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17,700 | Prolongation of The Activation Time in Ischemic Myocardium is Associated with J-wave Generation in ECG and Ventricular Fibrillation. | J-wave pattern has been recognized as an arrhythmic risk marker, particularly in myocardial infarction patients. Mechanisms underlying J-wave development in ischemia remain unknown. In myocardial infarction model, we evaluated activation time delay as a prerequisite of J-wave appearance and predictor of ventricular fibrillation. Body surface ECGs and myocardial unipolar electrograms were recorded in 14 anesthetized pigs. 48 intramural leads were positioned across ventricular free walls and interventricular septum. Myocardial ischemia was induced by ligation of the left anterior descending coronary artery and the recordings were done during 40-minute coronary occlusion. The local activation times were determined as instants of dV/dt minimum during QRS complex in unipolar electrograms. During occlusion, ventricular local activation time prolonged in the middle portion of the left ventricular free wall, and basal and middle portions of septum, while J-waves appeared in precordial leads in 11 animals. In logistic regression and ROC curve analyses, activation time delay at a given time-point was associated with J-wave development, and a longer activation time was associated with ventricular fibrillation appearance. In experimental coronary occlusion, activation delay in ischemic myocardium was associated with generation of the J waves in the body surface ECG and predicted ventricular fibrillation. |
17,701 | Case study of thyrotoxic cardiomyopathy. | We present the case of a 65-year-old woman who was referred urgently from primary care with worsening breathlessness for 3 weeks, associated with tachycardia and left bundle branch block (LBBB). She had a background of type 2 diabetes, asthma and hypertension. Initial ECG revealed atrial fibrillation with the fast ventricular rate on the background of LBBB. ECHO findings were consistent with systolic impairment. Initial testing including checking thyroid function test revealed hyperthyroidism. It became evident that this patient had thyrotoxic cardiomyopathy. Early advice from the endocrine team was sought and the patient was treated with a combination of carbimazole and ivabradine. After a hospital stay, she made a remarkable recovery. |
17,702 | The Prognostic Value of Early Repolarization Pattern for the Ventricular Tachyarrhythmias of Acute Myocardial Infarction Patients: A Meta-Analysis. | Several studies have indicated that early repolarization (ER) is a risk factor for ventricular tachyarrhythmias (VTAs) in acute myocardial infarction (AMI) patients. The prognostic values of ER detail characteristics except J-point morphology, and inferior leads ER location for VTAs are still unclear. We searched PubMed, Embase, and the Cochrane Library for eligible studies up to March 4, 2019. Studies to investigate the relationship between ER and the incidence of VTAs in AMI patients were extracted. A total of 10 studies with 2,672 participants were included in the analysis. ER significantly predicted the incidence of VTAs (odds ratio [OR] 3.62, 95% confidence intervals [CI] 2.77-4.73), regardless of the type of AMI. The presence of ER before AMI (OR 5.58, 95% CI 3.41 to 9.12) and after AMI (OR 3.02, 95% CI 2.19-4.15) increased the risk of VTAs. The prognostic value of ER for VTAs in the long follow-up (≥30 days) (OR 2.39, 95% CI 1.59-3.59) fell by half compared to the short follow-up duration (<30 days) (OR 4.97, 95% CI 3.48-7.09). Patients with ER displayed a higher risk of developing ventricular fibrillation (VF) (OR 6.94, 95% CI 3.87-12.43) than those without ER. However, neither J-point elevation with OR = 2.48 nor lateral leads' ER location with OR = 3.83 remarkably increased the risk of VTAs in patients with AMI. ER is significantly associated with increasing risk of VTAs, particularly VF, in AMI patients. This relationship is weaker in the 30-day follow-up and is not reinforced by J-point elevation and lateral leads' ER location. |
17,703 | Automated external defibrillator use in a previously healthy 31-day-old infant with out-of-hospital cardiac arrest due to ventricular fibrillation. | Current resuscitation guidelines state that the safety of automated external defibrillators (AEDs) in infants less than 1 year of age is unknown.</AbstractText>We report successful AED use in a 31-day-old previously healthy infant with out-of-hospital cardiac arrest. Chest compressions began immediately, pediatric AED pads were applied in less than 5 minutes and the initial rhythm was ventricular fibrillation. After two 50 J shocks, return of spontaneous circulation was achieved. She was diagnosed with a rare but previously described syndrome of infant ventricular fibrillation and was discharged to home in good condition after epicardial defibrillator placement.</AbstractText>This case represents, to our knowledge, the youngest patient successfully defibrillated by an AED in a nonmedical setting. Although she received two shocks more than 11 J/kg each, she had no apparent myocardial damage at presentation.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,704 | Three-dimensional echocardiography investigation of the mechanisms of tricuspid annular dilatation. | Tricuspid annular (TA) size, assessed by 2D transthoracic echocardiography (TTE), has a well-established prognostic value in patients undergoing mitral valve surgery, with TA dilatation triggering simultaneous tricuspid annuloplasty. While TA dilatation is common in patients with dilated atria secondary to atrial fibrillation, little is known about the mechanisms of TA dilatation in patients with sinus rhythm (SR). This study aimed to identify echocardiographic parameters most closely related to the TA size as a potential tool for identification of patients prone to developing TA enlargement. 120 patients with SR underwent clinically indicated TTE, including 30 patients with normal hearts and 90 patients diagnosed with at least one right heart abnormality, defined as: right ventricular (RV) or right atrial (RA) dilatation, ≥ moderate tricuspid regurgitation (TR) and elevated systolic pulmonary artery pressure (sPAP). RA and RV end-diastolic and end-systolic volumes (EDV, ESV) and function were measured using commercial 3D software (TomTec). 3D RV long and short axes were used as surrogate indices of RV shape. Degrees of TR and sPAP were estimated by 2D TTE. 3D TA sizing was performed at end-diastole using 3D custom software. Linear regression analysis was used to identify variables best correlated with TA size, followed by multivariate analysis to identify independent associations. The highest correlations were found between TA area and: RA ESV (r = 0.73; p < 0.01), RV EDV (r = 0.58; p < 0.01), RV end-diastolic long and short axes (r = 0.53, 0.42; both p < 0.01), TR degree (r = 0.40; p < 0.01) and sPAP (r = 0.32; p < 0.01). Multivariate analysis revealed that RA ESV was the only parameter independently associated with TA area (p < 0.05, r = 0.85). In conclusion, RA volume plays an important role in TA dilatation even in patients with normal SR. Understanding of annular remodeling mechanisms could aid in identifying patients at higher risk for TA dilatation, especially those scheduled for mitral valve surgery. |
17,705 | Heart Failure With Preserved Ejection Fraction and Adipose Tissue: A Story of Two Tales. | Heart failure with preserved ejection fraction (HFpEF) is characterized by signs and symptoms of heart failure in the presence of a normal left ventricular ejection fraction. Although it accounts for up to 50% of all clinical presentations of heart failure, there are no evidence-based therapies for HFpEF to reduce morbidity and mortality. Additionally there is a lack of mechanistic understanding about the pathogenesis of HFpEF. HFpEF is associated with many comorbidities (such as obesity, hypertension, type 2 diabetes, atrial fibrillation, etc.) and is coupled with both cardiac and extra-cardiac abnormalities. Large outcome trials and registries reveal that being obese is a major risk factor for HFpEF. There is increasing focus on investigating the link between obesity and HFpEF, and the role that the adipose tissue and the heart, and the circulating milieu play in development and pathogenesis of HFpEF. This review discusses features of the obese-HFpEF phenotype and highlights proposed mechanisms implicated in the inter-tissue communication between adipose tissue and the heart in obesity-associated HFpEF. |
17,706 | Percutaneous extraction of a leadless Micra pacemaker after dislocation: a case report. | Leadless pacemaker implantation rates are increasing worldwide. Until now leadless pacemaker dislocation and extraction has been rarely reported.</AbstractText>An 83-year-old patient with cardiac amyloidosis, chronic atrial fibrillation, and complete heart block was implanted with a leadless pacemaker (Micra, Medtronic). On the day after implantation, the device showed an exit block and on cardiac echocardiography and cardiac computer tomography, a device dislocation could be detected. During the day, the device moved at least three times between the tricuspid valve and the right ventricular apex. Each time causing non-sustained ventricular tachycardia. At the next day device extraction was scheduled. After 189 minutes of procedure time, it was possible to retrieve the device with the help of two steerable introducers (Agilis) and two snare catheters.</AbstractText>Implantable transcatheter leadless pacemakers can be implanted safely most of the time. However, in rare cases device dislocations may occur. Device extraction is possible, but is described as challenging in most published cases 10.1093/ehjcr/ytz113_audio1 ytz113_audio1 6074457264001.</AbstractText>© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.</CopyrightInformation> |
17,707 | Ruptured saphenous venous graft pseudoaneurysm presenting as a pulsatile chest mass. | A 72-year-old man with prior history of coronary artery bypass grafting and sternal wire infection presented with non-ST-segment elevation myocardial infarction. His coronary angiogram revealed stenosis of the distal left main coronary artery (LMCA) and a pseudoaneurysm of saphenous venous graft (SVG) to right posterior descending artery. Patient developed ventricular fibrillation during admission, and postcardiopulmonary resuscitation, a pulsatile chest mass was observed which was diagnosed with computed tomography as a chest wall collection resulting from rupture of the pseudo-aneurysm. He underwent percutaneous coronary intervention of the LMCA with drug-eluting stents followed by successful coil embolization of the SVG pseudoaneurysm. Patient had an uneventful recovery postprocedure. |
17,708 | Prevention of ventricular fibrillation through de-networking of the Purkinje system: Proof-of-Concept Paper on the Substrate Modification of the Purkinje Network. | Sudden cardiac death from ventricular fibrillation (VF) remains a major health problem worldwide. Currently, there are limited treatment options available to patients who suffer from episodes of VF. Because Purkinje fibers have been implicated as a source of initiation of VF, we are presenting the first paper of a series highlighting the promising results of substrate modulation through "De-Networking" of the Purkinje system preventing VF in patients without an alternative ablation strategy.</AbstractText>We studied 10 consecutive patients (two female) all but one implanted with an ICD with documented VF or fast polymorphic Ventricular tachycardia (VT) (five patients without history of structural heart disease, two with ischemic cardiomyopathy, one with hypertrophic obstructive cardiomyopathy, one with dilated cardiomyopathy, and one with aortic valve disease). After 3D electroanatomical mapping, the left bundle branch (LBB) and left ventricular Purkinje potentials were annotated creating a virtual triangle with the apex formed by the distal LBB and the base by the most distal Purkinje potentials. Linear radiofrequency catheter ablation at the base of the triangle was performed, followed by ablation within the virtual triangle sparing the LBB and both fascicles ("de-networking"). All patients were treated without complications. During 1-year follow-up, only 2/10(20%) patients experienced recurrence in form of a single episode of polymorphic VT/VF.</AbstractText>Catheter ablation of VF through "de-networking" of the Purkinje system in patients without overt arrhythmia substrate or trigger appears safe and effective and will require further study in a larger patient cohort.</AbstractText>© 2019 The Authors. Pacing and Clinical Electrophysiology published by Wiley Periodicals, Inc.</CopyrightInformation> |
17,709 | Experimental verification of the value of the T<sub>peak</sub> -T<sub>end</sub> interval in ventricular arrhythmia inducibility in an early repolarization syndrome model. | In patients with early repolarization patterns on ECG, many researchers have studied to find predictors of fatal arrhythmia. However, there are no satisfying clinical predictors. We evaluated the value of the Tpeak</sub> -Tend</sub> interval on pseudo-ECG in canine myocardial wedge preparation models of early repolarization syndrome.</AbstractText>Transmural pseudo-ECG and endocardial/epicardial action potentials were recorded from coronary-perfused canine left ventricular wedge preparations (n = 34). The Ito</sub> agonist NS5806 (8-10 µM), the calcium channel blocker verapamil (3 µM) and acetylcholine (2-3 µM) were used to mimic the disease model. A ventricular arrhythmia induction test was performed. QTpeak</sub> , QTend</sub> , Tpeak</sub> -Tend</sub> , and Tpeak</sub> -Tend</sub> /QTend</sub> were measured at 15 to 20 minutes after the provocative agent infusion. Polymorphic ventricular tachycardias (pVT) developed in 23 of the 34 preparations (67%). The maximal values of Tpeak</sub> -Tend</sub> and Tpeak</sub> -Tend</sub> /QTend</sub> were recorded just before pVT induction. At baseline, without the provocative agents, Tpeak</sub> -Tend</sub> and Tpeak</sub> -Tend</sub> /QTend</sub> were not different between pVT-induced and pVT-noninduced preparations. The Tpeak</sub> -Tend</sub> of the pVT-induced preparations was longer than that of non-induced preparations (58 ± 26.8 msec vs 33 ± 6.8 msec, P < .001). The Tpeak</sub> -Tend</sub> /QTend</sub> of pVT- induced preparations was larger than that of noninduced preparations (0.220 ± 0.1017 vs 0.128 ± 0.0312, P < .001). The transmural and epicardial dispersion of repolarization of pVT-induced preparations were larger than those of pVT-noninduced preparations. The transmural dispersion of repolarization showed a positive correlation with Tpeak</sub> -Tend</sub> .</AbstractText>Tpeak</sub> -Tend</sub> predicted malignant ventricular arrhythmias in early repolarization syndrome models. Tpeak</sub> -Tend</sub> reflects the repolarization heterogeneity of ventricular myocardium.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,710 | Cardiovascular safety of macrolide and fluoroquinolone antibiotics: An analysis of the WHO database of adverse drug reactions. | The cardiovascular safety profile of macrolides and fluoroquinolones has been widely discussed. The aim of the present study is to provide the contribution of real-world data onto the ongoing discussion about cardiovascular toxicity of both macrolides and fluoroquinolones.</AbstractText>Reports of adverse drug reactions (ADRs) were retrieved from VigiBase. Macrolides and fluoroquinolones were compared with amoxicillin by using the reporting odds ratio (ROR) as a measure of disproportionality. Macrolides were then compared with fluoroquinolones.</AbstractText>Overall, 6810 reports of ADRs were retrieved: 62% of them were serious and 35% concerned female. Macrolides were more frequently associated with "atrial fibrillation" (ROR = 1.26, CI 1.02-1.57) and "ventricular fibrillation" ROR = 2.60, CI 1.92-3.54) than fluoroquinolones. Antimicrobials more frequently reported for "cardiac disorder" were azithromycin (375 reports) and clarithromycin (302) for macrolides and levofloxacin (470) and moxifloxacin (391) for fluoroquinolones.</AbstractText>Our data highlighted that macrolides and fluoroquinolones may influence cardiac rhythm and suggest caution in the prescribing of these drugs to patients with hidden cardiovascular risk factors. Although these ADRs seem to be not common, they have a notable impact in clinical practice because of the huge number of the exposed subjects.</AbstractText>© 2019 John Wiley & Sons, Ltd.</CopyrightInformation> |
17,711 | Cardiorespiratory fitness and heart rate recovery predict sudden cardiac death independent of ejection fraction. | To evaluate whether cardiorespiratory fitness (CRF) and heart rate recovery (HRR) associate with the risk of sudden cardiac death (SCD) independently of left ventricular ejection fraction (LVEF).</AbstractText>The Finnish Cardiovascular Study is a prospective clinical study of patients referred to clinical exercise testing in 2001-2008 and follow-up until December 2013. Patients without pacemakers undergoing first maximal or submaximal exercise testing with cycle ergometer were included (n=3776). CRF in metabolic equivalents (METs) was estimated by achieving maximal work level. HRR was defined as the reduction in heart rate 1 min after maximal exertion. Adjudication of SCD was based on death certificates. LVEF was measured for clinical indications in 71.4% of the patients (n=2697).</AbstractText>Population mean age was 55.7 years (SD 13.1; 61% men). 98 SCDs were recorded during a median follow-up of 9.1 years (6.9-10.7). Mean CRF and HRR were 7.7 (SD 2.9) METs and 25 (SD 12) beats/min/min. Both CRF and HRR were associated with the risk of SCD in the entire study population (HRCRF</sub>0.47 (0.37-0.59), p<0.001 and HRHRR</sub>0.57 (0.48-0.67), p<0.001 with HR estimates corresponding to one SD increase in the exposure variables) and with CRF, HRR and LVEF in the same model (HRCRF</sub>0.60 (0.45-0.79), p<0.001, HRHRR</sub>0.65 (0.51-0.82), p<0.001) or adjusting additionally for all significant risk factors for SCD (LVEF, sex, creatinine level, history of myocardial infarction and atrial fibrillation, corrected QT interval) (HRCRF</sub>0.69 (0.52-0.93), p<0.01, HRHRR</sub>0.74 (0.58-0.95) p=0.02).</AbstractText>CRF and HRR are significantly associated with the risk of SCD regardless of LVEF.</AbstractText>© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.</CopyrightInformation> |
17,712 | Subtypes of Atrial Functional Mitral Regurgitation: Imaging Insights Into Their Mechanisms and Therapeutic Implications. | Functional mitral regurgitation (MR) in patients with atrial fibrillation (AF) without left ventricular dysfunction, namely, atrial functional MR, has been increasingly recognized. Whether mitral annular dilatation causes MR in patients without left ventricular dysfunction has remained controversial; however, recent studies using novel imaging technologies, including 3-dimensional echocardiography, have shown that significant functional MR can sometimes occur in AF patients with significant dilatation of mitral annulus and left atrium. Additional contributors such as atriogenic leaflet tethering, annulus area to leaflet area imbalance resulting from insufficient leaflet remodeling and reduced annular contractility, increased valve stress by flattened saddle shape of the annulus, and left atrial dysfunction may be important triggers of atrial functional MR in the presence of dilated mitral annulus and left atrium. The prevalence of atrial functional MR is reported to be between 3% and 15% in AF patients and those with atrial functional MR are associated with worse clinical outcomes. Because there are few published data regarding therapeutic strategies of atrial functional MR, understanding the principles of therapeutic options and their target mechanisms is important with regards to clinical practice until sufficient evidence is established. In this review, the known mechanisms, clinical implications and, when possible, potential therapeutic options of atrial functional MR are discussed. |
17,713 | Empirical mode decomposition based ECG features in classifying and tracking ventricular arrhythmias. | Ventricular arrhythmias (VA) are life-threatening pathophysiological conditions that seriously impact the normal functioning of the heart. Ventricular tachycardia (VT) and ventricular fibrillation (VF) are the two well known types of VA. VF is the lethal of the VAs and could be characterized by its organizational progression over time. The success of cardiac resuscitation strongly depends on the type of VA, its evolution over time and response to therapy. Due to the time critical nature of VF, computationally efficient quantification of VAs and swift feedback are essential. This work attempted to arrive at computationally efficient and data-driven techniques based on Empirical Mode Decomposition for classifying and tracking VAs over time. The approaches are divided into two aims: (1) 'in-hospital' scenarios for characterizing the dynamics of VA episodes to assist clinicians in planning long-term therapy options, and (2) 'out-of-hospital' scenarios for providing near real-time feedback to detect/track the progression of VAs over time to assist medical personnel select/modify therapy options. Using an ECG database of 61 60-s VA segments obtained for classifying VT vs. VF and sub-classifying VF into organized VF (OVF) and disorganized VF (DVF), maximum classification accuracies of 96.7% (AUC = 0.993) and 87.2% (AUC = 0.968) were obtained for classifying VT vs. VF and OVF vs. DVF during 'in-hospital' analysis. Additionally, two near real-time approaches were presented for 'out-of-hospital' analysis where average accuracies of 71% and 73% were achieved for VT/VF and OVF/DVF classification, as well as demonstrating strong potential for monitoring VA progressions over time. |
