Publications by authors named "Elaine Y Wan"

54 Publications

Cardiac Sympathetic Denervation for the Management of Ventricular Arrhythmias.

J Interv Card Electrophysiol 2022 Apr 9. Epub 2022 Apr 9.

Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.

Background: The autonomic nervous system contributes to the pathogenesis of ventricular arrhythmias (VA). Though anti-arrhythmic drug therapy and catheter ablation are the mainstay of management of VAs, success may be limited in patients with more refractory arrhythmias. Sympathetic modulation is increasingly recognized as a valuable adjunct tool for managing VAs in patients with structural heart disease and inherited arrhythmias.

Results: In this review, we explore the role of the sympathetic nervous system and rationale for cardiac sympathetic denervation (CSD) in VAs and provide a disease-focused review of the utility of CSD for patients both with and without structural heart disease.

Conclusions: We conclude that CSD is a reasonable therapeutic option for patients with VA, both with and without structural heart disease. Though not curative, many studies have demonstrated a significant reduction in the burden of VAs for the majority of patients undergoing the procedure. However, in patients with unilateral CSD and subsequent VA recurrence, complete bilateral CSD may provide long-lasting reprieve from VA.
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http://dx.doi.org/10.1007/s10840-022-01211-2DOI Listing
April 2022

Risk factor management of atrial fibrillation using mHealth: The Atrial Fibrillation - Helping Address Care with Remote Technology (AF-HEART) Pilot Study.

Cardiovasc Digit Health J 2022 Feb 24;3(1):14-20. Epub 2021 Nov 24.

Division of Cardiology, Department of Medicine, Columbia University, Vagelos College of Physicians and Surgeons, New York, New York.

Background: Personalized treatment of atrial fibrillation (AF) risk factors using mHealth and telehealth may improve patient outcomes.

Objective: The purpose of this study was to assess the feasibility of the Atrial Fibrillation Helping Address Care with Remote Technology (AF-HEART) intervention on the following patient outcomes: (1) heart rhythm tracking; (2) weight, alcohol, blood pressure (BP), and sleep apnea reduction; (3) AF symptom reduction; and (4) quality-of-life (QOL) improvement.

Methods: A total of 20 patients with AF undergoing antiarrhythmic therapy, cardioversion, and/or catheter ablation were enrolled and followed for 6 months. The AF-HEART intervention included remote heart rhythm, weight, and BP tracking; televisits with a dietician focusing on AF risk factors; and referrals for sleep apnea and hypertension treatment.

Results: Patients transmitted a median of 181 rhythm recordings during the 6-month follow-up period. Patients lost an average of 3.5 kilograms at 6 months ( = .005). Patients had improved SF-12 scores ( = .01), AFSS score ( = .01), EQ-5D score ( = .006), and AFEQT Global Score ( = .03). There was significant correlation between weight loss and decrease in symptom severity (r = -0.45, = .05), and between % weight loss and decrease in symptom severity (r = -0.49, = .03).

Conclusion: This study described the feasibility of the AF-HEART intervention for (1) consistent remote tracking of heart rhythm, weight, and BP; (2) achievement of weight loss; (3) reduction of symptoms; and (4) improvement in QOL. Expansion to a larger randomized study is planned.
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http://dx.doi.org/10.1016/j.cvdhj.2021.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8890079PMC
February 2022

HRS White Paper on Clinical Utilization of Digital Health Technology.

Cardiovasc Digit Health J 2021 Aug 10;2(4):196-211. Epub 2021 Jul 10.

Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA.

This collaborative statement from the Digital Health Committee of the Heart Rhythm Society provides everyday clinical scenarios in which wearables may be utilized by patients for cardiovascular health and arrhythmia management. We describe herein the spectrum of wearables that are commercially available for patients, and their benefits, shortcomings and areas for technological improvement. Although wearables for rhythm diagnosis and management have not been examined in large randomized clinical trials, undoubtedly the usage of wearables has quickly escalated in clinical practice. This document is the first of a planned series in which we will update information on wearables as they are revised and released to consumers.
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http://dx.doi.org/10.1016/j.cvdhj.2021.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8890053PMC
August 2021

Arrhythmias in the COVID-19 patient.

Heart Rhythm O2 2022 Feb 14;3(1):8-14. Epub 2022 Jan 14.

Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.

Coronavirus disease 2019 (COVID-19) has encompassed the globe since it was first observed just under 2 years ago. Although the disease is predominantly a respiratory illness, there have been observed complications throughout the various organ systems. Namely, cardiovascular complications, and, more specifically, arrhythmic complications have been described throughout the pandemic in patients with COVID-19. Management of atrial arrhythmias, ventricular arrhythmias, and bradyarrhythmias in patients with COVID-19 infection has been largely guided by our prior experience in the management of these arrhythmias in similar patient populations without infection. However, this review aims to highlight the specific considerations as they pertain to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the various arrhythmic manifestations observed with this disease.
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http://dx.doi.org/10.1016/j.hroo.2022.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8758199PMC
February 2022

Autonomic dysfunction post-acute COVID-19 infection.

HeartRhythm Case Rep 2022 Mar 27;8(3):143-146. Epub 2021 Nov 27.

Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York.

