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17,300 | Effects of Inotropes on the Mortality in Patients With Septic Shock. | Although surviving sepsis campaign guidelines recommend the use of inotropes in the presence of myocardial dysfunction, the effects of inotropes, including epinephrine, dobutamine, and milrinone, on in-hospital mortality in patients with septic shock remains unclear.</AbstractText>We conducted an international,2-center, retrospective cohort study. The Cox proportional hazards regression model with time-varying covariates was used to investigate whether epinephrine, milrinone, or dobutamine reduces in-hospital mortality in patients with septic shock. Sensitivity analysis was performed using propensity score matching. The primary outcome was in-hospital mortality. The secondary outcome included atrial fibrillation (Afib) with a rapid ventricular response (RVR) in the intensive care unit (ICU) and ICU-free days.</AbstractText>A total of 417 patients with septic shock were included, 72 (17.3%) of whom received inotropes. The use of epinephrine and dobutamine was associated with significantly higher in-hospital mortality (epinephrine, hazard ratio [HR]: 4.79, 95% confidence interval [CI]: 2.12-10.82, P</i> = .001; dobutamine, HR: 2.53, 95% CI: 1.30-4.95, P</i> = .046). The effects of epinephrine and dobutamine were time- and dose-dependent. The use of milrinone was not associated with increased mortality (HR: 1.07, 95% CI: 0.42-2.68, P</i> = .345). The use of epinephrine, dobutamine, and milrinone was associated with significantly increased odds of Afib with RVR (epinephrine, odds ratio [OR]: 3.88, 95% CI: 1.11-13.61, P</i> = .034; dobutamine, OR: 3.95, 95% CI: 1.14-13.76; and milrinone, OR: 3.77, 95% CI: 1.05-13.59). On the other hand, the use of epinephrine, dobutamine, and milrinone was not associated with less ICU-free days (epinephrine, adjusted OR: 0.30, 95% CI: 0.09-1.01, P</i> = .053; dobutamine, adjusted OR: 0.91, 95% CI: 0.29-2.84; and milrinone, adjusted OR: 0.60, 95% CI: 0.19-1.87).</AbstractText>The present study showed that the use of epinephrine and dobutamine was associated with significantly increased in-hospital mortality in patients with septic shock. These effects were both time- and dose-dependent. On the other hand, the use of milrinone was not associated with increased in-hospital mortality.</AbstractText> |
17,301 | Challenges in Diagnosis and Management of Spontaneous Coronary Artery Dissection in a Young Patient. | Spontaneous coronary artery dissection (SCAD) is characterized by tear of the inner layer in the coronary artery, creating a false lumen between the inner and central layer. Its infrequent incidence often leads to delay in diagnosis posing challenges in management. There are currently no guidelines for the treatment of this condition. We describe an adult patient who presented with multiple episodes of ventricular fibrillation, in whom cardiac catheterization showed SCAD, treated by off-pump coronary artery bypass. |
17,302 | Inhibition of MicroRNA-206 Ameliorates Ischemia-Reperfusion Arrhythmia in a Mouse Model by Targeting Connexin43. | Reperfusion arrhythmias (RA) are an important cause of sudden cardiac death and is closely associated with gap junction protein in the heart, connexin 43 (Cx43). This study is aimed at elucidating the molecular association between microRNA-206 (miR-206) and Cx43 in ischemia-reperfusion arrhythmia using experimental animal model. Our results showed that miR-206 inhibitor alleviated ischemia-reperfusion-induced arrhythmias, indicated by the lower extent of changes in heart rate (HR), PR interval, rate pressure product (RPP), and mean arterial pressure (MAP). miR-206 inhibitor also downregulated the serum creatine kinase isoenzyme (CKMB) and cardiac troponin I (cTnI) levels in mice under myocardial ischemia-reperfusion (IR) process. The knockdown of Cx43 inversed the protective effects of miR-206 inhibitor on cardiac arrhythmias. These results supported that inhibition of miR-206 ameliorates ischemia-reperfusion arrhythmia by targeting Cx43, and this miR-206/Cx43 axis could serve as a potential target for the management of ischemic-perfusion arrhythmia. |
17,303 | Beta-blockade for the treatment of cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia: A systematic review and meta-analysis. | Refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) refers to cases that do not respond to traditional Advanced Cardiac Life Support measures and are associated with significantly lower survival rates. Beta-blockade may improve outcomes by protecting against the deleterious effects associated with epinephrine's beta-receptor effect.</AbstractText>This systematic review and meta-analysis aimed to evaluate whether beta-blockade compared with control improved outcomes among patients in cardiac arrest due to refractory VF/VT.</AbstractText>PubMed, Scopus, CINAHL, LILACS, the Cochrane databases, Google Scholar, and bibliographies of selected articles were assessed on September 2nd, 2019 for all studies evaluating beta-blockade versus control groups in patients with cardiac arrest due to refractory VF/VT. PRISMA guidelines were followed. Data were dual extracted into a predefined worksheet and quality analysis was performed with the Cochrane Risk of Bias in Non-randomised Studies of Interventions tool. Data were summarized and a meta-analysis was performed assessing temporary and sustained return of spontaneous circulation (ROSC), survival-to-admission, survival-to-discharge, and survival with a favorable neurologic outcome.</AbstractText>Three studies (n = 115 patients) were selected for final inclusion. Beta-blockade was associated with an increased rate of temporary ROSC (OR 14.46; 95% CI 3.63-57.57), sustained ROSC (OR 5.76; 95% CI 1.79-18.52), survival-to-admission (OR 5.76; 95% CI 1.79-18.52), survival-to-discharge (OR 7.92; 95% CI 1.85-33.89), and survival with a favorable neurologic outcome (OR 4.42; 95% CI 1.05-18.56). Overall risk of bias ranged from moderate-to-severe, which was primarily influenced by selection of participants and potential confounding. This study was registered with PROSPERO (CRD42019126902).</AbstractText>The data suggest that beta-blockade may be associated with improved outcomes ranging from ROSC to survival with a favorable neurologic outcome. Future randomized controlled trials are needed to further evaluate this intervention in refractory VF/VT.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,304 | Electrocardiogram-based pulse prediction during cardiopulmonary resuscitation. | Resuscitation requires CPR interruptions every 2 min to assess rhythm and pulse status. We developed a method to predict real-time pulse status in organized rhythm ECG segments with and without CPR artifact.</AbstractText>The study cohort included patients who received attempted resuscitation following ventricular fibrillation arrest. Using audio-supplemented defibrillator recordings, we annotated CPR, rhythm, and pulse status at each two-minute rhythm/pulse check. Paired ECG segments with and without CPR were extracted at each rhythm/pulse check. Using one-third of cases for training and two-thirds for validation, we developed three wavelet-based ECG features and combined them with a logistic model to predict pulse status. Predictive performances of each individual ECG feature and the combined logistic model were measured by the area under the receiver operator characteristic curve (AUC) in the validation cases with and without CPR.</AbstractText>There were 238 cases and 911 ECG segment pairs. Among 319 organized rhythm segments in the validation set, AUC for pulse prediction during CPR ranged from 0.67 to 0.79 for the individual ECG features. The logistic model was more predictive than any individual feature (AUC 0.84, 95% CI 0.80-0.89, p < 0.05 for each comparison) and performed similarly regardless of CPR (p = 0.2 for difference).</AbstractText>ECG features extracted by wavelet analysis predicted pulse status with moderate accuracy among organized rhythm segments with and without CPR. Further study is required to understand how real-time pulse prediction during CPR could help direct care while limiting CPR interruption.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,305 | Pulmonary Delivery of Metoprolol Reduces Ventricular Rate During Atrial Fibrillation and Accelerates Conversion to Sinus Rhythm. | Safe, effective pulmonary delivery of cardioactive agents in humans is under development.</AbstractText>We examined whether intratracheal delivery of metoprolol can reduce ventricular rate during atrial fibrillation (AF) and accelerate conversion to sinus rhythm.</AbstractText>In 7 closed-chest, anesthetized Yorkshire pigs, AF was induced by intrapericardial infusion of acetylcholine (1 mL of 102.5-mM solution) followed by atrial burst pacing and was allowed to continue for 2 minutes before intratracheal instillation of sterile water or metoprolol (0.2-mg/kg bolus) using a catheter positioned at the bifurcation of the main bronchi. High-resolution electrograms were obtained from catheters fluoroscopically positioned in the right atrium and left ventricle.</AbstractText>Rapid intratracheal instillation of metoprolol caused a 32-beat/min reduction in ventricular rate during AF (from 272 ± 13.7 to 240 ± 12.6 beats/min, P = 0.008) and a 2.3-minute reduction in AF duration (from 10.3 ± 2.0 to 8.0 ± 1.4 minutes, P = 0.018) compared with sterile water control. Conversion of AF to sinus rhythm was associated with rapid restoration (5-6 minutes) of heart rate and arterial blood pressure toward control values. Intratracheal metoprolol reduced AF dominant frequency by 31% (from 8.7 ± 0.9 to 6.0 ± 1.1 Hz, P = 0.04) compared with control and resulted in a trend toward a 5% increase in PR interval (from 174 ± 11.2 to 182 ± 11.4 ms, P = 0.07).</AbstractText>Intratracheal delivery of metoprolol effectively reduces ventricular rate during AF and accelerates conversion to normal sinus rhythm in a pig model of acetylcholine-induced AF.</AbstractText> |
17,306 | Achieving Osmotic Stability in the Context of Critical Illness and Acute Kidney Injury During Continuous Renal Replacement Therapy. | The concept of osmotic stability during renal replacement therapy has received limited attention thus far. We report an illustrative case of a previously healthy 22 year old male presenting after prolonged ventricular fibrillation with 75 minutes of resuscitative efforts before regaining spontaneous perfusing rhythm. Central nervous system protecting hypothermia protocol and veno-arterious (VA) extracorporeal membrane oxygenator (ECMO) therapy were initiated at hospital admission due to refractory hypoxemia. Cardiovascular imaging procedures described global hypokinesis. Due to the combination of anuria, mixed acidosis and hemodynamic instability, we started continuous renal replacement therapy (CRRT) in continuous veno-venous hemodiafiltration functionality with added hypertonic saline solution (HTS) protocol, calculated to stabilize his serum sodium between 148 and 150 mEq/L. Serum osmolality also ranged between 321 and 317 mOsm/kg thereafter. Course was complicated by an acute right leg ischemia distal to VA ECMO cannula placement, requiring salvage therapy with cryoamputation. Vasoactive medication requirement and hemodynamics improved after the addition of intravenous (IV) hydrocortisone. Brain magnetic resonance imaging (MRI) 22 days post-arrest showed signals of limited hypoxic injury. He left the hospital in stable condition with limited neurologic sequelae. Therefore, the use of HTS during CRRT is a viable way to address potential or manifest cerebral edema and reduce the degree of cerebral injury. |
17,307 | Sinus Venosus Atrial Septal Defect: A Challenging Diagnosis. | Sinus venosus atrial septal defect (SVASD) is a rare adult congenital heart disease which permits shunting of blood from the systemic to the pulmonary circulation and is commonly associated with anomalous pulmonary venous return. We report a case of a 27-year-old man with a history of premature birth and unilateral cryptorchidism who was admitted for syncope. Electrocardiogram (ECG) demonstrated atrial fibrillation (AF)and S1Q3T3 pattern along with an incomplete right bundle branch block. Transthoracic echocardiography (TTE) suggested the presence of right ventricular pressure and volume overload and severe right ventricular and right atrial enlargement. The agitated saline study was negative suggesting no inter-atrial communication. Transesophageal echocardiography (TEE) demonstrated a superior SVASD and raised the possibility of an anomalous pulmonary venous connection. Chest computed tomography identified the right superior pulmonary vein connection to the superior vena cava. The diagnosis of SVASD poses multiple challenges from the variety of symptoms to the selection of appropriate imaging and the complexity of surgical treatment. |
17,308 | Ventricular Fibrillation Induced by Takotsubo Syndrome with Congenital Long QT Syndrome. | We herein report a case of congenital long QT syndrome (LQTS) in which the QT interval was prolonged by Takotsubo syndrome (TTS), inducing ventricular fibrillation (VF). The patient was a 55-year-old woman who had been diagnosed with LQTS. Cardiopulmonary arrest occurred while coughing during sleep. VF was observed, and her heartbeat returned after two defibrillations. An electrocardiogram showed marked QT prolongation and large negative T waves. Echocardiography demonstrated hyperkinesis at the base of the left ventricle and akinesis at the apex. As there was no significant stenosis in the coronary artery, she was diagnosed with TTS. |
17,309 | Reference values for mid-diastolic right ventricular volume in population referred for cardiac computed tomography: An additional diagnostic value to cardiac computed tomography. | While an assessment of the right ventricular (RV) size remains challenging, the entire RV is can be imaged on coronary computed tomography angiography (CCTA) studies. With prospective ECG-triggering, the RV end diastolic volume (RVEDV) cannot be measured; however, the RV mid-diastolic volume (RVMDV) can still be measured accurately from routine CCTA data sets. The objective of this study is to establish normal reference values for RVMDV.</AbstractText>Right ventricular mid-diastolic volumes were measured in 4855 consecutive patients undergoing prospectively ECG-triggered coronary CTA. All patients with known cardiac or pulmonary disease (coronary artery disease, myocardial infarction, revascularization, heart failure, pulmonary hypertension, congenital heart disease, valvular heart disease, atrial fibrillation, implantable cardiac defibrillator implantation, cardiac transplant, or cardiac surgery) or smoking history (3313 patients) were excluded.</AbstractText>1542 patients were analyzed (mean age 56.4 ± 11.1 years, mean BSA 1.96 ± 0.26 and 47% male). The mean RVMDV for men and women was 168.6 ± 37.6 mL and 117.6 ± 26.4 mL, respectively. Mean BSA-indexed RVMDV was 80.0 ± 15.3 mL/m2</sup> and 64.1 ± 12.2 mL/m2</sup> for men and women, respectively. The presence of hypertension and diabetes did not have an impact on these values. RVMDV and BSA-indexed RVMDV were lower in women and in older individuals.</AbstractText>Normal reference ranges for RVMDV were established using prospectively ECG-triggered coronary CTA studies. This data can be used to identify patients with abnormal RV volumes and potentially RV dysfunction, adding incremental diagnostic value to routine CCTA studies.</AbstractText>Copyright © 2020 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,310 | Isolated functional tricuspid regurgitation: When should we go to surgical treatment? | The tricuspid valve has been called a "forgotten" valve; however, it is receiving increasing attention, since tricuspid regurgitation (TR) may be the next target of transcatheter intervention. Atrial fibrillation-related TR and TR that develops late after left-sided valve surgery are the main etiologies of isolated functional TR, in both of which annular dilatation is the main mechanism of TR. Isolated functional TR has been undertreated because of the high mortality rate of isolated tricuspid valve surgery. Furthermore, a recent study showed that surgery does not improve survival as long as it is performed at the late timing as is common in the current clinical settings. Right ventricular function is a key factor in determining the indication for isolated tricuspid valve surgery and in predicting early and late outcomes. However, none of them have been validated as predictors of prognosis for patients with severe functional TR. Liver function and renal function are also important predictors, but the cut-off values of these parameters for improved outcomes of isolated tricuspid valve surgery should be determined by large-scale data analysis. Now is a good time to reconsider the indications and the optimal timing of isolated tricuspid valve surgery in light of the upcoming transcatheter interventions. |
17,311 | Successful resuscitation from prolonged hypothermic cardiac arrest without extracorporeal life support: a case report. | We report a case of successful prolonged cardiopulmonary resuscitation (5 hours and 44 minutes) following severe accidental hypothermia with cardiac arrest treated without rewarming on extracorporeal life support.</AbstractText>A 52-year-old Italian mountaineer, was trapped in a crevasse and rescued approximately 7 hours later by a professional rescue team. After extrication, he suffered a witnessed cardiac arrest with ventricular fibrillation. Immediate defibrillation and cardiopulmonary resuscitation were started. His core temperature was 26.0 °C. Due to weather conditions, air transport to an extracorporeal life support center was not possible. Thus, he was rewarmed with conventional rewarming methods in a rural hospital. Auto-defibrillation occurred at a core temperature of 29.8 °C after 5 hours and 44 minutes of continued cardiopulmonary resuscitation. With a core temperature of 33.4 °C, he was finally admitted to a level 1 trauma center and extracorporeal life support was no longer required. Seven weeks following the accident, he was discharged home with complete neurological recovery.</AbstractText>Successful rewarming from severe hypothermia without extracorporeal life support use as performed in this case suggests that patients with primary hypothermic cardiac arrest have a chance of a favorable neurological outcome even after several hours of cardiac arrest when cardiopulmonary resuscitation and conventional rewarming are performed continuously. This may be especially relevant in remote areas, where extracorporeal life support rewarming is not available.</AbstractText> |
17,312 | Medical Therapies for Heart Failure With Preserved Ejection Fraction. | Current cardiovascular pharmacotherapy targets maladaptive overactivation of the renin-angiotensin-aldosterone system (RAAS), which occurs throughout the continuum of cardiovascular disease spanning from hypertension to heart failure with reduced ejection fraction. Over the past 16 years, 4 prospective, randomized, placebo-controlled clinical trials using candesartan, perindopril, irbesartan, and spironolactone in patients with heart failure with preserved ejection fraction (HFpEF) failed to demonstrate increased efficacy of RAAS blockade added to guideline-directed medical therapy. We reappraise these trials and their weaknesses, which precluded statistically significant findings. Recently, dual-acting RAAS blockade with sacubitril-valsartan relative to stand-alone valsartan failed to improve outcome in the PARAGON-HF trial (Efficacy and Safety of LCZ696 Compared with Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction). The majority of patients with HFpEF experience hypertension, frequently with subclinical left ventricular dysfunction, contributed to by comorbidities such as coronary disease, diabetes mellitus, overweight, and atrial fibrillation. Contrasting the findings in HFpEF, trials evaluating RAAS blockade on either side of HFpEF on the cardiovascular continuum in patients with high-risk hypertension and heart failure with reduced ejection fraction, respectively, showed positive outcomes. We do not have a biologically plausible explanation for such divergent efficacy of RAAS blockade. Based on considerations of well-established clinical efficacy in hypertension and heart failure with reduced ejection fraction and the shortcomings of aforementioned clinical trials in HFpEF, we argue that RAAS blockers including MRAs (mineralocorticoid receptor antagonists; aldosterone antagonists) should be used in the treatment of patients with HFpEF. |
17,313 | Value of Index Beat in Evaluating Left Ventricular Systolic and Diastolic Function in Patients with Atrial Fibrillation: A Dual Pulsed-Wave Doppler Study. | Atrial fibrillation (AF) poses challenges in use of the echocardiogram to assess left ventricular (LV) function. The index beat method has been found to agree well with the average method. We aimed to assess the value of the index beat method in evaluation of LV function using the dual pulsed wave Doppler technique. Peak early diastolic mitral inflow velocity (E) and diastolic (e') and systolic (s') mitral annulus velocity were simultaneously obtained and measured beat-to-beat in patients with AF. The index beat s' exhibited the best correlation (r = 0.96 and 0.92, respectively, for septal and lateral wall, both p values = 0.000) with the mean, while E/e' at the pre-index beat, rather than at the index beat-initiated cycle, had the best correlation with the mean (r = 0.88 for septal and 0.97 for lateral wall, both p values = 0.000). |
17,314 | Permanent HIS bundle Pacing Feasibility in Routine Clinical Practice: Experience from an Indian Center. | There is a paucity of experience regarding His bundle pacing (HBP) at laboratories initially attempting the procedure, especially in the Indian scenario. Patient who underwent HBP were selected for pacing therapy or in lieu of cardiac resynchronization therapy (CRT) at a single center. Among 22 patients attempted, 19 patients underwent successful implant, achieving selective HBP in 14 patients. There was a significant improvement in left ventricular ejection fraction (LVEF) (49.3 ± 9.3 vs. 36.7 ± 9.2) in the LV dysfunction subgroup (n = 6). Over a follow-up of 15 ± 6.5 months, thresholds were stable in all except one patient, and there was no requirement of lead revision. In summary, we found that HBP is a feasible option for achieving physiological pacing. |
