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Feng X.D.,Shanghai Eastern Hospital | Wang X.N.,Shanxi Cardiovascular Hospital | Yuan X.H.,Changzhi Peace Hospital | Wang W.,Scripps Memorial Hospital
Journal of Thoracic and Cardiovascular Surgery | Year: 2014

Objective Postoperative atrial fibrillation (POAF) is the most frequent complication arising after cardiac surgery, occurring in 30% of cases. Amiodarone is the most effective drug for prophylaxis and treatment. However, because of significant extracardiac side effects, only high-risk patients are eligible for prophylactic amiodarone therapy. We performed a randomized prospective study of 100 patients undergoing cardiac surgery with epicardial application of amiodarone-releasing hydrogel to determine the effectiveness of preventing POAF. Methods After institutional review board approval, 100 patients, from January 2012 to July 2013, who had undergone cardiac surgery, were randomized to 2 equal groups. The study group received poly-based hydrogel with amiodarone sprayed diffusely over the epicardium. The control group underwent the procedure without the spray. Continuous telemetry monitored for POAF, and amiodarone levels in the atria, plasma, and tissue were measured postoperatively. Daily electrocardiographic parameters were measured until postoperative day 14. Results The incidence of POAF was significantly less in the study group, with 4 of 50 patients (8%) incurring atrial fibrillation compared with 13 of 50 patients (26%) in the control group (P <.01). The mean amiodarone concentrations in the atria (12.06 ± 3.1) were significantly greater than those in the extracardiac tissues (1.32 ± 0.9; P <.01). The plasma amiodarone levels remained below the detection limit (<8 μg/mL) during the 14 days of follow-up. Bradycardia was observed less in the study group (76 ± 29) than in the control group (93 ± 18; P <.01). Conclusions Epicardial application of amiodarone-releasing adhesive hydrogel is a less invasive, well-tolerated, quick, and effective therapeutic option for preventing POAF at minimal risk of extracardiac adverse side effects. © 2014 by The American Association for Thoracic Surgery. Source


Schreiber D.,Stanford University | Sattar A.,Stanford University | Drigalla D.,Texas A&M University | Higgins S.,Scripps Memorial Hospital
Western Journal of Emergency Medicine | Year: 2014

Introduction: Many emergency department (ED) patients have symptoms that may be attributed to arrhythmias, necessitating outpatient ambulatory cardiac monitoring. Consensus is lacking on the optimal duration of monitoring. We describe the use of a novel device applied at ED discharge that provides continuous prolonged cardiac monitoring. Methods: We enrolled discharged adult ED patients with symptoms of possible cardiac arrhythmia. A novel, single use continuous recording patch (Zio®Patch) was applied at ED discharge. Patients wore the device for up to 14 days or until they had symptoms to trigger an event. They then returned the device by mail for interpretation. Significant arrhythmias are defined as: ventricular tachycardia (VT) ≥4 beats, supraventricular tachycardia (SVT) ≥4 beats, atrial fibrillation, ≥3 second pause, 2nd degree Mobitz II, 3rd degree AV Block, or symptomatic bradycardia. Results: There were 174 patients were enrolled and all mailed back their devices. The average age was 52.2 (± 21.0) years, and 55% were female. The most common indications for device placement were palpitations 44.8%, syncope 24.1% and dizziness 6.3%. Eighty-three patients (47.7%) had ≥1 arrhythmias and 17 (9.8%) were symptomatic at the time of their arrhythmia. Median time to first arrhythmia was 1.0 days (IQR 0.2-2.8) and median time to first symptomatic arrhythmia was 1.5 days (IQR 0.4-6.7). 93 (53.4%) of symptomatic patients did not have any arrhythmia during their triggered events. The overall diagnostic yield was 63.2%. Conclusion: The Zio®Patch cardiac monitoring device can efficiently characterize symptomatic patients without significant arrhythmia and has a higher diagnostic yield for arrhythmias than traditional 24-48 hour Holter monitoring. It allows for longer term monitoring up to 14 days. Copyright 2014 by the article author(s). Source


