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11,400 | Systematic downloading and analysis of data from automated external defibrillators used in out-of-hospital cardiac arrest. | Valuable information can be retrieved from automated external defibrillators (AEDs) used in victims of out-of-hospital cardiac arrest (OHCA). We describe our experience with systematic downloading of data from deployed AEDs. The primary aim was to compare the proportion of shockable rhythm from AEDs used by laypersons with the corresponding proportion recorded by the Emergency Medical Services (EMS) on arrival.</AbstractText>In a 20-month study, we collected data on OHCAs in the Capital Region of Denmark where an AED was deployed prior to arrival of EMS. The AEDs were brought to the emergency medical dispatch centre for data downloading and rhythm analysis. Patient data were retrieved from the medical records from the admitting hospital, whereas data on EMS rhythm analyses were obtained from the Danish Cardiac Arrest Register between 2001 and 2010.</AbstractText>A total of 121 AEDs were deployed, of which 91 cases were OHCAs with presumed cardiac origin. The prevalence of initial shockable rhythm was 55.0% (95% CI [44.7-64.8%]). This was significantly greater than the proportion recorded by the EMS (27.6%, 95% CI [27.0-28.3%], p<0.0001). Shockable arrests were significantly more likely to be witnessed (92% vs. 34%, p<0.0001) and the bystander CPR rate was higher (98% vs. 85%, p=0.04). More patients with initial shockable rhythm achieved return of spontaneous circulation upon hospital arrival (88% vs. 7%, p<0.0001) and had higher 30-day survival rate (72% vs. 5%, p<0.0001).</AbstractText>AEDs used by laypersons revealed a higher proportion of shockable rhythms compared to the EMS rhythm analyses.</AbstractText>Copyright © 2014 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.</CopyrightInformation> |
11,401 | Comparative persistence on β-blockers versus calcium channel blockers for ventricular rate control in nonelderly patients with atrial fibrillation. | For patients with atrial fibrillation (AF), early treatment is essential to prevent serious complications such as stroke. Several randomized clinical trials have shown that rate-control may be as effective as rhythm-control medications, whereas the latter have serious side effects. Little evidence exists, however, about which class of rate-control medication-β-blockers (BBs) or calcium channel blockers (CCBs)-may be superior.</AbstractText>The objective was to compare the long-term persistence on BBs versus CCBs in nonelderly adult patients with AF.</AbstractText>A longitudinal retrospective cohort study for patients 40 to 60 years old with newly diagnosed AF (identified by ICD-9 code 427.31) was performed using data from Ohio Medicaid physician, institutional, and pharmacy claims from January 2006 through June 2011. A Cox proportional hazard regression, with time to change out of rate-control therapy as the dependent variable, was estimated to compare persistence on (proxy for effectiveness of) rate-control medication across drug classes. A propensity-score analysis was used to control for selection bias. Additional covariates included age, development of heart failure, and medication adherence.</AbstractText>Out of 1239 patients included in the cohort, 1016 received a BB; 223 received a CCB. Over time, patients on CCBs were significantly more likely to switch out of rate-control therapy (hazard ratio = 1.89; 95% CI = 1.14-3.09) than patients on BBs.</AbstractText>Evidence suggests that nonelderly AF patients, when prescribed rate-control therapy, persist longer on BBs than CCBs. Because this is the first long-term study comparing the 2 drug classes in the nonelderly population, further research is suggested.</AbstractText>© The Author(s) 2014.</CopyrightInformation> |
11,402 | Spanish Catheter Ablation Registry. 13th Official Report of the Spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2013). | This report presents the results of the 2013 Spanish Catheter Ablation Registry.</AbstractText>Data were collected using 2 systems: retrospectively by completing a dedicated form and prospectively by reporting to a central database. Each participating center chose 1 of the 2 data collection methods.</AbstractText>Eighty centers voluntarily contributed data to the registry. A total of 11 987 ablation procedures were performed, with a mean (standard deviation) of 149 (105) procedures per center. The 3 main arrhythmic substrates treated were atrioventricular nodal reentrant tachycardia (n=2959; 24.6%), cavotricuspid isthmus ablation (n=2700; 22.5%), and atrial fibrillation (n=2201; 18.4%). The number of ventricular ablation procedures was similar to the 2012 activity, but there was a slight increase in procedures for scar-related postmyocardial infarction ventricular tachycardia. The success rate was 94.4%, major complications occurred in 1.8%, and the mortality rate was 0.03%.</AbstractText>In line with previous reports, the data from the 2013 registry show a continuing increase in the number of ablations performed. Overall, there was a high success rate and few complications. Ablation of complex substrates has continued to increase.</AbstractText>Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.</CopyrightInformation> |
11,403 | Clinical features, risk factors, and treatment experience: a review of 74 patients with ST-segment elevation myocardial infarction complicated by ventricular fibrillation. | Ventricular fibrillation (VF) is one of the most serious complications of acute myocardial infarction, with a high mortality rate. There is a lack of value of rescue thrombolysis in ST-segment elevation myocardial infarction (STEMI) complicated by VF.</AbstractText>To examine the relationship between risk factors and mortality, and assess the value of rescue thrombolysis in STEMI complicated by VF.</AbstractText>A total 74 cases of STEMI complicated by VF were enrolled. The experimental group consisted of 26 patients who underwent rescue thrombolysis, and the control group included 48 cases without rescue thrombolysis. The two groups were compared in terms of demographic and clinical features including gender, age, onset time, blood pressure, patient's history, creatine kinase-MB, infarct area, complications, therapy, and outcomes, including mortality.</AbstractText>The mortality rate of the experimental group was 15.38%, lower than 37.50% of the control group (p < 0.05). The bleeding rate was 34.62% (n = 9) in the experimental group. The risk factors of smoking, shock, and rescue thrombolysis were correlated with mortality of STEMI complicated by VF (p < 0.05 for all): Smoking and shock both were positively correlated with mortality, their regression coefficients/odds ratios (OR) were, respectively, 4606/100,041 and 5552/247,711; the rescue thrombolysis was negatively correlated with mortality, its regression coefficient/OR was -1942/0.143.</AbstractText>Rescue thrombolysis combined with cardiopulmonary resuscitation and defibrillation is beneficial to patients with STEMI complicated by VF. Smoking, shock upon admission, and lack of rescue thrombolysis were risk factors for mortality in STEMI complicated by VF.</AbstractText>Copyright © 2014 Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,404 | Left atrial passive emptying function is preserved in patients with permanent atrial fibrillation--a 320-slice multidetector computed tomography study. | Left atrial (LA) mechanical function is thought to be virtually inexistent in patients with permanent atrial fibrillation (AF). Due to recent advances in multidetector computed tomography (MDCT) technology, it is now possible to acquire images of the entire heart in a single heartbeat. The objective of this study was to compare individual components of LA function assessed by MDCT in patients with permanent AF and patients in sinus rhythm (SR).</AbstractText>320-slice MDCT was performed in 30 patients with permanent AF. Measurements of LA volumes during the cardiac cycle were compared to 30 patients in SR, who were matched with respect to age, sex, left ventricular ejection fraction and body surface area.</AbstractText>LA volumes were significantly larger in patients with AF than SR patients at all times during the cardiac cycle (LA maximal volume; 82 vs. 55 ml/m(2), p < 0.0001, LA minimal volume; 71 vs. 30 ml/m(2), p < 0.0001). However, except for the absence of active LA emptying, the overall trend of the LA time-volume curve was similar in patients with AF and SR.</AbstractText>Compared to SR patients, patients with permanent AF have significantly increased LA volumes throughout the cardiac cycle. Yet, a residual hemodynamic role of LA function may be maintained during permanent AF.</AbstractText>© 2014 S. Karger AG, Basel.</CopyrightInformation> |
11,405 | Effects of different LAD-blocked sites on the development of acute myocardial infarction and malignant arrhythmia in a swine model. | To explore the effects of various left anterior descending (LAD) artery-blocked sites on the development of acute myocardial infarction (AMI) and malignant arrhythmia in a swine model.</AbstractText>Twenty-two pigs underwent occlusion of the coronary artery with balloon angioplasty were randomly divided into three groups according to the blocked site of the balloon: middle-site-blocked LAD group, bottom-third-blocked LAD group and control group. Then, the development of AMI and malignant arrhythmia, including ventricular tachycardia and ventricular fibrillation during the process of model creation, were recorded. Changes of the hemodynamics, blood gas analysis, electrocardiography, and myocardial enzymes were analyzed in each group before and after occlusion.</AbstractText>Middle-site-LAD blockage resulted in a larger infarction size and the corresponding incidence of ventricular fibrillation was significantly higher than that of the bottom-third-blocked group (P<0.05). After the occlusion, the QTc interval of the Middle-site-blocked LAD group was significantly longer than that in the other groups (P<0.01). Moreover, mean arterial blood pressure (MAP), left ventricular ejection fraction (LVEF), and partial pressure of oxygen (PaO2) were significantly lower, but partial pressure of carbon dioxide (PaCO2) increased, in the Middle-site-blocked-LAD group compared with that in the bottom-third-blocked group (P<0.01). Compared with the control group, the two LAD-blocked groups showed significantly higher levels of Mb, CK-MB, LDH, AST and cTnT (P<0.01) four hours after the artery occlusion. However, these indexes were not significantly different between the two LAD-blocked groups (P>0.05).</AbstractText>Location of LAD blockages in swine models may affect the development of AMI and malignant arrhythmia.</AbstractText> |
11,406 | Short-term ECG recordings for heart rate assessment in patients with chronic atrial fibrillation. | There is no consensus on the length of ECG tracing that should be recorded to represent adequate rate control in patients with atrial fibrillation (AFib). The purpose of the study was to examine whether heart rate measurements based on short-term ECGs recorded at different periods of the day may correspond to the mean heart rate and rate irregularity analyzed from standard 24-hour Holter monitoring.</AbstractText>The study enrolled 50 consecutive patients with chronic AFib who underwent 24-hour Holter monitoring. Mean heart rate (mHR) and the coefficient of irregularity (CI) were assessed from 5- and 60-minute intervals of Holter recordings in different periods of the day.</AbstractText>The highest correlation in mean heart rate interval within 24 h was found during a 6-hour sample and in the periods 11.00 AM-12.00 PM, 12 PM-1.00 PM, and 1.00 PM-2.00 PM. With respect to irregularity, only the CI measurements based on a 6-hour interval (7.00 AM-1.00 AM) show a correlation > 0.08 compared to data from the 24-hour recording.</AbstractText>Only long-term (6-hour) recordings provide a high correlation within 24 h in mean heart rate interval and coefficient of irregularity. It seems that the mean heart rate interval in 1-hour periods between 11 AM and 2 PM might be predictive for 24-hour data. Short time recordings of the coefficient of irregularity of heart rate in AFib patients at this moment are not useful in clinical practice for long-term prognosis of ventricular irregularity.</AbstractText> |
11,407 | Prediction of atrial fibrillation recurrence after cardioversion in patients with left-atrial dilation. | Little is known about the impact of left-ventricular (LV) diastolic dysfunction on risk of atrial fibrillation (AF) recurrence in patients with left-atrial (LA) dilation. To evaluate, in patients with symptomatic persistent AF and LA dilation, the incremental role of LV diastolic dysfunction in predicting early AF recurrence after cardioversion (CV).</AbstractText>From July 2011 to July 2013, 175 patients with persistent AF referred to our centre for CV were screened. Inclusion criteria were: European Heart Rhythm Association (EHRA) class ≥2 despite optimal medical treatment and heart rate at rest ≤80 bpm, LA volume ≥34 mL/m(2), EF > 35%, absence of untreated ischaemic disease and significant valvular disease, successful CV. Finally, 127 patients (age 64 ± 10 years, 60% EHRA ≥3, LA volume 42 ± 15 mL/m(2)) were enrolled. At 3 months, 37 (29%) patients presented AF recurrence. At univariate analysis, AF duration >90 days before CV (P < 0.01), septal e' <8 cm/s (P 0.03), and septal E/e' ratio ≥11 (P < 0.001) but no LA dimensions significantly correlated with AF recurrence. Logistic regression analysis confirmed septal E/e' ratio ≥11 as the best predictor of recurrence (OR 3.25 95% CI 1.19-8.86 P 0.001) together with an AF duration >90 days before the CV (OR 2.69 95% CI 1.01-7.53 P 0.04). At ROC curve analysis, the septal E/e' ratio ≥11 showed the best diagnostic accuracy (AUC 0.66, 95% CI 0.55-0.76, P 0.007).</AbstractText>In this population with symptomatic persistent AF and LA enlargement, septal E/e' ratio ≥11 and AF duration >90 days predicted AF recurrence at 3 months.</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> |
11,408 | Calcium-activated potassium current modulates ventricular repolarization in chronic heart failure. | The role of I(KCa) in cardiac repolarization remains controversial and varies across species. The relevance of the current as a therapeutic target is therefore undefined. We examined the cellular electrophysiologic effects of I(KCa) blockade in controls, chronic heart failure (HF) and HF with sustained atrial fibrillation. We used perforated patch action potential recordings to maintain intrinsic calcium cycling. The I(KCa) blocker (apamin 100 nM) was used to examine the role of the current in atrial and ventricular myocytes. A canine tachypacing induced model of HF (1 and 4 months, n = 5 per group) was used, and compared to a group of 4 month HF with 6 weeks of superimposed atrial fibrillation (n = 7). A group of age-matched canine controls were used (n = 8). Human atrial and ventricular myocytes were isolated from explanted end-stage failing hearts which were obtained from transplant recipients, and studied in parallel. Atrial myocyte action potentials were unchanged by I(KCa) blockade in all of the groups studied. I(KCa) blockade did not affect ventricular myocyte repolarization in controls. HF caused prolongation of ventricular myocyte action potential repolarization. I(KCa) blockade caused further prolongation of ventricular repolarization in HF and also caused repolarization instability and early afterdepolarizations. SK2 and SK3 expression in the atria and SK3 in the ventricle were increased in canine heart failure. We conclude that during HF, I(KCa) blockade in ventricular myocytes results in cellular arrhythmias. Furthermore, our data suggest an important role for I(KCa) in the maintenance of ventricular repolarization stability during chronic heart failure. Our findings suggest that novel antiarrhythmic therapies should have safety and efficacy evaluated in both atria and ventricles. |
11,409 | Effect of different resuscitation strategies on post-resuscitation brain damage in a porcine model of prolonged cardiac arrest. | The choice of a defibrillation or a cardiopulmonary resuscitation (CPR)-first strategy in the treatment of prolonged cardiac arrest (CA) is still controversial. The purpose of this study was to compare the effects of defibrillation or CPR administered first on neurological prognostic markers in a porcine model of prolonged CA.</AbstractText>After 8 minutes of untreated ventricular fibrillation (VF), 24 inbred Chinese Wuzhishan minipigs were randomized to receive either defibrillation first (ID group, n = 12) or chest compression first (IC group, n = 12). In the ID group, a shock was delivered immediately. If defibrillation failed to attain restoration of spontaneous circulation (ROSC), manual chest compressions were rapidly initiated at a rate of 100 compressions/min and a compression-to-ventilation ratio of 30:2. If VF persisted after five cycles of CPR, a second defibrillation attempt was made. In the IC group, chest compressions were delivered first, followed by a shock. After successful ROSC, hemodynamic status and blood samples were obtained at 0.5, 1, 2, 4, 6, and 24 hours after ROSC. Porcine-specific neuron-specific enolase (NSE) and S100B were measured from sera using enzyme-linked immunosorbent assays. Porcine cerebral performance category scores were used to evaluate preliminary neurological function following 24 hours recovery. Surviving pigs were sacrificed at 24 hours after ROSC and brains were removed for electron microscopy analysis.</AbstractText>The number of shocks, total defibrillation energy, and time to ROSC were significantly lower in the ID group compared with the IC group. Compared with the IC group, S100B expression was decreased at 2 and 4 hours after ROSC, and NSE expression decreased at 6 and 24 hours after ROSC in the ID group. Brain tissue analysis showed that injury was attenuated in the ID group compared with the IC group. There were no significant differences between 6 and 24 hours survival rates.</AbstractText>Defibrillation first may result in a shorter time to ROSC and lower biochemical markers of brain injury in a porcine model of 8-minute CA due to VF, but the choice of different resuscitation strategies did not affect the rate of ROSC and 24-hour survival.</AbstractText> |
11,410 | [Arrhythmia in patients with chronic heart insufficiency and type 2 diabetes mellitus]. | The aim of the work was to study character, frequency and peculiarities of arrhythmia in patients with chronic heart insufficiency (CHI) depending on its etiology and type 2 diabetes mellitus (DM2).</AbstractText>In-depth clinical observation of 197 patients (mean age 61.3 +/- 0.63 yr, 56-61% men) included EchoCG, 6 min walk test, Holter ECG monitoring. Group 1 was comprised of 74 patients with CHI (NYHA FC II), group of 280 patients with HPI an DM2, group 3 of 50 patients with CD2 (ADA criteria, 2011). The groups were matched for sex, age, severity of disease and complications. Exclusion criteria were acute coronary heart disease, CHI and DM2 decompensation, CHI according to BHOK and OCCH National recommendations (2009).</AbstractText>43.2% of the patients showed ventricular arrhythmia (VA) (p < 0.02), 10.8% had ciliary arrhythmia. Combined arrhythmia (ventricular and supraventricular arrhythmias, hemodynamically significant atrial fibrillation and high-grade ventricular arrhythmias) occurred in 41.2% of the patients having CHI+DM2 62.8% of the DM2 patients had supraventricular arrhythmias.</AbstractText>Hemodynamically and prognostically unfavourable arrhythmias are most frequently diagnosed in the patients with CHI and DM2 due to more pronounced myocardial failure and DM2-associated pathogenetic factors (dysglycemia, cardiac neuropathy, nephropathy).</AbstractText> |
11,411 | Mitochondrial instability during regional ischemia-reperfusion underlies arrhythmias in monolayers of cardiomyocytes. | Regional depolarization of the mitochondrial network can alter cellular electrical excitability and increase the propensity for reentry, in part, through the opening of sarcolemmal KATP channels. Mitochondrial inner membrane potential (ΔΨm) instability or oscillation can be induced in myocytes by exposure to reactive oxygen species (ROS), laser excitation, or glutathione depletion, and is thought to be a major factor in arrhythmogenesis during ischemia-reperfusion. Nevertheless, the correlation between ΔΨm recovery kinetics and reperfusion-induced arrhythmias has been difficult to demonstrate experimentally. Here, we investigate the relationship between subcellular changes in ΔΨm, cellular glutathione redox potential, electrical excitability, and wave propagation during coverslip-induced ischemia-reperfusion (IR) in neonatal rat ventricular myocyte (NRVM) monolayers. Ischemia led to decreased action potential amplitude and duration followed by electrical inexcitability after ~15min of ischemia. ΔΨm depolarization occurred in two phases during ischemia: in phase 1 (<30min ischemia), mitochondrial clusters within individual NRVMs depolarized, while phase 2 ΔΨm depolarization (30-60min) was characterized by global functional collapse of the mitochondrial network across the whole ischemic region of the monolayer, typically involving a propagating metabolic wave. Oxidation of the glutathione (GSSG:GSH) redox potential occurred during ischemia, followed by recovery upon reperfusion (i.e., lifting the coverslip). ΔΨm recovered in the mitochondria of individual myocytes quite rapidly upon reperfusion (<5min), but was highly unstable, characterized by subcellular oscillations or flickering of clusters of mitochondria in NRVMs across the reperfused region. Electrical excitability also recovered in a heterogeneous manner, providing an arrhythmogenic substrate which led to formation of sustained reentry. Treatment with 4'-chlorodiazepam, a peripheral benzodiazepine receptor ligand, prevented ΔΨm oscillation, improved GSH recovery rate, and prevented reentry during reperfusion, indicating that stabilization of mitochondrial network dynamics is important for preventing post-ischemic arrhythmias. This article is part of a Special Issue entitled "Mitochondria: From Basic Mitochondrial Biology to Cardiovascular Disease". |