17,315 | CHA2DS2-VASc score as a novel predictor for contrast-induced nephropathy after percutaneous coronary intervention in acute coronary syndrome. | CHA2DS2-VASc score, used for atrial fibrillation to assess the risk of embolic complications, have shown to predict adverse clinical outcomes in acute coronary syndrome (ACS), irrespective of atrial fibrillation. This study envisaged to assess the predictive role of CHA2DS2-VASc score for contrast-induced nephropathy (CIN) in patients with ACS undergoing percutaneous coronary intervention (PCI).</AbstractText>A total of 300 consecutive patients with ACS undergoing PCI were enrolled in this study. CHA2DS2-VASc score was calculated for each patient. These patients were divided into two groups as Group 1 (with CIN) and Group 2 (without CIN). CIN was defined as increase in serum creatinine level ≥0.5 mg/dL or ≥25% increase from baseline within 48 h after PCI. After receiver operating characteristic curve analysis, the study population was again classified into two groups: CHA2DS2-VASc score ≤3 group (Group A) and score ≥4 group (Group B).</AbstractText>CIN was reported in 41 patients (13.6%). Patients with CIN had a higher frequency of hypertension, diabetes mellitus, and had a lower left ventricular ejection fraction and baseline estimated glomerular filtration rate. Receiver operating characteristic curve analysis showed good predictive value of CHA2DS2-VASc score for CIN (area under the curve 0.81, 95% CI 0.73-0.90). Patients with a CHA2DS2-VASc score of ≥4 had a higher frequency of CIN as compared with patients with score ≤3 (56.8% vs 4.8%; p = 0.0001) with multivariate analysis demonstrating CHA2DS2-VASc score of ≥4 to be an independent predictor of CIN.</AbstractText>In patients with ACS undergoing PCI, CHA2DS2-VASc score can be used as a novel, simple, and a sensitive diagnostic tool for the prediction of CIN.</AbstractText>Copyright © 2019 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,316 | Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. | Acute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. In patients with myocarditis, electrocardiogram (ECG) can display a variety of non-specific abnormalities. Nevertheless, ECG is widely used as an initial screening tool for myocarditis.</AbstractText>We researched all possible ECG alterations during acute myocarditis evaluating prevalence, physiopathology, correlation with clinical presentation patterns, role in differential diagnosis, and prognostic yield.</AbstractText>The most common ECG abnormality in myocarditis is sinus tachycardia associated with nonspecific ST/T-wave changes. The presence of PR segment depression both in precordial and limb leads, a PR segment depression in leads with ST segment elevation, a PR segment elevation in aVR lead or a ST elevation with pericarditis pattern favor generally diagnosis of perimyocarditis rather than myocardial infarction. In patients with acute myocarditis, features associated with a poorer prognosis are: pathological Q wave, wide QRS complex, QRS/T angle ≥ 100°, prolonged QT interval, high-degree atrioventricular block and malignant ventricular tachyarrhythmia. On the contrary, ST elevation with a typical early repolarization pattern is associated with a better prognosis.</AbstractText>ECG alterations in acute myocarditis could be very useful in clinical practice for a patient-tailored approach in order to decide appropriate therapy, length of hospitalization, and frequency of followup.</AbstractText>© 2019 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals, LLC.</CopyrightInformation> |
17,317 | Protective effect of extracorporeal membrane oxygenation on intestinal mucosal injury after cardiopulmonary resuscitation in pigs. | The present study aimed to explore the protective effects of extracorporeal membrane oxygenation (ECMO) on intestinal mucosal injury following cardiopulmonary resuscitation (CPR), and to assess the potential mechanisms involved. A total of 24 healthy adult domestic pigs were selected as the study subjects. A ventricular fibrillation model was induced through programmed electric stimulation. Subsequently, the animals were randomly divided into conventional CPR and CPR+ECMO groups (n=12 per group). The mortality and hemodynamic parameters of the two groups were compared. The expression levels of inflammatory cytokines in the serum and intestinal mucosa were detected by ELISAs. The intestinal mucosa was subjected to hematoxylin and eosin, and immunohistochemical staining, followed by electron microscopy, to assess the degree of apoptosis and necrosis. The animals in both groups recovered from the programmed ventricular fibrillation. In the CPR group, two animals died at 2 h and two more animals died a further 2 h later, resulting in a 33.3% mortality rate, whereas no cases of mortality were observed in the CPR+ECMO group. Compared with the animals in the CPR group, the hemodynamic parameters of the animals in the CPR+ECMO group revealed significantly improved outcomes. Multiple inflammatory factors (tumor necrosis factor α, interleukin-1 and interleukin-6), myeloperoxidase and malondialdehyde levels were decreased, whereas Na/Ca-ATPase and superoxide dismutase levels were elevated in the intestinal mucosa of animals in the CPR+ECMO group compared with those in the CPR group. Additionally, pathological staining demonstrated that the intestinal mucosa tissue in the CPR+ECMO group exhibited less apoptosis, necrosis and inflammatory cell infiltration, which was further supported by a decrease in Bax expression and an increase in Bcl-2 expression. Overall, ECMO after CPR reduced the intestinal mucosal barrier injury after spontaneous circulation recovery, and the mechanism involved decreased inflammation and apoptosis. |
17,318 | Regulations for using semiautomatic external defibrillators outside health care settings in Spain: a review and comparison of the current situation across autonomous communities. | We compared Spanish autonomous communities' regulations affecting the use of semiautomatic external defibrillators (semi-AEDs), including requirements for training and providing devices outside health care settings. We analyzed differences in the development of regulations across the different geographic areas. Regulations published in the official bulletins of Spain's 17 autonomous communities and 2 autonomous cities in effect in May 2019 were reviewed to extract directives affecting training, authorized use, and the provision of semi-AEDs outside health care centers. We found that both doctors and nurses are authorized to use the devices in most communities, with the exception of Murcia, where only doctors may use them. Fourteen communities also authorize emergency responders to operate semi-AEDs. Other individuals must call for emergency help before using one, and specific rules vary by community. In the Basque Country anyone may use them, but in other communities, only individuals who have taken a training course on how to use a semi-AED may. The duration of training programs varies from 4 to 9 hours in different parts of Spain, and retraining is required at intervals that vary from 1 to 3 years. However, in 11 communities any citizen may use a semi-AED in an emergency in which authorized persons are not present (after first calling for emergency responders). Eleven autonomous communities regulate the required provision of semi-AEDs outside health care centers. We conclude that although Spain's autonomous communities have regulations in place for the use of these devices, the regulatory map is highly diverse. Therefore, we think that harmonization is desirable in the interest of unifying criteria and encouraging the use of semi-AEDs when they are needed.</Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Ballesteros-Peña</LastName><ForeName>Sendoa</ForeName><Initials>S</Initials><AffiliationInfo><Affiliation>Organización Sanitaria Integrada de Bilbao-Basurto, Bilbao, España. Facultad de Medicina y Enfermería, Universidad del País Vasco/Euskal Herriko Unibertsitatea, Leioa, Bizkaia, España.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Fernández-Aedo</LastName><ForeName>Irrintzi</ForeName><Initials>I</Initials><AffiliationInfo><Affiliation>Facultad de Medicina y Enfermería, Universidad del País Vasco/Euskal Herriko Unibertsitatea, Leioa, Bizkaia, España.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>de la Fuente-Sancho</LastName><ForeName>Itxaro</ForeName><Initials>I</Initials><AffiliationInfo><Affiliation>Organización Sanitaria Integrada de Bilbao-Basurto, Bilbao, España.</Affiliation></AffiliationInfo></Author></AuthorList><Language>spa</Language><Language>eng</Language><PublicationTypeList><PublicationType UI="D003160">Comparative Study</PublicationType><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList><VernacularTitle>Regulación de la desfibrilación externa semiautomática fuera del entorno sanitario en las comunidades autónomas de España: situación actual.</VernacularTitle></Article><MedlineJournalInfo><Country>Spain</Country><MedlineTA>Emergencias</MedlineTA><NlmUniqueID>9805751</NlmUniqueID><ISSNLinking>1137-6821</ISSNLinking></MedlineJournalInfo><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D047548" MajorTopicYN="Y">Defibrillators</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D004630" MajorTopicYN="N">Emergencies</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D033161" MajorTopicYN="Y">Government Regulation</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D009726" MajorTopicYN="N">Nurses</DescriptorName><QualifierName UI="Q000331" MajorTopicYN="N">legislation & jurisprudence</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D058687" MajorTopicYN="N">Out-of-Hospital Cardiac Arrest</DescriptorName><QualifierName UI="Q000628" MajorTopicYN="Y">therapy</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D010820" MajorTopicYN="N">Physicians</DescriptorName><QualifierName UI="Q000331" MajorTopicYN="N">legislation & jurisprudence</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D011633" MajorTopicYN="N">Public Facilities</DescriptorName><QualifierName UI="Q000331" MajorTopicYN="N">legislation & jurisprudence</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D013030" MajorTopicYN="N" Type="Geographic">Spain</DescriptorName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="spa">El objetivo de este trabajo es comparar las legislaciones autonómicas españolas en materia de formación, utilización y obligatoriedad de la instalación de desfibriladores externos automatizados (DEA) fuera del ámbito sanitario y analizar la variabilidad territorial con que se han desarrollado las regulaciones. Llevamos a cabo una revisión de las normativas publicadas en los boletines oficiales de las 17 comunidades autónomas y las 2 ciudades autónomas de España hasta mayo de 2019, extrayendo datos referidos a la regulación de la formación, el uso y la instalación de los DEA fuera del ámbito sanitario. Observamos que médicos y enfermeros están autorizados a utilizar los DEA, salvo en Murcia, donde únicamente tienen autorizado su uso los médicos. En 14 comunidades autónomas también se consideran habilitados los técnicos en emergencias sanitarias. Excepto en el País Vasco, donde cualquier ciudadano puede utilizar un DEA previa alerta a los servicios de emergencia, es necesario realizar un curso inicial acreditado para estar habilitado en el uso de estos dispositivos (cuya duración varía, según la comunidad, entre 4 y 9 horas) y debe ser renovado con una periodicidad que oscila entre uno y 3 años. Sin embargo, 11 comunidades permiten que, en caso de emergencia y en ausencia de personal habilitado, cualquier ciudadano pueda utilizar un DEA, previa alerta a los servicios de emergencia. Once autonomías regulan la obligación de instalar DEA fuera del ámbito sanitario. Se concluye que si bien todas las comunidades autónomas de España disponen de una normativa reguladora del uso y la acreditación de DEA, el mapa legislativo es muy diverso, por lo que sería deseable una política armonizadora para unificar criterios e incentivar el uso de estos dispositivos en caso de necesidad. |
17,319 | Left atrial structure and function and the risk of death or heart failure in atrial fibrillation. | The present study aimed to assess the association between left atrial (LA) structure and function and the risk for cardiovascular (CV) death or heart failure (HF) hospitalization in a population with atrial fibrillation (AF).</AbstractText>In a prospective echocardiographic substudy of the Effective Anticoagulation with Factor Xa Next Generation in AF-Thrombolysis in Myocardial Infarction 48 (ENGAGE AF-TIMI 48) study, 971 patients underwent transthoracic echocardiography. The associations between LA structure (LA volume index [LAVi]) and function (LA emptying fraction [LAEF] and LA expansion index [LAEi]) and risk for the composite endpoint of CV death or HF hospitalization, and its components, were assessed. Over a median follow-up of 2.5 years, 142 patients (14.6%) experienced CV death or HF hospitalization. Higher LAVi and lower LAEF and LAEi were each associated with a higher unadjusted risk for the composite outcome and its components. After adjustment for clinical and echocardiographic confounders, only measures of impaired LA function were predictive of the composite outcome (hazard ratio [HR] per 1 standard deviation [SD] decrease in LAEF: 1.35; 95% confidence interval [CI] 1.09-1.67 [P = 0.005]; HR per 1 SD decrease in LAEi: 1.34; 95% CI 1.06-1.69 [P = 0.012]). These findings were similar regardless of left ventricular ejection fraction, history of HF or whether patients were in AF or sinus rhythm at the time of the echocardiographic examination.</AbstractText>In patients with AF, LA dysfunction was significantly associated with an increased risk for CV death or HF hospitalization and was more predictive of these outcomes than LA size. These parameters may help to identify AF patients at greatest risk for the development of HF.</AbstractText>ClinicalTrials.gov, NCT00781391.</AbstractText>© 2019 The Authors. European Journal of Heart Failure © 2019 European Society of Cardiology.</CopyrightInformation> |
17,320 | Ischemic Postconditioning Reduces Reperfusion Arrhythmias by Adenosine Receptors and Protein Kinase C Activation but Is Independent of K<sub>ATP</sub> Channels or Connexin 43. | Ischemic postconditioning (IPoC) reduces reperfusion arrhythmias but the antiarrhythmic mechanisms remain unknown. The aim of this study was to analyze IPoC electrophysiological effects and the role played by adenosine A<sub>1</sub>, A<sub>2A</sub> and A<sub>3</sub> receptors, protein kinase C, ATP-dependent potassium (K<sub>ATP</sub>) channels, and connexin 43. IPoC reduced reperfusion arrhythmias (mainly sustained ventricular fibrillation) in isolated rat hearts, an effect associated with a transient delay in epicardial electrical activation, and with action potential shortening. Electrical impedance measurements and Lucifer-Yellow diffusion assays agreed with such activation delay. However, this delay persisted during IPoC in isolated mouse hearts in which connexin 43 was replaced by connexin 32 and in mice with conditional deletion of connexin 43. Adenosine A<sub>1</sub>, A<sub>2A</sub> and A<sub>3</sub> receptor blockade antagonized the antiarrhythmic effect of IPoC and the associated action potential shortening, whereas exogenous adenosine reduced reperfusion arrhythmias and shortened action potential duration. Protein kinase C inhibition by chelerythrine abolished the protective effect of IPoC but did not modify the effects on action potential duration. On the other hand, glibenclamide, a K<sub>ATP</sub> inhibitor, antagonized the action potential shortening but did not interfere with the antiarrhythmic effect. The antiarrhythmic mechanisms of IPoC involve adenosine receptor activation and are associated with action potential shortening. However, this action potential shortening is not essential for protection, as it persisted during protein kinase C inhibition, a maneuver that abolished IPoC protection. Furthermore, glibenclamide induced the opposite effects. In addition, IPoC delays electrical activation and electrical impedance recovery during reperfusion, but these effects are independent of connexin 43. |
17,321 | Meta-Analysis of Atrial Fibrillation Ablation in Patients with Systolic Heart Failure. | Atrial fibrillation (AF) and heart failure (HF) are two common conditions that often coexist and predispose each to one another. AF increases hospitalization rates and overall mortality in patients with HF. The current available therapeutic options for AF in patients with HF are diverse and guidelines do not provide a clear consensus regarding the best management approach. To determine if catheter ablation for AF is superior to medical therapy alone in patients with coexisting HF, we conducted this systematic review and meta-analysis. The primary outcomes evaluated are left ventricular ejection fraction (LVEF), Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores, 6-minute walk test (6MWT) distance, heart failure hospitalizations, and mortality. The results are presented as a mean difference for continuous outcome measures and odds ratios for dichotomous outcomes (using Mantel-Haenszel random effects model). 7 full texts met inclusion criteria, including 856 patients. AF catheter ablation was associated with a significant increase in LVEF (mean difference 6.8%; 95% CI: 3.5 - 10.1; P<0.001) and 6MWT (mean difference 29.3; 95% CI: 11.8 - 46.8; P = 0.001), and improvement in MLWHFQ (mean difference -12.1; 95% CI: -20.9 - -3.3; P = 0.007). The risk of all-cause mortality was significantly lower in the AF ablation arm (OR 0.49; 95% CI: 0.31 - 0.77; P = 0.002). In conclusion, atrial fibrillation ablation in patients with systolic heart failure is associated with significant improvement in LVEF, quality of life, 6MWT, and overall mortality. |
17,322 | Impact of Late Ventricular Arrhythmias on Cardiac Mortality in Patients with Acute Myocardial Infarction. | This study investigated the relationship between the timing of ventricular tachycardia or ventricular fibrillation (VT or VF) and prognosis in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI).</AbstractText>It is unknown whether the timing of VT/VF occurrence affects the prognosis of patients with AMI.</AbstractText>From January 2004 to December 2014, 1004 patients with AMI underwent primary PCI. Of these patients, 888 did not have VT/VF (non-VT/VF group) and 116 had sustained VT/VF during prehospitalization or hospitalization. Patients with VT/VF were divided into two groups: early VT/VF (VT/VF occurrence before and within 2 days of admission, 92 patients) and late VT/VF (VT/VF occurrence >2 days after admission; 24 patients) groups.</AbstractText>The frequency of VT/VF occurrence was high between the day of admission and the 2nd day and between days 6 and 10 of hospitalization. The late VT/VF group had a significantly longer onset-to-balloon time, lower ejection fraction, poorer renal function, and higher creatine phosphokinase (CK)-MB level on admission (p< 0.001). They also had a lower 30-day cardiac survival rate than the early VT/VF and non-VT/VF groups (42% vs. 76% vs. 96%, p < 0.001). Moreover, independent predictors of in-hospital cardiac mortality among patients with AMI who had sustained VT/VF were higher peak CK-MB [Odds ratio (OR: 1.001, 95%confidence interval (CI): 1.000-1.002, p= 0.03)], higher Killip class (OR: 1.484, 95%CI 1.017-2.165, p= 0.04), and late VT/VF (OR: 3.436, 95%CI 1.115-10.59, p= 0.03).</AbstractText>The timing of VT/VF occurrences had a bimodal peak. Although late VT/VF occurrence after primary PCI was less frequent than early VT/VF occurrence, patients with late VT/VF had a very poor prognosis.</AbstractText>Copyright © 2019 Takuma Takada et al.</CopyrightInformation> |
17,323 | Ventricular conduction delay as marker of risk in Brugada Syndrome. Results from the analysis of clinical and electrocardiographic features of a large cohort of patients. | Brugada Syndrome is a genetic arrhythmogenic disease with a variable clinical spectrum. The role of clinical and ECG parameters in the risk stratification is still uncertain.</AbstractText>In a large cohort of Brugada patients we analysed clinical and ECG features to determine the variables with prognostic value for the occurrence of a first documented arrhythmic event and for recurrences.</AbstractText>We enrolled 614 patients, subdivided into 3 groups according to their clinical presentation: 531 (88%) asymptomatic, 69 (10%) with previous unexplained syncope and 14 (2%) with aborted sudden death. We also compared the ECG characteristics of patients with a single documented arrhythmic event (either at presentation or at follow-up, 17 patients), with those of patients with arrhythmic recurrences (13 patients).</AbstractText>The event rate was 1.3% in the asymptomatic patients and 15% among patients with unexplained syncope (median follow-up 6 years), p < 0.0001. In both groups a QRS duration ≥110 ms in lead II and/or V6 and/or S wave duration ≥40 ms in lead I and/or II were significant risk factors for the occurrence and timing of events at follow-up. The same ECG risk factors were also significantly associated with arrhythmic recurrences.</AbstractText>The arrhythmic risk of Brugada patients is related not only to the symptoms at presentation, but also to the presence of a ventricular conduction delay (QRS duration ≥ 110 ms and/or S wave duration ≥ 40 ms). The ECG conduction parameters also affect the timing of events and recurrences.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,324 | Electrical storm 11 days after acute myocardial infarction: a case report. | The definition of electrical storm is still debated. For example, an electrical storm is defined as a clustering of three or more separate episodes of ventricular tachycardia/ventricular fibrillation within 24 hours or one or more episodes occurring within 5 minutes of termination of the previous episode of ventricular tachycardia/ventricular fibrillation. When it is refractory to medications, prompt assessments by coronary angiography, sedation, and overdrive pacing should be performed. An electrical storm may occur anytime, including at night or after the patient leaves an intensive care unit.</AbstractText>A 70-year-old Japanese man with type 2 diabetes mellitus was diagnosed as having ST-elevation myocardial infarction. His clinical course after an urgent percutaneous coronary intervention was uneventful, but he developed electrical storm that was refractory to antiarrhythmic medications on day 11 of hospitalization. We used sedative medications and performed ventricular overdrive pacing and transferred him to a university hospital for further treatment, which included electrical ablation and cardioverter-defibrillator implantation.</AbstractText>An electrical storm is a relatively rare and fatal complication of acute myocardial infarction. It is important that the treatment choices for this condition are known by non-cardiologist physicians who might encounter this rare condition.</AbstractText> |
17,325 | Levosimendan Reduces Mortality and Low Cardiac Output Syndrome in Cardiac Surgery. | There has been conflicting evidence concerning the effect of levosimendan on clinical outcomes in patients undergoing cardiac surgery. Therefore, we performed a systematic review and conducted this meta-analysis to provide evidence for/against the administration of levosimendan in cardiac surgery patients.</AbstractText>We performed a meta-analysis from literature search in PubMed, EMBASE, and Cochrane Library. Only randomized controlled trials comparing the administration of levosimendan in cardiac surgery patients with a control group (other inotrope, standard therapy/placebo, or an intra-aortic balloon pump) were included. In addition, at least one clinical outcome had to be mentioned: mortality, myocardial infarction, low cardiac output syndrome (LCOS), acute kidney injury, renal replacement therapy, atrial fibrillation, prolonged inotropic support, length of intensive care unit, and hospital stay. The pooled treatment effects (odds ratio [OR], 95% confidence intervals [CI]) were assessed using a fixed or random effects model.</AbstractText>The literature search retrieved 27 randomized, controlled trials involving a total of 3,198 patients. Levosimendan led to a significant reduction in mortality (OR: 0.67; 95% CI: 0.49-0.91; p</i> = 0.0087). Furthermore, the incidence of LCOS (OR: 0.56, 95% CI: 0.42-0.75; p</i> < 0.0001), acute kidney injury (OR: 0.63; 95% CI: 0.46-0.86; p</i> = 0.0039), and renal replacement therapy (OR: 0.70; 95% CI: 0.50-0.98; p</i> = 0.0332) was significantly decreased in the levosimendan group.</AbstractText>Our meta-analysis suggests beneficial effects for the prophylactic use of levosimendan in patients with severely impaired left ventricular function undergoing cardiac surgery. The administration of levosimendan was associated with a reduced mortality, less LCOS, and restored adequate organ perfusion reflected in less acute kidney injury.</AbstractText>Georg Thieme Verlag KG Stuttgart · New York.</CopyrightInformation> |