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http://dx.doi.org/10.1016/j.hrcr.2021.11.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8626157PMC
March 2022

Long-term complications of COVID-19.

Am J Physiol Cell Physiol 2022 01 24;322(1):C1-C11. Epub 2021 Nov 24.

Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York City, New York.

SARS-CoV-2 has rapidly spread across the globe and infected hundreds of millions of people worldwide. As our experience with this virus continues to grow, our understanding of both short-term and long-term complications of infection with SARS-CoV-2 continues to grow as well. Just as there is heterogeneity in the acute infectious phase, there is heterogeneity in the long-term complications seen following COVID-19 illness. The purpose of this review article is to present the current literature with regards to the epidemiology, pathophysiology, and proposed management algorithms for the various long-term sequelae that have been observed in each organ system following infection with SARS-CoV-2. We will also consider future directions, with regards to newer variants of the virus and their potential impact on the long-term complications observed.
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http://dx.doi.org/10.1152/ajpcell.00375.2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8721906PMC
January 2022

Implantation of cardiac electronic devices in active COVID-19 patients: Results from an international survey.

Heart Rhythm 2022 02 26;19(2):206-216. Epub 2021 Oct 26.

UCLA Cardiac Arrhythmia Center, Los Angeles, California.

Background: Cardiac implantable electronic device (CIED) implantation rates as well as the clinical and procedural characteristics and outcomes in patients with known active coronavirus disease 2019 (COVID-19) are unknown.

Objective: The purpose of this study was to gather information regarding CIED procedures during active COVID-19, performed with personal protective equipment, based on an international survey.

Methods: Fifty-three centers from 13 countries across 4 continents provided information on 166 patients with known active COVID-19 who underwent a CIED procedure.

Results: The CIED procedure rate in 133,655 hospitalized COVID-19 patients ranged from 0 to 16.2 per 1000 patients (P <.001). Most devices were implanted due to high-degree/complete atrioventricular block (112 [67.5%]) or sick sinus syndrome (31 [18.7%]). Of the 166 patients in the study survey, the 30-day complication rate was 13.9% and the 180-day mortality rate was 9.6%. One patient had a fatal outcome as a direct result of the procedure. Differences in patient and procedural characteristics and outcomes were found between Europe and North America. An older population (76.6 vs 66 years; P <.001) with a nonsignificant higher complication rate (16.5% vs 7.7%; P = .2) was observed in Europe vs North America, whereas higher rates of critically ill patients (33.3% vs 3.3%; P <.001) and mortality (26.9% vs 5%; P = .002) were observed in North America vs Europe.

Conclusion: CIED procedure rates during known active COVID-19 disease varied greatly, from 0 to 16.2 per 1000 hospitalized COVID-19 patients worldwide. Patients with active COVID-19 infection who underwent CIED implantation had high complication and mortality rates. Operators should take these risks into consideration before proceeding with CIED implantation in active COVID-19 patients.
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http://dx.doi.org/10.1016/j.hrthm.2021.10.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8547796PMC
February 2022

Attenuating persistent sodium current-induced atrial myopathy and fibrillation by preventing mitochondrial oxidative stress.

JCI Insight 2021 10 28;6(23). Epub 2021 Oct 28.

Division of Cardiology, Department of Medicine, and.

Mechanistically driven therapies for atrial fibrillation (AF), the most common cardiac arrhythmia, are urgently needed, the development of which requires improved understanding of the cellular signaling pathways that facilitate the structural and electrophysiological remodeling that occurs in the atria. Similar to humans, increased persistent Na+ current leads to the development of an atrial myopathy and spontaneous and long-lasting episodes of AF in mice. How increased persistent Na+ current causes both structural and electrophysiological remodeling in the atria is unknown. We crossbred mice expressing human F1759A-NaV1.5 channels with mice expressing human mitochondrial catalase (mCAT). Increased expression of mCAT attenuated mitochondrial and cellular reactive oxygen species (ROS) and the structural remodeling that was induced by persistent F1759A-Na+ current. Despite the heterogeneously prolonged atrial action potential, which was unaffected by the reduction in ROS, the incidences of spontaneous AF, pacing-induced after-depolarizations, and AF were substantially reduced. Expression of mCAT markedly reduced persistent Na+ current-induced ryanodine receptor oxidation and dysfunction. In summary, increased persistent Na+ current in atrial cardiomyocytes, which is observed in patients with AF, induced atrial enlargement, fibrosis, mitochondrial dysmorphology, early after-depolarizations, and AF, all of which can be attenuated by resolving mitochondrial oxidative stress.
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http://dx.doi.org/10.1172/jci.insight.147371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8675199PMC
October 2021

The mitochondrial calcium uniporter promotes arrhythmias caused by high-fat diet.

Sci Rep 2021 09 8;11(1):17808. Epub 2021 Sep 8.

Department of Medicine, College of Physicians and Surgeons of Columbia University, New York, NY, 10032, USA.