17,714 | Aortic Insufficiency and Hemocompatibility-related Adverse Events in Patients with Left Ventricular Assist Devices. | Hemocompatibility-related adverse events (HRAE) are a major cause of readmissions in patients with left ventricular assist devices (LVAD). The impact of aortic insufficiency (AI) on HRAE remains uncertain. We aimed to investigate the impact of AI on HRAE.</AbstractText>Patients who underwent LVAD implantation between August 2014 and July 2017 and had echocardiograms 3 months post-LVAD implantation were enrolled. AI severity was assessed by measuring the systolic/diastolic ratio of flow and the rate of diastolic flow acceleration using Doppler echocardiography of the outflow cannula. Regurgitation fraction was derived from these parameters. Significant AI was defined as regurgitation fraction > 30%. Among 105 patients (median age, 56 years; 76% male), 36 patients (34%) had significant AI. Baseline characteristics were statistically not significantly different between those with and without significant AI except for higher rates of ischemic etiology and atrial fibrillation in the significant AI group (P < 0.05 for both). One-year survival free from HRAE was 44% in patients with AI compared to 67% in patients without significant AI (P = 0.018). The average hemocompatibility score, which defines the net burden of HRAE, was higher in the AI group (1.72 vs 0.64; P = 0.009), due mostly to higher tier I (mild HRAE; P = 0.034) and tier IIIB scores (severe HRAE; P = 0.011).</AbstractText>Significant AI, as assessed by Doppler echocardiographic parameters, was associated with HRAE during LVAD support.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,715 | A small-molecule LF3 abrogates β-catenin/TCF4-mediated suppression of Na<sub>V</sub>1.5 expression in HL-1 cardiomyocytes. | Increased nuclear β-catenin interacting with T-cell factor 4 (TCF4) affects the expression of target genes including SCN5A in ischemic heart disease, which is characterized by frequent ventricular tachycardia/fibrillation. A complex of β-catenin and TCF4 inhibits cardiac Na<sup>+</sup> channel activity by reducing Na<sub>V</sub>1.5 expression through suppressing SCN5A promoter activity in HL-1 cardiomyocytes. LF3, a 4-thioureido-benzenesulfonamide derivative and an inhibitor of β-catenin/TCF4 interaction, has been shown to block the self-renewal capacity of cancer stem cells. We performed studies to determine if LF3 can reverse suppressive effects of β-catenin/TCF4 signaling on the expression of Na<sub>V</sub>1.5 in HL-1 cardiomyocytes. Western blotting and real-time qRT-PCR analyses showed that 10 μM LF3 significantly increased the expression of Na<sub>V</sub>1.5 but it did not alter β-catenin and TCF4 expression. Subcellular fractionation analysis demonstrated that LF3 significantly increased the levels of Na<sub>V</sub>1.5 in both membrane and cytoplasm. Whole-cell patch-clamp recordings revealed that Na<sup>+</sup> currents were significantly increased with no changes in the steady-state parameters, activation and inactivation time constants and recovery from inactivation of Na<sup>+</sup> channel in HL-1 cells treated with LF3. Immunoprecipitation exhibited that LF3 blocked the interaction of β-catenin and TCF4. Luciferase reporter assays performed in HEK 293 cells and HL-1 revealed that LF3 increased the SCN5A promoter activity in HL-1 cells and prevented β-catenin suppressive effect on SCN5A promoter activity in HEK 293 cells. Taken together, we conclude that LF3, an inhibitor of β-catenin/TCF4 interaction, elevates Na<sub>V</sub>1.5 expression, leading to increase Na<sup>+</sup> channel activity in HL-1 cardiomyocytes. |
17,716 | Diagnostic evaluation and arrhythmia mechanisms in survivors of unexplained cardiac arrest. | Identifying the cause of unexplained cardiac arrest is critical for appropriate management of both survivors and their family members. Aborted cardiac arrests whose cause remains unknown following investigation with a surface ECG, echocardiogram, and coronary angiogram are deemed unexplained. Many of these unexplained arrests are felt to be secondary to concealed forms of cardiac channelopathies and latent or subtle cardiomyopathies. This recognition has led to evaluating a diagnostic role for a series of additional investigations, including advanced imaging, genetic testing, and provocative forms of testing, including sodium channel blockade and treadmill testing. Despite evidence of an improved diagnostic yield through their systematic usage, clinical guidelines have yet to endorse a formal algorithm delineating investigations that must be performed before assigning a label of idiopathic ventricular fibrillation, which has resulted in markedly variables thresholds for concluding this diagnosis. Debate remains regarding the need for an invasive electrophysiology study among these patients, though identification of arrhythmic culprits requiring intracardiac electrograms for diagnostic confirmation have suggested a potential role when an initial comprehensive evaluation is unrevealing. Although progress is being made, the sizeable portion of arrests that remain unexplained despite completion of a comprehensive evaluation highlights an ongoing need for further research and additional tools to help unravel the ongoing mysteries of these near fatal events. |
17,717 | An inappropriate shock after reprogramming tachycardia zones. | A patient with an implantable cardioverter-defibrillator (ICD) (Abbott®) had episodes of slow monomorphic ventricular tachycardia (VT) and his ICD was programmed with three tachycardia zones. During the follow-up, he received an inappropriate shock. Upon interrogation (of the device), trigeminal pattern binned as ventricular sensing (VS)-VS-ventricular fibrillation (VF) was detected. VF was assumed according to binning system. When VF is present, discrimination algorithms are not available and five consecutive sinus beats are necessary to reset binning system. Catheter ablation was performed to treat VT in order to reprogram tachycardia zones. |
17,718 | Burden and trends of arrhythmias in hypertrophic cardiomyopathy and its impact of mortality and resource utilization. | Hypertrophic cardiomyopathy (HCM) accounts for significant morbidity and mortality worldwide. Arrhythmias are considered the main cause of mortality, however, there is paucity of data relating to trends of arrhythmia and associated outcomes in HCM patients.</AbstractText>Nationwide Inpatient Sample from 2003 to 2014 was analyzed. HCM related hospitalizations were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) code 425.1 and 425.11 in all diagnosis fields.</AbstractText>Overall, there was an increase in number of hospitalizations related to arrhythmias among HCM patients from 7784 in 2003 to 8380 in 2014 (relative increase 10.5%, P</i> < 0.001). The increase was most significant in patients ≥ 80 years and those with higher comorbidity burden. Atrial fibrillation (AF) was the most frequently occurring arrhythmia however atrial flutter (AFL) witnessed the highest rise during the study period. In general, there was a down trend in mortality with the greatest reduction occurring in patients with ventricular fibrillation/flutter (VF/VFL). The mean length of stay was higher if patients had arrhythmia, which led to increased cost of care from $16105 in 2003 to $19310 in 2014 (relative increase 22.9%, P </i>< 0.001).</AbstractText>There is overall decline in HCM related hospitalizations but rise in hospitalization among HCM patients with arrhythmias. HCM with arrhythmia accounts for significant inpatient mortality coupled with prolonged hospital stay and increased cost of care. However, there is an encouraging downtrend in the mortality most likely because of improved clinical practice, cardiac screening and primary and secondary prevention strategies.</AbstractText> |
17,719 | Association between PR Interval, First-degree atrioventricular block and major arrhythmic events in patients with Brugada syndrome - Systematic review and meta-analysis. | Risk stratification in patients with asymptomatic Brugada Syndrome is challenging, and despite recent advances, there is no clear evidence. The first-degree atrioventricular block was hypothesized to be a predictor of arrhythmic events. Measurement of the PR interval and diagnosing atrioventricular block from surface ECG is easy, noninvasive, and cost-effective. We aimed to assess the latest evidence on PR interval or first-degree atrioventricular block and major arrhythmic events related to Brugada Syndrome.</AbstractText>We performed a comprehensive search in PubMed for "atrioventricular block" OR "PR interval" and "Brugada syndrome." We included studies that have a component of PR interval and/or first-degree atrioventricular block and major arrhythmic events related to Brugada Syndrome including syncope/VT/VF/appropriate ICD shocks/ICD implantation.</AbstractText>We included 1526 subjects from 7 studies. Pooled mean difference of PR interval in 4 studies showed a significant difference [MD 10.77 ms (2.97-18.57) P</i> = 0.007, moderate-high heterogeneity I2</sup> = 53% P</i> = 0.08]. On sensitivity analysis by removing a study, it became MD 6.50 ms [1.97-11.03], P</i> = 0.005, heterogeneity I2</sup> = 0% P</i> = 0.52. Indicating that PR interval was prolonged by small margin. Pooled analysis of the association between a first-degree atrioventricular block and major arrhythmic events was significant [OR 3.33 (2.02-5.50) P</i> < 0.001, low heterogeneity I2</sup> = 0% P</i> = 0.57].</AbstractText>First-degree AV block is associated with more frequent major arrhythmic events in Brugada syndrome patients. PR interval seemed to be prolonged but is yet to be determined whether the PR interval association is still significant if it did not cross the first-degree AVB threshold.</AbstractText> |
17,720 | A case of near-sudden unexpected death in epilepsy due to ventricular fibrillation. | Sudden unexpected death in epilepsy (SUDEP) refers to the sudden and unexpected death of an epileptic patient with no other health issues, during normal activity, and for whom no other particular cause of death can be found. The exact cause of SUDEP has not been established yet; however, it is assumed to be caused by multiple organ failure involving the respiratory and cardiovascular systems. Some of the known risk factors are generalized tonic-clonic seizure, frequent epileptic seizure, early onset of epilepsy, long duration of seizure, nocturnal seizure, and combined therapy with antiepileptics. A number of seizure-related cardiac arrhythmia cases have been reported. Arrhythmias are mostly benign tachycardia or bradycardia, and ventricular fibrillation (VF) or asystole is very rare. It is considered that fatal cardiac arrhythmia is a cause of SUDEP. Here, we describe the case of a near-SUDEP patient who was successfully revived without complications by immediate defibrillation with an automated external defibrillator and cardiopulmonary resuscitation, although VF occurred after a convulsive seizure. Based on our experience, when treating a patient with an epileptic seizure, one should always keep in mind the possibility of SUDEP as a seizure-induced emergency situation involving fatal arrhythmia and cardiac arrest, even in young healthy adults. |
17,721 | Atrial fibrillation incidence and impact of biventricular pacing on long-term outcome in patients with heart failure treated with cardiac resynchronization therapy. | In patients with cardiac resynchronization therapy (CRT), atrial fibrillation (AF) is associated with an unfavorable outcome and may cause loss of biventricular pacing (BivP). An effective delivery of BivP of more than 98% of all ventricular beats has been shown to be a major determinant of CRT-success.</AbstractText>At a Swedish tertiary referral center, data was retrospectively obtained from patient registers, medical records and preoperative electrocardiograms. Data regarding AF and BivP during the first year of follow-up was assessed from CRT-device interrogations. No intra-cardiac electrograms were studied. Kaplan-Meier curves and Cox-regression analyses adjusted for age, etiology of heart failure, left ventricular ejection fraction, left bundle branch block and NYHA class were performed to assess the impact of AF and BivP on the risk of death or heart transplantation (HTx) at 10-years of follow-up.</AbstractText>Preoperative AF-history was found in 54% of the 379 included patients and was associated with, but did not independently predict death or HTx. The one-year incidence of new device-detected AF was 22% but not associated with poorer prognosis. At one-year, AF-history and BivP≤98%, was associated with a higher risk of death or HTx compared to patients without AF (HR 1.9, 95%CI 1.2-3.0, p = 0.005) whereas AF and BivP> 98% was not (HR 1.4, 95%CI 0.9-2.3, p = 0.14).</AbstractText>In CRT-recipients, AF-history is common and associated with poor outcome. AF-history does not independently predict mortality and is probably only a marker of a more severe underlying disease. BivP≤98% during first-year of CRT-treatment independently predicts poor outcome thus further supporting the use of 98% threshold of BivP, which should be attained to maximize the benefits of CRT.</AbstractText> |
17,722 | Melatonin receptor activation protects against low potassium-induced ventricular fibrillation by preserving action potentials and connexin-43 topology in isolated rat hearts. | Hypokalemia prolongs the QRS and QT intervals, deteriorates intercellular coupling, and increases the risk for arrhythmia. Melatonin preserves gap junctions and shortens action potential as potential antiarrhythmic mechanisms, but its properties under hypokalemia remain unknown. We hypothesized that melatonin protects against low potassium-induced arrhythmias through the activation of its receptors, resulting in action potential shortening and connexin-43 preservation. After stabilization in Krebs-Henseleit solution (4.5 mEq/L K<sup>+</sup> ), isolated hearts from Wistar rats underwent perfusion with low-potassium (1 mEq/L) solution and melatonin (100 μmol/L), a melatonin receptor blocker (luzindole, 5 μmol/L), melatonin + luzindole or vehicle. The primary endpoint of the study was the prevention of ventricular fibrillation. Electrocardiography was used, and epicardial action potentials and heart function were measured and analyzed. The ventricular expression, dephosphorylation, and distribution of connexin-43 were examined. Melatonin reduced the incidence of low potassium-induced ventricular fibrillation from 100% to 59%, delayed the occurrence of ventricular fibrillation and induced a faster recovery of sinus rhythm during potassium restitution. Melatonin prevented QRS widening, action potential activation delay, and the prolongation of action potential duration at 50% of repolarization. Other ECG and action potential parameters, the left ventricular developed pressure, and nonsustained ventricular arrhythmias did not differ among groups. Melatonin prevented connexin-43 dephosphorylation and its abnormal topology (lateralization). Luzindole abrogated the protective effects of melatonin on electrophysiological properties and connexin-43 misdistribution. Our results indicate that melatonin receptor activation protects against low potassium-induced ventricular fibrillation, shortens action potential duration, preserves ventricular electrical activation, and prevents acute changes in connexin-43 distribution. All of these properties make melatonin a remarkable antifibrillatory agent. |
17,723 | Arrhythmia development during inhibition of small-conductance calcium-activated potassium channels in acute myocardial infarction in a porcine model. | Acute myocardial infarction (AMI) is associated with intracellular Ca2+ build-up. In healthy ventricles, small conductance Ca2+-activated K+ (SK) channels are present but do not participate in repolarization. However, SK current is increased in chronic myocardial infarction and heart failure, and recently, SK channel inhibition was demonstrated to reduce arrhythmias in AMI rats. Hence, we hypothesized that SK channel inhibitors (NS8593 and AP14145) could reduce arrhythmia development during AMI in a porcine model.</AbstractText>Twenty-seven pigs were randomized 1:1:1 to control, NS8593, or AP14145. Haemodynamic and electrophysiological parameters [electrocardiogram (ECG) and monophasic action potentials (MAP)] were continuously recorded. A balloon was placed in the mid-left anterior descending artery, blinded to treatment. Infusion lasted from 10 min before occlusion until 30 min after. Occlusion was maintained for 1 h, followed by 2 h of reperfusion. Upon occlusion, cardiac output dropped similarly in all groups, while blood pressure remained stable. Heart rate decreased in the NS8593 and AP14145 groups. QRS duration increased upon occlusion in all groups but more prominently in AP14145-treated pigs. Inhibition of SK channels did not affect QT interval. Infarct MAP duration shortened comparably in all groups. Ventricular fibrillation developed in 4/9 control-, 4/9 AP14145-, and 2/9 NS8593-treated pigs. Ventricular tachycardia was rarely observed in either group, whereas ventricular extrasystoles occurred comparably in all groups.</AbstractText>Inhibition of SK channels was neither beneficial nor detrimental to ventricular arrhythmia development in the setting of AMI in this porcine model.</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> |
17,724 | Head Rules Over the Heart: Cardiac Manifestations of Cerebral Disorders. | The Brain-Heart interaction is becoming increasingly important as the underlying pathophysiological mechanisms become better understood. "Neurocardiology" is a new field which explores the pathophysiological interplay of the brain and cardiovascular systems. Brain-heart cross-talk presents as a result of direct stimulation of some areas of the brain, leading to a sympathetic or parasympathetic response or it may present as a result of a neuroendocrine response attributing to a clinical picture of a sympathetic storm. It manifests as cardiac rhythm disturbances, hemodynamic perturbations and in the worst scenarios as cardiac failure and death. Brain-Heart interaction (BHI) is most commonly encountered in traumatic brain injury and subarachnoid hemorrhage presenting as dramatic electrocardiographic changes, neurogenic stunned myocardium or even as ventricular fibrillation. A well-known example of BHI is the panic disorders and emotional stress resulting in Tako-tsubo syndrome giving rise to supraventricular and ventricular tachycardias and transient left ventricular dysfunction. In this review article, we will discuss cardiovascular changes caused due to the disorders of specific brain regions such as the insular cortex, brainstem, prefrontal cortex, hippocampus and the hypothalamus; neuro-cardiac reflexes namely the Cushing's reflex, the Trigemino-cardiac reflex and the Vagal reflex; and other pathological states such as neurogenic stunned myocardium /Takotsubo cardiomyopathy. There is a growing interest among intensivists and anesthesiologists in brain heart interactions as there are an increasing number of cases being reported and there is a need to address unanswered questions, such as the incidence of these interactions, the multifactorial pathogenesis, individual susceptibility, the role of medications, and optimal management.</AbstractText>BHI contribute in a significant way to the morbidity and mortality of neurological conditions such as traumatic brain injury, subarachnoid hemorrhage, cerebral infarction and status epilepticus. Constant vigilance and a high index of suspicion have to be exercised by clinicians to avoid misdiagnosis or delayed recognition. The entire clinical team involved in patient care should be aware of brain heart interaction to recognize these potentially life-threatening scenarios.</AbstractText>Hrishi AP, Lionel KR, Prathapadas U. Head Rules Over the Heart: Cardiac Manifestations of Cerebral Disorders. Indian J Crit Care Med 2019;23(7):329-335.</AbstractText> |