11,412 | Associations of electrocardiographic P-wave characteristics with left atrial function, and diffuse left ventricular fibrosis defined by cardiac magnetic resonance: The PRIMERI Study. | Abnormal P-terminal force in lead V1 (PTFV1) is associated with an increased risk of heart failure, stroke, atrial fibrillation, and death.</AbstractText>Our goal was to explore associations of left ventricular (LV) diffuse fibrosis with left atrial (LA) function and electrocardiographic (ECG) measures of LA electrical activity.</AbstractText>Patients without atrial fibrillation (n = 91; mean age 59.5 years; 61.5% men; 65.9% white) with structural heart disease (spatial QRS-T angle ≥105° and/or Selvester QRS score ≥5 on ECG) but LV ejection fraction >35% underwent clinical evaluation, cardiac magnetic resonance, and resting ECG. LA function indices were obtained by multimodality tissue tracking using 2- and 4-chamber long-axis images. T1 mapping and late gadolinium enhancement were used to assess diffuse LV fibrosis and presence of scar. P-prime in V1 amplitude (PPaV1) and duration (PPdV1), averaged P-wave-duration, PR interval, and P-wave axis were automatically measured using 12 SLTM algorithm. PTFV1 was calculated as a product of PPaV1 and PPdV1.</AbstractText>In linear regression after adjustment for demographic characteristics, body mass index, maximum LA volume index, presence of scar, and LV mass index, each decile increase in LV interstitial fibrosis was associated with 0.76 mV*ms increase in negative abnormal PTFV1 (95% confidence interval [CI] -1.42 to -0.09; P = .025), 15.3 ms prolongation of PPdV1 (95% CI 6.9 to 23.8; P = .001) and 5.4 ms prolongation of averaged P-duration (95% CI 0.9-10.0; P = .020). LV fibrosis did not affect LA function. PPaV1 and PTFV1 were associated with an increase in LA volumes and decrease in LA emptying fraction and LA reservoir function.</AbstractText>LV interstitial fibrosis is associated with abnormal PTFV1, prolonged PPdV1, and P-duration, but does not affect LA function.</AbstractText>Copyright © 2015 Heart Rhythm Society. All rights reserved.</CopyrightInformation> |
11,413 | Work-up and management of lone atrial fibrillation: results of the European Heart Rhythm Association Survey. | The purpose of this European Heart Rhythm Association (EHRA) survey was to explore the work-up and management of lone atrial fibrillation (AF) among the European centres. Thirty-two European centres, all members of the EHRA electrophysiology (EP) research network, responded to this survey and completed the list of questions. The prevalence of lone AF has been reported to be ≤10% by 19 (60%) of the participating centres. The presence of isolated left atrial enlargement and left ventricular diastolic dysfunction represent heart disease according to 50 and 84% of the centres, respectively, and exclude the diagnosis of lone AF. Fifty-nine per cent of responders do not routinely consider genetic testing in lone AF patients. The initial therapeutic approach in symptomatic paroxysmal lone AF is antiarrhythmic drug therapy as reported by 31 (97%) of the centres. Pulmonary vein isolation only is the first ablation strategy for patients with symptomatic persistent lone AF at 27 (84%) of the responding centres. Assessment for sleep apnoea, obesity, and intensive sports activity in lone AF is performed at 27 (84%) centres. In conclusion, this EP Wire survey confirms that the term 'lone AF' is still used in daily practice. The work-up typically includes screening for known risk factors but not genetic testing. The preferred management of paroxysmal lone AF is rhythm control with antiarrhythmic drugs, whereas pulmonary vein isolation is the first ablation strategy for the majority of patients with symptomatic persistent lone AF. |
11,414 | Ventricular tachyarrhythmia recurrence in primary versus secondary implantable cardioverter-defibrillator patients and role of electrophysiology study. | In recent years, there has been a shift away from performing electrophysiologic study (EPS) to guide implantable cardioverter-defibrillator (ICD) implantation with a reliance on left ventricular ejection fraction (LVEF) alone.</AbstractText>ICD patients were prospectively recruited from the multicentre COMFORT (Concept of Optimal Management of ventricular Fibrillation Or Very fast ventricular Tachycardia) trial. Primary prevention ICD patients (n = 260, groups 1 and 2) were compared to secondary prevention ICD patients (n = 210, group 3). Primary prevention ICDs were implanted in patients with ischemic cardiomyopathy based on LVEF ≤ 40 % and inducible ventricular tachycardia (VT) at EPS (n = 123, group 1) or impaired LVEF alone (LVEF ≤ 30 % or LVEF ≤ 35 % with NYHA class II or III; n = 137, group 2). EPS was performed in 61 % of secondary prevention ICD patients (n = 129). Patients were followed up for >12 months with a primary endpoint of spontaneous VT/ventricular fibrillation (VF).</AbstractText>A significantly higher rate of spontaneous VT/VF occurred in secondary versus primary prevention ICD patients (P < 0.001) and in EPS-guided versus LVEF-guided primary prevention ICD patients (P = 0.029). At 2 years, the proportion of patients with ≥1 VT/VF episode was 24.6 ± 4.2 %, 19.9 ± 4.6 % and 37.1 ± 3.9 % for groups 1, 2 and 3, respectively. In the secondary prevention, patients who underwent EPS, VT/VF occurred in 44.4 ± 5.9 % and 14.1 ± 6.6 % with a positive versus negative result, respectively (P = 0.02).</AbstractText>Secondary prevention ICD patients have more spontaneous VT/VF than primary prevention ICD patients. Secondary and primary prevention ICD patients with inducible VT at EPS have more VT/VF than patients without inducible VT or impaired LVEF alone.</AbstractText> |
11,415 | Magnetic resonance imaging for identifying patients with cardiac sarcoidosis and preserved or mildly reduced left ventricular function at risk of ventricular arrhythmias. | The purpose of this study was to assess whether delayed enhancement (DE) on MRI is associated with ventricular tachycardia (VT)/ventricular fibrillation or death in patients with cardiac sarcoidosis and left ventricular ejection fraction >35%.</AbstractText>Fifty-one patients with cardiac sarcoidosis and left ventricular ejection fraction >35% underwent DE-MRI. DE was assessed by visual scoring and quantified with the full-width at half-maximum method. The patients were followed for 48.0 ± 20.2 months. Twenty-two of 51 patients (63%) had DE. Forty patients had no prior history of VT (primary prevention cohort). Among those, 3 patients developed VT and 2 patients died. DE was associated with risk of VT/ventricular fibrillation or death (P=0.0032 for any DE and P<0.0001 for right ventricular DE). The positive predictive values of the presence of any DE, multifocal DE, and right ventricular DE for death or VT/ventricular fibrillation at mean follow-up of 48 months were 22%, 48%, and 100%, respectively. Among the 11 patients with a history of VT before the MRI, 10 patients had subsequent VTs, 1 of whom died.</AbstractText>RV DE in patients with cardiac sarcoidosis is associated with a risk of adverse events in patients with cardiac sarcoidosis and preserved ejection fraction in the absence of a prior history of VT. Patients with DE and a prior history of VT have a high VT recurrence rate. Patients without DE on MRI have a low risk of VT.</AbstractText>© 2014 American Heart Association, Inc.</CopyrightInformation> |
11,416 | Off-pump versus on-pump coronary artery bypass surgery in patients with triple-vessel disease and enlarged ventricles. | Off-pump coronary artery bypass grafting (OPCAB) is a popular treatment for patients with ischemic heart disease, especially for high-risk patients. However, whether OPCAB can lead to better clinical outcomes than on-pump coronary artery bypass grafting (ONCAB) in patients with enlarged ventricles remains controversial. This prospective randomized study was designed to characterize comparison of early clinical outcome and mid-term follow-up following ONCAB versus OPCAB in patients with triple-vessel disease and enlarged ventricles.</AbstractText>Prospective randomized trial of patients treated at The First Affiliated Hospital, China Medical University, over a 3-year period (2007-2010).</AbstractText>A total of 102 patients with triple-vessel disease and enlarged ventricles (end-diastolic dimension >=6.0 cm) were randomized to OPCAB or ONCAB between July 2007 and December 2010. The in-hospital out.comes were analyzed. The study included a mid-term follow-up, with a mean follow-up time of 49.40 (12.88 months).</AbstractText>No significant differences were recorded in the baseline clinical characteristics of ONCAB and OPCAB groups. A statistical difference was found between the two groups at the time of extubation, intensive care unit stay, hospital stay, blood requirements, incidence of intra-aortic balloon pump support, pulmonary complications, stroke, reoperation for bleeding, and inotropic requirements > 24 hours (P < .05). The number of anastomoses performed per patient, the incidence of postoperative ventricular arrhythmia, myocardial infarction, new-onset atrial fibrillation, hemodialysis, infective complications, recurrent angina, and percutaneous reintervention were similar between the 2 groups (P > .05). The left ventricular end-diastolic dimension was significantly smaller at 6 months' follow-up in the 2 groups than it was before operation ( < .05). No differences in hospital mortality and mid-term mortality between OPCAB and ONCAB groups were found. During the follow-up, no patient in either group had undergone repeat coronary artery bypass grafting.</AbstractText>No differences in early and mid-term mortality were found between OPCAB and ONCAB in patients with triple-vessel disease and enlarged ventricles. However, OPCAB seems to have a beneficial effect on postoperative complications.</AbstractText> |
11,417 | Hemodynamic improvement of a LUCAS 2 automated device by addition of an impedance threshold device in a pig model of cardiac arrest. | The combination of the LUCAS 2 (L-CPR) automated CPR device and an impedance threshold device (ITD) has been widely implemented in the clinical field. This animal study tested the hypothesis that the addition of an ITD on L-CPR would enhance cerebral and coronary perfusion pressures.</AbstractText>Ten female pigs (39.0 ± 2.0 kg) were sedated, intubated, anesthetized with isofluorane, and paralyzed with succinylcholine (93.3 μg/kg/min) to inhibit the potential confounding effect of gasping. After 4 min of untreated ventricular fibrillation, 4 min of L-CPR+an active ITD or L-CPR+a sham ITD was initiated and followed by another 4 min of the alternative method of CPR. Systolic blood pressure (SBP), diastolic blood pressure (DBP), diastolic right atrial pressure (RAP), intracranial pressure (ICP), airway pressure, and end tidal CO2 (ETCO2) were recorded continuously. Data expressed as mean mmHg ± SD.</AbstractText>Decompression phase airway pressure was significantly lower with L-CPR+active ITD versus L-CPR+sham ITD (-5.3 ± 2.2 vs. -0.5 ± 0.6; p<0.001). L-CPR+active ITD treatment resulted in significantly improved hemodynamics versus L-CPR+sham ITD: ETCO2, 35 ± 6 vs. 29 ± 7 (p=0.015); SBP, 99 ± 9 vs. 93 ± 15 (p=0.050); DBP, 24 ± 12 vs. 19 ± 15 (p=0.006); coronary perfusion pressure, 29 ± 8 vs. 26 ± 7 (p=0.004) and cerebral perfusion pressure, 24 ± 13 vs. 21 ± 12 (p=0.028).</AbstractText>In pigs undergoing L-CPR the addition of the active ITD significantly reduced intrathoracic pressure and increased vital organ perfusion pressures.</AbstractText>Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,418 | Ablation of the epicardial substrate in the right ventricular outflow tract in a patient with Brugada syndrome refusing implantable cardioverter defibrillator therapy. | Brugada syndrome is associated with a high risk of sudden cardiac death. Currently, the cornerstone of therapy is implantation of an implantable cardioverter defibrillator (ICD). Recently, a novel approach to preventively ablate the substrate located in the anterior epicardial region of the right ventricular outflow tract showed promising results by reducing the number of ventricular fibrillation episodes in patients with ICD. Here we report on a patient with Brugada syndrome who refused ICD therapy in whom a successful epicardial right ventricular outflow tract substrate ablation was performed. In some special cases, ablation therapy might be considered as the sole therapeutic option for these patients. |
11,419 | Does digoxin increase the risk of ischemic stroke and mortality in atrial fibrillation? A nationwide population-based cohort study. | Digoxin and related cardiac glycosides have been used for almost 100 years in atrial fibrillation (AF). However, 2 recent analyses of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) trial showed inconsistent results regarding the risk of mortality associated with digoxin use. The goal of the present study was to investigate the relationship between digoxin and the risk of ischemic stroke and mortality in Asians.</AbstractText>This study used the National Health Insurance Research Database (NHIRD) in Taiwan. A total of 4781 patients with AF who did not receive any antithrombotic therapy were selected as the study population. Among the study population, 829 participants (17.3%) received the digoxin treatment. The risk of ischemic stroke and mortality in patients who received digoxin and those who did not was compared.</AbstractText>The use of digoxin was associated with an increased risk of clinical events, with an adjusted hazard ratio of 1.41 (95% confidence interval [CI], 1.17-1.70) for ischemic stroke and 1.21 (95% CI, 1.01-1.44) for all-cause mortality. In the subgroup analysis based on coexistence with heart failure or not, digoxin was a risk factor for adverse events in patients without heart failure but not in those with heart failure (interaction P < 0.001 for either end point). Among patients with AF without heart failure, the use of β-blockers was associated with better survival, with an adjusted hazard ratio of 0.48 (95% CI, 0.34-0.68).</AbstractText>Digoxin should be avoided for patients with AF without heart failure because it was associated with an increased risk of clinical events. β-Blockers may be a better choice for controlling ventricular rate in these patients.</AbstractText>Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,420 | Atrial fibrillation and its association with sudden cardiac death. | Evidence is emerging to indicate that atrial fibrillation (AF) is independently associated with an increased risk of sudden cardiac death (SCD). This association has been consistently observed in specific patient subgroups such as patients with myocardial infarction (MI), heart failure, and hypertension, and importantly, in the general population. Data from studies of implantable cardioverter-defibrillator recipients suggest that the rapid and irregular rhythm of AF and the short-long-short cycles that are highly prevalent in AF increase susceptibility to ventricular tachycardia and ventricular fibrillation. An alternative explanation for the association between AF and SCD includes confounding or mediation by shared risk factors such as coronary artery disease and heart failure. Possible risk factors for SCD in patients with AF include black race, left ventricular hypertrophy, history of MI, and diabetes. Additional research is needed to confirm the inherent proarrhythmic nature of AF, identify patients' characteristics or clinical conditions that potentiate SCD risk, and define effective SCD prevention strategies for patients with AF. (Circ J 2014; 78: 2588-2593). |
11,421 | Catheter ablation of atrial fibrillation in patients with left ventricular systolic dysfunction: a systematic review and meta-analysis. | Catheter ablation of atrial fibrillation (AFCA) is an established therapeutic option for rhythm control in symptomatic patients. Its efficacy and safety among patients with left ventricular systolic dysfunction is based on small populations, and data concerning long-term outcome are limited. We performed this meta-analysis to assess safety and long-term outcome of AFCA in patients with left ventricular systolic dysfunction, to evaluate predictors of recurrence and impact on left ventricular function.</AbstractText>A systematic review was conducted in MEDLINE/PubMed and Cochrane Library. Randomized controlled trials, clinical trials, and observational studies including patients with left ventricular systolic dysfunction undergoing AFCA were included. Twenty-six studies were selected, including 1838 patients. Mean follow-up was 23 (95% confidence interval, 18-40) months. Overall complication rate was 4.2% (3.6%-4.8%). Efficacy in maintaining sinus rhythm at follow-up end was 60% (54%-67%). Meta-regression analysis revealed that time since first atrial fibrillation (P=0.030) and heart failure (P=0.045) diagnosis related to higher, whereas absence of known structural heart disease (P=0.003) to lower incidence of atrial fibrillation recurrences. Left ventricular ejection fraction improved significantly during follow-up by 13% (P<0.001), with a significant reduction of patients presenting an ejection fraction <35% (P<0.001). N-terminal pro-brain natriuretic peptide blood levels decreased by 620 pg/mL (P<0.001).</AbstractText>AFCA efficacy in patients with impaired left ventricular systolic function improves when performed early in the natural history of atrial fibrillation and heart failure. AFCA provides long-term benefits on left ventricular function, significantly reducing the number of patients with severely impaired systolic function.</AbstractText>© 2014 American Heart Association, Inc.</CopyrightInformation> |
11,422 | Prognostic significance of left atrial appendage "sludge" in patients with atrial fibrillation: a new transesophageal echocardiographic thromboembolic risk factor. | When stratifying thromboembolic risk to patients with atrial fibrillation (AF), left atrial appendage (LAA) thrombus is currently the only echocardiographic index that absolutely contraindicates cardioversion. The aim of this study was to identify the predictors of LAA "sludge" and its impact on subsequent thromboembolism and survival in patients with AF.</AbstractText>A total of 340 patients (mean age, 66 ± 12 years; 75% men) who underwent transesophageal echocardiography to exclude LAA thrombus before electrical cardioversion or radiofrequency pulmonary vein isolation) for AF were retrospectively studied. LAA sludge was defined as a dynamic, viscid, layered echodensity without a discrete mass, visualized throughout the cardiac cycle. Follow-up was obtained after a mean of 6.7 ± 3.7 years, and patients were analyzed according to LAA thrombus (n = 62 [18%]), sludge (n = 47 [14%]), or spontaneous echocardiographic contrast (n = 84 [25%]). Patients without these transesophageal echocardiographic characteristics served as controls (n = 147 [43%]).</AbstractText>LAA sludge was independently predicted by enlarged left atrial area (odds ratio, 4.54; 95% confidence interval [CI], 2.38-8.67; P < .001), reduced LAA emptying velocity (odds ratio, 12.7; 95% CI, 6.11-26.44; P < .001), and reduced left ventricular ejection fraction (odds ratio, 2.11; 95% CI, 1.03-4.32; P < .001). Thromboembolic event and all-cause mortality rates in patients with sludge were 23% and 57%, respectively. Multiple logistic regression analyses identified the presence of LAA sludge to be independently associated with thromboembolic complications (adjusted hazard ratio, 3.43; 95% CI, 1.42-8.28; P = .006) and all-cause mortality (adjusted hazard ratio, 2.02; 95% CI, 1.22-3.36; P = .007).</AbstractText>Sludge within the LAA is independently associated with subsequent thromboembolic events and all-cause mortality in patients with AF.</AbstractText>Copyright © 2014 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,423 | HyperOxic Therapy OR NormOxic Therapy after out-of-hospital cardiac arrest (HOT OR NOT): a randomised controlled feasibility trial. | To investigate the feasibility of delivering titrated oxygen therapy to adults with return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) caused by ventricular fibrillation (VF) or ventricular tachycardia (VT).</AbstractText>We used a multicentre, randomised, single blind, parallel groups design to compare titrated and standard oxygen therapy in adults resuscitated from VF/VT OHCA. The intervention commenced in the community following ROSC and was maintained in the emergency department and the Intensive Care Unit. The primary end point was the median oxygen saturation by pulse oximetry (SpO2) in the pre-hospital period.</AbstractText>159 OHCA patients were screened and 18 were randomised. 17 participants were analysed: nine in the standard care group and eight in the titrated oxygen group. In the pre-hospital period, SpO2 measurements were lower in the titrated oxygen therapy group than the standard care group (difference in medians 11.3%; 95% CI 1.0-20.5%). Low measured oxygen saturation (SpO2<88%) occurred in 7/8 of patients in the titrated oxygen group and 3/9 of patients in the standard care group (P=0.05). Following hospital admission, good separation of oxygen exposure between the groups was achieved without a significant increase in hypoxia events. The trial was terminated because accumulated data led the Data Safety Monitoring Board and Management Committee to conclude that safe delivery of titrated oxygen therapy in the pre-hospital period was not feasible.</AbstractText>Titration of oxygen in the pre-hospital period following OHCA was not feasible; it may be feasible to titrate oxygen safely after arrival in hospital.</AbstractText>Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,424 | Deceptive meaning of oxygen uptake measured at the anaerobic threshold in patients with systolic heart failure and atrial fibrillation. | Oxygen uptake at the anaerobic threshold (VO2AT), a submaximal exercise-derived variable, independent of patients' motivation, is a marker of outcome in heart failure (HF). However, previous evidence of VO2AT values paradoxically higher in HF patients with permanent atrial fibrillation (AF) than in those with sinus rhythm (SR) raised uncertainties.</AbstractText>We tested the prognostic role of VO2AT in a large cohort of systolic HF patients, focusing on possible differences between SR and AF.</AbstractText>Altogether 2976 HF patients (2578 with SR and 398 with AF) were prospectively followed. Besides a clinical examination, each patient underwent a maximal cardiopulmonary exercise test (CPET).</AbstractText>The follow-up was analysed for up to 1500 days. Cardiovascular death or urgent cardiac transplantation occurred in 303 patients (250 (9.6%) patients with SR and 53 (13.3%) patients with AF, p = 0.023). In the entire population, multivariate analysis including peak oxygen uptake (VO2) showed a prognostic capacity (C-index) similar to that obtained including VO2AT (0.76 vs 0.72). Also, left ventricular ejection fraction, ventilation vs carbon dioxide production slope, β-blocker and digoxin therapy proved to be significant prognostic indexes. The receiver-operating characteristic (ROC) curves analysis showed that the best predictive VO2AT cut-off for the SR group was 11.7 ml/kg/min, while it was 12.8 ml/kg/min for the AF group.</AbstractText>VO2AT, a submaximal CPET-derived parameter, is reliable for long-term cardiovascular mortality prognostication in stable systolic HF. However, different VO2AT cut-off values between SR and AF HF patients should be adopted.</AbstractText>© The European Society of Cardiology 2014.</CopyrightInformation> |