Obesity and diabetes increase the risk of arrhythmia and sudden cardiac death. However, the molecular mechanisms of arrhythmia caused by metabolic abnormalities are not well understood. We hypothesized that mitochondrial dysfunction caused by high fat diet (HFD) promotes ventricular arrhythmia. Based on our previous work showing that saturated fat causes calcium handling abnormalities in cardiomyocytes, we hypothesized that mitochondrial calcium uptake contributes to HFD-induced mitochondrial dysfunction and arrhythmic events. For experiments, we used mice with conditional cardiac-specific deletion of the mitochondrial calcium uniporter (Mcu), which is required for mitochondrial calcium uptake, and littermate controls. Mice were used for in vivo heart rhythm monitoring, perfused heart experiments, and isolated cardiomyocyte experiments. MCU KO mice are protected from HFD-induced long QT, inducible ventricular tachycardia, and abnormal ventricular repolarization. Abnormal repolarization may be due, at least in part, to a reduction in protein levels of voltage gated potassium channels. Furthermore, isolated cardiomyocytes from MCU KO mice exposed to saturated fat are protected from increased reactive oxygen species (ROS), mitochondrial dysfunction, and abnormal calcium handling. Activation of calmodulin-dependent protein kinase (CaMKII) corresponds with the increase in arrhythmias in vivo. Additional experiments showed that CaMKII inhibition protects cardiomyocytes from the mitochondrial dysfunction caused by saturated fat. Hearts from transgenic CaMKII inhibitor mice were protected from inducible ventricular tachycardia after HFD. These studies identify mitochondrial dysfunction caused by calcium overload as a key mechanism of arrhythmia during HFD. This work indicates that MCU and CaMKII could be therapeutic targets for arrhythmia caused by metabolic abnormalities.
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http://dx.doi.org/10.1038/s41598-021-97449-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8426388PMC
September 2021

Structure and function of the ventricular tachycardia isthmus.

Heart Rhythm 2022 01 6;19(1):137-153. Epub 2021 Aug 6.

Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York.

Catheter ablation of postinfarction reentrant ventricular tachycardia (VT) has received renewed interest owing to the increased availability of high-resolution electroanatomic mapping systems that can describe the VT circuits in greater detail, and the emergence and need to target noninvasive external beam radioablation. These recent advancements provide optimism for improving the clinical outcome of VT ablation in patients with postinfarction and potentially other scar-related VTs. The combination of analyses gleaned from studies in swine and canine models of postinfarction reentrant VT, and in human studies, suggests the existence of common electroanatomic properties for reentrant VT circuits. Characterizing these properties may be useful for increasing the specificity of substrate mapping techniques and for noninvasive identification to guide ablation. Herein, we describe properties of reentrant VT circuits that may assist in elucidating the mechanisms of onset and maintenance, as well as a means to localize and delineate optimal catheter ablation targets.
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http://dx.doi.org/10.1016/j.hrthm.2021.08.001DOI Listing
January 2022

Sex and Race Disparities in Presumed Sudden Cardiac Death: One Size Does Not Fit All.

Circ Arrhythm Electrophysiol 2021 05 17;14(5):e010053. Epub 2021 May 17.

Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York (E.Y.W.).

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http://dx.doi.org/10.1161/CIRCEP.121.010053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8153376PMC
May 2021

Pandemic Highlights Disparities in Health Care.

Circ Arrhythm Electrophysiol 2021 05 17;14(5):e009908. Epub 2021 May 17.

Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (W.K.C.).

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http://dx.doi.org/10.1161/CIRCEP.121.009908DOI Listing
May 2021

Cardiac Corrected QT Interval Changes Among Patients Treated for COVID-19 Infection During the Early Phase of the Pandemic.

JAMA Netw Open 2021 04 1;4(4):e216842. Epub 2021 Apr 1.

Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.

Importance: Critical illness, a marked inflammatory response, and viruses such as SARS-CoV-2 may prolong corrected QT interval (QTc).

Objective: To evaluate baseline QTc interval on 12-lead electrocardiograms (ECGs) and ensuing changes among patients with and without COVID-19.

Design, Setting, And Participants: This cohort study included 3050 patients aged 18 years and older who underwent SARS-CoV-2 testing and had ECGs at Columbia University Irving Medical Center from March 1 through May 1, 2020. Patients were analyzed by treatment group over 5 days, as follows: hydroxychloroquine with azithromycin, hydroxychloroquine alone, azithromycin alone, and neither hydroxychloroquine nor azithromycin. ECGs were manually analyzed by electrophysiologists masked to COVID-19 status. Multivariable modeling evaluated clinical associations with QTc prolongation from baseline.

Exposures: COVID-19, hydroxychloroquine, azithromycin.

Main Outcomes And Measures: Mean QTc prolongation, percentage of patients with QTc of 500 milliseconds or greater.