17,725 | Multi-lead vs single-lead T<sub>peak</sub> -T <sub>end</sub> interval measurements for prediction of reperfusion ventricular tachyarrhythmias. | Electrocardiographic Tpeak</sub> -Tend</sub> interval (Tp-Te) is a promising marker for the prediction of ventricular tachycardia and/or ventricular fibrillation (VT/VF). The study was aimed to compare single-lead vs multilead Tp-Te variables as VT/VF predictors in experimental ischemia/reperfusion model.</AbstractText>Computer simulations were done using the ECGSIM model with an ischemic region set in anterior left ventricular apex. In 18 anesthetized cats, myocardial ischemia was induced by 30-minute ligation of left anterior descending coronary artery followed by reperfusion. Body surface ECGs in limb leads and modified precordial leads were recorded. Tp-Te was detected automatically in individual leads with a custom-designed parametric algorithm. Tp-Te dispersion and total Tp-Te were calculated as a difference between the maximal and minimal value of individual Tp-Te(s) and an interval between the earliest Tpeak and the latest Tend throughout all leads, respectively. Simulations showed that the increase of local, but not total, dispersion of repolarization characteristic for ischemic damage led to nonuniform shortening of T-peak times across 12 standard leads, which in turn resulted in the increase of single-lead Tp-Te(s), total Tp-Te and Tp-Te dispersion. Animals experienced VT/VF showed increased Tp-Te dispersion and total Tp-Te during reperfusion. In univariate logistic regression analysis, only the Tp-Te dispersion at the beginning of reperfusion was associated with the VT/VF incidence. According to ROC curve analysis, the optimal cut-off value of the Tp-Te dispersion was 17 ms (sensitivity 0.71, specificity 0.80).</AbstractText>The reperfusion VT/VFs were independently predicted by increased Tp-Te dispersion, which suggests the importance of multi-lead evaluation of Tp-Te intervals.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,726 | [Interventional management of atrial fibrillation]. | In 2030, the European Union will include 14 to 17 million atrial fibrillation (AF) patients, with 120,000 to 215,000 new cases each year. The increase in the prevalence of this arrhythmia has led to the development of new therapeutic intervention strategies to manage the different aspects of this disease. Thus, endocavitary or epicardial ablation of AF, by radiofrequency or cryoablation, provides superior results to antiarrhythmic therapy in controlling symptoms and preventing heart failure in paroxysmal or persistent AF. In heart failure patients with advanced AF, the ablation of the atrioventricular junction associated with the implantation of a bi-ventricular pacemaker has just demonstrated its clear superiority, bringing this technique up to date. Finally, in the event of a major bleeding risk and contraindication to anticoagulants, percutaneous occlusion of the left atrium has proven its value in preventing AF-related embolic events. The future will certainly see the emergence of new technologies but also personalized strategies based on an optimal selection of the right candidates for these interventions, thanks in particular to the contribution of imaging before the procedure. |
17,727 | Outcome after out-of-hospital ventricular fibrillation or pulseless ventricular tachycardia: comparison of before and after the implementation of the 2010 Guidelines in a single centre. | Improvements to guidelines and efforts to train and equip laypersons and medical professionals are expected to result in improvements in the outcomes of patients experiencing out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate changes in the survival and neurological outcomes of patients before and after the implementation of the 2010 guidelines.</AbstractText>In a retrospective chart review, we analysed the outcomes of 182 patients who suffered bystander-witnessed, out-of-hospital ventricular fibrillation or pulseless ventricular tachycardia of cardiac aetiology. These definitions were based on the Utstein style. Survival at hospital discharge (study period 2006 to 2015), 1-year survival (study period 2011 to 2015), neurological outcome (cerebral performance category [CPC] score) and the corresponding changes over time were evaluated. In addition, the results were compared with results obtained from a systematic review of the literature.</AbstractText>Of 1423 confirmed OHCAs, 182 fulfilled our inclusion criteria. 91 were treated between 2006 and 2010, and 91 from 2011 to 2015. Thirty-one (34%) survived until hospital discharge in the first time period, 44 (48%) in the second time period (p = 0.071); 26/31 (83%) and 40/44 (91%) respectively had a CPC score of 1&ndash;2. Between 2011 and 2015, the 1-year survival rate of the patients discharged from hospital was 36/44 (82%). All of these 36 patients (100%) had a favourable neurological outcome (CPC 1&ndash;2). These results were well within the range reported in the literature, although this range is wide (11 to 52% for survival at discharge and 6 to 47% for survival at 1 year).</AbstractText>Survival was found to be at the upper range of the results retrieved by the systematic literature review. However, we found no significant improvements over time. The neurological outcomes of the survivors were favourable. The generalisability of this study is limited by its small sample size. To further improve outcomes, more public health measures, such as a functioning chain of survival, are required (e.g. an effective first responder network).</AbstractText> |
17,728 | Left atrial ejection fraction and outcomes in heart failure with preserved ejection fraction. | The aim of this study was to determine whether left atrial ejection fraction (LAEF) quantified with cardiovascular magnetic resonance (CMR) was different between heart failure with preserved ejection fraction (HFpEF) and controls, and its relation to prognosis. As part of our single-centre, prospective, observational study, 188 subjects (HFpEF n = 140, controls n = 48) underwent phenotyping with contrast-enhanced CMR, transthoracic echocardiography, blood sampling and six-minute walk testing. LAEF was calculated using the biplane method. Atrial fibrillation (AF) was present in 43 (31%) of HFpEF subjects. Overall, LAEF (%) was lower in HFpEF patients inclusive of AF (32 ± 16) or those in sinus rhythm alone (41 ± 12) compared to controls (51 ± 11), p < 0.0001. LAEF correlated inversely with maximal and minimal left atrial volumes indexed (r =  - 0.602, r =  - 0.762), and plasma N-terminal pro-atrial natriuretic peptide (r =  - 0.367); p < 0.0001. During median follow-up (1429 days), there were 67 composite events of all-cause death or hospitalization for heart failure (22 deaths, 45 HF hospitalizations) in HFpEF. Lower LAEF (below median) was associated with an increased risk of composite endpoints (Log-Rank: all p = 0.028; sinus p = 0.036). In multivariable Cox regression analysis, LAEF (adjusted hazard ratio [HR] 0.767, 95% confidence interval [CI] 0.591-0.996; p = 0.047) and indexed extracellular volume (HR 1.422, CI 1.015-1.992; p = 0.041) were the only parameters that remained significant when added to a base prognostic model comprising age, prior HF hospitalization, diastolic blood pressure, lung disease, NYHA, six-minute-walk-test-distance, haemoglobin, creatinine and B-type natriuretic peptide. CMR-derived LAEF is lower in HFpEF compared to healthy controls and is a strong prognostic biomarker. |
17,729 | Reinserting Physiology into Cardiac Mapping Using Omnipolar Electrograms. | Omnipolar electrograms (EGMs) make use of biophysical electric fields that accompany activation along the surface of the myocardium. A grid-like electrode array provides bipolar signals in orthogonal directions to deliver catheter-orientation-independent assessments of cardiac electrophysiology. Studies with myocyte monolayers, isolated animal and human hearts, and anesthetized animals validated the tenets of omnipolar EGMs. The combination of information from omnipolar-based activation vectors and voltages may aid in localizing areas of scar, lesion gaps, wavefront disorganization, and fractionation or collision during arrhythmias. The goal of omnipolar EGMs is to better characterize myocardium through reintroducing electrogram direction related fundamentals of cardiac electrophysiology. |
17,730 | High-resolution/Density Mapping in Patients with Atrial and Ventricular Arrhythmias. | High-definition/ultra-high-definition mapping, owing to an impressive increase of the point density of electroanatomic maps, provides improved substrate characterization, better understanding of the arrhythmia mechanism, and a better selection of the ablation target in patients with atrial and ventricular arrhythmias. Despite the scarce comparative data on ablation results versus standard mapping, ultra-high-definition mapping is increasingly used by the electrophysiology community. |
17,731 | Optical Mapping. | Optical mapping of electrical activity in the heart is based on voltage-sensitive and lipophilic fluorescence dyes. Optical signals recorded from cardiac cells correlate well with their transmembrane potentials. High spatiotemporal resolution, wide field mapping, and high sensitivity to transmembrane potential enable detailed characterization of action potential initiation and propagation. Optical mapping is used to study complex patterns of excitation propagation, including propagation across the sinoatrial and atrioventricular nodes and during atrial and ventricular arrhythmias.Optical mapping is used to study the role of reentrant activity in atrial and ventricular fibrillation. |
17,732 | Noninvasive Cardioablation. | Stereotactic body radiotherapy uses the principle of 3-dimensional localization of a target to deliver a high dose of radiation to a precise location. The aim of this technique is to ablate tissue noninvasively. Because of its high precision and target conformity, it can deliver a high dose of radiation to a specific area in a tissue without significantly affecting nearby tissues. It is being actively studied and even used in therapy for atrial fibrillation and ventricular tachycardia. |
17,733 | Anatomic Considerations Relevant to Atrial and Ventricular Arrhythmias. | Knowledge of relevant cardiac anatomy is crucial in understanding the pathophysiology and treatment of arrhythmias, and helps avoid potential complications in mapping and ablation. This article explores the anatomy, relevant to electrophysiologists, relating to atrial flutter and atrial fibrillation, ventricular tachycardia relating to the outflow tracts as well as endocardial structure, and also epicardial considerations for mapping and ablation. |
17,734 | Prognostic role of diastolic dysfunction in patients undergoing transcatheter aortic valve replacement. | Prior studies have shown that left ventricular diastolic dysfunction (DD) is associated with increased mortality after surgical aortic valve replacement but studies on transcatheter aortic valve replacement (TAVR) are limited and have not taken into account mitral annular calcification (MAC), which limits the use of mitral valve annular tissue Doppler imaging. We performed a single-center retrospective analysis to better evaluate the role of baseline DD on outcomes after TAVR.</AbstractText>After excluding patients with atrial fibrillation, mitral valve prostheses and significant mitral stenosis, 359 consecutive TAVR patients were included in the study. Moderate-to-severe MAC was present in 58% of the patients. We classified patients into severe versus nonsevere DD based on the evaluation of elevated left ventricular filling pressure. The outcome measure was all-cause mortality or heart failure hospitalization.</AbstractText>Over a mean follow-up time of 13 months, severe DD was associated with an increased risk for the outcome measure (HR 2.02 [1.23-3.30], p = .005). However, this association was lost in a propensity-matched cohort. In multivariate analysis, STS score was the only independent predictor of all cause mortality of heart failure hospitalization (HR 1.1 [1.05-1.15], p < .001).</AbstractText>We evaluated the role of baseline DD on outcomes after TAVR by taking into account the presence of MAC. Severe DD was associated with increased all-cause mortality or heart failure hospitalization but not independently of other structural parameters and known predictors of the outcome measure.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,735 | Cardiovascular Adverse Events Associated With BRAF and MEK Inhibitors: A Systematic Review and Meta-analysis. | Cardiovascular adverse events (CVAEs) after treatment with BRAF and MEK inhibitors in patients with melanoma remain incompletely characterized.</AbstractText>To determine the association of BRAF and MEK inhibitor treatment with CVAEs in patients with melanoma compared with BRAF inhibitor monotherapy.</AbstractText>PubMed, Cochrane, and Web of Science were systematically searched for keywords vemurafenib, dabrafenib, encorafenib, trametinib, binimetinib, and cobinimetinib from database inception through November 30, 2018.</AbstractText>Randomized clinical trials reporting on CVAEs in patients with melanoma being treated with BRAF and MEK inhibitors compared with patients with melanoma being treated with BRAF inhibitor monotherapy were selected.</AbstractText>Data assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Pooled relative risks (RRs) and 95% CIs were determined using random-effects and fixed-effects analyses. Subgroup analyses were conducted to assess study-level characteristics associated with CVAEs.</AbstractText>The selected end points were pulmonary embolism, a decrease in left ventricular ejection fraction, arterial hypertension, myocardial infarction, atrial fibrillation, and QTc interval prolongation. All-grade and high-grade (≥3) CVAEs were recorded.</AbstractText>Overall, 5 randomized clinical trials including 2317 patients with melanoma were selected. Treatment with BRAF and MEK inhibitors was associated with an increased risk of pulmonary embolism (RR, 4.36; 95% CI, 1.23-15.44; P = .02), a decrease in left ventricular ejection fraction (RR, 3.72; 95% CI, 1.74-7.94; P < .001), and arterial hypertension (RR, 1.49; 95% CI, 1.12-1.97; P = .005) compared with BRAF inhibitor monotherapy. The RRs for myocardial infarction, atrial fibrillation, and QTc prolongation were similar between the groups. These results were consistent when assessing high-grade CVAEs (left ventricular ejection fraction: RR, 2.79; 95% CI, 1.36-5.73; P = .005; I2 = 29%; high-grade arterial hypertension: RR, 1.54; 95% CI, 1.14-2.08; P = .005; I2 = 0%), but RRs for high-grade pulmonary embolism were similar between groups. A higher risk of a decrease in left ventricular ejection fraction was associated with patients with a mean age younger than 55 years (RR, 26.50; 95% CI, 3.58-196.10; P = .001), and the associated risk of pulmonary embolism was higher for patients with a mean follow-up time longer than 15 months (RR, 7.70; 95% CI, 1.40-42.12; P = .02).</AbstractText>Therapy with BRAF and MEK inhibitors was associated with a higher risk of CVAEs compared with BRAF inhibitor monotherapy. The findings may help to balance between beneficial melanoma treatment and cardiovascular morbidity and mortality.</AbstractText> |
17,736 | A comprehensive multi-index cardiac magnetic resonance-guided assessment of atrial fibrillation substrate prior to ablation: Prediction of long-term outcomes. | Multiple cardiac magnetic resonance (CMR)-derived indices of atrial fibrillation (AF) substrate have been shown in isolation to predict long-term outcome following catheter ablation. Left atrial (LA) fibrosis, LA volume, LA ejection fraction (EF), left ventricular ejection fraction (LVEF), LA shape (sphericity) and pulmonary vein anatomy have all been shown to correlate with late AF recurrence. This study aimed to validate and assess the relative contribution of multiple indices in a long-term single-center study.</AbstractText>Eighty-nine patients (53% paroxysmal AF, 73% male) underwent comprehensive CMR study before first-time AF ablation (median follow-up 726 days [IQR: 418-1010 days]). The 3D late gadolinium-enhanced acquisition (1.5T, 1.3 × 1.3 × 2 mm) was quantified for fibrosis; LA volume and sphericity were assessed on manual segmentation at atrial diastole; LAEF and LVEF were quantified on multislice cine imaging. AF recurred in 43 patients (48%) overall (31 at 1 year). In the recurrence group, LA fibrosis was higher (42% vs 29%; hazard ratio [HR]: 1.032; P = .002), left atrial ejection fraction (LAEF) lower (25% vs 34%; HR: 0.063; P = .016) and LVEF lower (57% vs 63%; HR: 0.011; P = .008). LA volume (135 vs 124 mL) and sphericity (0.819 vs 0.822) were similar. Multivariate Cox regression analysis was adjusted for age and sex (Model 1), additionally AF type (Model 2) and combined (Model 3). In Models 1 and 2, LA fibrosis, LAEF, and LVEF were independently associated with outcome, but only LA fibrosis was independent in Model 3 (HR: 1.021; P = .022).</AbstractText>LAEF, LVEF, and LA fibrosis differed significantly in the AF recurrence cohort. However, on combined multivariate analysis only LA fibrosis remained independently associated with outcome.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,737 | [Early Invasive Strategy in Patients over 75 Years with Acute Coronary Syndrome. A Single Center Study]. | to assess the clinical status, comorbidities, complications, in-hospital mortality and its structure in dependence of age and type of acute coronary syndrome (ACS) in case of early invasive strategy of ACS management.</AbstractText>we included in this retrospective study data of all patients (n=1353) with ACS subjected to emergency and urgent myocardial revascularization in High Medical Technologies Center (Kaliningrad, Russia) in 2014-2016. Age of 984 patients was &lt;75 (group 1) and of 369 &gt;75 years (group 2).</AbstractText>Mean age was 60±8.6 and 80.1±4.2 years, in groups 1 and 2, respectively. Anamnesis of group 2 patients was substantially burdened by myocardial infarction and stroke, they significantly more often had reduced left ventricular ejection fraction (EF), congestive heart failure, valve disorders, and atrial fibrillation. Patients of group 2 more frequently had severe manifestations of acute heart failure (AHF) and cardiogenic shock. Portions of patients with Killip class III were 5.9 and 11.4%, IV -2.1% and 9.1% in 1 and 2, respectively. Group 2 patients compared with those of group 1 had higher GRACE score and higher bleeding risk. In-hospital all-cause mortality was 3.1 and 10%, ST elevation myocardial infarction mortality - 2.6 and 9.5% in groups 1 and 2, respectively. Non-ST elevation myocardial infarction + unstable angina mortality (0.5%) did not differ between groups. Mortality from AHF (2 and 6.5%) and percutaneous coronary intervention complications (stent thrombosis and no-reflow) (0.5 and 2.4%) was significantly higher in group 2. AHF mortality was similar in patients with preserved and mid-range EF of both groups, but among those with reduced EF it was significantly higher in group 2 compared with group 1 (7.3 vs. 18.6%, respectively). There were no significant differences between groups in rates of gastro-intestinal and major bleedings.</AbstractText>Clinical course of ACS was more severe in patients aged &gt;75 years compared with patients aged &lt;75 years. Early invasive strategy was effective irrespective of patient's age and ACS type. Rate of fatal outcomes due to complications of stenting and AHF were higher among very elderly patients. AHF more often caused death in very elderly patients with reduced EF. The rest of the structure of complications and mortality was similar in patients of different ages.</AbstractText> |
17,738 | Clinical implications of sarcomere and nonsarcomere gene variants in patients with left ventricular noncompaction cardiomyopathy. | Robust data regarding genotype-phenotype correlations in left ventricular noncompaction cardiomyopathy (LVNC) are lacking.</AbstractText>About 72 cardiomyopathy-related genes were comprehensively screened in a cohort of LVNC patients using targeted sequencing. Baseline and follow-up data were collected. The primary endpoint was a composite of death and heart transplantation.</AbstractText>A total of 83 unrelated adult patients were included in analyses. Following stringent classification according to the American College of Medical Genetics and Genomics (ACMG) guidelines, 36 pathogenic variants of 14 genes were detected in 32 patients. Among them, 12 patients carried at least one nonsarcomere variant (NSV). At baseline, NSV carriers had a higher frequency of atrial fibrillation, but lower left ventricular ejection fraction, than did noncarriers. During a median follow-up of 4.2 years, NSV carriers experienced a higher rate of the primary endpoint compared with noncarriers. There was no significant difference in the rate between carriers of sarcomere variant (SV) and noncarriers, as well as between carriers of SV and NSV. The presence of NSV was associated with an increased risk of the primary endpoint independent of age, sex, and cardiac function (hazard ratio: 3.61, 95% confidence interval: 1.42-9.19, p = .002).</AbstractText>NSV may act as a genetic modifier and worsen the clinical phenotype in patients with LVNC.</AbstractText>© 2019 The Authors. Molecular Genetics & Genomic Medicine published by Wiley Periodicals, Inc.</CopyrightInformation> |
17,739 | Arrhythmic Burden and Outcomes in Pulmonary Arterial Hypertension. | Pulmonary arterial hypertension (PAH) is a devastating, life-limiting disease driven by small vessel vascular remodeling leading to a rise in pulmonary vascular resistance (PVR). Patients present with a range of symptoms including shortness of breath, exercise intolerance, palpitations or syncope. Symptoms may be related to vascular disease progression or arrhythmia secondary to the adaptation of the right heart to pressure overload. Arrhythmic burden is high in patients with left heart disease and guideline-based treatment of arrhythmias improves quality of life and prognosis. In PAH the incidence and prevalence of arrhythmias is less well-defined and there are no PAH-specific guidelines for arrhythmia management. We undertook a literature search identifying 13 relevant papers; detection of arrhythmias was acquired from 12-lead electrocardiogram (ECG) or Holter monitors. In all forms of pulmonary hypertension (PH) the prevalence of supraventricular arrhythmias (SVA) was 26-31%, ventricular arrhythmias (VA) 24% and a 5-year incidence of SVA ~13.2-25.1%. Prevalence and incidence of arrhythmias in PAH is less clear due to limited study numbers and the heterogenous nature of the patient population studied. For arrhythmia treatment, only single-arm studies of therapeutic strategies were reported using antiarrhythmic drugs (AAD), direct current cardioversion (DCCV) and ablation. Periods between ECG or Holter have not been investigated, highlighting the possibility that significant arrhythmias may be undetected. Advances in monitoring allow long-term surveillance via implanted/non-invasive monitors. Use of such technologies may provide an accurate estimate of incidence and prevalence of arrhythmias in patients with PAH, further defining relationships to adverse outcomes, and therapeutic options. |