11,425 | Global left atrial strain in the prediction of sinus rhythm maintenance after catheter ablation for atrial fibrillation. | Left atrial (LA) strain is a sensitive measure of LA mechanics. However, its relationship with rhythm outcomes after catheter ablation in patients with atrial fibrillation (AF) is not well established. The aim of this study was to evaluate whether baseline LA global longitudinal strain (LAε) predicts rhythm outcomes in patients who undergo catheter ablation for AF.</AbstractText>In 256 patients with AF (paroxysmal, 204; persistent, 52), comprehensive echocardiography was performed with assessment of LAε by using Velocity Vector Imaging to calculate average strain values from apical four- and two-chamber views before ablation (median, 41 days; interquartile range, 1-95 days).</AbstractText>After a median of 8.0 months (interquartile range, 4.0-23.3 months) of follow-up, 149 patients (58%) had maintained sinus rhythm and 107 patients (42%) had recurrence of AF. In our study cohort (mean age 59 ± 11 years; mean left ventricular ejection fraction, 58 ± 10%), impaired total LAε (LAεtotal) was associated with greater left ventricular mass index (r = -0.245, P < .001) and worsening left ventricular diastolic function (ratio of transmitral flow peak early diastolic velocity to peak early diastolic velocity of the mitral annulus: r = -0.357, P < .001; maximal LA volume index: r = -0.393, P < .001). Patients with LAεtotal < 23.2% showed a higher incidence of AF recurrence compared with patients with LAεtotal ≥ 23.2% (log-rank P < .001). In multivariate Cox proportional-hazards analysis, LAεtotal was independently related to rhythm outcomes (hazard ratio, 0.944; 95% confidence interval, 0.915-0.975; P < .001) after AF ablation. Moreover, LAεtotal provided incremental predictive value for rhythm outcomes over clinical features (increment in global χ(2) = 14.63, P < .001).</AbstractText>In patients with AF, baseline LAεtotal was associated with rhythm outcome after catheter ablation.</AbstractText>Copyright © 2014 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,426 | P-wave dispersion and its relationship to aortic stiffness in patients with acute myocardial infarction after cardiac rehabilitation. | The aim of our study was to investigate the P-wave dispersion from standard electrocardiograms (ECGs) in patients with acute myocardial infarction (AMI) after cardiac rehabilitation (CR) and determine its relation to arterial stiffness.</AbstractText>This is a prospective study included 33 patients with AMI and successfully re-vascularized by percutaneous coronary intervention (PCI) underwent CR. Left ventricular ejection fraction (LVEF) was measured by biplane Simpson's method. Left atrium (LA) volume was calculated. The maximum and minimum durations of P-waves (Pmax and Pmin, respectively) were detected, and the difference between Pmax and Pmin was defined as P-wave dispersion (Pd = Pmax-Pmin). Aortic elasticity parameters were measured.</AbstractText>LVEF was better after CR. The systolic and diastolic blood pressures decreased after CR, these differences were statistically significant. With exercise training, LA volume decreased significantly. Pmax and Pd values were significantly shorter after the CR program. The maximum and minimum P-waves and P-wave dispersion after CR were 97 ± 6 ms, 53 ± 5 ms, and 44 ± 5 ms, respectively. Aortic strain and distensibility increased and aortic stiffness index was decreased significantly. Aortic stiffness index was 0.4 ± 0.2 versus 0.3 ± 0.2, P = 0.001. Aortic stiffness and left atrial volume showed a moderate positive correlation with P-wave dispersion (r = 0.52, P = 0.005; r = 0.64, P < 0.001, respectively).</AbstractText>This study showed decreased arterial stiffness indexes in AMI patient's participated CR, with a significant relationship between the electromechanical properties of the LA that may raise a question of the preventive effect of CR from atrial fibrillation and stroke in patients with acute myocardial infarction.</AbstractText> |
11,427 | Association of amplitude spectral area of the ventricular fibrillation waveform with survival of out-of-hospital ventricular fibrillation cardiac arrest. | Previous investigations of out-of-hospital cardiac arrest (OHCA) have shown that the waveform characteristic amplitude spectral area (AMSA) can predict successful defibrillation and return of spontaneous circulation (ROSC) but has not been studied previously for survival.</AbstractText>To determine whether AMSA computed from the ventricular fibrillation (VF) waveform is associated with pre-hospital ROSC, hospital admission, and hospital discharge.</AbstractText>Adults with witnessed OHCA and an initial rhythm of VF from an Utstein style database were studied. AMSA was measured prior to each shock and averaged for each subject (AMSA-avg). Factors such as age, sex, number of shocks, time from dispatch to monitor/defibrillator application, first shock AMSA, and AMSA-avg that could predict pre-hospital ROSC, hospital admission, and hospital discharge were analyzed by logistic regression.</AbstractText>Eighty-nine subjects (mean age 62 ± 15 years) with a total of 286 shocks were analyzed. AMSA-avg was associated with pre-hospital ROSC (p = 0.003); a threshold of 20.9 mV-Hz had a 95% sensitivity and a 43.4% specificity. Additionally, AMSA-avg was associated with hospital admission (p < 0.001); a threshold of 21 mV-Hz had a 95% sensitivity and a 54% specificity and with hospital discharge (p < 0.001); a threshold of 25.6 mV-Hz had a 95% sensitivity and a 53% specificity. First-shock AMSA was also predictive of pre-hospital ROSC, hospital admission, and discharge. Time from dispatch to monitor/defibrillator application was associated with hospital admission (p = 0.034) but not pre-hospital ROSC or hospital discharge.</AbstractText>AMSA is highly associated with pre-hospital ROSC, survival to hospital admission, and hospital discharge in witnessed VF OHCA. Future studies are needed to determine whether AMSA computed during resuscitation can identify patients for whom continuing current resuscitation efforts would likely be futile.</AbstractText>Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,428 | History and clinical significance of early repolarization syndrome. | The early repolarization (ER) pattern has historically been regarded as a benign ECG variant. However, in recent years this view has been challenged based on multiple reports linking the ER pattern with an increased risk of sudden cardiac death. The mechanistic basis of ventricular arrhythmogenesis in ER syndrome is presently incompletely understood. Furthermore, strategies for risk stratification and therapy for ER syndrome remain suboptimal. The recent emergence of novel mapping techniques for cardiac arrhythmia has ushered a new era of research into the mechanistic basis of ER syndrome. This review provides an overview of current evidence relating to ER and risk of ventricular arrhythmias and discusses potential future areas of research to elucidate the mechanisms of ventricular arrhythmogenesis. |
11,429 | Cancer antigen 125 levels and increased risk of new-onset atrial fibrillation. | Elevated cancer antigen 125 (CA-125) levels are associated with cardiopulmonary disorders such as acute and chronic heart failure (HF), coronary artery disease, chronic obstructive pulmonary disease, and atrial fibrillation (AF). The development of atrial fibrillation (AF) is related to morbidity and mortality in patients with HF: therefore, it is important to identify patients with increased risk for development of AF. We investigated whether plasma CA-125 levels in patients with hospitalized systolic HF could predict the development of AF.</AbstractText>A total of 149 consecutive patients with sinus rhythm who were admitted to the emergency department with hospitalized systolic HF were evaluated prospectively. Serum CA-125 levels were obtained after initial stabilization during their hospital stay.</AbstractText>AF developed in 36 (% 24.2) patients during a follow-up period of 22.1 ± 11  months (range 3-61). CA-125 levels were significantly higher in patients who developed AF than in patients with sinus rhythm [99 U/ml (48-172) vs. 47 U/ml (18-108), p = 0.001]. The optimal cut-off level of CA-125 to predict development of AF was found to be > 68.49 U/ml. CA-125 > 68.49 U/ml, left atrial diameter, right ventricular dilatation, moderate to severe mitral and tricuspid regurgitations were found to have prognostic significance in univariate analysis. In a multivariate Cox proportional hazards model with the backward stepwise method, CA-125 > 68.49 U/ml (HR = 2.693, % 95 CI = 1.285-5.641, p = 0.009) and moderate to severe mitral regurgitation (HR = 2.708, % 95 CI = 1.295-5.663, p = 0.008) were associated with an increased risk of new-onset AF after adjustment for variables found to be statistically significant in univariate analysis and correlated with CA-125 level.</AbstractText>CA-125 level is associated with the development of AF in patients with hospitalized systolic HF.</AbstractText> |
11,430 | Effects of Chinese medicine shen-fu injection on the expression of inflammatory cytokines and complements during post-resuscitation immune dysfunction in a porcine model. | To investigate the action of Shen-Fu Injection (SFI) in regulating the expression of the serum complements and inflammatory cytokines synthesized and released in response to the stress of global ischemia accompanying cardiac arrest (CA) and resuscitation.</AbstractText>Thirty pigs were randomly divided into the sham (n=6) and 3 returns of spontaneous circulation (ROSC) groups (n=24). After 8-min untreated ventricular fibrillation and 2-min basic life support, 24 pigs of the ROSC groups were randomized into three groups (n=8 per group), which received central venous injection of SFI (SFI group), epinephrine (EP group), or saline (SA group). Hemodynamic status and blood samples were obtained at 0, 0.5, 1, 2, 4, 6, 12, and 24 h after ROSC.</AbstractText>Serum concentrations of specific activation markers of the complement system C3, C4 and C5b-9 were increased during cardiopulmonary resuscitation through 24 h after ROSC. There were intense changes of various pro-inflammatory cytokines and anti-inflammatory cytokines as early as 0.5 h after CA. Compared with the EP and SA groups, SFI treatment reduced the proinflammatory cytokines levels of interleukin (IL)-6, IL-8 and tumor necrosis factor α (TNF-α, P<0.05), and increased the anti-inflammatory cytokine levels of IL-4 and IL-10 (P<0.05). Further, SFI treatment decreased the values of C3, C4 and C5b-9 compared with the EP and SA groups.</AbstractText>SFI, derived from the ancient Chinese medicine, has significant effects in attenuating post-resuscitation immune dysfunction by modulating the expression of complements and cytokines levels. The current study provided an experimental basis for the clinical application of a potential pharmacologic target for post resuscitation immune dysfunction.</AbstractText> |
11,431 | [Survival and neurological outcome in out-of-hospital cardiac arrests due to shockable rhythms treated with mild therapeutic hypothermia]. | To analyze survival and neurological outcome at short and medium term in patients treated with mild therapeutic hypothermia (HTM) in our hospital after suffering an out-of-hospital cardiac arrest (CA) secondary to a shockable rhythm.</AbstractText>Prospective, observational study from September 1, 2010 to December 31, 2012, with a follow up of 6 months.</AbstractText>Tertiary hospital.</AbstractText>All patients who suffer an out-of-hospital CA due to shockable rhythms.</AbstractText>non-shockable rhythms, resuscitation >45 minutes without pulse recovery, septic shock, previous coagulopathy, terminal illness or order for withholding treatment.</AbstractText>Mild hypothermia (33°C) and postresuscitation care on the basis of standardized protocols.</AbstractText>Demographic and epidemiological data, CA data and survival and neurological outcome at hospital discharge and after 6 months. To assess the patients' neurological status, Cerebral Performance Categories (CPC) scale was used.</AbstractText>A total of 54 patients were analyzed. 37 patients were discharged to hospital, representing a survival at discharge of 68.5%, which remains 6 months later because no discharged patient died during the follow up period. Regarding neurological outcome, 44.4% of patients were alive and with CPC 1-2 at discharge and up to 54.71% at 6 months.</AbstractText>The results of survival and neurological functional status obtained in our center after implementation of HTM are comparable to those published in the literature.</AbstractText>Copyright © 2013 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.</CopyrightInformation> |
11,432 | Risk factors for atrial fibrillation in patients with normal versus dilated left atrium (from the Atherosclerosis Risk in Communities Study). | Epidemiological data are limited regarding risk factors of atrial fibrillation (AF) in patients with normal-sized left atria (LA). We evaluated whether traditional risk factors of AF differ between patients with normal-sized and dilated LA. This is a cross sectional study of community-dwelling participants of the Atherosclerosis Risk in Communities study. LA volume index was measured by 2-dimensional echocardiography. LA volume index ≥29 mm(3)/m(2) defined dilated LA. Prevalent AF was defined by electrocardiogram and hospital discharge International Classification of Diseases-9 codes. Multivariate adjusted logistic regression analysis was used to examine whether magnitude of association of risk factors with AF differ by LA cavity size. Interaction of risk factors by LA cavity size was evaluated to determine significance of these differential associations. Of 5,496 participants (mean age 75 ± 5 years, women 58%), 1,230 participants (22%) had dilated LA. The prevalence of AF was 11% in patients with normal-sized LA and 15% in patients with dilated LA. Age >75 years (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.49 to 2.35, interaction p = 0.12) and heart failure (OR 5.43, 95% CI 3.77 to 7.87, interaction p = 0.10) were stronger risk factors for AF in normal-sized LA than dilated LA. Female gender (OR 1.67, 95% CI 1.01 to 2.77, interaction p = 0.09), weight (OR 1.32, 95% CI 1.02 to 1.71, interaction p = 0.19), and alcohol use (OR 1.61, 95% CI 1.08 to 2.41, interaction p = 0.004) were stronger risk factors for AF in patients with dilated LA than normal-sized LA. In conclusion, risk factors of AF may differ by left ventricular cavity size. |
11,433 | Validation of the Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF) for predicting 30-day adverse events in emergency department patients with atrial fibrillation. | In the United States, nearly 70% of emergency department (ED) visits for atrial fibrillation result in hospitalization. The incidence of serious 30-day adverse events after an ED evaluation for atrial fibrillation remains low. This study's goal was to prospectively validate our previously reported Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF) model for estimating a patient's risk of experiencing a 30-day adverse event.</AbstractText>This was a prospective cohort study, which enrolled a convenience sample of ED patients presenting with atrial fibrillation. RED-AF, previously derived from a retrospective cohort of 832 patients, assigns points according to age, sex, coexisting disease (eg, heart failure, hypertension, chronic obstructive pulmonary disease), smoking, home medications (eg, β-blocker, diuretic), physical examination findings (eg, dyspnea, palpitations, peripheral edema), and adequacy of ED ventricular rate control. Primary outcome was occurrence of greater than or equal to 1 atrial fibrillation-related adverse outcome (ED visits, rehospitalization, cardiovascular complications, death) within 30 days. We identified a clinically relevant threshold and measured RED-AF's performance in this prospective cohort, assessing its calibration, discrimination, and diagnostic accuracy.</AbstractText>The study enrolled 497 patients between June 2010 and February 2013. Of these, 120 (24%) had greater than or equal to 1 adverse event within 30 days. A RED-AF score of 87 was identified as an optimal threshold, resulting in sensitivity and specificity of 96% (95% confidence interval [CI] 91% to 98%) and 19% (95% CI 15% to 23%), respectively. Positive and negative predictive values were 27% (95% CI 23% to 32%) and 93% (95% CI 85% to 97%), respectively. The c statistic for RED-AF was 0.65 (95% CI 0.59 to 0.71).</AbstractText>In this separate validation cohort, RED-AF performed moderately well and similar to the original derivation cohort for identifying the risk of short-term atrial fibrillation-related adverse events in ED patients receiving a diagnosis of atrial fibrillation.</AbstractText>Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,434 | Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases. | Abstract Background. Ventricular fibrillation (VF) is considered the out-of-hospital cardiac arrest (OOHCA) rhythm with the highest likelihood of neurologically intact survival. Unfortunately, there are occasions when VF does not respond to standard defibrillatory shocks. Current American Heart Association (AHA) guidelines acknowledge that the data are insufficient in determining the optimal pad placement, waveform, or energy level that produce the best conversion rates from OOHCA with VF. Objective. To describe a technique of double sequential external defibrillation (DSED) for cases of refractory VF (RVF) during OOHCA resuscitation. Methods. A retrospective case series was performed in an urban/suburban emergency medical services (EMS) system with advanced life support care and a population of 900,000. Included were all adult OOHCAs having RVF during resuscitation efforts by EMS providers. RVF was defined as persistent VF following at least 5 unsuccessful single shocks, epinephrine administration, and a dose of antiarrhythmic medication. Once the patient was in RVF, EMS personnel applied a second set of pads and utilized a second defibrillator for single defibrillation with the new monitor/pad placement. If VF continued, EMS personnel then utilized the original and second monitor/defibrillator charged to maximum energy, and shocks were delivered from both machines simultaneously. Data were collected from electronic dispatch and patient care reports for descriptive analysis. Results. From 01/07/2008 to 12/31/2010, a total of 10 patients were treated with DSED. The median age was 76.5 (IQR: 65-82), with median resuscitation time of 51minutes (IQR: 45-62). The median number of single shocks was 6.5 (IQR: 6-11), with a median of 2 (IQR: 1-3) DSED shocks delivered. VF broke after DSED in 7 cases (70%). Only 3 patients (30%) had ROSC in the field, and none survived to discharge. Conclusion. This case series demonstrates that DSED may be a feasible technique as part of an aggressive treatment plan for RVF in the out-of-hospital setting. In this series, RVF was terminated 70% of the time, but no patient survived to discharge. Further research is needed to better understand the characteristics of and treatment strategies for RVF. |
11,435 | Subcutaneous implantable cardioverter-defibrillator: Initial experience. | Implantable cardioverter-defibrillators (ICDs) are important tools in the prevention of sudden death, but implantation requires transvenous access, which is associated with complications. Subcutaneous implantable cardioverter-defibrillators (S-ICDs) may prevent some of these complications.</AbstractText>To evaluate the therapeutics and complications associated with S-ICD systems.</AbstractText>S-ICD implantation was planned in 23 patients, for whom the indications were vascular access problems, increased risk of infection or young patients with long predicted follow-up. The population consisted of four patients with ischemic heart disease, three of them on hemodialysis (two with subclavian vein thrombosis), five with left ventricular noncompaction, four with Brugada syndrome, three with arrhythmogenic right ventricular cardiomyopathy, one with transposition of the great vessels, two with dilated cardiomyopathy and four with hypertrophic cardiomyopathy.</AbstractText>S-ICDs were implanted in 21 patients, two having failed to fulfil the initial screening criteria. Mean implantation time was 77 minutes, with no complications. Defibrillation tests were performed, and in one patient the generator had to be repositioned to obtain an acceptable threshold. In a mean follow-up of 14 months, 10 patients had S-ICD shocks, which were appropriate in half of them; one developed infection, one needed early replacement due to loss of telemetry and one patient died of noncardiac cause.</AbstractText>S-ICD implantation can be performed by cardiologists with a high success rate. Initial experience appears favorable, but further studies are needed with longer follow-up times to assess the safety and efficacy of this strategy compared to conventional devices.</AbstractText>Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.</CopyrightInformation> |
