lapland Central Hospital, Department of Internal Medicine, Rovaniemi, Finland.

Background: Atrial fibrillation (AF) is the most common arrhythmia worldwide and has a complex association with physical fitness. The relationship of cardiorespiratory fitness (CRF) with the risk for AF has not been previously investigated in population-based studies.

Objective: The purpose of this study was to determine the relationship of CRF with incident AF.

Methods: CRF, as assessed by maximal oxygen uptake (VO2max) during exercise testing, was measured at baseline in 1950 middle-aged men (mean age 52.6 years, SD 5.1) from the Kuopio Ischaemic Heart Disease (KIHD) study.

Results: During average follow-up of 19.5 years, there were 305 incident AF cases (annual AF rate of 65.1/1000 person-years, 95% confidence interval [CI] 58.2-72.8). Overall, a nonlinear association was observed between CRF and incident AF. The rate of incident AF varied from 11.5 (95% CI 9.4-14.0) for the first quartile of CRF, to 9.1 (95% CI 7.4-11.2) for the second quartile, 5.7 (95% CI 4.4-7.4) for the third quartile, and 6.3 (95% CI 5.0-8.0) for the fourth quartile. Age-adjusted hazard ratio comparing top vs bottom fourth of usual CRF levels was 0.67 (95% CI 0.48-0.95), attenuated to 0.98 (95% CI 0.66-1.43) upon further adjustment for risk factors. These findings were comparable across age, body mass index, history of smoking, diabetes, and cardiovascular disease status at baseline.

Conclusion: Improved fitness as indicated by higher levels of CRF is protective of AF within a certain range, beyond which the risk of AF rises again. These findings warrant further replication.
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http://dx.doi.org/10.1016/j.hrthm.2015.03.024DOI Listing
July 2015

Lesion-specific differences for implantable cardioverter defibrillator therapies in adults with congenital heart disease.

Pacing Clin Electrophysiol 2014 Nov 1;37(11):1492-8. Epub 2014 Jun 1.

Department of Medicine, Division of Cardiology, Emory University, Atlanta, Georgia.

Background: Sudden cardiac death is a major cause of late mortality in adults with congenital heart disease (ACHD). While data exist for adults with repaired Tetralogy of Fallot (TOF), little is known about those with non-TOF lesions. We examined the relative rates in implantable cardioverter defibrillator (ICD) therapy according to congenital lesion type in a large-volume adult congenital heart center.

Methods: A cohort of 59 individuals (median follow up time, 3.2 years range 0-10) with ACHD and ICDs was stratified according to underlying congenital lesion and implant indication. Appropriate therapies were defined as any therapy for a physician-adjudicated ventricular arrhythmia. Rates of inappropriate and appropriate ICD therapies were analyzed according to several relevant clinical variables.

Results: Thirty-three (56%) TOF, 15 (25.4%) L- or D-transposition of great arteries, and 11 (18.6%) with other lesions were included in the analysis. Approximately half (52.5%) were implanted for primary prevention indications. During follow-up, 12 (20.3%) patients received appropriate ICD therapies and 13 (22%) patients received inappropriate therapies. The incidence of appropriate shocks among patients with TOF was 27.3% (9/33) compared to 11.5% (3/26) among non-TOF diagnoses during the follow-up time (p = 0.043).

Conclusions: ACHD patients with non-TOF congenital lesions are significantly less likely to receive appropriate ICD therapy than those with TOF. Our analysis calls into question the validity of traditional ICD implantation guidelines in this growing and diverse patient population.
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http://dx.doi.org/10.1111/pace.12434DOI Listing
November 2014

Cardiac resynchronization therapy in adult patients with repaired tetralogy of fallot and left ventricular systolic dysfunction.

Pacing Clin Electrophysiol 2014 Mar 25;37(3):321-8. Epub 2013 Oct 25.

Emory University School of Medicine, Atlanta, Georgia.

Background: Although left ventricular (LV) systolic dysfunction is known to occur in adults with repaired Tetralogy of Fallot (TOF), the effects of cardiac resynchronization therapy (CRT) are not well characterized.

Methods: We retrospectively divided all patients with repaired TOF and impaired LV ejection fraction (LVEF ≤ 40%) undergoing CRT at our institution (n = 10) into two groups: de novo CRT (group A, n = 6) or upgrade from existing device (group B, n = 4). Echocardiograms were reviewed at baseline, medium-term (>6 months post-CRT), and long-term follow-up. CRT response was defined as reduction in LV end-systolic volume (LVESV) ≥15% at medium term.

Results: Age at surgical repair was 13.1 ± 16.0 years, age at CRT was 44.4 ± 12.5 years, and baseline LVEF was 24.0 ± 10.5%. Group A demonstrated a preponderance of right ventricular (RV) conduction delay, whereas all patients in group B demonstrated RV pacing at baseline. At medium-term follow-up, patients in group A showed significant improvements in LVEF, LV end-diastolic volume (LVEDV), and LVESV. Group B also demonstrated a significant improvement in LVEF with favorable trends in LV volumes. Of nine patients with complete data at medium term, eight showed evidence of CRT response. Average long-term follow-up was 53.4 ± 29.3 months. At long-term follow-up, LVEF, LVEDV, and LVESV remained numerically better than baseline, although the results were no longer significant.