17,740 | J-Wave Elevation in the Inferior Leads Predicts Lethal Ventricular Arrhythmia Initiated by Premature Ventricular Contractions With Right Bundle Branch Block and Superior Axis. | Lethal ventricular arrhythmia (VA) can be initiated by idiopathic premature ventricular contractions (PVCs) originating from the left ventricular (LV) inferior wall. Furthermore, J-wave elevation in the inferior leads on ECG is sometimes associated with lethal VA. However, the relationship between these PVCs and J-wave elevation in patients with lethal VA is unclear, so we investigated it in the present study.Methods and Results:We studied 32 consecutive patients who underwent radiofrequency (RF) ablation of idiopathic PVCs with right bundle branch block (RBBB) and superior axis. Thee PVCs were originating from the inferior wall of the LV. Lethal VA was defined as ventricular fibrillation (VF) or ventricular tachycardia (VT) with loss of consciousness (LOC). Among 32 patients, 3 had VF and 2 had VT with LOC. Other 27 had non-lethal VA. Baseline clinical characteristics were not significantly difference between lethal and non-lethal VA. The ratio of J-wave elevation in lethal VA was significantly higher as compared with non-lethal VA (100% vs. 11.1%, P<0.0001). Furthermore, no patients with J-wave elevation in the inferior leads had recurrence of lethal VA after RF ablation of the PVCs.</AbstractText>We speculate that J-wave elevation in the inferior leads might be a predictor of lethal VA initiated by PVCs with RBBB and superior axis. RF ablation of these PVCs was a useful method of treating lethal VA.</AbstractText> |
17,741 | Long-term prognosis of patients withJ-wave syndrome. | Limited data are currently available regarding the long-term prognosis of patients with J-wave syndrome (JWS). The aim of this study was to investigate the long-term prognosis of patients with JWS and identify predictors of the recurrence of ventricular fibrillation (VF).</AbstractText>This was a multicentre retrospective study (seven Japanese hospitals) involving 134 patients with JWS (Brugada syndrome (BrS): 85; early repolarisation syndrome (ERS): 49) treated with an implantable cardioverter defibrillator. All patients had a history of VF. All patients with ERS underwent drug provocation testing with standard and high intercostal ECG recordings to rule out BrS. The impact of global J waves (type 1 ECG or anterior J waves and inferolateral J waves in two or more leads) on the prognosis was evaluated.</AbstractText>During the 91±66 months of the follow-up period, 52 (39%) patients (BrS: 37; ERS: 15) experienced recurrence of VF. Patients with BrS and ERS with global J waves showed a significantly higher incidence of VF recurrence than those without (BrS: log-rank, p=0.014; ERS: log-rank, p=0.0009). The presence of global J waves was a predictor of VF recurrence in patients with JWS (HR: 2.16, 95% CI 1.21 to 3.91, p=0.0095), while previously reported high-risk electrocardiographic parameters (high-amplitude J waves ≥0.2 mV and J waves associated with a horizontal or descending ST segment) were not predictive of VF recurrence.</AbstractText>This multicentre long-term study showed that the presence of global J waves was associated with a higher incidence of VF recurrence in patients with JWS.</AbstractText>© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.</CopyrightInformation> |
17,742 | What causes sudden death in patients with chronic heart failure and a reduced ejection fraction? | Sudden death characterizes the mode of demise in 30-50% of patients with chronic heart failure and a reduced ejection fraction. Occasionally, these events have an identifiable pathophysiological trigger, e.g. myocardial infarction, catecholamine surges, or electrolyte imbalances, but in most circumstances, there is no acute precipitating mechanism. Instead, adverse left ventricular remodelling and fibrosis creates an exceptionally fragile and highly vulnerable substrate, which can be characterized using the model developed in theoretical physics of 'self-organizing criticality'. This framework has been applied to describe the genesis of avalanches, nodes of traffic congestion unrelated to an accident, the abrupt system-wide failure of electrical grids, and the initiation of cancer and neurodegenerative diseases. Self-organizing criticality within the ventricular myocardium relies on complex adaptations to progressive stress and stretch, which evolve inevitably to an abrupt end (termed 'cascading failure'), even though the rate of deterioration of the underlying disease process has not changed. The result is acute circulatory collapse (i.e. sudden death) in the absence of an identifiable triggering event. Cascading failure in a severely remodelled or fibrotic heart can become manifest electrically as a first-time ventricular tachyarrhythmia that is responsive to the shock delivered by an implantable cardioverter-defibrillator (ICD). Alternatively, it may present as an acute mechanical failure, which is manifest as (i) asystole, bradyarrhythmia, or electromechanical dissociation; or (ii) incessant ventricular fibrillation that persists despite repetitive ICD discharges; in both instances, the sudden deaths cannot be prevented by an ICD. This conceptual framework explains why anti-remodelling and antifibrotic interventions (i.e. neurohormonal antagonists and cardiac resynchronization) reduce the risk of sudden death in patients with heart failure in the absence of an ICD and provide incremental benefits in those with an ICD. The adoption of anti-remodelling and antifibrotic treatments may explain why the incidence of sudden death in clinical trials of heart failure has declined dramatically over the past 10-15 years, independent of the use of ICDs. |
17,743 | Atrial fibrillation as a clinical characteristic of arrhythmogenic right ventricular cardiomyopathy: Experience from the Nordic ARVC Registry. | Recent studies in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients have drawn attention to atrial fibrillation (AF) as an arrhythmic manifestation of ARVC and as an indicator of atrial involvement in the disease progression. We aimed to assess the prevalence of AF in the Scandinavian cohort of ARVC patients and to evaluate its association with disease clinical manifestations.</AbstractText>Study sample comprised of 293 definite ARVC patients by 2010 Task Force criteria (TFC2010) and 141 genotype-positive family members (total n = 434, 43% females, median age at ARVC diagnosis 41 years [interquartile range (IQR) 28-52 years]). ARVC diagnostic score was calculated as the sum of major (2 points) and minor (1 point) criteria in all categories of the TFC2010.</AbstractText>AF was diagnosed in 42 patients (10%): in 41 patients with definite ARVC diagnosis (14%) vs in one genotype-positive family member (1%), p < 0.001. The median age at AF onset was 51 (IQR 38-58) years. The prevalence of AF was related to the ARVC diagnostic score: it significantly increased starting with the diagnostic score 4 (2% in those with score 3 vs 13% in those with score 4, p = 0.023) and increased further with increased diagnostic score (Somer's d value is 0.074, p < 0.001).</AbstractText>AF is seen in 14% of definite ARVC patients and is related to the severity of disease phenotype thus suggesting AF being an arrhythmic manifestation of this cardiomyopathy indicating atrial myocardial involvement in the disease progression.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,744 | Early Versus Late New-Onset Atrial Fibrillation in Acute Myocardial Infarction: Differences in Clinical Characteristics and Predictors. | New-onset atrial fibrillation (NOAF) during acute myocardial infarction (AMI) has significant consequences but is often misdiagnosed. The aim of the study was to evaluate predictors of NOAF throughout different phases of AMI. Patients with AMI admitted to a tertiary medical center were analyzed. Exclusion criteria were preexisting AF, AMI onset ≥24 hours prior to admission, in-hospital death, significant valvular disease, and in-hospital coronary artery bypass graft. Study population were AMI without-NOAF, early-AF (AF terminated within 24 hours of admission), and late-AF (beyond the first 24 hours). Overall 5946 patients were included, age: 64.8 ±14.8 years; 30% women. The incidence of NOAF was 4.6%: 1.6% early-AF, and 3% late-AF. Patients with NOAF comprised greater rate of women, cardiovascular risk-factors burden, severe left ventricular-dysfunction, pulmonary hypertension, valvular disorders, and left atrial enlargement compared with patients without-NOAF. Non-ST-elevation myocardial infarction and inferior-ST-elevation myocardial infarction (STEMI) were significantly more prevalent among early-AF group, while anterior-STEMI, in late-AF. The final multivariate models showed c-statistics of 0.73 and 0.76 for the prediction of new-onset early-AF and late-AF, respectively. In conclusion, there are different clinical predictors of early- versus late-NOAF. The study points out "high risk" AMI population for more meticulous heart rate monitoring for NOAF. |
17,745 | Mid-term outcome following second-generation cryoballoon ablation for atrial fibrillation in heart failure patients: effectiveness of single 3-min freeze cryoablation performed in a cohort of patients with reduced left ventricular systolic function. | Currently, information on the mid-term outcome of cryoballoon ablation (CB-A) for drug-resistant atrial fibrillation in patients with reduced left ventricular systolic function is limited.</AbstractText>Thirty-eight consecutive patients with paroxysmal or persistent atrial fibrillation (84.2% male), with median left ventricular ejection fraction of 37.3% were included in our study. All patients underwent the procedure with the 28-mm cryoballoon advance.</AbstractText>There were no mayor complications related to the CB-A procedure. Median follow-up was 26.5 ± 13.7 months. The freedom from atrial fibrillation after a blanking period of 3 months was 42.9% in our cohort of patients. During the follow-up period, 13 patients underwent at least a new electrophysiological procedure. After a single procedure, the univariate predictors of clinical recurrence after the blanking period were age and persistent atrial fibrillation.</AbstractText>Second-generation CB-A of atrial fibrillation seems feasible and safe in patients with heart failure with reduced ejection fraction and heart failure with mid-range ejection fraction, in terms of complications rate and number of applications per vein. All pulmonary veins could be isolated with the 28-mm cryoballoon advance only.</AbstractText> |
17,746 | Transtelephonic ECG Monitoring to Guide Outpatient Antiarrhythmic Drug Therapy in Patients With Non-Permanent Atrial Fibrillation: Efficacy and Safety From a Single-Center Experience. | Initiation of antiarrhythmic drug therapy (AADx) for atrial fibrillation (AF) on an outpatient basis requires intensive ECG monitoring in order to assess antiarrhythmic efficacy as well as ECG signals of potential proarrhythmia. Dronedarone (DRO) reduces cardiovascular endpoints in AF patients fulfilling criteria of the ATHENA trial [1]. In the present study transtelephonic ECG monitoring was used to guide initiation of AADx in AF patients fulfilling the ATHENA criteria. In 19 consecutive patients (37% female; age 65+10 years; LVEF 62+7%; mean CHA2DS2-VASc score 2.9 + 1.6 (median=2), with symptomatic non-permanent AF and additional cardiovascular risk factors, DRO was prescribed as AADx of first choice. Initiation of therapy and follow-up were monitored by transtelephonic ECG recordings (VITAPHONE™100 IR; Vitaphone GmbH; Germany). In patients with persistent AF, electrical cardioversion was performed on an outpatient basis when DRO was started. Patients were followed for changes in QT intervals as well as AF recurrency. ECGs were transmitted according to a scheduled FU form as well as any time in case of pts symptoms. Patients in whom DRO did not prevent AF recurrence were switched to alternative AADx, or to pulmonary vein isolation (PVI), respectively. At the end of long-term follow-up, DRO alone was successful in preventing AF recurrence in 5 of 19 patients (26%). When pts who responded to AADx of second or third choice or who underwent PVI were included, SR could be maintained in 17/19 pts (89%). No patient required discontinuation of AADx due to ventricular depolarization abnormalities, symptomatic bradycardia or pathologic QT prolongation. In conclusion, transtelephonic ECG transmission is useful for close rhythm monitoring during initiation and follow-up of AADx, also during change from DRO to other AADx. DRO was effective to prevent AF recurrence in 26% of patients during a mean long-term follow-up of more than 30 months - which is well in line with data from the literature. |
17,747 | Evidence-Based Case Report: The Use of D-Dimer Assay to Exclude Left Atrial Thrombus in Patient with Atrial Fibrillation >48 Hours. | Patients with atrial fibrillation (AF) for >48 hours who are a candidate for cardioversion should have transesophageal echocardiography (TEE) performed to exclude left atrial thrombus (LAT) that may cause systemic thromboembolism upon conversion to sinus rhythm. However, TEE facilities were limited, especially in developing countries.</AbstractText>A 50 years-old man presented with exertional dyspnea and palpitation for 72 hours prior to admission. Electrocardiography showed AF with a ventricular rate of 140x/minute. Cardioversion was decided to be the best approach. This patient has an AF >48 hours of onset, hence, LAT should be excluded by the use of TEE. Unfortunately, there was no TEE facility nearby.</AbstractText>Upon comprehensive search on the use of D-Dimer assay to exclude the LAT in AF patients, we found seven studies showed increased D-dimer level in those with left atrial thrombus. In 4 studies, AUC was > 0.70, sensitivity and specificity varied from 75.9% to 89% and 73.1% to 95% respectively. However, there is no single cut-off point, due to the heterogeneity of cut-off points.</AbstractText>D-dimer assay combined with other variables of atrial thrombus exclusion score is valuable in excluding LAT. Previously, weeks of anticoagulation is more advisable before attempting cardioversion in the absence of nearby TEE facilities. With current evidence, a low D-dimer and ATE score of 0 is safe for cardioversion.</AbstractText> |
17,748 | Prolonged Ventricular Dyssynchrony Due to Atrial Fibrillation and Pre-Excitation Syndrome Induced Cardiomyopathy. | Various degree of ventricular activation by accessory pathway (AP) and normal conduction system in a patient with pre-excited atrial fibrillation (AF) may lead to ventricle dyssynchrony and cardiomyopathy. |
17,749 | Current Use of Neuromuscular Blocking Agents in Intensive Care Units. | Neuromuscular blocking agents can be used for purposes such as eliminating ventilator-patient dyssynchrony, facilitating gas exchange by reducing intra-abdominal pressure and improving chest wall compliance, reducing risk of lung barotrauma, decreasing contribution of muscles to oxygen consumption by preventing shivering and limiting elevations in intracranial pressure caused by airway stimulation in patients supported with mechanical ventilation in intensive care units. Adult Respiratory Distress Syndrome (ARDS), status asthmaticus, increased intracranial pressure and therapeutic hypothermia following ventricular fibrillation-associated cardiac arrest are some of clinical conditions that can be sustained by neuromuscular blockade. Appropriate indication and clinical practice have gained importance considering side effects such as ICU-acquired weakness, masking seizure activity and longer durations of hospital and ICU stays. We mainly aimed to review the current literature regarding neuromuscular blockade in up-to-date clinical conditions such as improving oxygenation in early ARDS and preventing shivering in the therapeutic hypothermia along with summarising the clinical practice in adult ICU in this report. |
17,750 | Use and Outcomes Associated With Perioperative Amiodarone in Cardiac Surgery. | Background In randomized controlled trials, perioperative administration of amiodarone has been shown to reduce the incidence of postoperative atrial arrhythmias and length of stay (LOS) among patients undergoing coronary bypass surgery. However, little is known about the use or effectiveness of perioperative amiodarone in routine clinical practice. Methods and Results We studied patients ≥18 years old without a previous history of atrial or ventricular arrhythmias who underwent elective coronary bypass surgery between 2013 and 2014 within a network of 235 US hospitals. Perioperative amiodarone was defined as receipt of amiodarone either on the day of or the day preceding surgery. We used covariate-adjusted modeling and instrumental variable methods to examine the association between receipt of amiodarone and the development of atrial arrhythmias, in-hospital mortality, readmission, LOS, and cost. Of 12 758 patients, 2195 (17.2%) received perioperative amiodarone, 3330 (26.1%) developed atrial arrhythmias postoperatively, and the average LOS was 6.4 days (±2.6 days). Instrumental variable analysis showed that receipt of perioperative amiodarone was associated with lower risk of atrial arrhythmias (risk difference -11 percentage points, 95% CI -19 to -4 percentage points; P=0.002) and a shorter LOS (-0.7 day, 95% CI -1.39 to -0.01 days; P=0.048). There was no association between receipt of perioperative amiodarone and in-hospital mortality, cost, or readmission. Conclusions Among patients undergoing coronary bypass surgery without previous arrhythmias, perioperative amiodarone is associated with a lower risk of atrial arrhythmias and shorter LOS. These findings are consistent with previous randomized trials and lend support to current guideline recommendations. |
17,751 | Young Vasospastic Angina Patients Less Than 20 Years Old. | Japanese Circulation Society (JCS) guidelines do not include adolescents with coronary artery spasm.Methods and Results:We recruited 18 adolescents less than 20 years old with vasospastic angina (VSA): 11 were Japanese and 3 had chest symptoms for >12 months before admission. ST-segment elevation was observed in 11 patients and none of the 18 patients had a fixed stenosis. Spasm provocation tests were performed in 9 patients and two-thirds had multiple spasms; 6 suffered from acute myocardial infarction and ventricular fibrillation occurred in 2 patients; 1 patient died and the remaining 17 patents survived.</AbstractText>Clinical status of adolescents with VSA was as severe as in adults with refractory VSA. Cardiologists should cooperate with pediatricians to diagnose and treat adolescents with VSA. There is a need to establish the additional issues for adolescents with coronary spasm in the JCS guidelines.</AbstractText> |
17,752 | Arrhythmias in Congenital Heart Disease. | Cardiac defects are the most common congenital defects, accounting for approximately 9 per 1000 births. Patients with structural heart disease related to congenital diseases are prone to develop intrinsic rhythm abnormalities as a result of altered physiology. In addition, they are at an increased risk of developing acquired arrhythmias secondary to the nature of surgical interventions done to improve physiologic function in the setting of these defects. Arrhythmia management and risk stratification pose particularly complex challenges to clinicians managing this population. |
17,753 | Sudden Cardiac Death: Who Is at Risk? | Sudden cardiac death (SCD) is a leading cause of death in the United States. Despite improvements in therapy, the incidence of SCD as a proportion of overall cardiovascular death remains relatively unchanged. This article aims to answer the question, "Who is at risk for SCD?" In the process, it reviews the definition, pathophysiology, epidemiology, and risk factors of SCD. Patients at risk for SCD and appropriate treatment strategies are discussed. |
17,754 | Basic Principles of Cardiac Electrophysiology. | This article represents an overview of the basic concepts of cardiac electrophysiology. This relatively new field became a subspecialty of cardiology in the mid-1990s due to the rapid development of equipment that allowed the study and cure of cardiac arrhythmias percutaneously. Simultaneously, technology provided the field with percutaneous cardiac implantable electronic devices designed to protect patients from life-threatening bradyarrhythmias and tachyarrhythmias. Recently, the field has focused on the ablative treatment of atrial fibrillation, the most common arrhythmia facing an aging population, and the diagnosis and management of many inherited arrhythmias through advances in understanding of their genetic cause. |