17,326 | Left atrial diameter in heart failure with left ventricular preserved, mid-range, and reduced ejection fraction. | Left atrial (LA) remodeling has been identified to predict atrial fibrillation (AF) and heart failure. However, the role of LA diameter (LAD) in patients with heart failure (HF) with preserved (HFpEF), mid-range (HFmrEF), and reduced ejection fraction (HFrEF) remains poorly understood.A total of 142 patients including 71 subjects with AF (21 of HFpEF, 22 of HFmrEF, and 28 of HFrEF) and 71 ejection fraction (EF)-matched subjects with sinus rhythm (SR) were included in the study. Baseline characteristics and echocardiographic parameters including LAD were compared between both groups as well as among HFpEF, HFmrEF, and HFrEF.In receiver-operating characteristic (ROC) analyses, LAD predicted AF in HFpEF, HFmrEF, and HFrEF [area under the curve (AUC): 0.646; P = .03]. LAD was negatively association with left ventricular ejection fraction while positively with Nt-proNP and left ventricular end-diastolic diameter (regression coefficient: -0.239, P = .004; regression coefficient: 0.191, P = .023; regression coefficient: 0.357, P < .001). In ROC analyses, LAD predicted HFrEF among the 3 categories (AUC: 0.629, P = .01).In the setting of HF, LAD was higher in AF than in and SR, and predicted AF. Furthermore, LAD was associated with severity of HF in HFpEF, HFmrEF, and HFrEF, and also predicted HFrEF. |
17,327 | Which patients with atrial fibrillation undergo an ablation procedure today in Europe? A report from the ESC-EHRA-EORP Atrial Fibrillation Ablation Long-Term and Atrial Fibrillation General Pilot Registries. | Rhythm control management in patients with atrial fibrillation (AF) may be unequal across Europe. The aim of this study was to investigate how selective the patient cohort referred for AF ablation is, as compared to the general AF population in Europe, and to describe the governing mechanisms for such selection.</AbstractText>Descriptive comparative statistical analyses of the baseline characteristics were performed between the cohorts of Atrial Fibrillation Ablation Long-Term (ESC EORP AFA-LT) registry, designed to provide a picture of contemporary real-world AF ablation, and the AF population from the AF-General (ESC EORP AF-Gen) pilot registry. Data collection was performed using a web-based system. In the AFA and in the Atrial Fibrillation General (AFG) pilot registries, 3593 and 3049 patients were enrolled, respectively. Patients who underwent AF ablation were younger, more commonly male, and had significantly less comorbidities. Atrial Fibrillation Ablation patients often presented without comorbidities, resulting in a lower risk of stroke (CHA2DS2-VASc ≥5: 2.9% vs. 24.5%, all P < 0.001) and bleeding (HAS-BLED ≥2: 8.5% vs. 40.5%, P < 0.001) but with European Heart Rhythm Association (EHRA) scores >1 and more prevalent AF-related symptoms such as palpitations, fatigue, and weakness (all P < 0.001) as compared to the general AF patients. Atrial Fibrillation Ablation patients were significantly more often male, had higher left ventricular ejection fraction (59.5% vs. 52.4%) and smaller left atrial size on echocardiogram (P < 0.001 each).</AbstractText>The comparison of the patient cohorts in the AFA and AFG registries showed that AF ablation in European clinical practice is mostly performed in relatively young, symptomatic and relatively healthy patients.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.</CopyrightInformation> |
17,328 | Heart failure and its complications in patients with diabetes: Mounting evidence for a growing burden. | Heart failure (HF) is one of the major challenges in the management of diabetes patients. Among subjects with diabetes, up to 20% could have HF. Conversely, diabetes prevalence in HF patients varies greatly from more than 10% up to 50%. When it is present, the risk of mortality and rehospitalization increases substantially. In addition, current evidence points to an increased risk of atrial fibrillation and sudden cardiac death in patients with diabetes. The inter-relation between diabetes cardiomyopathy, left ventricular hypertrophy, coronary artery disease and renal dysfunction indicates complex and intricate pathways. Despite the great value of clinical assessment and echocardiography, there is insufficient data to suggest systematic screening for HF in asymptomatic patients with diabetes. There is little evidence to indicate that improved glycaemic control improves HF outcome in this population. In the case of established HF, the general guidelines apply in diabetes patients. However, recent advances concerning glucose-lowering treatment in patients with cardiovascular disease suggest that the choice of glucose-lowering agent is of crucial interest and should be based on the patient's phenotype. New drug classes, such as SGLT2 inhibitors, seem to be of particular benefit in these patients. In the future, new personalized strategies should aim at not only good control of the glycaemic level but also the reduction and possibly the prevention of HF onset. |
17,329 | Predictors and outcomes of atrial tachyarrhythmia among patients with implantable defibrillators. | Atrial tachyarrhythmias (ATAs) are common among heart failure (HF) patients.</AbstractText>The purpose of this study was to assess predictors for the development of new ATA and its components (atrial fibrillation/flutter [AF], supraventricular tachycardia [SVT]), and their association with subsequent clinical outcomes.</AbstractText>We assessed predictors for first and recurrent ATA, AF, and SVT among 1500 patients in MADIT-RIT (Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy). We also investigated the association of new ATA, AF, or SVT with subsequent ventricular arrhythmia (VA), adverse events (HF hospitalization, syncope, or death), or death by time-dependent analysis.</AbstractText>During 17 months of follow-up, 286 patients (19%) developed new ATA, of whom 92 (6%) had AF and 194 (12%) had SVT. Younger age (≤65 years), diastolic blood pressure ≥72 mm Hg, heart rate ≥63 bpm, absence of diabetes, and prior atrial arrhythmia were independent predictors of ATA. Prior atrial arrhythmia was the only predictor of AF (hazard ratio 3.14; P <.001). New ATA was associated with significantly increased risk for subsequent VA (HR 2.12; P <.001), increased adverse events (HR 1.42; P <.001), and death (HR 1.85; P = .038). New AF and new SVT were both independently associated with >2-fold increased risk for the development of subsequent VA (HR 2.21; P = .012l and HR 2.15; P <.001, respectively) and adverse events.</AbstractText>Among MADIT-RIT patients, younger age, absence of diabetes, higher blood pressure, higher heart rate, and prior atrial arrhythmia predicted device-detected ATA. Both AF and SVT were associated with increased risk for subsequent VA and adverse events. Aggressive management should be considered in HF patients who develop new-onset, device-detected ATA to improve clinical outcomes.</AbstractText>Published by Elsevier Inc.</CopyrightInformation> |
17,330 | Validating defibrillation simulation in a human-shaped phantom. | We previously developed a computational model to aid clinicians in positioning implantable cardioverter-defibrillators (ICDs), especially in the case of abnormal anatomies that commonly arise in pediatric cases. We have validated the model clinically on the body surface; however, validation within the volume of the heart is required to establish complete confidence in the model and improve its use in clinical settings.</AbstractText>The goal of this study was to use an animal model and thoracic phantom to record the ICD potential field within the heart and on the torso to validate our defibrillation simulation system.</AbstractText>We recorded defibrillator shock potentials from an ICD suspended together with an animal heart in a human-shaped torso tank and compared them with simulated values. We also compared the scaled distribution threshold, an analog to the defibrillation threshold, calculated from the measured and simulated electric fields within the myocardium.</AbstractText>ICD potentials recorded on the tank and cardiac surface and within the myocardium agreed well with those predicted by the simulation. A quantitative comparison of the recorded and simulated potentials yielded a mean correlation of 0.94 and a relative error of 19.1%. The simulation can also predict scaled distribution thresholds similar to those calculated from the measured potential fields.</AbstractText>We found that our simulation could predict potential fields with high correlation with the measured values within the heart and on the torso surface. These results support the use of this model for the optimization of ICD placements.</AbstractText>Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,331 | Bolus potassium in frustrated ventricular fibrillation storm. | Ventricular fibrillation (VF) is a well-known ominous complication of ischemic heart disease. While firmly structured algorithms have been developed for its management, yet its mortality rate remains high.</AbstractText>This is a case report of a 46-year-old gentleman who was a victim of recurrent cardiac arrest in the ward while awaiting coronary artery bypass grafting (CABG) surgery. Emergency CABG was performed, intraoperatively he experienced recurrent VF which was reverted by direct current cardioversion-Defibrillation. He was sent to the Cardiac Surgery Intensive Care Unit (CSICU) with an open chest on extracorporeal membrane oxygenation (ECMO) support and an intra-aortic balloon pump. Postoperatively in CSICU he still experienced malignant ventricular arrhythmia with dropping of ejection fraction to less than 10%. The last few episodes of VF were lengthy, lasting more than an hour (while on ECMO support) with the failure of various antiarrhythmic medications to abort them. Eventually, a decision was made to give him 20 mmol boluses of potassium chloride (KCl) intravenously aiming at introducing a state of asystole, but the rhythm changed to sinus rhythm.</AbstractText>This report highlighted the fact that optimum management of VF is still lacking and necessitates more studies. The appropriate effective dose of potassium replacement during VF might need to be reconsidered in patients with persistent VF.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,332 | Allogeneic cardiosphere-derived cells for the treatment of heart failure with reduced ejection fraction: the Dilated cardiomYopathy iNtervention with Allogeneic MyocardIally-regenerative Cells (DYNAMIC) trial. | The DYNAMIC trial assessed the safety and explored the efficacy of multivessel intracoronary infusion of allogeneic cardiosphere-derived cells (CDCs) in patients with heart failure and reduced ejection fraction (HFrEF). Here we report the results of the DYNAMIC trial.</AbstractText>We enrolled 14 patients with EF ≤35% and NYHA Class III-IV despite maximal medical and device-based therapy in this single-centre, open-label trial. Intracoronary catheterisation delivered four escalating doses (totalling 37.5-75 million cells) by sequential non-occlusive technique to all three major coronary arteries. The primary safety endpoint was a composite of post-infusion TIMI flow, ventricular tachycardia/fibrillation, sudden death, major adverse cardiac events or acute myocarditis within 72 hours. Twelve patients were male and EF averaged 23.0% (±4.5%). No primary safety endpoints were observed. Two patients died of HFrEF progression nine and 12 months following infusion. Compared to baseline, there was an improvement in EF (26.8% vs 22.9%, p=0.023) and left ventricular end-systolic volume (139.5 vs 177.8 cm3, p=0.03) at six months. Quality of life (QoL) scores and NYHA class (p=0.006) improved at six months. At 12 months, the improvement in EF and QoL remained significant.</AbstractText>Global intracoronary infusion of allogeneic CDCs is safe and feasible. The efficacy of allogeneic CDCs in HFrEF needs to be tested in larger randomised trials.</AbstractText> |
17,333 | Ventricular Fibrillation Cardiac Arrest in Young Female from Diffuse Left Anterior Descending Coronary Vasospasm. | This is a case of the most severe and potentially fatal complication of coronary artery vasospasm. We report a case of a 40-year-old female presenting to the emergency department (ED) via emergency medical services with chest pain. The patient experienced a ventricular fibrillation cardiac arrest while in the ED. Post-defibrillation electrocardiogram showed changes suggestive of an ST-elevation myocardial infarction (STEMI). Cardiac catheterization showed severe left anterior descending spasm with no evidence of disease. Coronary vasospasm is a consideration in the differential causes of ventricular fibrillation and STEMI seen in the ED. |
17,334 | Atrial fibrillation: a leading cause of heart failure-related hospitalizations; a dual epidemic. | Atrial fibrillation (AF), and heart failure (HF) are a major cardiovascular epidemic over the last decade. The prevalence and rehospitalization of heart failure are on rising edge, and many factors are responsible for these re-exacerbations of heart failure. In this study, we sought to determine an association of a risk factor for frequent rehospitalization of heart failure at our institute. We aimed to find the re-admission rate, heart rate, and rhythm of heart failure exacerbation.</AbstractText>We performed a single-center retrospective study at the Abington Hospital - Jefferson health and 418 patients having a history of heart failure, and AF were selected. The heart failure readmission rate (days), heart rate, and rhythm were analyzed.</AbstractText>The mean age of the included population was 82.8 years SD ± 9.2. About 53% had AF with a mean heart rate 90 SD ± 21 bpm, and 47% had normal sinus rhythm (NSR) with a mean heart rate of 78 ± 16 bpm on re-admission. This difference was statistically significant (p=0.02). The mean re-admission rate for atrial fibrillation was 27.49 days SD ± 18.97, compared to 32.68 SD ± 20.26 days for NSR, statistically significant (p=0.007) and the Pearson Chi-square was also significant P = 0.006.</AbstractText>There is a significantly increased rate of re-admission in heart failure patients with atrial fibrillation with a rapid ventricular rate. Efforts should be taken to keep the patient in NSR or controlled AF to minimize the rehospitalization rate, and this, in turn, reduces the financial burden on patients and institutes.</AbstractText>AJCD Copyright © 2019.</CopyrightInformation> |
17,335 | A case of pheochromocytoma presenting with cardiopulmonary arrest. | A 33-year-old woman complained of sudden chest pain and intense headache. She was unconscious and underwent defibrillation for ventricular fibrillation in the ambulance. In the emergency room, she was placed on an artificial respirator. Diffuse wall hypokinesis and decreased left ventricular ejection fraction (31%) were identified on transthoracic echocardiography, and an intra-aortic balloon pump was inserted to address the cardiogenic shock. A mass was identified in the right adrenal gland on abdominal ultrasonography. Since a pheochromocytoma was suspected, doxazosin and carvedilol were administered. Blood and urinary norepinephrine and dopamine levels were elevated, confirming the pheochromocytoma diagnosis, and right adrenalectomy was performed 23 days after the initial hospitalization. After surgery, the left ventricular wall motion and left ventricular ejection fraction had improved to 62% on echocardiography. Blood and urinary norepinephrine and dopamine levels also decreased to within the normal range. This case highlights that the patient returned to normalcy and recovered to a transient myocardial disorder or malignant arrhythmia after cardiopulmonary arrest due to early diagnosis of and accurate treatment for pheochromocytoma. <<b>Learning objective:</b> Pheochromocytomas secrete excessive levels of catecholamines that may cause cardiac dysfunction, including fatal arrhythmias. It is necessary for the transient hypertension and fatal arrhythmia appearance to consider the possibility of pheochromocytoma. The decreased cardiac function may be reversible with resection of the tumor. Therefore, early diagnosis and treatment can be lifesaving in such cases. Pheochromocytomas provide an interesting model to evaluate the vulnerability of the myocardium to adrenergic stimulation, such as in cases of takotsubo cardiomyopathy or catecholamine-induced cardiomyopathy.>. |
17,336 | Serial changes of L wave according to heart rates in a heart failure patient with persistent atrial fibrillation. | Mid-diastolic forward flow velocity of transmitral flow (L wave) is known as a marker of diastolic dysfunction and is occasionally observed in patients with fluid retention, low heart rate, and atrial fibrillation (AF). However, how hemodynamic condition affects L wave is still unknown. An 81-year-old woman who underwent implantation of a DDD pacemaker due to complete atrioventricular block 38 years previously suffered from congestive heart failure and was admitted to our hospital. At the time of admission, electrocardiogram showed new-onset AF resulting in mode switch to VVI, and echocardiography showed a giant L wave. At the mid-term of the treatment, AF was converted to sinus rhythm resulting in mode switch to DDD, and pacemaker check-up was performed at pre- and post-cardioversion. During the pacemaker check-ups, L wave was assessed in various pacing rates. As pacing rate was increased, L wave altered according to heart rates and disappeared at 85 bpm in VVI with AF, whereas at 75 bpm in DDD. Through the treatment, L wave got smaller as fluid retention was improved and finally disappeared at the time of discharge. This case suggests that L wave is highly variable and affected by fluid volume, heart rate, and heart rhythm. <<b>Learning objective:</b> Although L wave is known as a marker of diastolic dysfunction and occasionally observed in patients with high left ventricular filling pressure, low heart rate, and atrial fibrillation, how hemodynamics affects L wave is still unknown. In this case, it was observed that L wave is highly variable in the therapeutic process of heart failure and affected by fluid volume, heart rate, and heart rhythm. L wave potentially can be a useful indicator to evaluate treatment efficacy for heart failure.>. |
17,337 | Does Ventricular Tachycardia Ablation Targeting Local Abnormal Ventricular Activity Elimination Reduce Ventricular Fibrillation Incidence? | Various strategies for ablation of ventricular tachycardia (VT) have been described, but their impact on ventricular fibrillation (VF) is largely unknown. The aim of our study was to assess the effect of substrate-based VT ablation targeting local abnormal ventricular activity (LAVA) on recurrent VF events in patients with structural heart disease.</AbstractText>A retrospective 2-center study was performed on patients with structural heart disease and both VT and VF, with incident VT ablation procedures targeting LAVAs. Generalized estimating equations with a Poisson loglinear model were used to assess the impact of catheter ablation on VF episodes. The change in VF events before and after catheter ablation was compared with matched controls without ablation.</AbstractText>From a total of 686 patients with an incident VT ablation procedure targeting LAVAs, 21 patients (age, 57±14 years; left ventricular ejection fraction, 30±10%) had both VT and VF and met inclusion criteria. A total of 80 VF events were recorded in the implantable cardioverter-defibrillator logs the 6 months preceding ablation. Complete and partial LAVA elimination was achieved in 11 (52%) and 10 (48%) patients, respectively. Catheter ablation was associated with a highly significant reduction in VF recurrences (P</i><0.0001), which were limited to 3 (14%) patients at 6 months. The total number of VF events thereby decreased from 80 to 3, from a median of 1.0 (range, 1-29) to 0.0 (range, 0-1) in the 6 months before and after ablation, respectively. The reduction in VF events was significantly greater in patients with catheter ablation compared with 21 matched controls during 6-month periods following and preceding a baseline assessment (Poisson β-coefficient, 1.39; P</i>=0.0003).</AbstractText>Substrate-guided VT ablation targeting LAVAs may be associated with a significant reduction in recurrent VF, suggesting that VT and VF share overlapping arrhythmogenic substrates in patients with structural heart disease.</AbstractText> |
17,338 | Avoidance of Vagal Response During Circumferential Pulmonary Vein Isolation: Effect of Initiating Isolation From Right Anterior Ganglionated Plexi. | Circumferential pulmonary vein isolation (CPVI) often cause unavoidable vagal reflexes during procedure due to the coincidental modification of ganglionated plexus which are located on pulmonary vein (PV) antrum. The right anterior ganglionated plexi (RAGP) which located at superoanterior area of right superior PV antrum is an essential station to regulate the cardiac autonomic nerve activities and is easily coincidentally ablated during CPVI. The aim of this study is to assess the effect of RAGP ablation on vagal response (VR) during CPVI.</AbstractText>A total of 80 patients with paroxysmal atrial fibrillation who underwent the first time CPVI were prospectively enrolled and randomly assigned to 2 groups: group A (n=40), CPVI started with right PVs at RAGP site; group B (n=40): CPVI started with left PVs first, and the last ablation site is RAGP. Electrophysiological parameters include basal cycle length, A-H interval, H-V interval, sinus node recovery time, and atrioventricular node Wenckebach point were recorded before and after CPVI procedure.</AbstractText>During CPVI, the positive VR were only observed on 1 patient in group A and 25 patients in group B (P</i><0.001). A total of 21 patients with positive VR in group B needed for temporary ventricular pacing during procedure, while the only patient with positive VR in group A did not need for temporary ventricular pacing (P</i><0.001). Compared with baseline, basal cycle length, sinus node recovery time, and atrioventricular node Wenckebach point were decreased significantly after CPVI procedure in both groups (all P</i><0.05) and without differences between 2 groups.</AbstractText>Circumferential PV isolation initiated from RAGP could effectively inhibit VR occurrence and significantly increase heart rate during procedure.</AbstractText> |
17,339 | Catheter Ablation Versus Best Medical Therapy in Patients With Persistent Atrial Fibrillation and Congestive Heart Failure: The Randomized AMICA Trial. | Optimal treatment of patients with persistent atrial fibrillation (AF) and heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and an indication for internal defibrillator therapy is controversial.</AbstractText>Patients with persistent/longstanding persistent AF and LVEF ≤35% were randomly allocated to catheter ablation of AF or best medical therapy (BMT). The primary study end point was the absolute increase in LVEF from baseline at 1 year. Secondary end points included 6-minute walk test, quality-of-life, and NT-proBNP (N-terminal pro-brain natriuretic peptide). Pulmonary vein isolation was the primary ablation approach; BMT comprised rate or rhythm control. All patients were discharged after index hospitalization with a cardioverter-defibrillator or cardiac resynchronization therapy defibrillator implanted. The study was terminated early for futility.</AbstractText>Of 140 patients (65±8 years, 126 [90%] men) available for the end point analysis, 68 and 72 patients were assigned to ablation and BMT, respectively. At 1 year, LVEF had increased in ablation patients by 8.8% (95% CI, 5.8%-11.9%) and in BMT patients by 7.3% (4.3%-10.3%; P</i>=0.36). Sinus rhythm was recorded on 12-lead electrocardiograms at 1 year in 61/83 ablation patients (73.5%) and 42/84 BMT patients (50%). Device-recorded AF burden at 1 year was 0% or maximally 5% of the time in 28/39 ablation patients (72%) and 16/36 BMT patients (44%). There was no difference in secondary end point outcome between ablation patients and BMT patients.</AbstractText>The AMICA trial (Atrial Fibrillation Management in Congestive Heart Failure With Ablation) did not reveal any benefit of catheter ablation in patients with AF and advanced HF. This was mainly because of the fact that at 1 year, LVEF increased in ablation patients to a similar extent as in BMT patients. The effect of catheter ablation of AF in patients with HF may be affected by the extent of HF at baseline, with a rather limited ablation benefit in patients with seriously advanced HF.</AbstractText>URL: https://www.clinicaltrials.gov. Unique identifier: NCT00652522.</AbstractText> |
