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11,100 | Prompt and accurate diagnosis of ventricular arrhythmias with a novel index based on phase space reconstruction of ECG. | To develop a statistical index based on the phase space reconstruction (PSR) of the electrocardiogram (ECG) for the accurate and timely diagnosis of ventricular tachycardia (VT) and ventricular fibrillation (VF).</AbstractText>Thirty-two ECGs with sinus rhythm (SR) and 32 ECGs with VT/VF were analyzed using the PSR technique. Firstly, the method of time delay embedding were employed with the insertion of delay "τ" in the original time-series X(t), which produces the Y(t)=X(t-τ). Afterwards, a PSR diagram was reconstructed by plotting Y(t) against X(t). The method of box counting was applied to analyze the behavior of the PSR trajectories. Measures as mean (μ), standard deviation (σ) and coefficient of variation (CV=σ/μ), kurtosis (β) for the box counting of PSR diagrams were reported.</AbstractText>During SR, CV was always <0.05, while with the onset of arrhythmia CV increased >0.05. A similar pattern was observed with β, where <6 was considered as the cut-off point between SR and VT/VF. Therefore, the upper threshold for SR was considered CVth=0.05 and βth<6. For optimisation of the accuracy, a new index (J) was proposed: J=wCVCVth+1-wββth. During SR the upper limit of J was the value of 1. Furthermore CV, β and J crossed the cut-off point timely before the onset of arrhythmia (average time: 4min 31s; SD: 2min 30s); allowing sufficient time for preventive therapy.</AbstractText>The J index improved ECG utility for arrhythmia monitoring and detection utility, allowing the prompt and accurate diagnosis of ventricular arrhythmias.</AbstractText>Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,101 | Prevalence of atrial fibrillation and its risk factors in rural China: a cross-sectional study. | To evaluate the prevalence of atrial fibrillation (AF) in physical laborers in rural China and identify contributing risk factors.</AbstractText>A cross-sectional study of 11,956 permanent residents of Liaoning Province in rural China≥35y of age (primarily physical laborers) was conducted between January and August 2013 (response rate 85.3%). All participants completed a questionnaire and underwent a physical exam, echocardiography and electrocardiography. Blood samples were drawn for laboratory analyses, and AF was diagnosed on the basis of history and electrocardiograph findings. Risk factors for AF were evaluated with a stepwise logistic regression analysis.</AbstractText>The prevalence of AF was 1.2% overall, but rose steeply with age (0.1% in those 35-44y of age, and 4.6% in those≥75y); there was no significant gender difference at any age. Independent risk factors for AF were age (odds ratio [OR] 1.89; P<0.001), diabetes (OR 2.07; P=0.001), history of myocardial infarction (OR 5.91; P<0.001), low left ventricular ejection fraction (OR 1.85; P=0.005), and low physical activity (OR 1.72; P=0.003), whereas obesity, hypertension, cholesterol and triglyceride levels, current smoking and drinking, left ventricular hypertrophy, and family history of AF were not significant contributors.</AbstractText>Although the prevalence of AF in physical labors in rural China is low, age, diabetes, history of myocardial infarction, low left ventricular ejection fraction, and low physical activity are independent risk factors.</AbstractText>Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,102 | The Outcome and Predictors of Mortality in Patients Therapeutically Cooled Postcardiac Arrest. | To review the outcomes of patients postcardiac arrest admitted to a metropolitan intensive care unit (ICU) where therapeutic hypothermia is practiced.</AbstractText>Patients admitted from 2004 to 2012 were reviewed. The management protocol included cooling to 33°C for 24 hours. The primary outcome assessed was hospital mortality. Secondary outcome measures included mortality in patients admitted to ICU after in-hospital cardiac arrest (IHCA) when compared to those with out-of-hospital cardiac arrest (OHCA) and to review initial cardiac rhythm as an indicator of mortality.</AbstractText>A total of 330 patients were included. The overall hospital mortality was 58.1%. Hospital mortality was significantly higher in patients who had OHCA when compared to IHCA (62.5% vs 51%; P = .04). Patients who had asystole and pulseless electrical activity (PEA) had a higher mortality when compared to ventricular tachycardia/ventricular fibrillation (VT/VF) arrest (81.7% vs 67.8% vs 41.9%, respectively; P < .01).</AbstractText>Patients admitted to ICU postcardiac arrest after therapeutic cooling have a high mortality. An initial rhythm of VT/VF confers a mortality benefit when compared to asystole and PEA.</AbstractText>© The Author(s) 2015.</CopyrightInformation> |
11,103 | Limitations of animal electrical cardiac safety models. | Human electrical safety standards are based almost exclusively on animal studies and there is an unjustified assumption that ventricular fibrillation (VF) thresholds in animals are the same as those in humans.</AbstractText>We analyzed differences between animals and humans in cardiac stimulation. A broad literature survey revealed that swine are a fragile electrophysiologic research species and have a dense intramural Purkinje fiber network, which is not found in some other species, including humans. Anesthesia agents have to be chosen carefully as swine are prone to malignant hyperthermia. Cardiac stimulation thresholds depend on weight and capture rates. Thus, the animal weight has to be representative of the weight of human subjects. Studies have shown significant ECG differences between humans and other species, including swine and canine. At least one study suggested that rabbit hearts tend to develop VF in a manner more similar to that seen in humans.</AbstractText>Animal studies can play a role in conservatively evaluating cardiac safety. However, while still abiding by the precautionary principle, animal study design has to take into account the significant anatomical and electrophysiological differences between humans and other mammals. Data from multiple animal models may offer broader perspectives. If attempts are made to extrapolate animal results to humans then appropriate numerical correction factors should be applied, such as some of those discussed in this article.</AbstractText> |
11,104 | ETD: an extended time delay algorithm for ventricular fibrillation detection. | Ventricular fibrillation (VF) is the most serious type of heart attack which requires quick detection and first aid to improve patients' survival rates. To be most effective in using wearable devices for VF detection, it is vital that the detection algorithms be accurate, robust, reliable and computationally efficient. Previous studies and our experiments both indicate that the time-delay (TD) algorithm has a high reliability for separating sinus rhythm (SR) from VF and is resistant to variable factors, such as window size and filtering method. However, it fails to detect some VF cases. In this paper, we propose an extended time-delay (ETD) algorithm for VF detection and conduct experiments comparing the performance of ETD against five good VF detection algorithms, including TD, using the popular Creighton University (CU) database. Our study shows that (1) TD and ETD outperform the other four algorithms considered and (2) with the same sensitivity setting, ETD improves upon TD in three other quality measures for up to 7.64% and in terms of aggregate accuracy, the ETD algorithm shows an improvement of 2.6% of the area under curve (AUC) compared to TD. |
11,105 | Fusion of structural and functional cardiac magnetic resonance imaging data for studying ventricular fibrillation. | Magnetic Resonance Imaging (MRI) techniques such as Current Density Imaging (CDI) and Diffusion Tensor Imaging (DTI) provide a complementing set of imaging data that can describe both the functional and structural states of biological tissues. This paper presents a Joint Independent Component Analysis (jICA) based fusion approach which can be utilized to fuse CDI and DTI data to quantify the differences between two cardiac states: Ventricular Fibrillation (VF) and Asystolic/Normal (AS/NM). Such an approach could lead to a better insight on the mechanism of VF. Fusing CDI and DTI data from 8 data sets from 6 beating porcine hearts, in effect, detects the differences between two cardiac states, qualitatively and quantitatively. This initial study demonstrates the applicability of MRI-based imaging techniques and jICA-based fusion approach in studying cardiac arrhythmias. |
11,106 | Transthoracic cardiac stimulation thresholds for short pulses. | The most common cause of death due to electric shock is ventricular fibrillation (VF). This work reviews applicable results from the literature and provides an estimation model for the risk of VF with short-duration pulses.</AbstractText>For 1 ms pulses, the predicted current and charge thresholds required for successful transthoracic cardiac stimulation were 1.12 A and 1.12 mC, respectively. For pulses of 0.1 ms durations, the transthoracic current and charge thresholds predicted by the model are 10.9 A and 1.09 mC, respectively.</AbstractText>In humans, the charge required for single-response cardiac capture using transthoracic electrodes and 0.1 ms pulses is at least 0.5 mC. The transthoracic charge required to trigger repetitive ventricular responses in humans is at least several times higher than that for single responses. Hence, in adult humans, the transthoracic charge threshold required to induce repetitive ventricular responses, tachycardia, or fibrillation, with 0.1 ms pulses is expected to be significantly greater than 1 mC.</AbstractText> |
11,107 | The sternum as an electrical shield. | The TASER(®) conducted electrical weapon (CEW) delivers electrical pulses that can temporarily incapacitate subjects. We analyzed the distribution of TASER CEW currents in tissues posterior to the sternum to understand the likelihood of triggering cardiac arrhythmias. We also assessed the electrical `shielding' effects of the sternum.</AbstractText>Finite element modeling (FEM) was used to approximate the current density and electric field strength in tissues around the sternum. We analyzed 2 CEW dart deployment scenarios: (a) both darts over the anterior aspect of the sternum; and (b) a CEW dart anterior to the sternum and the other over the abdomen. In both scenarios, the sternum provided significant attenuation of CEW currents. Particularly, both FEMs predicted that the residual electrical current or charge from CEWs would be insufficient to cause either cardiac capture or induction of ventricular fibrillation at locations where cardiac tissue would reside relative to the posterior aspect of the sternum.</AbstractText>The sternum offers significant 'shielding' effect and protects the tissues posterior to it against effects of electrical current flow from anteriorly-placed CEW electrodes.</AbstractText> |
11,108 | Electrophysiological properties under heart failure conditions in a human ventricular cell: a modeling study. | Heart failure (HF) is one of the major diseases across the world. During HF the electrophysiology of the failing heart is remodeled, which renders the heart more susceptible to ventricular arrhythmias. In this study, we quantitatively analyze the effects of electrophysiological remodeling of the major currents of human ventricular myocytes on the dynamics of the failing heart. We develop a HF model using a modified version of a recently published model of the human ventricular action potential, the O'Hara-Virag-Varro-Rudy (OVVR) model. The proposed HF model incorporates recently available HF clinical data. It can reproduce most of the action potential (AP) properties of failing myocytes, including action potential duration (APD), amplitude (APA), notch (APN), plateau (APP), resting membrane potential (RMP), and maximum upstroke velocity (dV/dtmax). In addition, the model reproduces the behavior of the [Na+], concentration and [Ca(2)+]i dynamics. Moreover, the HF model exhibits alternans with a fast pacing frequency and can induce early afterdepolarizations (EADs). Additionally, blocking the late sodium current shortens the APD and suppresses EADs, in agreement with experimental findings. The dynamics of the proposed model are assessed through investigating the rate dependence of the AP and the dynamics of the major currents. The steady-state (S-S) and S1-S2 restitution curves along with accommodation to an abrupt change in cycle length were evaluated. Our study should help to elucidate the roles of alterations in electrophysiological properties during HF. Also, this HF cellular model could be used to study HF in a realistic geometry and could be embedded into a model of HF electromechanics to investigate electrical and mechanical properties simultaneously during HF. |
11,109 | Comparison of arrhythmia prevalence in NUVANT Mobile Cardiac Telemetry System patients in the US and India. | The Corventis NUVANT™ Mobile Cardiac Telemetry System provides continuous monitoring of symptomatic and asymptomatic cardiac abnormalities to help physicians diagnose and treat non-lethal cardiac arrhythmias. Analysis of a sample of 2231 US and 1053 Indian NUVANT patients has revealed interesting statistics on the prevalence of various cardiac arrhythmias in the patient populations of the two nations. The population is non-randomized and consists of US patients where often a traditional Holter Monitor study was negative and self-pay Indian patients. Mean age was 61.3 for the US and 57.8 for India with 57% of US patients and 32% of India patients being female. Presentation of specific arrhythmia types was similar across populations with the exception of atrial fibrillation and flutter being more prevalent in the older US population as well as increased prevalence of symptomatic atrial and ventricular ectopic rhythms in all patients and SVT for female patients in India. Utilization as defined by the number of patient triggers was 50% higher for Indian patients. |
11,110 | Cardiovascular effects of Adonis aestivalis in anesthetized sheep. | Adonis aestivalis (summer pheasant-eye) is an annual plant with a crimson flower, distributed in southern Europe and Asia. The plant has large buttercup-like blossoms and soft, fern-like leaves. It blooms in spring and is often found as a weed in cereal fields. Like other Adonis spp., the plant produces cardiac glycosides. It is used in remedies for mild weakness of the heart, especially when accompanied by nervous complaints. Cardiovascular and toxic effects of a hydroalcoholic extract from the aerial parts of A. aestivalis were investigated in sheep and mice. Six male sheep were anesthetized with sodium pentobarbital and arterial blood pressure was measured with a transducer connected to the left femoral artery. Heart rate and electrocardiogram (ECG) were registered from lead base-apex ECG derivatives connected to a Powerlab recorder. Three successive equal doses (75 mg kg(-1)) of the hydroalcoholic extract of A. aestivalis intravenously administered to anesthetized sheep. Adonis aestivalis extract induced a significant bradycardia and hypotension in sheep. Various ECG abnormalities in sheep included sinus arrhythmia, shortened and depressed S-T interval, and absence of P wave and flattened or inverted T wave. In addition, ventricular arrhythmias, bradyarrhythmias, atrioventricular block, ventricular premature beats, ventricular tachycardia and ventricular fibrillation have also been observed. The acute intraperitoneal toxicity (LD50) of the extract in mice was 2150 mg kg(-1). In conclusion, bradycardia and ECG alterations induced by the extract could explain the justification of traditional use of the of Adonis aestivalis in treating cardiovascular insufficiency. |
11,111 | Ventricular dysrhythmias associated with poisoning and drug overdose: a 10-year review of statewide poison control center data from California. | Ventricular dysrhythmias are a serious consequence associated with drug overdose and chemical poisoning. The risk factors for the type of ventricular dysrhythmia and the outcomes by drug class are not well documented.</AbstractText>The aim of this study was to determine the most common drugs and chemicals associated with ventricular dysrhythmias and their outcomes.</AbstractText>We reviewed all human exposures reported to a statewide poison control system between 2002 and 2011 that had a documented ventricular dysrhythmia. Cases were differentiated into two groups by type of arrhythmia: (1) ventricular fibrillation and/or tachycardia (VT/VF); and (2) torsade de pointes (TdP).</AbstractText>Among the 300 potential cases identified, 148 cases met the inclusion criteria. Of these, 132 cases (89%) experienced an episode of VT or VF, while the remaining 16 cases (11%) had an episode of TdP. The most commonly involved therapeutic classes of drugs associated with VT/VF were antidepressants (33/132, 25%), stimulants (33/132, 25%), and diphenhydramine (16/132, 12.1%). Those associated with TdP were antidepressants (4/16, 25%), methadone (4/16, 25%), and antiarrhythmics (3/16, 18.75%). Drug exposures with the greatest risk of death in association with VT/VF were antidepressant exposure [odds ratio (OR) 1.71; 95% confidence interval (CI) 0.705-4.181] and antiarrhythmic exposure (OR 1.75; 95% CI 0.304-10.05), but neither association was statistically significant. Drug exposures with a statistically significant risk for TdP included methadone and antiarrhythmic drugs.</AbstractText>Antidepressants and stimulants were the most common drugs associated with ventricular dysrhythmias. Patients with suspected poisonings by medications with a high risk of ventricular dysrhythmia warrant prompt ECG monitoring.</AbstractText> |
11,112 | Home monitoring of implantable cardioverter-defibrillators: interpretation reliability of the second-generation "IEGM Online" system. | Intracardiac electrograms (IEGMs) are essential for the assessment of implantable cardioverter-defibrillator (ICD) function. The Biotronik Home Monitoring systems transmit an 'IEGM Online' that is shorter than the full-length programmer IEGM due to technical constrains. The aim of this study was to evaluate the accuracy of the physician's classification of the underlying rhythm based on the second-generation IEGM Online.</AbstractText>In total, 1533 patients treated with single- and dual-chamber ICDs and cardiac resynchronization therapy defibrillators were enrolled at 67 investigational sites and followed for 15 months. The investigators classified the rhythm shown in IEGM Online as ventricular tachycardia, ventricular fibrillation, atrial fibrillation, other supraventricular tachyarrhythmia, oversensing due to lead failure, T-wave oversensing, or other rhythm. At the next in-office follow-up, the investigators classified independently the rhythm seen in the corresponding programmer IEGM. The two rhythm classifications were compared thereafter. Both IEGM Online and programmer IEGM were available in 2099 arrhythmic or oversensing events, of which 146 (7.0%) were classified as other rhythm or artefacts and were excluded as inconclusive or atypical. The remaining 1953 events, affecting 352 patients (23.0%), were classified correctly in 1803 cases (92.3%). The accuracy of rough rhythm classification as ventricular, supraventricular, or oversensing was 97.2%.</AbstractText>The Lumax and IEGM Online HD Evaluation study demonstrates that remote IEGM analysis is reasonably accurate in a remote monitoring system that transmits shorter IEGM than the full-length programmer IEGM for the sake of frequent, fully automatic data transmission.</AbstractText>© The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.</CopyrightInformation> |
11,113 | Efficacy of cardiac resynchronization with defibrillator insertion in patients undergone coronary artery bypass graft: a cohort study of cardiac function. | Cardiac resynchronization therapy (CRT) is a proven therapeutic method in selected patients with heart failure and systolic dysfunction which increases left ventricular function and patient survival. We designed a study that included patients undergoing coronary artery bypass graft (CABG), with and without CRT-defibrillator (CRT-D) inserting and then measured its effects on these two groups.</AbstractText>Between 2010 and 2013, we conducted a prospective cohort study on 100 coronary artery disease patients where candidate for CABG. Then based on the receiving CRT-D, the patients were categorized in two groups; Group 1 ( n = 48, with CRT-D insertion before CABG) and Group 2 ( n = 52 without receiving CRT-D). Thereafter both of these groups were followed-up at 1-3 months after CABG for mortality, hospitalization, atrial fibrillation (AF), echocardiographic assessment, and New York Heart Association (NYHA) class level.</AbstractText>The mean age of participants in Group 1 (48 male) and in Group 2 (52 male) was 58 ± 13 and 57 ± 12 respectively. Difference between Groups 1 and 2 in cases of mean left ventricular ejection fraction (LVEF) changes and NYHA class level was significant ( P > 0.05). Hospitalization ( P = 0.008), mortality rate ( P = 0.007), and AF were significantly different between these two groups.</AbstractText>The results showed that the increase in LVEF and patient's improvement according to NYHA-class was significant in the first group, and readmission, mortality rate and AF was increased significantly in the second group.</AbstractText> |
