Introduction: The optimal timing to initiate direct oral anticoagulants (DOACs) after acute ischemic stroke in patients with atrial fibrillation (AF) remains uncertain. Therefore, we performed a meta-analysis comparing early versus later DOAC initiation in this population. Methods: We searched PubMed, Embase, and Cochrane for randomized controlled trials (RCTs) answering this clinical question. We pooled risk ratios (RR) with 95% confidence intervals (CI) for binary endpoints. A restricted likelihood random-effects model was used for all outcomes. Quality assessment and risk of bias were performed according to Cochrane recommendations. Results: We included 6541 patients from three RCTs, of whom 3,270 (49.9%) received early treatment. There were no significant differences in recurrent ischemic stroke (RR 0.80; 95% CI 0.56-1.15; p=0.23), all-cause mortality (RR 0.97; 95% CI 0.81-1.18; p=0.27), and systemic embolism (RR 0.43; CI 0.16-1.11; p=0.08) in the early DOAC compared to delayed initiation groups. Similarly, symptomatic intracranial hemorrhage (RR 0.93; 95% CI 0.44-1.96; p=0.84) and major extracranial bleeding (RR 0.67; 95% CI 0.28-1.59; p=0.36) were non-significantly different between groups. Conclusion: In conclusion, early initiation of DOACs in patients with AF after acute ischemic stroke did not reduce recurrent ischemic stroke and was not associated with increased rates of symptomatic intracranial bleeding.

Background: Transvenous leads have been implicated in tricuspid valve (TV) dysfunction, but limited data are available regarding the effect of extracting leads across the TV on valve regurgitation. Objective: The aim of this study is to quantify tricuspid regurgitation (TR) before and after lead extraction and identify predictors of worsening TR. Methods: We studied 321 patients who had echocardiographic data before and after lead extraction. TR was graded on a scale (0=none/trivial, 1=mild, 2=moderate, 3=severe). A change of > 1 grade following extraction was considered significant. Results: A total of 321 patients underwent extraction of a total of 338 leads across the TV (1.05 ± 0.31 leads across the TV per patient). There was no significant difference in average TR grade pre- and post-extraction (1.18 ± 0.91 vs. 1.15 ± 0.87; p=0.79). TR severity increased after extraction in 84 patients, but was classified as significantly worse (i.e. > 1 grade change in severity) in only 8 patients (2.5%). Use of laser lead extraction was associated with a higher rate of worsening TR post-extraction (44.0% vs. 31.6%, p=0.04). Conclusion: In our single-center analysis, extraction of leads across the TV did not significantly affect the extent of TR in most patients. Laser lead extraction was associated with a higher rate of worsening TR after extraction.

Background: The Micra Coverage with Evidence Development (CED) Study is a novel comparative analysis of Micra (leadless VVI) and transvenous single-chamber ventricular pacemakers (transvenous VVI) using administrative claims data. Objective: To compare chronic complications, device reinterventions, heart failure hospitalizations, and all-cause mortality after 3 years of follow-up.  Methods: U.S. Medicare claims data linked to manufacturer device registration information were used to identify Medicare beneficiaries with a de novo implant of either a Micra VR leadless VVI or transvenous VVI pacemaker from March 9, 2017-December 31, 2018. Unadjusted and propensity score overlap-weight adjusted Fine-Gray competing risk models were used to compare outcomes at 3 years.   Results: Leadless VVI patients (N=6,219) had a 32% lower rate of chronic complications and a 41% lower rate of reintervention compared with transvenous VVI patients (N=10,212) (chronic complication hazard ratio [HR] 0.68; 95% CI, 0.59-0.78; reintervention HR 0.59; 95% CI 0.44-0.78). Infections rates were significantly lower among patients with a leadless VVI (<0.2% versus 0.7%, P<0.0001). Patients with a leadless VVI also had slightly lower rates of heart failure hospitalization (HR 0.90; 95% CI 0.84-0.97). There was no difference in the adjusted 3-year all-cause mortality rate (HR 0.97; 95% CI, 0.92-1.03).  Conclusion: This nationwide comparative evaluation of leadless VVI versus transvenous VVI de novo pacemaker implants demonstrated that the leadless group had significantly fewer complications, reinterventions, heart failure hospitalizations, and infections than the transvenous group at 3 years, confirming that the previously reported shorter-term advantages associated with leadless pacing persist and continue to accrue in the medium-to-long-term.

Background: Infection remains a major complication of cardiac implantable electronic devices (CIEDs) and can lead to significant morbidity and mortality. Extrathoracic devices that avoid epicardial or transvenous leads, such as the subcutaneous implantable cardioverter-defibrillator (S-ICD), can reduce the risk of serious infection-related complications, such as bloodstream infection and infective endocarditis. While the 2017 AHA/ACC/HRS guidelines include recommendations for S-ICD use for patients at high risk of infection, currently, there are no clinical trial data that address best practices for the prevention of S-ICD infections. Therefore, an expert panel was convened to develop consensus on these topics. Methods: An expert process mapping methodology was used to achieve consensus on the appropriate steps to minimize or prevent S-ICD infections. Two face-to-face meetings of high-volume S-ICD implanters and an infectious diseases specialist, with expertise on cardiovascular implantable electronic device infections, were conducted to develop consensus on useful strategies pre-, peri-, and post-implant to reduce S-ICD infection risk. Results: Expert panel consensus of recommended steps for patient preparation, S-ICD implantation, and post-operative management were developed to provide guidance in individual patient management. Conclusion: Achieving expert panel consensus by process mapping methodology for S-ICD infection prevention was attainable, and the results should be helpful to clinicians in adopting interventions to minimize risks of S-ICD infection.