17,340 | Sources of QTc variability: Implications for effective ECG monitoring in clinical practice. | Pharmaceuticals that prolong ventricular repolarization may be proarrhythmic in susceptible patients. While this fact is well recognized, schemes for sequential QTc interval monitoring in patients receiving QT-prolonging drugs are frequently overlooked or, if implemented, underutilized in clinical practice. There are several reasons for this gap in day-to-day clinical practice. One of these is the perception that serially measured QTc intervals are subject to substantial variability that hampers the distinction between potential proarrhythmic signs and other sources of QTc variability. This review shows that substantial part of the QTc variability can be avoided if more accurate methodology for electrocardiogram collection, measurement, and interpretation is used. Four aspects of such a methodology are discussed. First, advanced methods for QT interval measurement are proposed including suggestion of multilead measurements in problematic recordings such as those in atrial fibrillation patients. Second, serial comparisons of T-wave morphologies are advocated instead of simple acceptance of historical QTc measurements. Third, the necessity of understanding the pitfalls of heart rate correction is stressed including the necessity of avoiding the Bazett correction in cases of using QTc values for clinical decisions. Finally, the frequently overlooked problem of QT-heart rate hysteresis is discussed including the possibility of gross QTc errors when correcting the QT interval for simultaneously measured short-term heart rate. |
17,341 | Disease-specific aspects of management of cardiac arrhythmias in patients with muscular dystrophies. | Cardiac arrhythmias are common in patients with various types of muscular dystrophies. The pathophysiological mechanisms of arrhythmias are complex and related to direct involvement of the conduction system and to the development of cardiomyopathy. The occurrence of atrio-ventricular conduction abnormalities and ventricular arrhythmias are associated with increased risk of sudden cardiac death. The threshold for device therapy ( cardiac pacemaker, implantable cardioverter defibrillator) is relatively low according to current guidelines due to the risk of rapid progression of the disease. Atrial arrhythmias carry high risk of stroke and anticoagulation should be considered even in young patients without coexisting risk factors for stroke as estimated by the CHA2DS2-VASc score. Patients with muscular dystrophies should be under regular cardiology follow up even in the absence of symptoms. Early detection of cardiac involvement is crucial. The management of patients with muscular dystrophies requires disease-specific and multidisciplinary approach due to the multi-organ involvement. |
17,342 | Incidence of, risk factors for and impact of readmission for heart failure after successful transcatheter aortic valve implantation. | The incidence of and risk factors for readmission for heart failure after successful transcatheter aortic valve implantation (TAVI) are unclear.</AbstractText>We sought to evaluate the incidence of, risk factors for and clinical impact of readmission for heart failure after successful TAVI in an unselected patient population.</AbstractText>All patients who underwent successful TAVI in two high-volume French tertiary centres from February 2010 to December 2016 were included prospectively and followed up for 1 year. A Cox multivariable model was used to assess risk factors for readmission for heart failure and mortality.</AbstractText>A total of 1139 patients (mean age 82.4±7.7years; 52.2% male sex) were included. Readmission for heart failure occurred in 99 (9.2%) patients. Risk factors for readmission for heart failure were previous atrial fibrillation (adjusted hazard ratio [adj</sub>HR] 1.62, 95% confidence interval [CI] 1.09-2.40), diabetes mellitus (adj</sub>HR 1.67, 95% CI 1.11-2.50), chronic kidney disease (adj</sub>HR 1.72, 95% CI 1.13-2.62), chronic pulmonary disease (adj</sub>HR 1.81, 95% CI 1.17-2.81) and left ventricular ejection fraction after TAVI ≤ 35% (adj</sub>HR 2.12, 95% CI 1.20-3.75). Readmission for heart failure was strongly associated with mortality (adj</sub>HR 3.11, 95% CI 1.95-4.94), along with increased Society of Thoracic Surgeons' score (adj</sub>HR 1.07, 95% CI 1.03-1.12), chronic pulmonary disease (adj</sub>HR 1.45, 95% CI 1.00-2.09), previous atrial fibrillation (adj</sub>HR 2.11, 95% CI 1.52-2.93) and shock during the index hospitalization (adj</sub>HR 2.56, 95% CI 1.41-4.65).</AbstractText>Readmission for heart failure occurs in one in 10 patients after successful TAVI, and is a strong risk factor for mortality. Co-morbidities and left ventricular ejection fraction after TAVI≤35% are the main risk factors for readmission for heart failure.</AbstractText>Copyright © 2019 Elsevier Masson SAS. All rights reserved.</CopyrightInformation> |
17,343 | Embolic Pattern of Stroke Associated with Cardiac Wall Motion Abnormalities; Narrowing the Embolic Stroke of Undetermined Source Category. | There is ambiguity regarding the role of left ventricle wall motion abnormalities (LVWMAs) as a potential cardioembolic source in patients, who satisfy embolic stroke of undetermined source (ESUS) criteria.</AbstractText>We analyzed prospectively collected data in 345 acute stroke patients, 185 (53.6%) stroke with atrial fibrillation (SwAF), and 160 (46.4%) stroke with LVWMA. LVWMA were younger (P = .003), had significantly higher frequency of stroke risk factors and lower ejection fraction (P < .001). No significant difference was found between the stroke pattern in SwAF and LVWMA except focal cortical, cortical-subcortical lesions were more frequent in LVWMA (P = .002). Mean wall motion score index (WMSI) was 1.523 (range 1.05-2.71) without any correlation between the severity of WMSI and multiple strokes (P = .976). In subgroup analyses vertical basal WMSI (P = .030) and vertical mid cavity WMSI (P = .010) was significantly related to branch arterial stroke. LVWMA 94 (65%) patients were on antiplatelet/anticoagulation compared to 47 (52.4%) with atrial fibrillation (AF), with no significant difference in stroke recurrence during 4 years follow-up (P = .15).</AbstractText>Patients with LVWMA who satisfy ESUS criteria, have stroke pattern on diffusion-weighted magnetic resonance imaging and risk of stroke recurrence similar to AF-related stroke despite being on appropriate antiplatelet medications. Further studies with anticoagulation therapy may be required in this group of patients to improve the high risk of recurrent stroke.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,344 | Prognostic implications of N-terminal pro-B-type natriuretic peptide in patients with normal left ventricular ejection fraction undergoing transcatheter aortic valve implantation. | Biomarkers may significantly improve risk stratification algorithms for patients undergoing transcatheter aortic valve implantation (TAVI). While N-terminal pro-B-type natriuretic peptide (NT-proBNP) is established as a biomarker in the context of heart failure, its prognostic implications in patients with normal left ventricular ejection fraction (LVEF) undergoing TAVI are unclear.</AbstractText>A total of 504 TAVI patients with normal LVEF were analyzed. Based on preprocedural NT-proBNP levels, patients were stratified into two groups comparing the upper quartile ("Q4", n = 126) with the lower three quartiles ("Q1-3", n = 378). The primary outcome of our study was survival.</AbstractText>The "Q4" group included more men (46.8% vs. 34.9%, p = 0.017), had higher rates of atrial fibrillation (55.6% vs. 28.3%, p < 0.001) and showed features of more advanced aortic stenosis (mean pressure gradient 49 mmHg vs. 40 mmHg, aortic valve area 0.6 cm2</sup> vs. 0.7 cm2</sup>; p < 0.001, respectively). The "Q4" group was also characterized by more extensive cardiac remodeling including severe diastolic dysfunction (18.1% vs. 6.5%, p < 0.001) and left atrial dilation (26.8% vs. 10.8%, p < 0.001). Kaplan-Meier analysis demonstrated superior survival of the "Q1-3" group (median follow-up 22.1 months, log-rank test p < 0.001). In a multivariable analysis, preprocedural NT-proBNP emerged as a significant risk factor for all-cause mortality after TAVI (HR 1.87, CI 1.31-2.65, p < 0.001).</AbstractText>NT-proBNP is associated with survival in TAVI patients with normal LVEF. In this patient group, preprocedural NT-proBNP levels do not only correlate with aortic stenosis, but reflect advanced cardiovascular dysfunction, including HFpEF, that might not be completely reversible after TAVI.</AbstractText>Copyright © 2019. Published by Elsevier B.V.</CopyrightInformation> |
17,345 | New electromechanical substrate abnormalities in high-risk patients with Brugada syndrome. | The relationship between the typical electrocardiographic pattern and electromechanical abnormalities has never been systematically explored in Brugada syndrome (BrS).</AbstractText>The aims of this study were to characterize the electromechanical substrate in patients with BrS and to evaluate the relationship between electrical and mechanical abnormalities.</AbstractText>We enrolled 50 consecutive high-risk patients with BrS (mean age 42 ± 7.2 years), with implantable cardioverter-defibrillator implantation for primary or secondary prevention of ventricular tachyarrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]), undergoing substrate mapping and ablation. Patients underwent 3-dimensional (3D) echocardiography with 3D wall motion/deformation quantification and electroanatomic mapping before and after ajmaline administration (1 mg/kg in 5 minutes); 3D mechanical changes were compared with 50 age- and sex-matched controls. The effect of substrate ablation on electromechanical abnormalities was also assessed.</AbstractText>In all patients, ajmaline administration induced Brugada type 1 pattern, with a significant increase in the electrical substrate (P < .001), particularly in patients with previous spontaneous VT/VF (P = .007). Induction of Brugada pattern was associated with lowering of right ventricular (RV) ejection fraction (P < .001) and worsening of 3D RV mechanical function (P < .001), particularly in the anterior free wall of the RV outflow tract, without changes in controls. RV electrical and mechanical abnormalities were highly correlated (r = 0.728, P < .001). By multivariate analysis, only the area of RV dysfunction was an independent predictor of spontaneous VT/VF (odds ratio 1.480; 95% confidence interval 1.159-1.889; P = .002). Substrate ablation abolished both BrS-electrocardiographic pattern and mechanical abnormalities, despite ajmaline rechallenge.</AbstractText>BrS is an electromechanical disease affecting the RV. The typical BrS pattern reflects an extensive RV arrhythmic substrate, driving consistent RV mechanical abnormalities. Substrate ablation abolished both Brugada pattern and mechanical abnormalities.</AbstractText>Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,346 | Skin sympathetic nerve activity and ventricular rate control during atrial fibrillation. | The relationship between the ventricular rate (VR) during atrial fibrillation (AF) and skin sympathetic nerve activity (SKNA) remains unclear.</AbstractText>The purpose of this study was to test the hypothesis that SKNA bursts accelerate VR during AF.</AbstractText>We simultaneously recorded electrocardiogram and SKNA in 8 patients (median age 66.0 years [interquartile range {IQR} 59.0-77.0 years]; 4 men [50%]) with 30 paroxysmal AF episodes (all >10-minute long) and 12 patients (73.0 years [IQR 60.5-80.0 years]; 6 men [50%]) with persistent AF. The average amplitude of SKNA (aSKNA [μV]) during AF was analyzed in 1-minute windows and binned, showing 2 Gaussian distributions. We used the mean + 3SD of the first Gaussian distribution as the threshold that separates burst from baseline (nonburst) SKNA. All 1-minute aSKNA values above the threshold were detected, and the area between aSKNA and baseline of every 1 minute was calculated and added as burst area.</AbstractText>VR was higher during SKNA bursts than during the nonburst period (103 beats/min [IQR 83-113 beats/min] vs 88 beats/min [IQR 76-101 beats/min], respectively; P = .003). In the highest quartile of the burst area during persistent AF, the scatterplot of maximal aSKNA and VR during each SKNA burst shows higher aSKNA and VR. The overall estimate of the correlation between maximal VR and aSKNA during bursts show a positive correlation in the highest quartile of the burst area (0.64; 95% confidence interval 0.54-0.74; P < .0001).</AbstractText>SKNA bursts are associated with VR acceleration. These SKNA bursts may be new therapeutic targets for rate control during AF.</AbstractText>Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,347 | Impact of initial heart failure emergence on clinical outcomes of atrial fibrillation patients in the AFFIRM trial. | Heart failure (HF) emergence in atrial fibrillation (AF) patients undergoing different treatment strategies has not been studied.</AbstractText>AFFIRM trial subjects with no history of HF, without clinical HF and normal left ventricular ejection fraction at enrollment were identified. The principal outcome was time to development of a composite of New York Heart Association class ≥II HF and/or cardiovascular (CV) death. It was compared for rate and rhythm strategies and correlated with electrocardiographic parameters on follow-up (FU).</AbstractText>A total of 1,771 patients (880 rate, 891 rhythm) were evaluated. The principal outcome occurred in 21.4% of rate and 16.8% of rhythm subjects at 5 years (hazard ratio [HR] 1.32, 95% CI 1.04-1.69, P = .024). HF increment by 2 classes increased total mortality (HR 2.83, 95% CI 1.91-4.18, P < .0001), cardiac mortality, (HR 4.27, 95% CI 2.03-9.04, P = .0001), and CV hospitalizations (HR 3.04, 95% CI 2.15-4.29, P < .0001). HF emergence during FU was associated with AF (P = .0004), ventricular rate >80 beats/min (P = .0106), and higher frequency of recorded AF in the rhythm arm (25%-75% vs <25%, HR 1.69, 95% CI 1.09-2.64, P = .020; >75% vs <25%, HR 3.15, 95% CI 1.87-5.34, P =< .001).</AbstractText>(1) In AF patients without HF, symptomatic HF emergence was more frequent with rate control than with rhythm control. (2) HF appearance presages increased mortality risk. (3) Delaying HF emergence is associated with effective rhythm control with documented sinus rhythm during >75% of FU visits as well as ventricular rate control.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,348 | The role of amiodarone in contemporary management of complex cardiac arrhythmias. | Amiodarone is an iodinated benzofuran derivative, a highly lipophilic drug with unpredictable pharmacokinetics. Although originally classified as a class III agent due to its ability to prolong refractoriness in cardiac regions and prevent/terminate re-entry, amiodarone shows antiarrhythmic properties of all four antiarrhythmic drug classes. Amiodarone is a potent coronary and peripheral vasodilator and can be safely used in patients with left ventricular dysfunction after myocardial infarction or those with congestive heart failure or hypertrophic cardiomyopathy. Its use is regularly accompanied with QT and QTc-interval prolongation but rarely with ventricular proarrhythmia. It is the most powerful pharmacological agent for long-term sinus rhythm maintenance in patients with atrial fibrillation. Amiodarone, particularly if co-administered with beta-blockers, reduces the rate of arrhythmic death due to ventricular tachyarrhythmias in patients with heart failure, but its benefit on cardiovascular and overall survival in these patients is uncertain. In addition, amiodarone is an important adjuvant drug for the reduction of shocks in patients with an implantable cardioverter-defibrillator. Over the past 40 years, amiodarone became the most prescribed antiarrhythmic. Nevertheless, the slow onset of its antiarrhythmic action requires a loading dose while the high risk of non-cardiac toxicity and common drug-drug interactions limit its long-term use. Furthermore patients treated with amiodarone require a close supervision by the treating physician. Therefore amiodarone is generally considered a secondary therapeutic option. Long-term treatment with amiodarone should be based on the use of minimal doses for satisfactory arrhythmia outcome and serial screening for thyroid, liver and pulmonary toxicity. |
17,349 | Cabins, castles, and constant hearts: rhythm control therapy in patients with atrial fibrillation. | Recent innovations have the potential to improve rhythm control therapy in patients with atrial fibrillation (AF). Controlled trials provide new evidence on the effectiveness and safety of rhythm control therapy, particularly in patients with AF and heart failure. This review summarizes evidence supporting the use of rhythm control therapy in patients with AF for different outcomes, discusses implications for indications, and highlights remaining clinical gaps in evidence. Rhythm control therapy improves symptoms and quality of life in patients with symptomatic AF and can be safely delivered in elderly patients with comorbidities (mean age 70 years, 3-7% complications at 1 year). Atrial fibrillation ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy, but recurrent AF remains common, highlighting the need for better patient selection (precision medicine). Antiarrhythmic drugs remain effective after AF ablation, underpinning the synergistic mechanisms of action of AF ablation and antiarrhythmic drugs. Atrial fibrillation ablation appears to improve left ventricular function in a subset of patients with AF and heart failure. Data on the prognostic effect of rhythm control therapy are heterogeneous without a clear signal for either benefit or harm. Rhythm control therapy has acceptable safety and improves quality of life in patients with symptomatic AF, including in elderly populations with stroke risk factors. There is a clinical need to better stratify patients for rhythm control therapy. Further studies are needed to determine whether rhythm control therapy, and particularly AF ablation, improves left ventricular function and reduces AF-related complications. |
17,350 | Complications of catheter ablation: incidence, diagnosis and clinical management. | Catheter ablation is a well-recognized treatment for a number of cardiac arrhythmias. Initially used to treat supraventricular tachycardia, this technique is now also widely used to treat ventricular arrhythmia and atrial fibrillation. This review aims to describe all the possible types of complication related to this invasive procedure. Definitions according to the current guidelines are provided, as are some details on the frequency of complications and how to diagnose and treat them appropriately. Finally, each section of the review provides guidance on how to prevent the complications associated with catheter ablation. |
17,351 | Association of the low e' and high E/e' with long-term outcomes in patients with normal ejection fraction: a hospital population-based observational cohort study. | We aimed to evaluate the association of the severity of left ventricular (LV) diastolic dysfunction with long-term outcomes in patients with normal ejection fraction.</AbstractText>Retrospective study.</AbstractText>A single centre in Japan.</AbstractText>We included 3576 patients who underwent both scheduled transthoracic echocardiography and ECG between 1 January and 31 December 2013, in a hospital-based population after excluding valvular diseases or low ejection fraction (<50%) or atrial fibrillation and categorised them into three groups: septal tissue Doppler early diastolic mitral annular velocity (e')≥7 (without relaxation disorder, n=1593), e'<7 and early mitral inflow velocity (E)/e'≤14 (with relaxation disorder and normal LV end-diastolic pressure, n=1337) and e'<7 and E/e'>14 (with relaxation disorder and high LV end-diastolic pressure, n=646).</AbstractText>The primary outcome measure was a composite of all-cause death and major adverse cardiac events (MACE). The secondary outcome measure were all-cause death and MACE, separately.</AbstractText>The cumulative 3-year incidences of the primary outcome measures were significantly higher in the e'<7 and E/e'≤14 (19.0%) and e'<7 and E/e'>14 group (23.4%) than those for the e'≥7 group (13.0%; p<0.001). After adjusting for confounders, the excess 3-year risk of primary outcome for the groups with e'<7 and E/e'≤14 related to e'≥7 (HR: 1.24; 95% CI 1.02 to 1.52) and e'<7 and E/e'>14 related to e'<7 (HR: 1.57; 95% CI 1.28 to 1.94) were significant. The severity of diastolic dysfunction was associated with incrementally higher risk for primary outcomes (p<0.001).</AbstractText>The severity of LV diastolic dysfunction using e'<7 and E/e'>14 was associated with the long-term prognosis in patients with normal ejection fraction in an incremental fashion.</AbstractText>© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.</CopyrightInformation> |