Higgins S.L.,Scripps Memorial Hospital
Future Cardiology | Year: 2013

A number of substantial improvements to the 60-year-old concept of the Holter monitor have recently been developed. One promising advance is the Zio® Patch (iRhythm Technologies, Inc., CA, USA), a small 2 × 5-inch patch, which can continuously record up to 14 days of a single ECG channel of cardiac rhythm without the need for removal during exercise, sleeping or bathing. Its ease-of-use, which enables optimal long-term monitoring, has been established in the ambulatory setting, although some insurance carriers have been reluctant to reimburse appropriately for this advance, an issue characteristic of other heart monitors, treated as 'loss-leaders.' In this article, in addition to discussing possible reasons for this reluctance, a novel model for direct-to-consumer marketing of heart monitoring, outside of the traditional health insurance reimbursement model, is also presented. Additional current and future advances in heart rhythm recording are also discussed. Such potentially revolutionary opportunities have only recently become possible as a result of technologic advances. © 2013 Future Medicine Ltd. Source


Aguilar M.I.,Mayo Medical School | Kuo R.S.,Scripps Memorial Hospital | Freeman W.D.,Mayo Medical School
Neurologic Clinics | Year: 2013

New oral anticoagulants have been found to be as efficacious as warfarin and safer in terms of intracranial bleeding. All patients with nonvalvular atrial fibrillation should receive antithrombotic therapy for stroke prevention. For those at low risk, antiplatelet therapy is probably sufficient. For those at intermediate or high risk, anticoagulation is superior to antiplatelet therapy. Four oral anticoagulants are currently approved for stroke and systemic embolism prevention in atrial fibrillation: warfarin, dabigatran, rivaroxaban, and apixaban. Management of bleeding complications while on the new agents remains an area of concern and management is based on anecdotal experience and observational studies. © 2013 Elsevier Inc. Source


Wang W.,Scripps Memorial Hospital | Mei Y.Q.,Shanghai Tongji Hospital | Yuan X.H.,Changzhi Peace Hospital | Feng X.D.,Shanghai East Hospital
Journal of Thoracic and Cardiovascular Surgery | Year: 2016

Objective Postoperative atrial fibrillation is the most frequent complication arising after cardiac surgery, occurring in 40% of cases. The treatment of postoperative atrial fibrillation with epicardial amiodarone/corticosteroid hydrogel delivery can increase efficacy and reduce side effects. To further evaluate whether amiodarone hydrogel is superior to corticosteroid hydrogel or placebo, we performed a randomized prospective study in 150 patients with coronary artery bypass grafting to compare the effectiveness with different epicardial drug approaches in the postoperative period. Methods After institutional review board approval, 150 patients, from January 2012 to July 2014, who had undergone cardiac surgery were randomized to 3 equal groups. Group I received poly-based hydrogel with amiodarone, and group II received poly-based hydrogel with triamcinolone. Both hydrogels were sprayed diffusely over the biatrial epicardium. The control group underwent the procedure with only hydrogel spray. Continuous telemetry monitored for postoperative atrial fibrillation, and amiodarone or triamcinolone levels in the atria, plasma, and tissue were measured postoperatively. Daily electrocardiographic parameters were measured until postoperative day 14. Results The incidence of postoperative atrial fibrillation was significantly less in group I, with 4 of 50 patients (8%) incurring atrial fibrillation compared with 11 of 50 patients (22%) in group II and 13 of 50 patients (26%) in the control group (P <.01). The mean amiodarone and triamcinolone concentrations in the atria (12.06 ± 3.1/1.5 ± 0.7) were significantly greater than those in the extracardiac tissues (1.32 ± 0.9/0.2 ± 0.4; P <.01). The plasma amiodarone and triamcinolone levels remained below the detection limit (<8 μg/mL and <0.2 μg/mL) during the 14 days of follow-up. Bradycardia was observed less in the control group (93 ± 18) than in study group I (76 ± 29; P <.01). Conclusions Epicardial application of amiodarone-releasing adhesive hydrogel is a less-invasive, well-tolerated, quick, and effective therapeutic option for preventing postoperative atrial fibrillation with minimal risk of extracardiac adverse side effects. However, there was no clinical evidence that epicardial corticosteroid prevented postoperative atrial fibrillation. © 2016 The American Association for Thoracic Surgery. Source

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