11,114 | Neuroanatomical correlates of atrial fibrillation: a longitudinal MRI study. | To determine baseline volume and rate of volume change of whole brain, hippocampus, and entorhinal cortex in patients with atrial fibrillation.</AbstractText>We analyzed clinical and neuroimaging data collected as part of Alzheimer's Disease Neuroimaging Initiative in the United States and Canada. Patients with atrial fibrillation were identified based on baseline clinical/cognitive assessments, and age and gender-matched controls without atrial fibrillations were selected (1:1 ratio). All participants underwent 1.5 T structural magnetic resonance imaging (MRI) at specified intervals (6 or 12 months) for 2-3 years.</AbstractText>A total of 33 persons with atrial fibrillation were included. There was no difference in whole brain and ventricular volumes at baseline MRI between cases and controls. There was significantly lower entorhinal cortex volume on right (p = 0.01) and left (p = 0.01) sides in patients with atrial fibrillation. There was significantly lower volume for middle temporal lobes on right (p = 0.04) and left (p = 0.001) sides. The rate of progression of atrophy in entorhinal cortex and middle temporal lobes was not different between patients with atrial fibrillation and controls.</AbstractText>The association of atrial fibrillation with volume loss in entorhinal cortex and middle temporal lobes may provide new insights into pathophysiology of atrial fibrillation.</AbstractText> |
11,115 | Optimal conditions for cardiac catheter ablation using photodynamic therapy. | Photodynamic therapy (PDT) is based on non-thermal injury mediated by singlet oxygen species and is used clinically in cancer therapy. In our continuing efforts to apply this technology to cardiac catheter ablation, we clarified the optimal condition for creating PDT-mediated lesions using a laser catheter.</AbstractText>In a total of 35 canines, we applied a laser directly to the epicardium of the beating heart during open-chest surgery at 15 min after administration of a photosensitizer, talaporfin sodium. We evaluated the lesion size (depth and width) using hematoxylin-eosin staining under varying conditions as follows: laser output (5, 10, 20 W/cm(2)), irradiation time (0-60 s), photosensitizer concentration (0, 2.5, 5 mg/kg), blood oxygen concentration (103.5 ± 2.1 vs. 548.0 ± 18.4 torr), and contact force applied during irradiations (low: <20 g, high: >20 g). A laser irradiation at 20 W/cm(2) for 60 s under 5 mg/kg (29 µg/mL) of photosensitizer induced a lesion 8.7 ± 0.8 mm deep and 5.2 ± 0.2 mm wide. The lesion size was thus positively correlated to the laser power, irradiation time, and photosensitizer concentration, and was independent of the applied contact force and oxygen concentration. In addition, the concentration of the photosensitizer strongly correlated with the changes in the pulse oximetry data and fluorescence of the backscattering laser, suggesting that a clinically appropriate condition could be estimated in real time.</AbstractText>Photodynamic therapy-mediated cardiac lesions might be controllable by regulating the photosensitizer concentration, laser output, and irradiation time.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.</CopyrightInformation> |
11,116 | β-Blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review. | This is a systematic review of the literature to compare the efficacy of calcium channel blockers to β-blockers for acute rate control of atrial fibrillation with rapid ventricular response in the emergency department setting. PubMed, EMBASE, and the Cochrane Registry were searched. Relative risk (95% confidence interval) was calculated between drugs and methodological quality of included studies was evaluated. Of the 1003 studies yielded by our initial search, two met inclusion criteria and provided sufficient data. These were randomized double-blinded studies (n=92) comparing intravenous diltiazem with intravenous metoprolol. The combined relative risk of acute rate control by diltiazem versus metoprolol was 1.8 (95% confidence interval 1.2-2.6). On the basis of the paucity of available evidence, diltiazem may be more effective than metoprolol in achieving rapid rate control, but high-quality randomized studies are needed. |
11,117 | Negative impact of atrial fibrillation and pulmonary hypertension after mitral valve surgery in asymptomatic patients with severe mitral regurgitation: a 20-year follow-up. | The timing for mitral valve (MV) surgery in asymptomatic patients with severe mitral regurgitation (MR) and preserved left ventricular (LV) function remains controversial. We aimed at analysing the long-term outcome of asymptomatic patients with atrial fibrillation (AF) and/or pulmonary hypertension (PHT) after successful MV repair.</AbstractText>From January 1992 to December 2012, 382 patients with severe degenerative MR, with no or mild symptoms, preserved LV function (ejection fraction > 60%) and LV systolic dimensions <45 mm were submitted to surgery and followed up for up to 22 years (3209 patient-years). Patients with associated surgeries, other than tricuspid repair, were excluded. Patients with AF and/or PHT (Group A; n = 106, 24.4%) were compared with patients without these comorbidities (Group B; n = 276, 63.6%). Propensity-score matching (for preoperative variables) was performed obtaining 102 patients in each arm. Survival and event-free survival [major cardiac and cerebrovascular events (MACCEs); freedom from mitral reoperation and recurrent moderate and severe MR] were analysed.</AbstractText>MV repair was performed in 98.2% of cases and tricuspid annuloplasty in 6.9%. Overall 30-day mortality was 0.8%, not different between groups, and absent in patients with isolated posterior leaflet prolapse (n = 211). Patients with AF/PHT had worse late survival by comparison with Group B patients (67.0 ± 7.4 vs 86.5 ± 3.9% at 15 years, P < 0.001), survival free from MACCE (52.7 ± 8.7 vs 74.5 ± 5.0%, P < 0.001), from recurrent moderate and severe MR (65.1 ± 10.3 vs 87.0 ± 3.8%, P = 0.002) and from mitral reoperation during the follow-up (87.3 ± 6.3 vs 94.2 ± 2.7%, P = 0.04). These differences were confirmed in the propensity score-matched population. Patients from Group A also displayed a lesser degree of reverse remodelling. There was a significant reduction in the systolic pulmonary artery pressure (SPAP) after surgery, more pronounced in Group A patients; nonetheless, the mean SPAP at late follow-up was higher in these patients (45 vs 30 mmHg).</AbstractText>MV repair can be achieved in the great majority of patients with degenerative regurgitation, with low mortality (<1%). Asymptomatic or mildly symptomatic patients with severe MR, preserved LV function and AF/PHT had poorer long-term survival and event-free survival even after a successful surgery. The durability of MV repair was also compromised in these patients, which indicates that they should have been operated earlier.</AbstractText>© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.</CopyrightInformation> |
11,118 | Atrial fibrillation in cardiac resynchronization recipients with and without prior arrhythmic history. How much of arrhythmia is too much? | The aim of the study was to assess long-term incidence of atrial fibrillation (AF) in cardiac resynchronization (CRT) recipients with and without prior arrhythmic history, factors predisposing to arrhythmia, as well as to evaluate the prognostic power of cumulative arrhythmia burden, duration of the longest episode and the number of episodes.</AbstractText>Device-collected data on AF episodes during 24 months in 96 participants of a randomized CRT-trial were analyzed (15% in NYHA class IV, sinus rhythm, median left ventricular ejection fraction 24% and QRS 169 ms). Blindly adjudicated major adverse cardiac events (MACE) and any-cause death were censoring variables.</AbstractText>Two-year incidence of AF was 70%, including 66% of patients without previous AF history. No baseline characteristics distinguished those who developed new onset AF. Percent of time spent in AF, but not number of episodes predicted mortality (adjusted hazard ratio [HR] 1.05 ± 95% confidence interval CI 1.01-1.10) and MACE incidence (HR 1.03 ± 1.01-1.07; p = 0.03). Duration of the longest episode also predicted mortality (HR 1.06 ± 1.01-1.12; both p = 0.03). Prognostic impact of AF load was marked only in patients with slower ventricular response (< 98/min), but was independent from CHADS2 scores, pacing burden, or prior atrioventricular nodal ablation.</AbstractText>Seven out of 10 CRT-patients had AF within 2 years, including two-thirds of subjects without arrhythmic history. No baseline features distinguished those who developed new onset AF. Arrhythmia burden and duration of the longest episode, but not number of episodes influenced outcomes in CRT-patients, irrespectively from pacing burden or prior atrioventricular node ablation.</AbstractText> |
11,119 | Successful extracorporeal resuscitation after perioperative anaphylactic shock during living donor liver transplantation. | A 46-year-old man was admitted for emergent donor hepatectomy. His circulatory condition became unstable 75 minutes after induction and then deteriorated to ventricular fibrillation due to latex-induced anaphylaxis. Following 35 minutes of futile conventional resuscitation without spontaneous cardiac rhythm, extracorporeal resuscitation was initiated and electric cardiac activity returned 10 minutes later. He was discharged home without any sequelae. Extracorporeal cardiopulmonary resuscitation would offer an alternative choice compared with conventional cardiopulmonary resuscitation. |
11,120 | Incidence and risk factors of ventricular fibrillation before primary angioplasty in patients with first ST-elevation myocardial infarction: a nationwide study in Denmark. | We aimed to investigate the incidence and risk factors for ventricular fibrillation (VF) before primary percutaneous coronary intervention (PPCI) among patients with ST-segment elevation myocardial infarction (STEMI) in a prospective nationwide setting.</AbstractText>In this case-control study, patients presenting within the first 12 hours of first STEMI who survived to undergo angiography and subsequent PPCI were enrolled. Over 2 years, 219 cases presenting with VF before PPCI and 441 controls without preceding VF were enrolled. Of the 219 case patients, 182 (83%) had STEMI with out-of-hospital cardiac arrest due to VF, and 37 (17%) had cardiac arrest upon arrival to the emergency room. Medical history was collected by standardized interviews and by linkage to national electronic health records. The incidence of VF before PPCI among STEMI patients was 11.6%. Multivariable logistic regression analysis identified novel associations between atrial fibrillation and alcohol consumption with VF. Patients with a history of atrial fibrillation had a 2.80-fold odds of experiencing VF before PPCI (95% CI 1.10 to 7.30). Compared with nondrinkers, patients who consumed 1 to 7 units, 8 to 14 units, or >15 units of alcohol per week had an odds ratio (OR) of 1.30 (95% CI, 0.80 to 2.20), 2.30 (95% CI, 1.20 to 4.20), or 3.30 (95% CI, 1.80 to 5.90), respectively, for VF. Previously reported associations for preinfarction angina (OR 0.46; 95% CI 0.32 to 0.67), age of <60 years (OR 1.75; 95% CI 1.20 to 2.60), anterior infarction (OR 2.10; 95% CI 1.40 to 3.00), preprocedural thrombolysis in myocardial infarction flow grade 0 (OR 1.65; 95% CI 1.14 to 2.40), and family history of sudden death (OR 1.60; 95% CI 1.10 to 2.40) were all associated with VF.</AbstractText>Several easily assessed risk factors were associated with VF occurring out-of-hospital or on arrival at the emergency room before PPCI in STEMI patients, thus providing potential avenues for investigation regarding improved identification and prevention of life-threatening ventricular arrhythmias.</AbstractText>© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.</CopyrightInformation> |
11,121 | Paradoxical carbon dioxide embolism during laparoscopic cholecystectomy as a cause of cardiac arrest and neurologic sequelae: a case report. | An 81-year-old male patient was scheduled for a laparoscopic cholecystectomy due to acute cholecystitis. About 50 minutes into the operation, the arterial blood pressure suddenly decreased and ventricular fibrillation appeared on the electrocardiography. The patient received cardiopulmonary resuscitation and recovered a normal vital sign. We suspected a carbon dioxide embolism as the middle hepatic vein had been injured during the surgery. We performed a transesophageal echocardiography and were able to confirm the presence of multiple gas bubbles in all of the cardiac chambers. After the operation, the patient presented a stable hemodynamic state, but showed weaknesses in the left arm and leg. There were no acute lesions except for a chronic cerebral cortical atrophy and chronic microvascular encephalopathy on the postoperative brain-computed tomography, 3D angiography and magnetic resonance image. Fortunately, three days after the operation, the patient's hemiparesis had entirely subsided and he was discharged without any neurologic sequelae. |
11,122 | Prolonged Tpeak-end and Tpeak-end/QT ratio as predictors of malignant ventricular arrhythmias in the acute phase of ST-segment elevation myocardial infarction: a prospective case-control study. | Prolonged Tpeak-end (the interval from the peak of the T wave to the end of the T wave) and Tpeak-end/QT ratio have been shown to be markers of arrhythmogenesis in various cardiac disorders.</AbstractText>The purpose of this study was to evaluate the utility of Tpeak-end and Tpeak-end/QT ratio at admission in patients with acute ST-segment elevation myocardial infarction (STEMI) in predicting malignant ventricular arrhythmias.</AbstractText>The study group included 50 patients presenting with STEMI, in whom Tpeak-end and Tpeak-end/QT ratio were measured at admission; these patients were monitored for arrhythmias with a continuous electrocardiogram in the intensive care unit for 48 hours, and 50 healthy individuals acted as controls.</AbstractText>The Tpeak-end (0.11 ± 0.04 seconds vs 0.08 ± 0.006 seconds; P < .0010) and Tpeak-end/QT ratio (0.30 ± 0.06 vs 0.21 ± 0.02; P < .001) were prolonged in patients with STEMI. Three patients with STEMI who sustained ventricular fibrillation (VF) within 24 hours of admission had prolonged corrected QT interval (0.39 ± 0.04 seconds vs 0.46 ± 0.13 seconds; P = .019), Tpeak-end (0.10 ± 0.02 seconds vs 0.20 ± 0.11 seconds; P < .001), and Tpeak-end/QT ratio (0.26 ± 0.05 vs 0.41 ± 0.09; P < .001) as compared with patients with STEMI without VF. Tpeak-end > 0.1 seconds and Tpeak-end/QT ratio > 0.3 predicted VF with a sensitivity of 100%. However, the Tpeak-end/QT ratio had a higher specificity (82.9% for Tpeak-end/QT ratio vs 44.7% for Tpeak-end) and accuracy (84% for Tpeak-end/QT ratio vs 48% for Tpeak-end).</AbstractText>Tpeak-end and Tpeak-end/QT ratio are prolonged in patients with STEMI compared with healthy individuals, and Tpeak-end > 0.1 and Tpeak-end/QT ratio > 0.3 predict malignant ventricular arrhythmias within 24 hours of STEMI.</AbstractText>Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,123 | Inaccurate treatment decisions of automated external defibrillators used by emergency medical services personnel: incidence, cause and impact on outcome. | The rhythm analysis algorithm (RAA) of automated external defibrillators (AEDs) may be deceived by many factors. In this observational study we assessed RAA accuracy in prehospital interventions. For every rhythm analysis judged to be inaccurate, we looked for causal factors and estimated the impact on outcome.</AbstractText>In 135 consecutive patients, two physicians reviewed 837 rhythm analyses independently. When they disagreed, a third physician made the final decision.</AbstractText>Among 148 shockable episodes, 23 (16%) were not recognized by the RAA due to external artifacts (n=7), fine ventricular fibrillation (VF; n=7), RAA error without external artifacts (n=4) or a combination of factors (n=5). In six cases the omitted/delayed shock was judged to be of clinical relevance: survival with some neurological deficit (n=4), death without regaining consciousness (n=1) and no restoration of spontaneous circulation (n=1). In 689 non-shockable episodes, the RAA decided "shockable" 25 times (4%). This wrongful decision was due to external artifacts (n=9), a concurrent shock of an internal cardioverter defibrillator (n=1), RAA error without external artifacts (n=13) or a combination of factors (n=2). Fifteen spurious shocks were delivered. As these non-shockable rhythms did not deteriorate after the shock, we assumed that no significant harm was done.</AbstractText>Up to 16% of shockable rhythms were not detected and 4% of non-shockable rhythms were interpreted as shockable. Therefore, all AED interventions should be reviewed. Feedback to caregivers may avoid future deleterious interactions with the AED, whereas AED manufacturers may use this information to improve RAA accuracy. This approach may improve the outcome of some VF patients.</AbstractText>Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,124 | Measured Lead Parameters and Electrogram Sensing Over Time in Patients With Cardiac Sarcoidosis and an Implanted Cardiac-Defibrillator. | The study sought to characterize the performance of implanted leads among a cohort of patients with cardiac sarcoidosis (CS) and implantable cardiac-defibrillators (ICDs).</AbstractText>An ICD is indicated for some patients with CS for the prevention of sudden cardiac death. CS can lead to myocardial inflammation and scar that may interfere with lead performance.</AbstractText>We performed a case-control study within the cohort of patients at the University of Colorado Hospital with CS and an ICD (n = 48) compared with randomly selected controls (n = 117) who had other indications for an ICD. We compared the measured lead parameters at the time of routine interrogation to assess the differences between groups over time. The mean duration of follow-up was 51 months. Survival analysis was performed by the method of Kaplan and Meier and by Cox proportional hazards regression.</AbstractText>There was no significant difference in measured lead impedance, capture thresholds, or sensed electrograms at implantation between the CS and control groups. There were no significant differences between the mean parameters between groups over the follow-up period. However, patients with CS have a high incidence of significant (>50%) drop in measured electrograms (16 of 46 [33%] CS patients vs. 4 of 117 [3.4%] controls; hazard ratio: 10.49, 95% confidence interval: 3.47 to 31.67). As a result of alterations in lead parameters, 2 patients (4.3%) required lead revision, and 6 patients (13%) required ICD testing to ensure adequate detection of induced ventricular fibrillation.</AbstractText>Reductions over time in ICD sensing of P- and/or R-wave electrograms are common in patients with CS. Although further investigation is needed to determine the mechanism of these changes, these findings suggest that patients with CS who have an ICD should be closely monitored for clinically relevant changes in P- and R-wave amplitudes.</AbstractText>Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,125 | Prediction of Nonarrhythmic Mortality in Primary Prevention Implantable Cardioverter-Defibrillator Patients With Ischemic and Nonischemic Cardiomyopathy. | The objective of this study was to investigate the feasibility of identifying heart failure patients who are less likely to benefit from implantable cardioverter-defibrillator (ICD) therapy among those eligible for primary prevention ICDs.</AbstractText>The cost-effectiveness of ICDs in primary prevention may be improved dramatically.</AbstractText>Using a cause-of-death analysis approach, we evaluated the discriminative and predictive values of a risk score with regard to overall mortality and specific causes of death by examining 2,485 patients enrolled in the French Primary Prevention ICD program (2002 to 2012). The risk score included points for New York Heart Association functional class III or greater, age >70 years, QRS duration >120 ms, atrial fibrillation, and glomerular filtration rate <60 ml/min. Sensitivity analyses were performed for ischemic and nonischemic cardiomyopathy, as well as for patients undergoing cardiac resynchronization therapy.</AbstractText>After a mean follow-up of 3.0 ± 2.1 years, the overall mortality rate was 5.9 per 100 patient-years (95% confidence interval: 5.4 to 6.5), which increased with the number of risk factors (0 to 5, respectively), as follows: 2.5, 2.9, 4.8, 9.0, 12.3, and 14.8 per 100 patient-years (p < 0.001). The higher mortality rate among patients with the highest scores resulted from an increase in nonarrhythmic mortality (from 2.1 to 14.8 per 100 patient-years, p < 0.001), whereas the occurrence of appropriate ICD therapies did not change significantly across the categories. The C statistic testing of the score was observed to be highly similar for patients with ischemic cardiomyopathy (0.685) and nonischemic cardiomyopathy (0.658) and those receiving cardiac resynchronization therapy (0.678).</AbstractText>Our findings suggest the feasibility of and interest in identifying patients eligible for primary prevention ICD implantation who are at significant risk of nonarrhythmic death in the real-world setting.</AbstractText>Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,126 | [Age characteristics of the cardiovascular system, depending on the thyroid function in type 2 diabetes mellitus]. | To study the features of cardiovascular system in patients with diabetes mellitus type 2 considering the thyroid pathology and age, 264 patients were examined. They were divided into three groups: 1st - patients with diffuse-nodular changes in the thyroid gland, 2nd - patients with autoimmune thyroid disease, 3rd - a control group of patients without thyroid disease. The patients of different ages were examined in each of these groups. All patients were in euthyroid state. It was established that identified in diabetes mellitus type 2 thyroid pathology and the thyroid disease contribute special features to the clinical picture for combined diabetic and cardiovascular pathology even in a euthyroid state including the age features. The laboratory and instrumental researches showed that the patients with combined diabetes and thyroid pathology have a higher incidence of atrial fibrillation, ischemic heart disease, and ventricular arrhythmias of high grades. They also were noticed to have a more adverse form of the left ventricle remodeling, also the combination of diastolic and systolic dysfunctions were found to be more frequent. It was concluded about the necessity of early diagnosis and correction of the cardiovascular disorders and thyroid systems in type 2 diabetes mellitus patients, including euthyroid patients.</Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Ignateva</LastName><ForeName>P A</ForeName><Initials>PA</Initials><AffiliationInfo><Affiliation>Saint-Petersburg Clinical Hospital of RAS, Saint-Petersburg, 194017, Russian Federation; marina.ballyzek@mail.ru.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Ballyuzek</LastName><ForeName>M F</ForeName><Initials>MF</Initials><AffiliationInfo><Affiliation>Saint-Petersburg Clinical Hospital of RAS, Saint-Petersburg, 194017, Russian Federation; marina.ballyzek@mail.ru.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Shpakov</LastName><ForeName>A O</ForeName><Initials>AO</Initials><AffiliationInfo><Affiliation>I. M. Sechenov Institute of Evolutionary Physiology and Biochemistry, RAS, Saint-Petersburg, 194223, Russian Federation.</Affiliation></AffiliationInfo></Author></AuthorList><Language>rus</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList></Article><MedlineJournalInfo><Country>Russia (Federation)</Country><MedlineTA>Adv Gerontol</MedlineTA><NlmUniqueID>100971443</NlmUniqueID><ISSNLinking>1561-9125</ISSNLinking></MedlineJournalInfo><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D000328" MajorTopicYN="N">Adult</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D001145" MajorTopicYN="Y">Arrhythmias, Cardiac</DescriptorName><QualifierName UI="Q000175" MajorTopicYN="N">diagnosis</QualifierName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName><QualifierName UI="Q000503" MajorTopicYN="N">physiopathology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D002319" MajorTopicYN="N">Cardiovascular System</DescriptorName><QualifierName UI="Q000503" MajorTopicYN="Y">physiopathology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D003924" MajorTopicYN="N">Diabetes Mellitus, Type 2</DescriptorName><QualifierName UI="Q000150" MajorTopicYN="Y">complications</QualifierName><QualifierName UI="Q000503" MajorTopicYN="N">physiopathology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D042241" MajorTopicYN="N">Early Diagnosis</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005260" MajorTopicYN="N">Female</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006334" MajorTopicYN="N">Heart Function Tests</DescriptorName><QualifierName UI="Q000379" MajorTopicYN="N">methods</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008297" MajorTopicYN="N">Male</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008875" MajorTopicYN="N">Middle Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D017202" MajorTopicYN="Y">Myocardial Ischemia</DescriptorName><QualifierName UI="Q000175" MajorTopicYN="N">diagnosis</QualifierName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName><QualifierName UI="Q000503" MajorTopicYN="N">physiopathology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D018570" MajorTopicYN="N">Risk Assessment</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D012307" MajorTopicYN="N">Risk Factors</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D012426" MajorTopicYN="N">Russia</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D013959" MajorTopicYN="N">Thyroid Diseases</DescriptorName><QualifierName UI="Q000150" MajorTopicYN="Y">complications</QualifierName><QualifierName UI="Q000503" MajorTopicYN="N">physiopathology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D020257" MajorTopicYN="N">Ventricular Remodeling</DescriptorName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="rus">Для изучения особенностей состояния сердечно-сосудистой системы у пациентов с сахарным диабетом 2-го типа в зависимости от наличия тиреоидной патологии и возраста были обследованы 264 больных. Их разделили на три группы: 1-я пациенты с диффузно-узловыми изменениями щитовидной железы, 2-я пациенты с аутоиммунными болезнями щитовидной железы, 3-я пациенты без тиреоидной патологии (контрольная), в каждой из них обследовали разные возрастные группы. Все пациенты находились в эутиреоидном состоянии. В ходе обследования обнаружено, что выявляемая при сахарном диабете 2-го типа тиреоидная патология, даже в состоянии эутиреоза, вносит особенности в клиническую картину и течение сочетанной диабетической и сердечно-сосудистой патологии. По данным лабораторно-инструментальных исследований установлено, что у пациентов с сочетанной диабетической и тиреоидной патологией имеются более высокая встречаемость фибрилляции предсердий, ИБС, желудочковой экстрасистолии высоких градаций. У них также отмечали более неблагоприятные формы ремоделирования ЛЖ, чаще встречали сочетание диастолической и систолической дисфункций. Сделан вывод о необходимости ранней диагностики и коррекции нарушений сердечно-сосудистой и тиреоидной систем у больных сахарным диабетом 2-го типа, в том числе в состоянии эутиреоза. |
11,127 | [Incidence of atrial fibrillation after cardiac surgery: Influence of the type of surgery, cardiopulmonary bypass and preoperative and perioperative predictive factors]. | Atrial fibrillation (AF) is the arrhythmia with higher incidence in postoperative period after cardiac surgery. In individuals undergoing valve replacement surgeries (VRS) it occurs in about 64% and in individuals undergoing coronary artery bypass grafting (CABG) it can occurs in about 30-40%. Its incidence in postoperative period can still be influenced by pre and perioperative risk factors.</AbstractText>To study the incidence of AF after cardiac surgery, its association with the type of surgery, cardiopulmonary bypass (CPB), and with the main pre and perioperative risk/predictive factors.</AbstractText>Longitudinal retrospective observational study of individuals undergoing CABG and VRS in 2014, in a central hospital in the northern region. Cardiac rhythm was evaluated in four moments of postoperative period (end of CPB, Intensive Care Unit (ICU)/hospitalization, pre-hospital discharge, follow-up). The association of cardiac rhythm and preoperative risk/predictive factors (size of the atria, cardiomegaly, left ventricular hypertrophy (LVH)) and intraoperative risk factors (type of surgery, duration of CPB, aortic clamping time and cardioplegia administration) were explored through Odds ratio (OR).</AbstractText>We studied 416 individuals, 73.6 % male, mean age 66.8±10.5 years old. VRS showed incidence values of AF in all evaluation moments, and CABG only in ICU/internment and pre-hospital discharge. The incidence of AF was higher in ICU/internment in all types of surgery, ranging from 3.7% (CABG with CPB) to 71.4% (mitral VRS). Preoperative predictive factors with an OR>1 were age upper 65 years old (2.51 end of CPB, 10.62 pre-hospital discharge), dilation of the right atrium (RA) (1.08 follow-up, 3.41 pre-hospital discharge), and LVH (1.68 end of CPB, 2.78 pre-hospital discharge). Perioperative predictive factors with an OR>1 were CPB (2.74 ICU/interment, 3.37 pre-hospital discharge), and cardioplegia (2.93 ICU/internment, 5.40 pre-hospital discharge).</AbstractText>VRS were the type of surgery with higher incidence of AF. CABG had a higher incidence of AF in surgeries without CPB. Age upper 65 years old, RA dilation and LVH were the preoperative predictive factors with positive association with AF incidence in all evaluation moments.</AbstractText> |
11,128 | Therapeutic hypothermia after cardiac arrest in Long QT syndrome: Could it be an adjunctive treatment to prevent dysrhythmias? | Therapeutic hypothermia has been used for neuroprotection following cardiac arrest presenting with ventricular tachycardia or ventricular fibrillation regardless of underlying cause. Long QT syndrome is a cause for polymorphic ventricular tachycardia, and we know that therapeutic hypothermia increases the QT interval. We managed a 27-year-old woman, who was 10 weeks post-partum, who collapsed secondary to ventricular fibrillation at home. Bystander cardiopulmonary resuscitation was started with successful resuscitation after a rescue shock from paramedics. On hospital admission, her computerised tomography head, computerised tomography pulmonary angiogram and echocardiography did not show any abnormality. Her baseline electrocardiogram showed prolonged QTc interval of 504 ms without ischaemic changes. After intubation and ventilation, she was treated with therapeutic hypothermia for 48 h. She had a further episode of polymorphic ventricular tachycardia requiring rescue shock just prior to starting therapeutic hypothermia in hospital. No dysrhythmias occurred during therapeutic hypothermia, although the QTc further increased. After stopping the therapeutic hypothermia, she had two further ventricular tachycardia episodes. After commencement of beta blockers, she remained free of arrhythmias, and an implantable cardioverter defibrillator was implanted, she has recovered without any neurological deficit. Ventricular dysrhythmias caused by prolongation of the QT interval during or after therapeutic hypothermia are not well understood. There has been a report of a patient also having ventricular dysrhythmia 2 h after re-warming post therapeutic hypothermia and also a report of arrhythmia free period during therapeutic hypothermia in a long QT syndrome patient; both these features are present in our patient. Re-warming is not usually known to cause any arrhythmias; however, it could be a problem in those with long QT syndrome. Whether therapeutic hypothermia has a place in helping to control ventricular dysrhythmias needs further study. |
11,129 | Assessing the Relative Integrity of Formed Cardiac Linear Lesions by Recording Both Focal Monophasic Action Potentials and Contact Forces: A Technical Brief. | The use of therapeutic ablation in patients with atrial fibrillation has become a mainstay in the treatment of this disease, yet often these individuals require multiple procedures. In other words, successful first time treatments are impacted by challenges, including the generation of linear lesions in certain anatomies like the mitral isthmus of the left atrium. Hence, there is a need to find ways to address the presence of unwanted conduction gaps at the time of lesion creation. In this paper, we describe a novel approach to examine conduction gaps, by using a proof of concept device to examine local electrical activation within the cardiac areas of an applied lesion, i.e., to locate gaps in the lesion set. To accomplish this, both epicardial and endocardial linear ablation lines composed of spot lesions with conduction gaps were created in a porcine model. The forces necessary to elicit monophasic action potentials (MAP) were collected from >200 measurements on the epicardium of the right ventricle. Ablations were then performed on the ventricular epicardium and left atrial mitral isthmus endocardially, while recording MAPs. We were able to successfully demonstrate the use of a proof of concept device to identify conduction gaps in linear lesion sets; furthermore, we were able to determine required contact forces to appropriately determine focal electrical changes of the underlying tissues. New catheter designs that incorporate capabilities to record focal MAPs could be employed clinically to better assess a given lesion quality and/or to determine the existence of an undesired conduction gap. |
11,130 | Targeted temperature management in emergency medicine: current perspectives. | Landmark trials in 2002 showed that therapeutic hypothermia (TH) after out-of-hospital cardiac arrest due to ventricular tachycardia or ventricular fibrillation resulted in improved likelihood of good neurologic recovery compared to standard care without TH. Since that time, TH has been frequently instituted in a wide range of cardiac arrest patients regardless of initial heart rhythm. Recent evidence has evaluated how, when, and to what degree TH should be instituted in cardiac arrest victims. We outline early evidence, as well as recent trials, regarding the use of TH or targeted temperature management in these patients. We also provide evidence-based suggestions for the institution of targeted temperature management/TH in a variety of emergency medicine settings. |
11,131 | [Left Atrial Remodeling and Thromboembolic Risk in Patients With Recurrent Atrial Fibrillation]. | To assess the relationship between left ventricular and left atrial (LA) structural and functional characteristics and thromboembolic (TE) risk in patients (pts) with recurrent atrial fibrillation (AF).</AbstractText>Sixty pts (mean age 65 [61; 72] years, 42% men) with nonvalvular paroxysmal and persistent AF during sinus rhythm were divided into three groups based on CHA₂DS₂-VASc score: 1, 2, and ≥ 3. All pts underwent conventional and speckle tracking echocardiography. Apical four- and two-chamber views images of 6 myocardial segments in the filling phase were obtained to assess global peak left atrial longitudinal strain (PALS) in the reservoir (r) and contractile (c) phase. RESULTS. Patients with paroxysmal AF had significantly higher PALSr compared with patients with persistent AF (15.1 vs 11.2%, p = 0.0002) and PALSc (-15.0 vs -12.0%; p = 0.0002]. In logistic regression analyses, only higher PALSr was significantly associated with lower CHA₂DS₂-VASc score (OR 0.61; 95% Cl 0.38-0.97; p = 0.03). In order to distinguish patients with moderate and high TE risk we performed ROC curve analysis. Effective PALSr cut-off point was 16.7% with sensitivity of 62.5%, specificity of 39.0% and an area under the curve of 0.85 (95% Cl 0.72-0.98; p = 0.002).</AbstractText>In patients with AF PALSr was independently associated with CHA₂DS₂-VASc score. Use of a PALSr threshold allows to detect patients with moderate and high TE risk and can be considered in the process of decision making on initiation of anticoagulation treatment in patients with AF and CHA₂DS₂-VASc score of 1.</AbstractText> |
11,132 | Decreased Cardiac Expression of Heat Shock Protein 27 is Associated with Atrial Fibrillation in Patients with Rheumatic Heart Disease. | The objective of this study was to compare the expression of heat shock proteins (HSPs) between rheumatic heart disease (RHD) patients with atrial fibrillation (AF) and RHD patients without AF, and its efficacy in predicting the occurrence of AF in RHD patients.</AbstractText>Ninety-five patients were enrolled in our study, including 60 RHD patients with AF, and 35 RHD patients without AF. The baseline characteristics of the patients such as gender, age, AF duration, left atrial diameter and left ventricular ejection fraction were collected, and erythrocyte sedimentation rate and high-sensitivity C-reaction protein were measured from all patients. Tissue samples were obtained from the right atrial appendage during open-heart surgery and then detected using immunohistochemical methods and Western blot with HSP27, HSP60, HSP70 and HSP90 antibodies.</AbstractText>Compared with RHD patients without AF, the density of HSP27 positive protein in RHD patients with AF was significantly lower. The density of HSP60, HSP70 or HSP90 antibodies did not indicate significant difference between the two groups. Use of the Western blot experiment showed consistent results with immunohistochemical staining. In RHD patients with AF, the expression level of HSP27 protein was negatively associated with AF duration and left atrial diameter. Left atrial enlargement and low expression of HSP27 were the independent predictors of AF.</AbstractText>The decreased expression level of HSP27 is associated with AF in RHD patients.</AbstractText>Atrial fibrillation; Heat shock protein; Rheumatic heart disease.</AbstractText> |
11,133 | [ETACISIN-INDUCED BRUGADA SYNDROME IN A PATIENT WITH LONG-STANDING SUPRAVENTRICULAR EXTRASYSTOLE]. | Brugada syndrome is a commonest cause of malignant disorders of cardiac rhythm associated with sudden death. It is diagnosed based on characteristic ECG signs and ventricular arrhythmia. This paper reports a 49 year-old patient with long-standing latent BS manifest as supraventricular and transient blockade of the right branch of the His bundle. The ECG pattern of BS became apparent in association with a 7 day treatment with class IC antiarrhythmic agent etacisin. Diagnostic difficulties account for the fact that the disease was initially described as myocardial infarction. Diagnosis of BS was confirmed by an electrophysiological study in which stable ventricular tachycardia and fibrillation were induced by etacisin. A cardioverter defibrillator was implanted to the patient. |
11,134 | Predictors of ventricular fibrillation at reperfusion in patients with acute ST-elevation myocardial infarction treated by primary percutaneous coronary intervention. | Ventricular fibrillation (VF) during reperfusion (rVF) in ST-segment elevation myocardial infarction (STEMI) is an infrequent but serious event that complicates coronary interventions. The aim of this study was to analyze clinical predictors of rVF in an unselected population of patients with STEMI treated with percutaneous coronary intervention (PCI). Consecutive patients with STEMI admitted to a tertiary care hospital for primary PCI from 2007 to 2012 were retrospectively assessed for the presence of rVF. Admission electrocardiograms, stored in a digital format, were analyzed for a maximal ST-segment elevation in a single lead and the sum of ST-segment deviations in all leads. Clinical, electrocardiographic, and angiographic characteristics were tested for associations with rVF using logistic regression analysis. Among 3,724 patients with STEMI admitted from 2007 to 2012, 71 (1.9%) had rVF. In univariate analysis, history of myocardial infarction, aspirin and β-blocker use, VF before PCI, left main coronary artery disease, inferior myocardial infarction localization, symptom-to-balloon time <360 minutes, maximal ST-segment elevation in a single lead >300 μV, and sum of ST-segment deviations in all leads >1,500 μV were associated with increased risk for rVF. In a multivariate analysis, sum of ST-segment deviations in all leads >1500 μV (odds ratio 3.7, 95% confidence interval 1.45 to 9.41, p = 0.006) before PCI remained an independent predictor of rVF. In-hospital mortality was 18.3% in the rVF group and 3.3% in the group without VF (p <0.001), but rVF was not an independent predictor of in-hospital death. In conclusion, the magnitude of ST-segment elevation before PCI for STEMI independently predicts rVF and should be considered in periprocedural arrhythmic risk assessment. Despite higher in-hospital mortality in patients with rVF, rVF itself has no independent prognostic value for prognosis. |
11,135 | J Wave Syndrome: Clinical Diagnosis, Risk Stratification and Treatment. | J wave syndrome has emerged from a benign electrocardiographic abnormality to a proarrythmic state and a significant cause of idiopathic ventricular fibrillation responsible for sudden cardiac death. Electrical genesis, genetics and ionic mechanisms of J wave syndromes are active areas of research. Typically two of these viz., Early repolarization syndrome (ER) and Brugada syndrome (BrS) are fairly well characterized enabling correct diagnosis in most patients. In early repolarization syndrome, J waves are seen in inferior (2,3, avF) or lateral leads (V4, V5, V6), while in Brugada syndrome they are best seen in right precordial leads (V1-V3). The first part of repolarization of ventricular myocardium is governed by Ito current i.e., rapid outward potassium current. The proposed mechanism of ventricular fibrillation (VF) and ventricular tachycardia (VT) storms is faster Ito current in the epicardium than in the endocardium resulting in electrical gradient that forms the substrate for phase 2 re-entry. Prevention of Ito current with quinidine supports this mechanism. Morphological features of benign variety of J wave syndrome and malignant/ proarrythmic variety have now been fairly well characterized. J waves are very common in young, athletes and blacks; risk stratification for VF/sudden cardiac death (SCD) is not easy. Association of both ER syndrome and Brugada syndrome with other disease states like coronary artery disease is being reported frequently. Those with ECG abnormality as the only manifestation are difficult to manage. Certain ECG patterns are more proarrythmic. Individuals resuscitated from VF definitely need an implantable cardiac defibrillator (ICD) but in others there is no consensus regarding therapy. Role of electrophysiology study to provoke ventricular tachycardia or fibrillation is not yet well defined. Radiofrequency ablation of epicardial substrate in right ventricle in Brugada syndrome is reported and is also under critical evaluation. In this review we shall discuss some interesting historical features, epidemiology, electrocardiographic features, and ionic mechanisms on pathogenesis, clinical features, risk stratification and treatment issues in J wave syndromes. Brugada syndrome is not discussed in this review. |
11,136 | Right Ventricular Outflow Tract Arrhythmias: Benign Or Early Stage Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia? | Ventricular arrhythmias (VAs) arising from the right ventricular outflow tract (RVOT) are a common and heterogeneous entity. Idiopathic right ventricular arrhythmias (IdioVAs) are generally benign, with excellent ablation outcomes and long-term arrhythmia-free survival, and must be distinguished from other conditions associated with VAs arising from the right ventricle: the differential diagnosis with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is therefore crucial because VAs are one of the most important causes of sudden cardiac death (SCD) in young individuals even with early stage of the disease. Radiofrequency catheter ablation (RFCA) is a current option for the treatment of VAs but important differences must be considered in terms of indication, purposes and procedural strategies in the treatment of the two conditions. In this review, we comprehensively discuss clinical and electrophysiological features, diagnostic and therapeutic techniques in a compared analysis of these two entities. |