17,352 | Weight-based versus non-weight-based diltiazem dosing in the setting of atrial fibrillation with rapid ventricular response. | There is conflicting evidence to support the superiority of weight-based (WB) dosing of intravenous (IV) diltiazem over non-weight-based (NWB) dosing strategies in the management of atrial fibrillation (AFib) with rapid ventricular response (RVR).</AbstractText>A retrospective review evaluated patients presenting to the emergency department (ED) in AFib with RVR and receiving IV diltiazem from 2015 to 2018. Those receiving a NWB dose were compared with those receiving a WB dose based on actual body weight (ABW). Secondary analyses evaluated safety profiles of the regimens and compared response in groups defined by ABW or ideal body weight (IBW).</AbstractText>A total of 371 patients were included in the analysis. No significant difference was observed in achieving a therapeutic response (66.5% vs. 73.1%, p = 0.18) or adverse events between the groups. Patients receiving a WB dose were significantly more likely to have a HR < 100 bpm than those receiving a NWB dose (40.9% vs. 53.5%, p = 0.01). When groups were defined by IBW, WB dosing was associated with a significantly higher incidence of achieving a therapeutic response (62.7% vs. 74.3%, p = 0.02).</AbstractText>In patients presenting with AF with RVR, there was no significant difference in achieving a therapeutic response between the two strategies. A WB dosing approach did result in a greater proportion of patients with a HR < 100 bpm. The utilization of IBW for WB dosing may result in an increased achievement of a therapeutic response.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,353 | Early mortality after implantable cardioverter defibrillator: Incidence and associated factors. | According to guidelines, implantable cardioverter defibrillator (ICD) candidates must have a "reasonable expectation of survival with a good functional status >1 year". Identifying risk for early mortality in ICD candidates could be challenging. We aimed to identify factors associated with a ≤1-year survival among patients implanted with ICDs.</AbstractText>The DAI-PP program was a multicenter, observational French study that included all patients who received a primary prevention ICD in the 2002-2012 period. Characteristics of patients who survived ≤1 year following the implantation were compared with those who survived >1 year, and predictors of early death determined.</AbstractText>Out of the 5539 enrolled patients, survival status at 1 year was known for a total of 5,457, and overall 230 (4.2%) survived ≤1 year. Causes of death were similar in the two groups. Patients with ≤1-year survival had lower rates of appropriate (14 vs. 23%; P = 0.004) and inappropriate ICD therapies (2 vs. 7%; P = 0.009) than patients who lived >1 year after ICD implantation. In multivariate analysis, older age, higher NYHA class (≥III), and atrial fibrillation were significantly associated with ≤1-year survival. Presence of all 3 risk factors was associated with a cumulative 22.63% risk of death within 1 year after implantation.</AbstractText>This is the largest study determining the factors predicting early mortality after ICD implantation. Patients dying within the first year had low ICD therapy rates. A combination of clinical factors could potentially identify patients at risk for early mortality to help improve selection of ICD candidates.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,354 | Dynamic Atrial Substrate During High-Density Mapping of Paroxysmal and Persistent AF: Implications for Substrate Ablation. | This study sought to determine the impact of rate and direction on left atrial (LA) substrate.</AbstractText>The extent to which substrate mapped in sinus rhythm varies according to cycle length and direction of wave front propagation is unknown.</AbstractText>A total of 73 consecutive patients with atrial fibrillation (AF) underwent electroanatomic LA mapping before pulmonary vein isolation using multipolar catheter during distal coronary sinus (CS) pacing at 600 ms and 300 ms. Additional maps were created during left superior pulmonary vein pacing at 300 ms. Bipolar voltage, conduction velocity (CV), and complex signals were determined.</AbstractText>Mean age was 61 ± 9 years, 67% were men, and 53% had persistent AF. Global mean voltage was lower with CS pacing at 300 ms compared with 600 ms (1.56 ± 0.47 mV vs. 1.74 ± 0.48 mV; p < 0.001). This was seen in all LA segments. Global CV was reduced (30.4 ± 13.0 cm/s vs. 38.6 ± 14.0 cm/s; p < 0.001) with greater complex signals at 300 ms (8.9% vs. 5.3%; p < 0.005). Compared with CS pacing, left superior pulmonary vein pacing demonstrated highly regional changes with decreased voltage (1.04 ± 0.43 mV vs. 1.47 ± 0.53 mV; p = 0.01) and CV (24.4 ± 13.0 cm/s vs. 39.9 ± 16.6 cm/s; p = 0.008), and greater complex signals posteriorly. Longer AF duration in paroxysmal AF (p = 0.02) and shorter duration in persistent AF (p = 0.015) and left ventricular ejection fraction (p = 0.016) were independent predictors of voltage change.</AbstractText>In patients with AF, variation in cycle length and direction of wave front activation produce both generalized and regional changes in voltage, CV, and complex fractionation, resulting in significant changes in substrate maps. This study highlights the potential limitations of static low-voltage maps to identify the AF ablation target zone.</AbstractText>Copyright © 2019. Published by Elsevier Inc.</CopyrightInformation> |
17,355 | Effects of Interatrial Shunt on Pulmonary Vascular Function in Heart Failure With Preserved Ejection Fraction. | Implantation of an interatrial shunt device (IASD) in patients with heart failure (HF) reduces left atrial hypertension by shunting oxygenated blood to the right heart and lungs. The attendant increases in pulmonary blood flow (Qp) and oxygen content may alter pulmonary vascular function, while left-to-right shunting might compromise systemic perfusion.</AbstractText>The authors hypothesized that IASD would improve indexes of pulmonary artery (PA) function at rest and during exercise in HF patients without reducing systemic blood flow (Qs).</AbstractText>This is a pooled analysis from 2 trials assessing the effects of the IASD on resting and exercise hemodynamics in HF patients (n = 79) with EF ≥40% with baseline and repeated hemodynamic evaluation between 1 and 6 months. Patients with pulmonary vascular resistance (PVR) >4 WU or right ventricular dysfunction were excluded.</AbstractText>Qp and PA oxygen content increased by 27% and 7% following IASD. These changes were associated with salutary effects on pulmonary vascular function (17% reduction in PVR, 12% reduction in PA elastance [pulmonary Ea], and 24% increase in PA compliance). Qp increased during exercise to a greater extent following IASD compared with baseline, which was associated with reductions in exercise PVR and pulmonary Ea. Patients with increases in PA compliance following IASD experienced greater improvements in supine exercise duration. There was no reduction in Qs following IASD at rest or during exercise.</AbstractText>Implantation of an IASD improves pulmonary vascular function at rest and during exercise in selected patients with HF and EF ≥40%, without compromising systemic perfusion. Further study is warranted to identify underlying mechanisms and long-term pulmonary hemodynamic effects of IASD. (REDUCE LAP-HF Trial [REDUCE LAP-HF]; NCT01913613; and REDUCE LAP-HF Randomized Trial I [REDUCE LAP-HF I]; NCT02600234).</AbstractText>Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,356 | Genetic Variants on SCN5A, KCNQ1, and KCNH2 in Patients with Ventricular Arrhythmias during Acute Myocardial Infarction in a Chinese Population. | Acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality worldwide. About half of sudden deaths from AMI are mainly because of malignant ventricular arrhythmias (VA) after AMI. The sodium channel gene SCN5A and potassium channel genes KCNQ1 and KCNH2 have been widely reported to be genetic risk factors for arrhythmia including Brugada syndrome and long QT syndrome (LQTS). A few studies reported the association of SCN5A variant with ventricular tachycardia (VT)/ventricular fibrillation (VF) complicating AMI. However, little is known about the role of KCNQ1 and KCNH2 in AMI with VA (AMI_VA). This study focuses on investigating the potential variants on SCN5A, KCNQ1, and KCNH2 contributing to AMI with VA in a Chinese population.</AbstractText>In total, 139 patients with AMI_VA, and 337 patients with AMI only, were included. Thirty exonic sites were selected to be screened. Sanger sequencing was used to detect variants. A subsequent association study was also performed between AMI_VA and AMI.</AbstractText>Twelve variants [5 on KCNH2(NM_000238.3), 3 on KCNQ1(NM_000218.2), and 4 on SCN5A(NM_198056.2)] were identified in AMI_VA patients. Only 5 (KCNH2: c.2690A>C; KCNQ1: c.1927G>A, c.1343delC; SCN5A: c.1673A>G, c.3578G>A) of them are missense variants. Two (KCNQ1: c.1343delC and SCN5A: c.3578G>A) of the missense variants were predicted to be clinically pathogenic. All these variants were further genotyped in an AMI without VA group. The association study identified a statistically significant difference in genotype frequency of KCNH2: c.1539C>T and KCNH2: c.1467C>T between the AMI and AMI_VA groups. Moreover, 2 rare variants (KCNQ1: c.1944C>T and SCN5A: c.3621C>T) showed an elevated allelic frequency (more than 1.5-fold) in the AMI_VA group when compared to the AMI group.</AbstractText>Twelve variants (predicting from benign/VUS to pathogenic) were identified on KCNH2, KCNQ1, and SCN5A in patients with AMI_VA. Genotype frequency comparison between AMI_VA and AMI identified 2 significant common variants on KCNH2. Meanwhile, the allelic frequency of 2 rare variants on KCNQ1 and SCN5A, respectively, were identified to be enriched in AMI_VA, although there was no statistical significance. The present study suggests that the ion-channel genes KCNH2, KCNQ1, and SCN5A may contribute to the pathogenesis of VA during AMI.</AbstractText>© 2019 S. Karger AG, Basel.</CopyrightInformation> |
17,357 | I<sub>K1</sub> channel agonist zacopride suppresses ventricular arrhythmias in conscious rats with healing myocardial infarction. | Arrhythmogenesis of chronic myocardial infarction (MI) is associated with the prolongation of action potential, reduction of inward rectifier potassium (IK1</sub>, Kir) channels and hyper-activity of Calcium/calmodulin-dependent kinase II (CaMKII) in cardiomyocytes. Zacopride, a selective IK1</sub> agonist, was applied to clarify the cardioprotection of IK1</sub> agonism via a CaMKII signaling on arrhythmias post-MI.</AbstractText>Male SD rats were implanted wireless transmitter in the abdominal cavity and subjected to left main coronary artery ligation or sham operation. The telemetric ECGs were monitored per day throughout 4 weeks. At the endpoint, isoproterenol (1.28 mg/kg, i.v.) was administered for provocation test. The expressions of Kir2.1 (dominant subunit of IK1</sub> in ventricle) and CaMKII were detected by Western-blotting.</AbstractText>In the telemetric rats post-MI, zacopride significantly reduced the episodes of atrioventricular conduction block (AVB), premature ventricular contraction (PVC), ventricular tachycardia (VT) and ventricular fibrillation (VF), without significant effect on superventricular premature contraction (SPVC). In provocation test, zacopride suppressed the onset of ventricular arrhythmias in conscious PMI or sham rats. The expression of Kir2.1 was significantly downregulated and p-CaMKII was upregulated post-MI, whereas both were restored by zacopride treatment.</AbstractText>IK1</sub>/Kir2.1 might be an attractive target for pharmacological controlling of lethal arrhythmias post MI.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,358 | In-hospital ventricular arrhythmia in heart failure patients: 7 year follow-up of the multi-centric HEARTS registry. | The aim of this study was to determine the incidence, predictors, and short-term and long-term outcomes associated with in-hospital sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) collectively termed ventricular arrhythmia (VA) in the heart failure (HF) patients.</AbstractText>The HEart function Assessment Registry Trial in Saudi Arabia (HEARTS registry) is a prospective national registry of patients with chronic HF from18 tertiary care hospitals across Saudi Arabia. Diagnosis of HF was in accordance with American Heart Association/European Society of Cardiology definition criteria. The registry had enrolled 2610 HF patients during the 14 month recruitment period between October 2009 and December 2010. Occurrence of in-hospital cardiac events, prognosis, and outcome were monitored during the 7 year follow-up period. The incidence of in-hospital VA in HF was 4.2%. VA was more common among men, and mean age was lesser than non-VA patients (58.5 ± 16: 61.5 ± 15 years; P = 0.042). Smoking and family history of cardiomyopathy were significant risk factors of VA. Previous history of arrhythmia, ST elevated myocardial infarction, infections, and hypotension remained significant predictors of in-hospital VA associated with three to seven times more risk. Patients with VA had higher rates of in-hospital events like recurrent HF, haemodialysis, shock, sepsis, major bleeding, intra-aortic balloon pump, and stroke compared with those without VA, all being highly significant (P < 0.001). After adjustment for age, gender, and co-morbidities, in-hospital VA increased the risk of cardiogenic shock by 24 times, dialysis and major bleeding by 10 times, and recurrent congestive HF and pacing by five times. Survival analysis showed that all-cause mortality was significantly higher in the VA patients (P < 0.001). Presence of VA increased in-hospital and 1 month mortality to 23 and 17 times, respectively.</AbstractText>Lower mean age of VA complicated HF patients is a matter of concern in the Saudi population. HF associated with VA increased in-hospital events and all-cause mortality indicating poor prognosis and survival. These findings enable risk stratification and reflect on the importance of early recognition of the clinical markers and predictors of VA prompting immediate management.</AbstractText>© 2019 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.</CopyrightInformation> |
17,359 | Ventricular Arrhythmias in First Acute Myocardial Infarction: Epidemiology, Mechanisms, and Interventions in Large Animal Models. | Ventricular arrhythmia and subsequent sudden cardiac death (SCD) due to acute myocardial infarction (AMI) is one of the most frequent causes of death in humans. Lethal ventricular arrhythmias like ventricular fibrillation (VF) prior to hospitalization have been reported to occur in more than 10% of all AMI cases and survival in these patients is poor. Identification of risk factors and mechanisms for VF following AMI as well as implementing new risk stratification models and therapeutic approaches is therefore an important step to reduce mortality in people with high cardiovascular risk. Studying spontaneous VF following AMI in humans is challenging as it often occurs unexpectedly in a low risk subgroup. Large animal models of AMI can help to bridge this knowledge gap and are utilized to investigate occurrence of arrhythmias, involved mechanisms and therapeutic options. Comparable anatomy and physiology allow for this translational approach. Through experimental focus, using state-of-the-art technologies, including refined electrical mapping equipment and novel pharmacological investigations, valuable insights into arrhythmia mechanisms and possible interventions for arrhythmia-induced SCD during the early phase of AMI are now beginning to emerge. This review describes large experimental animal models of AMI with focus on first AMI-associated ventricular arrhythmias. In this context, epidemiology of first AMI, arrhythmogenic mechanisms and various potential therapeutic pharmacological targets will be discussed. |
17,360 | Comprehensive Cardiac Safety Assessment using hiPS-cardiomyocytes (Consortium for Safety Assessment using Human iPS Cells: CSAHi). | Current cardiac safety assessment platforms (in vitro hERG-centric, APD, and/or in vivo animal QT assays) are not fully predictive of drug-induced Torsades de Pointes (TdP) and do not address other mechanism-based arrhythmia, including ventricular tachycardia or ventricular fibrillation, or cardiac safety liabilities such as contractile and structural cardiotoxicity which are another growing safety concerns. We organized the Consortium for Safety Assessment using Human iPS cells (CSAHi; http://csahi.org/en/) in 2013, based on the Japan Pharmaceutical Manufacturers Association (JPMA), to verify the application of human iPS/ES cell-derived cardiomyocytes for drug safety evaluation. The CSAHi HEART team focused on comprehensive screening strategies to predict a diverse range of cardiotoxicities using recently introduced platforms such as the Multi-Electrode Array (MEA), cellular impedance, Motion Field Imaging (MFI), and optical imaging of Ca transient to identify strengths and weaknesses of each platform. Our study showed that hiPS-CMs used in these platforms could detect pharmacological responses that were more relevant to humans compared to existing hERG, APD, or Langendorff (MAPD/contraction) assays. Further, MEA and other methods such as impedance, MFI, and Ca transient assays provided paradigm changes of platforms for predicting drug-induced QT risk and/or arrhythmia or contractile dysfunctions. In contrast, since discordances such as overestimation (false positive) of arrhythmogenicity, oversight, or opposite conclusions in positive inotropic and negative chronotropic activities to some compounds were also confirmed, possibly due to their functional immaturity of hiPS-CMs, hiPS-CMs should be used in these platforms for cardiac safety assessment based upon their advantages and disadvantages. |
17,361 | Multimodal mechanisms and enhanced efficiency of atrial fibrillation cardioversion by pulmonary delivery of a novel flecainide formulation. | Inhaled flecainide significantly alters atrial electrical properties with the potential to terminate atrial fibrillation (AF) efficiently by optimizing dose and drug formulation.</AbstractText>Seventeen Yorkshire pigs were studied. Intrapericardial acetylcholine and burst pacing were used to induce AF. Effects of a novel cyclodextrin formulation (hydroxypropyl-ß-cyclodextrin [HPßCD]) of flecainide (75 mg/mL, 0.5 or 1.0 mg/kg, bolus) instilled intratracheally at 2 minutes after AF initiation were studied. Concentration time-area analyses of flecainide HPßCD were compared to the traditional acetate formulation.</AbstractText>Intratracheal instillation of flecainide HPßCD accelerated the conversion of AF to sinus rhythm in a dose-proportional manner, shortening AF duration by 47% (P = .014) and 79% (P = .002) at the lower and higher doses, respectively, compared to intratracheal sterile water placebo. AF dominant frequency was reduced by 11% (P = .04) and 29% (P = .004) respective to dose. At 2 minutes after intratracheal flecainide HPßCD, atrial depolarization (Pa</sub> ) duration increased by 12% (P = .02) and 17% (P = .009) at the lower and higher doses, respectively. At this time, the PR interval was prolonged by 9% (P = .04 for the higher dose) and AV node conduction was slowed, decreasing the ventricular rate during AF by 16% (P = .002) and 28% (P = .007) for the lower and higher doses. Flecainide HPßCD achieved the more efficient conversion of AF than the acetate formulation, reflected in a markedly reduced area under the curve (P = .04).</AbstractText>Intratracheal instillation of the new flecainide HPßCD formulation effectively terminates AF through efficient multimodal actions including slowing of atrial conduction velocity and decreasing AF dominant frequency, allowing reduced net drug delivery and inhalation time.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,362 | Clinical Profile and Long-Term Follow-Up of Children with Brugada Syndrome. | Brugada syndrome (BrS) is a rare channelopathy associated with sudden cardiac death (SCD). Although outcome data of adult cohorts are well known, information on children are lacking. The aim of the present study was to analyze the clinical profile, treatment approach and long-term outcome of children affected with BrS. After a systematic review of the literature compiled from a thorough database search (PubMed, Web of Science, Cochrane Libary, Cinahl), data from a total of 4 studies which included 262 BrS patients were identified. The mean age of patients was 12.1 ± 5.5, 53.8% males and 19.8% spontaneous BrS type I. 80.2% of patients presented BrS ECG I after receiving sodium channel blockers. 76% of these patients were asymptomatic while only 17.9% suffered from recurrent syncope. Around 1.5% of the patients were admitted due to aborted SCD, and 3% suffered from atrial arrhythmias. Electrophysiological work-up was performed in 132 patients. Induction of ventricular tachycardia/ventricular fibrillation using programmed ventricular stimulation was inducible in 16 patients. 56 children received an ICD. 11 patients received quinidine. An electrical storm was documented in 1 patient. Appropriate shocks occured in 16% of the patients over a median follow-up period of 62.2 (54-64). ICD-related complications were observed in 11 patients (19.6%) with a predominance of inappropriate shocks and lead failure and/or fracture. Although BrS in the childhood is rare, diagnosis and management continues to be challenging. ICD therapy is an effective therapy in high-risk children with BrS, however, with relevant ICD-related complications. |
17,363 | Mechanisms and clinical course of cardiovascular toxicity of cancer treatment II. Hematology<sup>☆</sup>. | Session II of the Second International Colloquium on Cardio-Oncology, chaired by Dr Breccia (Rome, Italy) and Dr Jurczak (Krakòw, Poland), focused on mechanisms and clinical course of cardiovascular toxicity of cancer treatment. Whereas the venerable anthracyclines keep challenging patients and clinicians with risk of left ventricular dysfunction and heart failure, other newer drugs cause substantially different clinical phenotypes of cardiovascular toxicity. In particular, Session II not only focused on arterial thrombosis and venous thromboembolism, but also hypertension or cardiomyopathy or atrial fibrillation induced by many otherwise life-saving drugs. Dr Breccia (Rome, Italy) reviewed incidence, mechanisms, risk factors, and principles for prevention of cardiovascular events induced by tyrosine kinase inhibitors of hematologic interest, such as those used to treat chronic myeloid leukemia. Dr Carver (Philadelphia) reviewed the incidence, predisposing factors, and principles for proactive management of cardiovascular events in patients treated by conventional chemotherapy or new drugs for treatment of multiple myeloma. Dr Szmit (Warsaw, Poland) discussed on how coagulation disorders should be classified according to patient- or drug-related factors and how they should be diagnosed and treated in patients with solid or hematologic tumors. Dr Minotti (Rome. Italy) illustrated some potential pitfalls of accelerated drug development and approval and their possible impact on clinical incidence of cardiovascular events induced by tyrosine kinase inhibitors of hematologic interest. Session II therefore offered a broad perspective of the risk-benefit ratio of new drugs that are plagued with concerns about cardiovascular events. |
17,364 | Ablation Therapy for Refractory Ventricular Arrhythmias. | Recurrent ventricular arrhythmias (VAs) are a leading cause of cardiovascular morbidity and mortality. In the last three decades, important advancements have occurred in the understanding of the mechanisms of recurrent VAs, their prognostic implications in different clinical contexts, and their treatment options. VAs occur in structurally normal hearts as well as in patients with underlying heart disease, but the latter group has a particularly high risk of recurrent VAs. Catheter ablation offers the possibility of cure for a substantial proportion of patients. Research has focused on identifying optimal targets for ablation, correlating the underlying structural abnormalities with the site of origin of VAs, and determining the optimal procedural approach. Ablation therapy can be life-saving in select patients with high burden of repetitive VAs or advanced heart failure syndromes. This article focuses on clinical aspects of catheter ablation of VAs, particularly the selection and clinical management of patients undergoing catheter ablation procedures and expected outcomes. |
17,365 | Arrhythmic events in Brugada syndrome patients induced by fever. | The Brugada syndrome is associated with arrhythmic events, which may even lead to sudden cardiac death (SCD) as it causes arrhythmic events. A typical Brugada syndrome ECG type I can be triggered at fever situations. The aim of this pooled meta-analysis is to further explore the baseline characteristics and the association of fever to BrS-related arrhythmic events.</AbstractText>We compiled data from a search of databases (PubMed, Web of Science, Cochrane Library, and Google Scholar). We included 17 studies including 14 case reports and a total of 53 patients.</AbstractText>Our population including 53 patients showed a male predominance of 92% with a mean age of 40.6 ± 17.7 years. 58% of patients had a family history of SCD or BrS. Genetic screening was performed in 14 patients (26%) and revealed a SCN5A mutation in 21% of the patients. ICD implantation was initiated in six patients. 75% (n = 39) of patients did not have symptoms before the fever event. Symptoms at fever included life-threatening arrhythmia such as ventricular fibrillation (VF) or ventricular tachycardia (VT; 17%), syncope (13%), and cardiac arrest or aborted SCD (13%). One patient developed electrical storm which led to not aborted SCD.</AbstractText>Fever is a great risk factor for arrhythmia events in BrS patients. Patients with known fever triggered Brugada syndrome should be surveilled closely during fever and be started on antipyretic therapy as soon as possible.</AbstractText>© 2019 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals, LLC.</CopyrightInformation> |