11,436 | Defibrillation in the movies: a missed opportunity for public health education. | To characterize defibrillation and cardiac arrest survival outcomes in movies.</AbstractText>Movies from 2003 to 2012 with defibrillation scenes were reviewed for patient and rescuer characteristics, scene characteristics, defibrillation characteristics, additional interventions, and cardiac arrest survival outcomes. Resuscitation actions were compared with chain of survival actions and the American Heart Association (AHA) Emergency Cardiovascular Care (ECC) 2020 Impact Goals. Cardiac arrest survival outcomes were compared with survival rates reported in the literature and targeted by the AHA ECC 2020 Impact Goals.</AbstractText>Thirty-five scenes were identified in 32 movies. Twenty-five (71%) patients were male, and 29 (83%) rescuers were male. Intent of defibrillation was resuscitation in 29 (83%) scenes and harm in 6 (17%) scenes. Cardiac arrest was the indication for use in 23 (66%) scenes, and the heart rhythm was made known in 18 scenes (51%). When the heart rhythm was known, defibrillation was appropriately used for ventricular tachycardia or ventricular fibrillation in 5 (28%) scenes and inappropriately used for asystole in 7 (39%) scenes. In 8 scenes with in-hospital cardiac arrest, 7 (88%) patients survived, compared to survival rates of 23.9% reported in the literature and 38% targeted by an AHA ECC 2020 Impact Goal. In 12 movie scenes with out-of-hospital cardiac arrest, 8 (67%) patients survived, compared to survival rates of 7.9-9.5% reported in peer-reviewed literature and 15.8% targeted by an AHA ECC 2020 Impact Goal.</AbstractText>In movies, defibrillation and cardiac arrest survival outcomes are often portrayed inaccurately, representing missed opportunities for public health education.</AbstractText>Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,437 | Paradoxical effects of KB-R7943 on arrhythmogenicity in a chronic myocardial infarction rabbit model. | Na(+)/Ca(2+) exchanger blockade has been reported to be anti-arrhythmic in different models. The effects of KB-R7943, a Na(+)/Ca(2+) exchanger blocker, on arrhythmogenesis in hearts with chronic myocardial infarction (MI) remain unclear.</AbstractText>Dual voltage and intracellular Ca(2+) (Cai) optical mapping was performed in nine rabbit hearts with chronic MI and four control hearts. Electrophysiology studies including inducibility of ventricular tachyarrhythmias, ventricular fibrillation dominant frequency, action potential, Cai alternans, Cai decay, and conduction velocity were performed. The same protocol was repeated in the presence of KB-R7943 (0.5, 1, and 5μM) after the baseline studies.</AbstractText>KB-R7943 was effective in suppressing afterdepolarizations and spontaneous ventricular tachyarrhythmias in hearts with chronic MI. Surprisingly, KB-R7943 increased the inducibility of ventricular tachyarrhythmias in a dose-dependent manner (11%, 11%, 22%, and 56% at baseline and with 0.5, 1, and 5μM KB-R7943, respectively, p=0.02). Optical mapping analysis revealed that the underlying mechanisms of the induced ventricular tachyarrhythmias were probably spatially discordant alternans with wave breaks and rotors. Further analysis showed that KB-R7943 significantly enhanced both action potential (p=0.033) and Cai (p=0.001) alternans, prolonged Cai decay (tau value) in a dose-dependent manner (p=0.004), and caused heterogeneous conduction delay especially at peri-infarct zones during rapid burst pacing. In contrast, KB-R7943 had insignificant effects in control hearts.</AbstractText>In this chronic MI rabbit model, KB-R7943 has contrasting effects on arrhythmogenesis, suppressing afterdepolarizations and spontaneous ventricular tachyarrhythmias, but enhancing the inducibility of tachyarrhythmias. The mechanism is probably the enhanced spatially discordant alternans because of prolonged Cai decay and heterogeneous conduction delay.</AbstractText>Copyright © 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.</CopyrightInformation> |
11,438 | [ICD inappropriate shock for atrial fibrillation: use of home-monitoring for the prevention]. | In this case report, we describe the example of an ICD inappropriate shocks. These inappropriate shocks were induced by atrial fibrillation with a high ventricular rate. The first message transmitted by the home-monitoring preceded the first shocks. Use of home-monitoring permits explanations for these inappropriate shocks. Home-monitoring will also be used for the follow-up of these patients for the prevention of other shocks associated with atrial fibrillation. |
11,439 | Near fatal ventricular fibrillation in Brugada syndrome despite presence of an implanted implantable cardioverter defibrillator. | A 38-year-old man with Brugada syndrome and aborted cardiac arrest was treated with quinidine only, based on the results of electrophysiologic drug testing. Six months later, after suffering a vaso-vagal syncope, he opted to receive an implantable cardioverter defibrillator and decided to discontinue quinidine against our recommendation. Sixty-seven months later, he had recurrent ventricular fibrillation that was terminated only by the sixth maximal energy shock delivered by the device (which has the capability to deliver a maximum of 8 shocks). This case suggests the possible risk in only relying on an implantable cardioverter defibrillator in the management of cardiac arrest survivors with Brugada syndrome. |
11,440 | Idiopathic ventricular arrhythmias originating from the moderator band: Electrocardiographic characteristics and treatment by catheter ablation. | The moderator band (MB) can be a source of premature ventricular contractions (PVCs), monomorphic ventricular tachycardia (VT), and idiopathic ventricular fibrillation (IVF).</AbstractText>The purpose of this study was to define the electrocardiographic (ECG) characteristics and procedural techniques to successfully identify and ablate MB PVCs/VT.</AbstractText>In 10 patients with left bundle branch block morphology PVCs/VT, electroanatomic mapping in conjunction with intracardiac echocardiography (ICE) localized the site of origin of the PVCs to the MB. Clinical characteristics of the patients, ECG features, and procedural data were collected and analyzed.</AbstractText>Seven patients presented with IVF and 3 presented with monomorphic VT. In all patients, the ventricular arrhythmias (VAs) had a left bundle branch block QRS with a late precordial transition (>V4), a rapid downstroke of the QRS in the precordial leads, and a left superior frontal plane axis. Mean QRS duration was 152.7 ± 15.2 ms. Six patients required a repeat procedure. After mean follow-up of 21.5 ± 11.6 months, all patients were free of sustained VAs, with only 1 patient requiring antiarrhythmic drug therapy and 1 patient having isolated PVCs no longer inducing VF. There were no procedural complications.</AbstractText>VAs originating from the MB have a distinctive morphology and often are associated with PVC-induced ventricular fibrillation. Catheter ablation can be safely performed and is facilitated by ICE imaging.</AbstractText>Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,441 | Postprocedural anticoagulation for specific therapeutic indications after revascularization for ST-segment elevation myocardial infarction (from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction Trial). | Postprocedural anticoagulation (AC) after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) may be administered for a number of specific therapeutic indications (e.g. atrial fibrillation or left ventricular thrombus). However, the safety and effectiveness of such post-PCI AC for specific indications are not well defined. Thus, we sought to study outcomes after postprocedural AC for specific indications in patients undergoing primary PCI for STEMI in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial. Patients who underwent primary PCI for STEMI in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial were grouped according to whether they received specific indication AC. Adverse outcomes were assessed using propensity-adjusted multivariate analyses. After excluding patients who received post-PCI AC solely for routine prophylaxis, 410 patients (16.6%) received postprocedural AC for specific indications and 2,063 patients (83.4%) received no post-PCI AC. After propensity adjustment, use of postprocedural AC for specific indications was associated with higher rates of cardiac mortality, reinfarction, stent thrombosis, and major bleeding at 30 days compared with patients who received no AC post-PCI. In conclusion, in this large prospective study, use of postprocedural AC for specific indications after primary PCI for STEMI was independently associated with early rates of adverse ischemic and hemorrhagic outcomes. Post-PCI AC for specific indications was also associated with worse outcomes from 30 days to 3 years. Further studies are warranted to determine the optimal use of postprocedural AC after primary PCI in STEMI. |
11,442 | Cardiac arrest with coronary artery spasm: does the use of epinephrine during cardiopulmonary arrest exacerbate the spasm? | Coronary artery spasm can lead to sudden cardiac death due to ventricular arrhythmias or heart block. Cardiopulmonary resuscitation guidelines recommend the use of epinephrine during cardiopulmonary arrest. However, in the event of cardiac arrest caused by coronary artery spasm, the use of epinephrine may be harmful. We report 2 cases who had witnessed cardiac arrest due to ventricular fibrillation and complete heart block. Intravenous epinephrine was administered during resuscitation.Their hemodynamics did not improve. Emergent coronary angiography revealed that the entire right and left coronary artery systems diffuse spasm. One patient's coronary artery spasm was successfully reversed immediately with administration of intracoronary boluses of nitroglycerin. The other patient's hemodynamic instability persisted,requiring temporary mechanical circulatory support with an intra aortic balloon pump. His hemodynamics finally improved with administration of intravenous diltiazem and nitroglycerin under the intraaortic balloon pump support. They both were discharged from the hospital without any other complications. |
11,443 | Ankyrin-G coordinates intercalated disc signaling platform to regulate cardiac excitability in vivo. | Nav1.5 (SCN5A) is the primary cardiac voltage-gated Nav channel. Nav1.5 is critical for cardiac excitability and conduction, and human SCN5A mutations cause sinus node dysfunction, atrial fibrillation, conductional abnormalities, and ventricular arrhythmias. Further, defects in Nav1.5 regulation are linked with malignant arrhythmias associated with human heart failure. Consequently, therapies to target select Nav1.5 properties have remained at the forefront of cardiovascular medicine. However, despite years of investigation, the fundamental pathways governing Nav1.5 membrane targeting, assembly, and regulation are still largely undefined.</AbstractText>Define the in vivo mechanisms underlying Nav1.5 membrane regulation.</AbstractText>Here, we define the molecular basis of an Nav channel regulatory platform in heart. Using new cardiac-selective ankyrin-G(-/-) mice (conditional knock-out mouse), we report that ankyrin-G targets Nav1.5 and its regulatory protein calcium/calmodulin-dependent kinase II to the intercalated disc. Mechanistically, βIV-spectrin is requisite for ankyrin-dependent targeting of calcium/calmodulin-dependent kinase II-δ; however, βIV-spectrin is not essential for ankyrin-G expression. Ankyrin-G conditional knock-out mouse myocytes display decreased Nav1.5 expression/membrane localization and reduced INa associated with pronounced bradycardia, conduction abnormalities, and ventricular arrhythmia in response to Nav channel antagonists. Moreover, we report that ankyrin-G links Nav channels with broader intercalated disc signaling/structural nodes, as ankyrin-G loss results in reorganization of plakophilin-2 and lethal arrhythmias in response to β-adrenergic stimulation.</AbstractText>Our findings provide the first in vivo data for the molecular pathway required for intercalated disc Nav1.5 targeting/regulation in heart. Further, these new data identify the basis of an in vivo cellular platform critical for membrane recruitment and regulation of Nav1.5.</AbstractText>© 2014 American Heart Association, Inc.</CopyrightInformation> |
11,444 | Admission interleukin-6 is associated with post resuscitation organ dysfunction and predicts long-term neurological outcome after out-of-hospital ventricular fibrillation. | To study plasma concentrations of interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP) and S-100B during intensive care after out-of-hospital cardiac arrest from ventricular fibrillation (OHCA-VF), and their associations with the duration of ischemia, organ dysfunction and long-term neurological outcome.</AbstractText>A 12-month prospective observational multicentre study was conducted in 21 Finnish intensive care units in 2011. IL-6, hs-CRP and S-100B were measured at 0-6 h, 24 h, 48 h and 96 h after ICU admission. Associations with the time to return of spontaneous circulation (ROSC), sequential organ failure assessment (SOFA) scores divided into tertiles and 12-month cerebral performance category (CPC) were tested.</AbstractText>Of 186 OHCA-VF patients included in the study, 110 (59.1%) patients survived with good neurological outcome (CPC 1-2) 12 months after cardiac arrest. Admission plasma concentrations of IL-6 but not hs-CRP were higher with prolonged time to ROSC (p<0.001, 0.203, respectively), in patients with subsequent higher SOFA scores (p<0.001, 0.069) and poor long-term neurological outcome (CPC 3-5) (p<0.001, 0.315). S-100B concentrations over time were higher in patients with CPC of 3-5 (p<0.001). The area under the curve for prediction of poor 12-month outcome for admission levels was 0.711 IL-6, 0.663 for S-100B and 0.534 for hs-CRP. With multivariate logistic regression analysis only admission IL-6 (p=0.046, OR 1.006, 95% CI 1.000-1.011/ng/L) was an independent predictor of poor neurological outcome.</AbstractText>Admission high IL-6, but not hs-CRP or S-100B, is associated with extra-cerebral organ dysfunction and along with age and time to ROSC are independent predictors for 12-month poor neurologic outcome (CPC 3-5).</AbstractText>Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,445 | Atrial fibrillation is an independent risk factor for ventricular fibrillation: a large-scale population-based case-control study. | Atrial fibrillation (AF) is associated with sudden cardiac death. We aimed to study whether AF is associated with ventricular fibrillation (VF), the most common cause of sudden cardiac death and whether this association is independent of confounders, ie, concomitant disease, use of antiarrhythmic or QT-prolonging drugs, and acute myocardial infarction.</AbstractText>We performed a community-based case-control study. Cases were patients with out-of-hospital cardiac arrest because of ECG-documented VF. Controls were age-/sex-matched non-VF subjects from the community. VF risk in AF patients was studied by means of (conditional) logistic regression, adjusting for all available confounders. We studied 1397 VF cases and 3474 controls. AF occurred in 215 cases (15.4%) and 90 controls (2.6%). AF was associated with a 3-fold increased risk of VF (adjusted odds ratio, 3.1 [2.1-4.5]). VF risk in AF cases was increased to the same extent across all age/sex groups and in AF cases who had no comorbidity (adjusted odds ratio 3.0 [1.6-5.5]) or used no confounding drugs (antiarrhythmics, 2.4 [1.4-4.3]; QT-prolonging drugs, 3.1 [1.8-5.4]). VF risk was similarly increased in AF cases with acute myocardial infarction-related VF (adjusted odds ratio 2.6 [1.4-4.8]), and those with non-acute myocardial infarction-related VF (adjusted odds ratio 4.3 [1.9-10.1]).</AbstractText>AF is independently associated with a 3-fold increased risk of VF. Comorbidity, use of antiarrhythmic or QT-prolonging drugs, or acute myocardial infarction does not fully account for this increased risk.</AbstractText>© 2014 American Heart Association, Inc.</CopyrightInformation> |
11,446 | Clinical application of the fibrillation number in patients with an implantable cardioverter defibrillator. | Although ventricular tachycardia/fibrillation (VT/VF) develops suddenly with catastrophic results, its prediction is limited. We tested the fibrillation number (FibN) for potential predictor of VT/VF using clinical data of implantable cardioverter-defibrillator (ICD) patients after validating the number by computational modeling.</AbstractText>For clinical application of FibN, we used electrocardiography and echocardiography data: QRS width, QTc, and left ventricular (LV) end-systolic dimension (FibNVT/VF1) or LV end-diastolic dimension (FibNVT/VF2). We compared the maintenance duration of VT/VF for various FibN values using computational modeling, and tested FibNVT/VF in 142 patients with ICD for secondary prevention and 426 patients in age-sex matched control group (81.9% male, 56.1 ± 12.3 years old).</AbstractText>1. Computational results showed a positive correlation between VT/VF maintenance duration and FibN (R = 0.82, p < 0.001). 2. FibNVT/VFs were significantly higher in patients with ICD than in control (both FibNVT/VF1 and FibNVT/VF2, p < 0.001). 3. Within ICD group, FibNVT/VF values were higher in patients with cardiomyopathy than those without (both FibNVT/VF1 and FibNVT/VF2, p < 0.001). 4. During 50 ± 39 months follow-up period, the frequency of appropriate ICD therapy was higher in the high FibNVT/VF group (FibNVT/VF1, p = 0.001; FibNVT/VF2, p = 0.002). Both FibNVT/VF1 (HR 2.51, 95%CI 1.48-4.24, p = 0.001) and FibNVT/VF2 (HR 2.11, 95%CI 1.25-3.55, p = 0.005) were independently associated with appropriate ICD therapy in multi-variate analyses.</AbstractText>FibNVT/VF, a parameter based on wavelength and heart size, correlates well with maintenance of VT/VF in computational modeling, and may have predictive value for VT/VF events in patients with ICD for secondary prevention.</AbstractText>Copyright © 2014 Elsevier Ltd. All rights reserved.</CopyrightInformation> |
11,447 | Multilead template-derived residua of surface ECGS for quantitative assessment of arrhythmia risk. | Contemporary electrocardiographic (ECG) markers including ventricular ectopy and arrhythmias have not proved reliable in risk assessment for life-threatening arrhythmias.</AbstractText>We developed the "Multilead ECG Template-Derived Residua" approach to remove intrinsic morphologic differences and allow calculation of pathologic ECG heterogeneities among spatially separated leads. Prediction by R-wave and T-wave heterogeneity (RWH, TWH) analysis was tested in simulated and clinical ECGs.</AbstractText>An enabling description of the Residua algorithm is provided. Simulated ECGs with but not without Residua produced a linear relationship (correlation coefficient r(2) = 0.999) between input and output RWH and TWH values. In heart failure patients, Residua disclosed a marked crescendo in RWH from 164.1 ± 33.1 at baseline to 299.8 ± 54.5 μV and TWH from 134.5 ± 20.6 at baseline to 239.2 ± 37.0 μV at 30-45 minutes before the arrhythmia (both, P < 0.05), which remained elevated until arrhythmia onset. Without Residua, mean RWH and TWH were elevated at 1061.0 ± 222.9 and 882.5 ± 375.2 μV, respectively, throughout the recording and were not different prior to ventricular tachycardia onset.</AbstractText>Calculation of ECG-template derived Residua provides a highly accurate means for assessing arrhythmia risk from standard ECGs. Potential widespread applications include resting diagnostic 12-lead, ambulatory, and exercise ECGs, electrophysiologic study laboratory recordings, and implantable devices.</AbstractText>© 2014 Wiley Periodicals, Inc.</CopyrightInformation> |
11,448 | Electrocardiogram characteristics prior to in-hospital cardiac arrest. | Survival after in-hospital cardiac arrest (I-HCA) remains < 30 %. There is very limited literature exploring the electrocardiogram changes prior to I-HCA. The purpose of the study was to determine demographics and electrocardiographic predictors prior to I-HCA. A retrospective study was conducted among 39 cardiovascular subjects who had cardiopulmonary resuscitation from I-HCA with initial rhythms of pulseless electrical activity (PEA) and asystole. Demographics including medical history, ejection fraction, laboratory values, and medications were examined. Electrocardiogram (ECG) parameters from telemetry were studied to identify changes in heart rate, QRS duration and morphology, and time of occurrence and location of ST segment changes prior to I-HCA. Increased age was significantly associated with failure to survive to discharge (p < 0.05). Significant change was observed in heart rate including a downtrend of heart rate within 15 min prior to I-HCA (p < 0.05). There was a significant difference in heart rate and QRS duration during the last hour prior to I-HCA compared to the previous hours (p < 0.05). Inferior ECG leads showed the most significant changes in QRS morphology and ST segments prior to I-HCA (p < 0.05). Subjects with an initial rhythm of asystole demonstrated significantly greater ECG changes including QRS morphology and ST segment changes compared to the subjects with initial rhythms of PEA (p < 0.05). Diagnostic ECG trends can be identified prior to I-HCA due to PEA and asystole and can be further utilized for training a predictive machine learning model for I-HCA. |