11,137 | Echocardiographic Parameters Associated With Asymmetrical Structural Remodeling In Patients With Or Without Atrial Fibrillation. | Left atrial (LA) dilation can evolve into asymmetrical remodeling. The aim of this study was to determine the echocardiographic parameters associated with LA asymmetric structural remodeling (ASR) in patients with and without nonvalvular atrial fibrillation (AF).</AbstractText>A total of 170 patients with a dilated LA were prospectively enrolled. ASR was defined as an atrium shape that is no longer ellipsoidal (LA basal dimension measured at the junction between the pulmonary vein and atrium greater than the mitral annular dimension). Symmetric structural remodeling (SSR) was defined as all other cases. Echocardiographic parameters of LA function and left ventricular diastolic function, measured by pulsed-wave Doppler and Tissue Doppler Imaging, were analyzed to identify the parameters associated with ASR. The mean age of the patients was 67 ± 11 years. Forty-one percent had a stable sinus rhythm (SR), and 59% had AF. LA-ASR was detected in 66% of the patients: 55% with AF and 45% with SR (p=0.002). The mean LA-ASR and LA-SSR volume indexes were 49 ± 14 ml/m² and 29 ± 13 ml/m², respectively (p<0.001). LA systolic myocardial velocity (p=0.036) and peak systolic pulmonary venous flow velocity (p=0.033) were the parameters best associated with ASR. The sensitivity and specificity of both parameters, based on ROC curve analysis, were 77 and 70%, respectively. The AUC was 0.765 (95% CI: 0.662-0.849, p=0.0001).</AbstractText>LA dilation is associated with a great number of asymmetrical structural remodeling. Echocardiographic parameters that reflect LA reservoir function are best associated with asymmetrical remodeling.</AbstractText> |
11,138 | Which Is The Appropriate Arrhythmia Burden To Offer RF Ablation For RVOT Tachycardias? | Premature ventricular complexes (PVCs) and ventricular tachycardia (VT) in patients with structurally normal hearts originate from the right ventricular outflow tract (RVOT) in the majority of cases. In the last few decades catheter ablation of these arrhythmias has been proven to be effective. RVOT VT/PVCs may cause disabling symptoms or arrhythmia induced cardiomyopathy. However, the PVC burden at which catheter ablation should be recommended is still controversial. What adds to the controversy is why some patients with only a low number of PVCs can be highly symptomatic and may even develop arrhythmia induced cardiomyopathy, whilst others may have a higher PVC/VT burden and remain asymptomatic and do not develop cardiomyopathy for a long period of time. Therefore, although catheter ablation of RVOT PVCs has high success and low complication rates, the time point of when ablation should be recommended is currently still under debate. This review discusses the treatment strategies and prognosis for RVOT tachycardias and focuses on the question of which arrhythmia burden is appropriate to offer RF ablation. |
11,139 | Rate Control Strategy Elevated To Primary Treatment For Atrial Fibrillation: Has The Last Word Already Been Spoken? | In the last decade, we were able to see the light shed by several trials and observational studies that dealt with the appropriate manner of treating patients with atrial fibrillation (AF). Recently the AF management by cardiologists has become more aggressive, in part because of an improved comprehension of this rhythm disturbance, as well as, the availability of new treatment strategies. Increasing awareness of AF as a disease rather than as an acceptable alternative to sinus rhythm has led to search for clear arguments to support a certain strategy as a gold standard. In this respect, the decision of whether to restore sinus rhythm, or to control the ventricular rate and allow AF to persist is of critical importance. The results of randomized, controlled trials addressing this matter shed some light on the proper way of treatment for these AF patients. The AFFIRM and RACE trials and their respective sub-studies showed surprising results. The vast majority of physicians were surprised to learn that the rate control strategy was elevated to the position of primary treatment for the AF management instead of the all-time recognized rhythm control approach to restoration and maintenance of sinus rhythm. The use of anticoagulants in the trials was different in the treatment strategies. There was a greater anticoagulant use in the rate control arm because of the belief that anticoagulation can be discontinued in the rhythm control arm when sinus rhythm was restored and maintained for one month. On the other hand, only pharmacological agents were used to maintain sinus rhythm in those trials, however, there is increasing evidence that AF ablation can restore and maintain sinus rhythm in a great proportion of patients. Indeed, there are some limitations and several interesting aspects of these trials and other studies that will be discussed. The last word has not been spoken yet. |
11,140 | Importance Of Delayed Enhanced Cardiac MRI In Idiopathic RVOT-VT: Differentiating Mimics Including Early Stage ARVC And Cardiac Sarcoidosis. | A detailed understanding of cardiac anatomy and pathophysiology is necessary to optimize catheter ablation procedural success for patients with symptomatic ventricular tachycardia (VT)/premature ventricular contractions (PVCs) of outflow tract origin. Comprehensive imaging with cardiac magnetic resonance imaging (cMRI) is now at the forefront of procedural planning for complex ventricular arrhythmia ablation for patients with structural heart disease, but is increasingly used in patients with presumed "idiopathic" outflow VT/PVCs as well. cMRI with late gadolinium enhancement (LGE) can localize small regions of myocardial scar from previous myocardial infarction, fibrosis from non-ischemic cardiomyopathy, or edema/fibrosis from inflammatory disorders and help define targets for ablation. LGE, in combination with structural assessment, can help differentiate true idiopathic outflow VT/PVCs from those caused by early stage disease secondary to more significant pathology, such as arrhythmogenic right ventricular cardiomyopathy or cardiac sarcoidosis. We review the benefits of cMRI with LGE for patients with VT/PVCs of outflow origin. |
11,141 | A novel ultrasound predictor of pulmonary capillary wedge pressure assessed by the combination of left atrial volume and function: A speckle tracking echocardiography study. | We hypothesized that a development of a novel index based on the combination of left atrial volume (LAV) and left atrial (LA) function evaluated by the time-LA volume curve using speckle tracking echocardiography (STE) would be accurate and useful to estimate pulmonary capillary wedge pressure (PCWP). Our goal was to develop a novel index of PCWP based on a combination of LAV and LA function using STE.</AbstractText>A cross-validation study was performed with the patients divided into a training study to define the novel index (n=50) and a testing study to validate the index (n=196). PCWP was measured by right heart catheterization, and phasic LAV and emptying function (EF) were measured by STE.</AbstractText>Simple linear regression analysis in the training study revealed that the novel index that best estimated PCWP was the kinetics-tracking index [KT index=log10 (active LAEF/minimum LAV index)]. Multiple regression analysis revealed that the KT index was the most reliable predictor of PCWP. It had the strongest correlation with PCWP (r=-0.86, p<0.001) among all echocardiographic parameters. In the testing study, PCWP estimated by the KT index was also strongly correlated with measured PCWP (r=0.92, p<0.001). These correlations were also strong in the patients with reduced left ventricular ejection fraction (<50%), chronic heart failure, and chronic atrial fibrillation (r=0.92, r=0.91, r=0.79, p<0.001, respectively).</AbstractText>A novel index (KT index) using a combination of LAV and LA function was a powerful and useful predictor of PCWP and may be valuable in routine clinical practice.</AbstractText>Copyright © 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.</CopyrightInformation> |
11,142 | Effects of sinus rhythm maintenance on left heart function after electrical cardioversion of atrial fibrillation: implications for tachycardia-induced cardiomyopathy. | The role of tachycardia-induced cardiomyopathy vs tachycardia-related short diastolic filling period and reduced atrial contraction in decline of left ventricular ejection fraction (LVEF) in atrial fibrillation (AF) is uncertain. We aimed to characterize left heart changes over time in patients with AF who undergo electrical cardioversion (ECV).</AbstractText>Consecutive AF patients who were to undergo ECV were enrolled. Patients with unstable or acute heart failure, severe valvular diseases, recent open-heart surgery, major disorders, or an unsuccessful ECV were excluded. Transthoracic echocardiography, including 3-dimensional left atrial and ventricular volume acquisitions, was performed 1-2 hours before and after ECV, and 4-6 weeks later.</AbstractText>In 73 patients (77% male, 66 ± 11 years), ECV resulted in an immediate increase in LVEF (from 43 [interquartile range (IQR), 33-50%] to 48 [IQR, 40-53%]; P < 0.0001). Four to 6 weeks after ECV, ejection fraction increased further in patients who remained in sinus rhythm (SR) (n = 55) to 55 (IQR, 44-62)%; P < 0.001. In patients with AF relapse, LVEF returned to values comparable to pre-ECV (n = 18) (44 [IQR, 32-51]%; P = 0.03). The atrial emptying fraction did not significantly change immediately after ECV (n = 69; from 20 [IQR, 13-25]% to 20 [IQR, 15-28]%; P = 0.14). Only patients who remained in SR showed an increase in atrial emptying fraction after 4-6 weeks (n = 51; to 37 [IQR, 26-48]%; P < 0.0001 vs post-ECV).</AbstractText>Immediate improvement in LVEF after ECV explains approximately 50% of total LVEF increase over time. However, in SR, LVEF, and atrial function continuously increase over 4-6 weeks after ECV. This might be attributable to recovery of tachycardia-induced cardiomyopathy.</AbstractText>Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,143 | Inhibition of IKr potentiates development of atrial-selective INa block leading to effective suppression of atrial fibrillation. | The availability of safe and effective drugs for the management of atrial fibrillation (AF) remains an unmet medical need.</AbstractText>The purpose of this study was to test the hypothesis that the inhibition of the rapidly activating delayed rectifier potassium current (IKr) greatly potentiates the development of atrial-selective sodium channel current (INa) block, leading to more effective suppression of AF.</AbstractText>Electrophysiological and anti-AF effects of highly selective INa and IKr blockers (lidocaine and E-4031) individually and in combination were determined in canine coronary-perfused atrial and ventricular preparations. Acetylcholine (1 µM) was used to induce persistent AF.</AbstractText>Lidocaine (10 µM) caused a relatively small abbreviation of the action potential duration measured at 90% repolarization in both atria and ventricles, but caused atrial-selective prolongation of the effective refractory period owing to the induction of post-repolarization refractoriness. Lidocaine also caused modest atrial-selective depression of other INa-mediated parameters including excitability, maximum rate of rise of the action potential upstroke, and conduction time. E-4031 (1 µM) prolonged the action potential duration measured at 90% repolarization and effective refractory period in an atrial-predominant manner. A combination of lidocaine and E-4031 caused a greater atrial-selective depression of INa-mediated parameters. Persistent acetylcholine-mediated AF developed in 100% of atria under control conditions, in 80% (4 of 5) after pretreatment with lidocaine (10 µM), in 100% (4 of 4) after E-4031 (1 µM), and in only 14% (1 of 7) after the combination of lidocaine and E-4031.</AbstractText>Our results provide a proof of concept that IKr block greatly potentiates the effects of rapidly dissociating INa blockers to depress sodium channel-dependent parameters in the canine atria but not in the ventricles, thus contributing significantly to suppression of AF.</AbstractText>Copyright © 2015. Published by Elsevier Inc.</CopyrightInformation> |
11,144 | Long-term arrhythmia follow-up of patients with myotonic dystrophy. | Myotonic dystrophy (MD) is the most common muscular dystrophy in adults and is associated with sudden death. Reported predictors of sudden death in this population include atrial tachyarrhythmias, a PR interval greater than 240 milliseconds, aberrant QRS conduction, and any degree of AV block.</AbstractText>We sought to report on the arrhythmic outcome of a cohort of patients with a new diagnosis of genetically proven MD.</AbstractText>We performed a retrospective review of 37 patients with genetically confirmed MD referred to our electrophysiology clinic for primary cardiac screening.</AbstractText>There were 25 patients with MD type 1 (MD1) and 12 patients with MD type 2 (MD2). Eight patients with MD1 (32%) had atrial fibrillation, compared to only one patient with MD2 (8.3%). Patients with MD1 were more likely to have evidence of conduction disease abnormalities (40% vs. 8.3%, P = ns) and had a higher all-cause mortality (16% vs. 0%) than those with MD2. Criteria for recommending ICD implantation were based on sudden death risk factors suggested by published literature. Eleven patients were offered an ICD, 2 refused and died within the next year. Of the 9 patients who received an ICD, 8 had MD1. Three patients received appropriate shocks, 2 for monomorphic VT, and one for polymorphic VT.</AbstractText>The presence of AV conduction disturbance in MD patients is associated with a greater risk for ventricular arrhythmias. MD1 was more likely to be associated with cardiac arrhythmias than MD2. The incidence of ventricular arrhythmias among those who received a primary prevention ICD was 33% over 22 months, with 2 patients experiencing monomorphic VT and one experiencing polymorphic VT.</AbstractText>© 2014 Wiley Periodicals, Inc.</CopyrightInformation> |
11,145 | Two Cases of Ventricular Proarrhythmia from Automatic Threshold Measurement Features in a CRTD and an ICD. | The present case report presents two cases in which automatic threshold measurement features in an implantable cardiac defibrillator and in a CRTD act proarrhythmic by inducing polymorphic ventricular arrhythmia. By programming these features off the problem was solved. The mechanisms seem to be different from previously reported proarrhythmic interactions from such device features. |
11,146 | Pharmacologic inhibition of small-conductance calcium-activated potassium (SK) channels by NS8593 reveals atrial antiarrhythmic potential in horses. | Small-conductance calcium-activated potassium (SK) channels have been found to play an important role in atrial repolarization and atrial fibrillation (AF).</AbstractText>The purpose of this study was to investigate the existence and functional role of SK channels in the equine heart.</AbstractText>Cardiac biopsies were analyzed to investigate the expression level of the most prominent cardiac ion channels, with special focus on SK channels, in the equine heart. Subcellular distribution of SK isoform 2 (SK2) was assessed by immunohistochemistry and confocal microscopy. The electrophysiologic and anti-AF effects of the relative selective SK channel inhibitor NS8593 (5 mg/kg IV) were evaluated in anesthetized horses, focusing on the potential of NS8593 to terminate acute pacing-induced AF, drug-induced changes in atrial effective refractory period, AF duration and vulnerability, and ventricular depolarization and repolarization times.</AbstractText>Analysis revealed equivalent mRNA transcript levels of the 3 SK channel isoforms in atria compared to ventricles. Immunohistochemistry and confocal microscopy displayed a widespread distribution of SK2 in both atrial and ventricular cardiomyocytes. NS8593 terminated all induced AF episodes (duration ≥15 minutes), caused pronounced prolongation of atrial effective refractory period, and reduced AF duration and vulnerability. QRS duration and QTc interval were not affected by treatment.</AbstractText>SK channels are widely distributed in atrial and ventricular cardiomyocytes and contribute to atrial repolarization. Inhibition by NS8593 terminates pacing-induced AF of short duration and decreases AF duration and vulnerability without affecting ventricular conduction and repolarization. Thus, inhibition by NS8593 demonstrates clear atrial antiarrhythmic properties in healthy horses.</AbstractText>Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,147 | Mechanical function of left atrium and pulmonary vein sleeves before and after their antrum isolation. | Pulmonary vein (PV) sleeves are established as the main substrate taking part in the mechanisms of atrial fibrillation (AF) initiation. However, we have extremely few data concerning their physiological role in the heart contractility. The aim of the study was to estimate the mechanical function of the left atrium (LA) and PV sleeves before and early after their isolation.</AbstractText>A total of 17 patients with a mean age of 57.4±8.3 years who underwent PVs isolation due to AF were enrolled in the study. A day before the procedure a computed tomography (CT) of the LA and PVs and dopplerography of transmitral flow were performed. During the procedure the mechanical function of the LA and PV sleeves were estimated by transesophageal echocardiography and manometry in the left heart chambers.</AbstractText>During the invasive study the patterns of the heart chambers and PV sleeves pressure were identified. These patterns confirmed the active role of the PV sleeves in LA filling and active LA relaxation during left ventricular systole. After PV isolation an alteration of transmitral blood flow and increase of LA pressure were registered. However, diastolic dysfunction was ruled out by LV manometry, thereby testifying LA mechanical function disturbance. The change in PV hemodynamics also occurred as a result of the decrease in PV sleeves contractility, revealed by manometry and paired CT scans.</AbstractText>The PVs take an active part in left atrial filling by contraction of their sleeves. Antrum isolation of the PVs leads to the deterioration of their contractility and LA reservoir function.</AbstractText>Copyright © 2014 Lithuanian University of Health Sciences. Production and hosting by Elsevier Urban & Partner Sp. z o.o. All rights reserved.</CopyrightInformation> |
11,148 | Systolic blood pressure on discharge after left ventricular assist device insertion is associated with subsequent stroke. | Stroke is a significant complication in patients supported with continuous-flow left ventricular assist devices (CF-LVAD) and hypertension is a significant risk factor for stroke, but the association between blood pressure and stroke in LVAD patients is not well characterized.</AbstractText>We identified 275 consecutive patients who survived implant hospitalization between January 2005 and April 2013. Patients were grouped according to systolic blood pressure (SBP) as above a median and below a median of 100 mm Hg by their averaged systolic blood pressure during the 48 hours before discharge from implantation hospitalization. The groups were compared for the primary outcome of time to stroke.</AbstractText>The above-median SBP group had mean SBP of 110 mm Hg and the below-median SBP group had mean SBP of 95 mm Hg. There were no significant between-group differences in body mass index, smoking, vascular disease, hypertension, atrial fibrillation, or prior stroke. During a mean follow-up of 16 months, stroke occurred in 16% of the above-median SBP group vs in 7% of the below-median SBP group (hazard ratio, 2.38; 95% confidence interval, 1.11-5.11), with a similar proportion of hemorrhagic and ischemic strokes in each group. In Cox proportional hazard models adjusting for age, diabetes, or prior stroke, the hazard ratio remained statistically significant. SBP as a continuous variable predictor of stroke had an area under the curve of 0.64 in a receiver operating characteristic curve analysis.</AbstractText>In this large, CF-LVAD cohort, elevated SBP was independently associated with a greater risk of subsequent stroke. These results identify management of hypertension as a potential modifiable risk factor for reducing the incidence of stroke in patients supported by CF-LVAD.</AbstractText>Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,149 | Cardiac function in types II and III spinal muscular atrophy: should we change standards of care? | In the last years, there has been increasing evidence of cardiac involvement in spinal muscular atrophy (SMA). Autonomic dysfunction has been reported in animal models and in several patients with types I and III SMA, these findings raising the question whether heart rate should be routinely investigated in all SMA patients. The aim of our study was to detect possible signs of autonomic dysfunction and, more generally, of cardiac involvement in types II and III SMA.</AbstractText>We retrospectively reviewed 24-hour electrocardiography (ECG) in 157 types II and III SMA patients (age range, 2-74 years). Of them, 82 also had echocardiography.</AbstractText>None of the patients had signs of bradycardia, atrial fibrillation, or the other previously reported rhythm disturbances regardless of the age at examination or the type of SMA. Echocardiography was also normal. There were no signs of congenital cardiac defects with the exception of one patient with a history of ventricular septal defects.</AbstractText>Our results suggest that cardiac abnormalities are not common in type II and type III SMA. These findings provide no evidence to support a more accurate cardiac surveillance or changes in the existing standards of care.</AbstractText>Georg Thieme Verlag KG Stuttgart · New York.</CopyrightInformation> |