17,366 | Anti‑Nogo‑A antibody promotes brain function recovery after cardiopulmonary resuscitation in rats by reducing apoptosis. | Brain injury after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) is the main cause of neurological dysfunction and death in cardiac arrest. To assess the effect of Nogo‑A antibody on brain function in rats following CPR and to explore the underlying mechanisms, CA/CPR (ventricular fibrillation) rats were divided into the CPR+Nogo‑A, CPR+saline and sham groups. Hippocampal caspase‑3 levels were detected by RT‑PCR and immunoblotting. Next, Nogo‑A, glucose regulated protein 78 (GRP78), C/EBP homologous protein (CHOP), cysteinyl aspartate specific proteinase‑12 (casapse‑12), Bcl‑2 and Bax protein levels in the hippocampus were detected by immunoblotting. Coronal brain sections were analyzed by TUNEL assay to detect apoptosis at 72 h, while Nissl staining and electron microscopy were performed to detect Nissl bodies and microstructure at 24 h, respectively. Finally, rats were assessed for neurologic deficits at various times. Nissl staining revealed morphological improvement after Nogo‑A antibody treatment. Sub‑organelle structure was preserved as assessed by electron microscopy in model animals post‑antibody treatment; neurological function was improved as well (P<0.05), while the apoptosis index was decreased (26.2±9.85 vs. 46.6±12.95%; P<0.05). Hippocampal caspase‑3 mRNA and protein, Nogo‑A protein levels were significantly decreased after antibody treatment (P<0.05). Hippocampal Nogo‑A expression was positively correlated with caspase‑3 (Pearson's correlation; r=0.790, P=0.000). Hippocampal GRP78 and Bcl‑2 protein levels were higher after antibody treatment than these levels noted in the model animals (P<0.05), while CHOP, caspase‑12 and Bax levels were reduced (P<0.05). Nogo‑A antibody ameliorates neurological function after restoration of spontaneous circulation (ROSC), possibly by suppressing apoptosis induced by endoplasmic reticulum stress. |
17,367 | Endomyocardial fibrosis presented by ventricular tachycardia: case report. | Endomyocardial fibrosis (EMF) is a form of restrictive cardiomyopathy that is diagnosed mainly in children and young adults and is geographically found in Africa, Latin America, and Asia. It is a condition with high morbidity and mortality, unknown etiology, and no definitive treatment. Although its main clinical presentation is congestive heart failure with or without related supraventricular arrhythmia like atrial fibrillation, it very rarely presents with ventricular arrhythmias and tachycardias (VA, VT).</AbstractText>We report a case of right ventricular (RV) EMF presented with recurrent attacks of hemodynamically unstable VT that required direct current (DC) cardioversion. The diagnosis was suspected by transthoracic echocardiography (TTE) and established by cardiac magnetic resonance (CMR). The patient underwent implantable cardioverter-defibrillator (ICD) implantation for secondary prevention of VT, and he was discharged safely on antiarrhythmic drugs with regular follow-up visits.</AbstractText>EMF presenting with VT are quite rare and to the best of our knowledge, our case is the fourth case in the literature to report VT as a clinical presentation of EMF.</AbstractText> |
17,368 | Throws of Death: Traumatic Coronary Artery Dissection Resulting From Jiu Jitsu Training. | The risk of cardiac injury in blunt thoracic trauma is quite rare, occurring in only 0.1% of patients. The least common cardiac injury is coronary artery dissection. Most cardiac injuries result from high-energy mechanisms such as motor vehicle collisions. Even low-mechanism injuries that have been reported involved rapid deceleration.</AbstractText>We present a case of traumatic coronary artery dissection that resulted from a low-energy blunt thoracic injury with no rapid deceleration. This patient had no other associated thoracic injuries, such as rib fractures or sternal fracture. Following presentation, our patient twice deteriorated into ventricular fibrillation and was successfully resuscitated each time. The coronary lesion was successfully stented and the patient was eventually discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case underscores the importance of maintaining a high level of suspicion for coronary artery dissection even in low-energy mechanisms. An electrocardiogram should be obtained early, even in low-energy mechanisms. While patients with traumatic cardiac injuries will commonly present with other injuries, such as rib fractures, the absence of these injuries does not rule out cardiac injury.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,369 | The role of entirely subcutaneous ICD™ systems in patients with dilated cardiomyopathy. | The subcutaneous implantable-cardioverter defibrillator (S-ICD™, Boston Scientific, Natick, MA, USA) is an important advance in device therapy for the prevention of sudden cardiac death (SCD). Although current guidelines recommend S-ICD™ use, long-term data are still limited, especially in subgroups. Dilated cardiomyopathy (DCM) is a common reason for the implantation of an ICD. However, there are no sufficient data on the performance of the S-ICD™ in this patient cohort.</AbstractText>All S-ICD™ patients with DCM as the main indication for ICD implantation (n=47 patients) in our large-scaled single-center S-ICD™ registry (n=294 patients) were included in this study. Baseline characteristics, appropriate and inappropriate shocks, and complications were documented in a mean follow-up of 22.9±18.5 months.</AbstractText>A total of 47 patients with DCM as the underlying structural heart disease received an S-ICD™ in our institution. Mean left ventricular ejection fraction was 37±12% and a 28% had a history of ventricular tachyarrhythmia. During follow-up eight ventricular tachyarrhythmias were adequately terminated in three patients. In four patients, oversensing resulting in an inappropriate shock was observed, which could be managed by changing the sensing vector. There was no need for a change to a cardiac resynchronization (CRT) system while one system was changed to a VVI-ICD due to S-ICD™ wound infection.</AbstractText>The S-ICD™ seems to be a valuable option for the prevention of SCD in patients with DCM and no indication for CRT. As clinically relevant ventricular arrhythmias consisted of ventricular fibrillation or fast ventricular tachycardia in all patients in our cohort, no change to transvenous ICDs for anti-tachycardia pacing delivery was necessary.</AbstractText>Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.</CopyrightInformation> |
17,370 | Differences in cardiac phenotype and natural history of laminopathies with and without neuromuscular onset. | To investigate differences in cardiac manifestations of patients affected by laminopathy, according to the presence or absence of neuromuscular involvement at presentation.</AbstractText>We prospectively analyzed 40 consecutive patients with a diagnosis of laminopathy followed at a single centre between 1998 and 2017. Additionally, reports of clinical evaluations and tests prior to referral at our centre were retrospectively evaluated.</AbstractText>Clinical onset was cardiac in 26 cases and neuromuscular in 14. Patients with neuromuscular presentation experienced first symptoms earlier in life (11 vs 39 years; p <  0.0001) and developed atrial fibrillation/flutter (AF) and required pacemaker implantation at a younger age (28 vs 41 years [p = 0.013] and 30 vs 44 years [p = 0.086] respectively), despite a similar overall prevalence of AF (57% vs 65%; p = 0.735) and atrio-ventricular (A-V) block (50% vs 65%; p = 0.500). Those with a neuromuscular presentation developed a cardiomyopathy less frequently (43% vs 73%; p = 0.089) and had a lower rate of sustained ventricular tachyarrhythmias (7% vs 23%; p = 0.387). In patients with neuromuscular onset rhythm disturbances occurred usually before evidence of cardiomyopathy. Despite these differences, the need for heart transplantation and median age at intervention were similar in the two groups (29% vs 23% [p = 0.717] and 43 vs 46 years [p = 0.593] respectively).</AbstractText>In patients with laminopathy, the type of disease onset was a marker for a different natural history. Specifically, patients with neuromuscular presentation had an earlier cardiac involvement, characterized by a linear and progressive evolution from rhythm disorders (AF and/or A-V block) to cardiomyopathy.</AbstractText> |
17,371 | [Prognostic value of N-terminal B-type natriuretic peptide on all-cause mortality in heart failure patients with preserved ejection fraction]. | <b>Objective:</b> To investigate the prognostic value of N-terminal B-type natriuretic peptide (NT-proBNP) on all-cause mortality in heart failure patients with preserved ejection fraction (HFpEF) at real world scenarios. <b>Methods:</b> Patients who met the diagnostic criteria of HFpEF in the China National Heart Failure Registration Study (CN-HF) were divided into death and survival groups. The demographic data, physical examination, results of the first echocardiography, laboratory results at admission, complications, drug use and clinical outcomes were obtained from CN-HF. The univariate Cox proportional hazard model was used to screen the variates that might predict prognosis, and then the covariates with statistical significance were included in the multivariate Cox regression model to analyze the predictive value of baseline NT-proBNP on all-cause death. Spearman correlation analysis was used to evaluate the relationship between NT-proBNP and estimated glomerular filtration rate (eGFR), so as to further explore the predictive value of the interaction between renal dysfunction and NT-proBNP on death. Since NT-proBNP did not obey the binary normal distribution, it was expressed by the natural logarithm of NT-proBNP (LnNT-proBNP). <b>Results:</b> A total of 1 846 HFpEF patients were enrolled in this study, with an average age of 71.5 years, 1 017 males(55.1%), median NT-proBNP 860 ng/L, and median eGFR 73.9 ml·min<sup>-1</sup>·1.73m<sup>-2</sup>. After a median follow-up of 34 months, 213 (11.5%) patients died. Patients in the death group were older, with higher NYHA classification Ⅲ-Ⅳ ratio, longer hospital stay, higher serum potassium and NT-proBNP level, prevalence of complications of diabetes mellitus, arrhythmia and atrial fibrillation, use of angiotensin receptor antagonist(ARB), mineralocorticoid receptor antagonists (MRA), diuretic and digoxin was significantly higher in death group than in survival group. Body mass index (BMI), diastolic blood pressure, left ventricular ejection fraction (LVEF), hemoglobin, serum cholesterol(TC), serum triglycerides (TG) and eGFR, and use of angiotensin converting enzyme inhibitors (ACEI), statins and aspirin were lower in death group than in survival group. Univariate Cox regression analysis showed that NT-proBNP was a predictor of all-cause death in HFpEF patients (<i>HR</i>=2.522, 95<i>%CI</i> 2.040-3.119, <i>P<</i>0.001). Multivariate Cox regression analysis showed that the elevated NT-proBNP remains as the independent predictor of all-cause death in patients with HFpEF (<i>HR</i>=1.230, 95<i>%CI</i> 1.049-1.442, <i>P=</i>0.011) after adjusting for age, BMI, diastolic blood pressure, LVEF, hemoglobin, serum potassium, serum sodium, TC, serum high-density lipoprotein cholesterol (HDL-C), TG, eGFR, atrial fibrillation, as well as the treatment of ACEI/ARB, MRA, diuretics and digoxin. Spearman correlation analysis showed that LnNT-proBNP was negatively correlated with eGFR (<i>r=</i>-0.361, <i>P<</i>0.001), but there was no interaction between NT-proBNP and renal dysfunction in predicting death in HFpEF patients (<i>P></i>0.05). <b>Conclusion:</b> The elevated level of NT-proBNP at admission is an independent predictor of all-cause mortality in HFpEF patients.</Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Cao</LastName><ForeName>J</ForeName><Initials>J</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai 200032, China; North Sichuan Medical College, Nanchong 637000, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Jin</LastName><ForeName>X J</ForeName><Initials>XJ</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai 200032, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Zhou</LastName><ForeName>J</ForeName><Initials>J</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai 200032, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Chen</LastName><ForeName>Z Y</ForeName><Initials>ZY</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Xu</LastName><ForeName>D L</ForeName><Initials>DL</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Yang</LastName><ForeName>X C</ForeName><Initials>XC</Initials><AffiliationInfo><Affiliation>Heart Center, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing 100020, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Dong</LastName><ForeName>W</ForeName><Initials>W</Initials><AffiliationInfo><Affiliation>Department of Cardiology, People's Liberation Army General Hospital, Beijing 100039, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Li</LastName><ForeName>L W</ForeName><Initials>LW</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Luo</LastName><ForeName>J</ForeName><Initials>J</Initials><AffiliationInfo><Affiliation>North Sichuan Medical College, Nanchong 637000, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Chen</LastName><ForeName>L</ForeName><Initials>L</Initials><AffiliationInfo><Affiliation>North Sichuan Medical College, Nanchong 637000, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Fu</LastName><ForeName>M</ForeName><Initials>M</Initials><AffiliationInfo><Affiliation>Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg 41650, Sweden.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Zhou</LastName><ForeName>J M</ForeName><Initials>JM</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai 200032, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Ge</LastName><ForeName>J B</ForeName><Initials>JB</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai 200032, China.</Affiliation></AffiliationInfo></Author></AuthorList><Language>chi</Language><GrantList CompleteYN="Y"><Grant><GrantID>2011BAI11B10</GrantID><Agency>National Science & Technology Pillar Program, 12th 5-year Plan of China</Agency><Country/></Grant></GrantList><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList></Article><MedlineJournalInfo><Country>China</Country><MedlineTA>Zhonghua Xin Xue Guan Bing Za Zhi</MedlineTA><NlmUniqueID>7910682</NlmUniqueID><ISSNLinking>0253-3758</ISSNLinking></MedlineJournalInfo><ChemicalList><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="D015415">Biomarkers</NameOfSubstance></Chemical><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="D010446">Peptide Fragments</NameOfSubstance></Chemical><Chemical><RegistryNumber>114471-18-0</RegistryNumber><NameOfSubstance UI="D020097">Natriuretic Peptide, Brain</NameOfSubstance></Chemical></ChemicalList><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D000368" MajorTopicYN="N">Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D015415" MajorTopicYN="N">Biomarkers</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D002681" MajorTopicYN="N" Type="Geographic">China</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005260" MajorTopicYN="N">Female</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006333" MajorTopicYN="Y">Heart Failure</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008297" MajorTopicYN="N">Male</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D020097" MajorTopicYN="N">Natriuretic Peptide, Brain</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D010446" MajorTopicYN="N">Peptide Fragments</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D011379" MajorTopicYN="N">Prognosis</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D013318" MajorTopicYN="N">Stroke Volume</DescriptorName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="chi"><b>目的：</b> 探讨入院基线N末端B型利钠肽原（NT-proBNP）对射血分数保留的心力衰竭（HFpEF）患者全因死亡的预测价值。 <b>方法：</b> 入选中国住院患者心力衰竭注册研究（CN-HF）中符合HFpEF诊断标准的患者，根据随访期间是否死亡分为死亡组和存活组。从CN-HF中获得研究对象的人口学信息、入院时体格检查信息、入院首次超声心动图检查结果、实验室检查结果、合并症情况、用药情况和临床结局等资料。通过单因素Cox回归模型对可能预测预后的变量进行筛选，将单因素分析中与全因死亡有统计学意义的协变量纳入多因素Cox回归模型，进而分析基线NT-proBNP对全因死亡的预测价值。采用Spearman相关分析分析NT-proBNP与估算的肾小球滤过率（eGFR）的关系，并进一步探讨肾功能不全与NT-proBNP预测全因死亡的交互作用。鉴于NT-proBNP不服从二元正态分布，本研究中NT-proBNP作连续变量分析时均取自然对数（LnNT-proBNP）。 <b>结果：</b> 共1 846例患者纳入本研究，平均年龄71.5岁，男性1 017例（55.1%），NT-proBNP中位数860 ng/L，eGFR中位数73.9 ml·min<sup>-1</sup>·1.73m<sup>-2</sup>。本研究中位随访时间34（24~42）个月，随访期间全因死亡213例（11.5%）被纳入死亡组，存活1 633例（88.5%）被纳入存活组。与存活组比较，死亡组患者年龄较大，纽约心脏协会（NYHA）心功能Ⅲ~Ⅳ级者比例较高，住院时间较长，血钾、NT-proBNP较高，合并糖尿病、心律失常、心房颤动者较多，服用血管紧张Ⅱ受体阻滞剂（ARB）、盐皮质激素受体拮抗剂（MRA）、利尿剂和地高辛者较多（<i>P</i>均<0.05）。与存活组比较，死亡组患者体重指数（BMI）、舒张压、左心室射血分数（LVEF）较低，血红蛋白、血清总胆固醇（TC）、血清甘油三酯（TG）、eGFR较低，服用血管紧张素转化酶抑制剂（ACEI）、他汀类药物和阿司匹林者较少（<i>P</i>均<i><</i>0.05）。单因素Cox回归分析结果显示NT-proBNP是HFpEF患者全因死亡的预测因素（<i>HR</i>=2.522，95<i>%CI</i> 2.040~3.119，<i>P<</i>0.001）。多因素Cox回归分析结果显示，校正了年龄、BMI、舒张压、LVEF、血红蛋白、血钾、血钠、TC、高密度脂蛋白胆固醇、TG、eGFR、心房颤动以及ACEI/ARB、MRA、利尿剂、地高辛使用情况后，NT-proBNP仍是HFpEF患者全因死亡的独立预测因素（<i>HR</i>=1.230，95<i>%CI</i> 1.049~1.442，<i>P=</i>0.011）。Spearman相关分析结果显示，LnNT-proBNP与eGFR呈负相关（<i>r=</i>-0.361，<i>P<</i>0.001）。而校正了混杂因素后，多因素Cox回归分析结果显示肾功能不全与NT-proBNP预测HFpEF患者全因死亡无交互作用（<i>P></i>0.05）。 <b>结论：</b> 入院基线NT-proBNP是HFpEF患者全因死亡的独立预测因素。. |
17,372 | [Contemporary epidemiology and treatment of hospitalized heart failure patients in real clinical practice in China]. | <b>Objective:</b> To observe the etiology, comorbidities, clinical features and treatment patterns of hospitalized patients with heart failure (HF) in China. <b>Methods:</b> Data were collected prospectively on hospitalized patients with HF who were enrolled in China Heart Failure Center Registry Study from 169 participating hospitals from January 2017 to August 2018. In this cross-sectional study, patients were stratified by left ventricular ejection fraction (LVEF) category: heart failure with reduced ejection fraction (HFrEF, LVEF<i><</i>40%); heart failure with mid-ranged ejection fraction (HFmrEF, 40%≤LVEF<i><</i>50%) and heart failure with preserved ejection fraction (HFpEF, LVEF≥50%). The clinical data were collected, including demographic information, diagnosis, signs, electrocardiogram, echocardiography, laboratory tests, and treatment. <b>Results:</b> A total of 31 356 hospitalized patients with HF were included, 19 072 (60.8%) were males and the average age was (67.9±13.6) years old. The common causes of HF were hypertension (57.2%), coronary heart disease (54.6%), dilated cardiomyopathy (14.7%), valvular heart disease (9.2%). The common complications were atrial fibrillation/atrial flutter (34.1%), diabetes (29.2%), and anemia (26.7%). 32.8% of patients had a history of hospitalization for HF within the previous 12 months. There were 11 034 (35.2%) patients with HFrEF, 6 825 (21.8%) patients with HFmrEF and 13 497 (43.0%) patients with HFpEF. Compared with patients with HFpEF, patients with HFrEF had a lower systolic blood pressure ((124.7±21.1)mmHg(1 mmHg=0.133 kPa) vs. (134.9±22.9)mmHg), faster heart rate ((85±19) beats/minutes vs. (81±19)beats/minutes), and higher percentage of New York Heart Association (NYHA) class Ⅳ, smoking, alcohol, left bundle branch block, and QRS time≥130 ms, and higher levels of blood uric acid, BNP, and NT-proBNP (all <i>P<</i>0.05). Compared with patients with HFmrEF and HFrEF, patients with HFpEF were older, more women, and higher comorbidity burden including hypertension, atrial fibrillation/atrial flutter, anemia and chronic obstructive pulmonary disease (all <i>P<</i>0.05). HFmrEF took a mid-position between HFrEF and HFpEF in age, gender, heart rate, systolic blood pressure, hypertension, atrial fibrillation/atrial flutter, anemia, and chronic obstructive pulmonary disease (all <i>P<</i>0.05). Patients with HFmrEF had the highest proportion of coronary heart disease, myocardial infarction and percutaneous coronary intervention (all <i>P<</i>0.05). During hospitalization, loop diuretics were used in 90.2% of patients, and intravenous inotropics were used in 20.4% of patients. The use of ACEI/ARB/ARNI, β blockers and aldosterone receptor antagonists at discharge were 71.8%, 79.1% and 83.6% in HFrEF and 69.9%, 75.5% and 72.4% in HFmrEF, respectively. The use of digoxin at discharge was 25.3% (HFrEF 36.7%, HFmrEF 23.1%, HFpEF 17.0%). The rates of cardiac resynchronization therapy and implantable cardioverter defibrillator in HFrEF were 2.7% and 2.1%. <b>Conclusions:</b> Among the hospitalized patients with HF in China, coronary heart disease and hypertension are the mostly prevalent causes. HFpEF accounts for a large proportion of hospitalized patients with HF. HFrEF, HFmrEF and HFpEF have different etiology and clinical features. In real-world, there are still large gaps in the effective application of the guideline recommended therapies to HF patients, especially the non-pharmacological therapy option, which needs to be improved further in China.</Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Wang</LastName><ForeName>H</ForeName><Initials>H</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Li</LastName><ForeName>Y Y</ForeName><Initials>YY</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Chai</LastName><ForeName>K</ForeName><Initials>K</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Zhang</LastName><ForeName>W</ForeName><Initials>W</Initials><AffiliationInfo><Affiliation>Department of Biostatistics, School of Public Health, Fudan University, Shanghai 200032, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Li</LastName><ForeName>X L</ForeName><Initials>XL</Initials><AffiliationInfo><Affiliation>Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Dong</LastName><ForeName>Y G</ForeName><Initials>YG</Initials><AffiliationInfo><Affiliation>First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Zhou</LastName><ForeName>J M</ForeName><Initials>JM</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Huo</LastName><ForeName>Y</ForeName><Initials>Y</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Peking University First Hospital, Beijing 100034, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Yang</LastName><ForeName>J F</ForeName><Initials>JF</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.</Affiliation></AffiliationInfo></Author></AuthorList><Language>chi</Language><GrantList CompleteYN="Y"><Grant><GrantID>2018-12M-1-002</GrantID><Agency>CAMS Innovation Fund for Medical Sciences</Agency><Country/></Grant></GrantList><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList></Article><MedlineJournalInfo><Country>China</Country><MedlineTA>Zhonghua Xin Xue Guan Bing Za Zhi</MedlineTA><NlmUniqueID>7910682</NlmUniqueID><ISSNLinking>0253-3758</ISSNLinking></MedlineJournalInfo><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D000368" MajorTopicYN="N">Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D000369" MajorTopicYN="N">Aged, 80 and over</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D002681" MajorTopicYN="N" Type="Geographic">China</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D003430" MajorTopicYN="N">Cross-Sectional Studies</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005260" MajorTopicYN="N">Female</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006333" MajorTopicYN="Y">Heart Failure</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName><QualifierName UI="Q000628" MajorTopicYN="N">therapy</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008297" MajorTopicYN="N">Male</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008875" MajorTopicYN="N">Middle Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D011379" MajorTopicYN="N">Prognosis</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D013318" MajorTopicYN="N">Stroke Volume</DescriptorName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="chi"><b>目的：</b> 调查并总结我国住院心力衰竭（心衰）患者的病因、合并症、临床特点和治疗情况。 <b>方法：</b> 本研究数据来源于中国心衰中心注册研究，该研究前瞻性入选了2017年1月至2018年8月169家医院的心衰患者。本研究为横断面调查，入选中国心衰中心注册研究中的住院心衰患者，根据左心室射血分数（LVEF）水平分组，分为射血分数降低的心衰（HFrEF）组（LVEF<i><</i>40%）、射血分数中间值的心衰（HFmrEF）组（40%≤LVEF<i><</i>50%）和射血分数保留的心衰（HFpEF）组（LVEF≥50%）。收集入选患者的临床资料，包括人口学信息、诊断、体征、心电图、超声心动图、实验室指标和治疗等。 <b>结果：</b> 本研究最终纳入住院心衰患者31 356例，其中男性19 072例（60.8%），年龄（67.9±13.6）岁。住院心衰患者的常见病因为冠心病（54.6%）、高血压（57.2%）、扩张型心肌病（14.7%）、瓣膜性心脏病（9.2%），常见合并症为心房颤动（房颤）/心房扑动（房扑）（34.1%）、糖尿病（29.2%）、贫血（26.7%）。心衰患者近1年内因心衰住院的比例为32.8%。HFrEF组患者共11 034例（35.2%），HFmrEF组患者共6 825例（21.8%），HFpEF组患者共13 497例（43.0%）。与HFpEF组比较，HFrEF组患者收缩压较低、心率较快（<i>P</i>均<0.05），纽约心脏协会（NYHA）心功能Ⅳ级、吸烟、饮酒、左束支传导阻滞及QRS时限≥130 ms的比例较高（<i>P</i>均<0.05），血尿酸、B型利钠肽及N末端B型利钠肽原水平较高（<i>P</i>均<0.05）。与HFmrEF组和HFrEF组比较，HFpEF组患者年龄较大，女性较多，合并高血压、房颤/房扑、贫血及慢性阻塞性肺疾病的比例较高（<i>P</i>均<0.05）。HFmrEF患者的年龄、女性比例、心率、收缩压以及合并高血压、房颤/房扑、贫血、慢性阻塞性肺疾病的比例均介于HFrEF与HFpEF之间。HFmrEF患者中冠心病、心肌梗死和接受冠状动脉介入治疗的比例均较其他两组高（<i>P</i>均<0.05）。住院期间，襻利尿剂的使用率为90.2%，静脉正性肌力药物的使用率为20.4%。出院时，血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体阻滞剂/血管紧张素受体脑啡肽酶抑制剂、β受体阻滞剂和醛固酮受体拮抗剂的使用率，在HFrEF组患者中分别为78.2%、79.1%和83.6%，在HFmrEF组患者中分别为72.6%、75.5%和72.4%。心衰患者出院时地高辛使用率为25.3%（HFrEF组为36.7%，HFmrEF组为23.1%，HFpEF组为17.0%）。HFrEF组患者心脏再同步治疗、植入式心脏复律除颤器植入率分别为2.7%和2.1%。 <b>结论：</b> 我国住院心衰患者中HFpEF患者占比较大，主要病因为冠心病和高血压。HFrEF、HFmrEF、HFpEF患者的病因、合并症和临床特征有所不同。真实世界中心衰患者的治疗现状与指南推荐差距较大，尤其是在非药物治疗方面，需改进。. |