Results: A total of 965 patients had more than 2 ECGs and were included in the study, with 561 (58.1%) men, 198 (26.2%) Black patients, and 191 (19.8%) aged 80 years and older. There were 733 patients (76.0%) with COVID-19 and 232 patients (24.0%) without COVID-19. COVID-19 infection was associated with significant mean QTc prolongation from baseline by both 5-day and 2-day multivariable models (5-day, patients with COVID-19: 20.81 [95% CI, 15.29 to 26.33] milliseconds; P < .001; patients without COVID-19: -2.01 [95% CI, -17.31 to 21.32] milliseconds; P = .93; 2-day, patients with COVID-19: 17.40 [95% CI, 12.65 to 22.16] milliseconds; P < .001; patients without COVID-19: 0.11 [95% CI, -12.60 to 12.81] milliseconds; P = .99). COVID-19 infection was independently associated with a modeled mean 27.32 (95% CI, 4.63-43.21) millisecond increase in QTc at 5 days compared with COVID-19-negative status (mean QTc, with COVID-19: 450.45 [95% CI, 441.6 to 459.3] milliseconds; without COVID-19: 423.13 [95% CI, 403.25 to 443.01] milliseconds; P = .01). More patients with COVID-19 not receiving hydroxychloroquine and azithromycin had QTc of 500 milliseconds or greater compared with patients without COVID-19 (34 of 136 [25.0%] vs 17 of 158 [10.8%], P = .002). Multivariable analysis revealed that age 80 years and older compared with those younger than 50 years (mean difference in QTc, 11.91 [SE, 4.69; 95% CI, 2.73 to 21.09]; P = .01), severe chronic kidney disease compared with no chronic kidney disease (mean difference in QTc, 12.20 [SE, 5.26; 95% CI, 1.89 to 22.51; P = .02]), elevated high-sensitivity troponin levels (mean difference in QTc, 5.05 [SE, 1.19; 95% CI, 2.72 to 7.38]; P < .001), and elevated lactate dehydrogenase levels (mean difference in QTc, 5.31 [SE, 2.68; 95% CI, 0.06 to 10.57]; P = .04) were associated with QTc prolongation. Torsades de pointes occurred in 1 patient (0.1%) with COVID-19.

Conclusions And Relevance: In this cohort study, COVID-19 infection was independently associated with significant mean QTc prolongation at days 5 and 2 of hospitalization compared with day 0. More patients with COVID-19 had QTc of 500 milliseconds or greater compared with patients without COVID-19.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.6842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8065381PMC
April 2021

Predictors of atrial fibrillation on implantable cardiac monitoring for cryptogenic stroke.

J Interv Card Electrophysiol 2021 Apr 2. Epub 2021 Apr 2.

Division of Cardiology, Section of Electrophysiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, NY, New York, USA.

Background: Since the CRYSTAL-AF trial, implantation and usage of implantable loop recorder (ICM) after cryptogenic stroke (CS) for detection of atrial fibrillation (AF) has increased. However, it is unclear which CS patients would most benefit from long term ICM monitoring. This study aims to determine the risk factors in patients that would confer maximum benefit from ICM placement following CS.

Methods: A Columbia University Institutional Review Board (IRB) approved retrospective analysis of medical records of 125 patients with CS followed by implantation of ICM was evaluated. Univariable and multivariable time-to-event analyses were performed on demographics, hours of activity and variability (HRV), stroke location, thrombosis etiology, and CHADS - VASc score. The primary outcome was presence of ICM-detected AF defined as AF lasting at least 2 min.

Results: One hundred twenty-five patients (mean 67.6 years ± 2.4 years, 60% male) were followed for at least 3 months. Twenty-two patients (18%) were found to have clinically verified detected AF; median of time to detection was 95 days. Upon univariable demographic analysis followed by multivariable Cox regression analysis, individuals with age 75 or older (HR: 3.987, p = 0.0046) or LVEF 40% and lower (HR: 3.056, p = 0.0213) had significantly higher risk of AF. Diabetics also had a lower AF detection in multivariable analysis (HR: 0.128, p = 0.0466).

Conclusions: Age 75 or older and LVEF ≤40% were the factors on multivariable analysis that predicted AF detection. Diabetes is a possible significant factor which should be evaluated further. CHADS - VASc score was notably not predictive of AF detected on ICM.
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http://dx.doi.org/10.1007/s10840-021-00985-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016653PMC
April 2021

Post-acute COVID-19 syndrome.

Nat Med 2021 04 22;27(4):601-615. Epub 2021 Mar 22.

Department of Neurology, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic, which has resulted in global healthcare crises and strained health resources. As the population of patients recovering from COVID-19 grows, it is paramount to establish an understanding of the healthcare issues surrounding them. COVID-19 is now recognized as a multi-organ disease with a broad spectrum of manifestations. Similarly to post-acute viral syndromes described in survivors of other virulent coronavirus epidemics, there are increasing reports of persistent and prolonged effects after acute COVID-19. Patient advocacy groups, many members of which identify themselves as long haulers, have helped contribute to the recognition of post-acute COVID-19, a syndrome characterized by persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms. Here, we provide a comprehensive review of the current literature on post-acute COVID-19, its pathophysiology and its organ-specific sequelae. Finally, we discuss relevant considerations for the multidisciplinary care of COVID-19 survivors and propose a framework for the identification of those at high risk for post-acute COVID-19 and their coordinated management through dedicated COVID-19 clinics.
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http://dx.doi.org/10.1038/s41591-021-01283-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8893149PMC
April 2021

Theoretical Models and Computational Analysis of Action Potential Dispersion for Cardiac Arrhythmia Risk Stratification.

Front Cardiovasc Med 2021 5;8:649489. Epub 2021 Mar 5.

Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States.