11,449 | Renal denervation for treatment of cardiac arrhythmias: state of the art and future directions. | It has now been more than a quarter of a century since modulation of the sympathetic nervous system was proposed for the treatment of cardiac arrhythmias of different origins. But it has also been some time since some of the early surgical attempts have been abandoned. With the development of ablation techniques, however, new approaches and targets have been recently introduced that have revolutionized our way of thinking about sympathetic modulation. Renal nerve ablation technology is now being successfully used for the treatment of resistant hypertension, but the indication spectrum might broaden and new therapeutic options might arise in the near future. This review focuses on the possible impact of renal sympathetic system modulation on cardiac arrhythmias, the current evidence supporting this approach, and the ongoing trials of this method in electrophysiological laboratories. We will discuss the potential roles that sympathetic modulation may play in the future. |
11,450 | Prognostic values of highly sensitive cardiac troponin T and B-type natriuretic peptide for clinical features in hypertrophic obstructive cardiomyopathy: a cross-sectional study. | Although B-type natriuretic peptide (BNP) and highly sensitive cardiac troponin T (cTnT) are useful for the evaluation of clinical features in various cardiovascular diseases, there are comparatively few data regarding the utility of these parameters in patients with hypertrophic obstructive cardiomyopathy (HOCM). The goal of this study was to assess the association between BNP, cTnT and clinical parameters in patients with HOCM.</AbstractText>Cross-sectional survey</AbstractText>The relationship between BNP, cTnT and clinical end points and echocardiographic data was investigated.</AbstractText>This study included 102 consecutive outpatients with HOCM who were clinically stable.</AbstractText>BNP was significantly associated with both maximum left ventricular (LV) wall thickness (r=0.28; p=0.003), and septal peak early transmitral filling velocity/peak early diastolic mitral annulus velocity (r=0.51; p=0.0001). No statistically significant associations were seen between cTnT and any echocardiographic parameters, but the presence of atrial fibrillation (AF) was associated with a high level of cTnT (p=0.01).</AbstractText>BNP is useful for monitoring clinical parameters and as a reflection of both LV systolic/diastolic function and increased LV pressure in patients with HOCM. A high level of serum cTnT is associated with the presence of AF.</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> |
11,451 | Selected CD133⁺ progenitor cells to promote angiogenesis in patients with refractory angina: final results of the PROGENITOR randomized trial. | Refractory angina constitutes a clinical problem.</AbstractText>The aim of this study was to assess the safety and the feasibility of transendocardial injection of CD133(+) cells to foster angiogenesis in patients with refractory angina.</AbstractText>In this randomized, double-blinded, multicenter controlled trial, eligible patients were treated with granulocyte colony-stimulating factor, underwent an apheresis and electromechanical mapping, and were randomized to receive treatment with CD133(+) cells or no treatment. The primary end point was the safety of transendocardial injection of CD133(+) cells, as measured by the occurrence of major adverse cardiac and cerebrovascular event at 6 months. Secondary end points analyzed the efficacy. Twenty-eight patients were included (n=19 treatment; n=9 control). At 6 months, 1 patient in each group had ventricular fibrillation and 1 patient in each group died. One patient (treatment group) had a cardiac tamponade during mapping. There were no significant differences between groups with respect to efficacy parameters; however, the comparison within groups showed a significant improvement in the number of angina episodes per month (median absolute difference, -8.5 [95% confidence interval, -15.0 to -4.0]) and in angina functional class in the treatment arm but not in the control group. At 6 months, only 1 simple-photon emission computed tomography (SPECT) parameter: summed score improved significantly in the treatment group at rest and at stress (median absolute difference, -1.0 [95% confidence interval, -1.9 to -0.1]) but not in the control arm.</AbstractText>Our findings support feasibility and safety of transendocardial injection of CD133(+) cells in patients with refractory angina. The promising clinical results and favorable data observed in SPECT summed score may set up the basis to test the efficacy of cell therapy in a larger randomized trial.</AbstractText>© 2014 American Heart Association, Inc.</CopyrightInformation> |
11,452 | Local dynamics of heart rate: detection and prognostic implications. | The original observation that reduced heart rate variability (HRV) confers poor prognosis after myocardial infarction has been followed by many studies of heart rate dynamics. We tested the hypothesis that an entropy-based local dynamics measure gave prognostic information in ambulatory patients undergoing 24-h electrocardiography. In this context, entropy is the probability that short templates will find matches in the time series. We studied RR interval time series from 24-h Holter monitors of 1564 consecutive patients over age 39. We generated histograms of the count of templates as a function of the number of templates matches in short RR interval time series, and found characteristic appearance of histograms for atrial fibrillation, sinus rhythm with normal HRV, and sinus rhythm with reduced HRV and premature ventricular contractions (PVCs). We developed statistical models to detect the abnormal dynamic phenotype of reduced HRV with PVCs and fashioned a local dynamics score (LDs) that, after controlling for age, added more prognostic information than other standard risk factors and common HRV metrics, including, to our surprise, the PVC count and the HRV of normal-to-normal intervals. Addition of the LDs to a predictive model using standard risk factors significantly increased the ROC area and the net reclassification improvement was 27%. We conclude that abnormal local dynamics of heart rate confer adverse prognosis in patients undergoing 24-h ambulatory electrocardiography. |
11,453 | Cardiac rehabilitation of a patient with an advanced dilated cardiomyopathy: a case report. | The dilated cardiomyopathy is the common type of cardiomyopathy, and its distinctive characteristic is the systolic dysfunction. Not many reports were issued about the efficacy of cardiac rehabilitation in patients with an advanced dilated cardiomyopathy until yet. A 50-year-old man who was diagnosed with dilated cardiomyopathy with congestive heart failure was admitted to the emergency room after a sudden collapse and a ventricular fibrillation was presented in the actual electrocardiogram. After three months, the patient participated in an 8-week cardiac rehabilitation program with electrocardiogram monitoring for 50 minutes per session at five times per week. The maximal oxygen consumption improved from 13.5 to 19.4 mL/kg/min during this time. At 3.9 metabolic equivalents, the myocardial oxygen demand decreased from 21,710 to 12,669 mmHg.bpm and the Borg's scale of perceived exertion decreased from 15 to 9. The left ventricular ejection fraction improved from 14% to 19%. So in this case report will be presented a patient after a successful cardiac rehabilitation program. Before this the patient suffered from a much more advanced dilated cardiomyopathy and was resuscitated from cardiac arrest. |
11,454 | Hypertrophic cardiomyopathy: Can the noninvasive diagnostic testing identify high risk patients? | Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death (SCD) in the young, particularly among athletes. Identifying high risk individuals is very important for SCD prevention. The purpose of this review is to stress that noninvasive diagnostic testing is important for risk assessment. Extreme left ventricular hypertrophy and documented ventricular tachycardia and fibrillation increase the risk of SCD. Fragmented QRS and T wave inversion in multiple leads are more common in high risk patients. Cardiac magnetic resonance imaging provides complete visualization of the left ventricular chamber, allowing precise localization of the distribution of hypertrophy and measurement of wall thickness and cardiac mass. Moreover, with late gadolinium enhancement, patchy myocardial fibrosis within the area of hypertrophy can be detected, which is also helpful in risk stratification. Genetic testing is encouraged in all cases, especially in those with a family history of HCM and SCD. |
11,455 | Electrophysiology assessment and radiofrequency ablation of arrhythmias in adult patients with congenital heart defects: the Christchurch experience. | Adults with congenital heart disease (CHD) frequently have cardiac arrhythmias, many of which are best treated with radiofrequency ablation (RFA). We present our experience in this group.</AbstractText>Retrospective chart based review of diagnosis, arrhythmia type, results of cardiac electrophysiological assessment, and procedural and long-term clinical success of radiofrequency ablation.</AbstractText>Forty-five patients were identified with CHD and arrhythmias undergoing RFA; including surgically repaired atrial septal defects (21), Ebstein's anomaly (12), repaired transposition of the great arteries (3), repaired Tetralogy of Fallot (4), repaired ventricular septal defect (3), repaired coarctation (1) and unrepaired anomalous pulmonary venous anatomy (1). Arrhythmias were atrial flutter (24), atrial fibrillation (1), atrial tachycardia (3), atrioventricular nodal re-entrant tachycardia (5), and atrioventricular re-entrant tachycardia (12). Procedural success was ultimately obtained in 36 patients, with 6 having unsuccessful ablation and 3 an undetermined result. Twelve patients required a repeat procedure. One patient required a third procedure and had insertion of permanent pacemaker and atrioventricular nodal ablation. With follow-up (range 2-264 months) 31 patients (69%) remained in sinus rhythm, 9 have developed atrial fibrillation, 3 are in atrial flutter or atrial tachycardia, 1 patient reports ongoing palpitations with no documented arrhythmia and 1 patient has died. Procedural complications were major venous access bleeding (2), transient heart block during slow pathway ablation with late complete heart block (1).</AbstractText>The majority of arrhythmias in adult patients with congenital heart defects can be successfully treated with radiofrequency ablation at a relatively low risk.</AbstractText> |
11,456 | Transcollateral retrograde diagnostic coronary angiogram - important therapeutic implications for an occluded arterial coronary artery bypass graft. | This case illustrates the potential clinical usefulness of retrograde approach for selective visualization of distal vessels in a patient with multiple coronary chronic total occlusions and previous coronary artery bypass graft (CABG) surgery. By knowing in extreme detail the exact anatomy of the complex post-surgical coronary system, a successful treatment can be planned for the patient. |
11,457 | Exome sequencing identifies a mutation in the ACTN2 gene in a family with idiopathic ventricular fibrillation, left ventricular noncompaction, and sudden death. | Potentially lethal and heritable cardiomyopathies and cardiac channelopathies are caused by heterogeneous autosomal dominant mutations in over 50 distinct genes, and multiple genes are responsible for a given disease. Clinical genetic tests are available for several of the inherited cardiac diseases and clinical investigations guide which test to order. This study describes a family with cardiac disease in which marked clinical diversity exists. In the absence of a unified clinical diagnosis, we used exome sequencing to identify a causal mutation.</AbstractText>Clinical evaluation of family members was performed, including physical examination, electrocardiography, 2D transthoracic echocardiography and review of autopsy records. Exome sequencing was performed on a clinically affected individual and co-segregation studies and haplotype analysis were performed to further confirm pathogenicity.</AbstractText>Clinically affected members showed marked cardiac phenotype heterogeneity. While some individuals were asymptomatic, other presentations included left ventricular non-compaction, a resuscitated cardiac arrest due to idiopathic ventricular fibrillation, dilated cardiomyopathy, and sudden unexplained death. Whole exome sequencing identified an Ala119Thr mutation in the alpha-actinin-2 (ACTN2) gene that segregated with disease. Haplotype analysis showed that this mutation segregated with an identical haplotype in a second, previously described family with clinically diverse cardiac disease, and is likely inherited from a common ancestor.</AbstractText>Mutations in the ACTN2 gene can be responsible for marked cardiac phenotype heterogeneity in families. The diverse mechanistic roles of ACTN2 in the cardiac Z-disc may explain this heterogeneous clinical presentation. Exome sequencing is a useful adjunct to cardiac genetic testing in families with mixed clinical presentations.</AbstractText> |
11,458 | Minimally invasive right thoracotomy approach for mitral valve surgery in patients with previous sternotomy: a single institution experience with 173 patients. | This study presents a review of our experience with minimally invasive mitral valve surgery (MIMVS) in patients with a previous cardiac procedure performed through a sternotomy over a 10-year period.</AbstractText>From November 2003 to August 2013, 173 patients (age 61.3 ± 12.4 years) underwent reoperative MIMVS through a right minithoracotomy. Previous operations were coronary artery bypass grafting (n = 49; 28.6%), a mitral valve procedure (n = 120; 70.1%), an aortic valve procedure (n = 32; 18.7%), and other operations (n = 14; 8.1%). The mean euroSCORE was 11.2 ± 3.8. The time to redo surgery was 6.9 ± 4.2 years.</AbstractText>Procedures were performed with central aortic cannulation in 55 patients (31.7%) and peripheral cannulation in 118 (68.3%). A transthoracic clamp was used in 58 patients (33.5%), an endoaortic balloon in 72 (41.6%), hypothermic ventricular fibrillation in 23 (13.2%), and beating heart in 20 (11.5%). Mean cardiopulmonary bypass and crossclamp times were 160 ± 58 minutes and 82 ± 49 minutes, respectively. Mitral repair was performed in 53 patients (30.6%). Forty-three patients (24.7%) had an additional cardiac procedure. Conversion to sternotomy was necessary in 2 patients (1.1%) and reoperation for bleeding in 11 patients (6.3%). Thirty-day mortality was 4.1% (n = 7). Major morbidities included stroke (n = 11; 6%) and new-onset dialysis requirement (n = 4; 2.3%). The mean blood transfusion requirement was 1.4 ± 1.1 units. Mean follow-up was 3.3 ± 2.6 years. Survival at 1, 5, and 10 years was 93.1% ± 1.9%, 87.5% ± 2.7%, and 79.7% ± 3.8%, respectively.</AbstractText>Reoperative mitral valve surgery can be safely performed through a right minithoracotomy with good early and late outcomes. The avoidance of extensive surgical dissection, optimal valve exposure, and low blood transfusion are the main advantages of this technique.</AbstractText>Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,459 | Torasemide reduces dilated cardiomyopathy, complication of arrhythmia, and progression to heart failure. | The aim of this study was to analyze the incidence and types of arrhythmia and their relationship with the severity and prognosis of chronic heart failure (CHF) in patients with dilated cardiomyopathy (DCM), and to investigate the therapeutic effect of torasemide versus furosemide on CHF and incidence of arrhythmia. DCM patients with NYHA cardiac function II-IV were continuously monitored using a 24-h dynamic electrocardiogram (Holter), and arrhythmia incidence was analyzed by computer automatic analysis combined with manual assessment. In total, 125 participants were evenly divided into two groups: torasemide group which received 10 mg oral torasemide once daily) and regular anti-heart failure treatment (N=65), and furosemide group which received torasemide (20 mg once daily orally) and regular antiheart failure treatment (N=60). Another 60 normal healthy persons served as the normal control group. Incidence and severity of arrhythmia increased when degree of CHF was elevated. Size of left atrium was related to atrial fibrillation and size of left ventricle was related to malignant arrhythmia. At 3 months after treatment, cardiac function in both groups improved and incidence and severity of arrhythmia in both groups were reduced. However, left ventricular ejection fraction (LVEF) was higher in the torasemide group than in the furosemide group, while incidence of arrhythmia was lower in the torasemide group. Arrhythmias frequently occurred in patients with DCM and HF. Type of cardiac arrhythmia is closely related to ventricular enlargement and cardiac function grade. Torasemide is better for improving cardiac function to reduce arrhythmia and CHF compared to furosemide. |
11,460 | Electrical storm in patients with brugada syndrome is associated with early repolarization. | Electrical storms (ESs) in patients with Brugada syndrome (BrS) are rare though potentially lethal.</AbstractText>We studied 22 men with BrS and ES, defined as ≥3 episodes/d of ventricular fibrillation (VF) and compared their characteristics with those of 110 age-matched, control men with BrS without ES. BrS was diagnosed by a spontaneous or drug-induced type 1 pattern on the ECG in the absence of structural heart disease. Early repolarization (ER) was diagnosed by J waves, ie, >0.1 mV notches or slurs of the terminal portion of the QRS complex. The BrS ECG pattern was provoked with pilsicainide. A spontaneous type I ECG pattern, J waves, and horizontal/descending ST elevation were found, respectively, in 77%, 36%, and 88% of patients with ES, versus 28% (P<0.0001), 9% (P=0.003), and 60% (P=0.06) of controls. The J-wave amplitude was significantly higher in patients with than without ES (P=0.03). VF occurred during undisturbed sinus rhythm in 14 of 19 patients (74%), and ES were controlled by isoproterenol administration. All patients with ES received an implantable cardioverter defibrillator and over a 6.0±5.4 years follow-up, the prognosis of patients with ES was significantly worse than that of patients without ES. Bepridil was effective in preventing VF in 6 patients.</AbstractText>A high prevalence of ER was found in a subgroup of patients with BrS associated with ES. ES appeared to be suppressed by isoproterenol or quinidine, whereas bepridil and quinidine were effective in the long-term prevention of VF in the highest-risk patients.</AbstractText>© 2014 American Heart Association, Inc.</CopyrightInformation> |
11,461 | Ablation of ventricular arrhythmias. | Ventricular arrhythmias (VAs) commonly occur in patients with structural heart disease and may present as ventricular premature depolarizations (VPDs), monomorphic ventricular tachycardia (VT), or polymorphic VT/ventricular fibrillation. Idiopathic VAs can also occur in patients with normal hearts. This review explores the etiology, clinical presentation, and management strategies for different types of VAs. Medical and invasive treatment strategies are discussed, and different approaches to catheter ablation are outlined. While ablation of VPDs and idiopathic VT provides a cure for the majority of patients, investigation is ongoing to define the optimal ablation strategy for patients with scar-related VT. |
11,462 | Feasibility of neuromuscular electrical stimulation immediately after cardiovascular surgery. | To determine the safety and feasibility of neuromuscular electrical stimulation (NMES) from postoperative days (PODs) 1 to 5 after cardiovascular surgery.</AbstractText>Pre-post interventional study.</AbstractText>Surgical intensive care unit and thoracic surgical ward of a university hospital.</AbstractText>Consecutive patients (N=144) who underwent cardiovascular surgery were included. Patients with peripheral arterial disease, psychiatric disease, neuromuscular disease, and dementia were excluded. Patients with severe chronic renal failure and those who required prolonged mechanical ventilation after surgery were also excluded because of the possibility of affecting the outcome of a future controlled study.</AbstractText>NMES to the lower extremities was implemented from PODs 1 to 5.</AbstractText>Feasibility outcomes included compliance, the number of the patients who had changes in systolic blood pressure (BP) >20 mmHg or an increase in heart rate >20 beats/min during NMES, and the incidence of temporary pacemaker malfunction or postoperative cardiac arrhythmias.</AbstractText>Sixty-eight of 105 eligible patients participated in this study. Sixty-one (89.7%) of them completed NMES sessions. We found no patients who had excessive changes in systolic blood pressure, increased heart rate, or pacemaker malfunction during NMES. Incidence of atrial fibrillation during the study period was 26.9% (7/26) for coronary artery bypass surgery, 18.2% (4/22) for valvular surgery, and 20.0% (4/20) for combined or aortic surgery. No sustained ventricular arrhythmia or ventricular fibrillation was observed.</AbstractText>The results of this study demonstrate that NMES can be safely implemented even in patients immediately after cardiovascular surgery.</AbstractText>Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,463 | Preoperative risk factors of medium-term mitral valve repair outcome. | This study aimed to evaluate risk factors that affect mitral valve (MV) repair outcomes.</AbstractText>From 2002 to 2012, 580 consecutive patients with mitral regurgitation (MR) underwent MV repair. Of the total number of patients, 48.9% were found to be in New York Heart Association (NYHA) Class III or IV. Anterior, posterior and bileaflet prolapse was present in 34.8, 47.6 and 17.6% of patients, respectively. Atrial fibrillation (AF) was found in 29.7% of patients. The mean follow-up was 5.3 ± 2.6 years.</AbstractText>There were eight early and 14 late deaths. NYHA Class III/IV, left ventricular ejection fraction ≤50%, systolic pulmonary artery pressure ≥50 mmHg, AF and low cardiac output syndrome with extracorporeal membrane oxygen were independent predictors of early mortality. AF, NYHA Class III/IV, left ventricular end-systolic diameter ≥40 mm and systolic pulmonary artery pressure ≥50 mmHg remained predictors of late mortality. At 5 years, the rate of survival, freedom from reoperation and recurrent moderate to severe MR was 99.0 ± 0.6 97.2 ± 0.8 and 93.3 ± 1.2%, respectively. Anterior leaflet involvement was predictive of reoperation and recurrent moderate to severe MR. In patients with a moderate tricuspid regurgitation (TR) and annulus <40 mm, the degree of TR during follow-up was worse with right ventricular dilatation.</AbstractText>MV repair should be performed before the deterioration of ventricular function, development of pulmonary hypertension and AF occurrence. The pathophysiology of MR affects MV repair durability, while concomitant tricuspid annuloplasty should be considered in patients with moderate TR despite annular dilatation.</AbstractText>© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.</CopyrightInformation> |