17,373 | Dual Chamber Pacemaker Implantation Complicated by Left Anterior Descending Coronary Artery Injury. | A 53-year-old female underwent dual-chamber pacemaker implantation for tachy-brady syndrome, which was complicated by anterior ST-segment elevation myocardial infarction and ventricular fibrillation due to right ventricular lead impingement on the left anterior descending coronary artery. Coronary artery injury is a rare complication of cardiac device implantation which requires a multidisciplinary team for management. (<b>Level of Difficulty: Beginner.</b>). |
17,374 | How to Prescribe Drugs With an Identified Proarrhythmic Liability. | This is an article in the Journal of Clinical Pharmacology's Core Entrustable Professional Activities in Clinical Pharmacology series that discusses drug-induced proarrhythmia and is offered as a teaching aid for medical students and residents. Drugs from diverse pharmacological classes can lead to multiple types of arrhythmias including the polymorphic ventricular tachycardia torsades de pointes (TdP). Although typically occurring in self-limiting bursts with or without associated symptoms, which can range from mild lightheadedness and palpitations to syncope and seizures, TdP can also occasionally progress to ventricular fibrillation and sudden cardiac death. To provide patients with the optimal therapeutic benefits of potentially proarrhythmic drugs, prescribers are responsible for obtaining a good understanding of the compound's benefit-risk properties and perform a judicious assessment of the patient's clinical characteristics and individual risk factors. Dose adjustments and/or additional monitoring of electrocardiograms and electrolyte balances may be appropriate in some cases. This article explains the pharmacological mechanism of action of drug-induced proarrhythmia associated with compounds that prolong the repolarization period, illustrates how this liability is conveyed in a drug's prescribing information (label), details the clinical characteristics of patients most susceptible to this type of proarrhythmia, and describes interventions that can be made if TdP occurs. Three clinical vignettes are provided at the end of the article to highlight the relevance of the preceding discussions. |
17,375 | Extracorporeal Membrane Oxygenation for Hypokalemia and Refractory Ventricular Fibrillation Associated with Caffeine Intoxication. | Caffeine has been reported as a cause of cardiac arrest after massive overdose. Here, we report the case of a patient with caffeine intoxication, which can cause fatal dysrhythmias and severe hypokalemia. They were successfully treated with extracorporeal membrane oxygenation (ECMO).</AbstractText>A 43-year-old woman with a history of bipolar disorder presented to the emergency department after suicidal drug ingestion (caffeine and amitriptyline). Immediately after arrival, she experienced multiple episodes of ventricular fibrillation with severe hypokalemia requiring cardiopulmonary resuscitation and medical therapy. However, conventional treatment was not successful. We instituted ECMO early during resuscitation because prolonged hypokalemia refractory to aggressive potassium replacement precluded the use of antidysrhythmic medications for refractory circulatory compromise with ventricular fibrillation. The use of ECMO provided time to correct hypokalemia (19.3 g potassium) and reduce the caffeine level with hemodialysis. Although she had sustained cardiac arrest, she recovered fully and was discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case indicates the potential effectiveness of ECMO in severely poisoned patients with fatal dysrhythmias. ECMO could provide time for removal of toxic drugs and correction of electrolyte abnormalities.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,376 | Point of View: Electrophysiological Endpoints Differ When Comparing the Mode of Action of Highly Successful Anti-arrhythmic Drugs in the CAVB Dog Model With TdP. | In the anaesthetized, chronic atrioventricular block (CAVB) dog, ventricular ectopic beats and Torsade de pointes arrhythmias (TdP) are believed to ensue from an abrupt prolongation of ventricular repolarization and increased temporal dispersion of repolarization, quantified as short-term variability (STV). These TdP stop spontaneously or, when supported by substantial spatial dispersion of repolarization (SDR), degenerate into ventricular fibrillation. However, most studies involving ventricular arrhythmias do not quantify SDR by means of an electrophysiological parameter. Therefore, we reviewed the effects of 4 highly effective anti-arrhythmic drugs (flunarizine, verapamil, SEA-0400, and GS-458967) on the repolarization duration and associated STV. All drugs were tested as anti-arrhythmic strategies against TdP in CAVB dogs, their high anti-arrhythmic efficacy was defined as suppressing drug-induced TdP in 100% of the experiments. This comparison demonstrates that even though the anti-arrhythmic outcome was similar for all drugs, distinct responses of repolarization duration and associated STV were observed. Moreover, the aforementioned and commonly adopted electrophysiological parameters were not always sufficient in predicting TdP susceptibility, and additional quantification of the SDR proved to be of added value in these studies. The variability in electrophysiological responses to the different anti-arrhythmic drugs and their inconsistent adequacy in reflecting TdP susceptibility, can be explained by distinct modes of interference with TdP development. As such, this overview establishes the separate involvement of temporal and spatial dispersion in ventricular arrhythmogenesis in the CAVB dog model and proposes SDR as an additional parameter to be included in future fundamental and/or pharmaceutical studies regarding TdP arrhythmogenesis. |
17,377 | Advanced mapping strategies for ablation therapy in adults with congenital heart disease. | Ultra-high density mapping (HDM) is a promising tool in the treatment of patients with complex arrhythmias. In adults with congenital heart disease (CHD), rhythm disorders are among the most common complications but catheter ablation can be challenging due to heterogenous anatomy and complex arrhythmogenic substrates. Here, we describe our initial experience using HDM in conjunction with novel automated annotation algorithms in patients with moderate to great CHD complexity.</AbstractText>We studied a series of consecutive adult patients with moderate to great CHD complexity and an indication for catheter ablation due to symptomatic arrhythmia. HDM was conducted using the Rhythmia™ mapping system and a 64-electrode mini-basket catheter for identification of anatomy, voltage, activation pattern and critical areas of arrhythmia for ablation guidance. To investigate novel advanced mapping strategies, postprocedural signal processing using the Lumipoint™ software was applied.</AbstractText>In 19 patients (53±3 years; 53% male), 21 consecutive ablation procedures were conducted. Procedures included ablation of atrial fibrillation (n=7; 33%), atrial tachycardia (n=11; 52%), atrioventricular accessory pathway (n=1; 5%), the atrioventricular node (n=1; 5%) and ventricular arrhythmias (n=4; 19%). A total of 23 supraventricular and 8 ventricular arrhythmias were studied with the generation of 56 complete high density maps (atrial n=43; ventricular n=11, coronary sinus n=2) and an average of 12,043±1,679 mapping points. Multiple arrhythmias were observed in n=7 procedures (33% of procedures; range of arrhythmias detected 2-4). A total range of 1-4 critical areas were defined per procedure and treated within a radiofrequency application time of 16 (interquartile range 12-45) minutes. Postprocedural signal processing using Lumipoint™ allowed rapid annotation of fractionated signals within specific windows of interest. This supported identification of a practical critical isthmus in 20 out of 27 completed atrial and ventricular tachycardia activation maps.</AbstractText>Our findings suggest that HDM in conjunction with novel automated annotation algorithms provides detailed insights into arrhythmia mechanisms and might facilitate tailored catheter ablation in patients with moderate to great CHD complexity.</AbstractText>2019 Cardiovascular Diagnosis and Therapy. All rights reserved.</CopyrightInformation> |
17,378 | Sacubitril/Valsartan Improves Left Atrial and Left Atrial Appendage Function in Patients With Atrial Fibrillation and in Pressure Overload-Induced Mice. | LCZ696 (sacubitril/valsartan) is an angiotensin receptor-neprilysin inhibitor and has shown beneficial effects in patients with heart failure. However, whether LCZ696 protects against left atrial (LA) and LA appendage (LAA) dysfunction is still unclear. The present study aimed to assess the efficacy of LCZ696 for improving the function of LA and LAA. We performed both a retrospective study comparing LCZ696 with angiotensin receptor blockers (ARBs) to assess the efficacy of LCZ696 in patients with atrial fibrillation and an animal study in a mouse model with pressure overload. LA peak systolic strain, LAA emptying flow velocity, and LAA ejection fraction (LAAEF) were significantly increased in patients with LCZ696 as compared with ARBs (p = 0.024, p = 0.036, p = 0.026, respectively). Users of LCZ696 had a lower incidence of spontaneous echocardiography contrast (p = 0.040). Next, patients were divided into two groups (LAAEF ≤ 20% and > 20%). Administration of LCZ696 in patients with LAAEF > 20% was more frequent than LAAEF ≤ 20% (p = 0.032). Even after controlling for LAA dysfunction-related risk factors (age, atrial fibrillation type, old myocardial infarction, hypertension, congestive heart failure, and prior stroke or transient ischemic attack), use of LCZ696 remained significantly associated with reduced probability of LAAEF ≤ 20% [odds ratio = 0.011; 95% confidence interval (0.000-0.533), p = 0.023]. To further confirmed effect of LCZ696 in LA function, we constructed a post-transverse aortic constriction model in mice. Mice with LCZ696 treatment showed lower LA dimension and higher left ventricular ejection fraction and LAA emptying flow velocity as compared with mice with vehicle or valsartan treatment. Meanwhile, as compared with vehicle or valsartan, LCZ696 significantly decreased LA fibrosis in mice. In summary, we provide evidence that LCZ696 may be more effective in improving LA and LAA function than ARBs in both humans and mice, which suggests that LCZ696 might be evaluated as a direct therapeutic for atrial remodeling and AF. |
17,379 | Impact of Baseline Left Ventricular Diastolic Dysfunction in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation. | We sought to assess the impact of diastolic dysfunction (DD) grade, as per the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines, on survival of patients with severe aortic stenosis (AS) who underwent transcatheter aortic valve implantation (TAVI). We included consecutive patients with severe AS who underwent TAVI in our institution. DD grading was determined retrospectively according to the 2016 ASE DD guidelines and categorized to grade I-III and indeterminate grade I-II DD. Comparison of 1-year survival according to DD grade was performed by Kaplan-Meier analysis, and evaluation of DD at 1 year was performed in a subset of patients. Among 606 TAVI patients, 394 (65%) had sufficient data for DD grading. Seventy-seven (20%) had grade I DD, 191 (48%) had grade II, 60 (15%) had grade III, and 66 (17%) had an indeterminate grade between I and II. Baseline characteristics indicate higher rates of atrial fibrillation, brain natriuretic peptide level, pulmonary artery systolic pressure, and indexed left ventricular mass as DD grade increases (all p ≤0.01). In conclusion, comparison of 1-year survival revealed a higher rate of mortality in patients with grade III DD that remained statistically significant following adjustment in a multivariate Cox proportional hazard model. DD grade after TAVI improved in patients with grades II and III. Severe AS patients with grade III DD have higher risk for 1-year mortality after TAVI compared with milder degrees of DD. Further research is warranted to explore a potential benefit for aortic valve therapy at an earlier stage of the disease process. |
17,380 | Cyclooxygenase inhibition prior to ventricular fibrillation induced ischemia reperfusion injury impairs survival and outcomes. | Nonsteroidal anti-inflammatory medications (NSAIDs) are one of the most commonly used analgesics in the world. NSAIDs decrease prostaglandin synthesis through cyclooxygenase inhibition (COX-1 or COX-2). The effects of NSAIDs on survival and outcomes from global ischemia reperfusion events and specifically from cardiac arrest (CA) remain controversial. We hypothesized that NSAIDs prior to global whole-body ischemia reperfusion (I/R) injury impairs survival and outcomes. We explored this hypothesis in our swine model of Cardiac Arrest (CA) which involves global I/R with pretreatment using a predominantly COX-1 inhibitor (Indomethacin [COX-1/min COX-2 Inh], a COX-2 Inhibitor [COX-2-Inh, (Celecoxib)] or placebo control. We determined the effects of each inhibitor on a) survival, b) myocardial injury biomarker (Troponin 1), and c) Autonomic Nervous System (ANS) injury marker (heart rate variability [HRV]) up to 3 h after resuscitation. There were no survivals in COX-1/min COX-2-Inh pretreated animals and, 87% survived in both COX-2 Inhibited and control animals. COX-2 Inh pretreated animals had an 1800 fold increase of Troponin 1 compared to baseline whereas control animals had a 90 fold increase (p < 0.001). These results along with literature review of focal I/R in animal models with COX-2 overexpression, human studies of CA, and post myocardial infarction treatment with NSAIDs, support the hypothesis that NSAIDs prior to an I/R event impairs survival and outcomes. Specifically, predominantly COX-1 inhibition impairs survival, and COX-2 inhibition induces myocardial damage, autonomic nervous system dysfunction, and increases the risk for all-cause mortality and morbidity in humans post-MI which has significant implications for the nearly 10% of the population who are taking NSAIDs. |
17,381 | Early repolarization pattern on ECG recorded before the acute coronary event does not predict ventricular fibrillation during ST-elevation myocardial infarction. | Generally considered benign, electrocardiographic (ECG) early repolarization (ER) pattern was claimed to be an indicator of increased susceptibility to ventricular arrhythmias during acute ischemia.</AbstractText>The purpose of this study was to assess in a nonselected population whether ER pattern documented before ST-elevation myocardial infarction (STEMI) is associated with risk of hemodynamically unstable ventricular tachycardia (VT) or ventricular fibrillation (VF) during acute STEMI.</AbstractText>For STEMI patients admitted for primary percutaneous coronary intervention from 2007-2010, the latest ECGs recorded before STEMI were exported in digital format. After excluding ECGs with paced rhythm and QRS duration ≥120 ms, the remaining ECGs were processed using the Glasgow algorithm allowing automatic ER detection. The association between ER pattern and VT/VF during the first 48 hours of STEMI was tested using logistic regression.</AbstractText>ECGs recorded before STEMI were available for 1584 patients. Of these patients, 124 did not meet inclusion criteria, leaving 1460 patients available for analysis (age 68 ± 12 years; 67% male). ER pattern was present in 272 patients (18.6%; ER+ group). ER+ and ER- groups did not differ with regard to clinical characteristics. VT/VF during the first 48 hours of STEMI occurred in 19 ER+ (7.0%) and 105 ER- patients (8.8%; P = .398). ER was not associated with any VT/VF (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.47-1.29; P = .324); VT/VF before reperfusion (OR 0.48; 95% CI 0.23-1.001; P = .051); or reperfusion-related VT/VF (OR 1.28; 95% CI 0.55-3.01; P = .569).</AbstractText>In a nonselected population of STEMI patients, the ER pattern on ECG recorded before the acute coronary event was not associated with VT/VF during the first 48 hours of STEMI.</AbstractText>Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,382 | Management of sustained arrhythmias for patients with cardiogenic shock in intensive cardiac care units. | Cardiac arrhythmias that occur in patients referred to intensive care units worsen symptoms and outcomes and need urgent correction, especially in patients admitted for refractory heart failure. Electrical storm is a frequent reason for referral to an intensive care unit. Specific, efficient and rapid management of patients presenting with various arrhythmias is therefore mandatory and procedures should be known by any physician involved in an intensive care unit. This article reviews the current knowledge on the management of supraventricular and ventricular arrhythmias in this setting, from medications and sedation to ablation and more exceptional therapy. It also covers the occasional indications of resynchronization in refractory heart failure and the interest for haemodynamic assistance when specific therapy fails. |
17,383 | Doxorubicin and its proarrhythmic effects: A comprehensive review of the evidence from experimental and clinical studies. | The cancer burden on health and socioeconomics remains exceedingly high, with more than ten million new cases reported worldwide in 2018. The financial cost of managing cancer patients has great economic impact on both an individual and societal levels. Currently, many chemotherapeutic agents are available to treat various malignancies. One of these agents is doxorubicin, which was isolated from Streptomyces peucetius in the 1960s. Doxorubicin is frequently administered in combination with other agents as a mainstay chemotherapeutic regimen in many settings, since there is well-documented evidence that it is effective in eliminating malignant cells. Doxorubicin exerts its anti-tumor properties through DNA intercalation and topoisomerase inhibition. It also contains a quinone moiety which is susceptible to redox reactions with certain intracellular molecules, thereby leading to the production of reactive oxygen species. The oxidative stress following doxorubicin exposure is responsible for its well-documented cardiotoxicity, impairing cardiac contractility, ultimately resulting in congestive heart failure. Despite the cumulative evidence noting its adverse effects on the heart, limited information is available regarding the mechanistic association between doxorubicin and cardiac arrhythmias. There is compelling evidence to suggest that doxorubicin also causes proarrhythmic effects. Several case reports and studies in cancer patients have attributed many arrhythmic events to doxorubicin, some of which are life-threatening such as complete heart block and ventricular fibrillation. In this review, reports regarding the potential arrhythmic complications associated with doxorubicin from previous studies investigating the effects of doxorubicin on cardiac electrophysiological properties are comprehensively summarized and discussed. Consistencies and controversial findings from in vitro, in vivo, ex vivo, and clinical studies are presented and mechanistic insights regarding the effects of doxorubicin are also discussed. |
17,384 | Value of dual Doppler echocardiography for prediction of atrial fibrillation recurrence after radiofrequency catheter ablation. | Increasing evidence has been presented which suggests that left ventricular (LV) diastolic dysfunction may play an important role in the development of atrial fibrillation (AF). However, the potential for LV diastolic dysfunction to serve as a predictor of AF recurrence after radiofrequency catheter ablation remains unresolved.</AbstractText>Dual Doppler and M-PW mode echocardiography were performed in 67 patients with AF before ablation and 47 patients with sinus rhythm. The parameters measured within identical cardiac cycles included, the time interval between the onset of early transmitral flow peak velocity (E) and that of early diastolic mitral annular velocity (e') (TE-e'), the ratio of E to color M-mode Doppler flow propagation velocity (Vp)(E/Vp), the Tei index, the ratio of E and mitral annular septal (S) peak velocity in early diastolic E/e'(S) and the ratio of E and mitral annular lateral (L) peak velocity E/e'(L). A follow-up examination was performed 1 year after ablation and patients were divided into two groups based on the presence or absence of AF recurrence. Risk estimations for AF recurrence were performed using univariate and multivariate logistic regression.</AbstractText>TE-e', E/Vp, the Tei index, E/e'(S) and E/e'(L) were all increased in AF patients as compared with the control group (p <  0.05). At the one-year follow-up examination, a recurrence of AF was observed in 21/67 (31.34%) patients. TE-e' and the Tei index within the recurrence group were significantly increased as compared to the group without recurrence (p <  0.001). Results from multivariate analysis revealed that TE-e' can provide an independent predictor for AF recurrence (p = 0.001).</AbstractText>Dual Doppler echocardiography can provide an effective and accurate technique for evaluating LV diastolic function within AF patients. The TE-e' obtained within identical cardiac cycles can serve as an independent predictor for the recurrence of AF as determined at 1 year after ablation.</AbstractText> |
17,385 | Functional mitral regurgitation, updated: ventricular or atrial? | Lone atrial fibrillation (AF) can cause functional mitral regurgitation (MR), commonly referred to as "atrial functional MR (AFMR)." This type of MR has recently received much attention as an important cause of heart failure, and it represents a considerable therapeutic target in heart failure patients with AF. Mitral annular dilatation due to left atrial (LA) dilatation can be recognized as an original cause of AFMR, whereas the exact cascade of AFMR etiologies has not been established. AFMR is typically classified as Carpentier type I, and is likely to have a central jet. In contrast, a proportion of AFMR is classified as a combination of Carpentier type I for a flattened anterior mitral leaflet and Carpentier type IIIb for a tethered posterior mitral leaflet and is likely to have an eccentric jet directed toward the LA posterior wall. The traditional functional MR occurring in patients with left ventricular (LV) dilatation and/or systolic dysfunction, which is classified as Carpentier type IIIb, has since been designated "ventricular functional MR (VFMR)" to distinguish it from AFMR. Traditional VFMR, newly recognized AFMR, and their etiologic relations to LV/LA size and function are discussed in this review article. |