Conclusions: Adult patients with repaired TOF and LV systolic dysfunction demonstrate significant medium-term response to CRT, even among those with RV conduction delay. The long-term impact of CRT in this population requires further characterization.
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http://dx.doi.org/10.1111/pace.12284DOI Listing
March 2014

New-onset atrial fibrillation after acute myocardial infarction and its relation to admission biomarkers (from the TRIUMPH registry).

Am J Cardiol 2013 Nov;112(9):1390-5

Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia. Electronic address:

Atrial fibrillation (AF) is an independent predictor of mortality after acute myocardial infarction (AMI). We analyzed the relation between biomarkers linked to myocardial stretch (NT-pro-brain natriuretic peptide [NT-proBNP]), myocardial damage (Troponin-T [TnT]), and inflammation (high-sensitivity C-reactive protein [hs-CRP]) and new-onset AF during AMI to identify patients at high risk for AF. In a prospective multicenter registry of AMI patients (from the Translational Research Investigating Underlying disparities in recovery from acute Myocardial infarction: Patients' Health status registry), we measured NT-proBNP, TnT, and hs-CRP in patients without a history of AF (n = 2,370). New-onset AF was defined as AF that occurred during the index hospitalization. Hierarchical multivariate logistic regression models were used to determine the association of biomarkers with new-onset AF, after adjusting for other covariates. New-onset AF was documented in 114 patients with AMI (4.8%; mean age 58 years; 32% women). For each twofold increase in NT-proBNP, there was an 18% increase in the rate of AF (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03 to 1.35; p <0.02). Similarly, for every twofold increase in hs-CRP, there was a 15% increase in the rate of AF (OR 1.15, 95% CI 1.02 to 1.30; p = 0.02). TnT was not independently associated with new-onset AF (OR 0.96, 95% CI 0.85 to 1.07; p = 0.3). NT-proBNP and hs-CRP were independently associated with new in-hospital AF after MI, in both men and women, irrespective of race. Our study suggests that markers of myocardial stretch and inflammation, but not the amount of myocardial necrosis, are important determinants of AF in the setting of AMI.
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http://dx.doi.org/10.1016/j.amjcard.2013.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323174PMC
November 2013

Stimulus intensity in left ventricular leads and response to cardiac resynchronization therapy.

J Am Heart Assoc 2012 Oct 25;1(5):e000950. Epub 2012 Oct 25.

Emory University School of Medicine, Atlanta, GA 30322, USA.

Background: Increased left ventricular (LV) stimulus intensity has been shown to improve conduction velocity and cardiac output. However, high-output pacing would shorten device battery life. Our prospective trial analyzed the clinical effects of high- versus low-output LV pacing.

Methods And Results: Thirty-nine patients undergoing initial cardiac resynchronization therapy device implantation with bipolar LV leads were assigned to 3 months of either high-output LV pacing (Hi) or low-output LV pacing (Lo) in a randomized, blinded crossover fashion. Hi and Lo settings were determined with a rigorous intraoperative protocol specific to each patient. Clinical and echocardiographic data were obtained at randomization, at 3 months, and a subsequent 3 months after crossover. Mean age was 66.4±9.8 years, and mean QRS duration was 159.3±23.1 ms. Compared to baseline, both arms had significant improvements in Minnesota Living With Heart Failure score (given as mean [95% confidence interval]) (baseline versus Lo: 43.3 [35.5 to 51.1] versus 21.3 [14.6 to 28.0], P<0.01; baseline versus Hi: 43.3 [35.5 to 51.1] versus 23.6 [16.1 to 31.1], P<0.01) and 6-minute walk distance (baseline versus Lo: 692 ft [581 to 804] versus 995 ft [876 to 1114], P<0.01; baseline versus Hi: 699 ft [585 to 813] versus 982 ft [857 to 1106], P<0.01). Although both Hi and Lo arms had some echocardiographic parameters that significantly improved compared to baseline (baseline end-diastolic diameter 5.7 cm [5.5 to 6.0] versus Lo 5.5 cm [5.1 to 5.8], P<0.01; baseline end-systolic diameter 4.9 cm [4.6 to 5.3] versus Hi 4.7 cm [4.3 to 5.0], P<0.05), there were no significant differences observed when comparing the Hi- versus Lo-output arms.

Conclusions: Low-output LV pacing with a relatively narrow safety margin above capture threshold affords significant improvement from baseline and is clinically equivalent to high-output LV pacing. These data support a strategy of minimizing the programmed LV safety margin to increase battery life in cardiac resynchronization therapy devices.

Clinical Trial Registration Information: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01060449.
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http://dx.doi.org/10.1161/JAHA.112.000950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3541614PMC
October 2012
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