17,755 | High-energy external defibrillation and transcutaneous pacing during MRI: feasibility and safety. | Rapid application of external defibrillation, a crucial first-line therapy for ventricular fibrillation and cardiac arrest, is currently unavailable in the setting of magnetic resonance imaging (MRI), raising concerns about patient safety during MRI tests and MRI-guided procedures, particularly in patients with cardiovascular diseases. The objective of this study was to examine the feasibility and safety of defibrillation/pacing for the entire range of clinically useful shock energies inside the MRI bore and during scans, using defibrillation/pacing outside the magnet as a control.</AbstractText>Experiments were conducted using a commercial defibrillator (LIFEPAK 20, Physio-Control, Redmond, Washington, USA) with a custom high-voltage, twisted-pair cable with two mounted resonant floating radiofrequency traps to reduce emission from the defibrillator and the MRI scanner. A total of 18 high-energy (200-360 J) defibrillation experiments were conducted in six swine on a 1.5 T MRI scanner outside the magnet bore, inside the bore, and during scanning, using adult and pediatric defibrillation pads. Defibrillation was followed by cardiac pacing (with capture) in a subset of two animals. Monitored signals included: high-fidelity temperature (0.01 °C, 10 samples/sec) under the pads and 12-lead electrocardiogram (ECG) using an MRI-compatible ECG system.</AbstractText>Defibrillation/pacing was successful in all experiments. Temperature was higher during defibrillation inside the bore and during scanning compared with outside the bore, but the differences were small (ΔT: 0.5 and 0.7 °C, p = 0.01 and 0.04, respectively). During scans, temperature after defibrillation tended to be higher for pediatric vs. adult pads (p = 0.08). MR-image quality (signal-to-noise ratio) decreased by ~ 10% when the defibrillator was turned on.</AbstractText>Our study demonstrates the feasibility and safety of in-bore defibrillation for the full range of defibrillation energies used in clinical practice, as well as of transcutaneous cardiac pacing inside the MRI bore. Methods for Improving MR-image quality in the presence of a working defibrillator require further study.</AbstractText> |
17,756 | Increased epicardial adipose tissue in young adults with congenital heart disease comorbid with major depressive disorder. | Congenital heart disease is the most common congenital malformation. In adult congenital heart disease (ACHD), the prevalence of major depressive disorder (MDD) is increased. Beyond its immanent health risks, increased epi‑ and paracardial adipose tissue has been described in MDD. Epicardial adipose tissue (EAT) is a fat depot surrounding the heart, and it is hypothesized to be associated with coronary artery disease, left-ventricular dysfunction and atrial fibrillation, being frequent problems in ACHD long-term management. We here examined whether EAT is increased in depressed patients with ACHD.</AbstractText>Two-hundred and ten ACHD outpatients (mean age 35.5y, 43% female) were included. MDD was diagnosed according to DSM-IV criteria using expert interviews. EAT was measured using echocardiography. Further assessments comprised NT-proBNP, left and right ventricular end-diastolic diameter, left-ventricular ejection fraction, smoking behavior and physical activity.</AbstractText>Of 210 patients, 53 (25.2%) were diagnosed with MDD. EAT was increased in depressed ACHD (F = 5.04; df = 1; p = 0.026). Depressed male patients were less physically active (p < 0.05) and smoked more cigarettes (p < 0.05). EAT was positively predicted by depression severity (p = 0.039), body mass index (p < 0.001), and negatively predicted by physical activity (p = 0.019).</AbstractText>The presence of MDD is associated with an increased amount of EAT in ACHD, and is dependent on depression severity. Further, the amount of EAT is at least in part mediated by a more sedentary lifestyle. Given the long-term health risks associated with increased EAT, interventions aiming at increased physical activity, smoking cessation and early identification of comorbid MDD may be recommended in ACHD.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,757 | The performance of a new shock advisory algorithm to reduce interruptions during CPR. | To explore a new algorithm and strategy for rhythm analysis during chest compressions (CCs), and to improve the efficiency of cardiopulmonary resuscitation (CPR) by minimizing interruptions.</AbstractText>The clinical data and ECG of patients with sudden cardiac arrest (CA) from three hospitals in China were collected with Philips MRx monitor/defibrillators. The length of each analyzed ECG segment was 23 s, the first 11.5 s was selected to contain CPR compressions, the next 5 s had no compressions, and the last 6.5 s had no requirement. Three experienced emergency doctors annotated the ECG segments without compression artifacts. A two-step analysis through CPR (ATC) algorithm was applied to the selected data. The first step was analysis during chest compressions. If a shockable rhythm was not detected, compression-free analysis followed. The results of the ATC algorithm were compared with the annotations by the physicians, to determine the sensitivity and specificity of the algorithm.</AbstractText>In total 166 CA patients were included with 100 out-of-hospital cardiac arrest (OHCA) patients and 66 in-hospital cardiac arrest (IHCA) patients. A total of 1578 ECG segments were analyzed, including 115 (7.3%) shockable rhythms, 1278 (81.0%) non-shockable rhythms, and 185 (11.7%) intermediate/unknown rhythms. The specificity of all non-shockable rhythms was 99.8% at the end of chest compressions, and 99.5% after analysis without compression artifact. 70.5% of ventricular fibrillation (VF) rhythms were detected by the end of chest compressions. After the CC-free analysis, 93.6% of VF was identified.</AbstractText>The ATC algorithm achieved sensitivity of 93.6% and specificity of 99.5% after the two-step analysis, and 70.5% of the patients with shockable rhythms did not require CC-free analysis. Such an approach has the potential to substantially reduce CC interruptions when identifying shockable rhythms.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,758 | Effect of Successful Edge-to-Edge Mitral Valve Repair on Ventricular Arrhythmic Burden in Patients With Functional Mitral Regurgitation and Implantable Cardiac Devices. | Significant mitral regurgitation (MR) may be present in up to half of patients with heart failure (HF) and it is associated with adverse cardiac remodeling and myocardial stretch. These are potential triggers for ventricular arrhythmias (VA) in patients with HF, and therefore MR may enhance electrical ventricular vulnerability. Our aim was to evaluate VA burden before and after percutaneous mitral valve repair (PMVR) in patients with implantable cardiac devices. We conducted a prospective registry of all consecutive patients (n = 34, age 69.0 ± 12.2 years, 77% male) with significant functional mitral regurgitation (FMR) who underwent MitraClip implantation in 2 centers between June 2014 and July 2018. VA burden was defined as the total number of events during device follow-up before and after PMVR. Among patients presenting VA during follow-up before or after PMVR, device success at hospital discharge was related to a significant reduction in the incidence of Nonsustained ventricular tachycardia (VT, p = 0.002) and any sustained VT or rapid VT/ventricular fibrillation (p = 0.034). Regarding implantable cardiac defibrillator (ICD) therapies, successful PMVR was related to a reduction in incidence of either antitachycardia pacing or appropriate shocks (p = 0.045) and in the occurrence of any defibrillation shocks (p = 0.045). Overall, effective repair lead to a significant reduction in the VA burden, with a significant decrease in the occurrence of any VA (p = 0.004) and any ICD therapies (p = 0.045). In conclusion, device success after PMVR was related to a reduction in overall arrhythmic burden and ICD therapies in our cohort. |
17,759 | Angiotensin II and angiotensin 1-7: which is their role in atrial fibrillation? | Atrial fibrillation (AF) is a significant cause of morbidity and mortality as well as a public health burden considering the high costs of AF-related hospitalizations. Pre-clinical and clinical evidence showed a potential role of the renin angiotensin system (RAS) in the etiopathogenesis of AF. Among RAS mediators, angiotensin II (AII) and angiotensin 1-7 (A1-7) have been mostly investigated in AF. Specifically, the stimulation of the pathway mediated by AII or the inhibition of the pathway mediated by A1-7 may participate in inducing and sustaining AF. In this review, we summarize the evidence showing that both RAS pathways may balance the onset of AF through different biological mechanisms involving inflammation, epicardial adipose tissue (EAT) accumulation, and electrical cardiac remodeling. EAT is a predictor for AF as it may induce its onset through direct (infiltration of epicardial adipocytes into the underlying atrial myocardium) and indirect (release of inflammatory adipokines, the stimulation of oxidative stress, macrophage phenotype switching, and AF triggers) mechanisms. Classic RAS blockers such as angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) may prevent AF by affecting the accumulation of the EAT, representing a useful therapeutic strategy for preventing AF especially in patients with heart failure and known left ventricular dysfunction. Further studies are necessary to prove this benefit in patients with other cardiovascular diseases. Finally, the possibility of using the A1-7 or ACE2 analogues, to enlarge current therapeutic options for AF, may represent an important field of research. |
17,760 | Increased aortic stiffness in adults with chronic indeterminate Chagas disease. | An ever-increasing number of patients with chronic indeterminate Chagas disease are diagnosed with early vascular and cardiac abnormalities, as cardiovascular imaging becomes more sensitive. However, the currently available information on aortic stiffness (a prognostic marker for adverse cardiovascular outcomes) in these patients is scarce. In this study, we consecutively recruited 21 asymptomatic Bolivian adult patients with chronic indeterminate Chagas disease and 14 Bolivian adults, who were seronegative for Trypanosoma cruzi infection. No participants had a prior history of heart disease, hypertension, diabetes, chronic kidney disease or atrial fibrillation. Carotid-femoral pulse wave velocity (cf-PWV), carotid-radial PWV (cr-PWV), carotid intima-media thickness and conventional echocardiographic measurements were recorded in all participants. Patients with chronic indeterminate Chagas disease had significantly higher cf-PWV (7.9±1.3 vs. 6.4±1.1 m/s, p = 0.003) and greater HOMA-estimated insulin resistance than subjects without Chagas disease. The two groups did not significantly differ in terms of age, sex, smoking, adiposity measures, blood pressure, plasma lipids, fasting glucose levels as well as cr-PWV, carotid intima-media thickness measurements, left ventricular mass and function. Presence of chronic indeterminate Chagas disease was significantly associated with increasing cf-PWV values (β coefficient: 1.31, 95% coefficient interval 0.44 to 2.18, p = 0.005), even after adjustment for age, sex, heart rate, systolic blood pressure and insulin resistance. In conclusion, asymptomatic Bolivian adult patients with chronic indeterminate Chagas disease have an early and marked increase in aortic stiffness, as measured by cf-PWV, when compared to Bolivian adults who were seronegative for Trypanosoma cruzi infection. |
17,761 | Predictive value of CHA2DS2-VASc scores regarding the risk of stroke and all-cause mortality in patients with atrial fibrillation (CONSORT compliant). | Patients with atrial fibrillation (AF) have a higher risk of fatal complications (e.g., stroke). This investigation was performed as an observational retrospective cohort study includes 137 patients (age 61 ± 15; 34.3% women) with a primary diagnosis of AF (paroxysmal, persistent, and permanent).</AbstractText>We collected information about the drug therapy, comorbidities and survival of AF patients and determined their congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age, sex category (CHA2DS2-VASc) scores. Statistical analysis identified patients with high CHA2DS2-VASc scores and defined the predictive value of individual parameters, or their combination, with regards to the outcomes of stroke and mortality.</AbstractText>CHA2DS2-VASc scores identified 43.8% of the patients as low to intermediate risk (score 0-1) and 56.2% of the patients as high risk (score ≥2). Increasing CHA2DS2-VASc scores were not only accompanied by an increase in the incidence of stroke (Ptrend < .001) but also by an increase in the 3 to 5 years mortality (P = .005). Comparison of anticoagulation and anti-aggregation treatment between the 3 groups of AF did not show any significant statistical difference. Highly significant predictors of death were the CHA2DS2-VASc score (OR 1.71, 95% CI 1.10-2.67, P < .017) as well as other risk factors not included in the CHA2DS2-VASc score such as valvular heart disease (OR 5.04, 95% CI 1.10-23.10, P = .037), hyperlipidemia (OR 4.82, 95% CI 1.03-22.63, P = .046) and chronic renal failure (OR 14.21, 95% CI 2.41-83.91, P = .003). The type of AF type did not affect survival (P = .158) nor the incidence of stroke (P = .466). Patients with paroxysmal AF were linked to significantly lower frequencies of ischemic heart disease (P < .0001), vascular disease (P = .002), diabetes mellitus (P = .047), valvular heart disease (P = .03) and heart failure/left ventricular dysfunction (P = .015).</AbstractText>The CHA2DS2-VASc score correctly predicted the patients at high-risk for 3 to 5 years mortality and confirmed its significant predictive value in the patients with AF.</AbstractText> |
17,762 | [Torsade de pointe resulting from a drug interaction between sotalol and ciprofloxacin]. | Sotalol is a bêta-blocker and class 3 anti-arrhythmic. Ciprofloxacin is a fluoroquinolone antibiotic used against Gram - germs. Both drugs have a common adverse effect : they increase QT interval with a risk of torsade de pointe. The risk increases even more if other risk factors are present such as old age, female gender, renal failure, high blood pressure and ionic disturbances. Because a long QT interval is not associated with symptoms, only an electrocardiogram can establish the diagnosis. However, it's not rare that a torsade de pointe will reveal it. We report a clinical case of a long QT interval due to the association of sotalol and ciprofloxacin, which led to a torsade de pointe. Intravenous magnesium sulphate is the recommended treatment if haemodynamic parameters are good. If not, an external electric shock may be needed.</Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Devaux</LastName><ForeName>F</ForeName><Initials>F</Initials><AffiliationInfo><Affiliation>Faculté de Médecine, ULiège, Belgique..</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Fillet</LastName><ForeName>M</ForeName><Initials>M</Initials><AffiliationInfo><Affiliation>Service d'Urologie, CHU Liège, Belgique.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Krzesinski</LastName><ForeName>F</ForeName><Initials>F</Initials><AffiliationInfo><Affiliation>Service de Cardiologie, CHR Huy, Belgique.</Affiliation></AffiliationInfo></Author></AuthorList><Language>fre</Language><PublicationTypeList><PublicationType UI="D002363">Case Reports</PublicationType><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList><VernacularTitle>Torsade de pointe sur interaction médicamenteuse entre sotalol et ciprofloxacine.</VernacularTitle></Article><MedlineJournalInfo><Country>Belgium</Country><MedlineTA>Rev Med Liege</MedlineTA><NlmUniqueID>0404317</NlmUniqueID><ISSNLinking>0370-629X</ISSNLinking></MedlineJournalInfo><ChemicalList><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="D000889">Anti-Arrhythmia Agents</NameOfSubstance></Chemical><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="D000900">Anti-Bacterial Agents</NameOfSubstance></Chemical><Chemical><RegistryNumber>5E8K9I0O4U</RegistryNumber><NameOfSubstance UI="D002939">Ciprofloxacin</NameOfSubstance></Chemical><Chemical><RegistryNumber>A6D97U294I</RegistryNumber><NameOfSubstance UI="D013015">Sotalol</NameOfSubstance></Chemical></ChemicalList><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D000889" MajorTopicYN="N">Anti-Arrhythmia Agents</DescriptorName><QualifierName UI="Q000009" MajorTopicYN="N">adverse effects</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D000900" MajorTopicYN="N">Anti-Bacterial Agents</DescriptorName><QualifierName UI="Q000009" MajorTopicYN="N">adverse effects</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D002939" MajorTopicYN="Y">Ciprofloxacin</DescriptorName><QualifierName UI="Q000009" MajorTopicYN="N">adverse effects</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D004347" MajorTopicYN="Y">Drug Interactions</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D004562" MajorTopicYN="N">Electrocardiography</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005260" MajorTopicYN="N">Female</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D013015" MajorTopicYN="Y">Sotalol</DescriptorName><QualifierName UI="Q000009" MajorTopicYN="N">adverse effects</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D016171" MajorTopicYN="Y">Torsades de Pointes</DescriptorName><QualifierName UI="Q000139" MajorTopicYN="N">chemically induced</QualifierName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="fre">Le sotalol est un bêta-bloquant utilisé principalement comme anti-arythmique de classe 3. La ciprofloxacine est un antibiotique de la classe des fluoroquinolones, actif sur les germes Gram négatif. Ces deux médicaments présentent, comme effet secondaire commun, le fait d’augmenter l’espace QT avec un risque de torsade de pointe. Si on y ajoute les autres facteurs de risque d’un allongement de QT que sont notamment l’âge, le sexe féminin, l’insuffisance rénale, l’hypertension artérielle et les troubles ioniques, le risque de torsade de pointe est encore majoré. Comme un QT long ne s’accompagne pas de symptômes, seul l’électrocardiogramme permet d’établir le diagnostic. Il n’est néanmoins pas rare qu’une torsade de pointe le révèle. Nous rapportons ici un cas dont le QT long engendré par une association sotalol-ciprofloxacine s’est manifesté par une torsade de pointe chez une patiente âgée avec insuffisance rénale. Le traitement est le sulfate de magnésium par voie intraveineuse si les paramètres hémodynamiques restent bons. S’ils viennent à se dégrader, un choc électrique externe peut s’avérer nécessaire. |
17,763 | Advancements in the diagnostic workup, prognostic evaluation, and treatment of takotsubo syndrome. | Takotsubo syndrome (TTS) is an acute and mostly reversible cardiomyopathy that mimics an acute coronary syndrome with left ventricular (LV) systolic dysfunction without relevant obstructive coronary artery disease. Its prevalence is probably underestimated and reaches 1.2-2% in patients with acute coronary syndrome undergoing coronary catheterization. Although supraphysiological epinephrine levels have been associated with TTS, the detailed pathophysiology is incompletely understood. Chest pain is the most common clinical presentation; however, cardiac decompensation, cardiogenic shock, and sudden cardiac death due to ventricular fibrillation may also be the first clinical manifestations. Patients are mostly postmenopausal women, in whom the condition is commonly associated with emotional triggers; however, men have a higher prevalence of TTS being associated with physical triggers, which has a worse prognosis compared with TTS associated with emotional triggers. As a diagnosis of exclusion, TTS has no single definitive diagnostic test. According to the distribution of LV wall motion abnormalities, various morphological subtypes have been identified. The final diagnosis depends on cardiac imaging with left ventricular angiography during acute heart catheterization, as well as on echocardiography and cardiac magnetic resonance. Most patients recover completely, albeit several factors have been associated with worse prognosis. Management is based on observational data, while randomized multicenter studies are still lacking. This review provides a general overview of TTS and focuses on the hypothesized pathophysiology, and especially on current practices in diagnosis, prognosis, and treatment. |
17,764 | Development of a novel ablation hood to prevent systemic embolization of microbubbles and particulate emboli. | Atrial fibrillation ablation results in microbubbles and particulate emboli formation. We aimed to develop and test the early feasibility of a novel ablation hood to contain microbubbles and particulate emboli with the ultimate goal of preventing systemic embolization.</AbstractText>In seven canines, we developed, iterated, and tested a novel retractable hood that can cover the catheter-tissue ablation site. The number and volume (nL) of microbubbles formed during ablation with and without the hood was measured using an extracorporeal circulation loop. Wilcoxon's signed-rank test was used to compare the number of bubbles detected with and without the hood.</AbstractText>The hood reduced systemic embolization of microbubbles in 21/28 (75%) of ablations. Both atrial and ventricular ablations showed a statistically significant reduction in bubble number (476 ± 811 without hood vs 173 ± 226 with hood, p = 0.02; 2669 ± 1623 without hood vs 1417 ± 970 with hood, p = 0.04, respectively) and bubble volume (3.3 ± 7.6 nL without hood vs 0.2 ± 0.56 nL with hood, p = 0.006; 6.1 ± 5.2 nL without hood vs 1.9 ± 1.4 nL with hood, p = 0.05, respectively).</AbstractText>Use of a novel hood to cover the ablation catheter at the site of catheter-tissue contact has the potential to provide a means to reduce systematic embolization of microbubbles. Further work is required to examine particulate emboli, but these data show the early feasibility of this design concept.</AbstractText> |