17,386 | Is paroxysmal supraventricular tachycardia truly benign? Insightful association between PSVT and stroke from a National Inpatient Database Study. | Atrial fibrillation and flutter are well-known causes of stroke. Whether other atrial arrhythmias categorized as paroxysmal supraventricular tachycardia (PSVT) are associated with stroke is less clear. We aimed to evaluate the association of PSVT with ischemic and embolic stroke and its impact on short-term outcomes in hospitalized stroke patients.</AbstractText>National Inpatient Sample database of the USA was used to assess the association of PSVT with ischemic stroke. Atrial fibrillation and flutter were excluded to minimize the confounding effects. The association of PSVT with stroke was evaluated using univariate and multivariate analysis. Subgroup analyses by gender, age, and stroke type were also performed.</AbstractText>PSVT was associated with increased odds of overall ischemic stroke in univariate [OR 1.18 (95% CI 1.09-1.27) p < 0.001] analysis. No such association was observed in multivariate analysis (OR 1.06 (95% CI 0.98-1.14) p = 0.1) or with subgroup analysis by gender and age. However, PSVT was associated with embolic stroke in both univariate (OR 2.01 (95%CI 1.67-2.43, p < 0.001) and multivariate analysis (OR 1.7 (95%CI 1.4-2.14) p < 0.001) as well as in subgroup analyses by gender and age. Furthermore, the presence of PSVT was associated with increased mortality in embolic stroke (OR 4.11, CI 2.29 to 7.39, p < 0.001) and increased total hospital cost and length of hospital stay in all stroke types.</AbstractText>PSVT is independently associated with higher prevalence of embolic stroke but not with overall ischemic stroke. Patients with embolic stroke in the presence of PSVT have worse in-hospital outcomes with increased mortality.</AbstractText> |
17,387 | Efficacy of Combined Cox-Maze IV and Ventricular Septal Myectomy for Treatment of Atrial Fibrillation in Patients With Obstructive Hypertrophic Cardiomyopathy. | Atrial fibrillation (AF) has important clinical consequences in hypertrophic cardiomyopathy (HC). Safety and efficacy of the Cox-Maze IV procedure (when combined with ventricular septal myectomy) in patients with obstructive HC and paroxysmal AF is largely unresolved. Records of 395 consecutive HC patients (age 55 ± 13 years) who underwent septal myectomy for heart failure symptoms between 2004 and 2015 were reviewed. Sixty-two patients also had concomitant complete biatrial Cox-Maze IV for a history of symptomatic paroxysmal AF (3.0 ± 3.6 episodes) combined with myectomy comprise the study cohort. Freedom from symptomatic AF recurrences after operation was assessed. Left ventricular outflow gradients were reduced from 81 ± 28 mm Hg preoperatively to 1.2 ± 6.8 mm Hg after operation. At most recent follow-up, 53 patients (85%) were asymptomatic or mildly symptomatic. Freedom from recurrent symptomatic AF after myectomy/Cox-Maze IV was: 85% (95% confidence interval [CI] 73, 92) at 1 year, 69% (95% CI 55, 79) at 3 years, and 64% (95% CI 48, 75) at 5 years, including 34 patients (54%) who have experienced no symptomatic AF episodes for up to 8.2 years following surgery. The only clinical predictor of recurrent AF over follow-up was preoperative transverse left atrial dimension ≥45 mm (p <0.01). In conclusion, biatrial Cox-Maze IV combined with septal myectomy is associated with favorable long-term freedom from symptomatic paroxysmal AF recurrence, as well as from obstructive heart failure symptoms. These data support myectomy/Cox-Maze as an effective management option for the subgroup of HC patients with symptomatic outflow obstruction and paroxysmal AF. |
17,388 | Cardiomyocyte-Specific STIM1 (Stromal Interaction Molecule 1) Depletion in the Adult Heart Promotes the Development of Arrhythmogenic Discordant Alternans. | STIM1 (stromal interaction molecule 1) is a calcium (Ca2+</sup>) sensor that regulates cardiac hypertrophy by triggering store-operated Ca2+</sup> entry. Because STIM1 binding to phospholamban increases sarcoplasmic reticulum Ca2+</sup> load independent of store-operated Ca2+</sup> entry, we hypothesized that it controls electrophysiological function and arrhythmias in the adult heart.</AbstractText>Inducible myocyte-restricted STIM1-KD (STIM1 knockdown) was achieved in adult mice using an αMHC (α-myosin heavy chain)-MerCreMer system. Mechanical and electrophysiological properties were examined using echocardiography in vivo and optical action potential (AP) mapping ex vivo in tamoxifen-induced STIM1flox/flox</sup>-Cretg</sup>/-</sup> (STIM1-KD) and littermate controls for STIM1flox/flox</sup> (referred to as STIM1-Ctl) and for Cretg/-</sup> without STIM deletion (referred to as Cre-Ctl).</AbstractText>STIM1-KD mice (N=23) exhibited poor survival compared with STIM1-Ctl (N=22) and Cre-Ctl (N=11) with >50% mortality after only 8-days of cardiomyocyte-restricted STIM1-KD. STIM1-KD but not STIM1-Ctl or Cre-Ctl hearts exhibited a proclivity for arrhythmic behavior, ranging from frequent ectopy to pacing-induced ventricular tachycardia/ventricular fibrillation (VT/VF). Examination of the electrophysiological substrate revealed decreased conduction velocity and increased AP duration (APD) heterogeneity in STIM1-KD. These features, however, were comparable in VT/VF(+) and VT/VF(-) hearts. We also uncovered a marked increase in the magnitude of APD alternans during rapid pacing, and the emergence of a spatially discordant alternans profile in STIM1-KD hearts. Unlike conduction velocity slowing and APD heterogeneity, the magnitude of APD alternans was greater (by 80%, P</i><0.05) in VT/VF(+) versus VT/VF(-) STIM1-KD hearts. Detailed phase mapping during the initial beats of VT/VF identified one or more rotors that were localized along the nodal line separating out-of-phase alternans regions.</AbstractText>In an adult murine model with inducible and myocyte-specific STIM1 depletion, we demonstrate for the first time the regulation of spatially discordant alternans by STIM1. Early mortality in STIM1-KD mice is likely related to enhanced susceptibility to VT/VF secondary to discordant APD alternans.</AbstractText> |
17,389 | Sex-specific cardiac phenotype and clinical outcomes in patients with hypertrophic cardiomyopathy. | It is unknown whether sex-specific differences in mortality observed in HCM are due to older age of women at presentation, or whether women have greater degree of LV myopathy than men.</AbstractText>We retrospectively compared clinical/imaging characteristics and outcomes between women and men in our overall cohort composed of 728 HCM patients, and in an age-matched subgroup comprised of 400 age-matched patients. We examined sex-specific differences in LV myopathy, and dissected the influence of age and sex on outcomes. LV myopathy was assessed by measuring LV mass, LVEF, global peak longitudinal systolic strain (LV-GLS), diastolic function (E/A, E/e'), late gadolinium enhancement (LV-LGE) and myocardial blood flow (MBF) at rest/stress. The primary endpoint was a composite outcome, comprising heart failure (HF), atrial fibrillation (AFib), ventricular tachycardia/fibrillation (VT/VF) and death; individual outcomes were defined as the secondary endpoint.</AbstractText>Women in the overall cohort were older by 6 years. Women were more symptomatic and more likely to have obstructive HCM. Women had smaller LV cavity size, stroke volume and LV mass, higher indexed maximum wall thickness (IMWT), more hyperdynamic LVEF and higher/similar LV-GLS. Women had similar LV-LGE and E/A, but higher E/e' and rest/stress MBF. Female sex was independently associated with the composite outcome in the overall cohort, and with HF in the overall cohort and age-matched subgroup after adjusting for obstructive HCM, LA diameter, LV-GLS.</AbstractText>Our results suggest that sex-specific differences in LV geometry, hyper-contractility and diastolic function, not greater degree of LV myopathy, contribute to a higher, age-independent risk of diastolic HF in women with HCM.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,390 | Adenoviral βARKct Cardiac Gene Transfer Ameliorates Postresuscitation Myocardial Injury in a Porcine Model of Cardiac Arrest. | The aim of the study was to determine whether the inhibition of the G-protein-coupled receptor kinase 2 by adenoviral βARKct cardiac gene transfer can ameliorate postresuscitation myocardial injury in pigs with cardiac arrest (CA) and explore the mechanism of myocardial protection.</AbstractText>Male landrace domestic pigs were randomized into the sham group (anesthetized and instrumented, but ventricular fibrillation was not induced) (n = 4), control group (ventricular fibrillation 8 min, n = 8), and βARKct group (ventricular fibrillation 8 min, n = 8). Hemodynamic parameters were monitored continuously. Blood samples were collected at baseline, 30 min, 2 h, 4 h, and 6 h after the return of spontaneous circulation (ROSC). Left ventricular ejection fraction was assessed by echocardiography at baseline and 6 h after ROSC. These animals were euthanized, and the cardiac tissue was removed for analysis at 6 h after ROSC.</AbstractText>Compared with those in the sham group, left ventricular +dp/dtmax, -dp/dtmax, cardiac output (CO), and ejection fraction (EF) in the control group and the βARKct group were significantly decreased at 6 h after the restoration of spontaneous circulation. However, the βARKct treatment produced better left ventricular +dp/dtmax, -dp/dtmax, CO, and EF after ROSC. The βARKct treatment also produced lower serum cardiac troponin I, CK-MB, and lactate after ROSC. Furthermore, the adenoviral βARKct gene transfer significantly increased β1 adrenergic receptors, SERCA2a, RyR2 levels, and decreased GRK2 levels compared to control.</AbstractText>The inhibition of GRK2 by adenoviral βARKct cardiac gene transfer can ameliorate postresuscitation myocardial injury through beneficial effects on restoring the sarcoplasmic reticulum Ca-handling proteins expression and upregulating the β1-adrenergic receptor level after cardiac arrest.</AbstractText> |
17,391 | Pacing induced cardiomyopathy. | Pacing induced cardiomyopathy (PICM) is most commonly defined as a drop in left ventricle ejection fraction (LVEF) in the setting of chronic, high burden right ventricle (RV) pacing. Recent data suggest, however, that some individuals may experience the onset of heart failure symptoms more acutely after pacemaker implantation. Definitions of PICM which emphasize drop in LVEF may underestimate the incidence of deleterious effects from RV pacing. Treatment of PICM has primarily focused on upgrade to cardiac resynchronization therapy (CRT) when LVEF has dropped. However, emerging data suggest that conduction system pacing (CSP) may offer an opportunity to prevent PICM in the first place. |
17,392 | Long-term follow-up in peripartum cardiomyopathy patients with contemporary treatment: low mortality, high cardiac recovery, but significant cardiovascular co-morbidities. | Peripartum cardiomyopathy (PPCM) establishes late in pregnancy or in the first postpartum months. Many patients recover well within the first year, but long-term outcome studies on morbidity and mortality are rare. Here, we present 5-year follow-up data of a German PPCM cohort.</AbstractText>Five-year follow-up data were available for 66 PPCM patients (mean age 34 ± 5 years) with a mean left ventricular ejection fraction (LVEF) of 26 ± 9% at diagnosis. Ninety-eight percent initially received standard heart failure therapy (beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and/or mineralocorticoid receptor antagonists), and 86% were additionally treated with dopamine D2 receptor agonists (mainly bromocriptine) and anticoagulation. After 1 year, mean LVEF had improved to 50 ± 11% (n = 48) and further increased to 54 ± 7% at 5-year follow-up with 72% of patients having achieved full cardiac recovery (LVEF >50%). At 5-year follow-up, only three patients (5%) displayed no recovery, of whom one had died. However, 20% had arterial hypertension and 17% arrhythmias, including paroxysmal supraventricular tachycardia, ventricular tachycardia, or ventricular fibrillation. Moreover, 70% were still on at least one heart failure drug. Subsequent pregnancy occurred in 16 patients with two abortions and 14 uneventful pregnancies. Mean LVEF was 55 ± 7% at 5-year follow-up in these patients.</AbstractText>Our PPCM collective treated with standard therapy for heart failure, dopamine D2 receptor agonists, and anticoagulation displays a high and stable long-term recovery rate with low mortality at 5-year follow-up. However, long-term use of cardiovascular medication, persisting or de novo hypertension and arrhythmias were frequent.</AbstractText>© 2019 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.</CopyrightInformation> |
17,393 | Dexmedetomidine Reduces Atrial Fibrillation After Adult Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials. | Dexmedetomidine has been shown to have antiarrhythmic effects by exhibiting sympatholytic properties and activating the vagus nerve in preclinical studies. Results from clinical trials of dexmedetomidine on atrial fibrillation (AF) following adult cardiac surgery are controversial.</AbstractText>We searched EMBASE, PubMed and Cochrane CENTRAL databases for randomized controlled trials (RCTs) comparing the antiarrhythmic effect of dexmedetomidine versus placebo or other anesthetic drugs in adult patients undergoing cardiac surgery. The primary outcome was the incidence of AF. The secondary outcomes were ventricular arrhythmias [ventricular fibrillation (VF), ventricular tachycardia (VT)], mechanical ventilation (MV) duration, intensive care unit (ICU) length of stay, and hospital length of stay, and all-cause mortality.</AbstractText>Thirteen trials with a total of 1684 study patients were selected. Compared with controls, dexmedetomidine significantly reduced the incidence of postoperative AF [odds ratio (OR) 0.75; 95% confidence interval (CI) 0.58-0.97; P = 0.03] and VT (OR 0.23; 95% CI 0.11-0.48; P < 0.0001). No significant difference for the incidence of VF existed (OR 0.80; 95% CI 0.21-3.03; P = 0.74). There was no significant difference between groups in MV duration [weighted mean difference (WMD) - 0.10; 95% CI - 0.42 to 0.21; P = 0.52], postoperative ICU stay (WMD - 0.49; 95% CI - 2.64 to 1.66; P = 0.65), hospital stay (WMD - 0.01; 95% CI - 0.16 to 0.13; P = 0.88) and mortality (OR 0.59; 95% CI 0.15-2.37; P = 0.46).</AbstractText>Perioperative administration of dexmedetomidine in adult patients undergoing cardiac surgery reduced the incidence of postoperative AF and VT. But there was no significant difference in incidence of VF, MV duration, ICU stay, hospital stay and mortality.</AbstractText> |
17,394 | Standardised Framework for Quantitative Analysis of Fibrillation Dynamics. | The analysis of complex mechanisms underlying ventricular fibrillation (VF) and atrial fibrillation (AF) requires sophisticated tools for studying spatio-temporal action potential (AP) propagation dynamics. However, fibrillation analysis tools are often custom-made or proprietary, and vary between research groups. With no optimal standardised framework for analysis, results from different studies have led to disparate findings. Given the technical gap, here we present a comprehensive framework and set of principles for quantifying properties of wavefront dynamics in phase-processed data recorded during myocardial fibrillation with potentiometric dyes. Phase transformation of the fibrillatory data is particularly useful for identifying self-perpetuating spiral waves or rotational drivers (RDs) rotating around a phase singularity (PS). RDs have been implicated in sustaining fibrillation, and thus accurate localisation and quantification of RDs is crucial for understanding specific fibrillatory mechanisms. In this work, we assess how variation of analysis parameters and thresholds in the tracking of PSs and quantification of RDs could result in different interpretations of the underlying fibrillation mechanism. These techniques have been described and applied to experimental AF and VF data, and AF simulations, and examples are provided from each of these data sets to demonstrate the range of fibrillatory behaviours and adaptability of these tools. The presented methodologies are available as an open source software and offer an off-the-shelf research toolkit for quantifying and analysing fibrillatory mechanisms. |
17,395 | A randomized controlled trial of cardiac resynchronization therapy in patients with prolonged atrioventricular interval: the REAL-CRT pilot study. | A prolonged PR interval is known to be associated with increased mortality and a higher risk of developing atrial fibrillation (AF). We tested the hypothesis that cardiac resynchronization therapy (CRT) is superior to conventional dual-chamber pacing with algorithms for right ventricular pacing avoidance (DDD-VPA) in preserving systolic and diastolic function and in preventing new-onset AF in patients with normal systolic function, indication for pacing and prolonged atrioventricular conduction (PR interval ≥220 ms).</AbstractText>We randomly assigned 82 patients with ejection fraction >35%, indication for pacing and PR interval ≥220 ms to CRT or to DDD-VPA. On 12-month follow-up examination, the study and control arms did not differ in terms of left ventricular end-systolic volume (44 ± 17 mL vs. 47 ± 16 mL, P = 0.511) or ejection fraction (55 ± 6% vs. 57 ± 8%, P = 0.291). The E to A mitral wave amplitude ratio was higher in the CRT arm (1.3 ± 1.3 vs. 0.8 ± 0.4, P = 0.046) and the E wave deceleration time was longer (262 ± 83 ms vs. 205 ± 51 ms, P = 0.027). Left atrial volume was smaller in the CRT arm (64 ± 17 mL vs. 84 ± 25 mL, P = 0.035). Moreover, the functional class was lower in CRT patients (1.4 ± 0.6 vs. 1.8 ± 0.5, P = 0.010). During follow-up, CRT was associated with a lower risk of new-onset AF [hazard ratio = 0.37 (0.13-0.98), P = 0.046].</AbstractText>Cardiac resynchronization therapy proved superior to DDD-VPA in terms of better diastolic function, less left atrial enlargement and lower risk of new-onset AF, at 12 months. These data need to be confirmed in a larger trial with longer follow-up.</AbstractText>URL: http://clinicaltrials.gov/ Identifier: NCT02150538.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.</CopyrightInformation> |
17,396 | [Atrial fibrillation : Recent studies and new treatment options]. | Catheter ablation by pulmonary vein isolation (PVI) is established in patients suffering from drug-refractory symptomatic atrial fibrillation (AF). According to recent guidelines, it can also be offered to AF patients as a first-line treatment. The CASTLE-AF study randomized AF patients with severely impaired left ventricular (LV) function to catheter ablation or drug therapy. The patients in the ablation group experienced a significantly lower all-cause mortality and hospitalization rate compared to the conservatively managed group. This result is supported by the CAMERA-MRI trial. The benefit of AF ablation in heart failure was not reproducible in the large randomized CABANA trial. Due to a high cross-over rate, the results are vigorously being discussed and the consequences for clinical practice remain unclear. The DECAAF study described a positive correlation with left atrial fibrosis and the risk for recurrence following PVI. Whether those fibrotic areas should be targeted during the first ablation attempt is now part of the ongoing DECAAF-II trial. Its results might affect the preprocedural planning phase and future ablation strategies. Finally, new ablation techniques are being investigated. In this context, high-power short-duration ablation (HPSD) is of growing interest. In the QDOT-FAST trial, the procedure and fluoroscopy times could be significantly reduce using HPSD catheter technology. However, future studies are still required to evaluate the long-term performance of this novel ablation approach. |
17,397 | Novel PRKAG2 Variant Manifesting with a Cardiac Arrest in a Child. | We describe the case of a novel PRKAG2 mutation that manifested with a ventricular fibrillation cardiac arrest in a child. The previously healthy 13-year old boy, was subsequently diagnosed with Wolff-White-Parkinson syndrome, mild left ventricular hypertrophy and atrial fibrillation. His father had also been diagnosed in the past with Wolff-White-Parkinson syndrome and developed left ventricular hypertrophy. A novel heterozygous likely pathogenic variant, c.911C>G, p.Ala304Gly was identified in the father and his son, which is absent from population databases. PRKAG2 gene variants have previously been shown to cause a familial syndrome of ventricular hypertrophy, ventricular pre-excitation, supraventricular tachycardia, and conduction abnormalities. However, to the best of our knowledge, this is the first description of this rare syndrome manifesting with a more severe phenotype in a second generation relative within the same family. |
17,398 | Cannabis-induced Acute Coronary Syndrome: A Coincidence or Not? | Marijuana, derived from the <i>Cannabis sativa</i> plant, is the most commonly abused illicit drug in the United States. Now, more than ever, due to changing regulations, marijuana is more readily available and is known to be habitually used by millions. The neuropsychiatric effects of marijuana are well-known which include chronic fatigue syndrome and polyphagia. However, marijuana is also known to exert cardiac effects, such as tachycardia, hypotension, and hypertension. Marijuana has also been described in association with atrial fibrillation, ventricular tachycardia, and cardiac arrest. However, acute coronary syndromes, such as myocardial infarction in the setting of marijuana use, is rare. Herein, we present the case of a non-ST-elevation myocardial infarction (NSTEMI) in the setting of marijuana use in a 42-year-old African American male with no significant past medical history who presented with chest pain at rest one hour after smoking marijuana. |
17,399 | Takotsubo syndrome and cardiac implantable electronic device therapy. | Recent studies have reported that takotsubo syndrome (TTS) patients are suffering from life-threatening arrhythmias. The aim of our study was to understand the short and long-term usefulness of cardiac implantable electronic devices in TTS patients.We constituted a collective of 142 patients in a bi-centric study diagnosed with TTS between 2003 and 2017. The patient groups, divided according to the treatment with (n = 9, 6.3%) or without cardiac devices (n = 133, 93.7%), were followed-up to determine the importance of devices and its complications. One patient was treated with a permanent pacemaker, five patients with a wearable cardioverter defibrillator, two patients with a subcutaneous defibrillator and one patient with a transvenous defibrillator. Regular device check-up was documented in all patients, presenting an ongoing high-degree AV-block. Neither device complications nor life-threatening tachyarrhythmias were documented after acute TTS event. However, patients comprising the device group suffered significantly more often from a highly reduced EF (30 ± 7.7% versus 39.1 ± 9.7%; p < 0.05), cardiogenic shock with use of inotropic agents (66.6% versus 16.6%; p < 0.05) and cardiopulmonary resuscitation (44.4% versus 5.3%; p < 0.05). Our data confirm the usefulness of pacemaker in TTS patients. However, the cardioverter defibrillator including wearable cardioverter defibrillator may not be recommended. |
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