The surface electrocardiogram (ECG) can provide many clues to a patient’s underlying medical condition or tendency for arrhythmogenesis. An 80-year-old man with severe aortic stenosis and an implantable cardioverter-defibrillator (ICD) for advanced heart block presented with burping, chest discomfort and intermittent pounding sensations. His ECG showed atrial fibrillation with intermittent ventricular pacing at 60 bpm characterized by irregularly irregular rhythm, absent P waves, narrow intrinsic QRS complexes alternating with wide-paced beats (left bundle branch block [LBBB] morphology, superior axis) and visible pacing spikes. Device interrogation revealed ventricular tachycardia (VT) storm with multiple appropriate ICD shocks explaining his pounding sensations. This report highlights two key teaching points: recognizing atrial fibrillation during ventricular pacing—a frequently missed diagnosis affecting nearly half of patients with pacemakers—and managing VT storm to reduce shock burden. After device reprogramming and antiarrhythmic adjustment, the patient became asymptomatic.

Human ; Male ; Aged: 65-79 Yrs Old ; Thorax ; Teaching ; Tachycardia, Ventricular ; Electrocardiography ; Atrial Fibrillation ; Bundle-branch Block ; Constriction, Pathologic

BACKGROUND

Hospitalization is a major complication of atrial fibrillation (AF) and its burden has been rising across Asia. In Korea alone, AF-related hospitalizations increased by 420% from 2006 to 2015. However, comparable data are lacking in the Philippines. This study aimed to determine the prevalence of AF-related hospitalizations among adult patients aged 19 years or older using database claims of the Philippine Health Insurance Corporation (PhilHealth) in 2017 and 2018.

RESULTS

In both 2017 and 2018, approximately 19–20 per 10,000 total hospital admissions were due to AF. The median patient age was 68 years in 2017 and 69 years in 2018. Most admissions occurred in private tertiary hospitals located in urban areas, with a median length of stay of three days. The in-hospital mortality rate was 1.1% for both years.

CONCLUSION

Among the arrhythmias, AF was the most common cause of hospitalization in the Philippines in 2017 and 2018, which accounted for 19 per 10,000 hospitalizations. Despite this burden, the associated in-hospital mortality rate remained low.

Atrial Fibrillation ; Hospitalization ; Mortality ; Philippines

BACKGROUND

Hospitalization is a major complication of atrial fibrillation (AF) and its burden has been rising across Asia. In Korea alone, AF-related hospitalizations increased by 420% from 2006 to 2015. However, comparable data are lacking in the Philippines. This study aimed to determine the prevalence of AF-related hospitalizations among adult patients aged 19 years or older using database claims of the Philippine Health Insurance Corporation (PhilHealth) in 2017 and 2018.

RESULTS

In both 2017 and 2018, approximately 19–20 per 10,000 total hospital admissions were due to AF. The median patient age was 68 years in 2017 and 69 years in 2018. Most admissions occurred in private tertiary hospitals located in urban areas, with a median length of stay of three days. The in-hospital mortality rate was 1.1% for both years.

CONCLUSION

Among the arrhythmias, AF was the most common cause of hospitalization in the Philippines in 2017 and 2018, which accounted for 19 per 10,000 hospitalizations. Despite this burden, the associated in-hospital mortality rate remained low.

Atrial Fibrillation ; Hospitalization ; Mortality ; Philippines

Introduction: Accounting for less than 2% of all pituitary adenomas, TSHsecreting pituitary adenomas (TSHoma) are an uncommon cause of hyperthyroidism. Majority are macroadenomas with delayed diagnosis as most patients are unwittingly treated for primary hyperthyroidism. Recurring discordant thyroid function test (TFT) with elevated thyroidstimulating hormone (TSH) and Free T4 is a hint and warrants additional investigation to facilitate diagnosis. Case: We report a case of a 48-year-old female who was treated for primary hyperthyroidism since her late 20s with multiple admissions for recurrent congestive heart failure and atrial fibrillation. The cardiac issue was preceded by worsening thyrotoxicosis. Previous thyroid autoantibodies were negative. Of note, she had recurring discordant TFT results from two different assays (TSH:84.7, free thyroxine 4 [FT4]:75.43) (TSH:37.86, FT4:27.34) during admission, excluding assay interference and prompting toward TSHoma or Resistance to Thyroid Hormone (RTH). Examination revealed a large goiter (10 × 8 cm) hard in consistency, and pansystolic murmur over tricuspid area. No thyroid eye disease nor bitemporal hemianopia or clinical sign of acromegaly. Echocardiography showed dilated left atrium and mild to moderate tricuspid regurgitation with preserved ejection fraction. Thyroid-releasing hormone (TRH) stimulation test demonstrated blunted TSH response confirming TSHoma. Anterior pituitary hormone profile revealed normal insulin-like growth factor-1 level with suppressed sex hormones and prolactin, thus excluding co-secreting hormone. Sex hormone-binding globulin level, α-subunit, and T3 suppression test were not done due to unavailability. Magnetic resonance imaging pituitary uncovered pituitary mass measuring (2.6 × 3.3 × 2.2 cm) suggestive of macroadenoma with encasement of cavernous internal carotid arteries and cavernous sinus compression. Computed tomography neck revealed diffuse thyroid enlargement with compressive mass effects onto adjacent structure with trachea narrowing. After discussing with a multidisciplinary team, we planned her for total thyroidectomy followed by transsphenoidal surgery. Conclusion Late presentation and diagnosis in TSHoma remain a major challenge. TFT interpretation is fundamental in identifying the causes of secondary hyperthyroidism to avert detrimental sequalae and to guide optimal treatment.
Atrial Fibrillation ; Thyrotropin