11,150 | [Anomalous origin of the left coronary artery from the pulmonary artery in infants: clinical features and the perioperative treatment strategies]. | To investigate the clinical features and individualized treatment strategies for infants with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).</AbstractText>Data of 25 less than 1-year-old infants with ALCAPA who presented at Guangdong Cardiovascular Institute between 2006 and 2013 were retrospectively reviewed. The patients' cardiac function was evaluated with echocardiography during follow-up.</AbstractText>Most patients presented with symptoms of heart failure, such as tachypnea, diaphoresis, poor feeding, failure to thrive etc. Electrocardiogram showed abnormal q wave in 23 patients and ST-T segment change in 16 patients.Echocardiography showed dilated left ventricle in 25 patients, endocardial hyperplasia in 5 patients, dilated right coronary artery and extensive collateralization between the right and left coronary artery systems in 11 patients. The left ventricular ejection fraction (LVEF) was (45.5±13.9)% (25%-77%). The left ventricular fractional shortening (LVFS) was (22.0±7.3)% (12%-38%). Twenty one patients underwent cardiovascular CT scan. Left coronary artery originated from left posterior sinus in 9 patients, from right posterior sinus in 1 patient, from lower main pulmonary artery in 5 patients, from the bifurcation of main pulmonary artery in 1 patient.Five patients showed ambiguous left coronary artery origination.Sixteen patients were misdiagnosed in other primary or secondary hospitals in 17 patients who were transferred to our tertiary hospital, only 1 case who underwent angiography was diagnosed correctly. Two patients were misdiagnosed in 8 patients first-presented in our hospital. Their diagnoses were corrected after reexamining with echocardiography and cardiovascular CT scan. The preoperative therapies included using inotropic agents, diuretics and vasodilators according to cardiac function. Two patients underwent left coronary artery orifice ligation. Twenty three patients underwent reimplantation of left coronary artery to reconstruct dual coronary system. Patients of NYHA IV with moderate mitral regurgitation (MR) and NYHA III with severe MR underwent mitral annuloplasty. If LVEF was less than 30% after weaning from cardiopulmonary bypass, blood pressure could not be maintained with medication, or lactates increased progressively, extracorporeal membrane oxygenation (ECMO) was demanded. Two patients showed low cardiac output syndrome immediately after surgical procedures, died from refractory ventricular fibrillation even with ECMO.In survived 23 patients during the early stage after surgeries, duration of ventilation was 7-500 hours, 11 of them were supported with ventilator for less than 60 hours. The mean length of hospital stay was (23.4±13.9) d (8-65 d). The follow-up duration ranged from 1-91 months (median 28.5 months). One case was lost to follow up. The patient died from infection 3 months after discharge. The cardiac functions of the remaining 22 patients were improved. The size of left ventricle of 14 patients recovered to normal. LVEF increased to the normal level in 20 cases. No patient underwent redo procedure.</AbstractText>The accurate diagnosis can be made based on history, electrocardiogram, echocardiography and other imaging diagnostic tools.Individualized treatment strategy is helpful for seriously sick infants. Aggressive ECMO support can increase surviving rate for patients with postoperative low cardiac output syndrome.</AbstractText> |
11,151 | Echocardiographic and clinical factors related to paravalvular leak incidence in low-gradient severe aortic stenosis patients post-transcatheter aortic valve implantation. | Paravalvular leak (PVL) following transcatheter aortic valve implantation (TAVI) is associated with poor outcomes. The association of clinical and echocardiographic parameters in the occurrence of even mild PVL in patients with low-gradient severe aortic stenosis (LGSAS) after TAVI and predictors of all-cause mortality and re-hospitalization during 2-year follow-up was studied, as data are sparse in the literature.</AbstractText>Seventy-five consecutive LGSAS patients (age 80 ± 8 years, 68% male, 89% Caucasians) were enrolled and followed-up for PVL development at hospital discharge, as well as mortality or re-hospitalization for cardiovascular disease, during a 2-year follow-up period. Patients' characteristics were retrospectively extracted from hospital's database. Mortality was determined either by chart review or the Social Security Death Index.</AbstractText>PVL was evident in 29 out of 75 patients. Patients with PVL had higher death rates at 6-month, 1-year of follow-up (27 vs. 7%, P = 0.05, 32 vs. 8%, P = 0.04, respectively) and lower stroke rates (0 vs. 7%, P = 0.009), compared with those who had no PVL. Patients with PVL were older, had lower BMI, higher prevalence of atrial fibrillation, higher brain natriuretic peptide (BNP), lower rest left ventricular ejection fraction, higher aortic cross-sectional area (Aa), lower stroke volume index, higher aortic resistance, stroke work, and higher energy loss index at rest and during dobutamine stress. Multivariable predictors of PVL post-TAVI were pre-procedural BNP levels and Aa.</AbstractText>PVL remains a common complication after TAVI, related to adverse events in LGSAS patients. Aa and BNP levels remain the most important predictors of PVL.</AbstractText>Published by Oxford University Press on behalf of the European Society of Cardiology 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.</CopyrightInformation> |
11,152 | Extracorporeal membrane oxygenation rewarming in the ED: an opportunity for success. | On average, approximately 1300 Americans die of hypothermia each year. Although accidental hypothermia is commonly associated with severely cold regions or mountain accident victims, hypothermia also commonly occurs in urban centers. Contributing factors often include homelessness, mental illness, and substance abuse. Hypothermia can profoundly affect the cardiovascular system. As the myocardium cools, the conduction system slows down,which results in prolongation of the QT interval as well as propensity for arrhythmias. Eventually, bradycardia, atrial fibrillation, and ventricular fibrillation (VF) can develop. The risk of cardiac arrest increases as the core temperature drops below 32°C and increases substantially when less than 28°C. |
11,153 | Five-year outcomes of catheter ablation in patients with atrial fibrillation and left ventricular systolic dysfunction. | Catheter ablation of atrial fibrillation (AF) is an established therapy for symptomatic patients. The long-term efficacy and impact of catheter ablation among patients with severe systolic heart failure (SHF) requires additional study to understand if outcomes achieved at 1 year are maintained and mechanisms of AF recurrence.</AbstractText>Three groups with SHF and 5 years of follow-up were matched 1:4:4 by age (±5 years) and sex: AF ablation patients receiving their first ablation (n = 267), AF patients that did not receive an ablation (n = 1,068), and SHF patient without AF (n = 1,068). SHF was based upon clinical diagnosis and an ejection fraction (EF) ≤35%. Patients were followed for 5-year primary outcomes of AF recurrence, heart failure, stroke, death, and cardiac function.</AbstractText>At 5 years, 60.7% of patients had clinical recurrence of AF. Diabetes and a prior heart attack were significant predictors of long-term risk of AF recurrence. Long-term mortality rates were 27%, 55%, 50%, in the AF ablation, AF, and no AF groups, respectively (P < 0.0001), with the lower rates attributed to lower cardiovascular mortality. At 5 years, there was no difference in EF, yet HF hospitalizations were lower following AF ablation compared to patients with AF and no ablation. Stroke rates at 5 years trended to be lower in the AF ablation group, but the difference was not statistically significant.</AbstractText>Recurrence rates of AF in patients with SHF after ablation are common at 5 years with an anticipated ongoing increase. Long-term AF-related comorbidities tended to be less in the AF ablation group.</AbstractText>© 2014 Wiley Periodicals, Inc.</CopyrightInformation> |
11,154 | Epidemiology and outcome of adult out-of-hospital cardiac arrest of non-cardiac origin in Osaka: a population-based study. | To evaluate epidemiological characteristics of out-of-hospital cardiac arrests (OHCAs) by detailed non-cardiac cause and factors associated with the outcomes after OHCAs of non-cardiac origin.</AbstractText>A prospective, population-based observational study.</AbstractText>The Utstein Osaka Project.</AbstractText>14,164 adult patients aged ≥20 years old with OHCAs due to non-cardiac origin who were resuscitated by emergency-medical-service personnel or bystanders, and then were transported to medical institutions from January 2005 to December 2011.</AbstractText>One-month survival after OHCA. Multiple logistic regression analysis was used to assess factors that were potentially associated with the outcome.</AbstractText>During the study period, the 1-month survival rate was 5.3% (755/14,164). The proportion of 1-month survival was 6.2% (510/8239) in external causes, 6.5% (94/1148) in respiratory diseases, 0.8% (11/1309) in malignant tumours, 4.9% (55/1114) in strokes and 4.1% (85/2054) in others. As for external causes, the proportion of 1-month survival was 14.3% (382/2670) in asphyxia, 4.2% (84/1999) in hanging, 0.7% (9/1300) in fall, 1.1% (12/1062) in drowning, 1.6% (12/765) in traffic injury, 3.7% (7/187) in drug overuse and 1.6% (4/256) in unclassified external causes. In a multivariate analysis, adults aged <65 years old with arrests witnessed by bystanders, with normal activities of daily living before the arrests, having ventricular fibrillation arrests, having arrests in public places, intravenous fluid levels and early Emergency Medical Service response time were significant predictors for 1-month outcome after OHCAs of non-cardiac origin. The proportion of 1-month survival of all OHCAs of non-cardiac origin did not significantly increase (from 4.3% (86/2023) in 2005 to 4.9% (105/2126) in 2011) and the adjusted OR for one-increment of year was 1.01 (95% CI 0.97 to 1.06).</AbstractText>From a large OHCA registry in Osaka, we demonstrated that 1-month survival after OHCAs of non-cardiac origin was poor and stable.</AbstractText>Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.</CopyrightInformation> |
11,155 | [Relationship between E/Em ratio and exercise capacity in patients with atrial fibrillation]. | To explore the relationship between the ratio of early diastolic transmitral velocity to early diastolic mitral annular velocity (E/Em) and exercise capacity in patients with atrial fibrillation.</AbstractText>A total of 94 consecutive patients with non-valvular atrial fibrillation and preserved left ventricular ejection fraction admitted into our department from December 2011 to June 2013 were included. Echocardiography and cardiopulmonary exercise test were performed. According to E/Em, they were divided into two groups of normal E/Em (E/Em ≤ 9) and elevated E/Em (E/Em>9). The parameters of exercise capacity, including VO2max/kg, anaerobic threshold/kg (AT/kg) and exercise time duration were compared between two groups. And the determinants of VO2max/kg were identified by multivariate regression analysis.</AbstractText>The number of patients was 57(60.6%) with normal E/Em and 37 (39.4%) with elevated E/Em. As compared to those with normal E/Em, the patients with elevated E/Em had lower VO₂max/kg [(26 ± 4) vs (20 ± 4) ml × min⁻¹ × kg⁻¹, P < 0.001], lower AT/kg [(25 ± 4) vs (19 ± 5) ml ×min⁻¹ × kg⁻¹, P < 0.001] and shorter exercise time duration [(7.2 ± 1.3) vs (5.8 ± 1.3) min, P < 0.001]. Multivariate regression analysis revealed that three significant variables were independently associated with VO₂max/kg: age (r = -0.412, P < 0.001), gender ((25 ± 5) and (21 ± 4) ml × min⁻¹ × kg⁻¹ for males and females separately, P < 0.001) and E/Em (r = -0.535, P < 0.001).</AbstractText>E/Em was independently associated with exercise capacity in patients with atrial fibrillation.</AbstractText> |
11,156 | The mechanisms of calcium cycling and action potential dynamics in cardiac alternans. | Alternans is a risk factor for cardiac arrhythmia, including atrial fibrillation. At the cellular level alternans manifests as beat-to-beat alternations in contraction, action potential duration (APD), and magnitude of the Ca(2+) transient (CaT). Electromechanical and CaT alternans are highly correlated, however, it has remained controversial whether the primary cause of alternans is a disturbance of cellular Ca(2+) signaling or electrical membrane properties.</AbstractText>To determine whether a primary failure of intracellular Ca(2+) regulation or disturbances in membrane potential and AP regulation are responsible for the occurrence of alternans in atrial myocytes.</AbstractText>Pacing-induced APD and CaT alternans were studied in single rabbit atrial and ventricular myocytes using combined [Ca(2+)]i and electrophysiological measurements. In current-clamp experiments, APD and CaT alternans strongly correlated in time and magnitude. CaT alternans was observed without alternation in L-type Ca(2+) current, however, elimination of intracellular Ca(2+) release abolished APD alternans, indicating that [Ca(2+)]i dynamics have a profound effect on the occurrence of CaT alternans. Trains of 2 distinctive voltage commands in form of APs recorded during large and small alternans CaTs were applied to voltage-clamped cells. CaT alternans was observed with and without alternation in the voltage command shape. During alternans AP-clamp large CaTs coincided with both long and short AP waveforms, indicating that CaT alternans develop irrespective of AP dynamics.</AbstractText>The primary mechanism underlying alternans in atrial cells, similarly to ventricular cells, resides in a disturbance of Ca(2+) signaling, whereas APD alternans are a secondary consequence, mediated by Ca(2+)-dependent AP modulation.</AbstractText>© 2014 American Heart Association, Inc.</CopyrightInformation> |
11,157 | Early Repolarization Pattern Is Associated with Increased Risk of Early Ventricular Arrhythmias during Acute ST Segment Elevation Myocardial Infarction. | Early repolarization (ER) and acute ST segment elevation myocardial infarction (STEMI) are sharing the pathophysiology of J wave syndromes. It is speculated that early ventricular arrhythmias (VAs) during STEMI may be predisposed by ER. Our aim was to study the association between ER pattern and risk of VAs during acute STEMI.</AbstractText>The study included 102 male patients with acute STEMI who were divided into two groups: cases and controls. Cases included 52 patients with sustained VAs during the first 48 hours from the onset of STEMI, while controls included 50 patients with no VAs. On 12-lead surface electrocardiogram, ER was defined as ≥ 1 mm elevation of J point in at least two inferior or lateral leads with or without ST segment elevation.</AbstractText>Mean age was 48.44 ± 10.08 years and mean left ventricular ejection fraction (LVEF) was 42.25 ± 11.1%. ER pattern was more frequent in cases than controls (29 vs 14 patients, P = 0.008). Notched J wave (P = 0.0007) and horizontal ST segment (P = 0.033) were more frequent in cases than controls. On adjusted regression model, LVEF (OR: 0.95, 95% CI: 0.91-0.99, P = 0.015) and ER (OR: 3.39, 95% CI: 1.41-8.12, P = 0.006) could predict VAs, while QTc interval (P = 0.24) and QTd (P = 0.86) did not have predictive effect. Inferior/inferolateral and global ER pattern (P = 0.044 and 0.031 respectively), notched J wave (P = 0.001), increasing J wave amplitude (P = 0.042), and ST segment elevation (P = 0.001) were associated with a higher risk of VAs.</AbstractText>ER is associated with increased risk of VAs in the setting of acute STEMI.</AbstractText>© 2014 Wiley Periodicals, Inc.</CopyrightInformation> |
11,158 | Can global longitudinal strain predict reduced left ventricular ejection fraction in daily echocardiographic practice? | Transthoracic echocardiography (TTE) is the most commonly used method for measuring left ventricular ejection fraction (LVEF), but its reproducibility remains a matter of controversy. Speckle tracking echocardiography assesses myocardial deformation and left ventricular systolic function by measuring global longitudinal strain (GLS), which is more reproducible, but is not used routinely in hospital practice.</AbstractText>To investigate the feasibility of on-line two-dimensional GLS in predicting LVEF during routine echocardiographic practice.</AbstractText>The analysis involved 507 unselected consecutive patients undergoing TTE between August 2012 and November 2013. Echocardiograms were performed by a single sonographer. Echogenicity was noted as good, moderate or poor. Simple linear regression was used to assess the relationship between LVEF and GLS, overall and according to quality of echogenicity. Receiver operating curve (ROC) analysis was used to identify the threshold GLS that predicts LVEF≤40%.</AbstractText>Mean LVEF was 64±11% and GLS was -18.0±4.0%. A reasonable correlation was found between LVEF and GLS (r=-0.53; P<0.001), which was improved when echogenicity was good (r=-0.60; P<0.001). GLS explained 28.1% of the variation in LVEF, and for one unit decrease in GLS, a 1.45 unit increase in LVEF was expected. Correlations between LVEF and GLS were -0.51 for patients in sinus rhythm (n=490) and -0.86 in atrial fibrillation (n=17). Based on ROC analysis, the area under the curve was 0.97 for GLS≥-14%, allowing detection of LVEF≤40% with a sensitivity of 95% and specificity of 86%.</AbstractText>Two-dimensional GLS is easy to obtain and accurately detects LVEF≤40% in unselected patients. GLS may be especially helpful when a suboptimal acoustic window makes LVEF measurement by Simpson's biplane method difficult and in atrial fibrillation patients with low heart rate variability.</AbstractText>Copyright © 2014 Elsevier Masson SAS. All rights reserved.</CopyrightInformation> |
11,159 | Percutaneous bi-atrial extracorporeal membrane oxygenation for acute circulatory support in advanced heart failure. | Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may improve survival after cardiac arrest by providing cardiopulmonary support. However, VA-ECMO increases left ventricular (LV) afterload, which can promote progressive LV distension and often requires a secondary approach to reduce LV pressure and volume in patients with left heart failure. We report a case of biventricular unloading via biatrial cannulation in the presence of LV thrombus using a TandemHeart percutaneous trans-septal cannula for VA-ECMO in an adult patient with refractory ventricular fibrillation. |
11,160 | Outcomes in patients with high-degree atrioventricular block as the initial manifestation of cardiac sarcoidosis. | Although high-degree atrioventricular block (AVB) is a common initial manifestation of cardiac sarcoidosis, little is known about the outcomes. The aim of this study was to assess outcomes in patients with AVB as an initial manifestation of cardiac sarcoidosis compared with those in patients with ventricular tachyarrhythmia (VT) and/or heart failure (HF). Fifty-three consecutive patients with cardiac sarcoidosis, who had high-degree AVB (n = 22) or VT and/or HF (n = 31), were enrolled. The end point was defined as major adverse cardiac events, including cardiac death, ventricular fibrillation, sustained VT, and hospitalization for HF. Over a median follow-up period of 34 months, the outcomes of major adverse cardiac events were better in patients with high-degree AVB than in those with VT and/or HF (log-rank test, p = 0.046). However, this difference was due mainly to HF hospitalization. The outcomes of fatal cardiac events, including cardiac death, ventricular fibrillation, and sustained VT, were comparable between the 2 groups (log-rank test, p = 0.877). The fatal cardiac events in patients with high-degree AVB were not associated with the initiation of steroid treatment or left ventricular dysfunction. In conclusion, the outcomes of major adverse cardiac events are better in patients with high-degree AVB than in those with VT and/or HF. However, patients with high-degree AVB have a high rate of fatal cardiac events, similar to those with VT and/or HF. An indication for an implantable cardioverter-defibrillator, but not a pacemaker system, can be considered in patients with cardiac sarcoidosis manifested by high-degree AVB. |
11,161 | Massive electrical storm at disease onset in a patient with Brugada syndrome. | Brugada syndrome (BrS) is a genetic arrhythmogenic disease characterized by ST-segment elevations in the right precordial leads of the electrocardiogram (ECG). These ECG changes may be concealed and BrS may present with electrical storm characterized by recurrent ventricular tachycardia and fibrillation.</AbstractText>A 49-year-old previously healthy man was admitted with electrical storm. The patient received direct current (DC) cardioversion shocks and only after intravenous lidocaine did the electrical storm slowly subside with a total of 255 DC shocks administered during the first 24 h after admission. He fully recovered and received an implantable cardioverter-defibrillator. Subsequent drug challenge with flecainide revealed type 1 BrS.</AbstractText>Massive electrical storm can be the first symptom of BrS and the diagnostic ECG changes may be concealed at presentation. Although hundreds of DC shocks may be required during initial treatment, full recovery can be achieved.</AbstractText> |