17,765 | In-hospital left ventricular thrombus following ST-elevation myocardial infarction. | In-hospital left ventricular (LV) thrombus following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale and was the focus of this investigation.</AbstractText>We used the 2003 to 2013 Nationwide Inpatient Sample database to identify adults ≥18 years old with a principal diagnosis code of ST-elevation myocardial infarction. Patients were divided into two groups defined by the presence or absence of LV thrombus. Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple linear and logistic regression models were conducted to identify factors associated with LV thrombus.</AbstractText>Of 1,035,888 STEMI patients hospitalized in the U. S from 2003 to 2013, 1982 (0.2%) developed acute in-hospital LV thrombus. Compared to no LV thrombus, patients with LV thrombus were more likely to have in-hospital complications; acute ischemic and hemorrhagic stroke, acute renal failure, gastrointestinal bleed, cardiogenic shock, in-hospital cardiac arrest and mortality. They also had longer mean length of stay and higher hospital charges. Factors associated with LV thrombus included: anterior/anterolateral STEMI, acute or chronic heart failure with reduced ejection fraction, atrial fibrillation, LV aneurysm, Left heart valvular disease, acute or chronic deep venous thrombosis/pulmonary embolism and alcohol abuse. Patients with LV thrombus were less likely to be female [AOR 0.66, 95% CI (0.51-0.84)].</AbstractText>The identification of factors associated with early development of LV thrombus following STEMI, will help direct resources for specific high-risk group and prompt cost-effective therapies. Gender variability in LV thrombus development warrants further investigations.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,766 | Renin-Angiotensin System Inhibition Following Transcatheter Aortic Valve Replacement. | Several studies have demonstrated the benefits of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis, but the presence of persistent fibrosis and myocardial hypertrophy has been related to worse prognosis.</AbstractText>The aim of this study was to explore the potential benefits of renin-angiotensin system (RAS) inhibitors on left ventricular remodeling and major clinical outcomes following successful transcatheter aortic valve replacement (TAVR).</AbstractText>Patients from 10 institutions with severe aortic stenosis who underwent TAVR between August 2007 and August 2017 were included. All baseline data were prospectively recorded, and pre-specified follow-up was performed. Doses and types of RAS inhibitors at discharge were recorded, and matched comparison according to their prescription at discharge was performed.</AbstractText>A total of 2,785 patients were included. Patients treated with RAS inhibitors (n = 1,622) presented similar surgical risk scores but a higher rate of all cardiovascular risk factors, coronary disease, and myocardial infarction. After adjustment for these baseline differences, reduction of left ventricular volumes and hypertrophy was greater and cardiovascular mortality at 3-year follow-up was lower (odds ratio: 0.59; 95% confidence interval: 0.41 to 0.87; p = 0.007) in patients treated with RAS inhibitors. Moreover, RAS inhibitors demonstrated a global cardiovascular protective effect with significantly lower rates of new-onset atrial fibrillation, cerebrovascular events, and readmissions.</AbstractText>Post-TAVR RAS inhibitors are associated with lower cardiac mortality at 3-year follow-up and offer a global cardiovascular protective effect that might be partially explained by a positive left ventricular remodeling. An ongoing randomized trial will help confirm these hypothesis-generating findings. (Renin-Angiotensin System Blockade Benefits in Clinical Evolution and Ventricular Remodeling After Transcatheter Aortic Valve Implantation [RASTAVI]; NCT03201185).</AbstractText>Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,767 | Age-Related Characteristics and Outcomes of Patients With Heart Failure With Preserved Ejection Fraction. | Although heart failure with preserved ejection fraction (HFpEF) is considered a disease of the elderly, younger patients are not spared from this syndrome.</AbstractText>This study therefore investigated the associations among age, clinical characteristics, and outcomes in patients with HFpEF.</AbstractText>Using data on patients with left ventricular ejection fraction ≥45% from 3 large HFpEF trials (TOPCAT [Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function], I-PRESERVE [Irbesartan in Heart Failure With Preserved Systolic Function], and CHARM Preserved [Candesartan Cilexetil in Heart Failure Assessment of Reduction in Mortality and Morbidity]), patients were categorized according to age: ≤55 years (n = 522), 56 to 64 years (n = 1,679), 65 to 74 years (n = 3,405), 75 to 84 years (n = 2,464), and ≥85 years (n = 398). This study compared clinical and echocardiographic characteristics, as well as mortality and hospitalization rates, mode of death, and quality of life across age categories.</AbstractText>Younger patients (age ≤55 years) with HFpEF were more often obese, nonwhite men, whereas older patients with HFpEF were more often white women with a higher prevalence of atrial fibrillation, hypertension, and chronic kidney disease (eGFR <60 ml/min/1.73 m2</sup>). Despite fewer comorbidities, younger patients had worse quality of life compared with older patients (age ≥85 years). Compared with patients age ≤55 years, patients age ≥85 years had higher mortality (hazard ratio: 6.9; 95% confidence interval: 4.2 to 11.4). However, among patients who died, sudden death was, proportionally, the most common mode of death (p < 0.001) in patients age ≤55 years. In contrast, older patients (age ≥85 years) died more often from noncardiovascular causes (34% vs. 20% in patients age ≤55 years; p < 0.001).</AbstractText>Compared with the elderly, younger patients with HFpEF were less likely to be white, were more frequently obese men, and died more often of cardiovascular causes, particularly sudden death. In contrast, elderly patients with HFpEF had more comorbidities and died more often from noncardiovascular causes. (Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function [TOPCAT]; NCT00094302; Irbesartan in Heart Failure With Preserved Systolic Function [I-PRESERVE]; NCT00095238; Candesartan Cilexetil in Heart Failure Assessment of Reduction in Mortality and Morbidity [CHARM Preserved]; NCT00634712).</AbstractText>Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,768 | National survey on the management of heart failure in individuals over 80 years of age in French geriatric care units. | To evaluate the prevalence and management of heart failure (HF) in very old patients in geriatric settings.</AbstractText>Members of the French Society of Geriatrics and Gerontology throughout France were invited to participate in a point prevalence survey and to include all patients ≥80 years old, hospitalized in geriatric settings, with HF (stable or decompensated) on June 18, 2012. General characteristics, presence of comorbidities, blood tests and medications were recorded.</AbstractText>Among 7,197 patients in geriatric institution, prevalence of HF was 20.5% (n = 1,478): (27% in acute care, 24.2% in rehabilitation care and 18% in nursing home). Mean age was 88.2 (SD = 5.2) and Charlson co morbidity score was high (8.49 (SD = 2.21)). Left ventricular ejection fraction (LVEF) was available in 770 (52%) patients: 536 (69.6%) had a preserved LVEF (≥ 50%), 120 (15.6%) a reduced LVEF (< 40%), and 114 (14.8%) a midrange LVEF (40-49%). Prescription of recommended HF drugs was low: 42.6% (629) used Angiotensin Converting Enzyme Inhibitors (ACEI) or Angiotensin Receptor Blockers (ARBs), 48.0% (709) β-blockers, and 21.9% (324) ACEI or ARB with β-blockers, even in reduced LVEF. In multivariate analysis ACEI or ARBs were more often used in patients with myocardial infarction (1.36 (1.04-1.78)), stroke (1.42 (1.06-1.91)), and diabetes (1.54 (1.14-2.06)). β blockers were more likely used in patients with myocardial infarction (2.06 (1.54-2.76)) and atrial fibrillation (1.70 (1.28-2.28)).</AbstractText>In this large very old population, prevalence of HF was high. Recommended HF drugs were underused even in reduced LVEF. These results indicate that management of HF in geriatric settings can still be improved.</AbstractText> |
17,769 | Risk Stratification of Cardiovascular Events in Very Elderly Patients with Known or Suspected Coronary Artery Disease Who Had Normal Single-photon Emission Computed Tomographic Myocardial Perfusion Imaging Findings. | Objective We aimed to stratify the risk of major cardiovascular (MCV) events in Japanese patients with known or suspected coronary artery disease (CAD) who had normal single-photon emission computed tomographic myocardial perfusion imaging (SPECT MPI) findings and to compare the risk by generation. Methods This was a retrospective study. The composite endpoint was the occurrence of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke. Patients The study subjects were 2,035 patients with normal SPECT MPI findings at baseline who had been followed up to confirm their prognosis for 3 years. The patients were categorized into 3 age groups: very elderly (≥80 years old, n=311), elderly (65-79 years old, n=1,097), and younger (<65 years old, n=542). Results During the follow-up, 68 patients experienced MCV events: cardiovascular death (n=29), non-fatal myocardial infarction (n=15), and non-fatal stroke (n=24). The MCV event rate was significantly higher in very elderly patients than in other patients. Multivariate predictors were age categories, the estimated glomerular filtration rate, atrial fibrillation, and stress left ventricular ejection fraction. The MCV event rate was 6.1% in very elderly patients. However, the MCV event rate in those with normal cardiac and renal functions without atrial fibrillation was 3.3%, which was similar to that in elderly and younger patients. Conclusion The MCV event rate was high in very elderly patients despite their normal SPECT MPI findings at baseline. Therefore, very elderly patients with multivariate risks should be carefully followed to avoid a poor prognosis. |
17,770 | Diurnal, weekly and seasonal variations of chest pain in patients transported by emergency medical services. | Chest pain is among the leading causes for emergency medical services (EMS) activation. Acute myocardial infarction (MI) is not only one of the most critical aetiologies of chest pain, but also one of few conditions encountered by EMS that has been shown to follow a circadian pattern. Understanding the diurnal relationship between the inflow of chest pain patients and the likelihood of acute MI may inform prehospital and emergency department (ED) healthcare providers regarding the prediction, and hence prevention, of dire outcomes.</AbstractText>This was a secondary analysis of previously collected data from an observational prospective study that enrolled consecutive chest pain patients transported by a large metropolitan EMS system in the USA. We used the time of EMS call to determine the time-of-day of the indexed encounter. Two independent reviewers examined available medical data to determine our primary outcome, the presence of MI, and our secondary outcomes, infarct size and 30-day major adverse cardiac events (MACE). We estimated infarct size using peak troponin level.</AbstractText>We enrolled 2065 patients (age 56±17, 53% males, 7.5% with MI). Chest pain encounters increased from 9:00 AM to 2:00 PM, with a peak at 1:00 PM and a nadir at 6:00 AM. Acute MI had a bimodal distribution with two peaks: 10 AM in ST-elevation MI, and 10 PM in non-ST-elevation MI. ST-elevation MI with afternoon onset was an independent predictor of infarct size. Acute MI with winter and early spring presentation was an independent predictor of 30-day MACE.</AbstractText>EMS-attended chest pain calls follow a diurnal pattern, with the most vulnerable patients encountered during afternoons and winter/spring seasons. These data can inform prehospital and ED healthcare providers regarding the time of presentation where patients are more likely to have an underlying MI and subsequently worse outcomes.</AbstractText>© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.</CopyrightInformation> |
17,771 | Change in Functional Moderate Mitral Regurgitation after Aortic Valve Replacement. | To evaluate the changes of the mitral valve geometrics and the degrees of moderate mitral regurgitation (MR) in patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS).</AbstractText>A retrospective analysis study of intraoperative transesophageal echocardiography (TEE) and postoperative transthoracic echocardiography (TTE) was performed in 49 patients diagnosed with pure AS combined with moderate MR, who underwent AVR from January 2013 to December 2017. TEE was used to evaluate the direct geometric changes of the mechanical effects on mitral annulus after AVR. TTE was used to evaluate the changes of MR after operation. All patients underwent TTE during the midterm follow-up. The mean follow-up time was 40.21 months.</AbstractText>All of the 49 patients had moderate MR. Anterolateral-posteromedial diameter, anterior-posterior diameter, and mitral annular area were significantly reduced after AVR, while no significant changes were found in the intraoperative left ventricular loading conditions before and after AVR. The degree of mitral valve regurgitation, left ventricular size, left atrial size, left ventricular end-diastolic volume, and left ventricular to aortic pressure gradient were significantly reduced before discharge, and midterm follow-up showed good results.</AbstractText>This study supports the belief that aortic outflow tract obstruction and an actual mechanical compression of the anterior mitral annulus after AVR would cause reduction in MR. Ventricular remodeling would also cause reduction in MR with time going on. Patients with AS, especially young patients with moderate MR, were most likely to benefit from AVR in early time.</AbstractText> |
17,772 | Audiovisual telesupport system for cardiovascular catheter interventions: A preliminary report on the clinical implications. | This study aimed to validate the clinical implications of audiovisual telesupport system use.</AbstractText>An audiovisual telesupport system with supervisors has been effective in guiding procedures when surgeons have limited experience with the technique. However, cardiovascular catheter interventions using an audiovisual telesupport system has not been previously reported.</AbstractText>Starting in September 2017, two cardiologists in Kamisu Saiseikai Hospital (Kamisu, Japan, with limited cardiologists) began performing cardiovascular catheter interventions using an audiovisual telesupport system. This system enabled them to perform catheter interventions with the support of advisors in the University of Tsukuba (Tsukuba, Japan). We retrospectively assessed procedure time and complications of percutaneous coronary intervention (PCI) and catheter ablation (CA).</AbstractText>In the first 10 months, 21 patients with coronary artery disease underwent PCI using this system. The mean procedure duration of PCI was 42 ± 10 min. Nine patients with tachyarrhythmia including supraventricular tachycardia (SVT), ventricular premature contraction (VPC), common atrial flutter, and paroxysmal atrial fibrillation (AF) underwent CA using this system. The mean CA procedure time was 134 ± 31 min for SVT, 100 ± 14 min for VPC, and 200 min for AF. All PCI and CA procedures were successfully performed without any complications.</AbstractText>The audiovisual telesupport system enabled cardiologists with limited human resources to provide safe and high-quality catheter interventions.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,773 | Prevalence and Overlap of Potential Embolic Sources in Patients With Embolic Stroke of Undetermined Source. | Background We aimed to assess the prevalence and degree of overlap of potential embolic sources (PES) in patients with embolic stroke of undetermined source (ESUS). Methods and Results In a pooled data set derived from 3 prospective stroke registries, patients were categorized in ≥1 groups according to the PES that was/were identified. We categorized PES as follows: atrial cardiopathy, atrial fibrillation diagnosed during follow-up, arterial disease, left ventricular disease, cardiac valvular disease, patent foramen ovale, and cancer. In 800 patients with ESUS (43.1% women; median age, 67.0 years), 3 most prevalent PES were left ventricular disease, arterial disease, and atrial cardiopathy, which were present in 54.4%, 48.5%, and 45.0% of patients, respectively. Most patients (65.5%) had >1 PES, whereas only 29.7% and 4.8% of patients had a single or no PES, respectively. In 31.1% of patients, there were ≥3 PES present. On average, each patient had 2 PES (median, 2). During a median follow-up of 3.7 years, stroke recurrence occurred in 101 (12.6%) of patients (23.3 recurrences per 100 patient-years). In multivariate analysis, the risk of stroke recurrence was higher in the atrial fibrillation group compared with other PES, but not statistically different between patients with 0 to 1, 2, or ≥3 PES. Conclusions There is major overlap of PES in patients with ESUS. This may possibly explain the negative results of the recent large randomized controlled trials of secondary prevention in patients with ESUS and offer a rationale for a randomized controlled trial of combination of anticoagulation and aspirin for the prevention of stroke recurrence in patients with ESUS. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02766205. |
17,774 | Curative effect of β-blocker on various ejection fractions of patients with atrial fibrillation. | The aim of this study was to retrospectively determine the effects of metoprolol on patients presenting with persistent atrial fibrillation (AF), but either with or without a reduced ejection fraction (EF). All patients meeting the inclusion criteria were treated for 2 years with metoprolol. Blood pressure, heart rate and echocardiography parameters were measured and analysed in patients before and after treatment. The patients were divided into 2 cohorts as follows: Those presenting with a low EF (<50%) and those with normal EF values (≥50%). In total, 151 patients enrolled were 136; however, of these 15 were lost to mortality during the follow-up period, thus leaving a total of 136 patients. In total, 42 patients presented EF values <50%, while the remaining 94 presented with normal EF values. Treatment with metoprolol controlled blood pressure (both diastolic and systolic) and heart rate in patients with both low and normal EF values. EF values in the low EF group significantly increased following treatment. In addition, the echocardiography data revealed a statistically significant decrease in left atrial and ventricular diameters in the low EF group. On the whole, the findings of this study demonstrate that patients with AF and low EF values who were treated with metoprolol presented with improved cardiac function parameters. However, metoprolol should be contraindicated for patients with high EF values (i.e., absence of heart failure) as it seemed to increase their risk of heart failure based on the N-terminal pro b-type natriuretic peptide (NT-pro BNP) results. |
17,775 | Does mitral regurgitation reduce the risks of thrombosis in atrial fibrillation and flutter? | Blood stasis is the main cause of left atrial thrombosis (LAT) in atrial tachyarrhythmias. The high-velocity flow inside the left atrium, due to mitral valve regurgitation, may prevent clot formation but the topic has never been investigated in large-scale studies. The aim of our study was to evaluate whether the presence and degree of mitral regurgitation have a protective role against LAT risk.</AbstractText>A total of 1302 consecutive adult patients with paroxysmal or persistent atrial fibrillation or flutter undergoing cardioversion, submitted to transesophageal echocardiography, were retrospectively enrolled in the study. The study population was divided into three groups according to the mitral regurgitation degree: absent, mild-to-moderate and severe.</AbstractText>Among 1302 patients enrolled in the study, patients without mitral regurgitation were 248 (19%), those with mild-to-moderate 970 (75%), whereas 84 had severe mitral regurgitation (6%). LAT incidence was significantly lower in patients with severe mitral regurgitation compared with those with mild-to-moderate (mitral regurgitation) (2.4 vs. 8.9%, P < 0.05), and similar to subjects without mitral regurgitation (2.4%).</AbstractText>Despite patients with severe regurgitation having clinical and echo characteristics predisposing to LAT (higher age, heart failure, higher atrial size, lower ventricular function) thrombosis prevalence was significantly lower than for those with mild-to-moderate mitral regurgitation. The percentage of LAT in severe mitral regurgitation cases was very low and similar to that of cases without regurgitation which were characterized by lower age, normal left ventricular function or other risk factors, reinforcing the hypothesis of a protecting role against atrial thrombosis of mitral regurgitation.</AbstractText> |