BACKGROUND

Postoperative atrial fibrillation (POAF) is the most common arrythmia to occur after cardiovascular surgery. Inflammation being pivotal in POAF perpetuation has been utilized as a therapeutic target. Owing to their anti-inflammatory and anti-oxidant effects, beta-blockers (BB) and N-acetylcysteine (NAC) became research interests in the pursuit for an effective POAF prevention strategy.

OBJECTIVE

To determine the efficacy of NAC plus BB versus BB alone in preventing POAF in cardiac surgery patients.

METHODOLOGY

A literature search using the following search engines: PubMed/Medline, Cochrane Review Central, Clinical Trials Registry, ResearchGate, Mendeley and Google Scholar for relevant randomized trials were conducted. Published and unpublished studies indexed from inception until 2023 were included. Three independent reviewers evaluated the randomized clinical trials (RCTs) for eligibility. The pooled estimates for POAF prevention as primary outcome and MACE, mortality, myocardial infarction, stroke, ICU LOS and hospital LOS as secondary outcomes were measured using the RStudio statistical software.

RESULTS

Seven eligible RCTs allocated 1069 cardiac surgery patients to NAC + BB (n=539) and BB alone (N = 530) treatment arms. The effect estimate using random effect model disclosed significantly reduced POAF events (RR 0.62, 95% CI [0.44, 0.86], p = 0.005) in those on NAC + BB. While no statistical difference between the study arms were demonstrated in reducing mortality (RR 0.63, 95% CI [0.23, 1.73], p = 0.37); myocardial infarction (RR 1.02, 95% CI [0.49, 2.13], p = 0.96); stroke (RR 0.95, 95% CI [0.24, 3.68], p = 0.94); ICU LOS (std. mean difference 0.14, 95% CI [-0.43, 0.70], p = 0.41), and hospital LOS (std. mean difference 0.08, 95% CI [-0.06, 0.21], p = 0.19).

CONCLUSION

Among cardiac surgery patients, the use of NAC in combination with BB compared with BB alone significantly reduced POAF.

Acetylcysteine ; Arrhythmias, Cardiac ; Atrial Fibrillation ; Myocardial Infarction ; Omega-chloroacetophenone

INTRODUCTION

Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) poses a therapeutic dilemma for the attending physician. Standard anticoagulation with a vitamin K antagonist (VKA) plus dual antiplatelet therapy with a P2Y12 inhibitor and aspirin reduces the risk of stroke and thrombosis, but increases risk of bleeding. The effectiveness and safety of several novel oral anticoagulants are still unclear in these patients.

METHODS

PubMed, Cochrane and Embase databases were systematically searched for studies from 2016 until 30 November 2023. The search key terms were ‘DOACs,’ ‘atrial fibrillation,’ ‘percutaneous coronary intervention’ and ‘bleeding.’ Two independent reviewers appraised eligible studies using well-defined criteria. The main outcomes of interest were International Society on Thrombosis and Haemostasis (ISTH) major bleeding, stent thrombosis and major adverse cardiovascular events (MACE). The random-effects model was used to derive pooled estimates.

RESULTS

The search yielded four studies which were all randomized controlled trials (RCTs). There were a total of 10,963 participants. Pooled estimates showed a statistically significant difference between direct oral anticoagulants (DOAC) + P2Y12 and VKA + DAPT for ISTH major bleeding (OR 0.62, 95% CI 0.57 – 0.69, p = < 0.00001). There was no statistically significant difference between DOACs + P2Y12 and VKA + DAPT for stent thrombosis (RR 1.17, 95% CI 0.79 – 1.72, p = 0.43) and MACE (RR 1.00, 95% CI 0.87 – 1.13, p = 0.07).

DISCUSSION

In patients with AF who had undergone PCI, the risk of bleeding was lower among those who received dual therapy with DOAC + P2Y12 than among those who received triple therapy with warfarin, a P2Y12 inhibitor and aspirin. However, dual therapy was noninferior to triple therapy with respect to the risk of stent thrombosis and MACE.