11,464 | Frequency of supraventricular arrhythmias in patients with idiopathic pulmonary arterial hypertension. | Supraventricular arrhythmias (SVA) may be risk factors of prognosis in patients with pulmonary arterial hypertension. SVA are increasingly reported in patients with pulmonary hypertension, but little is known about their incidence and outcomes for patients with idiopathic pulmonary arterial hypertension (IPAH) in a large cohort. In this 6-year prospective multicenter study, 280 patients with IPAH were enrolled to investigate the incidence of SVA and assess risk factors, clinical manifestation, management, and impact on survival. The cumulative 6-year incidence of SVA was 15.8%. The most common types of SVA were atrial fibrillation (n = 16) and atrial flutter (n = 13), followed by atrial tachycardia (n = 11). Most episodes of SVA were associated with significant clinical deterioration and right-sided cardiac failure. Sinus rhythm was successfully restored in most patients, resulting in clinical recovery. Increased right ventricular diameter, left atrial area, and higher right atrial pressure and pulmonary vascular resistance were associated with increased risk for experiencing SVA. SVA predicted a greater risk for mortality in a stepwise forward Cox analysis (hazard ratio 4.757, 95% confidence interval 2.695 to 8.397, p <0.001). Kaplan-Meier survival curves showed that patients with SVA, mainly permanent SVA, had a lower survival rate than those who did not develop SVA (p = 0.008). In conclusion, SVA often lead to clinical deterioration and may be associated with an increased risk for death in a large cohort of patients with IPAH. Restoration and maintenance of sinus rhythm are important treatment goals in patients with IPAH. |
11,465 | Current approaches to antiarrhythmic therapy in heart failure. | Atrial fibrillation (AF) is exceedingly common in patients with heart failure (HF), as they share common risk factors. Rate control is the cornerstone of treatment for AF; however, restoration of sinus rhythm should be considered when more than minimal symptoms are present. Life-threatening ventricular arrhythmias are responsible for the primary mode of death in patients with NYHA I, II, or III HF. Although implantable cardioverter defibrillators protect against sudden cardiac arrest, many patients will present with VT or ICD shocks. Antiarrhythmic drug therapy beyond beta-blocker therapy remains fundamental to the termination of acute VT and the prevention of ICD shocks. |
11,466 | Enhancing approaches to therapeutic hypothermia in patients with sudden circulatory arrest. | Cardiac arrest is common and causes substantial morbidity and mortality. Despite advances in prevention and resuscitation, most patients remain unconscious and survival remains poor. Therapeutic hypothermia (32-34 °C) has emerged as a potent neuroprotective modality following resuscitation. In early clinical trials, application of therapeutic hypothermia improved survival in patients with ventricular fibrillation (VF), which led to the recommended use of therapeutic hypothermia for patients resuscitated from VF. However, two recent clinical trials have challenged some assumptions. First, the use of paramedic-initiated rapid infusion of cold crystalloids as a mean to achieve faster cooling rates after resuscitation in patients with and without VF arrest did not improve survival. Second, once patients were admitted to the hospital, targeting their temperature to 33 versus 36 °C for 36 h (in addition to active hyperthermia prevention) after out-of-hospital cardiac arrest did not to change clinical outcomes, suggesting that 36 °C may represent the target temperature instead of temperatures of less than 34 °C. |
11,467 | Mapping and ablating ventricular premature contractions that trigger ventricular fibrillation: trigger elimination and substrate modification. | Ventricular fibrillation (VF) is a malignant arrhythmia, usually initiated by a ventricular premature contraction (VPC) during the vulnerable period of cardiac repolarization. Ablation therapy for VF has been described and increasingly reported. Targets for VF triggers are VPC preceded Purkinje potentials or the right ventricular outflow tract (RVOT) in structurally normal hearts, and VPC triggers preceded by Purkinje potentials in ischemic cardiomyopathy. The most important issue before the ablation session is the recording of the 12-lead electrocardiogram (ECG) of the triggering event, which can prove invaluable in regionalizing the origin of the triggering VPC for more detailed mapping. In cases where the VPC is not spontaneous or inducible, ablation may be performed by pacemapping. During the session, mapping should be focused on the earliest activation and determining the earliest potential is the key to a successful ablation. However, a modification of the Purkinje network might be applied when the earliest site cannot be determined or is located close to the His-bundle. Furthermore, the electrical isolation of the pulmonary artery (PA) can suppress RVOT type polymorphic ventricular tachycardia in some patients with rapid triggers from the PA. Suppression of VF can be achieved by not only the elimination of triggering VPCs, but also by substrate modification of possible reentry circuits in the Purkinje network, or between the PA and RVOT. Further studies are needed to evaluate the precise mechanisms of this arrhythmia. |
11,468 | Effects of ramipril on ventricular arrhythmia after myocardial infarction in rabbits. | Ventricular arrhythmia (VA) is one of the most common complications of myocardial infarction (MI), and ventricular tachycardia and fibrillation are the main causes for sudden cardiac death. This study aimed to explore the effect of ramipril on the occurrence of VA and its mechanism after MI in rabbits.</AbstractText>Twenty-four New Zealand rabbits purchased from the Wuhan Laboratory Animal Research Center were divided into three groups: sham-operated (SHAM) group (n=8), MI group (n=8) and MI with ramipril (RAM) group (n=8). Rabbits in the SHAM group received a median sternotomy without ligation of the left ventricular coronary artery. Rabbits in the MI and RAM groups received a median sternotomy followed by ligation of the left coronary artery. The successful anterior MI was confirmed by elevation of the ST segment with more than 0.2 mV in lead II and III. After MI, rabbits in the RAM group were fed with intragastric ramipril (1 mg/kg per day) for 12 weeks. Before and 12 weeks after MI in the three groups, ventricular tachycardia or fibrillation (VT/VF) episodes and MAP in cadiocytes of the epicardium, mid-myocardium and endocardium were recorded by a multichannel physiograph. Student's t test and ANOVA were used for statistical analysis.</AbstractText>VT/VF episodes were decreased more markedly in the RAM group than in the MI group after 12 weeks (2.6±0.8 vs. 12.4±2.9, P<0.05). Twelve weeks after MI, the duration of repolarization for 90% (APD90) of three-tier ventricular myocytes in the MI group was longer than that before MI (258.2±21.1 vs. 230.1±23.2, 278.0±23.8 vs. 245.8±25.4, 242.6±22.7 vs. 227.0±21.7, P<0.05). However, the APD90 was not significantly different at 12 weeks before and after MI in the RAM group (P>0.05). Moreover, the transmural dispersion of repolarization (TDR) was increased more markedly 12 weeks after MI in the MI group than in the SHAM and RAM groups (36.2±10.2 vs. 18.7±6.2, 24.9±8.7, P<0.05). But the TDR was not significantly different between the RAM and SHAM groups (18.7±6.2 vs. 24.9±8.7, P>0.05).</AbstractText>Ramipril may reduce the incidence of malignant ventricular arrhythmia via improvement of transmembrance repolarization heterogeneity after MI.</AbstractText> |
11,469 | Changes of end-tidal carbon dioxide during cardiopulmonary resuscitation from ventricular fibrillation versus asphyxial cardiac arrest. | Partial pressure of end-tidal carbon dioxide (PETCO2) has been used to monitor the effectiveness of precordial compression (PC) and regarded as a prognostic value of outcomes in cardiopulmonary resuscitation (CPR). This study was to investigate changes of PETCO2 during CPR in rats with ventricular fibrillation (VF) versus asphyxial cardiac arrest.</AbstractText>Sixty-two male Sprague-Dawley (SD) rats were randomly divided into an asphyxial group (n=32) and a VF group (n=30). PETCO2 was measured during CPR from a 6-minute period of VF or asphyxial cardiac arrest.</AbstractText>The initial values of PETCO2 immediately after PC in the VF group were significantly lower than those in the asphyxial group (12.8±4.87 mmHg vs. 49.2±8.13 mmHg, P=0.000). In the VF group, the values of PETCO2 after 6 minutes of PC were significantly higher in rats with return of spontaneous circulation (ROSC), compared with those in rats without ROSC (16.5±3.07 mmHg vs. 13.2±2.62 mmHg, P=0.004). In the asphyxial group, the values of PETCO2 after 2 minutes of PC in rats with ROSC were significantly higher than those in rats without ROSC (20.8±3.24 mmHg vs. 13.9±1.50 mmHg, P=0.000). Receiver operator characteristic (ROC) curves of PETCO2 showed significant sensitivity and specificity for predicting ROSC in VF versus asphyxial cardiac arrest.</AbstractText>The initial values of PETCO2 immediately after CPR may be helpful in differentiating the causes of cardiac arrest. Changes of PETCO2 during CPR can predict outcomes of CPR.</AbstractText> |
11,470 | A review of multisite pacing to achieve cardiac resynchronization therapy. | Non-response to cardiac resynchronization therapy remains a significant problem in up to 30% of patients. Multisite stimulation has emerged as a way of potentially overcoming non-response. This may be achieved by the use of multiple leads placed within the coronary sinus and its tributaries (dual-vein pacing) or more recently by the use of multipolar (quadripolar) left ventricular pacing leads which can deliver pacing stimuli at multiple sites within the same vein. This review covers the role of multisite pacing including the interaction with the underlying pathophysiology, the current and planned studies, and the potential pitfalls of this technology. |
11,471 | Cardiopulmonary resuscitation (CPR) plus delayed defibrillation versus immediate defibrillation for out-of-hospital cardiac arrest. | Sudden cardiac arrest (SCA) is a common health problem associated with high levels of mortality. Cardiac arrest is caused by three groups of dysrhythmias: ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), pulseless electric activity (PEA) and asystole. The most common dysrhythmia found in out-of-hospital cardiac arrest (OHCA) is VF. During VF or VT, cardiopulmonary resuscitation (CPR) provides perfusion and oxygenation to the tissues, whilst defibrillation restores a viable cardiac rhythm. Early successful defibrillation is known to improve outcomes in VF/VT. However, it has been hypothesized that a period of CPR before defibrillation creates a more conducive physiological environment, increasing the likelihood of successful defibrillation. The order of priority of CPR versus defibrillation therefore remains in contention. As previous studies have remained inconclusive, we conducted a systematic review of available evidence in an attempt to draw conclusions on whether CPR plus delayed defibrillation or immediate defibrillation resulted in better outcomes in OHCA.</AbstractText>To examine whether an initial one and one-half to three minutes of CPR administered by paramedics before defibrillation versus immediate defibrillation on arrival influenced survival rates, neurological outcomes or rates of return of spontaneous circulation (ROSC) in OHCA.</AbstractText>We searched the following databases: the Cochrane Central Register of Controlled trials (CENTRAL) (2013, Issue 6); MEDLINE (Ovid) (1948 to May 2013); EMBASE (1980 to May 2013); the Institute for Scientific Information (ISI) Web of Science (1980 to May 2013) and the China Academic Journal Network Publishing Database (China National Knowledge Infrastructure (CNKI), 1980 to May 2013). We included studies published in all languages. We also searched the Current Controlled Trials and Clinical Trials databases for ongoing trials. We screened the references lists of studies included in our review against the reference lists of relevant International Liaison Committee on Resuscitation (ILCOR) evidence worksheets.</AbstractText>Our participant group consisted of adults over 18 years of age presenting with OHCA who were in VF or pulseless VT at the time of emergency medical service (EMS) paramedic arrival. We included randomized controlled trials (RCTs) and quasi-randomized controlled trials that evaluated the effects of one and one-half to three minutes of CPR versus defibrillation as initial therapy on survival and neurological outcomes of these participants. We excluded observational and cross-over design studies.</AbstractText>Two review authors independently extracted the data. We contacted study authors to ask for additional data when required. The risk ratio (RR) for each outcome was calculated and summarized in the meta-analysis after heterogeneity was considered. We used Review Manager software for all analyses.</AbstractText>We included four RCTs with a total of 3090 enrolled participants (one study used a cluster-randomized design). Three trials were considered to have a relatively low risk of bias, and one trial was considered to have a relatively high risk. When survival to hospital discharge was compared, 38 of 320 (11.88%) participants survived to discharge in the initial CPR plus delayed defibrillation group compared with 39 of 338 participants (11.54%) in the immediate defibrillation group (RR 1.09, 95% CI 0.54 to 2.20, Chi(2) = 10.78, degrees of freedom (df) = 5, P value 0.06, I(2) = 54%, low-quality evidence).When we compared the neurological outcome at hospital discharge (RR 1.12, 95% CI 0.65 to 1.93, low-quality evidence), the rate of return of spontaneous circulation (ROSC) (RR 0.94, 95% CI 0.77 to 1.15,low-quality evidence) and survival at one year (RR 0.77, 95% CI 0.24 to 2.49, low-quality evidence), we could not rule out the superiority of either treatment.Adverse effects were not associated with either treatment.</AbstractText><AbstractText Label="AUTHORS' CONCLUSIONS" NlmCategory="CONCLUSIONS">Owing to the low quality of available evidence, we have been unable to determine conclusively whether immediate defibrillation and one and one-half to three minutes of CPR as initial therapy before defibrillation have similar effects on rates of return of spontaneous circulation, survival to discharge or neurological insult.We have also been unable to conclude whether either treatment approach provides a degree of superiority in OHCA.We propose that this is an area that needs further rigorous research through additional high-quality RCTs, including larger sample sizes and proper subgroup analysis.</AbstractText> |
11,472 | Off-pump coronary surgery: current justifications. | Although the literature has failed to project an overall superiority of off-pump vs. on-pump surgery, nevertheless, small randomized control trials and large meta-analysis studies have concluded that the incidence of a stroke is less than 1 % when anaortic off-pump techniques are advocated in patients with diseased ascending aorta. Furthermore, off-pump techniques or their combination with hybrid procedures may lead to a reduction of adverse outcome in the aged high-risk population with concomitant poor left ventricular function and co-morbidities. However, despite this, controversy still exists among the cardiac surgery community in terms of the benefit of this technique and its safety; hence, off-pump is becoming out of fashion. In this review paper, by looking at a "marginal group of patients" (elderly, high risks, atherosclerotic aortas) we attempt to re-establish and justify this technique and re-invent its usage. |
11,473 | Interhospital air transport of a blind patient on extracorporeal life support with consecutive and successful left ventricular assist device implantation. | The use of extracorporeal life support systems (ECLS) in patients with postcardiotomy low cardiac output syndrome (LCO) as a bridge to recovery and bridge to implantation of ventricular assist device (VAD) is common nowadays. A 59-year-old patient with acute myocardial infarction received a percutaneous transluminal angioplasty and stenting of the circumflex artery. During catheterization of the left coronary artery (LAD), the patient showed ventricular fibrillation and required defibrillation and cardiopulmonary resuscitation. After implantation of an intra-aortic balloon pump, the patient immediately was transmitted to the operating room. He received emergency coronary artery bypass grafting in a beating heart technique using pump-assisted minimal extracorporeal circulation circuit (MECC). Two bypass grafts were performed to the LAD and the right posterior descending artery. Despite initial successful weaning off cardiopulmonary bypass with high-dose inotropic support, the patient presented postcardiotomy LCO and an ECLS was implanted. The primary setup of the heparin-coated MECC system was modified and used postoperatively. As a result of the absence of an in-house VAD program, the patient was switched to a transportable ECLS the next day and was transferred by helicopter to the nearest VAD center where the patient received a successful insertion of a left VAD 3 days later. |
11,474 | Pre-hospital versus in-hospital thrombolysis for ST-elevation myocardial infarction. | Early thrombolysis for individuals experiencing a myocardial infarction is associated with better mortality and morbidity outcomes. While traditionally thrombolysis is given in hospital, pre-hospital thrombolysis is proposed as an effective intervention to save time and reduce mortality and morbidity in individuals with ST-elevation myocardial infarction (STEMI). Despite some evidence that pre-hospital thrombolysis may be delivered safely, there is a paucity of controlled trial data to indicate whether the timing of delivery can be effective in reducing key clinical outcomes.</AbstractText>To assess the morbidity and mortality of pre-hospital versus in-hospital thrombolysis for STEMI.</AbstractText>We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), two citation indexes on Web of Science (Thomson Reuters) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for randomised controlled trials and grey literature published up to June 2014. We also searched the reference lists of articles identified, clinical trial registries and unpublished thesis sources. We did not contact pharmaceutical companies for any relevant published or unpublished articles. We applied no language, date or publication restrictions. The Cochrane Heart Group conducted the primary electronic search.</AbstractText>We included randomised controlled trials of pre-hospital versus in-hospital thrombolysis in adults with ST-elevation myocardial infarction diagnosed by a healthcare provider.</AbstractText>Two authors independently screened eligible studies for inclusion and carried out data extraction and 'Risk of bias' assessments, resolving any disagreement by consulting a third author. We contacted authors of potentially suitable studies if we required missing or additional information. We collected efficacy and adverse effect data from the trials.</AbstractText>We included three trials involving 538 participants. We found low quality of evidence indicating uncertainty whether pre-hopsital thrombolysis reduces all-cause mortality in individuals with STEMI compared to in-hospital thrombolysis (risk ratio 0.73, 95% confidence interval 0.37 to 1.41). We found high-quality evidence (two trials, 438 participants) that pre-hospital thrombolysis reduced the time to receipt of thrombolytic treatment compared with in-hospital thrombolysis. For adverse events, we found moderate-quality evidence that the occurrence of bleeding events was similar between participants receiving in-hospital or pre-hospital thrombolysis (two trials, 438 participants), and low-quality evidence that the occurrence of ventricular fibrillation (two trials, 178 participants), stroke (one trial, 78 participants) and allergic reactions (one trial, 100 participants) was also similar between participants receiving in-hospital or pre-hospital thrombolysis. We considered the included studies to have an overall unclear/high risk of bias.</AbstractText><AbstractText Label="AUTHORS' CONCLUSIONS" NlmCategory="CONCLUSIONS">Pre-hospital thrombolysis reduces time to treatment, based on studies conducted in higher income countries. In settings where it can be safely and correctly administered by trained staff, pre-hospital thrombolysis may be an appropriate intervention. Pre-hospital thrombolysis has the potential to reduce the burden of STEMI in lower- and middle-income countries, especially in individuals who have limited access to in-hospital thrombolysis or percutaneous coronary interventions. We found no randomised controlled trials evaluating the efficacy of pre-hospital thrombolysis for STEMI in lower- and middle-income countries. Large high-quality multicentre randomised controlled trials implemented in resource-constrained countries will provide additional evidence for the efficacy and safety of this intervention. Local policy makers should consider their local health infrastructure and population distribution needs. These considerations should be taken into account when developing clinical guidelines for pre-hospital thrombolysis.</AbstractText> |