17,776 | Is Negative-Pressure Wound Therapy a "Bridge to Reconstruction" for Poststernotomy Mediastinitis? A Systematic Review. | To assess the efficacy of negative-pressure wound therapy (NPWT) in preparing sternal wounds for flap reconstruction.</AbstractText>Investigators searched standard research databases with terms including "post-sternotomy mediastinitis," "deep sternal wound infection," "negative pressure wound therapy," "vacuum assisted closure," and "VAC." Of 434 reports, 14 studies described patients diagnosed with poststernotomy mediastinitis who underwent NPWT followed by flap reconstruction. Eligible studies were assessed for length of stay, mortality, manufacturer involvement, and methodological rigor.</AbstractText>Among a total 429 patients, median length of stay was 29 (±16) days. There were 41 deaths in this inpatient group (10%). Seventy-one percent of the reports were nonrandomized, and 36% of the studies accurately accounted for baseline differences in severity, whereas 14% failed to report diagnostic criteria. Only one study reported follow-up results. Nine studies (64%) failed to make a statement regarding conflicts of interest. In this analysis of quality, 48% (n = 8) of the studies were of very low to low quality. One study was of high quality.</AbstractText>Investigators failed to find ample support for routine use of NPWT as a "bridge to reconstruction." Serious complications related to the use of NPWT including right ventricular rupture, atrial fibrillation, respiratory arrest, recurrent infection, and a retained sponge were reported in this group of studies. Rigorous evaluative studies that assess the true effectiveness of NPWT as a "bridge to reconstruction" must precede its adoption.</AbstractText> |
17,777 | The del Nido versus cold blood cardioplegia in aortic valve replacement: A randomized trial. | To compare the cardioprotective efficacy of a solution that requires only a single infusion at the start of the ischemic duration versus a solution that requires multiple infusions.</AbstractText>Aortic valve replacement was performed for 150 patients, who were randomized into the del Nido (DN) cardioplegia group or the cold blood (CB) cardioplegia group. The DN cardioplegia was delivered every 90 minutes and the CB cardioplegia was delivered every 20 to 30 minutes, or whenever cardiac activity was observed. The primary endpoints were electrical cardiac activity during crossclamp, ventricular fibrillation during reperfusion, and postoperative troponin and creatine kinase (CK-MB isoenzyme) at 24 and 48 hours.</AbstractText>Electrical activity during crossclamp occurred in 29 (39.7%) patients in the DN group versus 34 (45.3%) patients in the CB group (adjusted P = 1.0). The number of procedures with ventricular fibrillation after removing the crossclamp was 41 (54.7%) in the CB group versus 17 (22.7%) in the DN group (adjusted P = .001; relative risk, 2.41). Troponin values appeared to be lower in the DN group (median, 223.10; interquartile range, 168.35-364.77 pg/mL vs 285.5; 196.20-419.45 pg/mL at 24 hours and 159.60; 125.42-217.20 pg/mL vs 201.60; 160.62-268.45 pg/mL at 48 hours) and CK-MB (median, 14.94; interquartile range, 12.16-20.39 ng/mL vs 17.43; 13.66-22.43 ng/mL at 24 hours and 6.19; 4.41-7.63 ng/mL vs 7.38; 4.74-10.20 ng/mL at 48 hours), but no significance was found.</AbstractText>The del Nido cardioplegia protocol is an acceptable alternative for cold blood cardioplegia in patients undergoing aortic valve replacement.</AbstractText>Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,778 | Change in left atrial function predicts incident atrial fibrillation: the Multi-Ethnic Study of Atherosclerosis. | Longitudinal change in left atrial (LA) structure and function could be helpful in predicting risk for incident atrial fibrillation (AF). We used cardiac magnetic resonance (CMR) imaging to explore the relationship between change in LA structure and function and incident AF in a multi-ethnic population free of clinical cardiovascular disease at baseline.</AbstractText>In the Multi-Ethnic Study of Atherosclerosis (MESA), 2338 participants, free at baseline of clinically recognized AF and cardiovascular disease, had LA volume and function assessed with CMR imaging, at baseline (2000-02), and at Exam 4 (2005-07) or 5 (2010-12). Free of AF, 124 participants developed AF over 3.8 ± 0.9 years (2015) following the second imaging. In adjusted Cox regression models, an average annualized change in all LA parameters were significantly associated with an increased risk of AF. An annual decrease of 1-SD unit in total LA emptying fractions (LAEF) was most strongly associated with risk of AF after adjusting for clinical risk factors for AF, baseline LA parameters, and left ventricular mass-to-volume ratio (hazard ratio per SD = 1.91, 95% confidence interval = 1.53-2.38, P < 0.001). The addition of change in total LAEF to an AF risk score improved model discrimination and reclassification (net reclassification improvement = 0.107, P = 0.017; integrative discrimination index = 0.049, P < 0.001).</AbstractText>In this multi-ethnic study population free of clinical cardiovascular disease at baseline, a greater increase in LA volumes and decrease in LA function were associated with incident AF. The addition of change in total LAEF to risk prediction models for AF improved model discrimination and reclassification of AF risk.</AbstractText>© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.</CopyrightInformation> |
17,779 | A Rare Case of Spontaneous Isolated Dissection of the Superior Mesenteric Artery. | Isolated spontaneous dissection of the superior mesenteric artery (SMA) is a rare entity that is increasingly becoming recognized due to an improvement in imaging techniques. The pathogenesis of a spontaneous SMA dissection has yet to be fully elucidated. Here, we present the case of isolated SMA dissection in a 65-year-old female who was seen in the emergency room with acute substernal chest and left upper quadrant abdominal pain. She was managed for atrial fibrillation with a rapid ventricular response. She underwent computed tomography (CT) angiogram of the chest, abdomen, and pelvis, which revealed focal dissection involving SMA measuring 2.7 cm in width. Vascular surgery recommended conservative management with low-dose daily aspirin and the optimization of blood pressure control. She subsequently was seen as an outpatient with complete resolution of abdominal pain. Given the low incidence rate, vascular surgery evaluation may be required to determine the best course of management. Treatment needs to be individualized for each patient. Since abdominal pain is a common complaint for which patients are seen in each clinical setting, it is important to highlight this case to create awareness regarding the possibility of isolated SMA dissection as one of the underlying etiologies. |
17,780 | Atrial fibrillation and risk of major arrhythmic events in Brugada syndrome: A meta-analysis. | Brugada syndrome (BrS) is a common cause of sudden cardiac death (SCD). There is recent evidence that atrial fibrillation (AF) is associated with increased risk of SCD in general population. However, whether AF increases a risk of major arrhythmic events (MAE) in patients with BrS is still unclear. We performed a systematic review and meta-analysis to explore the effect of AF on MAE in BrS population.</AbstractText>We searched the databases of MEDLINE and EMBASE from inception to March 2019. Included studies were published cohort studies reporting rates of MAE (ventricular fibrillation, sustained ventricular tachycardia, SCD, or sudden cardiac arrest) in BrS patients, with and without previous documented AF. Data from each study were combined using the random-effects model.</AbstractText>Six studies from 1,703 patients were included. There was a significant association between AF and an increased risk of MAE in patients with BrS (pooled OR = 2.37, 95% CI = 1.36-4.13, p-value = .002, I2</sup>  = 40.3%).</AbstractText>Our meta-analysis demonstrated that AF is associated with an increased risk of MAE in patients with BrS.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,781 | Determinants of postoperative left atrial structural reverse remodeling in patients undergoing combined catheter ablation of atrial fibrillation and left atrial appendage closure procedure. | Catheter ablation of atrial fibrillation (AFCA) and left atrial appendage closure (LAAC) exert opposite effects on left atrial (LA) size. We aim to observe the net impact of combined AFCA and LAAC strategy on LA size and explore those factors which might affect the postprocedure LA structural remodeling.</AbstractText>A total of 53 patients, who underwent combined AFCA and Watchman LAAC in our center from March to December 2017, were enrolled. Atrial fibrillation (AF) recurrence was monitored after the procedure. Left atrial volume (LAV) and left atrial appendage volume (LAAV) were measured by Mimics based on dual-source computed tomography images.</AbstractText>At 6 months, sinus rhythm (SR) was maintained in 79.2% patients. LAV was significantly reduced (130.2 ± 36.3 mL to 107.1 ± 30.0 ml; P < .001) in SR maintenance group, but not in AF recurrence group (138.8 ± 39.3 mL to 137.9 ± 36.9 mL; P = .671). In SR group, preoperative LAAV/LAV ratio (B = -0.894; P = .015), NT-proBNP (B = 0.005; P = .019) and left ventricular ejection fraction (LVEF) (B = -0.778; P < .001) could interactively affect the extent of postoperative LA structural reverse remodeling, among which LAAV/LAV ratio could independently predict the significance of reverse remodeling (≥15% reduction in LAV) (OR, 0.56; 95% CI, 0.34-0.90; P = .018). A preoperative LAAV/LAV ratio less than 7.1% is indicative of significant LA structural reverse remodeling in this patient cohort.</AbstractText>LA structural reverse remodeling could be evidenced in patients with maintained SR following combined AFCA and LAAC. Smaller LAAV/LAV ratio, higher NT-proBNP or lower LVEF at baseline are associated with more significant LA structural reverse remodeling, while LAAV/LAV ratio can predict the significance of the process after one-stop treatment.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,782 | Cardiac arrhythmias in the emergency settings of acute coronary syndrome and revascularization: an European Heart Rhythm Association (EHRA) consensus document, endorsed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Acute Cardiovascular Care Association (ACCA). | Despite major therapeutic advances over the last decades, complex supraventricular and ventricular arrhythmias (VAs), particularly in the emergency setting or during revascularization for acute myocardial infarction (AMI), remain an important clinical problem. Although the incidence of VAs has declined in the hospital phase of acute coronary syndromes (ACS), mainly due to prompt revascularization and optimal medical therapy, still up to 6% patients with ACS develop ventricular tachycardia and/or ventricular fibrillation within the first hours of ACS symptoms. Despite sustained VAs being perceived predictors of worse in-hospital outcomes, specific associations between the type of VAs, arrhythmia timing, applied treatment strategies and long-term prognosis in AMI are vague. Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia that may be asymptomatic and/or may be associated with rapid haemodynamic deterioration requiring immediate treatment. It is estimated that over 20% AMI patients may have a history of AF, whereas the new-onset arrhythmia may occur in 5% patients with ST elevation myocardial infarction. Importantly, patients who were treated with primary percutaneous coronary intervention for AMI and developed AF have higher rates of adverse events and mortality compared with subjects free of arrhythmia. The scope of this position document is to cover the clinical implications and pharmacological/non-pharmacological management of arrhythmias in emergency presentations and during revascularization. Current evidence for clinical relevance of specific types of VAs complicating AMI in relation to arrhythmia timing has been discussed. |
17,783 | Atrial Arrhythmias and Atrial Involvement in Cardiac Sarcoidosis. | Severe ventricular arrhythmias such as high-grade atrioventricular block and ventricular tachycardia may cause lethal conditions or sudden death in patients with cardiac sarcoidosis (CS). Physicians should examine patients carefully for these conditions and treat them appropriately. As arrhythmias are being better diagnosed and treated, physicians are increasingly aware of atrial arrhythmias, which have not been focused upon as CS-related conditions, in patients with CS. This article reports a case of atrial flutter in sarcoidosis, and discusses literature findings on atrial arrhythmias and atrial involvement of CS. It is highly likely that atrial arrhythmia and supraventricular conduction disorder associated with or caused by CS are more common than previously thought. Physicians should pay careful attention for these conditions in the diagnosis and treatment of CS. |
17,784 | Neurological outcome and modifiable events after out-of-hospital cardiac arrest in patients managed in a tertiary cardiac centre: A ten years register. | A study was made of the events occurring in the early post-resuscitation phase that may help to improve the outcomes at hospital discharge.</AbstractText>A retrospective cohort study (2007-2017) of a prospective Utstein type registry database was carried using multivariate logistic regression analysis. Pre- and post-hospital admission events were investigated.</AbstractText>A tertiary cardiac centre.</AbstractText>Unconscious victims of out-of-hospital cardiac arrest (OHCA) with documented ventricular tachycardia or fibrillation.</AbstractText>Events occurring before and within 72h after intensive care unit (ICU) admission were recorded. The variables were analyzed to determine their impact on hospital survival and poor neurological outcome. One-year follow-up survival was also considered. Results are presented as odds ratio (OR) and 95% confidence interval (95%CI).</AbstractText>Of 245 patients admitted to our ICU after OHCA, 152 (62%) were alive and 131 (86.2%) presented good neurological outcomes (cerebral performance categories≤2) at hospital discharge. The one-year follow-up survival rate was 95.9%. Age >70 years (OR 2.0; 95%CI 1.1-4.1), previous myocardial infarction (OR 2.7; 95%CI 1.2-6.1), shock upon hospital admission (OR 2.9; 95%CI 1.3-6.2), time from call to return of spontaneous circulation (ROSC) >25min (OR 3.1; 95%CI 1.6-6.0) and anticonvulsant therapy (OR 18.2; 95%CI 5.5-60) were independent predictors of poor neurological outcome. Immediate admission to the cardiac centre (OR 0.5; 95%CI 0.3-0.9) and lactate clearance reaching plasma levels <2.5mmol/l at 12h (OR 0.4; 95%CI 0.2-0.8) were associated with better outcomes.</AbstractText>Unconscious OHCA patients with documented ventricular tachycardia or fibrillation may benefit from direct admission to a reference cardiac centre. Initial haemodynamic support, urgent coronary angiography and targeted management in the cardiac ICU seem to increase the likelihood of good neurological outcomes.</AbstractText>Copyright © 2019 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.</CopyrightInformation> |
17,785 | Common Postcardiothoracic Surgery Arrhythmias. | Cardiac arrhythmias are common after cardiac surgery and have profound sequelae. Bradycardias are typically transient and have reversible causes; however, persistent atrioventricular block is an indicator for permanent pacemaker implantation after valvular surgery. Transcatheter aortic valve surgery is associated with even higher rates of permanent pacemaker implantation. Atrial fibrillation, the most common postoperative arrhythmia, is associated with ischemic stroke, myocardial infarction, congestive heart failure, and short-term mortality. Ventricular arrhythmias have extremely high in-hospital mortality, as well as long-term mortality for those who survive the initial event. Implantable cardioverter-defibrillators have been shown to reduce long-term mortality for these patients. |
17,786 | Public location and survival from out-of-hospital cardiac arrest in the public-access defibrillation era in Japan. | The use of public-access automated external defibrillators (AEDs) has become common in Japan. To provide a strategy for appropriate public-access AED deployment, we assessed public-access defibrillation (PAD) by laypersons and the outcomes following out-of-hospital cardiac arrest (OHCA) among adult patients by location of arrest.</AbstractText>From a nationwide, prospective, population-based registry of patients after OHCA in Japan, we enrolled adult patients with bystander-witnessed OHCA of medical origin in public locations between 2013 and 2015. The primary outcome measure was one-month favorable neurological outcome defined by cerebral performance category 1 or 2. Factors associated with favorable neurological outcome after ventricular fibrillation (VF) were assessed by multivariable logistic regression analysis.</AbstractText>A total of 20,970 adult bystander-witnessed OHCAs of medical origin occurred in public locations. Of those, the proportions of PAD by location were: 13.1% (757/5761) in public areas, 15.9% (333/2089) at workplaces, 26.0% (544/2095) in recreation/sports areas, 36.1% (112/310) in educational institutions, and 5.8% (241/4151) on streets/highways. In a multivariable analysis of VF arrests, both bystander cardiopulmonary resuscitation [adjusted odds ratio (AOR), 1.78; 95% confidence interval (CI), 1.54-2.07] and PAD (AOR, 2.33; 95% CI, 2.05-2.66), and emergency medical service (EMS) response time (AOR, 0.89; 95% CI, 0.87-0.90) were associated with improved outcomes. Earlier PAD initiated by bystanders before EMS arrival was also associated with better outcomes after OHCA.</AbstractText>In Japan, where public-access AEDs are well-disseminated, the PAD program worked effectively for adult OHCA of medical origin occurring in public locations. Notably, the proportions of PAD differed substantially according to specific public locations.</AbstractText>Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.</CopyrightInformation> |
17,787 | Effectiveness of the Dual Dispatch to Cardiac Arrest Policy in Houston, Texas. | Houston policy is to dual dispatch medically trained firefighters, in addition to emergency medical services (EMS) units to out-of-hospital cardiac arrest (OHCA) cases. While believed to improve public health outcomes, no research exists supporting the policy that when firefighters respond before a better-equipped EMS unit, they increase the probability of survival.</AbstractText>To inform EMS policy decisions regarding the effectiveness of dual dispatch by determining the impact of medically trained firefighter dispatch on return of spontaneous circulation (ROSC), a measure of survivability, in OHCA 911 calls while controlling for the subsequent arrival of an EMS unit.</AbstractText>This retrospective study uses logistic regression to determine the association between ROSC and response time for fire apparatus first responders controlling for arrival of the EMS unit.</AbstractText>Out-of-hospital cardiac arrest cases in Houston between May 2008 and April 2013 when dual dispatch was used.</AbstractText>A total of 6961 OHCA cases with the complete data needed for the analysis.</AbstractText>Logistic regression of the dependence of OHCA survival using the indicator ROSC, as related to the fire first responder response times controlling for subsequent arrival of the EMS.</AbstractText>Fire apparatus arrived first in 46.7% of cases, a median value of 1.5 minutes before an EMS unit. Controlling for subsequent arrival time of EMS has no effect on ROSC achieved by the fire first responder. If the firefighters had not responded, the resulting 1.5-minute increase in response time equates to a decrease in probability of attaining ROSC of 20.1% for cases regardless of presenting heart rhythm and a 47.7% decrease for ventricular fibrillation cases in which bystander cardiopulmonary resuscitation was initiated.</AbstractText>The firefighter first responder not only improved response time but also greatly increased survivability independent of the arrival time of the better-equipped EMS unit, validating the public health benefit of the dual dispatch policy in Houston.</AbstractText> |