Human ; Atrial Fibrillation ; Percutaneous Coronary Intervention

OBJECTIVE

This study aims to determine the clinical profile and incidence of in-hospital outcomes of patients who underwent coronary artery bypass graft surgery (CABG) under the Philippine Health Insurance Corporation (Philhealth) Z Benefit Package (PZBP).

METHODS

A retrospective descriptive cohort study. A review of medical records was done from July 2017 to October 2023 to collect data and in-hospital outcomes of patients who underwent CABG surgery under Z benefit package.

RESULTS

One hundred twenty-six patients were included in the study. The mean age of patients was 60 years and majority of them were male and came from NCR. Hypertension was the leading cause of comorbidity. The top two most common in-hospital outcomes were hospital-acquired pneumonia and postoperative atrial fibrillation. Most commonly observed caused of increased length in hospitalization was pneumonia. The mean Society of Thoracic Surgeons (STS) (operative mortality) and Euro scores were 1.04 ± 0.82 and 0.88 ± 0.56, respectively. All patients had successful surgical outcome with no mortality and an average length of stay in the hospital of six days.

CONCLUSIONS

This study will serve as a future reference to enhance screening criteria and improved in-hospital outcomes for those who will undergo CABG under Z benefit package. The study also showed insights on clinical profile and in-hospital outcomes of patients who underwent CABG in our own institution and this may give way to a larger scale of study involving multiple centers who also offer the said program.

Human ; Coronary Artery Bypass ; Atrial Fibrillation ; Insurance, Health

Cardiac myxomas are primary cardiac tumors that presents with symptoms of hemodynamic derangement from obstruction of flow within the cardiac chambers or deformation of a cardiac valve and symptoms associated with embolization.

In this case report, we are presented with a 45-year-old female, diabetic with paroxysmal atrial fibrillation, fair functional capacity, ambulatory, with chief complaint of dyspnea. Admitted as a case of Left atrial myxoma with Pulmonary embolism (proximal right lower lobe, distal left main pulmonary artery division, and superior segmental division of the left lower lobe).

Left atrial myxoma was the first diagnostic consideration, followed by other primary cardiac tumors, and thrombus. Patient was then prepared for surgery and underwent excision of LA myxoma with CardioCel Bioscaffold patch on the inter-atrial septum, mitral ring annuloplasty with plication of the A2-A3 segment, thrombectomy of right inferior pulmonary vein, utilizing cardiopulmonary bypass. Upon pathological examination, the mass was found to be sarcoma with noted myxoid features. The objective of this report is to describe a case of this rare disease entity, and to discuss its presentation, pathological findings and management.

Human ; Female ; Middle Aged: 45-64 Yrs Old ; Pulmonary Embolism ; Pulmonary Artery ; Pulmonary Veins ; Atrial Fibrillation ; Atrial Septum ; Cardiopulmonary Bypass ; Hemodynamics ; Thrombectomy

This study aims to evaluate the application of flower petal-structured electrodes in pulsed field ablation (PFA) technology, with a particular focus on their performance in myocardial tissue ablation. Through a combination of simulation techniques and in vitro experiments, the study investigates the effects of different voltage levels, electrode-to-tissue contact distances, and their impact on ablation depth, continuity, and transmurality. The research methods include the construction of a myocardial tissue simulation model, electric field distribution simulation using COMSOL Multiphysics, and in vitro ablation experiments on potato tissue. The results indicate that as voltage increases, the ablation depth significantly increases. At a voltage of 2500 V, a transmural ablation depth of 4 mm can be achieved, and the ablation area remains relatively continuous. The in vitro experiments confirm the consistency of the simulation results, and pulsed field ablation does not induce significant temperature rise, confirming its non-thermal characteristic. The conclusion suggests that PFA technology requires less electrode contact and offers higher ablation efficiency, providing a new technological pathway for the clinical treatment of atrial fibrillation and effectively reducing the risk of complications associated with traditional ablation techniques.
Electrodes ; Catheter Ablation/instrumentation* ; Computer Simulation ; Flowers ; Atrial Fibrillation/surgery* ; Myocardium

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. It has a high prevalence and poor prognosis. The application of antiarrhythmic drugs and even surgery cannot completely treat the disease, and there are many sequelae. AF can be classified into the category of "palpitation" in Chinese medicine according to its symptoms. Acupuncture has a significant effect on AF. The authors find that an important mechanism of acupuncture in AF treatment is to regulate the cardiac vagus nerve. Therefore, this article intends to review the distribution and function of vagus nerve in the heart, the application and the regulatroy effect for the treatment of AF.
Atrial Fibrillation/physiopathology* ; Humans ; Acupuncture Therapy ; Vagus Nerve/physiology* ; Animals