11,475 | Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival. | To describe out-of-hospital cardiac arrest (OHCA) in Sweden from a long-term perspective in terms of changes in outcome and circumstances at resuscitation.</AbstractText>All cases of OHCA (n = 59,926) reported to the Swedish Cardiac Arrest Register from 1992 to 2011 were included. The number of cases reported (n/100,000 person-years) increased from 27 (1992) to 52 (2011). Crew-witnessed cases, cardiopulmonary resuscitation prior to the arrival of the emergency medical service (EMS), and EMS response time increased (P < 0.0001). There was a decrease in the delay from collapse to calling for the EMS in all patients and from collapse to defibrillation among patients found in ventricular fibrillation (P < 0.0001). The proportion of patients found in ventricular fibrillation decreased from 35 to 25% (P < 0.0001). Thirty-day survival increased from 4.8 (1992) to 10.7% (2011) (P < 0.0001), particularly among patients found in a shockable rhythm and patients with return of spontaneous circulation (ROSC) at hospital admission. Among patients hospitalized with ROSC in 2008-2011, 41% underwent therapeutic hypothermia and 28% underwent percutaneous coronary intervention. Among 30-day survivors in 2008-2011, 94% had a cerebral performance category score of 1 or 2 at discharge from hospital and the results were even better if patients were found in a shockable rhythm.</AbstractText>From a long-term perspective, 30-day survival after OHCA in Sweden more than doubled. The increase in survival was most marked among patients found in a shockable rhythm and those hospitalized with ROSC. There were improvements in all four links in the chain of survival, which might explain the improved outcome.</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> |
11,476 | Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest. | Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation.</AbstractText>We sought to describe our institution's experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge.</AbstractText>Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007-April 2014.</AbstractText>During the study period, 26 patients were included. Average age was 40±15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12-180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months.</AbstractText>ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.</AbstractText>Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,477 | Renewed impact of lidocaine on refractory ventricular arrhythmias in the amiodarone era. | Recent guidelines for treating ventricular fibrillation (VF) and ventricular tachycardia (VT) stress class III antiarrhythmic drugs, but some malignant arrhythmias refractory to these agents still occur in clinical practice. The possibility of a new treatment strategy involving lidocaine and amiodarone combination therapy was evaluated.</AbstractText>From September 2008 to September 2013, 62 patients were treated at our hospital with lidocaine. The medical records were retrospectively reviewed. Twenty inappropriate patients were excluded. The remaining 42 patients were analyzed. Patients were divided into two groups according to the effectiveness of lidocaine in terminating refractory ventricular arrhythmias: the effective group.</AbstractText>LVEF was significantly higher in the lidocaine effective (E) group compared to the ineffective (I) group (44±16% vs. 32±10%, p=0.027). There were more patients already on amiodarone at the start of lidocaine therapy in the E group compared to the I group (11/26 vs. 1/16, p=0.012). Furthermore, patients receiving lidocaine without amiodarone were re-analyzed to estimate the actual effect of lidocaine. Of the 30 patients not receiving amiodarone, 15 were in the effective without amiodarone (E w/o A) group and 15 were in the ineffective without amiodarone (I w/o A) group. LVEF was significantly higher in the E w/o A group than in the I w/o A group (51±16% vs. 32±9%, p=0.001).</AbstractText>This retrospective study suggests that combination therapy with lidocaine and amiodarone can terminate most refractory ventricular arrhythmias. Even in patients with a sufficient LVEF not receiving amiodarone, it is possible that lidocaine can contribute to a favorable outcome.</AbstractText>Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,478 | P-wave duration in lead aVR and the risk of atrial fibrillation in hypertension. | Hypertension entails atrial remodeling that affect P-wave (PW) duration on electrocardiogram (ECG). PW indices (e.g., variance, dispersion, and terminal force) are associated with a higher risk for atrial fibrillation (AF), but their calculation requires multiple measurements of PW duration, limiting their use in clinical practice. We evaluated whether PW duration in specific ECG leads may identify patients with increased susceptibility to AF in a population of hypertensive patients.</AbstractText>In a case-control study, AF and control subjects were matched for age, sex, and left atrial (LA) dimensions. PW duration was measured from digitally stored ECGs. Logistic regression was used to assess the association of PW duration and indices with AF.</AbstractText>We enrolled 44 hypertensive AF patients (16 paroxysmal and 28 persistent) and 44 hypertensive controls. AF and control subjects were matched for sex (males, n = 27), age (67 ± 8 years), LA diameter (40 ± 5 mm), and were comparable for left ventricular mass (45 ± 11 g/m(2.7) vs 48 ± 12 g/m(2.7) , P = 0.19), ejection fraction (58 ± 7% in both groups), and prevalence of mild valvular heart disease (7% vs 5%; P = 0.64). PW duration in lead aVR was significantly higher in AF patients as compared with controls (115 ± 18 ms vs 101 ± 14 ms; P < 0.0001) and was the best independent predictor of AF in multivariable logistic regression (PW ≥ 100 ms: RR = 3.7; 95% CI: 1.3-10.3; P = 0.02).</AbstractText>Simple measurement of PW duration in lead aVR allows effective identification of AF patients in a population of hypertensives. Confirmation of this finding in a larger population would provide a simple and effective risk marker of AF in hypertensive patients.</AbstractText>© 2014 Wiley Periodicals, Inc.</CopyrightInformation> |
11,479 | Usefulness of arrhythmias as predictors of death and resource utilization in children with myocarditis. | Myocarditis in children can result in significant morbidity and mortality, yet limited prognostic data exist. The aim of this study was to test the hypothesis that pediatric patients with arrhythmias during hospitalization for acute myocarditis have worse outcomes and increased resource utilization. A retrospective study using the Pediatric Health Information System database was performed to examine the effects of clinically significant arrhythmias on in-hospital mortality, length of stay, and costs per day. Data were obtained for children ≤18 years of age, discharged from January 1, 2004 to March 31, 2013, with a diagnosis of myocarditis. Clinically significant tachyarrhythmia was defined as supraventricular tachycardia, atrial fibrillation or flutter, or ventricular tachycardia or fibrillation in patients receiving antiarrhythmic medications or cardioversion. Clinically significant bradyarrhythmia was defined as second-degree, complete, or other heart block for which a pacemaker was placed. Multivariable analyses were performed. A total of 2,041 subjects with myocarditis were identified. Tachyarrhythmias were reported in 234 (11.5%) and bradyarrhythmias in 22 (1.1%). Overall mortality was 8.7%. In multivariable analyses, after considering the effects of gender, age at admission, geographic region, year and month of admission, presence of congenital heart disease or an identified virus, and use of steroids, nonsteroidal anti-inflammatories, or inotropes, and after controlling for clustering by institution, tachyarrhythmias were associated with a 2.3 times increase in the odds of mortality (95% confidence interval 1.6 to 3.3, p < 0.001), a 58% increase in length of stay (95% confidence interval 38% to 82%, p < 0.001), and a 28% increase in costs per day (95% confidence interval 15% to 43%, p < 0.001). Bradyarrhythmia was not associated with mortality, length of stay, or costs per day. In conclusion, tachyarrhythmias are associated with significant increases in mortality and resource utilization in children with myocarditis. |
11,480 | Prevalence and long-term outcome of aortic prosthesis-patient mismatch in patients with paradoxical low-flow severe aortic stenosis. | Patients with severe aortic stenosis (AS) and paradoxical low flow (PLF) have worse outcome compared with those with normal flow. Furthermore, prosthesis-patient mismatch (PPM) after aortic valve replacement is a predictor of reduced survival. However, the prevalence and prognostic impact of PPM in patients with PLF-AS are unknown. We aimed to analyze the prevalence and long-term survival of PPM in patients with PLF-AS.</AbstractText>Between 2000 and 2010, 677 patients with severe AS, preserved left ventricular ejection fraction, and aortic valve replacement were included (74±8 years; 42% women; aortic valve area, 0.69±0.16 cm(2)). A PLF (indexed stroke volume ≤35 mL/m(2)) was found in 26%, and after aortic valve replacement, 54% of patients had PPM, defined as an indexed effective orifice area ≤0.85 cm(2)/m(2). The combined presence of PLF and PPM was found in 15%. Compared with patients with noPLF/noPPM, those with PLF/PPM were significantly older, with more comorbidities. They also received smaller and biological bioprosthesis more often (all P<0.01). Although early mortality was not significantly different between groups, the 10-year survival rate was significantly reduced in case of PLF/PPM compared with noPLF/noPPM (38±9% versus 70±5%; P=0.002), even after multivariable adjustment (hazard ratio, 2.58; 95% confidence interval, 1.5-4.45; P=0.0007).</AbstractText>In this large catheterization-based study, the coexistence of PLF-AS before surgery and PPM after surgery is associated with the poorest outcome.</AbstractText>© 2014 American Heart Association, Inc.</CopyrightInformation> |
11,481 | Atrial fibrillation presented with syncope in a jet pilot during daily briefing on squadron. | Syncope may be the initial clinical presentation of atrial fibrillation (AF) and has a great potential for incapacitation during flight. Herein is presented the case of a jet pilot who had paroxysmal palpitations accompanied with presyncope which progressed to syncope and was found to be associated with AF.</AbstractText>A 23-yr-old male jet pilot had a sudden syncope at the fifth minute of his presentation during the daily flight briefing. After he regained consciousness, he was transferred to the intensive care unit of the military hospital. His medical history revealed two episodes of syncope which resulted in spontaneous recovery and were not reported to the flight surgeon. He had no abnormal findings on his physical examination except heart rate, which was irregular and 110 bpm with a rapid ventricular response. His diagnosis was AF. Laboratory tests, including thyroid hormones, CBC, transthoracic echocardiography, ultrasonography of the abdomen, chest X-rays, and also a tilt table test, were normal. He had completely normal findings on 24-h ECG Holter monitoring except rare ventricular extrasystoles and had a negative treadmill stress test. AF spontaneously converted to sinus rhythm during the follow-up in the intensive care unit. He was temporarily grounded and returned to flying duties after a 3-mo follow-up period without any recurrent arrhythmia.</AbstractText>Syncope has various mechanisms and etiologies, and also a benign prognosis on the ground. However, not only vasovagal syncope, but also AF may be among the frequent causes of syncope in aviators and pilots, as was the case in the current study.</AbstractText> |
11,482 | Arrhythmias in Complex Congenital Heart Disease. | Late after surgical repair of complex congenital heart disease, atrial arrhythmias are a major cause of morbidity, and ventricular arrhythmias and sudden cardiac death are a major cause of mortality. The six cases in this article highlight common challenges in the management of arrhythmias in the adult congenital heart disease population. |
11,483 | Unilateral and multilateral congenital coronary-pulmonary fistulas in adults: clinical presentation, diagnostic modalities, and management with a brief review of the literature. | Congenital coronary-pulmonary fistulas (CPFs) are commonly unilateral, but bilateral and multilateral fistulas may occur. In multilateral CPFs, the value of a multidetector computed tomography (MDCT) imaging technique as an adjuvant to coronary angiography (CAG) is eminent. The purpose of this study was to describe the clinical presentation, diagnostic modalities, and management of coincidentally detected congenital CPFs.</AbstractText>Unilateral and multilateral coronary-pulmonary fistulas are increasingly detected due to the wide speard application of multidetector computed tomography which might be a supplementary or replacing to conventional coronary angiography.</AbstractText>We evaluated 14 adult patients with congenital coronary artery fistulas (CAFs) who were identified from several Dutch cardiology departments.</AbstractText>Fourteen adult patients (5 female and 9 male), with a mean age of 57.5 years (range, 24-80 years) had the following abnormal findings: audible systolic cardiac murmur (n = 4), chronic atrial fibrillation (n = 2), nonsustained ventricular tachycardia (n = 1), and cardiomegaly on chest x-ray (n = 2). Echocardiography revealed normal findings with trivial valvular abnormalities (n = 9), depressed left ventricle systolic function (n = 3), and severe mitral regurgitation and atrial dilatation (n = 2). The findings in the rest of the patients were unremarkable. CAG and MDCT were used as a diagnostic imaging techniques either alone (CAG, n = 6; MDCT, n = 1) or in combination (n = 7). Single modality and multimodality diagnostic methods revealed 22 fistulas including CPFs (n = 15), coronary cameral fistulas terminating into the right (n = 2) and the left atrium (n = 1), and systemic-pulmonary fistulas (n = 4). Of all of the fistulas, 10 were unilateral, 6 were bilateral, and 6 was hexalateral. (13) N-ammonia positron emission tomography-computed tomography was performed in 3 patients revealing decreased myocardial perfusion reserve.</AbstractText>CAG remains the gold standard for detection of CPFs. An adjuvant technique using MDCT provides full anatomical details of the fistulas.</AbstractText>© 2014 Wiley Periodicals, Inc.</CopyrightInformation> |
11,484 | Permanent pacing in nonagenarians over 20-year period. | Life expectancy increases progressively and nonagenarians are a growing population. We report trends in pacing and long-term outcome in nonagenarians over a 20-year period in a single center compared with those of younger patients.</AbstractText>We retrospectively reviewed all the patients who underwent their first pacemaker implantation from January 1, 1991 to December 31, 2010 and were followed through December 31, 2013.</AbstractText>During the study period, 1,009 patients underwent first pacemaker implantation: 45 patients were older than 90 years (mean age 92.5 ± 2.6) (4.5%); 21 were men. Battery replacement was performed in four patients in whom first implant was made at age ≥ 90 years (8.9%) and in 231 patients aged <90 (24%; P < 0.01). Syncope was the most common symptom leading to pacing, followed by dizziness and fatigue in all age groups; no significant difference of symptoms was found between patient age groups. In patients aged ≥ 90 atrioventricular block and atrial fibrillation with slow ventricular response were more frequent, while sick sinus syndrome and carotid sinus hypersensitivity were less frequent than in younger patients. Ventricular chamber pacemakers were implanted with significant growing frequency, according to the older patients' age. Neither the indication for pacemaker implantation nor pacing mode influenced survival.</AbstractText>Nonagenarians are a growing population. Symptoms leading to pacing in patients aged ≥ 90 were similar to those of younger patients, but different frequency was found in the electrocardiographic indications. Ventricular chamber pacemakers were significantly more implanted than dual-chamber pacemakers but without negative survival influence.</AbstractText>©2014 Wiley Periodicals, Inc.</CopyrightInformation> |
11,485 | Severe central sleep apnea is associated with atrial fibrillation in patients with left ventricular systolic dysfunction. | The results of previous studies investigating the association between atrial fibrillation (AF) and central sleep apnea (CSA) in patients with left ventricular (LV) systolic dysfunction are contradictory.</AbstractText>We prospectively enrolled 267 patients in this cross-sectional study with LV ejection fractions ≤50%, who were screened for sleep disordered breathing using cardiorespiratory polysomnography after patients with predominantly obstructive sleep apnea or insufficient sleep studies had been excluded.</AbstractText>AF at study entry was found in 70 of 267 patients (26%). CSA with an apnea/hypopnea index (AHI) ≥15/hour was present in 116 patients (43%) and 67 patients (25%) had severe CSA with an AHI > 30/hour. Univariate analysis revealed a significant association between AF and severe CSA, age, male gender, arterial hypertension, left atrial diameter, brain natriuretic peptide, chronic kidney disease, New York Heart Association class, digitalis, and the lack of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Multivariate analysis revealed a significant association between AF and severe CSA (odds ratio [OR]: 5.21; 95% confidence interval [CI]: 1.67-16.27, P = 0.01), age (OR: 1.22 per 5-year increase; 95% CI: 1.05-1.40, P = 0.01), left atrial diameter (OR 1.61 per 5-mm increase; 95% CI: 1.22-2.01, P < 0.01), and digitalis (OR: 2.7; 95% CI: 1.26-5.79, P = 0.01).</AbstractText>AF is associated with severe CSA but not with moderate CSA in addition to age, use of digitalis, and left atrial size in patients with LV systolic dysfunction. Future studies evaluating the potential benefit of adaptive servo-ventilation therapy to prevent AF or to decrease the AF burden in heart failure patients should therefore focus on patients with severe central sleep apnea.</AbstractText>© 2014 Wiley Periodicals, Inc.</CopyrightInformation> |
11,486 | Beyond ventricular fibrillation analysis: comprehensive waveform analysis for all cardiac rhythms occurring during resuscitation. | To propose a method which analyses the electrocardiogram (ECG) waveform of any cardiac rhythm occurring during resuscitation and computes the probability of that rhythm converting into another with better prognosis (Pdes).</AbstractText>Rhythm transitions occurring spontaneously or due to defibrillation were analyzed. For each possible rhythm, ventricular fibrillation/ventricular tachycardia (VF/VT), pulseless electrical activity (PEA), pulse-generating rhythm (PR) and asystole (AS), the desired and undesired transitions were defined. ECG segments corresponding to the last 3s of rhythms prior to transition were used to extract waveform features. For each rhythm type, waveform features were combined into a logistic regression model to develop a rhythm specific classifier of desired transitions. This model was the monitoring function for the Pdes. The capacity of each rhythm specific classifier to discriminate between desired and undesired transitions was evaluated in terms of area under the curve (AUC). Pdes was integrated into a state sequence representation, which structures the information of cardiac arrest episodes, to analyze the effect of therapy on patient. As a case study, the effect of optimal/suboptimal cardiopulmonary resuscitation (CPR) on Pdes was analyzed. The mean Pdes was computed for the pre- and post-CPR intervals which presented the same underlying rhythm. The relationship between the optimal/suboptimal CPR and increase/decrease of Pdes was analyzed.</AbstractText>The AUC was 0.80, 0.79, 0.73 and 0.61 for VF/VT, PEA, PR and AS respectively. The Pdes quantified the probability of every rhythm of the episode developing to a better state, and the evolution of Pdes was coherent with the provided therapy. The case study indicated, for most rhythms, that positive trends in the dynamic behaviour could be associated with optimal CPR, whereas the opposite seemed true for negative trends.</AbstractText>A method for continuous ECG waveform analysis covering all cardiac rhythms during resuscitation has been proposed. This methodology can be further developed to be used in retrospective studies of CPR techniques, and, in the future, for potentially monitoring in real time the probability of survival of patients being resuscitated.</AbstractText>Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