17,788 | Monophasic action potential amplitude for substrate mapping. | Although radiofrequency ablation has revolutionized the management of tachyarrhythmias, the rate of arrhythmia recurrence is a large drawback. Successful substrate identification is paramount to abolishing arrhythmia, and bipolar voltage electrogram's narrow field of view can be further reduced for increased sensitivity. In this report, we perform cardiac mapping with monophasic action potential (MAP) amplitude. We hypothesize that MAP amplitude (MAPA) will provide more accurate infarct sizes than other mapping modalities via increased sensitivity to distinguish healthy myocardium from scar tissue. Using the left coronary artery ligation Sprague-Dawley rat model of ischemic heart failure, we investigate the accuracy of in vivo ventricular epicardial maps derived from MAPA, MAP duration to 90% repolarization (MAPD<sub>90</sub>), unipolar voltage amplitude (UVA), and bipolar voltage amplitude (BVA) compared with gold standard histopathological measurement of infarct size. Numerical analysis reveals discrimination of healthy myocardium versus scar tissue using MAPD<sub>90</sub> (<i>P</i> = 0.0158) and UVA (<i>P</i> < 0.001, <i>n</i> = 21). MAPA and BVA decreased between healthy and border tissue (<i>P</i> = 0.0218 and 0.0015, respectively) and border and scar tissue (<i>P</i> = 0.0037 and 0.0094, respectively). Contrary to our hypothesis, BVA mapping performed most accurately regarding quantifying infarct size. MAPA mapping may have high spatial resolution for myocardial tissue characterization but was quantitatively less accurate than other mapping methods at determining infarct size. BVA mapping's superior utility has been reinforced, supporting its use in translational research and clinical electrophysiology laboratories. MAPA may hold potential value for precisely distinguishing healthy myocardium, border zone, and scar tissue in diseases of disseminated fibrosis such as atrial fibrillation.<b>NEW & NOTEWORTHY</b> Monophasic action potential mapping in a clinically relevant model of heart failure with potential implications for atrial fibrillation management. |
17,789 | A Systematic Review and Meta-Analysis of del Nido Versus Conventional Cardioplegia in Adult Cardiac Surgery. | Del Nido cardioplegia (DC) has been used extensively in pediatric cardiac surgery but the efficacy and safety in adults remains uncertain. Our objective was to perform a systematic review and meta-analysis comparing DC and blood cardioplegia (BC) in our primary endpoint of 30-day or in-hospital mortality as well as other efficacy and safety endpoints.</AbstractText>Both MEDLINE and EMBASE were searched from 1996 to 2017 for studies comparing DC and BC. Data were extracted by 2 independent investigators and aggregated in a random effects model.</AbstractText>One randomized controlled trial (n</i> = 89), 7 adjusted (n</i> = 1,104), and 5 unadjusted observational studies (n</i> = 717) were included. There was no difference in in-hospital mortality between DC and BC (relative risk:0.67, 95% confidence interval [CI]: 0.22, 2.07; P</i> = 0.49). DC reduced cardioplegia volume requirements (mean difference [MD]:-1.1 L, 95% CI, -1.6, -0.6; P</i> < 0.0001), aortic cross-clamp time (MD: -8 minutes, 95% CI, -12, -3; P</i> = 0.0004), and cardiopulmonary bypass (CPB) times (MD: -8 minutes, 95% CI, -14, -3; P</i> = 0.03). DC reduced troponin release (standardized MD: -0.3, 95% CI, -0.5, -0.1; P</i> = 0.001). In-hospital outcomes of stroke, atrial fibrillation, acute kidney injury/dialysis, low cardiac output state, blood transfusion, reoperation rate, postoperative left ventricular EF, intensive care unit length of stay (LOS), and in-hospital LOS were comparable between groups.</AbstractText>DC is a safe alternative to BC in routine adult cardiac surgery. Its use is associated with reduction in CPB and aortic cross-clamp times and may potentially offer improved myocardial protection.</AbstractText> |
17,790 | Exercise and atrial fibrillation: how health turns harm, and how to turn it back. | Exercise is, together with diet, a powerful health-promoting habit. However, an association of intense physical activity with the onset of atrial and ventricular arrhythmias, and sudden death has been described. Although initially questioned, the atrial pro-arrhythmic role of endurance physical activity is now well accepted in the scientific community. Atrial fibrillation is common among endurance athletes, being a source of morbidity in otherwise healthy young and middle-aged individuals. The mechanisms for its development are still poorly understood, but likely involve some components of the athlete's heart (e.g., bradycardia, atrial enlargement) and some clearly pathological factors (e.g., atrial fibrosis). Its management must be a careful balance between exercise moderation and cessation, as extremes in exercise practice have both been related to atrial fibrillation. In this article, we review the current knowledge on exercise-induced atrial fibrillation through different perspectives, each focusing on the epidemiological evidence, the associated risk, the identification of individuals at risk, the potential approach to reduce its impact and how should these athletes be informed. |
17,791 | Heart Failure Duration Combined with Left Atrial Dimension Predicts Super-Response and Long-Term Prognosis in Patients with Cardiac Resynchronization Therapy Implantation. | Response to cardiac resynchronization therapy (CRT) varies significantly among patients. This study aimed to identify baseline characteristics that could predict super-response to CRT and to evaluate the long-term prognosis in super-responders.</AbstractText>We retrospectively reviewed the data of 73 consecutive patients who received CRT. Patients were considered as super-responders after 6-month follow-up when NYHA class reduction to I or II combined with left ventricular ejection fraction (LVEF) ≥ 50% was observed. Patients were divided into super-responders group and non-super-responders group. All-cause mortality or hospitalization for heart failure (HF) was referred to the combined end point.</AbstractText>17 (23.3%) patients were super-responders. HF duration, left atrial dimension (LAD), and left bundle branch block (LBBB) were independent predictors of super-response to CRT. The combination of HF duration and LAD could provide more robust prediction of super-response than standalone HF duration (0.899 versus 0.789, Z = 2.207, P = 0.027) or standalone LAD (0.899 versus 0.775, Z = 2.487, P = 0.013). super-responders had excellent LV reverse remodeling. The cumulative incidences of combined end point were significantly lower in the super-responders group, LAD ≤ 42mm group, and combination of HF duration ≤ 48 months and LAD ≤ 42mm group. LBBB remained associated with a lowered risk of the combined end point (HR: 0.19, 95% CI: 0.07-0.57, P = 0.003), whereas LAD was associated with a raised risk of the combined end point (HR: 1.09, 95% CI: 1.02-1.17, P = 0.014).</AbstractText>HF duration, LAD, and LBBB independently predicted super-response. The combination of HF duration and LAD makes more robust prediction of CRT super-response. Super-responders had excellent LV reverse remodeling and decreased the incidences of the combined end point. LBBB and LAD were independently associated with the combined end point.</AbstractText> |
17,792 | [Quality of life in patients with heart failure with preserved ejection fraction and the bendopnea symptom]. | The study of quality of life (QOL) in patients with CHF with preserved LVEF (left ventricular ejection fraction) and a symptom of bendopnea with different levels of salt intake. Materials and methods. The study included 66 patients. The main symptoms of CHF were edema in 54.5% of cases, dyspnea in 77% of cases, ascites was detected in only 2 patients, an enlarged liver in 7 patients. Abdominal obesity was detected in 53 patients. Quality of life was assessed by the SF‑36 questionnaire, the level of salt intake was assessed by the Charlton: SaltScreener questionnaire. Results. On average, the time of occurrence of the bendopnea was 22.5±9.3 seconds, the minimum was 5 seconds. The absence of the effect of abdominal obesity on the risk of bendopnea (relative risk 1.18 [0.76; 1.83]) was revealed. According to the SF‑36 questionnaire, a decrease in physical health indicators (median 31.3 points [20.7; 42.3]) and psychological health (average score 43.2±21.7) was found. In patients with bendopnea, QOL was reduced due to both physical and mental health, unlike patients without bendopnea: physical functioning (Physical Functioning - PF) 24.8±16.1 against 47±28.9 points, p=0.001 ; role‑based functioning due to physical condition (Role‑Physical Functioning - RP), 0 [0; 25] vs. 37.5 [0; 100] points, p=0.008; general health (General Health - GH) 29.9±15.8 against 50±14.2 points, p=0.0005, social functioning (Social Functioning - SF) 56 ± 38 against 78.9 ± 17.8 points ; p = 0.004. Multidimensional regression analysis revealed the relationship between the time of occurrence of the symptom bendopnea and the level of salt intake, physical and psychological activity (r2=0.25; p&lt;0.009). The time of onset of the symptom of bendopnea in patients with CHF decompensation was significantly longer (18.9±8.7 vs. 26.2±8.5 seconds, p=0.003). The presence of diseases such as hypertension, COPD, IHD, atrial fibrillation, cerebrovascular disease did not significantly affect QOL (p&gt; 0.05), while the presence of bronchial asthma or chronic kidney disease significantly reduced QOL of patients (p&lt;0.05). Conclusion. The presence of the symptom bendopnea significantly reduces the quality of life of patients with CHF with preserved LVEF (left ventricular ejection fraction). |
17,793 | [Cardiac arrhythmias in patients with chronic kidney disease]. | Patients with chronic kidney disease are at increased risk for cardiovascular morbidity and mortality, with the increased prevalence of supraventricular and ventricular arrhythmia being an important factor. The underlying pathomechanisms are diverse and mainly cause increasing atrial and ventricular fibrosis with so-called cardiac remodeling. In particular, patients with advanced kidney disease were excluded from many pioneering clinical trials, so there are no clear guidelines in the treatment of cardiac arrhythmia for these patients. The potential benefits of implantable cardioverter defibrillator (ICD) therapy for the prevention of sudden cardiac death or the benefits of anticoagulation for prevention of thromboembolic events in atrial fibrillation should therefore be evaluated individually for each patient with advanced kidney disease, taking comorbidities and the prognosis into account. When using antiarrhythmic drugs, a dose adjustment may be necessary depending on the pharmacokinetics and metabolism. Although atrial fibrillation treatment by means of pulmonary vein isolation can lead to an improvement in kidney function, the success rate seems to be significantly reduced in the presence of advanced kidney disease. Overall, an individual therapy and treatment concept for each patient with advanced chronic kidney disease is advisable. |
17,794 | Vernakalant and electrical cardioversion for AF - Safe and effective. | Rapid restoration of sinus rhythm is an integral part of the management of recent-onset atrial fibrillation. We aimed to assess safety and efficacy of vernakalant, a multi-channel blocking agent, in combination with external electrical cardioversion.</AbstractText>This prospective cohort study comprised 230 patients (female 35%; median age 50 IQR 42-55) with recent-onset AF presenting to a university tertiary care center during a 6-year period. Management included intravenous vernakalant followed by electrical cardioversion in case of pharmacological failure.</AbstractText>Within 11 min (IQR 8-29), sinus rhythm could be restored by sole pharmacological management in 167 patients (73%). A left ventricular function lower than 55% (OR 3.51 (1.45-8.52)) and prior atrial fibrillation episodes being classified as persistent (OR 2.33 (1.13-4.80)) were significant predictors for non-response to vernakalant. Electrical cardioversion was successful in all patients but one within 196 min (IQR 149-300) of administration of first dosage of vernakalant. No serious adverse events could be observed. 3 patients needed further in-patient care.</AbstractText>Management of recent-onset atrial fibrillation consisting of intravenous vernakalant followed by electrical cardioversion in case of failure appears safe and efficacious. Achieving a rapid conversion, this approach could potentially save resources and costs.</AbstractText> |
17,795 | Use of pulsed electron avalanche knife (PEAK) PlasmaBlade™ in patients undergoing implantation of subcutaneous implantable cardioverter-defibrillator. | Surgical implantation of subcutaneous implantable cardioverter-defibrillators (S-ICD) requires preparation of a deeper and larger pocket. Infection and bleeding complications are reported, particularly in patients requiring antiplatelet therapy (APT) or being on oral anticoagulation (OAC), with rates up to 25%. The pulsed electron avalanche knife (PEAK) PlasmaBlade™ has been reported to reduce bleeding complications. The purpose of this study was to evaluate the safety and feasibility of a PEAK guided S-ICD implantation with respect to perioperative complications.</AbstractText>We enrolled 36 consecutive patients (75% male; mean age 52.1 ± 14.4 years) undergoing S-ICD implantation. Periprocedural safety endpoints comprised major complications including pocket hematomas, wound infections, bleeding (BARC ≥2) or events requiring interventions. Patients were divided into three groups according to management of their anticoagulation: i.) APT, n = 15 (41.7%); ii.) OAC, n = 10 patients (27.8%); iii.) none (neither OAC nor APT), n = 11 (30.6%). Mean procedure duration was 33.1 ± 13.4 min. Mean length of hospital stay was 3.3 ± 2.1 days. Overall analysis showed no differences between the 3 groups with respect to major complications, major bleeding episodes or other procedural parameters, beside a trend towards more minor hematomas in the OAC group (OAC: 22.2% vs. APT: 11.4% vs. none: 9.1%; p</i> = 0.15).</AbstractText>The results of our pilot study suggest that intermuscular S-ICD implantation using PEAK is safe and potentially beneficial in patients receiving OAC or APT with respect to prevention of bleeding complications. These results support the rationale for large prospective controlled trials evaluating a beneficial effect of PEAK use in S-ICD implantation procedures.</AbstractText> |
17,796 | Cardiac arrhythmia from epinephrine overdose in epidural test dose. | Medication shortages are a clinical reality that force changes in practice patterns leading to unintended consequences. Potential solutions to any drug shortage require a thoughtful, multidisciplinary and often creative approach. Here, we report a case of unintentional epinephrine overdose leading to an unstable cardiac arrhythmia and our subsequent development of a visual cue system to prevent future errors. A 56-year-old man with a history of rectal adenocarcinoma presented for low anterior resection and creation of diverting loop ileostomy. Epidural placement was requested by the surgical team, and following administration of a second test dose (created by the physician), the patient experienced supraventricular tachycardia with heart rates of 200-210 BPM for approximately 2 minutes. This rhythm then converted to atrial fibrillation with rapid ventricular response with heart rate of 150-170 BPM. The patient was stabilized after cardioversion. Later evaluation of medication administration revealed that the second epidural test dose inadvertently contained 100 mcg epinephrine instead of the intended 10 mcg dose. The test dose had to be created because the original ampule with the kit had been utilized. Since this time, our kits have no test dose, and this shortage is concerning for increased provider error. We suggest a novel visual cue system that may prevent unintentional epinephrine overdoses in the setting of regional anesthesia. |
17,797 | Defibrillator charging before rhythm analysis causes peri-shock pauses exceeding guideline recommended maximum 5 s : A randomized simulation trial. | Charging defibrillators prior to analyzing heart rhythms may decrease the no-flow time during rhythm check pauses while resuscitating in cardiac arrest. Although this anticipatory method is already used in some centers little is known about its safety. This study was carried out to confirm the safety and feasibility of the anticipatory method. It was hypothesized that this anticipatory method results in shorter total no-flow times, while other parameters of defibrillation efficacy including defibrillator safety and minimization of peri-shock pauses are unchanged.</AbstractText>This manikin study assigned 243 medical students randomly to study groups, 121 to the anticipatory method and 122 to the recommended European Resuscitation Council (ERC) algorithm. Of these 237 students ultimately underwent training (112 anticipatory method vs. 125 ERC algorithm). Participants were assessed and video recorded during a simulated cardiac arrest scenario which included three different heart rhythms (ventricular fibrillation [VF], pulseless ventricular tachycardia [pVT], asystole) in randomized order. Video and software analyses were performed. Defibrillation safety was assessed using a 17-item checklist defined beforehand.</AbstractText>A total of 203 simulated cardiac arrests (75 anticipatory method and 128 ERC 2010 algorithm) were analyzed. The anticipatory method did not significantly reduce no-flow time (25.8 s, standard deviation, SD 7.4 s vs. 27.4 s SD 8.4 s, p = 0.19); however, peri-shock pauses were significantly longer in the anticipatory group compared to the ERC 2010 group (9.5 s SD 2.8 s vs. 3.3 s SD 1.9 s, p < 0.001). No significant difference concerning defibrillation safety between the groups was observed according to the 17-item checklist (14.6 SD 1.6 vs. 15.0 SD 1.4, p = 0.07).</AbstractText>Charging defibrillators before rhythm analysis did not decrease total no-flow time in simulated cardiac arrests but resulted in significantly longer peri-shock pauses exceeding 5 s. No significant differences in defibrillation safety were observed between the groups.</AbstractText> |
17,798 | Hypothermia Inhibits Cerebral Necroptosis and NOD-Like Receptor Pyrin Domain Containing 3 Pathway in a Swine Model of Cardiac Arrest. | Targeted temperature management (TTM) is commonly used in hypothermia after cardiopulmonary resuscitation (CPR), and its mechanism to improve cerebral function is complex. This study aimed to investigate the effects of TTM on necroptosis and the NOD-like receptor pyrin domain containing 3 (NLRP3) inflammasome in the brain tissue of pigs after CPR.</AbstractText>Ventricular fibrillation was induced, and CPR was performed 10 min later in nine pigs in the normothermia group and nine pigs in the TTM group. The body temperature in the TTM group was dropped to 33°C after CPR and maintained for 24 h, whereas in the normothermia group, it was maintained at 38°C. Before CPR and at 30 h after CPR, serum neuron-specific enolase and S-100β were measured. At 30 h after CPR, pigs were euthanized, and brain tissues were collected for measurement of receptor-interacting protein kinase (RIPIK) 1, RIPK3, mixed lineage kinase domain-like (MLKL), NLRP3, cysteinyl aspartate-specific proteinase (caspase)-1, interleukin (IL)-1β, and IL-18.</AbstractText>Serum neuron-specific enolase and S-100β were increased significantly (P < 0.05) in the two CPR-treated groups compared with the sham group and more obviously in the normothermia group. In addition, the expression of RIPK3, phosphorylated MLKL, and NLRP3 in brain tissues was increased. The expression of RIPK3, phosphorylated MLKL, NLRP3, and caspase-1 as well as the levels of IL-1β and IL-18 were lower (P < 0.05) in the TTM group compared with the normothermia group.</AbstractText>Necroptosis and the NLRP3 pathway were activated after CPR. TTM may attenuate postresuscitation brain injury through the regulation of necroptosis and the NLRP3 pathway.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,799 | Gender differences in utilization of coronary angiography and angiographic findings after out-of-hospital cardiac arrest: A registry study. | We investigated the impact of gender in performance and findings of early coronary angiography (CAG) and percutaneous coronary intervention (PCI), comorbidity and outcome in a large population of out-of-hospital cardiac arrest (OHCA) patients with an initially shockable rhythm.</AbstractText>Retrospective cohort study. Data retrieved 2008-2013 from the Swedish Register for Cardio-Pulmonary Resuscitation, Swedeheart Registry and National Patient Register.</AbstractText>We identified 1498 patients of whom 78% were men. Men and women had the same pathology on the first registered electrocardiogram (ECG): 30% vs. 29% had ST-elevation and 10% vs. 9% had left bundle branch block (LBBB) (P = 0.97). Proportions of performed CAG did not differ between genders. Among patients without ST-elevation/LBBB men more often had at least one significant stenosis, 78% vs. 54% (P = 0.001), more multi-vessel disease (P = 0.01), had normal coronary angiography less often, 22% vs. 46% and PCI more often, 59% vs. 42% (P = 0.03). Among patients without ST-elevation/LBBB on the initial ECG, more men had previously known ischaemic heart disease, 27% vs. 19% (P = 0.02) and a presumed cardiac origin of the cardiac arrest, 86% vs. 72% (P < 0.001). Multivariable analysis showed no association between gender and evaluation by early CAG. In men and women, 1-year survival was 56% vs. 50% (P = 0.22) in patients with ST-elevation/LBBB and 48% vs. 51% (P = 0.50) in patients without.</AbstractText>Despite no gender differences in ECG findings indicating an early CAG, men had more severe coronary artery disease while women more frequently had normal coronary angiography. However, this did not influence 1-year survival.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
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