Reentrant cardiac arrhythmias such as atrial fibrillation (AF) and ventricular fibrillation (VF) are common cardiac arrhythmias that account for substantial morbidity and mortality throughout the world. However, the mechanisms and optimal ablation treatment strategies for such arrhythmias are still unclear. Using 2D optical mapping of a mouse model with AF and VF, we have identified regional heterogeneity of the action potential duration (APD) in the atria and ventricles of the heart as key drivers for the initiation and persistence of reentry. The purpose of this paper is to discuss theoretical patterns of dispersion, demonstrate patterns of dispersion seen in our mouse model and discuss the computational analysis of APD dispersion patterns. These analyses and discussions may lead to better understanding of dispersion patterns in patients with these arrhythmias, as well as help comprehend whether and how reducing dispersion can lead to arrhythmia risk stratification and treatment strategies for arrhythmias.
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http://dx.doi.org/10.3389/fcvm.2021.649489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973016PMC
March 2021

Management of Arrhythmias After Heart Transplant: Current State and Considerations for Future Research.

Circ Arrhythm Electrophysiol 2021 03 9;14(3):e007954. Epub 2021 Mar 9.

Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS (G.M., D.L., R.G.).

Orthotropic heart transplantation remains the most effective therapy for patients with end-stage heart failure, with a median survival of ≈13 years. Yet, a number of complications are observed after orthotropic heart transplantation, including atrial and ventricular arrhythmias. Several factors contribute to arrhythmias, such as autonomic denervation, effect of the surgical technique, acute and chronic rejection, and transplant vasculopathy among others. To minimize risk of future arrhythmias, the bicaval technique and minimizing ischemic time are current surgical standards. Sinus node dysfunction is the most common indication for early (within 30 days) pacemaker implantation, whereas atrioventricular block incidence increases as time from transplant increases. Atrial fibrillation can occur in the first few weeks following transplantation but is uncommon in the long term unless secondary to a precipitant such as acute rejection. The most common atrial arrhythmias are atrial flutters, which are mainly typical, but atypical circuits can be observed such as those that involve the remnant donor atrium in regions immediately adjacent to the atrioatrial anastomosis suture line. Choosing the appropriate pharmacological therapy requires careful consideration due to the potential interaction with immunosuppressive agents. Despite historical concerns, adenosine is effective and safe at reduced doses if administered under cardiac monitoring. Catheter ablation has emerged as an effective treatment strategy for symptomatic supraventricular tachycardias, including ablation of atypical flutter circuits. Cardiac allograft vasculopathy is an important risk factor for sudden cardiac death, yet the role of prophylactic implantable cardioverter-defibrillator implant for sudden death prevention is unclear. Current indications for implantable cardioverter-defibrillator implantation are as in the nontransplant population. A number of questions for future research are posed.
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http://dx.doi.org/10.1161/CIRCEP.120.007954DOI Listing
March 2021

Cardiac Resynchronization Therapy Response Assessment with Electromechanical Activation Mapping within 24 Hours of Device Implantation: A Pilot Study.

J Am Soc Echocardiogr 2021 07 4;34(7):757-766.e8. Epub 2021 Mar 4.

Ultrasound Elasticity Imaging Laboratory, Department of Biomedical Engineering, Columbia University, New York, New York; Department of Radiology, Columbia University Irving Medical Center, New York, New York. Electronic address:

Background: Cardiac resynchronization therapy (CRT) response assessment relies on the QRS complex narrowing criterion. Yet one third of patients do not improve despite narrowed QRS after implantation. Electromechanical wave imaging (EWI) is a quantitative echocardiography-based technique capable of noninvasively mapping cardiac electromechanical activation in three dimensions. The aim of this exploratory study was to investigate the EWI technique, sensitive to ventricular dyssynchrony, for informing CRT response on the day of implantation.

Methods: Forty-four patients with heart failure with left bundle branch block or right ventricular (RV) paced rhythm and decreased left ventricular ejection fraction (LVEF; mean, 25.3 ± 9.6%) underwent EWI without and with CRT within 24 hours of device implantation. Of those, 16 were also scanned while in left ventricular (LV) pacing. Improvement in LVEF at 3-, 6-, or 9-month follow-up defined (1) super-responders (ΔLVEF ≥ 20%), (2) responders (10% ≤ ΔLVEF < 20%), and (3) nonresponders (ΔLVEF ≤ 5%). Three-dimensionally rendered electromechanical maps were obtained under RV, LV, and biventricular CRT pacing conditions. Mean RV free wall and LV lateral wall activation times were computed. The percentage of resynchronized myocardium was measured by quantifying the percentage of the left ventricle activated within 120 msec of QRS onset. Correlations between percentage of resynchronized myocardium and type of CRT response were assessed.

Results: LV lateral wall activation time was significantly different (P ≤ .05) among all three pacing conditions in the 16 patients: LV lateral wall activation time with CRT in biventricular pacing (73.1 ± 17.6 msec) was lower compared with LV pacing (89.5 ± 21.5 msec) and RV pacing (120.3 ± 17.8 msec). Retrospective analysis showed that the percentage of resynchronized myocardium with CRT was a reliable response predictor within 24 hours of implantation for significantly (P ≤ .05) identifying super-responders (n = 7; 97.7 ± 1.9%) from nonresponders (n = 17; 89.9 ± 9.9%).

