Implantable cardiac monitors (ICMs) are useful for long-term arrhythmia monitoring in patients with unexplained symptoms. Temporal trends in the use of ICMs in routine clinical practice, along with the clinical indications for use, arrhythmia detection accuracy, and association with clinical outcomes have not been described. We identified all patients who underwent ICM implantation at the Minneapolis Heart Institutet between January 1, 2011, and February 26, 2016, using diagnosis codes for device implantation. From 2011 to 2016, a total of 603 patients with ICM devices were identified and 570 patients were analyzed including 139 Medtronic Reveal XT between 2011 and 2014, and 431 Reveal LINQ between 2014 and 2016. The 3-fold increase in ICM implants was primarily tied to the rise of LINQ monitoring for cryptogenic stroke patients (36% for LINQ vs. 5% for XT; P , 0.001). LINQ patients had fewer complications than XT patients (2.3% vs. 7.9%; P , 0.001). Atrial fibrillation detection accuracy was similar between the devices. Of patients with ICM implants, 30% had at least 1 intervention. The intervention rate was similar between the 2 models (P ¼ 0.40) as was the time to intervention (P ¼ 0.81). Since the release of the LINQ device, there has been an increase in the use of ICM implants among patients with cryptogenic stroke. LINQ ICM monitors have fewer complications post-implant. Only 5.6% of all syncope and cryptogenic stroke patients had a diagnosis within 1 month of implant. Despite potential improvements in arrhythmia detection accuracy, clinic work-flow is influenced by a higher volume of patient activated events that require interpretation.

Introduction: Transesophageal echo (TEE) is routinely used to exclude left atrial appendage (LAA) thrombus prior to direct current cardioversion (DCCV) for atrial fibrillation (AF). However, the COVID-19 pandemic accelerated the use of non-invasive modalities such as cardiac computed tomography (CCT) to avoid aerosolizing viral particles during intubation, such as with introduction of a TEE probe. CCT is not routinely used as a clinical strategy to exclude LAA thrombus prior to DCCV. Therefore, we sought to determine the feasibility of CCT-guided DCCV.Hypothesis: CCT-guided elective cardioversion for atrial arrhythmias is a feasible modality to rule out left atrial appendage thrombus. Methods: We identified patients at Abbott Northwestern Hospital who underwent CCT in lieu of or in addition to TEE within 24 hours of elective DCCV for AF or atrial flutter from March 2020 to February 2022. Thirty-day outcomes were collected including cerebrovascular accident (CVA), myocardial infarction, cardiovascular death, re-hospitalization, arrhythmia recurrence, and overall mortality. Delayed imaging, 90 seconds after arterial phase, was obtained to exclude LAA thrombus. Results: Thirty-two patients were included in our analysis, 10 (31%) were female. Ten (31%) presented with new-onset of AF. CCT did not identify LAA thrombus in any patient. Post-DCCV, the mean time to arrhythmia recurrence was 16.5 days (SD: 9.3). At 30 days, 11 (34%) had been re-hospitalized but mostly for elective procedures. There was no CVA or mortality reported at the 30-day follow-up. Conclusion: CCT-guided elective cardioversion for atrial arrhythmias was evaluated for feasibility in a small pilot. In patients who had no LAA thrombus on CCT and subsequently underwent cardioversion, there were no CCT-related complications, CVA, or deaths at 30 days. Many patients benefit from early DCCV rather than waiting with uninterrupted anticoagulation. CCT guidance is a feasible alternative to TEE but needs further prospective comparison to TEE and uninterrupted anticoagulation in this clinical setting.

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More than 6 million patients are on anticoagulant therapy and more than one third of adults take antiplatelet therapy in the United States, many of whom will require a surgical procedure while on treatment. The answers to questions regarding periprocedural thrombotic therapy are not at all straightforward and there is tremendous variability in practice across the country and across specialties. While there will always be nuances in clinical care that necessitate variation in practice patterns, algorithms for care allow for less ambiguity and they provide guidelines that are consistent with the most recent evidence in the literature. In this review, we provide: 1) a framework for periprocedureal antithrombotic therapy around the time of surgical procedures, 2) an approach for considering the risk of bleeding at the time of surgery as well as the risk of a thrombotic or thromboembolic event should the antithrombotic therapy be stopped, and 3) a strategy for managing periprocedural bridging therapy. KEY WORDSperiprocedural anticoagulation, antithrombotic therapy, thrombosis, bleeding risk, oral anticoagulation. n IS ANTITHROMBOTIC THERAPY REQUIRED?Answering a question regarding antithrombotic therapy should start with the consideration of whether or not the anticoagulation is still indicated in the first place. However, assuming the patient still has an indication for anticoagulation (and assuming a non-emergent surgery), the next question involves answering questions regarding surgical bleeding risk and the risk of thrombosis/thromboembolism if therapy is withheld. n BLEEDING RISKOne of the major risk-stratifications in assessing bleeding risk involves the risk inherent to the surgery or procedure. There is minimal data to guide decisions regarding procedural bleeding risk. The 2 main factors that impact bleeding risk are the type of procedure and the patient factors that interfere with hemostasis. A frequently cited reference with regard to surgical bleeding is from the American College of Chest Physicians, 1 which used expert consensus to generate a list of high-risk procedures. Interestingly, the major reference for surgical bleeding risk dates back to a metaanalysis of perioperative subcutaneous heparin use for the prevention of pulmonary embolism in 1988.2 Table 1 includes a list of high-risk procedures compiled from these consensus guidelines as well as another recent review. 1,3 In general, this list comprises surgeries that involve highly vascular organs or large incisions. An extensive list of surgical procedures and their associated risk has also been compiled as an appendix to a recent review on periprocedural antithrombotic therapy 4 (also based on expert opinion).There are several validated nonprocedural factors that increase bleeding risk and these include abnormal renal function, nonsteroidal anti-inflammatory medications, low platelet count, and liver disease/coagulopathy. These factors have been combined into a variety of bleeding risk scores: (1) and (4) ATRIA (anticoagulation and risk f...