11,162 | Intravascular versus surface cooling speed and stability after cardiopulmonary resuscitation. | Mild therapeutic hypothermia (MTH) is used to limit neurological injury and improve survival after cardiac arrest (CA) and cardiopulmonary resuscitation, but the optimal mode of cooling is controversial. We therefore compared the effectiveness of MTH using invasive intravascular or non-invasive surface cooling with temperature feedback control.</AbstractText>This retrospective study in post-CA patients studied the effects of intravascular cooling (CoolGard, Zoll, n=97), applied on the intensive care unit (ICU) in one university hospital compared with those of surface cooling (Medi-Therm, Gaymar, n=76) applied in another university hospital.</AbstractText>Time to reach target temperature and cooling speeds did not differ between groups. During the maintenance phase, mean core temperature was 33.1°C (range 32.7-33.7°C) versus 32.5°C (range 31.7-33.4°C) at targets of 33.0 and 32.5°C in intravascularly versus surface cooled patients, respectively. The variation coefficient for temperature during maintenance was higher in the surface than the intravascular cooling group (mean 0.85% vs 0.35%, p<0.0001). ICU survival was 60% and 50% in the intravascularly and surface cooled groups, respectively (NS). Lower age (OR 0.95; 95% CI 0.93 to 0.98; p<0.0001), ventricular fibrillation/ventricular tachycardia as presenting rhythm (OR 7.6; 95% CI 1.8 to 8.9; p<0.0001) and lower mean temperature during the maintenance phase (OR 0.52; 95% CI 0.25 to 1.08; p=0.081) might be independent determinants of ICU survival, while cooling technique and temperature variability did not contribute.</AbstractText>In post-CA patients, intravascular cooling systems result in equal cooling speed, but less variation in temperature during the maintenance phase, as surface cooling. This may not affect the outcome.</AbstractText>Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.</CopyrightInformation> |
11,163 | Sodium nitroprusside-enhanced cardiopulmonary resuscitation facilitates intra-arrest therapeutic hypothermia in a porcine model of prolonged ventricular fibrillation. | The aim of this study was to assess the effect of sodium nitroprusside-enhanced cardiopulmonary resuscitation on heat exchange during surface cooling. We hypothesized that sodium nitroprusside-enhanced cardiopulmonary resuscitation would decrease the time required to reach brain temperature less than 35°C compared to active compression-decompression plus impedance threshold device cardiopulmonary resuscitation alone, in the setting of intra-cardiopulmonary resuscitation cooling. We further hypothesized that the addition of epinephrine during sodium nitroprusside-enhanced cardiopulmonary resuscitation would mitigate heat exchange.</AbstractText>Prospective randomized animal investigation.</AbstractText>Preclinical animal laboratory.</AbstractText>Female farm pigs (n=28).</AbstractText>After 10 minutes of untreated ventricular fibrillation, animals were randomized to three different protocols: sodium nitroprusside-enhanced cardiopulmonary resuscitation (n=8), sodium nitroprusside-enhanced cardiopulmonary resuscitation plus epinephrine (n=10), and active compression-decompression plus impedance threshold device alone (control, n=10). All animals received surface cooling at the initiation of cardiopulmonary resuscitation. Sodium nitroprusside-enhanced cardiopulmonary resuscitation included active compression-decompression plus impedance threshold device plus abdominal binding and 2 mg of sodium nitroprusside at 1, 4, and 8 minutes of cardiopulmonary resuscitation. No epinephrine was used during cardiopulmonary resuscitation in the sodium nitroprusside-enhanced cardiopulmonary resuscitation group. Control and sodium nitroprusside-enhanced cardiopulmonary resuscitation plus epinephrine groups received 0.5 mg of epinephrine at 4.5 and 9 minutes of cardiopulmonary resuscitation. Defibrillation occurred after 10 minutes of cardiopulmonary resuscitation. After return of spontaneous circulation, an Arctic Sun (Medivance, Louiseville, CO) was applied at maximum cooling on all animals. The primary endpoint was the time required to reach brain temperature less than 35°C beginning from the time of cardiopulmonary resuscitation initiation. Data are presented as mean±SEM.</AbstractText>The time required to reach a brain temperature of 35°C was decreased with sodium nitroprusside-enhanced cardiopulmonary resuscitation versus control or sodium nitroprusside-enhanced cardiopulmonary resuscitation plus epinephrine (24±6 min, 63±8 min, and 50±9 min, respectively; p=0.005). Carotid blood flow was higher during cardiopulmonary resuscitation in the sodium nitroprusside-enhanced cardiopulmonary resuscitation group (83±15 mL/min vs 26±7 mL/min and 35±5 mL/min in the control and sodium nitroprusside-enhanced cardiopulmonary resuscitation plus epinephrine groups, respectively; p=0.001).</AbstractText>This study demonstrates that sodium nitroprusside-enhanced cardiopulmonary resuscitation facilitates intra-cardiopulmonary resuscitation hypothermia. The addition of epinephrine to sodium nitroprusside-enhanced cardiopulmonary resuscitation during cardiopulmonary resuscitation reduced its improvement in heat exchange.</AbstractText> |
11,164 | Right ventricular dysfunction, but not tricuspid regurgitation, is associated with outcome late after left heart valve procedure. | Significant tricuspid regurgitation (TR) late after left heart valve procedure is frequent and associated with increased morbidity. Surgical correction carries a significant mortality risk, whereas the impact of TR on survival in these patients is unclear.</AbstractText>This study sought to assess the impact of significant TR late after left heart valve procedure.</AbstractText>A total of 539 consecutive patients with previous left heart valve procedure (time interval from valve procedure to enrollment 50 ± 30 months) were prospectively followed for 53 ± 15 months.</AbstractText>Significant TR (defined as moderate or greater severity by echocardiography) was present in 91 (17%) patients (65% female). Patients with TR presented with more symptoms (New York Heart Association functional class ≥II 55% vs. 31%), lower glomerular filtration rates (61 ± 19 ml/min vs. 68 ± 18 ml/min), and a higher likelihood of atrial fibrillation (41% vs. 20%), all statistically significant. Right ventricular (RV) systolic function was worse in patients with significant TR (RV fractional area change 43 ± 11% vs. 47 ± 9%, p < 0.001). A total of 117 (22%) patients died during follow-up. By Kaplan-Meier analysis, overall survival was significantly worse in patients with significant TR (log-rank p < 0.001). However, by multivariable Cox analysis, only RV fractional area change, age, left atrial size, diabetes, and previous coronary artery bypass graft procedure were significantly associated with mortality, but not tricuspid regurgitation.</AbstractText>RV dysfunction, but not significant TR, is independently associated with survival late after left heart valve procedure.</AbstractText>Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,165 | Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. | The incidence and prognostic impact of late bleeding complications after transcatheter aortic valve replacement (TAVR) are unknown.</AbstractText>The aim of this study was to identify the incidence, predictors, and prognostic impact of major late bleeding complications (MLBCs) (≥30 days) after TAVR.</AbstractText>Clinical and echocardiographic outcomes of patients who underwent TAVR within the randomized cohorts and continued access registries in the PARTNER (Placement of Aortic Transcatheter Valves) trial were analyzed after stratifying by the occurrence of MLBCs. Predictors of MLBCs and their association with 30-day to 1-year mortality were assessed.</AbstractText>Among 2,401 patients who underwent TAVR and survived to 30 days, MLBCs occurred in 142 (5.9%) at a median time of 132 days (interquartile range: 71 to 230 days) after the index procedure. Gastrointestinal complications (n = 58 [40.8%]), neurological complications (n = 22 [15.5%]), and traumatic falls (n = 11 [7.8%]) were identified as the most frequent types of MLBCs. Independent predictors of MLBCs were the presence of low hemoglobin at baseline, atrial fibrillation or flutter at baseline or 30 days, the presence of moderate or severe paravalvular leak at 30 days, and greater left ventricular mass at 30 days. MLBCs were identified as a strong independent predictor of mortality between 30 days and 1 year (adjusted hazard ratio: 3.91; 95% confidence interval: 2.67 to 5.71; p < 0.001).</AbstractText>MLBCs after TAVR were frequent and associated with increased mortality. Better individualized and risk-adjusted antithrombotic therapy after TAVR is urgently needed in this high-risk population. (THE PARTNER TRIAL: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894).</AbstractText>Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,166 | Clinical phenotype and outcome of hypertrophic cardiomyopathy associated with thin-filament gene mutations. | Mild hypertrophy but increased arrhythmic risk characterizes the stereotypic phenotype proposed for hypertrophic cardiomyopathy (HCM) caused by thin-filament mutations. However, whether such clinical profile is different from more prevalent thick-filament-associated disease is unresolved.</AbstractText>This study aimed to assess clinical features and outcomes in a large cohort of patients with HCM associated with thin-filament mutations compared with thick-filament HCM.</AbstractText>Adult HCM patients (age >18 years), 80 with thin-filament and 150 with thick-filament mutations, were followed for an average of 4.5 years.</AbstractText>Compared with thick-filament HCM, patients with thin-filament mutations showed: 1) milder and atypically distributed left ventricular (LV) hypertrophy (maximal wall thickness 18 ± 5 mm vs. 24 ± 6 mm; p < 0.001) and less prevalent outflow tract obstruction (19% vs. 34%; p = 0.015); 2) higher rate of progression to New York Heart Association functional class III or IV (15% vs. 5%; p = 0.013); 3) higher prevalence of systolic dysfunction or restrictive LV filling at last evaluation (20% vs. 9%; p = 0.038); 4) 2.4-fold increase in prevalence of triphasic LV filling pattern (26% vs. 11%; p = 0.002); and 5) similar rates of malignant ventricular arrhythmias and sudden cardiac death (p = 0.593).</AbstractText>In adult HCM patients, thin-filament mutations are associated with increased likelihood of advanced LV dysfunction and heart failure compared with thick-filament disease, whereas arrhythmic risk in both subsets is comparable. Triphasic LV filling is particularly common in thin-filament HCM, reflecting profound diastolic dysfunction.</AbstractText>Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,167 | [The cardiological evaluation in patients undergoing to Day Surgery: when is indicated]. | Guidelines established preoperative cardiac management of the patient undergoing non-cardiac surgery in hospitalization. Regarding the patients undergoing the surgery in DS, the management is not defined. Aim of this study was to evaluate the appropriateness of the cardiological consultation requested by the patients undergoing surgery with this method.</AbstractText>We examined the request of cardiological evaluation for patient admitted to DS of Sant'Andrea Hospital in Rome. We have considered: age, sex, clinic history, simpthomatology, electrocardiogram, cardiovascular objectivity, hemodynamic stability, comorbidity, therapy, type of the surgery, the motivation of the request.</AbstractText>Of 2350 patients, 495 patients (21%) have been undergone the preoperative cardiologic consultation. The request was resulted as unnecessary for 432 (87.2%) patients, appropriate for 63 (12.7%): 4 that had the ischemic heart disease without knowing this, 6 with severe hypertension; 2 with mitral valve prolapse and valvular regurgitation; 34 with congestive heart failure; 6 with the alterations in EKG : 3 with "Brugada pattern"; 1 with Pace Maker (PMK) that had to be reprogrammed before the operation; 3 under dual antiplatelet therapy; 7 that were taking the oral anticoagulant therapy. Cardiac complications occurred just in one case with patient suffering dilated cardiomyopathy, diabetes and hypertension; during the cataract surgery was presented the abrupt increase of blood pressure and left ventricular failure.</AbstractText>Preoperative cardiologic evaluation results as useless in most patients. However, in some particular situations had allowed the diagnosis of heart disease for the patients who did not know to have it.</AbstractText> |
11,168 | Age, sex, and hospital factors are associated with the duration of cardiopulmonary resuscitation in hospitalized patients who do not experience sustained return of spontaneous circulation. | Variability in the duration of attempted in‐hospital cardiopulmonary resuscitation (CPR) is high, but the factors influencing termination of CPR efforts are unknown.</AbstractText>We examined the association between patient and hospital characteristics and CPR duration in 45 500 victims of in‐hospital cardiac arrest who did not experience return of spontaneous circulation (ROSC) and who were enrolled in the Get With the Guidelines registry between 2001 and 2010. In a secondary analysis, we performed analyses in 46 168 victims of in‐hospital cardiac arrest who experienced ROSC. We used ordered logistic regression to identify factors associated with CPR duration. Analyses were conducted by tertile of CPR duration (tertiles: ROSC group: 2 to 7, 8 to 17, and 18 to 120 minutes; no‐ROSC group: 2 to 16, 17 to 26, 27 to 120 minutes). In those without ROSC, younger age (aged 18 to 40 versus >65 years; odds ratio [OR] 1.81; 95% CI 1.69 to 1.95; P<0.001), female sex (OR 1.05; 95% CI 1.02 to 1.09; P=0.005), ventricular tachycardia or fibrillation (OR 1.50; 95% CI 1.42 to 1.58; P<0.001), and the need to place an invasive airway (OR 2.59; 95% CI 2.46 to 2.72; P<0.001) were associated with longer CPR duration. In those with ROSC, ventricular tachycardia or fibrillation (OR 0.89; 95% CI 0.85 to 0.93; P<0.001) and witnessed events (OR 0.87; 95% CI 0.82 to 0.91; P<0.001) were associated with shorter duration.</AbstractText>Age and sex were associated with attempted CPR duration in patients who do not experience ROSC after in‐hospital cardiac arrest but not in those who experience ROSC. Understanding the mechanism of these interactions may help explain variability in outcomes for in‐hospital cardiac arrest.</AbstractText> |
11,169 | [Outcome of myocardial revascularisation in patients fifty years old and younger]. | Most patients that undergo coronary artery bypass grafting (CABG) are around 70 years of age when operated on. We investigated the outcome of CABG in patients 50 years and younger, focusing on early complications, operative mortality and long-term survival.</AbstractText>A retrospective study on 1626 patients that underwent CABG in Iceland 2001-2012. One hundred patients aged 50 years or younger were compared to 1526 older patients.</AbstractText>The male:female ratio, risk factors and extension of coronary artery disease were comparable in both groups, as was the proportion of patients with left main disease. Left ventricular ejection fraction was significantly lower in the younger patients (52 vs. 55%, p=0.004) and more of them had a recent myocardial infarction (41 vs. 27%, p=0.003). Minor complications were less common in the younger group (30 vs. 50%, p<0.001), especially new onset atrial fibrillation (14 vs. 35%, p<0,001). Chest tube bleeding for the first 24 hours postoperatively was also less in the younger group (853 vs. 999 ml, p=0.015) and they received fewer units of packed red cells (1.3 vs. 2.8 units, p<0.001). However, the incidence of major complications was comparable (6 vs. 11%, p=0.13) and the same was true for 30 day mortality (1 vs. 3%, p=0.5). Mean hospital stay was 2 days shorter for younger patients (p<0.001). There was a non-significant trend for improved disease-specific survival for the younger patients, or 99% vs. 95% 5-year survival (p=0.07).</AbstractText>In younger patients undergoing CABG minor complications are less common than in older patients, their hospital stay is shorter and transfusions less common. There was also a trend for improved disease specific survival for the younger patients.</AbstractText> |
11,170 | Attitudes and preferences for the clinical management of hypertension and hypertension-related cardiac disease in general practice: results of the Italian Hypertension and Heart Survey. | The aim of this study was to evaluate attitudes and preferences for the clinical management of hypertensive patients with cardiac organ disease, including left ventricular hypertrophy (LVH) and coronary artery disease (CAD), in Italy. A predefined 15-item questionnaire was anonymously administered to a large community sample of general practitioners (GPs) and specialised physicians between November 2012 and June 2013. Estimated prevalence of hypertension-related clinical conditions was stratified into four groups (10-20%, 20-40%, 40-50%, >50%); preferences were reported as percentage among valid answers to the survey questionnaire. A total of 1319 physicians (672 males, age 55.0 ± 7.1 years, age of medical activity 27.1 ± 7.6 years), among whom 1264 GPs and 55 specialised physicians, was included. LVH was reported to be the most frequent marker of organ damage by the majority of physicians (73.5%). LV diastolic dysfunction was reported to be relatively frequent (>40%) by more than half of the specialised physicians (58.2%) and less frequent (10-20%) by GPs (49.8%); LV systolic dysfunction, atrial fibrillation and CAD were considered to be less frequent (10-20%) by the majority of physicians (61.3, 71.6 and 53.3%, respectively). Echocardiography was the preferred diagnostic tool used to estimate LVH (76.6%). Tight blood pressure control (130/80 mm Hg) was considered to be the most appropriate by the majority of physicians, both in hypertensive patients with LVH and in those with CAD. With the well-known limitations of a cross-sectional survey, this study provides information on attitudes and preferences for the clinical management of outpatients with hypertension and high CV risk profile in general practice in Italy. |
11,171 | [Ventricular fibrillation following hyperventilation and apneic underwater swimming]. | This is a case study of an 18 years old boy who lost consciousness during apneic underwater swimming. When cardiopulmonary resuscitation was initiated ventricular fibrillation was seen on cardiac monitoring. Bradycardia, atrial and ventricular premature beats are a known response to hyperventilation and apneic underwater diving. This case is the first documentation of ventricular fibritllation as a cause of sudden cardiac death during apneic underwater swimming. |
11,172 | Pulsatile venoarterial perfusion using a novel synchronized cardiac assist device augments coronary artery blood flow during ventricular fibrillation. | Patients with cardiogenic shock have a very high mortality. Here we report the first use of a percutaneous pulsatile cardiac assist device, based on a diagonal pump synchronized with the heart cycle by means of an electrocardiographic signal in adult pigs. Eight domestic pigs underwent mandatory ventilation. During sinus rhythm, there were no differences between pulsatile and nonpulsatile perfusion with regard to pulmonary artery pressure, pulmonary wedge pressure, central venous pressure, mean arterial pressure (MAP), mean pulse pressure, and mean coronary artery flow (CAF). After 2 min of complete cardiac arrest (ventricular fibrillation), circulatory support with the i-cor in venoarterial nonpulsatile extracorporeal membrane oxygenation (ECMO) mode (3 L/min) restored systemic circulation, with an increase of MAP to 78.3 mm Hg and CAF to 5.27 mL/min. After changing from ECMO settings to pulsatile mode (3 L/min, 75 bpm, pulse amplitude range 3500 rpm), MAP did not change significantly (75.6 mm Hg); however, CAF increased to 8.45 mL/min. After changing back to nonpulsatile mode, MAP remained stable (83.6 mm Hg), but CAF decreased to 4.85 mL/min. Thereafter, pulsatile cardiac assist was established with a reduced blood flow of 2.5 L/min, and the pulse amplitude range was extended to 4500 rpm. Under these conditions, MAP remained stable (71.0 mm Hg), but CAF significantly increased to 15.2 mL/min (P < 0.05). Percutaneous cardiac support using a venoarterial cardiac assist device equipped with a novel diagonal pump is able to restore and increase systemic and coronary circulation during ventricular fibrillation. Electrocardiographically triggered synchronized cardiac assist provides an additional increase of coronary artery flow. These promising results are to be confirmed in humans. |
11,173 | Cheating the CHA2DS2-VASc Score: Thromboembolism in Apical Hypertrophic Cardiomyopathy. | Atrial fibrillation increases the risk of systemic thromboembolism in general and stroke in particular. Not all patients who develop atrial fibrillation are at significantly heightened risk of thromboembolic complications, however, with the development of risk scoring systems aiding clinicians in determining whether formal anticoagulation is mandated. The most commonly used contemporary scoring systems-CHADS2 and CHA2DS2-VASc-provide a reliable means of assessing stroke risk, but certain cardiac conditions are associated with an increased incidence of thromboembolism without impacting on these risk scores. Hypertrophic cardiomyopathy, with its apical variant, is such a condition. We present a case of a patient with apical hypertrophic cardiomyopathy and atrial fibrillation who suffered dire thromboembolic consequences despite a reassuringly low CHA2DS2-VASc score and suggest that this scoring system is modified to incorporate the thromboembolic risk inherent to certain cardiomyopathies irrespective of impairment of left ventricular systolic dysfunction or clinical heart failure. |