Conclusion: Electromechanical activation mapping constitutes a valuable three-dimensional visualization tool within 24 hours of implantation and could potentially aid in the timely assessment of CRT response rates, including during implantation for adjustment of lead placement and pacing outcomes.
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http://dx.doi.org/10.1016/j.echo.2021.02.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263475PMC
July 2021

Association between antecedent statin use and decreased mortality in hospitalized patients with COVID-19.

Nat Commun 2021 02 26;12(1):1325. Epub 2021 Feb 26.

NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, NY, USA.

The coronavirus disease 2019 (COVID-19) can result in a hyperinflammatory state, leading to acute respiratory distress syndrome (ARDS), myocardial injury, and thrombotic complications, among other sequelae. Statins, which are known to have anti-inflammatory and antithrombotic properties, have been studied in the setting of other viral infections, but their benefit has not been assessed in COVID-19. This is a retrospective analysis of patients admitted with COVID-19 from February 1 through May 12, 2020 with study period ending on June 11, 2020. Antecedent statin use was assessed using medication information available in the electronic medical record. We constructed a multivariable logistic regression model to predict the propensity of receiving statins, adjusting for baseline sociodemographic and clinical characteristics, and outpatient medications. The primary endpoint includes in-hospital mortality within 30 days. A total of 2626 patients were admitted during the study period, of whom 951 (36.2%) were antecedent statin users. Among 1296 patients (648 statin users, 648 non-statin users) identified with 1:1 propensity-score matching, statin use is significantly associated with lower odds of the primary endpoint in the propensity-matched cohort (OR 0.47, 95% CI 0.36-0.62, p < 0.001). We conclude that antecedent statin use in patients hospitalized with COVID-19 is associated with lower inpatient mortality.
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http://dx.doi.org/10.1038/s41467-021-21553-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910606PMC
February 2021

Frequency of Atrial Arrhythmia in Hospitalized Patients With COVID-19.

Am J Cardiol 2021 05 20;147:52-57. Epub 2021 Feb 20.

Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York.

There is growing evidence that COVID-19 can cause cardiovascular complications. However, there are limited data on the characteristics and importance of atrial arrhythmia (AA) in patients hospitalized with COVID-19. Data from 1,029 patients diagnosed with of COVID-19 and admitted to Columbia University Medical Center between March 1, 2020 and April 15, 2020 were analyzed. The diagnosis of AA was confirmed by 12 lead electrocardiographic recordings, 24-hour telemetry recordings and implantable device interrogations. Patients' history, biomarkers and hospital course were reviewed. Outcomes that were assessed were intubation, discharge and mortality. Of 1,029 patients reviewed, 82 (8%) were diagnosed with AA in whom 46 (56%) were new-onset AA 16 (20%) recurrent paroxysmal and 20 (24%) were chronic persistent AA. Sixty-five percent of the patients diagnosed with AA (n=53) died. Patients diagnosed with AA had significantly higher mortality compared with those without AA (65% vs 21%; p < 0.001). Predictors of mortality were older age (Odds Ratio (OR)=1.12, [95% Confidence Interval (CI), 1.04 to 1.22]); male gender (OR=6.4 [95% CI, 1.3 to 32]); azithromycin use (OR=13.4 [95% CI, 2.14 to 84]); and higher D-dimer levels (OR=2.8 [95% CI, 1.1 to 7.3]). In conclusion, patients diagnosed with AA had 3.1 times significant increase in mortality rate versus patients without diagnosis of AA in COVID-19 patients. Older age, male gender, azithromycin use and higher baseline D-dimer levels were predictors of mortality.
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http://dx.doi.org/10.1016/j.amjcard.2021.01.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7895683PMC
May 2021

High-density Grid Technology Aids in the Visualization of Purkinje Potentials in Fascicular Ventricular Tachycardia.

J Innov Card Rhythm Manag 2021 Jan 15;12(Suppl 1):56-59. Epub 2021 Jan 15.

Electrophysiology Section, Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.

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http://dx.doi.org/10.19102/icrm.2021.120121SDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885965PMC
January 2021

High-density Grid Mapping of Micro- and Macro-reentrant Left Atrial Arrhythmias.

J Innov Card Rhythm Manag 2021 Jan 15;12(Suppl 1):28-30. Epub 2021 Jan 15.

Electrophysiology Section, Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.

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http://dx.doi.org/10.19102/icrm.2021.120105SDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885948PMC
January 2021

Management of Arrhythmias Associated with COVID-19.

Curr Cardiol Rep 2020 11 24;23(1). Epub 2020 Nov 24.

Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA.

Purpose Of Review: Cardiac arrhythmias are known complications in patients with COVID-19 infection that may persist even after recovery from infection. A review of the spectrum of cardiac arrhythmias due to COVID-19 infection and current guidelines and assessment or risk and benefit of management considerations is necessary as the population of patients infected and covering from COVID-19 continues to grow.

Recent Findings: Cardiac arrhythmias such as atrial fibrillation, supraventricular tachycardia, complete heart block, and ventricular tachycardia occur in patients infected, recovering and recovered from COVID-19. Personalized care while balancing risk/benefit of medical or invasive therapy is necessary to improve care of patients with arrhythmias. Providers must provide thorough follow-up care and use necessary precaution while caring for COVID-19 patients.
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http://dx.doi.org/10.1007/s11886-020-01434-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7685181PMC
November 2020

Admission Cardiac Diagnostic Testing with Electrocardiography and Troponin Measurement Prognosticates Increased 30-Day Mortality in COVID-19.