11,487 | Thoracoscopic lung biopsy in 285 patients with diffuse pulmonary disease. | Surgical lung biopsy is generally considered the most appropriate method for diagnosing diffuse lung disease. However, there are few reports focusing on only one thoracoscopic technique. This study was designed to determine the morbidity and mortality related to video-assisted thoracoscopic lung biopsy in a single center, thereby providing data on the severity of morbidity and clarifying the risk factors.</AbstractText>We analyzed 285 patients with undiagnosed diffuse lung disease who underwent video-assisted thoracoscopic lung biopsy at Kanagawa Cardiovascular and Respiratory Center from February 2007 to April 2012. We recorded the severity of postoperative complications using the Clavien-Dindo classification.</AbstractText>The surgical morbidity was 7.0% (20/285), including delayed pulmonary fistulas in 11 patients, acute exacerbation in 3, prolonged air leakage (>7 days) in 2, hypoxemia in 2, atrial fibrillation in 1, and premature ventricular contraction in 1. Based on the Clavien-Dindo classification, grade I, II, IIIa, IIIb, and IVa complications accounted for 20%, 10%, 50%, 5%, and 15%, respectively. The 30-day mortality was 0%. The diagnostic yield was 100%. Although acute exacerbation occurred in 2 patients with idiopathic pulmonary fibrosis and 1 with fibrotic nonspecific interstitial pneumonia, there were no distinctive features that allowed preoperative prediction of acute exacerbation.</AbstractText>Our findings indicate that video-assisted thoracoscopic lung biopsy is a feasible procedure. We hope to clarify risk factors in future research.</AbstractText>© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.</CopyrightInformation> |
11,488 | Efficacy of β blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis. | Atrial fibrillation and heart failure often coexist, causing substantial cardiovascular morbidity and mortality. β blockers are indicated in patients with symptomatic heart failure with reduced ejection fraction; however, the efficacy of these drugs in patients with concomitant atrial fibrillation is uncertain. We therefore meta-analysed individual-patient data to assess the efficacy of β blockers in patients with heart failure and sinus rhythm compared with atrial fibrillation.</AbstractText>We extracted individual-patient data from ten randomised controlled trials of the comparison of β blockers versus placebo in heart failure. The presence of sinus rhythm or atrial fibrillation was ascertained from the baseline electrocardiograph. The primary outcome was all-cause mortality. Analysis was by intention to treat. Outcome data were meta-analysed with an adjusted Cox proportional hazards regression. The study is registered with Clinicaltrials.gov, number NCT0083244, and PROSPERO, number CRD42014010012.</AbstractText>18,254 patients were assessed, and of these 13,946 (76%) had sinus rhythm and 3066 (17%) had atrial fibrillation at baseline. Crude death rates over a mean follow-up of 1·5 years (SD 1·1) were 16% (2237 of 13,945) in patients with sinus rhythm and 21% (633 of 3064) in patients with atrial fibrillation. β-blocker therapy led to a significant reduction in all-cause mortality in patients with sinus rhythm (hazard ratio 0·73, 0·67-0·80; p<0·001), but not in patients with atrial fibrillation (0·97, 0·83-1·14; p=0·73), with a significant p value for interaction of baseline rhythm (p=0·002). The lack of efficacy for the primary outcome was noted in all subgroups of atrial fibrillation, including age, sex, left ventricular ejection fraction, New York Heart Association class, heart rate, and baseline medical therapy.</AbstractText>Based on our findings, β blockers should not be used preferentially over other rate-control medications and not regarded as standard therapy to improve prognosis in patients with concomitant heart failure and atrial fibrillation.</AbstractText>Menarini Farmaceutica Internazionale (administrative support grant).</AbstractText>Copyright © 2014 Elsevier Ltd. All rights reserved.</CopyrightInformation> |
11,489 | 20 years of cardiac resynchronization therapy. | Cardiac resynchronization therapy (CRT) is an accepted treatment for patients with heart failure (HF), impaired left ventricular (LV) function, and a wide QRS complex. It has been revolutionary for patients with advanced HF whose only previous option was cardiac transplantation, and it is now a realistic option for patients with mild HF. The development of CRT also has united the previously disparate cardiological subspecialties of electrophysiology and HF. This review, written on the occasion of the 20th anniversary of the first clinical use of CRT for HF, takes a historical perspective on CRT's evolution from "bench to bedside." We also comment on the task faced by electrophysiologists and HF specialists as they make this life-saving therapy available to an increasing number of eligible patients. |
11,490 | Effect of right ventricular pacing lead site on left ventricular function in patients with high-grade atrioventricular block: results of the Protect-Pace study. | Chronic right ventricle (RV) apical (RVA) pacing is standard treatment for an atrioventricular (AV) block but may be deleterious to left ventricle (LV) systolic function. Previous clinical studies of non-apical pacing have produced conflicting results. The aim of this randomized, prospective, international, multicentre trial was to compare change in LV ejection fraction (LVEF) between right ventricular apical and high septal (RVHS) pacing over a 2-year study period.</AbstractText>We randomized 240 patients (age 74 ± 11 years, 67% male) with a high-grade AV block requiring >90% ventricular pacing and preserved baseline LVEF >50%, to receive pacing at the RVA (n = 120) or RVHS (n = 120). At 2 years, LVEF decreased in both the RVA (57 ± 9 to 55 ± 9%, P = 0.047) and the RVHS groups (56 ± 10 to 54 ± 10%, P = 0.0003). However, there was no significant difference in intra-patient change in LVEF between confirmed RVA (n = 85) and RVHS (n = 83) lead position (P = 0.43). There were no significant differences in heart failure hospitalization, mortality, the burden of atrial fibrillation, or plasma brain natriutetic peptide levels between the two groups. A significantly greater time was required to place the lead in the RVHS position (70 ± 25 vs. 56 ± 24 min, P < 0.0001) with longer fluoroscopy times (11 ± 7 vs. 5 ± 4 min, P < 0.0001).</AbstractText>In patients with a high-grade AV block and preserved LV function requiring a high percentage of ventricular pacing, RVHS pacing does not provide a protective effect on left ventricular function over RVA pacing in the first 2 years.</AbstractText><AbstractText Label="PROTECT-PACE" NlmCategory="UNASSIGNED">ClinicalTrials.gov number NCT00461734.</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> |
11,491 | A pharmacologic review of cardiac arrest. | Cardiac arrest is manifested by arrhythmias (ventricular fibrillation or pulseless ventricular tachycardia, pulseless electrical activity, or asystole) resulting in minimal to no forward blood flow to the body's oxygen-dependent tissues. Defibrillation and cardiopulmonary resuscitation (CPR) should be initiated immediately as they have been shown to increase return of spontaneous circulation and survival to discharge rates. Cardiac arrest in the surgical patient population has devastating consequences. Data specific to the surgical patient found that 1 in 203 surgical patients experienced cardiac arrest requiring CPR within 30 days after surgery. A subgroup analysis found that 1 in 1,020 plastic surgery patients required CPR in this same time frame. Thirty-day mortality in the general surgery patient population was 72%. The American Heart Association updates the advanced cardiac life support (ACLS) guidelines every 5 years. Their latest publication in 2010 recommended that the resuscitative protocol be transitioned from its basic life support sequence of airway-breathing-chest compressions to chest compressions-airway-breathing. All health care professionals should have an understanding of the clinical presentation and medical management of cardiac arrest. Maintaining biannual basic life support and ACLS certification ensures that health care professionals remain current with American Heart Association guideline recommendations. Guideline-directed management of cardiac arrest should include timely implementation of the ACLS algorithm to maximize patient outcomes. |
11,492 | Echocardiographic abnormalities in patients with stroke during the subacute rehabilitation phase. | To evaluate cardiac function using echocardiography in patients with stroke admitted to subacute rehabilitation units.</AbstractText>Retrospective, cross-sectional study.</AbstractText>A total of 750 consecutive patients with stroke who were admitted to a suburban rehabilitation hospital. Mean age 67.5 years (standard deviation (SD) 12.3 years). Mean time since stroke 36.7 days (SD 13.2 days).</AbstractText>Patients were assessed using transthoracic echocardiography within 7 days of admission. The prevalence of echocardiographic abnormalities was analysed and compared between cerebral infarction and haemorrhage using the Mantel-Haenszel method controlled for age.</AbstractText>Arrhythmias were found in 13.7% of the patients, 94.2% of whom had atrial fibrillation. Left atrial enlargement and left ventricular hypertrophy were found in 20.4% and 19.5% of all patients, respectively. Left ventricular asynergy was detected in 6.1% of all patients, but 47.8% of them had no history of myocardial infarction. Left ventricular ejection fraction was low in 12.2% of all patients. Abnormal rhythms and left atrial enlargement were significantly more frequent in patients with cerebral infarction than in those with cerebral haemorrhage (p < 0.01).</AbstractText>The prevalence of cardiac problems is high among patients with subacute stroke regardless of a history of heart disease, and this should be taken into account when planning rehabilitation programmes.</AbstractText> |
11,493 | Mid-life Cardiovascular Risk Impacts Memory Function: The Framingham Offspring Study. | This study incorporates unique error response analyses with traditional measures of memory to examine the association between mid-life cardiovascular risk factors and later-life memory function.</AbstractText>The Framingham Stroke Risk Profile (FSRP), a composite score of cardiovascular risk, was assessed in 1755 Framingham Offspring participants (54% women, mean age=54±9 y) from 1991 to 1995. Memory tests including Logical Memory and Visual Reproductions were administered from 2005 to 2008. Linear and logistic regression examined the association between FSRP and memory measures. Interaction between the presence of the ApoE4 allele and each FSRP component on the memory measures was also assessed.</AbstractText>FSRP and the individual components of age, sex, and smoking were related to lower standard scores of memory. The new error response analyses reinforced the standard analyses and also identified new relationships. Participants with diabetes were found to make more errors on Logical Memory, and those with a history of smoking were found to make more errors on Visual Reproductions. Lastly, ApoE4 smokers experienced significant verbal memory loss, whereas ApoE4 smokers did not.</AbstractText>Middle-aged healthy adults with cardiovascular risk factors including diabetes, history of smoking, and ApoE4 positivity were found to have greater later-life memory impairments.</AbstractText> |
11,494 | Accidental intoxication with hydrochloric acid and hydrofluoric acid mixture. | The paper describes a fatal case of accidental ingestion of a mixture of hydrochloric acid and hydrofluoric acid. The man was admitted to hospital, where appropriate treatment, adequate to his condition, was instituted. Numerous ventricular fibrillation episodes, for which the patient was defibrillated repeatedly, were observed during the period of hospitalization. The patient was in a critical condition, with progressive symptoms of hypovolemic shock and multiorgan failure. On the next day after admission, signs of electromechanical dissociation progressing to asystole were noted. The instituted resuscitation procedure proved ineffective and the patient died. Autopsy revealed brownish discoloration of the esophageal, gastric, and small intestinal mucous membranes. Numerous ulcerations without signs of perforation were found both in the esophagus and in the stomach. The mucous membrane of the small intestine demonstrated focal rubefactions, whereas no focal lesions of the large intestinal mucosa were seen. Microscopic investigation of the biopsy specimens collected from the stomach, duodenum and small intestine revealed mucous membrane necrosis foci, reaching the deeper layers of the wall of these organs. The mucous membrane of the large intestine was congested. Bioptates obtained from the lungs indicated the presence of hemorrhagic infarcts and focal extravasations. Poisoning with the aforementioned acids with consequent necrosis of the esophageal, gastric, duodenal and small intestinal walls with hemorrhages to the gastrointestinal tract, as well as extravasations and hemorrhagic infarcts in the lungs was considered to be the cause of death. |
11,495 | Blood pressure variability in patients with atrial fibrillation. | The highly irregular ventricular rate during atrial fibrillation (AF) represents a unique and physiological experimental model to eliminate the influence of rhythmical components of RR variability on arterial pressure variability for investigating the origin of low frequency (LF) component in arterial pressure. Surface ECG, blood pressure and respiratory signals were recorded in thirty patients with persistent AF, at rest and during a passive orthostatic stimulus ("tilt test"). Short-term systolic (SAP) and diastolic arterial pressure (DAP) variability was estimated by autoregressive method. In 15 patients (group A), SAP significantly increased during tilt (from 98±16 to 114±18mmHg, p<0.001 rest vs. tilt), whereas in the remaining patients (group B) SAP remained almost unchanged (from 108±16 to 104±17mmHg, p=0.05, rest vs. tilt). No clinical differences were found between group A and B. When analyzing group A, a significant increase in the LF power in SAP and DAP variability was observed during tilt (SAP: 2.24±2.75 vs. 6.60±5.11mmHg(2), p<0.05, rest vs. tilt; DAP: 3.54±1.95 vs. 4.38±3.21mmHg(2), p<0.05, rest vs. tilt). No significant differences were found in group B. In AF patients, changes of arterial pressure variability during tilt were not uniform. Vascular regulatory mechanisms appeared to be still efficient only in the subgroup of patients who responded to a sympathetic stimulus with an increased SAP. In these subjects tilt increased the LF component in arterial pressure variability, thus mimicking the physiological response observed in subjects with sinus rhythm. |
11,496 | Stroke prophylaxis in atrial fibrillation: searching for management improvement opportunities in the emergency department: the HERMES-AF study. | We determine the prevalence of stroke prophylaxis prescription in emergency department (ED) patients with atrial fibrillation and the factors associated with a lack of prescription of anticoagulation in high-risk patients without contraindications.</AbstractText>This was a multicenter, observational, cross-sectional study with prospective standardized data collection carried out in 124 Spanish EDs. Clinical variables, risk factors for stroke, type of prophylaxis prescribed, and reasons for not prescribing anticoagulation in high-risk patients (congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes and previous stroke/transient ischemic attack/systemic embolism [CHADS2] score ≥2 and the congestive heart failure/left ventricular dysfunction, hypertension, age >75 years, diabetes, previous stroke/transient ischemic attack/systemic embolism, vascular disease age 65 to 74 years and sex category [CHA2DS2-VASc] score ≥2) without contraindications were collected.</AbstractText>Of 3,276 patients enrolled, 71.5% were at high risk according to CHADS2; 89.7% according to CHA2DS2-VASc. At discharge from the ED, 2,255 patients (68.8%) were receiving anticoagulants, 1,691 of whom (75%) were high-risk patients. Of the 1,931 patients discharged home, anticoagulation was prescribed for 384 patients (19.9%) de novo and for 932 patients (48.3%) previously receiving anticoagulation. The main reasons for not prescribing anticoagulation to eligible patients were considering antiplatelet therapy as adequate prophylaxis (33.1%), advanced age (15%), and considering stroke risk as low (8.3%). Advanced age (odds ratio 0.46; 95% confidence interval 0.30 to 0.69) and female sex (odds ratio 0.50; 95% confidence interval 0.36 to 0.71) were significantly associated with the lack of prescription of anticoagulation to eligible patients.</AbstractText>In Spain, most patients with atrial fibrillation treated in EDs who do not receive anticoagulation are at high risk of stroke, with relevant differences with regard to the risk stratification scheme used. Anticoagulation is underused, mainly because the risk of stroke is underestimated by the treating physicians and the benefits of antiplatelets are overrated, principally in female patients and the elderly. Efforts to increase the prescription of anticoagulation in these patients appear warranted.</AbstractText>Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
11,497 | Efficacy of amiodarone in patients with atrial fibrillation with and without left ventricular dysfunction: a pooled analysis of AFFIRM and AF-CHF trials. | Despite amiodarone's established safety profile in the setting of heart failure, it is unknown whether its impact on cardiovascular outcomes in patients with atrial fibrillation is modulated by left ventricular function.</AbstractText>A pooled analysis of 3,307 patients (age 68.0 ± 0.2 years; 31.1% female) enrolled in AFFIRM and AF-CHF trials was conducted to assess the effect of rhythm control with amiodarone on cardiovascular outcomes, according to left ventricular systolic function. In amiodarone-treated patients (N = 1,107), freedom from recurrent atrial fibrillation was 84% and 45% at 1 and 5 years, respectively, with no differences according to left ventricular function (P = 0.8754). Similarly, the adjusted proportion of time spent in atrial fibrillation (15.0 ± 1.8%) did not vary according to ventricular function (P = 0.6094). Over 40.0 ± 0.3 months of follow-up, 1,963 (59.4%) patients required at least one hospitalization, 1,401 (42.6%) of whom had cardiovascular-related hospitalizations. Adjusted all-cause and cardiovascular hospitalization rates were similar with amiodarone versus rate control in all patients and in subgroups with and without severe left ventricular dysfunction. A total of 729 (22.0%) patients died, 498 (15.1%) from cardiovascular causes. Adjusted all-cause and cardiovascular mortality rates were similar with amiodarone versus rate control overall and in subgroups with and without severe left ventricular dysfunction.</AbstractText>Amiodarone's efficacy in maintaining sinus rhythm and reducing the burden of atrial fibrillation is similar in the presence or absence of severe left ventricular dysfunction. Rhythm control with amiodarone is associated with comparable hospitalization and mortality rates to rate control in patients with and without left ventricular dysfunction.</AbstractText>© 2014 Wiley Periodicals, Inc.</CopyrightInformation> |
11,498 | Long-term clinical effects of ventricular pacing reduction with a changeover mode to minimize ventricular pacing in a general pacemaker population. | Right ventricular pacing (VP) has been hypothesized to increase the risk in heart failure (HF) and atrial fibrillation (AF). The ANSWER study evaluated, whether an AAI-DDD changeover mode to minimize VP (SafeR) improves outcome compared with DDD in a general dual-chamber pacemaker population.</AbstractText>ANSWER was a randomized controlled multicentre trial assessing SafeR vs. standard DDD in sinus node disease (SND) or AV block (AVB) patients. After a 1-month run-in period, they were randomized (1 : 1) and followed for 3 years. Pre-specified co-primary end-points were VP and the composite of hospitalization for HF, AF, or cardioversion. Pre-specified secondary end-points were cardiac death or HF hospitalizations and cardiovascular hospitalizations. ANSWER enrolled 650 patients (52.0% SND, 48% AVB) at 43 European centres and randomized in SafeR (n = 314) or DDD (n = 318). The SafeR mode showed a significant decrease in VP compared with DDD (11.5 vs. 93.6%, P < 0.0001 at 3 years). Deaths and syncope did not differ between randomization arms. No significant difference between groups [HR = 0.78; 95% CI (0.48-1.25); P = 0.30] was found in the time to event of the co-primary composite of hospitalization for HF, AF, or cardioversion, nor in the individual components. SafeR showed a 51% risk reduction (RR) in experiencing cardiac death or HF hospitalization [HR = 0.49; 95% CI (0.27-0.90); P = 0.02] and 30% RR in experiencing cardiovascular hospitalizations [HR = 0.70; 95% CI (0.49-1.00); P = 0.05].</AbstractText>SafeR safely and significantly reduced VP in a general pacemaker population though had no effect on hospitalization for HF, AF, or cardioversion, when compared with DDD.</AbstractText>© The Author 2014. Published by Oxford University Press on behalf of the European Society of Cardiology.</CopyrightInformation> |
11,499 | Macroscopic morphology of right atrial appendage in humans. | Atrial fibrillation (AF) is a common arrhythmia in elderly people, and in many cases it is responsible for stroke or pulmonary embolism. One of the factors facilitating atrial thrombus formation is anatomical morphology of the atria, and especially the appendages. The pharmacological treatment of arrhythmia is generally focused on ventricular rate control. Electrical cardioversion is the preferred treatment method in the majority of clinics but it can occasionally produce the potentially dangerous complication of AF.</AbstractText>A macroscopic study was carried out on 40 (25 male [M], 15 female [F]) human hearts, 18-72 years of age, and a microscopic study in a group of 20 human right atrial appendages (RAA) (M 10, F 10), 18-72 years of age. Only hearts without anomalies were included in the study. Classical anatomical studies and statistic analyses were applied.</AbstractText>RAA is triangle shaped with a mean area of 2.73 cm2. Muscle fascicules build the wall of RAA and compose a dense net inside a chamber. Sagittal bundle connecting terminal crest with an apex of RAA was observed in all examined hearts. In microscopic specimens longitudinal and perpendicular fascicles were described.</AbstractText> |
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