11,174 | Protective effect of shen-fu injection on neuronal mitochondrial function in a porcine model of prolonged cardiac arrest. | Background. Shen-Fu injection (SFI) following cardiac arrest exhibits neurological effects, but its effect on neurological dysfunction is unclear. This study sought to investigate the protective effect of SFI on nerve cells in a porcine model of cardiac arrest. Methods. After eight minutes of untreated ventricular fibrillation (VF) and 2 minutes of basic life support, 24 pigs were randomized and divided into three cardiopulmonary resuscitation groups, which received central venous injection of either Shen-Fu (SFI group; 1.0 ml/kg), epinephrine (EP group; 0.02 mg/kg), or saline (SA group). Surviving pigs were sacrificed at 24 h after ROSC and brains were removed for analysis for morphologic changes of mitochondria by electron microscopy, for mitochondrial transmembrane potential (MTP) by flow cytometry, and for opening of the mitochondrial permeability transition pore (MPTP) by mitochondrial light scattering. Results. Compared with the EP and SA groups, SFI treatment reduced opening of MPTP, showing higher MMP. In addition, animals treated with SFI showed slight cerebral ultrastructure damage under the electron microscopy. Conclusion. Shen-Fu injection alleviated brain injury, improved neurological ultrastructure, stabilized membrane potential, and inhibited opening of MPTP. Therefore, SFI could significantly attenuate postresuscitation cerebral ischemia and reperfusion injury by modulating mitochondrial dysfunction of nerve cells. |
11,175 | Detection of occult paroxysmal atrial fibrillation. | This work introduces a novel approach to the detection of brief episodes of paroxysmal atrial fibrillation (PAF). The proposed detector is based on four parameters which characterize RR interval irregularity, P-wave absence, f-wave presence, and noise level, of which the latter three are determined from a signal produced by an echo state network. The parameters are used for fuzzy logic classification where the decisions involve information on prevailing signal quality; no training is required. The performance is evaluated on a large set of test signals with brief episodes of PAF. The results show that episodes with as few as five beats can be reliably detected with an accuracy of 0.88, compared to 0.82 for a detector based on rhythm information only (the coefficient of sample entropy); this difference in accuracy increases when atrial premature beats are present. The results also show that the performance remains essentially unchanged at noise levels up to [Formula: see text] RMS. It is concluded that the combination of information on ventricular activity, atrial activity, and noise leads to substantial improvement when detecting brief episodes of PAF. |
11,176 | Dilated, arrhythmogenic cardiomyopathy in emery-dreifuss muscular dystrophy due to the emerin splice-site mutation c.449 + 1G>A. | Cardiac involvement in X-linked Emery-Dreifuss muscular dystrophy (X-EDMD) usually includes arrhythmias but not dilative cardiomyopathy (dCMP). Here, we report an X-EDMD patient with severe dCMP and life-threatening ventricular arrhythmias associated with other phenotypic features unusual for X-EDMD.</AbstractText>A 46-year-old patient with X-EDMD due to the known splice-site mutation c.449 + 1G>A in the emerin gene experienced palpitations for the first time at the age of 21 years, and a first syncope at the age of 23 years. He was started on phenprocoumon due to atrial fibrillation and systolic dysfunction. At the age of 28 years he received his first pacemaker. Echocardiography at the age of 36 years showed left ventricular dilatation, enlarged atria, myocardial thickening, 28% ejection fraction and diastolic dysfunction. dCMP was suspected. At the age of 38 years, a cardiac resynchronization therapy system was implanted, which was upgraded to an implantable cardioverter defibrillator (ICD) because of ventricular tachycardias (at the age of 42 years). During the following months, the ICD discharged 30 times due to ventricular tachycardias. In May 2013, he required recurrent cardio-pulmonary resuscitation because ventricular fibrillation occurred with no discharge of the ICD. He was listed for heart transplantation. He also had hypothyroidism, liver hemangiomas, thrombopenia, anemia and diverticulosis.</AbstractText>X-EDMD may occur along with dCMP. An ICD may be ineffective for ventricular fibrillation in X-EDMD. X-EDMD may be associated with unusual, atypical phenotypic features.</AbstractText> |
11,177 | Genetically engineered SCN5A mutant pig hearts exhibit conduction defects and arrhythmias. | SCN5A encodes the α subunit of the major cardiac sodium channel Na(V)1.5. Mutations in SCN5A are associated with conduction disease and ventricular fibrillation (VF); however, the mechanisms that link loss of sodium channel function to arrhythmic instability remain unresolved. Here, we generated a large-animal model of a human cardiac sodium channelopathy in pigs, which have cardiac structure and function similar to humans, to better define the arrhythmic substrate. We introduced a nonsense mutation originally identified in a child with Brugada syndrome into the orthologous position (E558X) in the pig SCN5A gene. SCN5A(E558X/+) pigs exhibited conduction abnormalities in the absence of cardiac structural defects. Sudden cardiac death was not observed in young pigs; however, Langendorff-perfused SCN5A(E558X/+) hearts had an increased propensity for pacing-induced or spontaneous VF initiated by short-coupled ventricular premature beats. Optical mapping during VF showed that activity often began as an organized focal source or broad wavefront on the right ventricular (RV) free wall. Together, the results from this study demonstrate that the SCN5A(E558X/+) pig model accurately phenocopies many aspects of human cardiac sodium channelopathy, including conduction slowing and increased susceptibility to ventricular arrhythmias. |
11,178 | A statistical index for early diagnosis of ventricular arrhythmia from the trend analysis of ECG phase-portraits. | In this paper, we propose a novel statistical index for the early diagnosis of ventricular arrhythmia (VA) using the time delay phase-space reconstruction (PSR) technique, from the electrocardiogram (ECG) signal. Patients with two classes of fatal VA-with preceding ventricular premature beats (VPBs) and with no VPBs-have been analysed using extensive simulations. Three subclasses of VA with VPBs viz. ventricular tachycardia (VT), ventricular fibrillation (VF) and VT followed by VF are analyzed using the proposed technique. Measures of descriptive statistics like mean (µ), standard deviation (σ), coefficient of variation (CV = σ/µ), skewness (γ) and kurtosis (β) in phase-space diagrams are studied for a sliding window of 10 beats of the ECG signal using the box-counting technique. Subsequently, a hybrid prediction index which is composed of a weighted sum of CV and kurtosis has been proposed for predicting the impending arrhythmia before its actual occurrence. The early diagnosis involves crossing the upper bound of a hybrid index which is capable of predicting an impending arrhythmia 356 ECG beats, on average (with 192 beats standard deviation) before its onset when tested with 32 VA patients (both with and without VPBs). The early diagnosis result is also verified using a leave one out cross-validation (LOOCV) scheme with 96.88% sensitivity, 100% specificity and 98.44% accuracy. |
11,179 | Endomyocardial biopsy technique for orthotopic heart transplantation and cardiac stem-cell harvesting. | Orthotopic heart transplantation (OHT) is performed using the bicaval and pulmonary venous anastomoses or the standard (biatrial) anastomoses. The special considerations of endomyocardial biopsy after OHT using the bicaval technique, and after myocardial infarction for harvesting of cardiac stem cells, have not been described.</AbstractText>When approached via the right or left internal jugular vein, important technical considerations were ultrasound guidance for vascular access; a soft, 80-cm, 0.035-inch, J-tipped guidewire; a long (23-cm), 7-Fr sheath; and a flexible 7-Fr, 50-cm bioptome. These technical aspects were helpful to avoid disruption of the superior vena cava suture line, avoid entry into the right atrial appendage or coronary sinus, avoid right ventricular free wall perforation, and provide ready access to the right ventricular septal wall. We used the same principles and technical considerations when obtaining the cardiac stem cells after myocardial infarction in patients enrolled in the CADUCEUS trial.</AbstractText>From January 2002 to December 2005, 754 biopsy procedures were performed in 179 patients after OHT with the bicaval technique, using bioptome A. There was 1 occurrence of ventricular fibrillation requiring cardioversion, and no occurrence of cardiac tamponade during the procedure. From January 2006 to September 2013, 2818 biopsy procedures were performed in 1064 patients using bioptome B. No patient developed ventricular fibrillation or cardiac tamponade during the procedure. In 2010 and 2011, 23 biopsy procedures were performed in 23 patients after acute myocardial infarction, using bioptome B. No immediate complications occurred while performing these biopsies. The late occurrence of tricuspid regurgitation was not evaluated in this study.</AbstractText>Endomyocardial biopsy procedures can be safely performed after OHT with the bicaval technique and after myocardial infarction for harvesting of cardiac stem cells. Ultrasound guidance for vascular access, a long guidewire and sheath, and a flexible bioptome are important features for the safe conduct of the biopsy procedure.</AbstractText>Copyright © 2014 Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,180 | Smokeless tobacco, sport and the heart. | Smokeless tobacco (snuff) is a finely ground or shredded tobacco that is sniffed through the nose or placed between the cheek and gum. Chewing tobacco is used by putting a wad of tobacco inside the cheek. Smokeless tobacco is widely used by young athletes to enhance performance because nicotine improves some aspects of physiology. However, smokeless tobacco has harmful health effects, including cardiovascular disorders, linked to nicotine physiological effects, mainly through catecholamine release. Nicotine decreases heart rate variability and the ventricular fibrillation threshold, and promotes the occurrence of various arrhythmias; it also impairs endothelial-dependent vasodilation and could therefore promote premature atherogenesis. At rest, heart rate, blood pressure, inotropism, cardiac output and myocardial oxygen consumption are increased by nicotine, leading to an imbalance between myocardial oxygen demand and supply. The same occurs at submaximal levels of exercise. These increases are accompanied by a rise in systemic resistances. At maximal exercise, heart rate, cardiac output and maximal oxygen uptake (V˙O2max) are unaffected by nicotine. Because endothelial dysfunction is promoted by nicotine, paradoxical coronary vasoconstriction may occur during exercise and recovery. Nicotine induces a decrease in muscular strength and impairs anaerobic performance. However, nicotine is used in sports as it diminishes anxiety, enhances concentration and agility, improves aerobic performance and favours weight control. Importantly, smokeless tobacco, similar to cigarette smoking, leads to nicotine dependence through dopaminergic pathways. Smokeless tobacco has harmful cardiovascular effects and is addictive: it fulfils all the criteria for inclusion in the World Anti-Doping Agency prohibited list as a doping product. Smokeless tobacco use in sporting activities must be discouraged. |
11,181 | [A combination of cardiac arrest and cerebral haemorrhage treated with extracorporeal membrane oxygenation]. | A 46-year-old, healthy woman with sudden hemiplegia and nausea suffered cardiac arrest during transport to the hospital. This was treated en route with LUCAS-2. A computed tomography ruled out cerebral haemorrhage, and an electricardiogramme showed inferior myocardial infarction. During percutaneous intervention the patient had another cardiac arrest. Despite revascularization she was very unstable and received more than 20 cardioversions of ventricular fibrillation. In the catheterization laboratory, the patient was connected to a heart lung machine (extracorporeal membrane oxygenation) while treated with LUCAS-2. After two months of hospitalization, the patient was able to walk and had minor cognitive impairment. |
11,182 | [Cardiac arrest with syndrome of apparent mineralocorticoid excess]. | Ventricular fibrillation is an unknown complication to the syndrome of apparent mineralocorticoid excess (SAME). This case report describes a young woman admitted with hypo-kalaemia and hypertension. Concentrations of both P-renin and P-aldosterone were low and urinary steroid metabolites revealed an abnormal excretion pattern pointing to the diagnosis of SAME. Three years later the woman suffered from ventricular fibrillation due to the hypokalaemia caused by her disease. This case report demonstrates the need for increased attention on the potassium concentration in patients with SAME. |
11,183 | Preclinical evaluation of implantable cardioverter-defibrillator developed for magnetic resonance imaging use. | Many patients with an implantable cardioverter-defibrillator (ICD) have indications for magnetic resonance imaging (MRI). However, MRI is generally contraindicated in ICD patients because of potential risks from hazardous interactions between the MRI and ICD system.</AbstractText>The purpose of this study was to use preclinical computer modeling, animal studies, and bench and scanner testing to demonstrate the safety of an ICD system developed for 1.5-T whole-body MRI.</AbstractText>MRI hazards were assessed and mitigated using multiple approaches: design decisions to increase safety and reliability, modeling and simulation to quantify clinical MRI exposure levels, animal studies to quantify the physiologic effects of MRI exposure, and bench testing to evaluate safety margin.</AbstractText>Modeling estimated the incidence of a chronic change in pacing capture threshold >0.5 V and 1.0 V to be less than 1 in 160,000 and less than 1 in 1,000,000 cases, respectively. Modeling also estimated the incidence of unintended cardiac stimulation to occur in less than 1 in 1,000,000 cases. Animal studies demonstrated no delay in ventricular fibrillation detection and no reduction in ventricular fibrillation amplitude at clinical MRI exposure levels, even with multiple exposures. Bench and scanner testing demonstrated performance and safety against all other MRI-induced hazards.</AbstractText>A preclinical strategy that includes comprehensive computer modeling, animal studies, and bench and scanner testing predicts that an ICD system developed for the magnetic resonance environment is safe and poses very low risks when exposed to 1.5-T normal operating mode whole-body MRI.</AbstractText>Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,184 | Effects of renal denervation on atrial arrhythmogenesis. | Atrial fibrillation is the most common sustained arrhythmia and is associated with significant morbidity and mortality. In addition to mechanisms such as atrial stretch and atrial remodeling, the activity of the autonomic nervous system has also been suggested to contribute to the progression from paroxysmal to persistent atrial fibrillation. Catheter-based renal denervation was introduced as a minimally invasive approach to reduce renal and whole body sympathetic activation with accompanying blood pressure reduction and left-ventricular morphological and functional improvement in drug-resistant hypertension. This review focuses on the potential effects of renal denervation on different arrhythmogenic mechanisms in the atrium and discusses potential anti-remodeling effects in atrial fibrillation patients with hypertension, heart failure and sleep apnea. |
11,185 | Full recovery case after 82 minutes out-of-hospital cardiac arrest: importance of chain of survival and predicting outcome. | A middle age man underwent immediate cardiopulmonary resuscitation (CPR) for ventricular fibrillation (VF) occurred in an ambulance. After arrival in a regional hospital, return of spontaneous circulation (ROSC) was achieved 82 minutes after the collapse. He was in coma even three hours after ROSC. So, he was transferred to our university hospital to receive therapeutic hypothermia (TH). An initial bispectral index (BIS) value suggested a favorable outcome. Thus we decided to aggressive therapies including TH of 34°C for 48 hours, followed by a very slow rewarming at the rate of 1°C per day. Eventually he was discharged from the hospital with good neurological state. This case shows us two points: 1) the importance of the chain of survival: CPR done immediately after the collapse, persistent CPR for refractory VF, followed by coronary interventions after ROSC, continuing care to the university hospital, 2) decision making for TH using BIS monitoring. |
11,186 | Probabilistic Linkage of Prehospital and Outcomes Data in Out-of-hospital Cardiac Arrest. | Lack of longitudinal patient outcome data is an important barrier in emergency medical services (EMS) research. We aimed to demonstrate the feasibility of linking prehospital data from the California EMS Information Systems (CEMSIS) database to outcomes data from the California Office of Statewide Health Planning and Development (OSHPD) database for patients with out-of-hospital cardiac arrest (OHCA).</AbstractText>We included patients age 18 years or older who sustained nontraumatic OHCA and were included in the 2010-2011 CEMSIS databases. The CEMSIS database is a unified EMS data collection system for California. The OSHPD database is a comprehensive data collection system for patient-level inpatient and emergency department encounters in California. OHCA patients were identified in the CEMSIS database using cardiac rhythm, procedures, medications, and provider impression. Probabilistic linkage blocks were created using in-hospital death or one of the following primary or secondary diagnoses (ICD-9-CM) in the OSHPD databases: cardiac arrest (427.5), sudden death (798), ventricular tachycardia (427.1), ventricular fibrillation (427.4), and acute myocardial infarction (410.xx). Blocking variables included incident date, gender, date of birth, age, and/or destination facility. Due to the volume of cases, match thresholds were established based on clerical record review for each block individually. Match variables included incident date, destination facility, date of birth, sex, race, and ethnicity.</AbstractText>Of the 14,603 cases of OHCA we identified in CEMSIS, 91 (0.6%) duplicate records were excluded. Overall, 46% of the data used in the linkage algorithm were missing in CEMSIS. We linked 4,961/14,512 (34.2%) records. Linkage rates varied significantly by local EMS agency, ranging from 1.4 to 61.1% (OR for linkage 0.009-0.76; p < 0.0001). After excluding the local EMS agency with the outlying low linkage rate, we linked 4,934/12,596 (39.2%) records.</AbstractText>Probabilistic linkage of CEMSIS prehospital data with OSHPD outcomes data was severely limited by the completeness of the EMS data. States and EMS agencies should aim to overcome data limitations so that more effective linkages are possible.</AbstractText> |
11,187 | Simulation Methods and Validation Criteria for Modeling Cardiac Ventricular Electrophysiology. | We describe a sequence of methods to produce a partial differential equation model of the electrical activation of the ventricles. In our framework, we incorporate the anatomy and cardiac microstructure obtained from magnetic resonance imaging and diffusion tensor imaging of a New Zealand White rabbit, the Purkinje structure and the Purkinje-muscle junctions, and an electrophysiologically accurate model of the ventricular myocytes and tissue, which includes transmural and apex-to-base gradients of action potential characteristics. We solve the electrophysiology governing equations using the finite element method and compute both a 6-lead precordial electrocardiogram (ECG) and the activation wavefronts over time. We are particularly concerned with the validation of the various methods used in our model and, in this regard, propose a series of validation criteria that we consider essential. These include producing a physiologically accurate ECG, a correct ventricular activation sequence, and the inducibility of ventricular fibrillation. Among other components, we conclude that a Purkinje geometry with a high density of Purkinje muscle junctions covering the right and left ventricular endocardial surfaces as well as transmural and apex-to-base gradients in action potential characteristics are necessary to produce ECGs and time activation plots that agree with physiological observations. |
11,188 | Randomized trial of a novel ACLS teaching tool: does it improve student performance? | Mounting evidence suggests that high-fidelity mannequin-based (HFMBS) and computer-based simulation are useful adjunctive educational tools for advanced cardiac life support (ACLS) instruction. We sought to determine whether access to a supplemental, online computer-based ACLS simulator would improve students' performance on a standardized Mega Code using high-fidelity mannequin based simulation (HFMBS).</AbstractText>Sixty-five third-year medical students were randomized. Intervention group subjects (n = 29) each received a two-week access code to the online ACLS simulator, whereas the control group subjects (n = 36) did not. Primary outcome measures included students' time to initiate chest compressions, defibrillate ventricular fibrillation, and pace symptomatic bradycardia. Secondary outcome measures included students' subjective self-assessment of ACLS knowledge and confidence.</AbstractText>Students with access to the online simulator on average defibrillated ventricular fibrillation in 112 seconds, whereas those without defibrillated in 149.9 seconds, an average of 38 seconds faster [p<.05]. Similarly, those with access to the simulator paced symptomatic bradycardia on average in 95.14 seconds whereas those without access paced on average 154.9 seconds a difference of 59.81 seconds [p<.05]. On a subjective 5-point scale, there was no difference in self-assessment of ACLS knowledge between the control (mean 3.3) versus intervention (mean 3.1) [p-value =.21]. Despite having outperformed the control group subjects in the standardized Mega Code test scenario, the intervention group felt less confident on a 5-point scale (mean 2.5) than the control group. (mean 3.2) [p<.05].</AbstractText>The reduction in time to defibrillate ventricular fibrillation and to pace symptomatic bradycardia among the intervention group subjects suggests that the online computer-based ACLS simulator is an effective adjunctive ACLS instructional tool.</AbstractText> |