J Am Heart Assoc 2021 01 10;10(1):e018476. Epub 2020 Nov 10.

Seymour, Paul, and Gloria Milstein Division of Cardiology Department of Medicine Columbia University Irving Medical Center New York NY.

Background Cardiovascular involvement in coronavirus disease 2019 (COVID-19) is common and leads to worsened mortality. Diagnostic cardiovascular studies may be helpful for resource appropriation and identifying patients at increased risk for death. Methods and Results We analyzed 887 patients (aged 64±17 years) admitted with COVID-19 from March 1 to April 3, 2020 in New York City with 12 lead electrocardiography within 2 days of diagnosis. Demographics, comorbidities, and laboratory testing, including high sensitivity cardiac troponin T (hs-cTnT), were abstracted. At 30 days follow-up, 556 patients (63%) were living without requiring mechanical ventilation, 123 (14%) were living and required mechanical ventilation, and 203 (23%) had expired. Electrocardiography findings included atrial fibrillation or atrial flutter (AF/AFL) in 46 (5%) and ST-T wave changes in 306 (38%). 27 (59%) patients with AF/AFL expired as compared to 181 (21%) of 841 with other non-life-threatening rhythms (<0.001). Multivariable analysis incorporating age, comorbidities, AF/AFL, QRS abnormalities, and ST-T wave changes, and initial hs-cTnT ≥20 ng/L showed that increased age (HR 1.04/year), elevated hs-cTnT (HR 4.57), AF/AFL (HR 2.07), and a history of coronary artery disease (HR 1.56) and active cancer (HR 1.87) were associated with increased mortality. Conclusions Myocardial injury with hs-cTnT ≥20 ng/L, in addition to cardiac conduction perturbations, especially AF/AFL, upon hospital admission for COVID-19 infection is associated with markedly increased risk for mortality than either diagnostic abnormality alone.
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http://dx.doi.org/10.1161/JAHA.120.018476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955502PMC
January 2021

Increased Incidence of Chronic Kidney Injury in African Americans Following Cardiac Transplantation.

J Racial Ethn Health Disparities 2021 12 28;8(6):1435-1446. Epub 2020 Oct 28.

Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA.

Objectives: This study examined whether African American race was associated with an elevated risk of chronic kidney disease (CKD) post-cardiac transplantation.

Background: CKD often occurs after cardiac transplantation and may require renal replacement therapy (RRT) or renal transplant. African American patients have a higher risk for kidney disease as well as worse post-cardiac transplant morbidity and mortality. It is unclear, however, if there is a propensity for African Americans to develop CKD after cardiac transplant.

Methods: The Institutional Review Board of Columbia University Medical Center approved the retrospective study of 151 adults (57 African American and 94 non-African American) who underwent single-organ heart transplant from 2013 to 2016. The primary outcome was a decrease in estimated glomerular filtration rate (eGFR), development of CKD, and end-stage renal disease (ESRD) requiring RRT after 2 years.

Results: African American patients had a significant decline in eGFR post-cardiac transplant compared to non-African American patients (- 34 ± 6 vs. - 20 ± 4 mL/min/1.73 m2, p < 0.0006). African American patients were more likely to develop CKD stage 2 or worse (eGFR < 90 mL/min/1.73 m2) than non-African American patients (81% vs. 59%, p < 0.0005).

Conclusions: This is the first study to report that African American patients are at a significantly higher risk for eGFR decline and CKD at 2 years post-cardiac transplant. Future investigation into risk reduction is necessary for this patient population.
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http://dx.doi.org/10.1007/s40615-020-00906-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8079548PMC
December 2021

Cardiac arrhythmias in patients with COVID-19.

J Arrhythm 2020 Oct 26;36(5):827-836. Epub 2020 Jul 26.

Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease Department of Cardiology Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin People's Republic of China.

The emergence of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major global public health concern. Although SARS-CoV-2 causes primarily respiratory problems, concurrent cardiac injury cannot be ignored since it may be an independent predictor for adverse outcomes. Cardiac arrhythmias are often observed in patients with COVID-19, especially in severe cases, and more likely contribute to the high risk of adverse outcomes. Arrhythmias should be regarded as one of the main complications of COVID-19. Mechanistically, a number of ion channels can be adversely affected in COVID-19, leading to alterations in cardiac conduction and/or repolarization properties, as well as calcium handling, which can predispose to cardiac arrhythmogenesis. In addition, several antimicrobials that are currently used as potential therapeutic agents for COVID-19, such as chloroquine, hydroxychloroquine and azithromycin, have uncertain benefit, and yet may induce electrocardiographic QT prolongation with potential ventricular pro-arrhythmic effects. Continuous electrocardiogram monitoring, accurate and prompt recognition of arrhythmias are important. The present review focuses on cardiac arrhythmias in patients with COVID-19, its underlying mechanisms, and proposed preventive and therapeutic strategies.
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http://dx.doi.org/10.1002/joa3.12405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532267PMC
October 2020

Clinical and cardiac characteristics of COVID-19 mortalities in a diverse New York City Cohort.

J Cardiovasc Electrophysiol 2020 12 20;31(12):3086-3096. Epub 2020 Oct 20.