11,189 | Hydrogen sulfide inhalation decreases early blood-brain barrier permeability and brain edema induced by cardiac arrest and resuscitation. | The effects of hydrogen sulfide (H2S) on blood-brain barrier (BBB) and brain edema after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) remain poorly understood. We investigated the effects of exogenous 80-p.p.m. H2S gas on BBB, brain water content, neurologic outcome, and survival rate after CA and CPR. Cardiopulmonary resuscitation followed CA induced in rats by ventricular fibrillation for 6 minutes. Results show that inhalation of 80-p.p.m. H2S significantly reduced the permeability of the BBB in both in the cortex and hippocampus at 24 hours after resuscitation. Hydrogen sulfide also lessened brain edema in the cortex and hippocampus, ameliorated neurologic outcome as evaluated by neurologic deficit score and tape removal test, and improved the 14-day survival rate. Hydrogen sulfide also attenuated CA and CPR-induced increases of matrix metalloproteinase-9 (MMP-9) activity and vascular endothelial growth factor (VEGF) expression, and increased the expression of angiogenin-1 (Ang-1). These results indicate that inhalation of 80-p.p.m. H2S immediately after CPR attenuated BBB permeability and brain edema, and improved neurologic outcome and 14-day survival of rats after CA. The therapeutic benefits of H2S could be associated with suppression of MMP-9 and VEGF expression and increased expression of Ang-1. |
11,190 | Differential survival for men and women from out-of-hospital cardiac arrest varies by age: results from the OPALS study. | The effect of sex on survival in out-of-hospital cardiac arrest (OHCA) is controversial. Some studies report more favorable outcomes in women, while others suggest the opposite, citing disparities in care. Whether sex predicts differential age-specific survival is still uncertain.</AbstractText>The objective was to study the sex-associated variation in survival to hospital discharge in OHCA patients as well as the relationship between age and sex for predicting survival.</AbstractText>The Ontario Prehospital Advanced Life Support (OPALS) registry, collected in a large study of rapid defibrillation and advanced life support programs, is Utstein-compliant and has data on OHCA patients (1994 to 2002) from 20 communities in Ontario, Canada. All adult OHCAs not witnessed by emergency medical services (EMS) and treated during one of the three main OPALS phases were included. Clinically significant variables were chosen a priori (age, sex, witnessed arrest, initial cardiopulmonary resuscitation [CPR], shockable rhythm, EMS response interval, and OPALS study phase) and entered into a multivariable logistic regression model with survival to hospital discharge as the outcome, with sex and age as the primary risk factors. Fractional polynomials were used to explore the relationship between age and survival by sex.</AbstractText>A total of 11,479 (out of 20,695) OPALS cases met inclusion criteria and 10,862 (94.6%) had complete data for regression analysis. As a group, women were older than men (median age = 74 years vs. 69 years, p < 0.01), had fewer witnessed arrests (43% vs. 49%; p < 0.01), had fewer initial ventricular fibrillation/ventricular tachycardia rhythms (24% vs. 42%; p < 0.01), had a lower rate of bystander CPR (12% vs. 17%; p < 0.01), and had lower survival (1.7% vs. 3.2%; p < 0.01). Survival to hospital admission and return of spontaneous circulation did not differ between women and men (p > 0.05). The relationship between age, sex, and survival to hospital discharge could not be analyzed in a single regression model, as age did not have a linear relationship with survival for men, but did for women. Thus, age was kept as a continuous variable for women but was transformed for men using fractional polynomials [ln(age) + age(3) ]. In sex-stratified regression models, the adjusted probability of survival for women decreased as age increased (adjusted odds ratio = 0.88, 95% confidence interval = 0.81 to 0.96, per 5-year increase in age) while for men, the probability of survival initially increased with age until age 65 years and then decreased with increasing age. Women had a higher probability of survival until age 47 years, after which men maintained a higher probability of survival.</AbstractText>Overall OHCA survival for women was lower than for men in the OPALS study. Factors related to the sex differences in survival (rates of bystander CPR and shockable rhythms) may be modifiable. The probability of survival differed across age for men and women in a nonlinear fashion. This differential influence of age on survival for men and women should be considered in future studies evaluating survival by sex in OHCA population.</AbstractText>© 2014 by the Society for Academic Emergency Medicine.</CopyrightInformation> |
11,191 | Prognostic value of high-sensitivity troponin T levels in patients with ventricular arrhythmias and out-of-hospital cardiac arrest: data from the prospective FINNRESUSCI study. | Myocardial dysfunction is common after out-of-hospital cardiac arrest (OHCA) and high-sensitivity troponin T (hs-TnT) levels may provide incremental prognostic information to established risk indices.</AbstractText>A total of 155 patients with OHCA and a shockable rhythm (98% ventricular fibrillation; OHCA-VF/VT) had blood samples drawn within six hours of admission. Blood samples were also available after 24 hours, 48 hours, and 96 hours in subsets of patients. The endpoints of the study were hospital mortality and neurological status and mortality after one year.</AbstractText>Admission hs-TnT levels were higher than the 99-percentile of the general population (14 ng/L) in all patients (range 18 to 17,837 ng/L). Admission hs-TnT levels were associated with acute coronary artery occlusion, time to return of spontaneous circulation, heart failure, and renal function. Admission hs-TnT levels were higher in one-year non-survivors compared to survivors (median 747 (quartile 1 to 3, 206 to 1061) ng/L versus 345 (184 to 740) ng/L, P =0.023) and in patients with a poor versus a favorable neurological outcome (739 (191 to 1061) ng/L versus 334 (195 to 716) ng/L, P =0.028). However, hs-TnT measurements did not add prognostic information to established risk variables in multivariate analyses. hs-TnT levels measured during the hospitalization for OHCA-VF/VT correlated closely with admission levels (r ≥0.63) and were inferior to Simplified Acute Physiology Score II (SAPS II) scores for the prediction of events during follow-up. hs-TnT dynamics did not discriminate between survivors and non-survivors or between a poor versus a favorable neurological outcome.</AbstractText>hs-TnT levels are elevated in critically ill patients with OHCA-VF/VT, but do not improve risk prediction.</AbstractText> |
11,192 | Atrial fibrillation induced by commotio cordis secondary to a blunt chest trauma in a teenage boy. | Low-energy blunt chest trauma can cause commotio cordis and ventricular fibrillation (VF) in otherwise healthy young individuals. If the chest wall impact occurs during a narrow vulnerable window of ventricular repolarization, the generated premature ventricular impulse can lead to VF and sudden death. Atrial fibrillation (AF) in association with a blunt chest trauma has not yet been reported in a child or adolescent. Our case describes a healthy 16-year-old boy who suffered blunt chest trauma during football practice. He was found to have AF, which resolved in 3 days without any therapy. He did not have any identifiable structural or electrical cardiac abnormality and had no previous history of arrhythmia. We hypothesize that AF, similar to commotio cordis-induced VF, may occur as a result of a blunt chest trauma in healthy young individuals. Animal studies evaluating arrhythmias related to chest wall impact may elucidate the timing and mechanism of AF induced by commotio cordis. |
11,193 | Patient discomfort following catheter ablation and rhythm device surgery. | Proper management of post-interventional pain relieves unwarranted patient distress and enhances patient satisfaction. There have been only a limited number of investigations into patient discomfort following electrophysiological interventions. This study aims to quantify pain after interventional procedures, including ablation of atrial fibrillation (AF) or ventricular tachycardia (VT), as well as implant or explant of pacemakers or implantable cardioverter defibrillators.</AbstractText>One-hundred and two consecutive patients (mean age 66 years, 70 men) were asked to quantify post-interventional pain on a numeric rating scale (NRS 0-10) every 2 h during a period of 24 h after their intervention (49 ablations in deep propofol sedation, 53 device surgeries in local anaesthesia with mepivacaine 1%) and to specify the type of pain. Pain was classified as moderate to severe in case of NRS > 3. Post-operative pain medication included non-opioid and opioid analgesics as per the treating physicians' discretion. Sixty-one patients (60%) suffered from moderate-to-severe pain within the first 24 h after the procedure, despite the use of analgesics in 47 patients (46%). Pain was present in an early period (0-6 h) in 54% and in a late period (8-24 h) in 40% of patients. Patients complained of back pain (44%), pain at the site of the device pocket (39%), pain at the groin after puncture (7%), and pericarditic pain (5%). Multivariate analysis identified female gender (P = 0.046) associated with early post-interventional pain while age, diabetes mellitus, body mass index, type of intervention, and procedure time were not related to early or late post-interventional pain.</AbstractText>The findings highlight the high prevalence and the poor predictability of moderate-to-severe post-interventional pain within the first 24 h after catheter ablation and cardiac device surgery procedures, despite the use of peri-interventional analgesics. These findings highlight the need for more careful pain assessment and management programmes.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.</CopyrightInformation> |
11,194 | Preexisting atrial fibrillation and cardiac complications after liver transplantation. | Atrial fibrillation (AF) is the most common cardiac arrhythmia, and it is associated with increased cardiovascular morbidity and all-cause mortality. Our aim was to determine the impact of preexisting AF on patients undergoing liver transplantation (LT). A retrospective case-control study was performed. Records from patients who underwent LT between January 2005 and December 2008 at Mayo Clinic Florida were reviewed. Patients with preexisting AF were identified and matched to patients who did not have a diagnosis of AF. Thirty-two of 717 LT recipients (4.5%) had AF before LT. These patients were compared to a control group of 63 LT recipients. Pre-LT left ventricular hypertrophy (P = 0.03), a history of congestive heart failure (P = 0.04), and a history of stroke or transient ischemic attack (P = 0.03) were significantly more prevalent in patients with AF versus controls. Intraoperative adverse cardiac events (P = 0.02) and AF-related adverse postoperative events (P < 0.001) were more common in the recipients with known AF. Six patients with paroxysmal AF (19%) developed chronic/persistent AF postoperatively. Graft survival and patient survival were similar in the groups. Although patients with AF had a higher incidence of intraoperative cardiac events, a higher cardiovascular morbidity rate, and a complicated postoperative course, this did not affect overall graft and patient survival. |
11,195 | The ventricular fibrillation waveform approach to direct postshock chest compressions in a swine model of VF arrest. | In retrospective swine and human investigations of ventricular fibrillation (VF) cardiac arrest, the amplitude-spectral area (AMSA), determined from the VF waveform, can predict defibrillation and a return of spontaneous circulation (ROSC).</AbstractText>We hypothesized that an algorithm using AMSA in real time to direct postshock chest compression (CC) duration would shorten the time to ROSC and improve neurological outcome in a swine model of VF cardiac arrest with acute myocardial infarction (AMI) or nonischemic myocardium.</AbstractText>AMI was induced by occlusion of the left anterior descending artery. VF was untreated for 10 min. Animals were randomized to either traditional resuscitation with 2 min of CC after each shock or to an AMSA-guided algorithm where postshock CCs were shortened to 1 min if the preshock AMSA exceeded 20 mV-Hz.</AbstractText>A total of 48 animals were studied, 12 in each group (AMI vs. normal, and traditional vs. AMSA-guided). There was a nonsignificant shorter time to ROSC with an AMSA-guided approach in AMI swine (17.2 ± 3.4 vs. 18.5 ± 4.7 min, p = NS), and in normal swine (13.5 ± 1.1 vs. 14.4 ± 1.2, p = NS). Neurological outcome was similar between traditional and AMSA-guided animals. AMSA predicted ROSC (p < 0.001), and a threshold of 20 mV-Hz gave a sensitivity of 89%, with specificity of 29%.</AbstractText>Although AMSA predicts ROSC in a swine model of VF arrest in both AMI and normal swine, a waveform-guided approach that uses AMSA to direct postshock CC duration does not significantly shorten the time to ROSC or alter neurological outcome.</AbstractText>Copyright © 2015 Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,196 | Cardiac resynchronisation therapy in patients with atrioventricular nodal disease and reduced ejection fraction - can we afford it? | Recent pacing guidelines from the European Society of Cardiology recommend cardiac resynchronisation therapy (CRT) in patients with an atrioventricular (AV) nodal pacing indication and reduced ejection fraction (EF). However, concerns over added expenditure may limit its widespread implementation. We investigate the potential incremental cost of biventricular over right ventricular pacing if such a practice was adopted.</AbstractText>Retrospective analysis was performed of devices implanted over eight years. The database was analysed for device type, pacing indication and EF. Cost analysis was performed.</AbstractText>1751 devices were implanted over eight years at an averaged cost of AUD$1,369,125 per year. 172 with CRT were excluded. 25.4 (11.6%) patients per year had an EF≤50% and AV nodal disease. 18.4 were in sinus rhythm (SR) and 7.0 in atrial fibrillation (AF). Of these, 13.5 (6.2%) had EF≤45% (9.9 SR, 3.6 AF) and 8.2 (3.8%) had EF≤35% (5.6 SR, 2.6 AF). Based on an incremental cost of $4,000 per device, if all patients with EF≤50% received CRT, the total cost increment per year equates to $73,500 for SR patients or $101,500 if AF patients were included. In patients with EF≤35% and EF≤45%, this amounts to $22,500 and $39,500 per year for SR patients respectively or $33,000 and $54,000 per year if AF patients were included. Depending on the EF and rhythm, this represents a 1.6% to 7.4% increase per year in the pacing budget for an increased patient population of between 2.6% (EF≤35% in SR) to 11.6% (EF≤50%).</AbstractText>A small proportion of additional patients will qualify for CRT based on the chosen cut-off and rhythm. Although the individual incremental cost for biventricular over right ventricular pacing is high in patients with AV nodal disease and reduced EF, overall this represents at most, a modest increase in the total pacing budget.</AbstractText>Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
11,197 | Atrial Fibrillation and <i>SCN5A</i> Variants. | Although atrial fibrillation (AF) is clinically and genetically a highly heterogeneous disease, recent studies suggest that the arrhythmia may arise because of interactions between genetic and acquired risk factors - the so called "double-hit" hypothesis. Genome-wide association studies have identified common AF susceptibility loci, and linkage analysis and candidate gene approaches have identified mutations in genes that encode for cardiac ion channels and signaling proteins; however, most of the heritability of AF still remains unexplained. The voltage-dependent cardiac sodium channel, encoded by <i>SCN5A</i>, conducts the main cardiac inward sodium current (I<sub>Na</sub>) and is responsible for the upstroke of the atrial action potential. Mutations in <i>SCN5A</i>, which encodes the α-subunit of the Na<sub>V</sub>1.5 channel, have been linked with increased susceptibility to not only AF but also ventricular arrhythmias (long QT syndrome, Brugada syndrome), progressive cardiac conduction disease, and overlap syndromes with mixed arrhythmia phenotypes. Over the last decade, functional characterization of <i>SCN5A</i> mutations by expressing the channel in heterologous expression systems and applying cellular electrophysiological techniques has not only advanced our understanding of molecular mechanisms of AF but also potentially identified a mechanism-based approach to treating this common and morbid condition. |
11,198 | Effectiveness of atrial antitachycardia pacing in the treatment of paroxysmal atrial fibrillation in patients with pacemakers. | The aim of this study was to assess the effectiveness of atrial antitachycardia pacing (ATP) in the conversion of atrial tachyarrhythmia episodes, and its impact in reducing arrhythmic burden.</AbstractText>We performed a retrospective study in the pacing laboratory of a district hospital of 57 consecutive patients implanted with a dual chamber pacemaker, capable of performing atrial antitachycardia pacing, between 2005 and 2010. The patients were divided into two groups: ATP_ON (n=24) and ATP_OFF (n=33). The follow-up period was 15 months, with data being collected at three follow-up consultations: the first at three months after implantation, the second at nine months and the last at 15 months. In this period, there were 12 428 ATP therapies of atrial tachyarrhythmias.</AbstractText>Although there were no statistically significant differences, there was a trend in favor of the ATP_ON group, the increase in arrhythmic burden being less marked in this group. The mean percentage of ventricular apical pacing was also significantly lower in this group, which was associated with a marginally significant reduction in arrhythmic burden (p=0.06). There was a significant positive correlation between changes in the percentage of ventricular pacing and changes in arrhythmic burden (r=0.417, p=0.02).</AbstractText>Atrial antitachycardia pacing converted 59.7% of episodes of atrial arrhythmia, but did not significantly reduce arrhythmic burden. There was a significant positive correlation between changes in the percentage of ventricular pacing and changes in arrhythmic burden.</AbstractText>Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.</CopyrightInformation> |
11,199 | Characteristics and outcomes of patients with advanced chronic systolic heart failure receiving care at the Veterans Affairs versus other hospitals: insights from the Beta-blocker Evaluation of Survival Trial (BEST). | Characteristics and outcomes of patients with heart failure and reduced ejection fraction receiving care at Veterans Affairs (VA) versus non-VA hospitals have not been previously reported.</AbstractText>In the randomized controlled Beta-blocker Evaluation of Survival Trial (BEST; 1995-1999), of the 2707 (bucindolol=1353; placebo=1354) patients with heart failure and left ventricular ejection fraction ≤35%, 918 received care at VA hospitals, of which 98% (n=898) were male. Of the 1789 receiving care at non-VA hospitals, 68% (n=1216) were male. Our analyses were restricted to these 2114 male patients. VA patients were older with higher symptom and comorbidity burdens. There was no significant between-group difference in unadjusted primary end point of 2-year all-cause mortality (35% VA versus 32% non-VA; hazard ratio associated with VA hospitals, 1.09; 95% confidence interval, 0.94-1.26), which remained unchanged after adjustment for age and race (hazard ratio, 1.00; 95% confidence interval, 0.86-1.16) or multivariable adjustment, including cardiovascular morbidities (hazard ratio, 0.94; 95% confidence interval, 0.80-1.10). There was no between-group difference in cause-specific mortalities or hospitalizations. Chronic kidney disease, pulmonary edema, left ventricular ejection fraction <20%, and peripheral arterial disease were significant predictors of mortality for both groups. African America race, New York Heart Association class IV symptoms, atrial fibrillation, and right ventricular ejection fraction <20% were associated with higher mortality among non-VA hospital patients only; however, these differences from VA patients were not significant.</AbstractText>Patients with heart failure and reduced ejection fraction receiving care at VA hospitals were older and sicker; yet their risk of mortality and hospitalization was similar to younger and healthier patients receiving care at non-VA hospitals.</AbstractText>http://www.clinicaltrials.gov. Unique identifier: NCT00000560.</AbstractText>© 2014 American Heart Association, Inc.</CopyrightInformation> |
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