Department of Medicine, Division of Cardiology, New York-Presbyterian Hospital-Columbia University Irving Medical Center, New York, New York, USA.

Introduction: Electrocardiographic characteristics in COVID-19-related mortality have not yet been reported, particularly in racial/ethnic minorities.

Methods And Results: We reviewed demographics, laboratory and cardiac tests, medications, and cardiac rhythm proximate to death or initiation of comfort care for patients hospitalized with a positive SARS-CoV-2 reverse-transcriptase polymerase chain reaction in three New York City hospitals between March 1 and April 3, 2020 who died. We described clinical characteristics and compared factors contributing toward arrhythmic versus nonarrhythmic death. Of 1258 patients screened, 133 died and were enrolled. Of these, 55.6% (74/133) were male, 69.9% (93/133) were racial/ethnic minorities, and 88.0% (117/133) had cardiovascular disease. The last cardiac rhythm recorded was VT or fibrillation in 5.3% (7/133), pulseless electrical activity in 7.5% (10/133), unspecified bradycardia in 0.8% (1/133), and asystole in 26.3% (35/133). Most 74.4% (99/133) died receiving comfort measures only. The most common abnormalities on admission electrocardiogram included abnormal QRS axis (25.8%), atrial fibrillation/flutter (14.3%), atrial ectopy (12.0%), and right bundle branch block (11.9%). During hospitalization, an additional 17.6% developed atrial ectopy, 14.7% ventricular ectopy, 10.1% atrial fibrillation/flutter, and 7.8% a right ventricular abnormality. Arrhythmic death was confirmed or suspected in 8.3% (11/133) associated with age, coronary artery disease, asthma, vasopressor use, longer admission corrected QT interval, and left bundle branch block (LBBB).

Conclusions: Conduction, rhythm, and electrocardiographic abnormalities were common during COVID-19-related hospitalization. Arrhythmic death was associated with age, coronary artery disease, asthma, longer admission corrected QT interval, LBBB, ventricular ectopy, and usage of vasopressors. Most died receiving comfort measures.
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http://dx.doi.org/10.1111/jce.14772DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675758PMC
December 2020

Digital Health and the Care of the Patient With Arrhythmia: What Every Electrophysiologist Needs to Know.

Circ Arrhythm Electrophysiol 2020 11 6;13(11):e007953. Epub 2020 Oct 6.

Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute (K.G.T., M.C.), Cleveland Clinic, OH.

The field of cardiac electrophysiology has been on the cutting edge of advanced digital technologies for many years. More recently, medical device development through traditional clinical trials has been supplemented by direct to consumer products with advancement of wearables and health care apps. The rapid growth of innovation along with the mega-data generated has created challenges and opportunities. This review summarizes the regulatory landscape, applications to clinical practice, opportunities for virtual clinical trials, the use of artificial intelligence to streamline and interpret data, and integration into the electronic medical records and medical practice. Preparation of the new generation of physicians, guidance and promotion by professional societies, and advancement of research in the interpretation and application of big data and the impact of digital technologies on health outcomes will help to advance the adoption and the future of digital health care.
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http://dx.doi.org/10.1161/CIRCEP.120.007953DOI Listing
November 2020

The Prognostic Value of Electrocardiogram at Presentation to Emergency Department in Patients With COVID-19.

Mayo Clin Proc 2020 10 15;95(10):2099-2109. Epub 2020 Aug 15.

Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY; Department of Medicine, Columbia University Irving Medical Center, New York, NY.

Objective: To study whether combining vital signs and electrocardiogram (ECG) analysis can improve early prognostication.

Methods: This study analyzed 1258 adults with coronavirus disease 2019 who were seen at three hospitals in New York in March and April 2020. Electrocardiograms at presentation to the emergency department were systematically read by electrophysiologists. The primary outcome was a composite of mechanical ventilation or death 48 hours from diagnosis. The prognostic value of ECG abnormalities was assessed in a model adjusted for demographics, comorbidities, and vital signs.

Results: At 48 hours, 73 of 1258 patients (5.8%) had died and 174 of 1258 (13.8%) were alive but receiving mechanical ventilation with 277 of 1258 (22.0%) patients dying by 30 days. Early development of respiratory failure was common, with 53% of all intubations occurring within 48 hours of presentation. In a multivariable logistic regression, atrial fibrillation/flutter (odds ratio [OR], 2.5; 95% CI, 1.1 to 6.2), right ventricular strain (OR, 2.7; 95% CI, 1.3 to 6.1), and ST segment abnormalities (OR, 2.4; 95% CI, 1.5 to 3.8) were associated with death or mechanical ventilation at 48 hours. In 108 patients without these ECG abnormalities and with normal respiratory vitals (rate <20 breaths/min and saturation >95%), only 5 (4.6%) died or required mechanical ventilation by 48 hours versus 68 of 216 patients (31.5%) having both ECG and respiratory vital sign abnormalities.

Conclusion: The combination of abnormal respiratory vital signs and ECG findings of atrial fibrillation/flutter, right ventricular strain, or ST segment abnormalities accurately prognosticates early deterioration in patients with coronavirus disease 2019 and may assist with patient triage.
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http://dx.doi.org/10.1016/j.mayocp.2020.07.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428764PMC
October 2020
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